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The Relationship between Dysmenorrhea and Selected Personality Variables
The Relationship between Dysmenorrhea and Selected Personality Variables MICHAEL HIRT, PH.D., RICHARD
KURTZ,
• Considerable disagreement exists as to the psychogenic and psychophysiologic aspects of dysmenorrhea. \Vhile some authors 2 •5 maintain that psychogenic factors are not an essential feature of dysmenorrhea, many have claimed there is a definite relationship between dysmenorrhea and specific modes of personality functioning. G,7 The psychological variables which have been suggested with the greatest frequency as being related to primary dysmenorrhea have been anxiety, neuroticism, and introversion. 7 Much of the difficulty in drawing inferences from the available literature is related to various methodological limitations. Among the more important of these are the following: 1. Assessment of dysmenorrhea by procedures inadequately described and/or subiective procedures which probably yield unreliable results. 2. Assessment of psychological characteristics by means of un standardized clinical interviews. The occasional reports which have used standardized psychological tests have relied exclusively upon the Maudsley Personality Inventory, which has been criticized on the grounds that, with patient or neurotic groups, no agreement between self-ratings and the iudgments of others could be demonstrated. 3 3. The use of preselected subiects, such as those attending gynecological clinics and/or subjects in psychotherapy. The purpose of this study is to explore the relationship between primary dysmenorrhea and the personality variables of anxiety, neu-
PH.D., and \Y. DON>\LD Ross, M.D.
roticism, and introversion, while controlling for some of the mentioned methodological problems. :METHOD
The subjects used in this study wert' the freshman and sophomore student nurse classes at a large metropolitan hospital. Reasons other than their availability suggested self'ction of this sample. The reported incidence of dvsmenorrhea for this age group is high. These subjects were relatively homogf'nf'ous with respect to age and socio-economic backgrounds, and possibly even in those personality or attitudinal factors which motivated them to enter nurse's training. This seemed a relevant consideration in view of the probable differences in attitude and response to menstruation by women from different socioeconomic and' educational backgrounds. A substantial amount of medical information was available for these subjects. !\ot only had tlwy all received a relatively thorough and comparable plwsical examination which scre('ned subjects with gross physical and/or psychological disea~es, but their student lwalth rpcords were examined by the Student Health PhysicianO to eliminate 'subjects who appeared to have gynecological diseases which would confound the results from the pr('sent study. Subject participation in the study was voluntary and no subject attrition occurred because of unwillingness to participate. The data was collected for each class on a group basis, resulting in a total sample of 105 subjects. Each subject was administered the "SemiThis investigation was supported in part by USPHS objective Criteria for Teenage DysmenorGrants 5Tl-~1H-8018 and 5-S01-FR-5408-5. rhea'" and the 16 PF.l The dysmenorrhea Dr. Hirt is Associate Professor, Department of Psymeasure is reproduced in Figure 1. It is the chology, Kent State University, Kent, Ohio. Drs. Kurtz and Ross are in the Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, Ohio. Dr. Kurtz is Instructor of Psychology and Dr. Ross is Professor of Psychiatry. 350
OWe are grateful to Bonnie L. ~IcNeely, her assistance and encouragement.
~I.D.
for
Volume VIII
DYSMENORRHEA AND PERSONALITY VARIABLES-HIRT, ET AL.
only objective assessment procedure of dysmenorrhea reported in the literature. It appears to have both face validity and some degree of predictive validity. The symptoms to which the scale addresses itself are those reported as appearing most frequently in clinical practice. The scale was validated on the basis of agreement between scale scores and "blind" gynecological examination. The 16 PF seemed particularly appropriate for this study because it contains welldocumented factor score combinations for estimating anxiety, neuroticism, and introversion-extraversion. It will be recalled that these are the personality characteristics which have been most frequently associated with primary dysmenorrhea. The data analysis consisted of correlating the dysmenorrhea scores with these three factors from the 16 PF. In each of these correlations, the individual 16 PF scales included in each factor were weighted with the beta weights reported by Cattell (1, pp. 46-47).
Direction.: For!!£h .,..pta. belw, ct\eck the .everity which be.t fit. you. Include .ppt~ both before Itld durina _n.truatloa.
....
Mild
5e.. I'•
Pdn
&ckache
Headache
VlJalitlng
lncre••ed lrdt.biltty
Abdoainal Svelltn, Drawing in Leg. Other SyaptOlU
None
Weighting
MUd
Hoderate
14
Pdn and CrupI
21
All other S)'1Iptoma
Cl.uific.tion: No dy.menorrbe.
- Score under 10 point.
Mild
- 10 through 19
Hoderate
Severe
..
- 20 throuah 29 ~
30 and up
RESULTS
Figure 1. Semiobjective Criteria of Teen-age Dysmenorrhea.
The incidence and severity of dysmenorrhea for this sample included 24 subjects with no dysmenorrhea, 25 subjects with mild symptoms, 14 subjects with moderate symptoms, and 42 subjects with severe symptoms. The incidence of some degree of dysmenorrhea was, for this sample, slightly higher than reported for a sample of 1200 girls. ' Seventyseven per cent of the present sample reported some degree of dysmenorrhea, compared to the 68 per cent previously reported. In general, however, it appears that the present sample is fairly typical of the population with respect to the incidence of primary dysmenorrhea. The correlations between the dysmenorrhea measure and the personality factors were .205 ( p < .05) with anxiety, .228 (p < .05) with neuroticism, and -.096 with introversion-extraversion. Although two of these correlations are significantly different from zero, they obviously account for very little of the variance. These results are surprisingly non-supportive of much of the existing literature. It was therefore decided to re-examine the data, as a means of developing new hypotheses and to
attempt to determine possible explanations for the obtained results. As a first step, the dysmenorrhea scale was rescored. The scale uses an arbitrary scoring system which weights the presence and severity of "pain" and "cramps" much more heavily than the other symptoms. Subjects' dysmenorrhea scores were recomputed with equal weighting for all symptoms and then correlated with their anxiety, neuroticism, and introversion-extraversion scores. This yielded correlations of .279 (p < .01), .297 (p < .01), and -.074, respectively. Although each of these correlations is larger than obtained with the original scoring system, their magnitude is still quite low. The second analysis consisted of correlating the three factors from the 16 PF with the subjects' scores on the symptoms of "pain" and "cramps" alone. The rationale for this procedure was the importance ascribed in the literature to these two symptoms and the fact that many of the subjects did not acknowledge having any of the other symptoms. This suggested the possibility that the other symptoms were not contributing differentially toward the dysmenorrhea score or were perhaps serving as suppressor variables. The correlations ob-
November-December, 1967
351
PSYCHOSOMATICS
tained between these two symptoms and anxiety, neuroticism, and introversion-extraversion were .52 (p < .01), .18, and -.12, respectively. The considerably larger correlation obtained with anxiety supports the possibility that some of the other symptoms were acting as suppressor variables. It also raises the possibility that the dysmenorrhea measure had a considerably constricted range, which contributed to the small correlations obtained.
of validation research. The results obtained in the present study when this scale was used with a different scoring system and when selected items only were used suggests some of the directions in which this scale could be improved. For example, the consistent increase in the magnitude of the obtained correlations between anxiety, neuroticism, and introversion-extraversion with the dysmenorrhea scale when the latter was scored without differential weighting of the scale items suggests DISCUSSION that the present scoring needs further evaluaThis study sought to demonstrate a rela- tion. Even more critical and promising was tionship between primary dysmenorrhea and the finding that the correlation between anxpsychological variables which have frequently iety and the symptoms of "pain" and "cramps" been used to describe women with dysmenor- alone increased considerably over the correlarhea. The data was collected under conditions tion obtained with the total dysmenorrhea intended to reduce some of the methodolog- scale. This finding has at least two implicaical limitations inherent in many of the re- tions. It suggests the possibility that some of ported studies. The results obtained suggest the other items in the dysmenorrhea scale are related to anxiety in a curvilinear manner and that the relationship between primary dysmenorrhea and anxiety, neuroticism, and in- are acting as suppressor variables in the correlation when total scores are used. Perhaps troversion~extraversion is relatively negligible. more promising for future research, however, Although two of these correlations reached is the possibility that women with dysmenorstatistical significance, their magnitude was rhea may have a lower threshold of pain so small as to preclude any major psychologtolerance and are generally more aware of ical significance. and responsive to their bodies and bodily Considering the implications of these findfunctions. Considering anxiety as a more genings, three possible alternatives suggest themeral behavioral disposition than neuroticism, selves: these results might suggest that women with 1. The 16 PF is an inadequate measure of dysmenorrhea are not neurotic in the usual the personality characteristics which sense of the concept, but have considerable are of primary relevance to women with intolerance for the pain associated with their dysmenorrhea. menses. It may well be that some of the 2. The scale used to assess dysmenorrhea previous studies, which reported patients with is inadequate and/or invalid. dysmenorrhea as being neurotic, were study3. There is indeed no relationship between ing subjects who indeed incorporated the dysmenorrhea and personality charac- symptom pattern of dysmenorrhea into their teristics. general neurotic symptom complex. It seems Considering the first alternative, the 16 PF probable that some women do not incorporate appears to be a carefully constructed test with dysmenorrhea in this fashion, but either rea considerable body of validation research to spond to these symptoms merely with insupport it. The factors which it measures, creased sensitivity to pain or are "normal," in particularly the second-order factors, have re- the sense of being neither responsive nor appeatedly been suggested as characteristics of preciably incapacitated by their dysmenorrhea women with dysmenorrhea. It would appear symptoms. The sample used in the present study is unlikely that different results would have been probably less neurotic than a random sample obtained with a different test. The matter of the validity of the dysmenor- might be. Not only was the present sample a rhea measure is both more difficult to evaluate selected one in terms of admission and retenand more subject to criticism. Although this tion in the nurses' training program, but the is the only objective assessment technique general attitude of the nursing staff mitigated available, it is not supported by a large body against incorporation of dysmenorrhea symp352
Volume VIII
DYSMENORRHEA AND PERSONALITY VARIABLES-HIRT, ET AL.
toms into a broader neurotic symptom complex. One aspect of such an attitude for example, is the standing rule that no student nurse is excused from either classes or ward assignments because of dysmenorrhea or comparable menstrual difficulties. Subject to the limitations of measurement which have been discussed, the results of this study indicate there is only a negligible relationship between dysmenorrhea and anxiety, neuroticism, and introversion-extraversion. There is however, a considerable relationship between "pain" and "cramps" and anxiety. REFERENCES
1. Cattell, R. B. and Eber, H. W.: Handbook for the Sixteen Personality FlU"tor Questionnaire. Illinois: The Institute for Personality and Ability Testing, 1957.
2. Coppen, A. and Kessel, N.: Menstruation and Personality. Brit.]. Psychiat., 109:711-721, 1963. 3. Francks, C. M.: Effects of Alcohol as Related to Personality. New Jersey: New Jersey Neuropsychiatric Institute, Psychiatric Service and Research Center, 1961. 4. Golub, L. J., et 01.: Semiobjective Criteria of Teen-age Dysmenorrhea. Obstet. and Gynecol., 14:179-183, 1957. 5. Jones, G. S.: Treatment of Dysmenorrhea. Obstet. Gyn. Surg., 21 :301, 1966. 6. Rees, L.: The Premenstrual Tension Syndrome and its Treatment. Brit. Med. J., 1:1014-1016, 1953. 7. Wittkower, E. and Wilson, T. T. M.: Dysmenorrhea and sterility: Personality Studies. Brit. Med. J., 2:586-590, 1940.
Department of Psychology Kent State University Kent, Ohio
Psychoanalysis is the third of impossible professions in which one can be sure of unsatisfying results.... The other two, much older established, are the bringing up of children and the government of nations. -SIGMUND FREUD, M.D., "Analysis Terminable and Interminable." Inter J. psychoanal. 18:373-405, 1937.
November-December, 1967
353
KURTZ,
• Considerable disagreement exists as to the psychogenic and psychophysiologic aspects of dysmenorrhea. \Vhile some authors 2 •5 maintain that psychogenic factors are not an essential feature of dysmenorrhea, many have claimed there is a definite relationship between dysmenorrhea and specific modes of personality functioning. G,7 The psychological variables which have been suggested with the greatest frequency as being related to primary dysmenorrhea have been anxiety, neuroticism, and introversion. 7 Much of the difficulty in drawing inferences from the available literature is related to various methodological limitations. Among the more important of these are the following: 1. Assessment of dysmenorrhea by procedures inadequately described and/or subiective procedures which probably yield unreliable results. 2. Assessment of psychological characteristics by means of un standardized clinical interviews. The occasional reports which have used standardized psychological tests have relied exclusively upon the Maudsley Personality Inventory, which has been criticized on the grounds that, with patient or neurotic groups, no agreement between self-ratings and the iudgments of others could be demonstrated. 3 3. The use of preselected subiects, such as those attending gynecological clinics and/or subjects in psychotherapy. The purpose of this study is to explore the relationship between primary dysmenorrhea and the personality variables of anxiety, neu-
PH.D., and \Y. DON>\LD Ross, M.D.
roticism, and introversion, while controlling for some of the mentioned methodological problems. :METHOD
The subjects used in this study wert' the freshman and sophomore student nurse classes at a large metropolitan hospital. Reasons other than their availability suggested self'ction of this sample. The reported incidence of dvsmenorrhea for this age group is high. These subjects were relatively homogf'nf'ous with respect to age and socio-economic backgrounds, and possibly even in those personality or attitudinal factors which motivated them to enter nurse's training. This seemed a relevant consideration in view of the probable differences in attitude and response to menstruation by women from different socioeconomic and' educational backgrounds. A substantial amount of medical information was available for these subjects. !\ot only had tlwy all received a relatively thorough and comparable plwsical examination which scre('ned subjects with gross physical and/or psychological disea~es, but their student lwalth rpcords were examined by the Student Health PhysicianO to eliminate 'subjects who appeared to have gynecological diseases which would confound the results from the pr('sent study. Subject participation in the study was voluntary and no subject attrition occurred because of unwillingness to participate. The data was collected for each class on a group basis, resulting in a total sample of 105 subjects. Each subject was administered the "SemiThis investigation was supported in part by USPHS objective Criteria for Teenage DysmenorGrants 5Tl-~1H-8018 and 5-S01-FR-5408-5. rhea'" and the 16 PF.l The dysmenorrhea Dr. Hirt is Associate Professor, Department of Psymeasure is reproduced in Figure 1. It is the chology, Kent State University, Kent, Ohio. Drs. Kurtz and Ross are in the Department of Psychiatry, University of Cincinnati College of Medicine, Cincinnati, Ohio. Dr. Kurtz is Instructor of Psychology and Dr. Ross is Professor of Psychiatry. 350
OWe are grateful to Bonnie L. ~IcNeely, her assistance and encouragement.
~I.D.
for
Volume VIII
DYSMENORRHEA AND PERSONALITY VARIABLES-HIRT, ET AL.
only objective assessment procedure of dysmenorrhea reported in the literature. It appears to have both face validity and some degree of predictive validity. The symptoms to which the scale addresses itself are those reported as appearing most frequently in clinical practice. The scale was validated on the basis of agreement between scale scores and "blind" gynecological examination. The 16 PF seemed particularly appropriate for this study because it contains welldocumented factor score combinations for estimating anxiety, neuroticism, and introversion-extraversion. It will be recalled that these are the personality characteristics which have been most frequently associated with primary dysmenorrhea. The data analysis consisted of correlating the dysmenorrhea scores with these three factors from the 16 PF. In each of these correlations, the individual 16 PF scales included in each factor were weighted with the beta weights reported by Cattell (1, pp. 46-47).
Direction.: For!!£h .,..pta. belw, ct\eck the .everity which be.t fit. you. Include .ppt~ both before Itld durina _n.truatloa.
....
Mild
5e.. I'•
Pdn
&ckache
Headache
VlJalitlng
lncre••ed lrdt.biltty
Abdoainal Svelltn, Drawing in Leg. Other SyaptOlU
None
Weighting
MUd
Hoderate
14
Pdn and CrupI
21
All other S)'1Iptoma
Cl.uific.tion: No dy.menorrbe.
- Score under 10 point.
Mild
- 10 through 19
Hoderate
Severe
..
- 20 throuah 29 ~
30 and up
RESULTS
Figure 1. Semiobjective Criteria of Teen-age Dysmenorrhea.
The incidence and severity of dysmenorrhea for this sample included 24 subjects with no dysmenorrhea, 25 subjects with mild symptoms, 14 subjects with moderate symptoms, and 42 subjects with severe symptoms. The incidence of some degree of dysmenorrhea was, for this sample, slightly higher than reported for a sample of 1200 girls. ' Seventyseven per cent of the present sample reported some degree of dysmenorrhea, compared to the 68 per cent previously reported. In general, however, it appears that the present sample is fairly typical of the population with respect to the incidence of primary dysmenorrhea. The correlations between the dysmenorrhea measure and the personality factors were .205 ( p < .05) with anxiety, .228 (p < .05) with neuroticism, and -.096 with introversion-extraversion. Although two of these correlations are significantly different from zero, they obviously account for very little of the variance. These results are surprisingly non-supportive of much of the existing literature. It was therefore decided to re-examine the data, as a means of developing new hypotheses and to
attempt to determine possible explanations for the obtained results. As a first step, the dysmenorrhea scale was rescored. The scale uses an arbitrary scoring system which weights the presence and severity of "pain" and "cramps" much more heavily than the other symptoms. Subjects' dysmenorrhea scores were recomputed with equal weighting for all symptoms and then correlated with their anxiety, neuroticism, and introversion-extraversion scores. This yielded correlations of .279 (p < .01), .297 (p < .01), and -.074, respectively. Although each of these correlations is larger than obtained with the original scoring system, their magnitude is still quite low. The second analysis consisted of correlating the three factors from the 16 PF with the subjects' scores on the symptoms of "pain" and "cramps" alone. The rationale for this procedure was the importance ascribed in the literature to these two symptoms and the fact that many of the subjects did not acknowledge having any of the other symptoms. This suggested the possibility that the other symptoms were not contributing differentially toward the dysmenorrhea score or were perhaps serving as suppressor variables. The correlations ob-
November-December, 1967
351
PSYCHOSOMATICS
tained between these two symptoms and anxiety, neuroticism, and introversion-extraversion were .52 (p < .01), .18, and -.12, respectively. The considerably larger correlation obtained with anxiety supports the possibility that some of the other symptoms were acting as suppressor variables. It also raises the possibility that the dysmenorrhea measure had a considerably constricted range, which contributed to the small correlations obtained.
of validation research. The results obtained in the present study when this scale was used with a different scoring system and when selected items only were used suggests some of the directions in which this scale could be improved. For example, the consistent increase in the magnitude of the obtained correlations between anxiety, neuroticism, and introversion-extraversion with the dysmenorrhea scale when the latter was scored without differential weighting of the scale items suggests DISCUSSION that the present scoring needs further evaluaThis study sought to demonstrate a rela- tion. Even more critical and promising was tionship between primary dysmenorrhea and the finding that the correlation between anxpsychological variables which have frequently iety and the symptoms of "pain" and "cramps" been used to describe women with dysmenor- alone increased considerably over the correlarhea. The data was collected under conditions tion obtained with the total dysmenorrhea intended to reduce some of the methodolog- scale. This finding has at least two implicaical limitations inherent in many of the re- tions. It suggests the possibility that some of ported studies. The results obtained suggest the other items in the dysmenorrhea scale are related to anxiety in a curvilinear manner and that the relationship between primary dysmenorrhea and anxiety, neuroticism, and in- are acting as suppressor variables in the correlation when total scores are used. Perhaps troversion~extraversion is relatively negligible. more promising for future research, however, Although two of these correlations reached is the possibility that women with dysmenorstatistical significance, their magnitude was rhea may have a lower threshold of pain so small as to preclude any major psychologtolerance and are generally more aware of ical significance. and responsive to their bodies and bodily Considering the implications of these findfunctions. Considering anxiety as a more genings, three possible alternatives suggest themeral behavioral disposition than neuroticism, selves: these results might suggest that women with 1. The 16 PF is an inadequate measure of dysmenorrhea are not neurotic in the usual the personality characteristics which sense of the concept, but have considerable are of primary relevance to women with intolerance for the pain associated with their dysmenorrhea. menses. It may well be that some of the 2. The scale used to assess dysmenorrhea previous studies, which reported patients with is inadequate and/or invalid. dysmenorrhea as being neurotic, were study3. There is indeed no relationship between ing subjects who indeed incorporated the dysmenorrhea and personality charac- symptom pattern of dysmenorrhea into their teristics. general neurotic symptom complex. It seems Considering the first alternative, the 16 PF probable that some women do not incorporate appears to be a carefully constructed test with dysmenorrhea in this fashion, but either rea considerable body of validation research to spond to these symptoms merely with insupport it. The factors which it measures, creased sensitivity to pain or are "normal," in particularly the second-order factors, have re- the sense of being neither responsive nor appeatedly been suggested as characteristics of preciably incapacitated by their dysmenorrhea women with dysmenorrhea. It would appear symptoms. The sample used in the present study is unlikely that different results would have been probably less neurotic than a random sample obtained with a different test. The matter of the validity of the dysmenor- might be. Not only was the present sample a rhea measure is both more difficult to evaluate selected one in terms of admission and retenand more subject to criticism. Although this tion in the nurses' training program, but the is the only objective assessment technique general attitude of the nursing staff mitigated available, it is not supported by a large body against incorporation of dysmenorrhea symp352
Volume VIII
DYSMENORRHEA AND PERSONALITY VARIABLES-HIRT, ET AL.
toms into a broader neurotic symptom complex. One aspect of such an attitude for example, is the standing rule that no student nurse is excused from either classes or ward assignments because of dysmenorrhea or comparable menstrual difficulties. Subject to the limitations of measurement which have been discussed, the results of this study indicate there is only a negligible relationship between dysmenorrhea and anxiety, neuroticism, and introversion-extraversion. There is however, a considerable relationship between "pain" and "cramps" and anxiety. REFERENCES
1. Cattell, R. B. and Eber, H. W.: Handbook for the Sixteen Personality FlU"tor Questionnaire. Illinois: The Institute for Personality and Ability Testing, 1957.
2. Coppen, A. and Kessel, N.: Menstruation and Personality. Brit.]. Psychiat., 109:711-721, 1963. 3. Francks, C. M.: Effects of Alcohol as Related to Personality. New Jersey: New Jersey Neuropsychiatric Institute, Psychiatric Service and Research Center, 1961. 4. Golub, L. J., et 01.: Semiobjective Criteria of Teen-age Dysmenorrhea. Obstet. and Gynecol., 14:179-183, 1957. 5. Jones, G. S.: Treatment of Dysmenorrhea. Obstet. Gyn. Surg., 21 :301, 1966. 6. Rees, L.: The Premenstrual Tension Syndrome and its Treatment. Brit. Med. J., 1:1014-1016, 1953. 7. Wittkower, E. and Wilson, T. T. M.: Dysmenorrhea and sterility: Personality Studies. Brit. Med. J., 2:586-590, 1940.
Department of Psychology Kent State University Kent, Ohio
Psychoanalysis is the third of impossible professions in which one can be sure of unsatisfying results.... The other two, much older established, are the bringing up of children and the government of nations. -SIGMUND FREUD, M.D., "Analysis Terminable and Interminable." Inter J. psychoanal. 18:373-405, 1937.
November-December, 1967
353