Gender differences in medical student distress: Contributions of prior socialization and current role-related stress

Sot. Sri. Med. Vol. 30, No. 7, pp. 777-787. 1990 Printed in Great Britain. All tights reserved

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0277-9536,90 53.00 + 0.00 C 1990 Pergamon Press plc

GENDER DIFFERENCES IN MEDICAL STUDENT DISTRESS: CONTRIBUTIONS OF PRIOR SOCIALIZATION AND CURRENT ROLE-RELATED STRESS* JUDITHA. RICHMANand JOSEPHA. FLAHERTY Department of Psychiatry, University of Illinois at Chicago, 912 S. Wood St, Chicago, IL 60612. U.S.A. Abstract-Gender differences in psychological distress among future physicians are addressed from contrasting role-related stress and socialization-based vulnerability perspectives. A medical student cohort was surveyed at medical school entrance and after one year of training, focusing on earlier familial relationships, personality and social support resources, perceived medical school stressors and alcohol consumption and depressive and anxiety symptomatology. Relative to socialization perspectives, the sexes manifested more similarities than differences at time I, although the females manifested lower overall psychopathology, but greater perceived paternal overprotection in childhood. Relative to role stress perspectives, both sexes reported increased psychopathology by the time 2 point. The sexes did not differ in perceived medical school-related stressors, while females manifested better social supports at time 2. The psychosocial predictors of increased subjective distress for both sexes included perceived earlier familial relationships and medical school stressors. The only predictor of increased drinking (by males) was time I drinking level. Future research on gender roles and distress should assess both male and female modes of psychopathology and should address antecedents of role entrance in addition to the (presumed) consequences of role incumbency.

During the past few decades, an increasing proportion of women have entered previously male occupations. Within medicine, the focus of this study, only 9% of medical students in the United States were female in 1968 [I], while a decade later this figure increased to 26.5% and has continued rising to 32% of medical students in 1985-86 [2]. The changing nature of women’s work roles has given rise to a prolific body of research addressing the extent and nature of various gender role changes and the consequences that these changes have for the comparative physical and psychological well being of men and women. The study reported here examines gender differences in psychosocial resources, earlier childhood and medical school-related social experiences, and corresponding mental health status in a cohort of future physicians. This group was surveyed at two time points: at entrance into medical school (assumed to reflect prior gender-related social influences) and after completion of a year of medical training (tapping the social environment characterizing the initial phase of physician socialization). Beyond examining the mental health of a sample representing a future occupational group, the study was designed to address a broader issue generally neglected in research on gender roles and mental health: to what extent do adult social roles have gender-linked consequences for mental health, or alternatively, to what extent do individuals with particular (gender-linked) vulnerabilities differentially enter into given social roles? We address this question within the context of training *This is a revised version of a paper presented at the American Sociological Associaiion Annual Meeting. Atlanta. Georgia, August 1988. SSM

?o7-a

for a particular profession in which females have previously manifested high levels of distress compared to males. THEORETICALBACKGROUND Gender roles and mental health in the general population

Since the publication of Gove and Tudor’s [3] analysis of the social stressors in modern society hypothesized to negatively influence women’s psychological status relative to that of men, research on sex roles and mental health has constituted one major focus of psychiatric epidemiologic investigations. On a theoretical level, psychosocial explanations of sex differences in psychopathology (primarily of the higher rate of female depression) have ranged from the consequences of differential childhood socialization experiences to the differing adult work and familial roles of men and women, and the politicaleconomic distribution of status and power in a (male-dominated) society [4]. Empiricai epidemiologic studies have examined female intra-sex variability in mental health as a function of work, marital and parental roles [5-81 and male-female differences in relation to the familial division of labor [9, lo], social functioning in various social roles (1 I] and the relative benefits to men and women of marital, familial and work role incumbency [12-141. Overall, this body of research has illuminated a set of acute and chronic adult role-related stressors associated with female psychological distress such as the lack of employment, the burdens associated with motherhood, and the overall inequitable division of Iabor in contemporary American marriages. Yet, despite the rapid accumulation of knowledge regarding major risk factors for women’s psychological impairment, two critical problems underlie the 777

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JUDITH

A. RICHMAN and JOSEPH A. FLAHERTY

majority of studies and leave open to question the interpretation of many findings. First, as the Dohrenwends [15] argued in response to Gove and Tudor’s [3] analysis of female stress and distress, males and females differ more in the nature of their psychopathologies than in their comparative rates. While women have higher rates of depression, men manifest higher rates of alcoholism, drug abuse and personality disorders, particularly anti-social behavior [16-181. However, the vast majority of psychosocial studies of the comparative mental health of men and women have focused solely on female modes of distress, primarily symptoms of anxiety and depression. If women are assumed to be more distressed than men as a consequence of role-related stressors, what then remains unexplained is the psychosocial etiology of disorders in which men predominate. One hypothesis put forward is that depression and alcoholism are different but equivalent disorders: women express distress in the form of depressive symptomatology while men may be reluctant to admit distress directly but attempt to mitigate it by drinking [17]. This perspective would suggest in part that the psy chosocial etiology of depression and alcohol-related problems is similar. Fortunately, researchers have recently begun to empirically examine sex differences in the etiology of ‘male’ as well as ‘female’ psychiatric disorders, particularly in the areas of heavy drinking, problem-related drinking and alcoholism [ 19-231. For example, Lennon [22] addressed the effect of occupational conditions and found that the substantive complexity of work is inversely related to drinking in males (but not females) and subjective distress in females (but not males). Second, and more rarely addressed empirically, is the extent to which prior socialization-based vulnerability versus adult role-related social stress factors explain the relationships between gender, adult social role incumbency and psychological status. The majority of psychosocial researchers addressing gender differences in psychopathology have tended to interpret their data from an adult role stress perspective. They view high rates of female distress as consequences of the stressors deriving from the adult roles that women occupy such as sex discrimination linked to occupational roles or the low prestige and ungratifying tasks linked to homemaker roles [3,6]. However, research has also shown that at the same level of exposure to stress, women exhibit higher levels of symptomatology compared to men [24]. Congruent with this perspective is the possibility that individuals bring with them varied psychosocial resources and prior experiences upon entrance into adult social roles as well as being selected into these roles on the basis of these characteristics. These sources of differential vulnerability may encompass earlier familial socialization experiences as well as biological and genetic factors [I 11. For example, researchers have demonstrated an enduring relationship between early childhood experiences involving parental loss [7,25] or perceived parental lack of warmth and overprotection [26-281 and adult psychological distress and adult impairment. In terms of gender-linked experiences in particular, sex differences in childhood familial socialization have been seen to produce enduring personality differences in

males and females which effect their later social interactions, behaviors, and feelings. Theory and research deriving from a variety of frameworks such as the psychoanalytic [29,30], social learning [31] or biosocial [32] frameworks have suggested that early familial socialization is more likely to encourage affiliative orientations in females (at the expense of autonomous development) and autonomy and differentiation in males (at the expense of interpersonal connectedness). These experiences have been hypothesized to influence females in later developing a sense of personal inadequacy or ‘learned helplessness’ related to instrumental role performance and an overdependence on other people, while males are more likely to develop greater feelings of self efficacy, but deficits in the ability to relate emotionally in close intimate relationships. In sum, the existing body of research leaves unresolved the question of whether gender differences in adult distress are primarily a consequence of the stressors inherent in adult social roles (and more likely to be attached to roles when they are performed by women), whether they are a consequence of the different personal and social resources which the two sexes acquired at earlier life cycle stages and which influence their differential vulnerability to adult rolerelated stressors, or whether both factors explain gender differences in distress. Gender roles. medical training and mental health

Applying these etiologic perspectives to the specific domain of physician training roles and mental health, two classical studies of the medical school environment both focus on the high levels of stressors experienced by students in the process of attempting to master the vast and changing knowledge base necessary for future medical practice [33,34]. While these earlier studies dealt with male student populations, more recent research on both male and female medical students has shown both sexes to experience high levels of stressors involving the heavy work load and quantity of material to be learned, the lack of time for recreation, and financial pressures [35]. However, while these stressors have been linked to feelings of distress in both sexes, female medical students have been found to manifest higher levels of psychiatric symptomatology, primarily involving depression and interpersonal sensitivity [36, 371 and a greater number of genera1 health and psychological identity problems [38] in contrast to male medical students. In addition, beyond the training period, female physicians have been shown to manifest suicide rates significantly higher than those of male physicians and four times that of white American women of the same age [39]. These authors speculate that female physician suicide may reflect underlying affective disorders and/or alcoholism. Psychosocially-oriented empirical research addressing the etiology of sex differences in medical student or physician mental health has generally focused on either the personality traits which women bring into medicine or on the discriminating environment of medical training and practice. For example, consistent with a gender-related differential vulnerability perspective, Roos et al. [40] found that, at medical school admission, females rated themselves

Gender differences in distress as less professionally able than males, despite equivalent or better actual performance prior to and during medical school. More recently, Grossman er al. [41] found that females entering medical school manifest a lower sense of personal mastery compared to male medical school entrants. Alternatively, from a current role-related stress perspective, Roeske and Lake [42] focused on the male-dominated social environment of medical schools and the lack of female role models as central to the identity conflicts experienced by female students. This orientation is congruent with analyses of the general lack of social support, particularly the lack of mentoring relationships, experienced by female medical students in contrast to male students [43]. Moreover, the experience of women in medical school (and other traditionally-male environments) might be seen from this perspective as discrepant from that of women in other (less male-oriented) environments who have been shown to manifest more positive support systems compared to men [44]. Finally, in their theoretical analysis of the psychological conflicts of female student physicians, Notman and Nadeison [45] argued that both the nature of earlier female socialization encouraging passivity and the denial of assertiveness, and the medical school environmental hostility directed at female students from male faculty and peers contribute to female medical students’ and physicians’ psychopathology. However, the relative contributions of these factors has not been addressed on an empirical level. The study reported here represents an empirical examination of the relative psychosocial contributions of earlier socialization-related vulnerability and current medical school-related environmental factors to the mental health status of female and male medical students. We assess gender differences in earlier familial experiences, personality traits, social supports, perceived medical school stressors and ‘male’ and ‘female’ modes of expressing psychopathology (depressive and anxiety symptomatology, quantity and frequency of alcohol consumption and drinking-related problems). Our specific hypotheses embodied two major assumptions derived from the earlier literature. First, differential male and female medical student distress is likely to be influenced by both pre-medical socialization and medical school role-related experiences. Second, to the extent that males and females express psychological distress in different modes as well as in greater or lesser magnitudes, depressive and anxiety symptomatology in women and heavy and problem-related drinking in men may represent sex-differentiated manifestations of an equivalent distressful condition. Support for this assumption would be evidenced by the extent to which similar psychosocial variables predict depressive and anxiety symptomatology in women and heavy and problem-related drinking in men. From socialization-based vulnerability perspectives, we hypothesized that males and females would bring differences in personality assets, social support resources, earlier familial experiences and psychiatric symptomatoiogy to the medical school context. More specifically, we hypothesized that males would be relatively more advantaged in personality assets involving lower external locus of control and

779

interpersonal dependency and a higher level of assertiveness. By contrast, females would manifest the development of more satisfying social support systems. With regard to perceived earlier familial experiences shown to correlate with adult distress, we expected females to report higher levels of earlier parental overprotection. In addition, on the basis of consistent gender differences in psychopathology, we expected females to bring higher levels of depressive and anxiety symptoms into the medical school environment, while males would bring heavier alcohol consumption and more drinking-related problems into the medical school environment. Finally, these socialization-based gender differences in medical students were assumed to be less pronounced compared to the general population since more masculine women may be differentially selected into medical training. From the perspective of medical school-related role encumbency factors, we predicted sex differences in changes from medical school entrance to the end of the first year of training on several variables. First, we hypothesized that the female social support advantage would be significantly lessened by the time 2 point, given the male-dominated social environment of medical schools. Secondly, we expected that females would manifest substantially elevated levels of depressive and anxiety symptomatology at time 2 compared to time 1, while males would manifest moderately increased alcohol levels and drinkingrelated problems. This was based on the assumption that medical school would be experienced as stressful by both sexes, but to a greater degree by females. Finally, we predicted that the psychosocial etiology of time 2 depressive and anxiety symptoms in females and heavy or problem-related alcohol consumption in males would include a combination of pre-medical school-based vulnerability factors (earlier familial experiences and psychosocial assets at medical school admission) and medical school-based environmental factors (perceived stressors and social supports during medical school). However, we expected female students to experience a higher level of medical school-related stress. In addition, we expected the female advantage involving the greater capacity to form social supports to play less of a protective role in relation to distress in the medical school environment in comparison to the experiences of the general population. This hypothesis derives from previous research on medical school populations which has shown internal personality resources rather than social support resources to be protective against medical student distress [46] and social ‘supports’ to be viewed negatively as well as positively [47]. METHOD Sample

The sample derives from the first year cohort of medical students (N = 210) entering a state College of Medicine in the fall of 1985. During the initial registration period, the entire class was administered a (time 1) self-report questionnaire with a final response rate of 93% of the cohort (N = 195). The sample was 66.5% male and 33.5% female, similar to the sex distribution of the total population. Seven

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JUDITHA. RICHMANand JOSEPHA. FLAHERTY

months later all time 1 participants were adminstered a time 2 self-report questionnaire with a response rate of 93% of the time I sample. Respondents remaining in the study (N = 180 and the basis for the quantitative analyses in this paper) did not significantly differ (at the P c 0.05or better level) from drop-outs in terms of sex composition or scores on each of the outcome variables, depressive and anxiety symptomatology and alcohol consumption. The mean age of the males was 23.1 yr and the mean age of the females was 24.4 yr, with most of the respondents in their twenties. Both the males and females are predominantly single (90.9 and 80.3%, respectively) and from socio-economic backgrounds characterized by parents with at least high school educations and, in many cases, college and post-graduate training. Measures

The questionnaire included socio-demographic information at time 1, perceived medical schoolrelated stressors at time 2. and the following information at each of the two time points: perceived earlier parent-child relations, personality resources (internal*xternal locus of control, interpersonal autonomy-dependency, self esteem, assertiveness and flexibility), social supports, and psychological distress (depressive and anxiety symptomology, quantity and frequency of alcohol consumption and alcoholrelated problems). The qualitative assessment of earlier parentxhild relations was made utilizing the ‘Parental Bonding Instrument’ [48]. The P.B.I. is a relatively brief (25 item) self-report instrument designed to characterize relations with each parent during the first 16 yr of life in terms of two dimensions (derived from factor analysis): levels of affection and control. It taps the two dimensions of early family relationships (lack of parental affection and parental over control) highlighted in the general clinical literature on depression [49] as well as in studies of the family backgrounds of substance abusing and distressed physicians [50]. Second, given the methodologic difficulties involved in retrospective data gathering, the P.B.I. has been shown by Parker and colleagues [26,51,52] and Richman and Flaherty [28] to manifest evidence of both reliability and concurrent and predictive validity.* Alpha coefficients for each of the parental bonding ratings used in this study were over 0.80 for both males and females at each time point. Focusing on personality resources, external locus of control was chosen due to its association with

depression and drinking in previously epidemiologic *For example, Parker and colleagues [26,48,51,52] have found significant correlations between respondents’ ratings of their mothers’ earlier behaviors and those ratings made by the mothers themselves regarding their own earlier behaviors. In addition, borh the respondents’ ratings and those made by the mothers were predictive of depression in the respondents. In their study of medical students, Richman and Flaherty [28] found that P.B.I. ratings at medical school entrance predicted depression at the end of a year of training, holding constant time I depression. In addition, P.B.I. ratings at the two time points were highly correlated (over 0.79), although ratings became somewhar more negative at the time 2 point.

studies. In addition, it can be seen as an indication of pessimistic ideation or ‘learned helplessness’ focused upon in cognitive theories of depression [53] and also hypothesized to more strongly characterize female compared to male personality development on the basis of familial socialization experiences. Locus of control was measured by 10 items (see Appendix) from the Rotter 29 item internal-external scale [54]. This is the most widely used scale assessing the belief that one is controlled by external forces, with considerable research available on reliability and validity (551. The alpha coefficients for both males and females were over 0.50 at each time point. In addition to locus of control, we included a measure of assertiveness, assumed to tap on a more behavioral level the ability (or inability) to affect the environment. To measure assertion, we selected three items derived from the Aggressive Scale of the Million Clinical Multiaxial Inventory (MCMI). The MCMI is a 175~item true-false self-report inventory that measures 20 clinical scales assessing personality types and disorders [56,57]. We selected three items, which were altered to begin with ‘He/she’ rather than ‘I’. They are: l-He/she will make a sharp and critical remark to someone if they deserve it; 2-He/she has a way of speaking directly that often makes people angry; 3-He/she speaks out his/her opinions about things no matter what others may think. For our purposes, respondents were asked to rate the items on a four point scale from ‘very like’ to ‘very unlike’ oneself. The items were choosen to reflect content characterizing healthy assertion rather than ‘pathological’ aggression. The alpha coefficients were over 0.64 for each sex at both time points. The personality resource, interpersonal autonomy/ dependency, reflects psychoanalytic theories of depression which focus on over-dependence on other people as an etiologic factor [58], particularly for women [29]. In addition, it is congruent with earlier research on physicians which pointed to unmet dependency needs from earlier inadequate parenting as central to the etiology of physician distress [50]. Interpersonal dependency was measured by 10 items from the 18 item Emotional Reliance on Another Person factor of the [59] Interpersonal Dependency Scale (see Appendix). This index taps degrees of attachment needs and feelings of dependency. The alpha coefficients for males and females were over 0.75 at each time point. Two additional personality characteristics, selfesteem and flexibility-rigidity, were also included in so far as they have been significantly linked to depression or distress in previous epidemiologic studies [60,61]. However, we did not hypothesize that they would differentially be linked to gender status. Self-esteem was measured here by five of the widely used Rosenberg items (see Appendix) which were also utilized in the epidemiologic research by Pearlin and Schooler [60]. Each item is rated on a four point scale from ‘strongly disagree’ to ‘strongly agree’. The alpha coefficients were over 0.60 for both sexes at both time points. Flexibility is measured by the seven items developed by Wheaton [61] rated on a four point scale from ‘very unlike’ to ‘very like’. The alpha coefficients were over 0.55 for males and females at each point in time.

Gender differences in distress

Shifting to the external environment prior to and during the first year of medical school, social support was measured by a shortened version of the Social Support Network Inventory (SSNI) [62,63]. It consists of three questions concerning five individuals defined as most significant to the respondent. Each of the responses was rated on a l-7 point scale indicating the amount of support received, from no support [I] to maximal support [7]. The questions tap three dimensions of social support: availability, intimacy and overall help received. The scale has demonstrated high reliability and convergent and concurrent validity. The alphas were all over 0.65 in this study. Perceived medical school stressors were assessed at time 2 by the 13 item index developed by Vitaliano et al. [64]. This scale has previously manifested high internal consistency and a significant relationship to anxiety in medical students, focusing on such content areas as long hours, mastering knowledge, limited personal time, peer competition, inadequate communication by the faculty and administration and a cold/bureaucratized environment. The alpha coefficients for this study were over 0.70. With regard to outcome variables, depressive symptomatology was measured by the Center for Epidemiologic Studies Depression (CES-D) scale. The CES-D is a 20 item self report symptom rating scale designed to measure depressive mood in community populations [65]. The CES-D is considered a reliable and valid indicator of depressive symptomatology, although it does not necessarily correspond to a clinical diagnosis of depression [66,67]. The instrument provides for a possible range of scores from 0 to 60, taking into account both the prevalence and persistence of each symptom. The alphas were all over 0.80. Anxiety is measured by the nine item tension-anxiety factor of the Profile of Mood States [68]. This measure has manifested high test-retest reliability, internal consistency, and a high correlation with other anxiety measures. It has been validated in both patient and community samples [68]. The alphas for our sample were over 0.80 for both sexes. Finally, to measure alcohol consumption, we first used a modified version of the Cahalen er al. [69] Quantity-Frequency-Variability model. For overall consumption of alcoholic beverages (beer, wine, distilled spirits), we ascertained: (1) for frequency: During the past month, about how many days did you drink any type of alcoholic beverage; and (2) for quantity: During the past month when you drank, how many drinks did you usually have per day? Recent research suggests that quantity and frequency are separate and independent dimensions. For example, Apao and Damen [70] found external locus of control to significantly predict frequency but not quantity of drinking. Thus, instead of combining the quantity-frequency measures to create overall drinking categories, we examine the two dimensions separately, as continuous variables. In addition to overall alcohol consumption, drinking-related problems were also measured using items from the Glynn ef nl. [71] and Parker et al. [21] epidemiologic alcohol studies and a few items tapping work/student impairment. The items include: As a result of drinking, once or more a month-“1 got drunk too often, I felt sick

781

upon awakening, I had memory lapses or blackouts, and had the shakes, I became hostile, It made me more depressed, I hurt myself physically when drunk, It affected my health, or It affected my family relationships”, or once or more a week as a result of drinking, “I had difficulty sleeping, I had trouble with my back, I was skipping meals, or I had been arrested for drunken driving or disturbing the peace, missed work or school because of a hangover, or became high or tight on the job or at school”. For this study, the problem drinking measure consists of an additive scale based upon the number of items rated positively. DATA

ANALYSIS

Following are a set of analyses which test (1) the hypotheses derived from the differential vulnerability perspective, (2) the hypotheses derived from the role stress perspective and (3) the question of the relative extent to which differential vulnerability versus role stress factors account for the time 2 mental health outcomes for males and females. In addition, these last set of analyses address the broader issue of whether depressive and alcohol-related psychopathology constitute different manifestations of an equivalent disorder (to the extent that they share similar etiologies). The differential vulnerability perspective

First, one-way analyses of variance were utilized to test the hypothesized sex differences in perceived earlier parental bonding, personality and social support resources, and mental health status at the point of medical school entrance. Table 1 (the time 1 section) presents these analyses. Most, although not all of the pre-medical school socialization-based predictions of sex differences at time 1 were disconfirmed. First, females did report a significantly higher level of paternal (although not maternal) overprotection in childhood (P < 0.05) as predicted. However, the two sexes did not significantly differ with regard to either personality or social support resources. Moreover, the data fail to show sex differences in either depressive or anxiety symptomatology. However, consistent with the initial hypotheses, the males were significantly higher in frequency of alcohol consumption (P < 0.001) as well as in drinkingrelated problems (P < 0.01) and in quantity of drinking at the trend level (P < 0.10). In sum, while the sexes do not differ in psychosocial resources at medical school entrance, the females appear healthier with regard to mental health status. They do not manifest the traditionally female predominance in depressive or anxiety symptomatology. Nor do they take on equivalent levels of male styles of psychopathology (e.g. drinking-related problems). The role stress perspective TO test the hypothesized effects of medical schoolrelated role stress, we first contrasted the time 1 gender differences with those found at time 2 (shown in Table l), as well as looking at psychosocial and mental health changes over time for each sex, as shown in Table 2.

782

JUDITH Table

A.

RICHMAS

I. Sex differences

in psychosocial Time

Males Psychosocial

measures

I, Perceived earlier familial relationships Mat. aKec. Pat. affec. Ma:. overpro. Pat. overpro. 2. Personality Ext. locus of control Interper. dep. Self-esteem Assertiveness Flexibility 3. Social supports (SSNI) 4. Depressive symptoms (CES-D) 5. Anxiety symptoms (Poms) 6. Alcohol consumption Quantity Frequency Drinking-related problems

and JOSEPHAFLAHERTY characteristics

1 and

at time

2

I

Time 2

Mean

SD

Females Mean SD

29.21 25.61 I I.65 9.30

5.60 6.49 6.98 6.17

29.80 26.07 12.75 II.82

4.10 20.38 3.15 2.30 3.34 5.13 10.72 1.20

I.87 4.44 0.3 I 0.70 0.5 I 0.77 7.62 0.64

I .86 9.72 0.74

I .57 7.56 1.20

Males F

Mean

SD

Females Mean SD

6.84 7.98 7.02 6.88

0.396 0.17 1.01 5.92+

29.29 24.66 13.26 10.48

5.57 6.57 7.54 6.90

30. IO 25.82 14.20 12.32

7.03 7.88 7.60 7.12

0.710 1.04 0.62 2.66’

3.84 20.52 3.75 2.26 3.41 5.31 9.98 I .08

I .94 5.32 0.30 0.72 0.55 0.66 7.60 0.58

O.-81 0.04 0.00 2.036 0.786 3 *, -.J0.38 I.49

4.00 21.17 2.73 2.33 3.30 5.30 12.51 0.98

1.74 5.40 0.31 0.65 0.52 0.64 8.7 0.68

4.43 21.49 2.69 2.16 3.35 5.70 13.84 I .26

1.92 5.75 0.35 0.75 0.58 0.63 9.15 0.83

2.18 0.13 0.694 2.65. 0.45 I l5.88$ 0.90 5.78t

I .45 5.33 0.28

I .62 5.63 0.57

2.669 l6.07,r 6.497:

2.57 7.02 0.58

2.16 6.30 I .28

I .49 3.92 0.28

1.59 3.56 0.77

I I.525 12.60$ 3.158’

F

lP < 0.10: tP < 0.05: $P < 0.01; §P < 0.001.

Table I indicates that by the end of the first year of medical training, the females appear lower than men in assertiveness (at the trend level) while also manifesting a clear advantage in social supports (P < 0.001). However, in contrast to the time 1 point, we now see a more typical pattern of gender differences in mental health: the females are significantly higher in anxiety (P -c 0.05) while the males consume alcohol more frequently and in greater quantities (P < 0.001). At the same time, there are no gender differences in depressive symptomatology and only a trend level difference in drinking-related problems. Finally, contrary to the initial hypothesis (and not included in Table 2), the two sexes did not significantly differ in their perceptions of the stressfulness of medical school. Looking at changes over time for each sex separately, as shown in Table 2, both similar and divergent trends are apparent. First, both males and females manifested significantly increases in interpersonal dependency, social supports and depressive symptomatology, and a decrease in the frequency of alcohol consumption. By contrast, females but not males manifested an increase in external locus of control. In addition, females manifested a trend level increase in anxiety. By contrast, male anxiety was significantly decreased (P c 0.001). while quantity of alcohol consumption increased (P < 0.001). In sum, males and females manifested changes in psychosocial resources and symptomatology during the first year of medical training in both overlapping and divergent ways. Contrary to the initial hypothesis (central to the gender-linked role stress argument), the medical school environment was not perceived as more stressful by female medical students. In

*This finding, however, is based on ratings of individuals whom the students defined as the most significant to them and are not necessarily individuals within the medical school environment. Additional analyses (to be expanded upon elsewhere) showed that the primary support providers were, in descending order: parent, friend, and spouse/lover.

addition, both males and females increased their social supports during the first year, with the females manifesting significantly greater perceived social supports at the end of the first year of medical training. The latter finding contrasts with descriptions of the lack of supports experienced by women in the medical school context.* Finally, the data suggest that both male and female medical students experience increases in psychopathology during medical school which is similar in some ways (e.g. in the area of depression) and divergent in other ways (e.g. in the areas of anxiety versus drinking). The retatice etiologic salience of differential culnerability and medical school role-related factors

The final set of analyses address, for male and females separately, psychosocial predictors of the particular distress outcomes which increased from medical school entrance to the end of the first year of medical training: depression and quantity of drinking for males and depression and anxiety for females. Four sets of hierarchical regression analyses were calculated (shown in Tables 3 and 4) in which the time 2 distress outcome was first regressed on the relevant time 1 distress measure and then on all of Table

2. Psychosocial

Psychosocial

changes over time for males and females: paired r-tests*

measure

Personality Ext. Icxus of control Interper. dep Self-esteem Assertiveness Flexibility Social supports (SSNI) Mental health Depressive symptoms Anxiety symptoms Quantity of alcohol Frequency of alcohol Drinking-related problems

Males

Females

0.63 -2.1: 0.58 -0.79 1.04 -2.645

- 3.038 -2.02: I .35 0.31 I.14 -5.29,

-2.54 3.3011 - 4.08 /I 4.6711 1.23

-3.055 - 1.87t -0.21 2.63s -0.52

*Note that negative scores indicate increases while positive indicate decreases. tP < 0.10: :P < 0.05; pP < O.Ol:l/ P < 0.001.

scores

Gender differences in distress Table 3. Hierarchical Deaendent

multiple regression analyses psychopathology at time 2 lndeoendent

variable

of alcohol

lP < 0.01: tP < 0.001

(T,)

Quantity of alcohol (T,) Mat. affect. (T,) Pat. affect. (T, j Mat. overpro. (T,) Pat. overpro. (T,) Ext. locus of control (T,) Interper. dep. (T,) Self-esteem (T, ) Flexibility (T,) Assertion (T, ) Social supports (T,) Med. school stress (T,) RZ

male

Beta

variables

CES-D (T, ) Mat. affec. (T, ) Pat.affec.(T,) Mat. overpro. (T,) Pat. overpro. (T, ) Ext. locus of control (T, Interper.dep (T,) Self-esteem (T, ) Flexibility (T,) Assertion (T, ) Social supports (T,) Med. school stress (T,) RZ

I. CES-D (T, )

2. Quantity

predicting

)

Table 4. Hierarchical Deuendent

variable

783 multiple regression analyses predicting psychopathology at time 2 Independent

variables

female Beta

0.46t -0.06 0.0 I 0.29’ 0.33’ 0.01 0.08 -0.01 -0.01 -0.05 -0.04 0.22’ 0.44

I. CES-D (T,)

CES-D (T,) Mat. afTec. (T,) Pat. affect. (T,) Mat. overpro. (T,) Pat. overpro. (T,) Ext. locus of control (T,) Interper. dep. (T,) Self-esteem (T, ) Flexibility (T, ) Assertion (T, ) Social supports (T:) Med. school stress (T,) RZ

0.30. -0.03 0.2 I 0.18 0.38+ 0.09 0. I7 -0.27 0.1 I -0.23. -0.15 0.21 0.41

0.37t 0.15 -0.12 0.21 -0.15 -0.05 0.05 -0.05 0.01 -0.06 -0.1 I 0.06 0. I7

2. Anxiety (T,)

Anxiety (T,) Mat. affect. (T,) Pat. affect. (T, j Mat. overpro. (T,) Pat. overpro. (T,) Ext locus of control (T,) Interper. dep. (T,) Self esteem (T,) Flexibility (T,) Assertion (T,) Social support (T2) Med. school stress (TZ) RI

0.06 -0.12 -0.33: 0.10 0.30* 0.20 0.16 -0.18 0.09 0.19 -0.07 0.44: 0.52

lP < 0.10: tP < 0.05; :P < 0.01.

school stressors (0.44, P c 0.01) contribute to time 2 the time 1 psychosocial resources and perceived anxiety in women. In addition, paternal overprotecearlier familial experiences, and time 2 perceived tion contributes to time 2 female anxiety at the trend medical school stressors and social supports. Our level (0.30, P < 0.10). In sum, earlier familial experimain goal was to assess the relative contribution ences with parents and perceived medical school of pre-medical school experiences and psychosocial stressors differentially contribute to subjective disresources which students brought to the medical tress in male and female medical students, depending school environment versus medical school-based on the particular outcome. However, none of the stressors and social supports experienced during psychosocial variables explain the increased level of medical school in the etiology of the time 2 distress drinking among male students. Thus, symptomatic measures after partialling out the effects of the distress and drinking do not appear to be different relevant time 1 distress measures. manifestations of an equivalent condition. Focusing first on male medical student distress, Table 3 shows that both perceived earlier parental (maternal and paternal) overprotection at time 1 (0.29 and 0.33, P < 0.01) and perceived medical DISCUSSION school stressors (0.22, P < 0.01) significantly contribute to time 2 depression, in addition to depression From the perspective of earlier studies of gender differences in distress among medical students and at time 1. However, none of the time 1 personality physicians several findings from this study were unresources or the experience of social supports at time expected. First, relative to socialization-based per2 predict depressive symptoms at the end of the first spectives, the male and female students entered year of medical training. With regard to time 2 male medical school with more similarities than differences alcohol consumption, the only significant predictor was time 1 alcohol consumption (0.37, P < O.OOl).*in psychosocial resources and indicators of psychological well being. In fact, the main difference beLooking at female medical student distress, Table tween the sexes involved a female advantage in 4 shows that paternal (but not maternal) overprotecmental health status. The females not only did not tion significantly predicts time 2 depression (0.38, differ from the males in classical female modes of P < 0.05). In addition, assertion relates to depression expressing distress (depression and anxiety) but also at the trend level (-0.23, P < 0.10). However, did not appear to manifest similar or higher levels of neither of the two medical school-related variables male psychopathology (heavy and problem-related predict time 2 depression. By contrast, both paternal drinking). These data suggest that particularly wellaffectivity (-0.33, P < 0.01) and perceived medical functioning women may be most likely to self select themselves into careers in medicine, or alternatively, *To examine the extent to which pre-medical school social that medical school admission processes utilize more factors may have impacted on time I drinking (but not stringent personal criteria for judging female comsubsequent drinking), a similar regression analysis was pared to male applicants. run, using all time I variables. However, none of the From the perspective of gender-linked role stresindependent variables accounted for significant varisors, most of these data are not congruent with ability in the quantity of alcohol consumed at medical arguments suggesting that medical school training (at school entrance.

784

JUDITH A. RICHMAN

least the initial year) embodies a higher level of stress and more limited social supports for female compared to male students. Not only did the two sexes fail to differ in their perceived level of medical school-related stress, but the females manifested higher rather than lower social supports at time 2. In addition, both males and females manifested increased distress levels during the first year of training in similar (e.g. increased depressive symptomatology) and divergent (e.g. increased anxiety versus drinking) styles. However, it could be argued that the increased female anxiety more clearly signifies distress than the increased male drinking which may not necessarily be pathological in nature. In addition, it might be argued that given the female superiority in mental health at medical school entrance, females should have manifested lesser increases in distress than males during the first year of training if ‘objective’ stressor levels for both sexes were equivalent. If the overall medical school context does embody a substantially greater degree of stressors for female students, an important issue not addressed in this study involves the distribution of stressors across the 4 years of training. We would speculate that the ‘objective’ experiences of male and female students are relatively more similar during the first 2 preclinical years of training which involves more impersonal and standardized modes of training and evaluation (e.g. lectures and written exams). By contrast, the last 2 clinically-oriented years of training involve extensive interaction between students and faculty (and residents) in the training and evaluation process and modeling of physician roles. Thus, female students may be more subject to stress-producing differential treatment involving more subjective criteria of evaluation during the latter years of training. Spiegel et al. [72] provide some evidence congruent with this perspective in their study of fourth year medical students. Alternatively, the greater representation of women in many medical schools at present may be productive of lower female stress in contrast to the experiences of women in earlier cohorts which were predominantly or almost entirely male in composition. Since we are now in the initial stage of a longitudinal study of medical students which includes a phase of the first clinical training year, we will empirically address this issue in a future report. Focusing on psychosocial predictors of medical student mental health after I year of exposure to the medical school context, the data clearly suggest that perceived pre-medical school familial experiences

*In a study of a different medical student population, Richman and Flaherty [ZS]addressed the extent to which internal parental representations at medical school entrance affected depressive symptomatology at the end of a year of training as the result of the development of personality characteristics assessed in this study as well as the differential capacity to form social supports. While some of the personality characteristics (e.g. flexibility/rigidity and self-esteem) were linked to both parental representations and the distress outcome, they did not reduce the link between parental representations and depressive mood to any sizable degree when their effects were first partialled out.

A. FLAHERTY

continue to influence the psychological well-being of both sexes in addition to the stressors characterizing more recent environmental experiences. For females, perceived earlier experiences with fathers but not mothers appear to be particularly salient (for depression and anxiety), while perceptions regarding both parents influence male depression. It is possible that females most likely to choose a medical career are those with strong identifications with their father. On a more general level, these data suggest the importance of tapping psychosocial experiences occurring at prior life cycle stages as well as those from the immediate past in psychiatric epidemiologic studies. For this particular medical student population, future research is necessary to clarify the mechanisms through which internal parental representations influence psychological status during medical school. In particular, internal (personality) resources other than those focused on in this study may be more salient for explaining psychological well being and distress in future physicians.* Finally. the data from this study do not provide support for theories suggesting that depression and alcohol-related psychopathology constitute different manifestations of an equivalent disorder. While certain psychosocial variables were predictive of increased time 2 depressive symptomatology in both sexes, none of these variables predicted the increased quantity of alchol consumed by males at time 2. However, the limitations of this data set for adequately addressing this issue should be noted. In particular, the measure involving gradations in alcohol consumption per se does not necessarily represent psychopathology. The measure which is more clearly indicative of psychopathology-that of drinkingrelated problems-did not increase over time. Future research is necessary to more adequately address the similarities between psychosocial predictors of depression and drinking-related pathology. We hypothesize that the medical student cohort that we are currently following will manifest increased drinking-related problems at the time 3 data collection point (i.e. in the midst of the clinical training phase of medical school). If this occurs, we will again empirically assess the extent to which vulnerability and stress-related psychosocial variables predict depression versus alcohol-related problems. Acknowledgemenrs-The

authors thank Deborah Hasin and Baila Miller for their helpful comments on an earlier version of this paper. This work-was supported in part by grant No. R29 AA 0731 l-01 from the National Institute on Alcohol Abuse and Alcoholism to the first author and a grant from the John 9. and Catherine T. MacArthur Foundation to the second author.

REFERENCES Nadelson C. and Notman M. What is different for female physicians? In The Inwaired Phvsiciun (Edited by Scheiber s. C. and Doyle i. B.). Plenum, New York, 1983. American Association of Medical Colleges. Private communication, 1986. Gove W. R. and Tudor J. Adult sex roles and mental illness. Am. J. Social. 78, 812, 1973.

Gender differences in distress 4. Herman M. Depression and women: theories and research. J. Am. Acud. Psychoanal. 11, 493, 1983. 5. Radloff L. Sex differences in depression: the effects of occupation and marital status. Sex Roles 1, 249, 1975. 6. Gove W. R. and Geerken M. The effect of children and employment on the mental health of married men and women. Sot. Forces 56, 66, 1977. 7. Brown Cl. and Harris T. Social Origins of Depression: A Study of Psychiatric Disorders in Women. Free Press, New York. 1978. 8. Kandel D. B., Davies M. and Raveis V. H. The stressfulness of daily social roles for women: marital, occupational and household roles. J. Hlth sot. Behac.

27. Richman J. A. and Flaherty J. A. Childhood relationships, adult coping and depression. Sot. Sci. Med. 23, 709, 1986.

28. Richman J. A. and Flaherty J. A. Adult psychosocial assets and depressive mood over time: effects of internalized childhood attachments. J. nerc. ment. Dis. 175, 703, 1987. 29. Chodorow N. The Reproduction of Mothering. University of California Press, Calif., 1978. 30. Philipson I. Gender and narcissism. Psychol. Women Q. 9, 229, 1985. 31. Bardwick J. M. and Douvan E. Ambivalence: the socialization of women. In Woman in Sexist Society

26, 64. 1985.

9. Ross C. E., Huber J. and Mirowsky J. Dividing work, sharing work, and in between; marriage patterns and depression. .4m. Social. Rev. 48, 809, 1983. IO. Ross C. E. and Huber J. Hardship and depression. J. Hlth sot. Behar. 26, 312, 1985. II. Richman J. A. Sex differences in social adjustment: effects of sex role socialization and role stress. J. nerr. ment. Dis. 172, 539, 1984. 12. Aneshensel C. A., Frerichs R. R. and Clark J. A. Family roles and sex differences in depression. J. Hlth sot. Behar. 22, 379, 1981. 13. Kessler R. and McRae J. A. Jr. Trends in sex and psychological distress. Am. Socioi. Rev. 47, 216, 1981. 14. McLanahan S. S. and Glass J. L. A note on the trend in sex differences in psychological distress. J. Hith sot. Behac. 26, 328, 1985.

15. Dohrenwend B. P. and Dohrenwend B. S. Sex differences in psychiatric disorders. Am. J. Social. 81, 1447, 1976. 16. Dohrenwend B. S. and Dohrenwend B. P. The 1980 Division 27 Award for Distinguished Contributions to Community Psychology and Community Mental Health. Am. J. Commun. PsychoI. 9, 123, 1981. 17. Weissman M. M. and Klerman G. L. Sex differences and the epidemiology of depression. Archs gen Psychiur. 34, 98, 1977.

18. Haglund R. M. J. and Schuckit M. A. The epidemiology of alcoholism. In Alcoholism: Development, Consequences and Interventions (Edited by Estes N. J. and Heinemann M. E.), 2nd edn. Mosby, St Louis, MO, 1982. 19. Ferrence R. G. Sex differences in the prevalence of problem drinking. In Alcohol and Drug Problems in Women: Research Advances in Alcohol and Drug Problems (Edited by Kalant 0. J.), Vol. 5, p. 69.

Plenum, New York, 1980. 20. Johnson P. B. Sex differences, women’s roles and alcohol use: preliminary national data. J. Sot. Issues 38, 93, 1982. 21. Parker D. A., Kaelber C., Harford T. C. and Brody J. Alcohol problems among employed men and women in metropolitan Detroit. J. Stud. Alcohol 44, 1026, 1983. 22. Lennon M. C. Sex differences in distress: the impact of gender and work roles. J. Hlth sot. Behav. 28,290, 1987. 23. Richman J. A. and Flaherty J. A. Sex differences in medical student drinking: patterns and psychosocial correlates. J. Stud. Alcohol 47, 283, 1986. 24. Kessler R. C. Stress, social status and psychological distress. J. Hlth sot. Behav. 20, 259, 1979. 25. Dohrenwend B. P. and Defigueredo J. Remote and recent life events and psychopathology. In Origins of Psychopathology: Problems trt Rese&h and Public Policv (Edited bv Ricks D. F. and Dohrenwend B. S.).

pp. 91-106. Cambridge University Press, New York; 1983. 26. Parker G. Parental affectionless control as an antecedent to adult depression. Archs gen Psychiat. 40,956. 1983.

785

32. 33.

34.

35. 36. 37.

38. 39.

(Edited by Gomick V. and Moran B.). Basic Books, New York, 1971. Rossi A. Gender and parenthood. Am. Social. Rev. 49, I, 1984. Becker H., Geer B., Hughes E. and Strauss A. Boys in White. University of Chicago Press, Chicago, Ill., 1961. Merton R. K.. Reader G. G. and Kendell P. (Eds) The Student Physician. Harvard, Cambridge, Mass., 1957. Lloyd C. and Gartrell N. K. A further assessment of medical school stress. J. med. Educ. 58, 964. 1983. Lloyd C. and Gartrell N. K. Psychiatric symptoms in medical students. Comprehens. Psychiut. 25, 552, 1984. Lloyd C. Sex differences in medical students requesting psychiatric intervention. J. net-v. menf. Dis. 171, 535, 1983. Heins M. and Thomas J. Women medical students: a new appraisal. J. Am. Med. Women’s Ass. 34,408, 1979. Pitts F., Schuller A. B., Rich C. I. and Pitts A. F. Suicide amone U.S. women nhvsicians. Am. J. Psychiut. 136, _ -

694, l-979. 40. Roos N., Gaumont M. and Colwill N. L. Female and physician: a sex role incongruity. J. med. Educ. 52, 345, 1977.

41. Grossman H.. Salt P., Nadelson C. and Notman N. Coping resources and health responses among men and women medical students. Sot. Sci. Med. 25, 1057, 1987. 42. Roeske N. A. and Lake K. Role models for women medical students. J. med. Educ. 52. 459, 1977. 43. Lorber J. Women Physicians. Tavistock, New York, 1984. 44. Butler T., Giovadano S. and Meren S. Gender and sex-role attitudes as predictors of utilization of natural support systems during personal stress events. Se.r Roles 13, 515, 1985. 45. Notman M. and Nadelson C. Medicine: a career conflict for women. Am. J. Psychiat. 130, 1123, 1973. 46. Richman J. A. and Flaherty J. A. Coping and depression: the relative contribution of internal and external resources during a life cycle transition. /. nerc. mew. Dis. 173, 590, 1985. 47. Foorman S. and Lloyd C. The relationship between social support and psychiatric symptomatology in medical students. J. nerv. ment. Dis. 174, 229, 1986. 48. Parker G., Tupling H. and Brown L. B. A parental bonding instrument. Br. J. med. Psychol. 52, I-IO, 1979. of depression. In 49. Mendelson M. Psychodynamics Handbook of Afictive Disorders (Edited by Paykel E. S.), pp. 162-174. Guilford, New York, 1982. 50. Vaillant G. E., Sabowale N. C. and McArthur C. Some psychological vulnerabilities of physicians. New Engl. J. Med. 287, 372, 1972.

51. Parker G. Parental characteristics in relation to depressive disorders. Br. J. Psychiat. 134, 138, 1979. 52. Parker G. Parental reports of depressives: an investination of several explanations. J. Affecf. __ Disorders 3, T31, 1981. 53. Seligman M. E. Helplessness. Freeman, San Francisco, Calif., 1975.

786

JUDITH

A. RICHMASand JOSEPHA. FLAHERTY

54. Rotter J. B. Generalized expectances for internal versus external control of reinforcement. Psychol. Monogr. 80, I, 1966. 55. Phares E. Locus of Control in Personality. General Learning Press, Morristown, N.J.. 1976. 56. Millon T. Millon Clinical Multiaxial Inoentor_vManual, 3rd edn. Minneapolis National Computer Systems, 1982. 57. Widiger T. A., Williams J. B., Spitzer R. L. and Frances A. The MCMI as a measure of DSM-III. J. Personal Assmt 49, 366, 1985. 58. Chodoff P. The depressive personality: a critical review. Archs gen. Psych&. 27, 666, 1972. _ 59. Hirschfeld R.. Klerman Cl. L.. Goueh H. G.. Barnett J.. Korchin S. J. and Clodoff P. A mea&ire of interpersonal dependency. J. Personal Assmt 41, 610, 1977. 60. Pearlin L. and Schooler C. The structure of coping. J. Hlth sot. Behac. 19, 2, 1978. 61. Wheaton B. Stress, personal coping resources and psychiatric symptoms: an investigation of interactive models. J. Hlth sot. Behac. 24, 208. 1983. 62. Flaherty J., Gaviria M. and Black E. The role of social support in the functioning of patients with unipolar depression. Am. J. Psychiat. 140, 473, 1983. 63. Flaherty J.. Gaviria M. and Pathak D. The measurement of social support: the social support network inventory. Comprehens. Psychiat. 24, 521. 1983. 64. Vitaliano P., Russo J., Car; J. E. and Heeriwagen J. H.

Medical school pressures and their relationship to anxiety. J. new. ment. Dis. 172, 730. 1987. 65. Weissman M. M., Sholomakas D., Pottenger M., Prusoff 8. and Loke 8. Assessing depressive symptoms in five psychiatric populations: a validation study. Am. J. Epidem. 106, 203. 1977. 66. Boyd J. H., Weissman M. M., Thompson

D. W. and Myers J. K. Screening for depression in a community sample. Archs gen. Psychiat. 39, 1195. 1982. 67. Breslau N. Depressive symptoms, maior depression, and generalized anxiety: a-comparison self-reportson CES-D and results from diagnostic interviews. Psvchiut.

of

Res. 15, 219. 1985. 68. McNair D. M., Lorr M. and Droppleman L. Profile of Mood States Educational and Industrial Testing Service,

San Diego, 1981. 69. Cahalan D., Cisin I. H. and Crossley H. M. American Drinking Practices. Rutgers Center for Alcohol Studies, New Jersey, 1969. 70. Apao W. K. and Damen A. M. Locus of control and the quantity-frequency index of alcohol use. J. Stud. Alcohol 43, 233. 1982. 71. Glynn R. J. et al. Social contexts and motives for drinking in men. J. Stud. Alcohol 44, 1011, 1983.

72. Spiegel D. A., Smolen R. C. and Hopfensperges K. A. Interpersonal stress in medical education: correlates for men and women students. J. Am. Med. Women’s Ass. 42, 19, 1987.

APPENDIX I. External

Locus of Control Items

(Items rated ‘E’ are scored one point) I more A. I. 2. B. I. 2. c. I. 2. D. I. 2. E. I. 2. F. G.

1. 2.

I. 2. H. I. 2. I. I. 2. J. I. 2.

strongly believe that: (Circle one for each pair) Many of the unhappy things in people’s lives are partly due to bad luck. People’s misfortunes result from the mistakes they make. One of the major reasons why we have wars is because people don’t take enough interest in politics. There will always be wars, no matter how hard people try to prevent them. The idea that teachers are unfair to students is nonsense. Most students don’t realize the extent to which their grades are influenced by accidental happenings. No matter how hard you try some people just don’t like you. People who can’t get others to like them don’t understand how to get along with others. I have often found that what is going to happen will happen. Trusting to fate has never turned out as well for me as making a decision to take a definite course of action. When I make plans, I am almost certain that I can make them work. It is not always wise to plan too far ahead because many things turn out to be a matter of good or bad fortune anyhow. It is hard to know whether or not a person really likes you. How many friends you have depends upon how nice a person you are. In the long run the bad things that happen to us are balanced by the good ones. Most misfortunes are the result of lack of ability, ignorance, laziness, or all three. With enough effort we can wipe out political corruption. It is difficult for people to have much control over the things politicians do in office. Sometimes I can’t understand how teachers arrive at the grades they give. There is a direct connection between how hard you study and the grades you get. II. Emotional

Reliance on Another

(Rated on a four point scale from ‘very characteristic I. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Person Items

of me’ to ‘not characteristic

of me’)

Disapproval by someone I care about is very painful to me. The idea of losing a close friend is terrifying to me. I would be completely lost if I didn’t have someone special. I easily get discouraged when I don’t get what I need from others. I must have one person who is very special to me. I’m never happier than when people say I’ve done a good job. I need to have one person who puts me above all others. I have always had a terrible fear that I will lose the love and support of people I desperately need. I would feel helpless if deserted by someone I love. I think that most people don’t realize how easily they can hurt me.

(E) (E) (E) (El (E)

(E) (E) (E) (E) (El

Gender differences in distress

III. Self-Esteem

787

Items

(Rated on a four point scale from ‘strongly agree’ to ‘strongly disagree’) I.

1 feel that I have a number of good qualities.

2. 3. 4. 5.

I feel that I’m a person of worth, at least on an equal plane with others. I am able to do things as well as most other people. I take a postive attitude toward myself. On the whole, I am satisfied with myself.

IV. Social Support Network Inoentory-Shortened I. 2. 3.

Version Items

How often do you see or talk to this person? How comforable are you in discussing very intimate or personal things about yourself with this person? How helpful is this person to you in general?