THESIS .- 1 ( ‘ Llfii’iAflY r Miehigan state 1 0.3-x erslty ‘ - ‘ .Mfl!‘ r-w This is to certify that the thesis entitled Behavioral and Health Factors Which Differentiate Among Women with Two Types of Dysmenorrhea and Women with no Dysmenorrhea presented by Mary Kathleen Roberson has been accepted towards fulfillment of the requirements for M.A. Psychology degree in / ‘ Major professor Elaine Donelson Date May 24, 1984 0-7639 MSUis an Affirmative Action/Equal Opportunity Institution MSU LIBRARIES .—::—_ RETURNING MATERIALS: Place in book drop to remove this checkout from your record. FINES will be charged if book is returned after the date stamped below. BEHAVIORAL AND HEALTH FACTORS WHICH DIFFERENTIATE AMONG WOMEN WITH TWO TYPES OF DYSMENORRHEA AND WOMEN WITH NO DYSMENORRHEA by Mary Kathleen Roberson A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF ARTS Department of Psychology 1984 ABSTRACT BEHAVIORAL AND HEALTH FACTORS WHICH DIFFERENTIATE AMONG WOMEN WITH TWO TYPES OF DYSMENORRHEA AND WOMEN WITH NO DYSMENORRHEA BY Mary Kathleen Roberson This thesis was designed to study health, physiological, and behavioral components of the life experiences of women who suffer from primary dysmenorrhea. Subjects (n=ll3, ages 18 through 25) were recruited from undergraduate classes. Measures used were the Jenkins Activity Survey (JAS), Habits of Nervous Tension (HNT), and Autonomic Nervous System Questionnaire (ANS). Additional questionnaires were constructed for dysmenorrhea classification, a health scale, an experience of anger scale, family medical history, and demographic data. The following variables (in descending order) significantly predicted dysmenorrhea classification in a stepwise discriminant function analysis: family history, parasympathetic nervous system related diseases; JAS, college Mary Kathleen Roberson involvement; ANS, adrenergic responder to anxiety; family history, sympathetic nervous system related diseases; experience of anger scale: HNT, dependency; health scale; HNT,anger; ANS, adrenergic responder to anger; attitude toward expression of anger. These results, as well as gender related measurement issues highlighted by this study, were discussed. tO women ACKNOWLEDGMENTS I conceived of this project years ago, and it seems sometimes as if I am almost a different person upon its completion. It was a journey of increasing my understanding and love for women which in turn led to my feminist awakening. Many groups of women contributed to this process: the Women's Research Group, the Women's Advisory Committee to the Provost, Women's Studies Program, Feminist Remedial Volleyball, and especially the women's community. I would like to acknowledge Elaine Donelson who allowed me the autonomy I needed, while challenging me in a way that enabled me to stretch my concept of academic work in a more positive direction. Also, I am grateful to John McKinney for supporting and guiding me in my relationship with the powers that be. And special thanks go to Deb Bybee, who both improved my understanding of measurement and also totally revised my notion of research, all while helping me to discover parts of my identity that had long been covered over. Another woman I must mention is Deborah Berry, my friend and colleague, who provided long term support in my growth and for my battles. Last, I would have never made it without the help of my family. They have continually provided me with a sense of continuity, security and plasticity that allows me to take the creative risks in my ii career that make it seem like a worthwhile endeavor. I am truly lucky to have a family with whom I can communicate clearly and honestly. I love them dearly! iii TABLE OF CONTENTS IntrOdUCtion .0...0.00.0.00....00.00.0... Statement of the Problem ........... Overview ........................... Basic Assumptions .................. Delimitations and Objectives ....... Limitations ........................ Review of the Literature ................ Medical Literature ................. Individual Psychological Research . Social Psychological Research ..... Health Psychology ................. Summary and Hypotheses ............ MethOd 0.0.0.0.... 0.0.0.000...0........ Subjects .......................... Measures .......................... Operationalized Hypotheses ........ Procedure ......................... Analyses .......................... Measurement 0000.00.00.00000000000000... Classification of Dysmenorrhea .... Health Scale ...................... Anger Scale ....................... Autonomic Nervous System .......... Questionnaire Habits of Nervous Tension ......... Jenkins Activity Survey ........... Results 000.000.00.000... 0.00.00.00.00. Demographic Data .0................ Hypothesis Testing ................ iv mowwr—a H 8 15 23 29 30 34 34 35 39 39 41 42 44 45 52 60 66 72 74 TABLE or CONTENTS (Continued) DiSCUSSion 00.0.0.0.00......000000...000 90 overView Of ReSUIts 0.0.00.0.00000. 91 Measurement Issues ................ 93 The Three Group Classification of Subjects ...................... 98 Conclusions ...................... 104 LiSt Of References 00.00....00000000000 107 Appendix Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table Table \I OUT “>00 N H mm 11 12 13 14 15 16 17 18 19 20 21 22 LIST OF TABLES Questions Relevant to Classification ..... 43 of Primary Dysmenorrhea Health Items and Response Percent ........ 46 Frequencies Item Statistics for Health Scale ......... 47 Anger Items and Response Percent ......... 48 Frequencies Item Statistics for the Anger Scale ...... 50 Comparison Descriptive Statistics on ..... 53 Autonomic Nervous System Questionnaire Most Frequently Endorsed Items on ........ 55 Autonomic Nervous System Questionnaire Factor Loading Matrix, Autonomic ...... 56&57 Nervous System Questionnaire Inter Scale Correlations for Autonomic ... 59 Nervous System Questionnaire Item Frequencies for the Habits of ....... 61 Nervous Tension Questionnaire 8-Factor Solution, Habits of Nervous ..... 63 Tension (Thomas & Ross,1963) 9-Factor Solution, Habits of Nervous ..... 64 Tension (Current Study) Factor Loading Matrix, Habits of Nervous . 65 Tension Jenkins Activity Survey, Student Form, ... 68 Glass (1977) Jenkins Activity Survey, Student Form, ... 70 Factor Loading Matrix (Current Study) Jenkins Activity Survey, Factor Scale .... 71 Item Statistics Analysis of Demographic Variables ........ 73 Analysis of Variance Summary for Three ... 77 Health Related Variables Chi Square Analysis for Smoking Variable . 78 Chi Square Analysis for Autonomic ........ 80 Nervous System Questionnaire Analysis of Variance Results for the ..... 81 Jenkins Activity Survey Analysis of Variance on the Habits of .... 83 Nervous Tension Questionnaire vi Table Table Table Table 23a 23b 24 LIST or TABLES (continued) Chi Square Analysis of Attitude Toward ... 84 Expression of Anger Analysis of Variance of Experience of .... 84 Anger Scale Discriminant Function Analysis ........... 88 Summary of Mean Values or Frequencies .... 89 of Variables in Discriminant Function vii Introduction Statement of the Problem The purpose of this study is to explore certain components of the life experiences of women who suffer from primary dysmenorrhea, a menstrual disorder characterized by pain during the first day or two of the menses. Historically, this condition has been placed by many physicians within the realm of psychoneurotic pain. Only in the last two decades have measurable physiological events been associated with primary dysmenorrhea. This research is not being undertaken in order once again to place the cause of primary dysmenorrhea on the psychological side of Cartesian mind-body split. "Concepts of single causes and of unilinear causal sequences--for example, from psyche to soma and vice versa--are simplistic and obsolete. The dynamic interaction of multiple factors occurring in varying constellations and time sequences, and modified by feedback effects, underlies all changes in health. To break down the complexity into testable hypotheses and validate them, to formulate integrative theories, and to develop effective preventative and therapeutic methods are the chief objectives of psychosomatic medicine today" (Lipowski, 1977, p. 234). Therefore, this study is a survey to explore hypotheses based on an interdisciplinary theoretical structure derived from research within the fields of medicine, psychology, and sociology. The ultimate purpose is to work toward the identification of: (l) life-style related behaviors and sociological phenomena that may be related to placing someone at higher risk to develop the physiological correlates and the experience of primary dysmenorrhea; (2) those factors associated with enhancing health and resistance to the disorder; (3) possible strategies that might help those who are suffering to cope more effectively with primary dysmenorrhea (Lipowski, 1977); and (4) strategies to reduce dependence upon pharmocological methods of balancing the physiology. Overview The major hypothesis of this study is that women who suffer from primary dysmenorrhea may respond to stress in such a way that involves an over response of the sympathetic nervous system. Very briefly, at the point in a woman's menstrual cycle when estrogen and progesterone are low, she may be at higher physiological risk for sympathetic over response when under stress. This is especially the case if she cannot discharge physiological arousal from anxiety provoking situations by expressing her autonomy, her needs, and her anger. These instrumental abilities are not as well socialized for women, and also society maintains powerful prohibitions against the direct expression of anger, especially for women. Therefore, women may be at greater risk to funnel these emotions into their physiology. Basic Assumptions Lipowski (1977) listed in his work two sets of core assumptions which form a framework to guide this research: (1) "man's (sic.) symbolic activity . . . influences organismic processes at all other levels of organizations down to the cellular level" and (2) there are “enduring psychological and physiological tendencies to react to specific stimuli with individually specific patterns of cognitive, emotional, behavioral, and physiological responses" (p. 236). Delimitations and Objectives This study is an inquiry into different aspects of women's experiences as they occur from the time of early adolescence (retrospectively) to young adulthood (currently). Recent research and theory indicates that people are best studied in their life environments, if possible. For example, Carol Gilligan's (1977, 1983) work on the moral development of women indicates that different and more valid results are obtained when using a moral dilemma that the women were actually experiencing rather than an abstract one constructed by the researcher. Although studying anyone in his or her context is optimal, it is especially important in studying females since their value systems and identities are very relationship oriented. Because of their socialization, women's identities or experience of self include to a greater extent the bonds of their relationships and the process aspect (as opposed to the end product) of completing tasks (e.g., Chodorow, 1978: Dinnerstein, 1976). This study is a limited attempt to identify some historical and self-reported physiological attributes, to identify patterns in descriptions of life events which may be indicative of socialization trends, and to describe individual life events which may be associated with either or both of those physical and sociological factors. The results of this study will be helpful in future research for purposes of identifying both at risk individuals and also what actual situations or contexts in which adolescent girls should be studied as they develop primary dysmenorrhea. Limitations The lack of direct physiological measures is one important limitation of this study. Primary dysmenorrhea is pain at the time of menses which has not been associated with an abnormality of anatomy or physiology. It has been estimated that approximately 10% of women diagnosed by a physician as having primary dysmenorrhea actually have secondary dysmenorrhea or pain which is caused by an anatomical abnormality or a clear disease process. There may be some diagnostic error in this study especially since it uses the women's self report of results of past gynecological exams. For a clear diagnosis, one must use very intrusive techniques which, for example, measure uterine contractions by the insertion of instruments into the uterine cavity at the onset of menses (Lundstrom, 1981). To diagnose endometriosis, the most common type of secondary dysmenorrhea, one must undergo a laparoscopy, a procedure usually performed under general anaethesia during which the physician inserts a small viewing device into the abdominal cavity. Review of the Literature As stated previously, this is a study which is interdisciplinary in its conception so that the subjects may be described phenomenologically or from numerous perspectives. Combining the physical, the psychological, and the sociological contexts constructs a fuller portrait of the individual and unites mind, body, and objects of experience. Therefore, this review will consist of a brief summary of four main branches of study related to this research: (1) Medicine: Normal menstrual cycle events, the etiology of primary dysmenorrhea, and the prostaglandins. (2) Individual Psychology: Biases and methodological problems in primary dysmenorrhea research and a summary of the findings. (3) Social Psychology: Both a review of findings that relate specifically to possible socialization or cultural factors in the development of primary dysmenorrhea and also a brief overview of the sex roles research and theory as it relates to the expression of anger by women in general in this culture. (4) Health Psychology: A summary of the interface of the overresponse of the sympathetic nervous system and its behavioral correlates. Medical Literature Pertinent Normal Menstrual Cycle Events In an average 28-day menstrual cycle there are 3 phases: (1) the menstrual phase (days 1-5); (2) the follicular phase (days 6-14): and the luteal phase (days 15-28). During these phases hormones are produced by the hypothalamus, the anterior pituitary and the ovaries, all of which in turn begin physiological changes in the reproductive system: production of an ovum, build-up of the endometrial lining, ovulation and (without fertilization) shedding of the endometrium. In the latter portion of the luteal phase, there is a rapid decrease in the production of the ovarian hormones, estradiol and progesterone. The fall of these hormone levels causes a breakdown of the endometrial tissues and the menstrual period begins (Lein, 1979). Definition of Primary Dysmenorrhea Dysmenorrhea is from the Greek word meaning difficult monthly flow (Ylikorkala & Dawood, 1978). A more colloquial expression is ”menstrual cramps,” which has been described as "a sharp gripping lower mid-abdominal pain which may radiate to the lower back or upper thigh" (Lamb, 1981). The adjective "primary" differentiates this type of dysmenorrhea from secondary dysmenorrhea, which is menstrual pain caused by a discernable abnormality in anatomy of the pelvic organs or a diagnosed disease process. Additionally, research indicates that primary dysmenorrhea occurs in normal ovulatory cycles as opposed to cycles in which ovulation does not occur (Wentz & Jones, 1976). In other words, primary dysmenorrhea occurs in women who have pelvic organs that appear to be normal in function and anatomy. The diagnosis of primary dysmenorrhea usually peaks in the teens and early twenties and begins to fall off as the chances for secondary organic difficulties rise in the thirties and forties. The pain is usually associated with the first day of the period and lasts up to 48 hours, i.e., 2 days out 28. Because the amount of pain or discomfort varies 10 greatly, Morrison (1981) recommends a further restriction in the definition of primary dysmenorrhea to limit it to women women who have self-medicated or have sought medications from a physician for the pain that they experience. Etiology of Primary Dysmenorrhea There is now substantial agreement within the medical field that the etiology of primary dysmenorrhea is related to a group of compounds called prostaglandins (PG) (e.g., Akerlund, 1979; Dawood, 1981; Pickles, Hall, Best & Smith, 1965; Wilqvist, 1979). Prostaglandins, in particular PGFZalpha' have been found in significantly higher amounts in the menstrual fluids of women who suffer from primary dysmenorrhea. PGF2alpha increases uterine contractility. On the other hand, PGEZ, although it seems to have a relaxing effect on the uterus, appears to increase neural sensitivity and thus perhaps to lower the threshold for contractility or pain. There is some evidence that indicates that the PGFZalpha/PGEZ ratio is important in establishing the contractility pattern of the uterus in non-pregnant women (Bygdeman, Bremme, Gillespie & Lundstrom, 1979). In women who have primary dysmenorrhea, the amplitude, frequency, and resting tonus of the uterine contractions and the 11 intrauterine pressure vare all higher than in controls (Lundstrom, 1981). At the end of a woman's normal menstrual cycle the progesterone level falls off, breakdown of the endometrial tissue occurs, and enzymes are released which initiates a biochemical reaction ending in the production of prostaglandins. Theoretically, an imbalanced ratio of PGFZalpha/PGE2 causes hypercontractility of the uterus, which in turn produces pain and decreased blood flow (ischemia) which is also often associated with pain (Akerlund, 1979). The linear medical model is one in which etiology or cause is so important that the possibility too often exists that the "cure” based on the theoretical cause often has side effects sometimes not apparent at the time the new drugs are approved for use. One extreme example of this is the widespread prescribing between 1943 and 1970 of diethylstilbestrol (DES), a synthetic nonsteroidal estrogen, to prevent miscarriage. Ninety percent of DES daughters have a condition of (benign) vaginal adenosis and DES daughters have a much higher incidence of adenocarcinoma (Sherman, Goldrath, Berlin, Vakariya, Banooni, Michaels, Goodman, and Brown, 1983). In addition, the fact that a certain drug is helpful in relieving symptoms of a disease state is sometimes cited as causal evidence. that the particular unbalanced physiological state is the primary cause of that disease. 12 Such assumptions are detrimental when they lead to abandonment of research aimed toward prevention. Instead when the process is not clear, researchers should strive to take a more global view of the associational links thus far identified by the research, despite the temptation to ascribe causality. They may then find further factors implicated in the disease process or further elaborate the body's physiological mechanisms so that nonpharmacological solutions may be sought. The literature on dysmenorrhea has numerous hints of such a factor related to the sympathetic nervous system. For instance, the uterus is innervated primarily by the sympathetic nervous system (Ash & Greenblatt, 1978). Some of these neurons are short adrenergic nerves which tend to degenerate during pregnancy and not to regenerate completely (deberg, 1979). Note that primary dysmenorrhea is less common in women who have had children than in those who have not (Morrison, 1981). Calcium antagonist drugs are helpful in certain cardiovascular diseases because of their effect on an over stimulated sympathetic nervous system. These drugs also relieve the pain of primary dysmenorrhea (Dawood, 1981). Jollie (1981), an anatomist, makes numerous statements which compare the similar functioning of uterine and cardiac muscle cells. For example, "In both the heart and uterus . . . efferent nerve impulses regulate the contraction of the 13 muscle instead of initiating it" (p. 5). He also stated that the contractility of the uterus is affected by changes in the autonomic nervous system (ANS). Researchers have asserted that women's ovarian hormones play a protective role with regard to the development of cardiovascular diseases until menopause (Vander, Sherman, & Luciano, 1980). At the time when women suffer from primary dysmenorrhea, these same ovarian hormones are at their lowest monthly level (Lein, 1979). This particular physiological state may place her at greater risk to experience sympathetic nervous system overarousal if she is under stress in her environment and/or has behavior patterns consonant with this physiological state and/or has a constitutional predisposition. Prostaglandins As stated earlier, abnormal prostaglandin production is clearly implicated in the occurrence of primary dysmenorrhea. However, prostaglandins are very enigmatic substances. They appear in the bloodstream, in joint fluids, and intracellularly in tissues all over the body. In a theoretical article, Yabrov (1980) defines the role of prostaglandins as being an intracellular hormone of sorts. 14 Prostaglandins would then be in charge of communication within the cell to provide for the adequate functioning of the cell. Indeed, research indicates that prostaglandins do provide specificity of function of different cells or organs when present in appropriate ratios (Lundstrom, 1981). In other words, normal ratios may lead to normal function. Yabrov (1980) also maintains that "two systems exist for the regulation of the adequate functioning of the cell: One enabling the cell to respond to the demand of the organism, and the other providing for the needs of the cell itself” (p. 337). There must be a relative balance because an extreme drift in either direction will lead either to a dysfunction of the organ, the organ system, or alternatively, to the death of the cell. Prostaglandins then may be a part of the process which maintains this balance for optimal functioning of the total person. In 1975 Wolfe reviewed numerous studies on the possible roles of prostaglandins in the nervous system. He concluded that ”stimulation of sympathetic or parasympathetic nerves is associated with the release of prostaglandins, principally PGE2 and PGFZalpha . . . . The prostaglandins are not released from preformed stores, rather, de novo biosynthesis is accelerated during the stimulation period" (p.31). In addition, there is considerable evidence that indicates that prostaglandins act as modulators of the ANS (Brody & 15 Kadowitz, 1974; Wolfe, 1975). These studies further indicate that ANS factors should be explored when studying primary dysmenorrhea. Individual Psychological Research "Dysmenorrhea is a disease of theories“ (Kroger, 1956). Psychosomatic reseach and theorizing on this subject through the mid-19705 have widely varied conclusions, most of which make bold statements regarding the supposed psychogenic aspects of primary dysmenorrhea. The early writers of the 19305 and 19405 based their comments primarily on clinical observations of women with primary dysmenorrhea. For example, ”Dysmenorrhea is generally of psychogenic origin. On the basis of several hundred cases it was shown that psychotherapy brings relief of menstrual difficulties (pain, migraine, nausea, vomiting, fainting, etc.)” (Nabor, 1931, p. 108). The conclusions of these authors influenced the hypotheses and designs of the research of the next generation. A small number of studies (Coppen & Kessel, 1963; Hirt, Kirtz, & Ross, 1967) found no significant correlation of dysmenorrhea with neuroticism. However, since studies with no significant results are usually not published, it is hard 16 to estimate the effect that bias against negative results has had on the publication of studies with findings in opposition to a psychoneurotic etiology of primary dysmenorrhea. Even those correlational studies which report positive findings and point out that directionality can be interpreted either way still make a statement which firmly links neuroticism and dysmenorrhea in the mind of the reader. Further, there is a general "sick" bias that runs through the menstrual research. Researchers tend to study only negative aspects and attitudes when in fact women also have positive attitudes toward menstruation (Brooks-Gunn, 1973). Following is a critique of the major historical lines of early research. In their literature review for a study which finds a significant negative association between acceptance of the feminine role and dysmenorrhea, Berry and McGuire (1972, p. 84) quote Menninger: ”The envy of the male cannot be repressed and serves to direct her hostility in two directions; she resents the more favored and envied males while secretly trying to emulate them, and at the same time she hates and would deny her own femaleness' (Menninger, 1939). Deutsch (1947) stated that the mother-daughter relationship is important in determining a girl's attitude toward menstruation and that there may be a tendency for the mother to pass the resentment and rejection of the feminine 17 role on to her daughter. Kroger and Freed (1956) found that a group of women with primary dysmenorrhea were four times as often emotionally maladjusted as children than the control group. They cite Wittkower and Wilson (1940) in their review: ”Many patients with dysmenorrhea had been either unusually aggressive and boisterous tomboys resentful of their feminine role or ailing, complaining children unwilling to give up their childish dependence on their parents and possessing strong needs or cravings for sympathy and protection." Kroger and Freed also describe these patients in their adult years: "Except during menstruation [they] present a facade of poise and maturity which conceals their underlying instability." Dunbar (1954) takes another approach to the cause of menstrual pain--the suggestibility of women. "The suggestive significance of the terms 'unwell' or 'sick' can hardly be overestimated" (Dunbar, 1954, p. 506). To substantiate her claim that dysmenorrhea is psychogenic, Dunbar cites Naber (1931) who concludes that in "several hundred cases it was shown that psychotherapy brings relief of menstrual difficulties (pain, migraine, nausea, vomiting, fainting, etc.)" (Dunbar, 1954, p. 507) She also cites Hunter and Rolf (1947) who state, "By suggestion, persuasion, introspection and fear some patients perceive subliminal impulses of which normally they would be unaware. Many 18 individuals, unfortunately, are born with a lowered 'pain threshold‘ and throughout their lives are considered by their friends as hypersensitive, delicate, and neurotic.” She also indicated that when hormone treatment affected dysmenorrhea it is only by suggestion, citing a number of articles (e.g., Novak, 1932; Randall & Odell, 1943) as evidence. The Novak reference is actually a theoretical article which posits that dysmenorrhea is a disorder of contractility of the uterus. Randall and Odell administered estrogen to dysmenorrheic women. Although they did not find significant treatment effects, some women did experience relief. In neither one of these references do the authors make a statement regarding the suggestibility of women from data. The research methods in these studies are quite questionable. There are no good operational definitions of primary dysmenorrhea, and many (as stated previously) are based on clinical observations. While this type of study can produce useful information, recent guidelines on non-sexist research conclude that researchers must clearly examine and state their biases before undertaking their studies so that the results may be interpreted accordingly (APA Division 35 Task Force, 1981). 19 Clearly, there is a strong flavor of misogynist bias in many of the above described publications. For instance, the studies which label as neurotic those women who reject the feminine role either as children or as adults are all too common. Gove's (1976) research strongly suggests that it is actually the traditional female role as defined in this society (increasingly since World War II) which contributes to the mental illness of women. With this information, one might then view these dysmenorrhea subjects somewhat differently. Women who rebel against conforming to society's narrow definition of what a female should be risk the disapproval of society but also behave in such a way that in the long run diminishes the risk of mental illness. There are two ways in which girls are said to reject their feminine roles: (1) the aggressive tomboy or (2) the complaining dependent. These are both labeled neurotic or maladjusted. This brings to mind the Broverman, Broverman, Clarkson, Rosenkrantz, and Vogel (1970) research. These researchers found that clinicians' judgments of mentally healthy women differed from judgments of mentally healthy men. Women were described as more submissive, less independent, less adventurous, less objective, more easily influenced, less aggressive, less competitive, more excitable in minor crises, more emotional, more conceited about their 20 appearance, and having their feelings more easily hurt. (These phrases also describe children.) However, when the clinicians were asked to characterize a healthy adult, the ratings did not differ from those that they choose to describe mentally healthy men. Therefore, healthy women are perceived as significantly less healthy than men. Furthermore, women who are not submissive, dependent, etc., are perceived as mentally unhealthy women. These biases described in the Broverman et. al (1972) study which placed women in a no-win double bind were prevalent in the early research and shaped subsequent research (e.g. Berry & McGuire, 1971; Kroger & Freed, 1956; Menninger, 1939; Wittkower & Wilson, 1940). It is no wonder that clinical studies and experimental studies using instruments designed with these underlying biases often found associated neurotic characteristics, especially considering the tendency of editors not to publish studies with nonsignficant results. Lennane and Lennane (1973) described the research and thought on dysmenorrhea as ”cloudy," as it is on a number of other disturbances affecting only women. "Although such scientific evidence as exists clearly implicates organic causes, acceptance of a psychogenic origin has led to an irrational and ineffective approach to [its] management" (p. 288). 21 The more recent researchers have been less willing to make causal statements, and therefore do not conclude that primary dysmenorrhea is psychoneurotic. However, the studies are still plagued by some methodological and conceptual problems. Psychological researchers often do not adequately define primary dysmenorrhea. For instance, many researchers still use the Menstrual Symptom Questionnaire (MSQ) which dichotomizes congestive and spasmodic dysmenorrhea (Chesney & Tasto, 1975). This differentiation was first proposed by Dalton (1964) and refers basically to premenstrual pain commencing up to three days prior to the onset of menstruation (congestive) and primary dysmenorrhea commencing on the first day of the menses ‘ (spasmodic). The physiological definitions of these types of dysmenorrhea have not been clarified thus far, leaving results from all studies which use the MSQ to define dysmenorrhea unclear. Further research by Cox (1977) found that the dimension was continuous rather than dichotomous. Yet another study (Webster, Martin, Uchalik, & Gannon, 1979) recommends that the labels be discontinued since their factor analysis revealed seven factors instead of two. 22 Additionally, Moos' Menstrual Distress Questionnaire (MDQ) (Moos & Leiderman, 41978) has been widely used to classify subjects. This questionnaire yields eight scale scores (e.g., pain, concentration, negative affect) which in turn permit the development of a profile for each woman. The pain scale has subcomponents of headache, cramps, and backache. The pain scale does not measure dysmenorrhea; rather, it is an ipsative measure of pain as it occurs in numerous areas of the body. Therefore, researchers who use this score cannot draw conclusions that relate specifically to dysmenorrhea (cramps) alone. Despite these limitations, behavioral medicine researchers have designed numerous treatment programs which provided relief for dysmenorrhea sufferers. The following studies had positive significant treatment effects: Reich (1972)--group systematic desensitization; Denmark, Kerenyi, and Murgatroyd (1976)--autogenic and temperature feedback training; Tubbs and Carnahan (l976)--biofeedback; Cox (1978)--individual systematic desensitization; Fleischauer (l977)"education, mechanics of breathing and conditioned neuromuscular relaxation (Lamaze); and Sedlacek and Heczey (1977)--biofeedback. A number of these studies associated anxiety with dysmenorrhea, as well. Heczey (1978) characterized the anxiety as trait anxiety (versus state 23 anxiety). It can be concluded from these studies that most dysmenorrheic women physiologically responded to behavioral treatment methods designed to relax them by increasing peripheral blood flow or decreasing muscle tensions. It seems reasonable to conclude that the physiology of these women were out of balance--geared up--and that calming the physiology was helpful. This is further evidence that the overaroused sympathetic nervous system may be involved in the process of primary dysmenorrhea. Social Psychological Research Although the behavioral medicine studies mentioned in the previous section did not usually address causality, they are still reductionistic in their design and conceptualization. The are based on a narrow definition of psychology. They do not begin to address the sociological and interpersonal context of these women's lives in order to understand the myriad and complex factors that enter into the formation of life style patterns associated with the physiological imbalance. Women who have primary dysmenorrhea are seen as responsible for their own pain, yet forced to be dependent upon either the medical or psychological community 24 for medication and/or treatment programs. In a chapter entitled, ”The Concept of Culture and the Psychosomatic Approach," Margaret Mead (1953) wrote, ”The culturally disoriented person is subject to new strains of loneliness and isolation which exacerbate the tensions within the personality, and [slhe is at the same time robbed of culturally usual means of reducing these tensions. The available materials on which to work out psychic conflict become one's own body and its immediate environment and one's own family, especially children" (p. 391). The purpose of this section is (l) to examine the sociological context of women as it is related to child rearing patterns in this culture which in turn are related to certain general adult behavioral patterns; and (2) to review relevant sociological research as it applies to primary dysmenorrhea. Since primary dysmenorrhea is a disorder affecting as many as 29-59% (Morrison, 1981) of women, "society is the patient" (Frank, 1936). Therefore, it may be helpful to explore anger, an emotion often linked to sympathetic nervous system functioning, as it relates to the socialization of women. When examining the range of behaviors most unavailable to women in this culture in terms both of deficits of their social learning histories and also of societal taboos, we find those behaviors which are clear expressions of anger and/or assertiveness which relate to 25 fulfillment of the individual woman's needs. There has been little research done which measures or explores anger because it is an experienced emotion. The behavioral trends have instead developed along a line of study using the concept of aggression. Maccoby and Jacklin's (1974) research found that indeed there is a sex difference, males behaving more aggressively than females. Research by Hyde and Schuck (1977) indicates that there are most likely small gender differences which are biologically-based, but that cultural forces interact to create a significant increase in this difference. Earilier work by Eron et. a} (1974) found that punishment of a child for aggressive behavior increases aggression if the child is not identified with the punisher (mother/son) while if the child is highly identified with the adult, aggression decreases with punishment (mother/daughter). This may be one of the ways socialization of children acts to exacerbate the gender gap relative to aggression. Current psychoanalytic and object relations theorists (e.g., Chodorow, 1974, 1976, 1978; Dinnerstein, 1976) describe the early development of girls and boys in relation to their mothers who are almost always the primary caretakers, fathers being predominantly absent from the home and nurturing activities. From infancy boys are socialized by caretakers to be more independent than girls are. They 26 develop their masculine identity in terms of becoming what mother is not. Since in their early childhood, abstract ability does not permit him to figure out how he then should behave, he learns by mother punishing him for inappropriate behaviors. He thus learns to deny his relatedness with mother, develops an identification with mother's idealized unconscious concept of masculinity, and begins to devalue that which is feminine or female. His identity is in terms of self and not in relationship to others. According to these object relations theorists, mothers with little girls, on the other hand, prolong the dependency due perhaps to the mother's identification with her daughter, redintegrating the bond with her own mother. Thus, the girl develops her sense of being female from direct identification with mother. For oedipalsaged girls who later appear heterosexual, the attraction transfers over to the father, but never completely. She maintains her primary relational attachment to the mother. Therefore, girls develop both a rich affective inner object life and also a feminine identity characterized as self in relation to others. Lerner (1981) summarizes other theorists' writings on the early mother-infant bond. The infant's first sense of self includes the mother as she provides for his or her needs. As the infant begins to differentiate, he or she experiences the mother as a separate omnipotent person whose 27 needs are not always in accord with his or her own, an experience which causes feelings of fear, impotence, and frustration. Bernardez (1978) suggests that men and women unconsciously collude in their relationships to maintain the woman in the role of the good, all-providing, selfless mother and to avoid reevoking the feelings associated with the frightening experiences of moments when mother did not provide. The expression of anger by a woman entails (l) achieving a sense of self-in-the-self, an identity for which women in general are not as well-socialized (Chodorow, 1978); (2) overcoming the unconscious myth that her anger will destroy the relationship (Bernardez, 1978); and last, (3) dealing with the probability of a negative response by the people to whom she is relating and of being labeled as castrating, neurotic, etc. Thus, many women's ability to express anger in a mature way may remain somewhat underdeveloped. Moving to research that relates specifically to primary dysmenorrhea, one of the most frequently cited sociological studies is by Paige (1973). She found that adherence to the Orthodox Jewish menstrual taboos and rituals was associated with increased menstrual distress. For Catholics, the traditional feminine woman who is not career-oriented and considers a woman's place to be in the home was most likely to experience cramps. She did not find a variable which 28 predicted for Protestants. Overall, however, no particular religious group had a higher incidence of menstrual difficulties. Sherif (1980) also emphasizes that women must be studied in their sociological contexts. In her study of the menstrual cycle relating numerous variables to experiences of men and women across a 35-day time span, she found in every case that the largest portion of the variance was accounted for by individual differences. This, in combination with Paige's study, indicates a need for more complex and larger studies which allow patterns of individual responses to varied sociological constructs to emerge. One study of interest was performed by Widholm and Kantero (1971) on 8,000 Finnish girls and their mothers. He found a significant correlation between mothers and daughters who had dysmenorrhea. One can intrepret such findings within the context of the nature-nurture controversy over genetics versus learning. But this research may also be indicative of the importance of the mother-daughter bond, as hypothesized by the object relations theorists.' 29 Health Psychology In 1968 Alexander proposed the theory of specificity which hypothesized that every emotional conflict has its own physiological syndrome. He drew a dichotomy between those who would respond to a stressful environmental event (a) by preparation for fight or flight response or (b) by withdrawal from activity. He believed that the latter type showed a regressive, help-seeking, dependent pattern and that this was associated physiologically with a response by the parasympathetic nervous system. Related diseases are ulcers, asthma, and ulcerative colitis. Alternatively, the person who responded with the fight or flight response would have conflicts that related to neurotic anxiety and repressed or inhibited rage. Examples of sympathetic diseases classically associated with these conflicts are rheumatoid arthritis (RA) and hypertension. The theory of specificity has had varied success when tested by research. It seems as though the conflicts themselves have never been unequivocally related to certain disease states, but there is some evidence that indicates that typically people physiologically respond to stress by activation of either the parasympathetic or the .30 sympathetic nervous system (Wenger & Cullin, 1972). People who develop cardiovascular diseases and rheumatoid arthritis have a higher incidence of these diseases in their family medical histories. Coronary heart disease and other cardiovascular difficulties are clearly associated with both the sympathetic nervous system (Vander, Sherman, & Luciano, 1980) and the Type A behavior pattern (Jenkins, Rosenman, & Zyzanski, 1974). Additionally, certain health behaviors have been associated with dysmenorrhea. For example, a higher incidence of dysmenorrhea has been reported in subjects who are obese and in subjects that smoke; also, there is a lower incidence of dysmenorrhea in female athletes (Timonen & Procope, 1973; Widholm & Kantero, 1971). Summary and Hypotheses This study falls mid-way between being exploratory and being firmly grounded in hypotheses derived from existing research. It is known that women who suffer from primary dysmenorrhea have a higher concentration of prostaglandins in their menstrual fluids. Some studies indicate that the function of prostaglandins is to maintain the balance of individual cells within organ systems. Last, it has been shown that there is an associational link between 31 prostaglandins and the autonomic nervous system. The major hypothesis of this study is that women who suffer from primary dysmenorrhea may respond to stress in such a way that involves an overresponse of the adrenergic nerves or the sympathetic nervous system. This hypothesis is based on an assumption that sympathetic tonus during early menstruation is higher than usual, associated with the hormonal balance specific to the onset of menses. This assumption has not yet been tested by physiological researchers. One of the possible reasons that these women may overrespond is that women are not as well-socialized as men to express their own needs for autonomy or their anger. In addition, this society also maintains powerful prohibitions against the expression of anger, particularly for women (Bernardez, 1978; Lerner, 1981). At the same time, the definition of what is an appropriate way of being for a woman is still constrained. The somaticization of unexpressed anger might occur either when women feel hurt and not angry in response to events in which they were victimized in some way or they realize that they feel angry but feel they must not express it because of prohibitions against doing so. The somaticization process most likely involves increased stimulation of the sympathetic nervous system. In primary dysmenorrhea then, the body may be responding by creating a physiological pain state. Pain usually leads people to 32 withdraw in order to heal or take care of their needs. This withdrawal from the stimulus leads to a situation in which the body and psyche can then begin to restore its balance. The rest then helps to calm the physiology and psychology. Numerous diseases have been associated to higher sympathetic arousal (e.g., forms of cardiovascular disease). Certain symptoms have also been linked to either sympathetic or parasympathetic arousal. Last, certain behavior patterns are associated with increased risk of disease. Through either genetic inheritance and/or social learning of lifestyle related behaviors, diseases such as coronary heart disease, rheumatoid arthritis, and cancer are passed along through the generations. In summary, it is hypothesized that difficulty with experiencing or expressing anger would be more likely to occur in women who suffer from primary dysmenorrhea. A second hypothesis links primary dysmenorrhea with a tendency toward sympathetic nervous system overarousal. A corollary of this hypothesis is that good health habits (e.g., diet and exercise) tend to mitigate the effects of sympathetic overarousal and therefore subjects with primary dysmenorrhea will tend to have poorer health habits than the nondysmenorrheic group. Last, since Type A behavior patterns have been linked to cardiovascular disorders (which have sympathetic nervous system involvement), it is hypothesized 33 that primary dysmenorrheic women would be more likely to exhibit these behavior patterns. The operationalized definition of primary dysmenorrhea for this study includes all of the following five conditions: (1) no anatomical or physiological abnormalities of the uterus, ovaries or fallopian tubes; (2) experience of menstrual pain or injestion of medication to avoid pain in either of the two previous .menstrual periods; (3) the menstrual pain begins the first or second day of the period; (4) the pain lasts two days or less; and (5) the woman either takes medication to mitigate or prevent pain or she finds that the pain interferes with her physical or mental activities. 34 Method Subjects Data were collected from both male and female participants as a part of a larger study. The data on male subjects were not analyzed for this thesis. Subjects were recruited in a number of settings. (1) Undergraduate students taking the following courses: Developmental Psychology, American Thought and Language--Women in America, The Psychology of Women, and Introductory Psychology. Subjects in the latter two classes received extra course credit for participating; (2) Olin Student Health Center Gynecology Clinic; and (3) WomanCare of Lansing, a health care clinic specializing in providing services to women. One hundred thirty-two women responded to the survey: 11 from WomanCare (7 working women and 4 undergraduate students), 5 from Olin Student Health Center, and 116 from the undergraduate classes. One of the research instruments (Jenkins Activity Survey) has different forms for working 35 persons as opposed to students. The 7 employed WomanCare subjects were therefore dropped because of insufficient numbers to analyze these data separately. Six subjects were dropped (l--WomanCare, 2--Olin, and 3-Classes) because they responded "Yes" to the question, "Are you taking oral contraceptives (birth control pills)?" This left only 3 subjects each in the WomanCare and the Olin samples. These 6 subjects were dropped in order to have a homogeneous sample with regard to method of recruitment. The final sample was 113 women from undergraduate classes. Measures Four measures were constructed and three existing measures were chosen for this thesis. (1) The following measures were constructed for the purpose of this study. More information on content, reliability, and construction appears in the measurement section. (a) Questionnaire to characterize the sample: age, marital status, education, religion, ethnicity, and family variables such as religion and socioeconomic status (Hollingshead & Redlich, 1950). 36 (b) Health psychology questions to obtain information on (1) family medical history of parasympathetic and sympathetic nervous system related diseases and (2) health habits of subjects (diet, exercise, smoking). (c) A survey to characterize subjects' experience of anger-provoking situations as they occurred during adolescence, subjects' attitude toward the expression of anger, and subjects' relative tendency to express anger. (d) A gynecological questionnaire to classify whether the subjects were experiencing primary dysmenorrhea; and to characterize the subjects' experience of the pain, how it impacts their lives, and how they cope with it. (2) Autonomic Nervous System (ANS) Questionnaire (Neziroglu & Yaryura-Tobias, 1977): This instrument asks the subjects to rate the frequency with which various physical symptoms occur when they experience both anger and anxiety. Half of the symptoms are signs of the adrenergic portions of the ANS; the other half are signs of the cholinergic portion. The test yields four scores: (a) adrenergic/anger, (b) cholinergic/anger, (c) adrenergic/anxiety, and (d) cholinergic/anxiety. Adrenergic responders correspond to 37 sympathetic nervous system responders in the Wenger & Cullen (1972) study mentioned earlier. Further background on the use of this and subsequent instruments will be given in the measurement section. (3) Habits of Nervous Tension (HNT) (Thomas & Ross, 1963). This instrument asks subjects to indicate whether they experience each of 25 symptoms when under stress. Subjects can then be scored on 8 different factors which indicate patterns of response to stress: (a) activity, (b) appetite, (c) irritation, (d) visceral reaction, (e) general stress, (f) dependency, (g)compulsivity, and (h) stimulation. In addition, one can obtain an HNT score (based on 8 items) which in the original study predicted concurrent serum cholesterol levels. The association of serum cholesterol with emotional stress, diet, heredity, and coronary heart disease all have been demonstrated (summary in Thomas & Ross, 1963). Research continues to the present to sort out these factors. (4) Jenkins Activity Survey. Two forms were utilized: (a) The first was Form C for employed people (Jenkins, Zyzanski, & Rosenman, 1979). This form generated four factor scores: Type A behavior; Factor S, speed and impatience; Factor J, job involvement; and Factor H, hard-driving and competitive. The Jenkins Activity Survey was first standardized on (b) 38 middle class, employed, middle-aged men. Males and females who score high on Type A behavior have been found to be significantly more likely to suffer from cardiovascular disease later in their lives (e.g., Jenkins, Rosenman, & Zyzanski, 1974; Jenkins, 1978). Form T for students (Glass, 1977). The wording of the adult Form C was modified by dropping 8 of 52 items that referred solely to employment (such as income and job responsibility) and by substituting words so that the -items related to college or scholastic involvement rather than job involvement.' For example, "When you are in the midst of doing a job . . ." was changed to "When you are in the midst of studying . . ." The student JAS is scored by a unit weighting procedure to derive a Type A score. Two factors emerged from Glass's analysis of 459 male college students: Factor H, hard driving and competitive; and Factor 8, speed and impatience. 39 Qperationalized Hypotheses It was hypothesized that subjects suffering from primary dysmenorrhea will have the following pattern of results of the measures used in this study: (1) fewer positive health habits, (2) greater incidence of sympathetic nervous system related diseases in their family medical histories, (3) less experience of anger or more experience of anger without expression of anger, (4) lower scores on the Activity and Appetite Factors and higher scores on the Dependency Factor and the HNT Scale on the Habits of Nervous Tension Instrument, (5) greater incidence of adrenergic responders on the Autonomic Nervous System Questionnaire, and (6) higher Type A behavior scores on the Jenkins Activity Survey. Procedure Either the researcher or an undergraduate research assistant in the classroom settings and personnel from the medical settings briefly explained the purpose of the study, criteria for participation, and an incentive drawing of three 40 $20 cash awards. (Criteria for participation were that subjects be between the ages of 18 and 25, inclusive, and that subjects not be taking oral contraceptives. The purpose of the study was stated as follows: "Some behavior patterns and emotions have been linked with physical symptoms. The purpose of this study is to explore these relationship as they occur for women who have menstrual cramps and those who do not. In addition, women's responses for some parts of the questionnaire will be compared to men's to see how they are different or how they are the same. The eventual aim of this research is not to find that emotions or behavior cause pain, disease, or discomfort, but to make people aware of potentially health-related and disease-related signs so that they may participate more actively in maintaining health rather than recovering from or treating disease or discomfort.” Last, the incentive of a drawing for three $20 awards among the first 150 subjects to respond was explained. Potential subjects simultaneously received a recruitment letter which explained the purpose of the study and also requested that those interested take a research packet with them to be completed at a later time and returned by mail. The packet included an instruction sheet, a drawing entry blank, a research consent form, and six research instruments. Copies of both the recruitment letter and research packet 41 contents can be found in the Appendix. This study was approved by the University Committee on Human Subjects. Informed consent was obtained prior to participation. Responses were anonymous and confidential in that all identifying forms were separated from the research documents immediately upon receipt. Subjects were also informed that if any questions arose during or after the process of completing the instruments, they were to feel free to call the researcher. Analyses Dependent variables using a nominal level of measurement were analyzed by Chi square against the dependent measure of primary dysmenorrhea. The remaining interval level variables were analyzed by analysis of variance (ANOVA). All variables were then entered into a discriminant function analysis in order to find which were signficant predictors of primary dysmenorrhea. 42 Measurement Classification of Dysmenorrhea Women subjects were classified as having primary dysmenorrhea if they satisfied all five of the following criteria: (1) no physiological or anatomical abnormalities in the reproductive system; (2) pain during either the last menstrual period or the period two months ago; (3) the pain usually begins on the day the menses begins; (4) the pain lasts for two days or less; (5) either the pain interferes somewhat with work or recreational activities or the subject takes medication for the pain. The specific related questions and percent frequencies of responses in this sample are listed in Table 1. When classifying subjects it became clear that the group that did fit the operationalized definition of primary dysmenorrhea outlined for this study actually had 2 distinct subgroups. These subgroups were (a) those who had either no pain/discomfort or very little and (b) those who violated the 43 Table 1 Questions Relevant to Classification of Primary Dysmenorrheaa Item Percent Number Item Content Frequency 3 Apart from vaginal discharges and infections, did any doctor ever mention any abnormalities in your uterus, ovaries, or fallopian tubes? (n-113) yes 8 *no 92 9 Did you either experience pain or take medication so that you would not have pain at the time of your period last month? (n-ll3) *yes 58 no 42 10 Did you experience pain and/or take medication at the time of your period two months ago? (n-ll3) *yes 63 no 37 13 When does your pain begin in relation to your period? (ti-82) the day before my period begins 36 *the day my period begins 48 1'the second day of my period 2 none of the above 14 14 How long does your pain last? (n-82) *less than one day 5 *one day 35 *two days 42 greater than two days 19 16 Does the pain usually interfere with the concentration you give to your work or recreational activities? Read through the follow- ing responses and check the response that best describes you dur- ing the time that you are in pain. (n-BZ) I find that my attention span increased during menstruation. 0 My concentration is no different. 23 *Hy attention is sometimes carried away from what I am doing. 44 *My attention is carried to the pain quite a lot. 31 17 To what extent does the pain interfere with your activities? Read through the following responses and check the response that best describes you during the time when you are in pain.(n-82) It does not interfere. 17 *I must limit my physical activity. 11 *I would like to limit my physical activity. but I don't. 33 *I must lie down and rest. 38 20 What, if anything, do you take for your pain most of the time? (p.82) 1 take no medication at all. 11 *Aspirin l9 *Tylenol, or other non-aspirin preparations (e.g., Anacin-3) 20 *Over-the-counter medications for menstrual painTblues (e.g., Pamprin, Midol?) 27 *Prescription medications for menstrual pain (e.g., Motrin, Naprosyn) l7 *Prescription medications for pain in general (e.g., Darvon. Tylenol l3) 4 *I'm not sure what I take. 0 *Other (please specify ) 2 a Subject must mark one astericked item in each of the five sections separated by a dotted line in order to be classified as having primary dysmenorrhea. 44 criteria primarily because either the pain lasted more than 2 days (8 subjects) or the pain began the day before the onset of menses (10 subjects). The subjects in the latter subgroup (b), however, were experiencing significant discomfort or pain. Because these 2 subgroups were so different, they were separated for the purpose of running further analyses. Therefore, regarding the classification of subjects for dysmenorrhea, three groups emerged: Group 1, Primary Dysmenorrhea (PD), n=51 or 48%; Group 2, Dysmenorrhea (DYS), n=21 or 20%; and Group 3, No Dysmenorrhea (ND), n=35 or 32%. Three Subjects were coded as disqualified because they had an IUD, endometriosis, and an ovarian cyst. Additionally, 3 subjects were classified as missing data because they had not answered all of the questions related to defining dysmenorrhea. There were a total of 107 subjects classified. Health Scale Six health habit related items were combined to form a scale. These included items about regularity of eating habits, amount of animal fat in diet, amount and regularity of exercising, and smoking. The items are numbered 12, l3, 14, 16, 17, and 18 on the first questionnaire, labeled "Health Psychology Research Study." The items and their 45 response frequencies are listed in Table 2. The standardized item alpha of the scale was .52. Examination of the corrected item-total correlations revealed that the smoking item did not contribute to the scale (r=.03). It was therefore dropped leaving five items for the Health Scale. The internal consistency reliability (alpha) for the new Health Scale was .62. Item statistics appear in Table 3. Analyses on the smoking item were run separately. Anger Scale Six items related to expression and experience of anger were combined to form a scale. The items and percent frequencies of responses are listed in Table 4. For items 3 and 4, subjects were asked to check feelings they had had as a result of disagreeing with each of their parents during adolescence. Since a number of subjects endorsed more than one response, the responses were dichotomized into those who had marked that they had been angry (65%) and those who had not experienced anger (35%). Item 5 asked subjects to imagine an event during which they had been very angry and to mark the response which corresponded to their experience of anger. The responses were: never felt angry, disappointment, dissatisfaction, irritation, somewhat angry, very angry. The ‘46 Table 2 Health Items and Response Percent Frequencies Percent Item Item Content Frequency (n-113) 12 Do you eat breakfast regularly? yes 47 no 53 13 Do you exercise regularly? yes 62 no 38 14 How many days per week do you usually engage in exercise or physical acticity? 8 days per week 0 l or 2 days per week 30 3 to 5 days per week 48 6 or 7 days per week 22 16 How would you characterize your activity level in relation to your peers? very minimal; sedentary 0 less than average 16 moderate or average 47 more than average 31 very active 6 17 Do you smoke cigarettes? no 86 I smoke less than % pack per day. 7 I smoke 8 to 1 pack per day. 7 I smoke more than 1 pack per day. 0 18 Do you eat meat? yes, I eat all kinds of meat. 78 yes, but I avoid red meat and eat mostly chicken and fish 19 4 no 47 . Table 3 Item Statistics for the Health Scale Corrected Alpha Item Content Item-Total If Item Correlation Deleted 1. Do you eat breakfast regularly? .21 .63 2. Do you exercise regularly? .52 .51 3. How many days per week do you exercise? .45 .52 4. What is your activity level in .48 .50 relation to your peers? 5. Do you eat meat? .25 .62 Internal Consistency Reliability for Scale 8 .62 48 Table 4 Anger Items and Response Percent Frequencies Item Item Content Percent Frequency 3 During incidents when you and your mother disagreed about something that was important to you, which of the following feelings described how you felt? experienced anger 65 did not experience anger 35 4 When it was your father and you disagreeing, how did you feel? experienced anger 46 did not experience anger 54 5 Think of an actual event when you were very angry with someone else (e.g., parent, friend, teacher, etc.) during high school. Read over the following responses and choose the one which most applies to you during the event. I didn't ever get angry during high school. 1 I felt disappointed and hurt. 28 I felt dissatisfied with the other person. 8 I was irritated at the other person. 13 I was somewhat angry at the person. 15 I was very angry at the person. 35 9 Did you let the other person know you were angry? yes 81 no 19 15 Do you think it is appropriate to express anger at someone? yes 92 no 8 16 Do you NOT get angry when you feel you should? Never 17 Sometimes 68 Often 15 49 frequency distribution of the subjects' responses was somewhat bimodal. Therefore, despite the fact that the stem asked subjects to envision an event during which they were very angry, 37% of the subjects reported that they had not experienced any or only a minor amount-of anger (never, disappointment, or dissatisfaction). The remaining items inquired if anger was expressed, if subjects thought it was appropriate to express anger, and how often subjects failed to get angry when they thought they should have. The standardized alpha for this scale was .46. Item 15, ”Do you think it is appropriate to express anger at someone?', had a corrected item-total correlation of -.03. For this reason and also because it is an attitudinal item while the others relate to subjects' experience, item 15 was dropped from the scale. The resulting new scale, Anger Scale (adolescent experience of anger), was composed of 5 items. Their content and item statistics are listed in Table 5. The internal consistency reliability for the Anger Scale was .89. Further analyses of the dropped item on appropriateness of the expression of anger were run separately. 50 Table 5 Item Statistics for the Anger Scale Corrected Alpha Item Content Item-Total If Item Correlation Deleted 1. How did you feel when you disagreed with your mother? .30 .96 2. How did you feel when you .88 .83 disagreed with your father? 3. Choose an event that made you angry. .88 .83 Characterize your experience of anger. 4. Did you express your anger? .86 .84 5. Do you NOT get angry when .88 .83 you feel you should? Internal Consistency Reliability for Scale . .89 51 Autonomic Nervous System Questionnaire Subjects were asked to rate how frequently they experienced certain physical symptoms under conditions of anxiety and anger. Neziroglu and Yaryura-Tobias (1977) recommended that subjects be given 15 points for endorsing "very frequently," 10 points for "often,” 5 points for ”sometimes,“ and no points for "never." They calculated scores for each of the scales: (1) cholinergic signs of anxiety, (2) cholinergic signs of anger, (3) adrenergic signs of anxiety, (4) adrenergic signs of anger. The cholinergic signs correspond to a parasympathetic nervous system response; the adrenergic signs correspond to a sympathetic nervous system response. The authors then used the means on each scale to determine a cut-off point. If a subject scored above the mean on a scale, they were said to have a response of the corresponding system to that particular emotion. If a subject scored above the mean on one system and below the mean on the other for a particular emotion, they were labeled as having a predominant response corresponding to the system with the high scale score. 52 Subjects for the original study were patients in a mental health center and a control group of staff with no history of psychiatric treatment. No diagnoses, sexual composition, ages, or other demographic data were given to characterize the sample. Summary statistics were reported only for the patient group with an accompanying statement that the control group was not statistically different. Additionally, frequency of item endorsements were similar for the two groups. Test-retest reliability on individual items tested varied from .60 to .80. The mean scale scores and their standard deviations from the original study and the current study are listed in Table 6. The cholinergic means from the two studies (Anxiety-1977 a 42.10, Anxiety-current = 42.45: Anger-1977 = 28.19, Anger-current = 28.30) are very similar. The adrenergic means are significantly larger in the current study (Anxiety-1977 = 57.75, Anxiety-current = 70.37, t=5.53, df=l75, p<.01; Anger-1977 c 40.72, Anger-current = 51.18, t=2.01, df=175, p<.05). All current standard deviations are smaller, indicating a more homogeneous sample for the current data set. One of the assumptions underlying the t-test is homogeneity of variance. Although this assumption is violated, the significant differences are not likely to be erroneous since the t-test is very robust against violations of this particular 53 Table 6 Comparison Descriptive Statistics on Autonomic Nervous System Questionnaire Neziroglu & Yaryura-Tobias (1977) and Current Study Anxietya Anger b 1977 Study Current Study 1977 Study Current Study n-69 n-108 n-69 n-106 Adrenergic x 57.75 70.37 40.72 51.18 S.D. 42.09 35.08 38.14 30.71 Cholinergic 3? 42.10 42.45 28.19 28.30 S.D. 31.52 24.48 26.88 18.49 aAdrenergic Response to Anxiety in the current study was significantly greater than the 1977 study (t - 5.53, df - 175, p < .01). bAdrenergic Response to Anger in the current study was significantly greater than the 1977 study (t - 2.01, df - 175, p < .05). 54 assumption (Keppel & Saufley. 1980). The most commonly endorsed items for both studies were somewhat similar. These items are listed in Table 7. The major difference between the two studies is that where all items on the most frequently endorsed list of the 1977 study were adrenergic symptoms, several cholinergic items appeared in the current study as well. 5 In the study some subjects did not mark every symptom correctly. If subjects skipped only 1 or 2 of the 24 items on either anxiety or anger, these items were recoded using the median score for that item. If a subject failed to mark 3 or more items, she was dropped from further analyses of this instrument as missing data. First, in order to check on the validity of this instrument and the proposed scoring system, two principle factor analyses (PA2) were run (Varimax rotation and minimum eigenvalue=1.0) on items 1 through 24 for anxiety and anger. These both produced 8-factor solutions, accounting for 65.4 and 62.7 percent of the variance, respectively. However, neither of the factor solutions made any theoretical sense in terms of obtaining factors that represent either pure adrenergic or cholinergic factors. The factor loading matrices appear in Table 8. Numerous other factor solutions were run with no improvement in finding theoretically pure factors. This finding indicates that the symptoms do not 55 Table 7 Most Frequently Endorsed Items on Autonomic Nervous System Questionnaire Niziroglu 6 Yaryura-Tobias (1977) and Current Study 1977 a Current 2 Study Study Endorsement (n-69) (n-113) Anxiety Butterflies in stomachc Butterflies in stomachc 76 Heart palpitationsc Wet armpitsc 64 Muscle(s) feel tenseC Sleeping less than usualC 52 Dry mouthc Muscle(s) feel tenseC 48 Sleeping less than usualc Wet handsc 47 Wet armpitsc Excessive appetited 47 Wet handsc Urge to frequent urinationd 41 822.2; Muscle(s) feel tenseC Huscle(s) feel tenseC 57 Sleeping less than usualc Flushing of faced 4s Butterflies in stomachc Wet armpitsc 41 Sleeping less than usualc 41 describe it as follows: The procedure the authors used to rank order the symptoms is unclear. They "To determine which were the most common or more frequently exhibited symptoms under anxiety...and aggression for the patient population, the frequency of response for each symptom was calculated. The 'very often” and ‘often' frequencies were used in this calculation since it was the higher incidence of the symptom which was of interest. Any symptom which scored above 20 was considered a symptom commonly or more frequently reported." data set. c adrenergic symptoms d cholinergic symptoms based on 2 of people who endorsed "very frequently" or "often" in the current 561 .eouH some ecu mnsHoooH mooHo umoann one ouoUHosH mosHHuooco m aoummn mso>uoz oHEo:0u=< xHuumz noHomoq nauomm mm «Hana no.1 no. no. NH.1 no. mN. NH. mN. ouHuooeo noon no. no. mo. No.1 NN. oH. «H. NN. newEOum snooze loud. oH. oH. oo.1 oo.1 MH. no. HH. muHoeHe unoon mH. oo. nN. no. 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Ho.1 sumo memo: oHnumoHHono n N o n o m N H nouoon ecuoom eouuom ecuumn ocuoom ecuomn nouoom ecuomm mEouH huono< nouHosCOHumoso 57' .aouH sumo non mnoHomoH unoHo umoan: one oumoHooH mosHHuooso m Seaman m=o>uoz oHsos0ue< xHuumz nsHomoq ecuoom NN «Hash Ho. NH. NH. NN. oH. No.1 NN. NH. uuHumaam noon HH. No. No. no.1 oN. No. No. nH. panacea hmooso No. .1 .NH11 No. No.1 No.1 No. NH. mmHaeHa mmooN oH.1 NH. NN. NN. omen. NH. He. No. Nazca New No.1 NN. .wN11 NH. NN. NH. so. NN. NaoHumuHaHNa sumo; Ho.1 oo.1 NN. No.1 No.1 No. NN. 1mmq. NNHNENN am: No. HH. NN. No.1 No. NH. no. 1NH4. mucus um: nH. NN. Ho. no.1 HN. 1w«41 HN.1 mm. upon oHou No.1 so. NH.1 NN. NH. NN. .aoa. me. some No uoHHaa me. No. no. No.1 NN. NH. NN. No. m8H NcHauwHN NH. No. NH. NH. HN. so. no. as. NoHoaaa wagon HH. HH. NN. NH.1 NH. oo.1 oN. no. coHuNaHumsou NHNmmmmmmq NH. NN.1 NN.1 NN. NN. 3N.1 HN. No. NaHma New «N.1 no. No. NN.1 NH. NN. HH. HH. mHaouN someone NH. NN. No. on. NH. NN. so. NH. Noumea 8H=UHNNHN HN. No. Ho.1 .mwnw HN. oo.1 Ho.1 No.1 Hamaoua Hanson Nc.1 NH. NN.1 No.1 NH. No.1 HN. NN. auHuwaaa .uaH NN. NH.1 HH.1 NN. NH. an. «N. N4. N0508 emHuouNs oH.1 oH. eo.1 NN. oN. NH. HH.1 NN. moan NoemaHN NH. NN.1 NN. No.1 NN.1 HN. NN. No.1 woos NaHaaoHN NN. No. no. NN. No.1 NN. NH. NH. NuHumss Nous NH.1 NN. NH.1 NN.1 No.1 NH. N8. NN. aoHuNcHua .uaH NH. No. No.1 NH. «H. No.1 .mma. Ho. auguuNHN Ho. NN. Ho. Ho.1 No.1 No. NH. No. span sumo: «NNNNNHHNNN. N N N m e N N H mauuom neuumm ecuumm homomm ecuomm weapon ecuomm ecuomm wEouH monc< mouHmcsoHummso 58 group in sets of 'symptoms that relate either to the parasympathetic or sympathetic nervous system. Therefore the factor scores were not used. A unit weighting system was applied to the data. The four scales, Anxiety Cholinergic, Anxiety Adrenergic, Anger Cholinergic, and Anger Adrenergic were calculated and correlated. . The intercorrelations of the four scales varied from .49 to .75. All correlations were statistically significant, indicating that subjects cannot differentiate along the lines of adrenergic and cholinergic responses to these emotional states. Possible implications of this finding follow in the discussion section. The scale intercorrelation matrix appears in Table 9. Based on the current sample, neither the factor analysis or the intercorrelations of the scales indicate that this measure differentiates between adrenergic anad cholinergic responders. This casts some doubt on the validity of the instrument, given that the authors claim that it is ”highly reliable and valid" in the measurement of predominance of the adrenergic or cholinergic system. The classification system suggested in the 1977 article will be used for further analyses of this instrument. The authors classified subjects as adrenergic responders if they scored above the mean for a particular emotion on the adrenergic scale responders were classified similarly. 59 Table 9 Inter Scale Correlations for Autonomic Nervous System Questionnairea Cholinergic Adrenergic Anxiety Anger Anxiety Anger Cholinergic Anxiety --- Adrenergic Anxiety .57 .49 --- aAll correlations are significant, p < .001 60 Habits of Nervous Tension This instrument was originally factor analyzed on 1085 medical students, 92% of whom were male (Thomas & Ross, 1963). Twenty-five typical reactions to stress were listed and subjects were asked to indicate whether or not they usually reacted in these ways. Table 10 is a comparison of the two studies in terms of the frequency with which each item was endorsed. The total mean level of item endorsement for the current study was significantly higher (t=10.90, df=1196, p< .001). The following items contribute most to this effect: exhaustion, depressed feelings, increased urge to sleep, increased urge to eat, anger, irritability, urge to confide in others, and urge to withdraw. These data suggest that the original factor analysis might also be different from one done on the current data set. In the original study all items with frequencies less than 5% were dropped, and a principal components analysis with varimax rotation was run, producing an B-factor solution with eigenvalues greater than 1.00. Low scores on Factors I (activity) and II (appetite) and high scores on Factor VI (dependency) were associated with concurrent increased serum 61 Table 10 Item Frequencies for the Habits of Nervous and Tension Questionnaire: Thomas 6 Ross (1963) and Current Study8 1 Frequency of Endorsement Item 1963 Study Current Study n-1085 n-113 1. Exhaustion 14 42 2. Exhilaration 21 13 3. Depressed feelings 20 65 4. Uneasy or anxious feelings 49 61 5. General tension 80 82 6. Increased activity 65 52 7. Decreased activity 5 20 8. Increased urge to sleep 14 34 9. Increased difficulty in sleeping 45 59 10. Increased urge to eat 18 47 11. Loss of appetite 37 41 12. Nausea 22 13. Vomiting 4 14. Diarrhoea 15 13 15. Constipation 4 6 l6. Urinary frequency 31 32 17. Tremulousness 16 24 18. Anger 22 57 19. Gripe sessions 16 38 20. Concern about physical health 4 12 21. Tendency to recheck work 23 39 22. Urge to confide 27 60 23. Urge to be alone 20 61 24. Irritability 9 25 25. Philosophic effort 24 10 Average percent endorsement per item 23.5% 36.8% a t-10.90, df-ll96, p < .001 62 cholesterol. Additionally, Thomas and Ross identified an HNT Scale using 942 white males. They rank ordered the men according to their serum cholesterol blood test and discovered items which differentiated those whose cholesterol levels were above the median from those below. The factors and the HNT Scale items for the 1963 study are displayed in Table 11. A principle factors analysis with varimax rotation was done on the current data set with the subcomponents on item 18 scored separately (anger concealed and anger expressed) and with item 13 (vomiting) dropped from the analysis (frequency=4%). This produced a 10 factor solution with eigenvalues greater than 1.00. Five through 9 factor solutions were also run. The 8 and 9 factor solutions were most satisfactory in terms of theory. Alpha reliabilities were run on scales derived from both the 8 and 9 factor solutions. Based on greater factor internal consistency, the 9 factor solution was chosen. The factors and their internal consistency statistics are listed in Table 12. These factors accounted for 60.84% of the variance. The rotated factor loading matrix appears in Table 13. Although in both studies the three major predicting factors (activity, appetite and dependency) emerged, the scales based on the factor solution of the current data set was chosen for further analysis. The internal consistency of 63 Table 11 8 - Factor Solution -- Habits of Nervous Tension (Thomas & Ross, 1963)8 Factor b I. Activity b II. Appetite II. Irritation IV. Visceral Reaction V. General Stress c VI. Dependency VII. Compulsivity VIII. Stimulation HNT Scaleb Items decreased activity depression exhaustion urge to sleep increased activity loss of appetite nausea urge to eat gripe sessions irritability anger urinary frequency nausea diarrhea general tension difficulty sleeping philosophic effort urge to confide and seek advice urge to be alone tendency to check & recheck work exhilaration increased activity loss of appetite exhaustion urge to eat nausea anxiety urge to be alone tremulousness depression a Sample 8 1085 medical students (92% men) b Associated with high concurrent serum cholesterol levels c Associated with )9! concurrent serum cholesterol levels Loading 1++++ ++ +++ ++ +++++1++ 64 TABLE 12 9-Factor Solution ' Habits of Nervous Tension (Current Study) Corrected Alpha Scale Item Total If Item Standardized Factor Item Correlation Deleted Alpha I Activity Depression .45 .60 .67 Increased Activity .47 .58 Decreased Activity .45 .60 Urge to Sleep .44 .61 II Appetite Loss of Appetite .60 Urge to Eat III Anxiety Anxiety .39 .35 .51 Urinary Frequency .28 .45 Tremulousness .35 .40 Check & Recheck Work .19 .53 IV Low Energy Exhaustion .30 .35 .47 General Tension .27 .40 Irritability .30 .34 V Physical Nausea .30 .34 .46 Health Diarrhea .23 .35 Constipation .24 .40 Health Concerns .23 .40 VI Dependency Gripe Sessions .26 .48 .50 Urge to Confide in Others .35 .33 Urge to Be Alone .33 .37 VII High Energy Exhiliaration .22 Difficulty Sleeping VIII Anger Anger Expressed .19 Anger Concealed Ix Philosophic Effort 65 ncHomoH unoumoun use on; EouH some :oHca so uOuuon ANHusuoH mosHHuooco m on.oo I Ho.m oN.m on.m om.n no.0 oo.N NN.N nn.N mn.n uucmHum> ucouuom mn.H mo.H n¢.H nm.H Hn.H NN.H Hn.H no.H HN.N oon>=oan Nm. No.1 nH. nH.1 nH.1 NN. no.1 no. No. vonoocou nono< nH. Hn. oH. no.1 No.1 no. No.1 no. No. voomounxu Nons< oN. mo. no.1 No. Ho. mwhw oo.1 nH.1 nH.1 uuouun uHcoomoHHam nH. Ho. oo.1 oN. oH.1 no. «N. No. oH. auHHHmouHuuH No. 8.1 No. 3.1 co. 3. No. No.1 8. 333qu 3 55.2.8. no. no.1 oH. nn. no. no. «0.1 no.1 on. ovHucou On one: NH.1 NN. NH.1 no.1 NH.1 NH.1 on. no.1 oH.1 xuo: soonoon a seven oo. NH. NH. No.1 NN. oH. no.1 oN.1 oo.1 :uHoon :uHs monsoosoo oH. on. NH. no. nH. nm. mH. Ho. no.1 moonmon ooHuo no.1 Ho.1 no. no.1 Ho. No. on. oo. oo. mmosmsoHsaous No. NH.1 oo.1 oH. mm. nH. on. mN.1 no. Nocoeoouh humsHuo NH.1 HN.1 No.1 NN. NN. HH. NH.1 No. NH.1 833338 No. No. HH.1 NH.1 on. nH.1 «N. oN. nN. moauuoHa 8. HH . 8 . No. 3. No. HN. .le.1 NH. 33.2 No.1 nH.1 nH. no.1 oo. NH. No. mn. Ho. ouHuooo< no omOH NH. NH.1 8. No.1 No. No. No. 8.1 NH. use 3 6N5 oo.1 No.1 mo. oo. oo.1 NH. oo. on. no.1 nsHoooHn NuH30HuuHo NN.1 HN. NH.1 HH. 8.1 NN. No. NN.- NN. .6on 3 «NS No.1 NH.1 NH. 8. 8. 8. 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HH.1 NN. 33s; uncunn hunc< Mnuosm Nocuocoooo :uHmon >nuoom Nuon=< ouHuooo< huH>Huu< EouH anoomoHHsm ann Hoonxnm 30H M Hansen ecouusov :oncoH mso>uoz no manoz 11 xHuumx ncHomoq ecuomm nH mHnHuHmoo duos ououHosH nouoon :nH: a .osHHuooos on Na nouuossou one mHmmHmsm co: umoo n.0wmonon ou nsHououom NucoquMHo hHuowUHMHonHm uosv neoconoaon one :uHsa mosouu m Honv moH oH.m Ne. mH. mm. no. munoomHo oHuonuoo25mmumm mo aneumHn AHHamh oH. moH Nn.H mn.H mN.H mm.N mm.H monmumHo oHsHansssNN no huoumHm NHHamm no. nOH mo.N om.0H NH.HH mm.oH nH.0H nonon :uHmmm a we a use: nz men on women mmsHm> coo: osoeo oHpmHum> m noHanum> ovumHoNInuHmom mouse ecu Numeaen oucmHum> mo nHthms< nH oHamH Chi Square Analysis for Smoking Variable 78 Table 19 PD DYS ND Total No 44 19 30 93 Less than 8 Pack 3 2 2 7 Half to 1 Pack 4 0 3 7 More than 1 Pack 0 0 0 0 Total 51' 21 35 107 x2 - 2.12 df - 4 p - .71 79 into four groups for each emotional state (anxiety and anger) included those who were (1) clear sympathetic responders (high adrenergic, low cholinergic): (2) clear parasympathetic responders (low adrenergic, high cholinergic): (3) high physical responders (high adrenergic, high cholinergic): and (4) low physical responders (low adrenergic, low cholinergic). Chi square analyses with dysmenorrhea classification as the other dependent variable were not significant for either anger or anxiety. Summary statistics appear in Table 20. Jenkins Activity Survey Analysis of variance tests were run on four sets of scores: Type A Behavior (Glass scoring scheme), Factors H, S, and C (using unit weighting from factor analysis on these data). Of these four dependent variables, only Factor C, college involvement, was statistically significant (F ratio=4.39, df=106, p<.05). Scheffe's procedure for post hoc analysis revealed two homogeneous subsets: (1) the dysmenorrheic group (DYS, mean=10.86) and (2) the primary dysmenorrheic (PD, mean-9.6) and the non-dysmenorrheic (ND, mean=9.20) groups. Summary statistics for these analyses are presented in Table 21. 80 Table 20 Chi Square Analyses Autonomic Nervous System Questionnaire Parasympa- Sympathetic thetic High Low Anxiety Responders Responders Responders Responders Total Primary Dysmenorrhea 3 7 l9 17 46 Dysmenorrhea 5 2 6 8 21 No Dysmenorrhea 4 l 12 18 35 Total 12 10 37 43 102 2 x - 8.56, df - 6, p - .20 Parasympa- Sympathetic thetic High Low Anger Responders Responders Responders Responders Total Primary Dysmenorrhea 9 5 15 17 45 Dysmenorrhea 3 2 6 9 20 No Dysmenorrhea 6 3 12 13 34 Total 18 10 33 39 100 x2 - .60, df - 6, p - 1.00 81 ooHHuooss so No nouuosoou ohm mHthooo so: once n.0uwonon ou noHououum AuouuouwHo hHuomuHchnHm uoev neoconoao: one :qua poncho o NN. NNH NN. Na.oH NN.oH HN.NH NH.oH N possum 11knW\\\\1IllllllllIlluurl. usosm>Ho>oH onoHHoo No. NoH oN.s om.N oN.N NN.oH NH.N u possum u>HUHuooaoo Nss NsHsHsN ease NN. NoH NN.H NN.N NN.N Ns.oH Ns.a N nausea No. NNH NN.N NN.N sH.oH NN.N co.oH uoHssssN 4 easy a He N ass: oz men as women mmosHm> one: osouo ho>usn muH>Huu< mstooo use you muHsmon moomHuo> mo monhHos< HN sHsse 82 Habits of Nervous Tension ANOVA was run on each of the nine factor scores (solution from these data) and the HNT Scale (from the literature) of the Habits of Nervous Tension instrument. Of these 10 tests, none were statistically significant. Results are summarized in Table 22. Anger Related Variables Neither of the two analyses on attitude toward expression of anger or the Anger Scale on the experience of anger were statistically significant. Results are summarized in Table 23. 83 No. no. HN. «N. no. on. nH. nN. nN. on. noH nOH ooH noH noH oOH noH nOH noH nOH no on. oo. mm. on. No. nH. mo.N om.H nN. Nn. OHumm on.N oo. oo. NN. no. om.H Hn.H om.H Ho. on.H one: woman Nm.N no. No. NN. oo. mo.H nN.H Hn.H oo. Hn.H Dz oo.m no. oo. nN. no. oN.H Nn.H mn.H oo.H Hn.H mwn mosHm> one: esouo MN.N NH. on. No. mm. Hn.H mn.H Nm.H on. HN.H am ououn Hz: ssoNNN saesosoHHNN uons< knuwcm £nH= honooaoooo esHssN HssHsaeN hneosm 36H muons< ouHuoeo< huH>Huu< Houomh ouHmscOHumoso sonsoH m=o>umz mo mqumm one so ouomHem> mo mothms< NN mHan 84 mm. NNH NN. NN.N NN.N N2 Ne OHHsN ass: m osmuo oo.n mo.N nun am mono: aspen onun euno< no oouoHuooxn no oocmHum> no mHmNHoo< nmN oHan NN. 1 a .N 1 Ne .Ns. 1 Nx moH oN oN . Hm Hmuoa m N N m on no Nm nH no mom Hooch moneeosoemzo monuuosoamho monuuosoamho Nuance mmouexo ou oz humaHem oumHuoouoom uH mH Hono< no GOHmmouoxm nemaoe ooeuHuu< no mothoo< summon Hon sNN sHase 85 Discriminant Function Analysis A discriminant function analysis was performed using 22 dependent variables to classify the 3 independent measure groups (PD, DYS, ND). The variables are as follows. 1. 7. 8. 9. 10. 11. Health Scale: The questions relate to diet and exercise health habits. High scores indicate positive health habits. Smoking: High scores indicate smaller frequency of smoking behavior and therefore a more positive health habit. FH-Symp: Family history of sympathetic nervous system related diseases. FH-Para: Family history of parasympathetic nervous system related disease. Adrenergic Responders to Anxiety: The categorical ANS data were recoded to create a dichotomous variable of clear adrenergic responders vs. all other classifications. Adrenergic Responders to Anger: The categorical ANS data were recoded to create a dichotomous variable of clear adrenergic responders vs. all other classifications. Type A Behavior (JAS). Factor H (JAS): Hard driving and competitive. Factor S (JAS): Speed and impatience. Factor C (JAS): College involvement. Factor I (HNT): Activity. 86 12. Factor II (HNT): Appetite. l3. Factor III (HNT): Anxiety. 14. Factor IV (HNT): Low Energy. 15. Factor V (HNT): Physical Health 16. Factor VI (HNT): Dependency 1?. Factor VII (HNT): High Energy 18. Factor VIII (HNT): Anger 19. Factor 13 (HNT): Philosophic Effort 20. HNT Scale 21. Anger Scale: The categorical questions on this scale were dichotomized and recoded as discussed in the measurement chapter. Low scores on this scale indicate a tendency toward predominantly having greater experiences of anger, but also toward expressing the anger. 22. Anger Attitude: Low scores indicate a positive attitude toward the expression of anger. The SPSS stepwise discriminant function analysis (RAO method) was used, specifying group size a priori to account for unequal n's. The following ten variables, in decending order were found to significantly predict classification of the dysmenorrhea groups: FH-Para, JAS Factor C (college involvement), Adrenergic Response to Anxiety (ANS), FH-Symp, Anger Scale, HNT Factor VI (dependency), Health Scale, HNT Factor VIII (anger), Adrenergic Response to Anger (ANS), Anger Attitude. The resulting two functions correctly classified 64% of the subjects. The discriminant function 87 analysis is summarized in Table 24. A summary of the means or frequencies of the variables contributing to the discriminant functions, broken down by dysmenorrhea group classification, is presented in Table 25. These data were listed in previous Tables. This is a collection of the significant function variables presented for the readers' convenience in order that the trends in the data can be more easily examined. 88 Nm. nH. N on. No. H sOHumHouuou oucmHum> soHuucsm HmoHsosmo no usoouom NH. nn.m Ho.v Hn. nuns< oumsoa oosuHuu< oH nH. No.m Ho.v nn. eons< ou Hooooomon oHuosquSNn o oN. oN.m Ho.v mn. eons< 1 Hz: n oH. Hm.m Ho.v nn. onun suHmon N NN. No.N Ho.v NN. ssssessssn 1 92: N nH. mn.m Ho.v oN. uHmon nonn< n no. nH.N Ho.v NN. oHuoaumoehn 1 an o no. oN.m Ho.v . NN. huona< cu eonsoemon oHuonumeahn n Ho. on.0H Ho.v Hn. acoao>Ho>=H stHHso 1 NNN N Ho. oo.oH Ho.v om. oHuosumoahmoumm 1 an H m > :H a monfimq oHamHum> monsoon unease stHz neum mothmc< GOHuossm usmsHEHuomHo oN oHan 853 .uoncm no oocoHuooxo oommouooH oumUHooH mououm 304 m soHuossm usmsHeHuumHo :H moHanum> mo moHosmsooum no mosHm> com: «o huneasn mN oHan NN No N NN N0 N .94No N ust< No soHssssaxN nuance ooeuHuu< oH eono< cu uncommon NN No N HN No H Na No N sHNsssssN< 1 Nz< N om. No. oo. on. nonc< 1 Hz: n om.oH NH.HH mn.oH nH.oH oHoon :uHoon N No. es. NN. NN. Nesmessama 1 Hz: N nn.N oN.n oo.n mo.N moHoum wonc< «0 oosoHuoexn m mn.H oN.H mm.N mm.H nomm0NHo oHuonumoshm No NuoNsHN NHHasN s 4N No s HN No N Na No N NastsN on assessse oHnuosouo< 1 nz< m om.o oN.m nn.oH nH.m usoso>Ho>sH unoHHoo 1 >o>u=n auH>Huo< mstsoo N No. nH. mm. mn. mommomHo oHuonumoahmoumm no huouon AHHENN H 5.: $18 E18 3.18 ocean oz nro om 90 Discussion The purpose of this study was to explore some physiological, historical and social aspects of the life experiences of women who suffer from primary dysmenorrhea and those who do not. It is known that women who suffer from primary dysmenorrhea have a higher concentration of a biochemical substance called prostaglandins in their menstrual fluids. It has also been shown that there is an associational relationship between prostaglandins and the autonomic nervous system. Levels. of estrogen are at the lowest monthly level at the time of onset of menstruation. And premenopausal levels of estrogen seem to protect women from the early development of sympathetic nervous system related diseases (e.g., cardiovascular disease, rheumatoid arthritis). In addition, other relationships between the sympathetic nervous .system and uterine physiology exist. Classically, sympathetic nervous system disorders have been linked with adopting the physiological stance of the fight or flight response to environmental stresses. However, in this society these responses are often not considered socially appr0priate. Psychoanalytically, sympathetic nervous system 91 disorders have been linked with unexpressed anger (Alexander, 1968). It is generally not considered appropriate in this society to express anger, especially for women. Girls are socialized to nurture, not to be autonomous and direct in expressing their own needs. Thus, they may be less likely to experience anger or to express it when they do experience it. Thus, they may be more likely to somaticize their feelings of anger. It was hypothesized that women who suffer from primary dysmenorrhea would have increased evidence of both (1) sympathetic nervous system related variables and also (2) difficulty with the experience and expression of anger. The goal of this research was to add to the known factors implicated in the process of primary dysmenorrhea (e.g., prostaglandins and anxiety) in order to work toward both prevention and also eventual nonpharmacological interventions for sufferers. Overview of Results Twenty-two variables were entered into the stepwise discriminant function analysis. All four of the variables that were related to anger (Experience of Anger Scale, HNT Anger Scale, Sympathetic Nervous System Responder to Anger, 92 and Attitude Toward ExpressiOn of Anger) contributed significantly to the function. In addition, ‘all three sympathetic nervous system measures (Family History of Sympathetic Nervous System Related Diseases, and Sympathetic Nervous System Reponder to Anger and to Anxiety) were also included in the function. Of the remaining 7 variables thought to be indirectly related to sympathetic overarousal, two were significant contributors (Health Scale, HNT Dependency Factor). The remaining two variables (Family History of Parasympathetic Nervous System Related Diseases and The Jenkins Activity Survey College Involvement Factor) were the most powerful ,predictors but were not originally hypothesized to contribute to the function. These results will be discussed in detail below. 93 Measurement 1 ssues The Jenkins Activity Survey For the Jenkins Activity Survey (JAS) Glass (1977) obtained two major factors based on his data set of 492 male subjects. The current data set on 113 women produced three. The new one that emerged (college involvement) was the only JAS scale that differentiated dysmenorrheic women. Therefore, without the development of a factor solution on women, an important finding would have been missed. Habits of Nervous Tension The HNT factor solution on the current data set was also somewhat different from the original study. Therefore, the patterns of symptoms experienced by men are likely different from those experienced by women. The results of this study indicate that women endorse significantly more symptoms on 94 this instrument than do men. Two previous studies conducted with both male and female physicians and medical students also found this difference (Nadelson, Salt, & Notman, 1983: Thomas, 1971). Some possible explanations for this phenomenon are (1) women have a greater tendancy to endorse items, (2) women have a greater response to stress, and (3) women are more perceptive of physical and psychological signs of stress. Given the socialization of women both to nurture and also to be passive, it makes sense that women may have both a greater response to stress and a finer awareness of themselves when under stress. It might also be argued that women first perceive the .symptoms and then recognize or attribute them to stress. Whether this differential response pattern is good, bad, or just different is an interesting health question. Anecdotally, many women state with pride their belief that women are more "in touch" with their bodies. Clearly, women are greater consumers of traditional health care for less serious physical disorders (e.g., gastrointestinal complaints, headaches), while men tend to utilize medical care less but suffer more catastrophic illness (e.g., cardiovascular diseases). Given that the HNT measure is predictive of high serum cholesterol (associated with subsequent cardiovascular disease) and given that women are less likely to suffer cardiovascular disease future 95 researchers may want to explore these gender response differences to instruments such as the HNT in order to identify (1) whether the women's response patterns are related to physiology (e.g., blood estrogen levels), perception, or socialization and (2) whether higher response rates are associated with lower incidence of cardiovascular disease. Thus, not exploring gender differences may obscure possible preventive lines of research as well as produce erroneous results when testing hypotheses. Differential socialization factors may, in fact, contribute to women endorsing significantly more items on this instrument. In her 'theory of feminine personality development, Chodorow (1978) maintains that women are socialized to be relationship keepers and to have an identity in terms of relational bonds. The primary sociological purpose of this pattern of child rearing with mother as the primary and only caretaker is the reproduction of mothering. Speculating more on the gender differences in the HNT, women may be more likely to hold an underlying value that life should be conflict free. Therefore, they may also be socialized to heighten their response and perception in situations of stress. If this is a response associated with positive health outcomes, it may be that males should be socialized to be more nurturing, fathers providing models of male nurturance by being more actively involved in child 96 care. Autonomic Nervous System Questionnaire The Autonomic Nervous System Questionnaire (ANS) was significantly different between the 1977 and current studies in terms of mean values of adrenergic response to both anger and anxiety. Since no sex or age composition was listed for the original patient population, it is impossible to state what may have contributed to this difference. A separate issue regarding the ANS Questionnaire is its questionable validity for differentiating adrenergic responders from cholinergic responders. The factor analysis did not produce pure adrenergic or cholinergic factors, indicating that the women did not have pure responses. This makes sense physiologically speaking, since a response of one portion of the autonomic nervous system (e.g., sympathetic) generally begets a response of the opposite system (e.g., parasympathetic) in order to rebalance the physiology. Thus,‘ the patterns of response on this measure likely depend on when in the process the subject is tuning in to her body. Another interpretation of the lack of pure factors is related to recent findings in animal research which indicate that the nervous system may not make a generalized sympathetic nervous 97 system response that affects organs equally throughout the body. For instance, Weaver, Fry, and Meckler (1984) found that in cats, ”sympathetic control of the kidney and spleen can be selective, illustrating significant potential discreteness of sympathetic outflow to the viscera” (p. R78). In other words the patterns may be extremely complex and/or variable in terms of how one's body responds to various stressors. Additionally or alternatively, the high level of intercorrelations of the ANS scales indicates that there may be a general response factor operating. There are actually high responding/perceiving women and low responding/perceiving women. This finding certainly does not invalidate Wenger and Cullin's findings that there are people who have a tendency to respond predominantly with either the sympathetic or parasympathetic nervous systems. Rather, these findings cast doubt on the validity of this instrument to determine whether a person has either of these tendencies. Clearly, criterion validity research should be conducted on the ANS Questionnaire with physiological measures. Since adrenergic (sympathetic) responders were defined as being high on the adrenergic and low on the cholinergic scales, it is possible that it does identify people who are predominantly sympathetic responders. Therefore, the results with this instrument will be interpreted as if the instrument 98 were valid but with a cautionary note. The psychometric analysis of these three measures (Jenkins Activity Survey, Habits of Nervous Tension, and Autonomic Nervous System Questionnaire) provide support for the notion that instruments standardized on or derived from samples of unknown or predominantly male samples should be checked psychometrically for appropriateness of fit for use on female samples. This is important not only because significant results may be obscured but also because there is valuable information in the differences and similarities of men and women. The Three Group Classification of Subjects Since the classification of subjects resulted in three groups (primary dysmenorrhea - PD, dysmenorrhea - DYS, and no dysmenorrhea - ND) rather than two, the primary focus of the discussion will center on (1) how the discriminating variables relate to the new classification schema and (2) what the meaning of the new group (DYS) might be. To repeat, in terms of the 10 predictors identified in the discriminant function, only Family History of Parasympathetic and Sympathetic Diseases and the Jenkins College Involvement Factor were significant predictors themselves. The seven 99 remaining variables contribute to the formation of a significant function which predicts dysmenorrhea group membership but are not significant when tested by themselves. To examine trends in the three groups, the comparative mean values of the variables were used to identify distinctively high or low values of the groups. Following is a discussion of findings for each of the three groups. Primary Dysmenorrhea Group The primary dysmenorrhea group has a higher incidence of family history of parasympathetic nervous system related diseases and the highest mean on the HNT Dependency Factor. This is interesting since Alexander's (1968) classic work connects parasympathetic diseases (e.g., ulcer, mucous colitis) with underlying dependency conflicts. The HNT Dependency Factor consists of three items, tendency to hold gripe sessions, to confide and seek advice or reassurance, and not to have an urge to be by yourself and get away from it all. To update the terminology used by Thomas and Ross (1963) when naming the factor, it might be renamed the HNT-Relational Factor. So, although these findings were not hypothesized, they do fit in with the groundwork laid in forming the hypotheses that the women who experience primary 100 dysmenorrhea are more relationally defined. In examining the configuration of the anger variables, there is partial support of the original hypotheses. The women with primary dysmenorrhea score highest on the experience of anger, lowest on the expression of anger, and they are most likely to believe that it is inappropriate to express anger. Additionally, the number of ANS sympathetic responders to anger is greatest for this group. Speculating on the trends in these data, this may suggest that although these women experience anger, they may be more likely to experience conflict in expressing it and may then more readily somaticize their feelings. In addition, they may be more unable to risk the temporary severing of a relationship in order to express anger clearly and have an identity of self in the self (Chodorow, 1978) as opposed identity of self in relationship to other. These findings do relate to the study hypotheses that women who experience primary dysmenorrhea have difficulty with the expression of anger. The mixture of a parasympathetic family medical history and sympathetic response to anger is, however, confusing. 101 Dysmenorrhea Group Two possible interpretations of the group labeled dysmenorrhea are (1) the definition of primary dysmenorrhea for this study is too narrow or (2) the women in this group are experiencing the pain of secondary dysmenorrhea as a result of an undiagnosed disease process (e.g., endometriosis) or anatomical problem. Examining the discriminant function data, it appears as if the latter explanation (2) is most appropriate. These women show a very different pattern from the other two groups on the more highly discriminating variables and therefore do not belong in either the primary dysmenorrhea group or the nondysmenorrhea group. They score (significantly) highest on the Jenkins Activity Survey College Involvement Factor. The items (abridged) on this scale are: people agree you take your work seriously; and compared with others I put forth more effort, am more responsible, am more precise, and approach life more seriously. One interpretation of this finding involves the fact that the traditional label given to endometriosis is the ”career woman's disease." 102 Endometrial tissue normally occurs on the inside of the uterus and part of it is shed monthly in the menstrual flow. In endometriosis, endometrial tissue is found on the outside of the uterus, on the fallopian tubes or ovaries, or at other locations in the abdominal cavity. Although the cause of endometriosis is unknown, it is known that full term pregnancy is an effective cure for many women and that endometriosis occurs more often among career-oriented women. Research has not been conclusive in sorting out whether endometriosis is related to the high physiological arousal or to the delay of childbirth. Both can occur when pursuing a career. Because of the’ young age of this sample, no statements can be made about [the incidence of delayed childbirth as it relates to membership in the dysmenorrhea group. However, the other two highly discriminating variables indicate that these women have the greatest incidence of family history of sympathetic nervous system related diseases and of ANS sympathetic nervous system responders to anxiety. Therefore, they may have some evidence of sympathetic nervous system overarousal as was originally hypothesized for the primary dysmenorrhea group. This is a very interesting finding in that the previously estimated error rate of 10% inclusion of undiagnosed secondary dysmenorrhea subjects in with research on primary 103 dysmenorrheic subjects may be low. It is difficult to say with any certainty since the recruitment method in this study was such that no generalized statements regarding occurrence rates can be made from these data. Both previous medical and psychological research on women with primary dysmenorrhea have not used a standardized and clear definition of how they arrive at the diagnosis. It may be that some of the findings linking primary dysmenorrhea with anxiety have tapped into some subjects with early and undiagnosed endometriosis. No Dysmenorrhea Group, The non-dysmenorrheic group (those who do not experience pain) are distinguished by having a higher Health Scale score. Three of the five items on this scale are exercise items and two are diet items. This finding may indicate that good health habits are associated with a more balanced physiology, whether one's tendancy is toward parasympathetic or sympathetic overresponse 'or whether one tends toward somaticization of anger or anxiety. Another interpretation of the higher reported levels of exercise in this group may be related to current research findings in physiology which posit a relationship between exercise and the enhanced ability to manufacture beta endorphins. Endorphins are an 104 endogenous Opiod peptide which have morphine-like activities. Therefore, exercise may possibly mitigate a potential for pain or alleviate the experience of pain (Imura & Nakai, 1981). No research has been published on either opiate receptors or beta endorphin levels in the circulation of women who have dysmenorrhea (Dawood, 1981). Relative to anger, the nondysmenorrheic group scored lowest on the Experience of Anger Scale, highest on the HNT anger factor and had the most positive attitude toward the expression of anger. Therefore, they are more likely to express anger when under stress, and to hold the attitude that it is appropriate to express anger and thus to be less conflicted about anger, in general. Conclusions The meaning of some discriminating variables which predict classification of primary and perhaps secondary dysmenorrhea has been clarified by this study. The two family history variables (sympathetic and parasympathetic) are both significant predictors. Those in the medical profession more often link this type of finding to hypotheses of genetic predisposition while those in the behavioral sciences would likely favor an explanation using social 105 learning passed down through the generations. The nature-nurture controversy goes on. What is important, however, is to recognize that the high incidence of family history of these diseases may help to identify girls at risk to develop dysmenorrhea so that prospective, longitudinal studies may be done. For instance, one might study groups of prepubertal girls at risk and not at risk, applying various intervention strategies (e.g., exercise, dietary modification programs, psychoeducational groups to enhance attitudes and skills related to expression of anger). This study is unique in that it includes variables related to patterns of behavior (e.g., expression of anger, dependency, a high level of college involvement) and related to physical symptoms when under higher levels of stress, anger and anxiety (Habits of Nervous Tension and Autonomic Nervous System Questionnaire). Together this multidisciplinary approach, borrowing from medicine, physiology, sociology and psychology, provides evidence that developing behaviors in terms of learning good health habits and effective strategies toward dealing with anger- and anxiety-provoking situations may be helpful. Future research indicated by this study includes physiological studies which measure whether or not a woman might have different response sensitivity of response of the autonomic nervous system (parasympathetic and/or sympathetic) 106 at the time of onset of menses when her monthly estrogen level is lowest. Also more elaborate scales measuring experience, expression, and attitudes toward anger would be helpful in further examining the relationship of anger, dependency, socialization toward identity of self in relationship to other, and primary dysmenorrhea. Further exploration of correlates with endometriosis is also recommended, especially since higher numbers of women are entering the work force and delaying childbirth. Last, how all of these factors fit in with those enigmatic prostaglandins, the known correlate with primary dysmenorrhea, remains a 'mystery. This study provides some evidence that autonomic nervous system factors are linked with both types of dysmenorrhea, primary and secondary. Since anti-prostaglandin medications are helpful for both types of dysmenorrhea, the links among prostaglandins, the autonomic nervous system, perception of experience, and behavior need to be further explored in a nondualistic and integrated way. LIST OF REFERENCES 107 List of References Akerlund, M. (1979). Pathophysiology of dysmenorrhea. Acta Obstetricia e; Gynecologica Scandanavica, Supplement. 91, 27-32. Alexander, F., French, T. M., & Pollack, G. H. (Eds.) (1968). Psychosomatic specificity. Volume I: Experimental study and results. Chicago: University of Chicago Press. American Psychological Association, Division 35 Task Force (1981). Guidelines' for Nonsexist Research. M. C. McHugg, R. D. Koeske, I. H.- Frieze, Co-Chairs. Asch, R. H., & Greenblatt, R. B. (1978). Primary and membranous dysmenorrhea. Southern Medical Journal, 11, 1247-1249. 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New York: McGraw Hill. Yabrov, A. (1980). Adequate function of the cell: Interactions between the needs of the cell and the needs of the organism. Medical Hypothesis, g, 337-374. Ylikorkala, 0., 6 Dawood, M. Y. (1978). New concepts in dysmenorrhea. American Journal gfi Obstetrics and Gynecology, 130, 833-847. APPENDIX MI CHI GAN STATE UNI VERS I TY Department of Psychology-Snyder Hall East Lansing, MI 48824 May 31, 1983 Dear Student, Are you between the ages of 18 and 25? If so you may have a chance to WIN $20. I am a graduate student in Clinical Psychology and am conducting a health psychology research study. Dr. Elaine Donelson, Professor of Psychology1 is supervising the projeét. Some behavior patterns and emotions have been linked with physical symptoms. The purpose of this study is to explore these relationships as they occur for women who have menstrual cramps and those who don't. In addition, women's responses for some parts of the questionnaire will be compared to men's to see how they are different and how they are the same. The eventual aim of this research is not to find that emotions or behavior cause pain, disease, or discomfort, but rather to make people aware of potentially health-related and disease-related signs so that they may participate more actively in maintaining health rather than recovering from or treating disease or discomfort. One requirement for all potential WOMEN subjects is that they be between the ages of 18 and 25. In addition, women who are taking birth control pills should NOT participate since oral contraceptives are known to alter certain menstrual symptoms. Therefore, WOMEN participating in this study SHOULD NOT be taking oral contraceptives. NOW--HOW CAN YOU WIN $20??? In order to provide an extra incen- tive for you to participate, I am conducting a drawing. For the first 150 people to respond, an independent party will draw three names. Therefore, each person will have a 1 in 50 chance of winning $20. The drawing will be held on June 10. Winners will be telephoned and/or sent their check through the mail. The questionnaire should take approximately 1 hour to complete and all replies will be strictly confidential. If you are willing to participate, please take one of the packets marked for either FEMALE or MALE participants. Complete instructions will be inside the envelope. 07 M y K. Roberson PURPOSE OF STUDY Some behavior patterns and emotions have been linked with physical symptoms. The purpose of this study is to explore these relationships as they occur for women who have menstrual cramps and those who do not. In addition, women's responses .for some parts of the questionnaire will be compared to men's to see how they are different and how they are the same. The eventual aim of this research is not to find that emotions or behavior cause pain, disease, or discomfort, but rather to make people aware of potentially health-related and disease-related signs so that they may participate more actively in maintaining health rather than recovering from or treating disease or discomfort. INSTRUCTIONS The data collected for this study will be analyzed anonymously. However, I must have your name on the following enclosed forms: (a) The Drawing Ticket. This is so that you can be notified if you are a winner. (b) A Request for Results. Complete this form if you would like a one to two page abstract of the results of this study. I will mail one to you in the Fall of 1983. (c) A research consent form. This informs you of your rights and is required by the MSU University Committee for Research on Human Subjects. All of the above-mentioned documents will be separated from the questionnaire (also enclosed) immediately upon receipt at my office. No identifying marks will occur on the questionnaire forms themselves. Therefore, your answers will be completely anonymous. Please complete each portion of the packet in sequence. Explicit instructions occur on each document. If at any time during or after the process of completing the survey you have any questions, feel free to call me at 353-5035 (office) or 351-1143 (home). When you are finished, please put all materials in the return envelope and then into the campus mail. There is campus mail pick up in each departmental office and in the dorms. Just ask the secretary or receptionist where the outgoing campus mail is placed. Thank you again for participating. Good luck in the drawing! Mary K. Roberson Michigan State University Department of Psychology East Lansing, Michigan 1. RESEARCH CONSENT FORM Health Psychology Study I have freely consented to take part in a scientific study conducted by Mary K. Roberson under the supervision of Dr. Elaine Donelson, Professor of Psychology. The study has been explained to me and I understand the explanation that has been given and what my participation will involve. I understand that I am free to discontinue my participation in the study at any time without penalty. I understand that the results of the study will be treated in strict confidence and that I will remain anonymous. With these restrictions, results of the study will be made available to me at my request. I understand that my participation in the study does not guarantee any beneficial results to me. I understand that, at my request, I can receive additional explanation of the study after my participation is completed. Signature Date HEALTH PSYCHOLOGY RESEARCH STUDY Please check the response that most accurately describes you or your parents. 1. How old are you? N a What is your marital status? single divorced widowed separated married remarried cohabitating (living with a person with whom you are having a romantic relationship) \lO‘U‘PMNH o e a e e o s 3. How much school did you and your parents complete? You Mother Father ____ ___ 1a. doctoral level degree ___ ___ lb. masters degree ___ ____ 2., bachelors degree ___ ___ ____ 3. some college (at least one year) ___ ___ 4. high school diploma ___ ___ 5. through the 10th grade ___ ___ 6. through the 8th grade ____ ___ 7. 7th grade or less 4. What is the ethnic or racial background of your parents. Mother Father Caucasian Black Hispanic Native American Asian American Other (specify ) O‘U'IIFWNi—i 01 What was the religion your parents and you were brought up in? «2 cu Mother Father . Catholic . Protestant . Jewish (Orthodox? ___ yes: ___ no) . Other (specify) . None mentor-1 Ch What is your present employment status? List all choices that apply. . homemaker, full time . student, part time . student, full time . employed, full time . employed, part time . unemployed, looking for work . other (please specify ) \lmmlthH N) If you are employed, what is your job title? Briefly describe your work. 8. If your parents have been employed five years or more, what is/was his or her most advanced job title? Mother: Father: 9. Briefly describe what work he or she does/did. Mother: Father: 10. Check the space under "you” or your parents if you KNOW that he, she or you have had any of the following medical disorders. - Medical Disorder You Father Mother. Rheumatoid Arthritis . . . Cardiovascular Diseases . . (e.g., hypertension, heart disease, arterio- sclerosis) Ulcer . . . . . . Mucous Colitis . . Ulcerative Colitis. Cancer . . . . . . Asthma . . . . . . NH 0 o O O O O O O 0 O O O \iO‘U’IIF-w O O O O O 11. Check the space under each of your grandparents' names if you KNOW that he or she had any of the following medical disorders. Your Mother's Your Father's Medical Disorder Mother Father Mother Father Rheumatoid Arthritis 1. ___ Cardiovascular Dis. . 2. (e.g., hypertension, heart disease, arteriosclerosis) Ulcer . . . . . . . Mucous Colitis . . Ulcerative Colitis Cancer . . . . . . Asthma . . . . . . o s o a o \la‘mipw a e o e s 12. Do you eat breakfast regularly? 1. yes 2. no 13. Do you exercise regularly? 1. yes 2. no I l 14. How many days per week do you usually engage in exercise 01' 1. 2. 3. 4. physical activity? days per week or 2 days per week to 5 days per week or 7 days per week mwF-‘O Please specify what type of physical activities or exercise you engage in. 16. How would you characterize your activity level in relation to your peers? 17. 1.1 (I) O ___ 2 mtthH DO 1. 2. 3. 4. very minimal; sedentary less than average moderate or average more than average very active you smoke cigaretteS? no I smoke less than 1/2 pack per day. I smoke 1/2 to 1 pack per day. I smoke more than 1 pack per day. Do you eat meat? 1. 3. yes, I eat all kinds of meat. yes, but I avoid red meat and eat mostly chicken and fish. no Habits of Nervous Tension Survey Whenever you find yourself in situations of undue pressure or stress, how do you usually react? (Underline all reactions which are characteristic of you.) 1. Exhaustion or excessive fatigue 2. Exhiliaration 3. Depressed feelings 4. Uneasy or anxious feelings (sighing, tight feelings in throat or chest, dry mouth, clammy hands, etc.) 5. General tension ("keyed up" feelings--difficulty in be- coming relaxed) 6. Increased activity 7. Decreased activity 8. An increased urge to sleep 9. Increased difficulty in sleeping 10. Increased urge to eat, I 11. Loss of appetite 12. Nausea l3. Vomiting l4. Diarrhea 15. Constipation l6. Urinary frequency 17. Tremulousness or shakiness 18a. Anger -- expressed 18b. Anger -- concealed 19. 20. 21. 22. 23. 24. 25. Gripe sessions Concern about your physical health A tendency to check and recheck your work to assure your- self of accuracy An urge to confide and seek advice or reassurance An urge to be by yourself and get away from it all Irritability with concern as to who is to blame Thinking about the meaning of the event with no reactions out of the ordinary Briefly describe your chief reactions to pressure or stress and the situations which they most commonly occur (competitions, examinations, family situations, etc.). Jenkins Activity Survey for Students Please answer the following pages by marking the answers that are true for you. Each person is different, so there are no "right" or "wrong” answers. For each of the following items, please check the number of the one answer that best describes you. 1. Do you ever have trouble finding time to get your hair cut or styled? - 1. never 2. occasionally 3. almost always 2. Does college "stir you into action"? 1. less often than most college students 2. about average 3. more often than most college students 3. Is your everyday life filled mostly by 1. problems needing solutions. 2. challenges to be met. 3. a rather predictable routine of events. 4. not enough things to keep me interested or busy. 4. Some people live a calm, predictable life. Others find them- selves often facing unexpected changes, frequent inter- ruptions, inconveniences or ”things going wrong." How often are you faced with these minor (or major) annoyances or frus- trations? 1. several times a day 2. about once a day 3. a few times a week 4. once a week 5. once a month or less 5. When you are under pressure or stress, what do you usually do? 1. Do something about it immediately. 2. Plan carefully before taking action. 6. Ordinarily, how rapidly to you eat? 1.’ I'm usually the first one finished. 2. I eat a little faster than average. 3. I eat at about the same speed as most people. 4. I eat more slowly than most people. \l (D o \O 1.1 O O ....1 1. 12. Has your spouse or some friend ever told you that you eat too fast? 1. yes, often 2. yes, once or twice 3. no, no one has told me that How often do you find yourself doing more than one thing at a time, such as working while eating, reading while dressing, figuring out problems while driving? 1. I do two things at once whenever practical. 2. I do this only when I'm short of time. 3. I rarely or never do more than once thing at a time. When you listen to someone talking, and this person takes too long to come to the point, do you feel like hurrying him or her along? 1. frequently 2. occasionally 3. almost never How often do you actually "put words in his/her mouth" to speed things up? . l. frequently 2. occasionally 3. almost never If you tell your spouse or a friend that you will meet them somewhere at a definite time, how often do you arrive late? 1. once in a while 2. rarely 3. I am never late Do you find yourself hurrying to get places even when there is plenty of time? 1. often 2. occasionally 3. rarely or never 13. Suppose you are to meet someone at a public place (street corner, building lobby, restaurant) and the other person is already 10 minutes late. Will you 14. 1.1 5. H 03 O H 7. 1.1 (I) O 1. 2. 3. sit and wait? walk about while waiting? usually carry some reading matter or writing paper so you can get something done while waiting? When you have to "wait in line," such as at a restaurant, a store, or the post office, do you 1. 2. 3. 4 accept it calmly. feel impatient but do not show it. feel so impatient that someone watching could tell you were restless. refuse to wait in line, and find ways to avoid such delays. When you play games with young children about 10 years old, how often do you purposely let them win? tthi-J 15>me most of the time half the time only occasionally, never most people consider yourself to be definitely hard driving and competitive. probably hard-driving and competitive. probably more relaxed and easy going. definitely more relaxed and easy going. Nowadays, do you consider yourself to be 1. 2. 3. 4. How bWNH definitely hard driving and competitive. probably hard-driving and competitive. probably more relaxed and easy going. definitely more relaxed and easy going. would your spouse (or closest friend) rate you? definitely hard driving and competitive. probably hard-driving and competitive. probably more relaxed and easy going. definitely more relaxed and easy going. 19. How would your spouse (or best friend) rate your general level of activity? 1. Too slow. Should be more active. 2. About average. Is busy most of the time. 3. Too active. Needs to slow down. N 0. Would people who know you well agree that you take your work seriously? 1. Definitely yes. 2. Probably yes. 3. Probably no. 4. Definitely no. N 1. Would pe0ple who know you well agree that you have less energy than most people? 1. Definitely yes. 2. Probably yes. 3. Probably no. 4. Definitely no. 22. Would people who know you well agree that you tend to get irritated easily? 1. Definitely yes. 2. Probably yes. 3. Probably no. 4. Definitely no. N 3. Would people who know you well agree that you tend to do most things in a hurry? l. Definitely yes. 2. Probably yes. 3. Probably no. 4. Definitely no. N 11:. 0 Would people who know you well agree that you enjoy "a contest" (competition) and try hard to win? 1. Definitely yes. 2. Probably yes. 3. Probably no. 4. Definitely no. 25. Would people who know you well agree that you get a lot of fun out of your life? N N N1 01 28. 29. 31. l. Definitely yes. 2. Probably yes. 3. Probably no. 4. Definitely no. How was your "temper" when you were younger? l. fiery and hard to control 2. 3. 4. How strong, but controllable no problem I almost never got angry is your "temper" nowadays? l. fiery and hard to control 2. strong, but controllable 3. no problem 4. I almost never get angry When Y°U1 1. 2. 3. you are in the midst of studying and someone interrupts how do you usually feel inside? I feel O.K. because I work better after an occasional break. I feel only mildly annoyed. I really feel irritated because most such interruptions are unnecessary. How often are there deadlines in your courses? (If deadlines occur irregularly, please circle the closest answer below.) IwaH daily or more often weekly monthly never Do these deadlines usually 1.1 O O carry minor pressure because of their routine nature. carry considerable pressure, since delay would upset things a great deal. Do you ever set deadlines or quotas for yourself in courses or other things? 1. 2. 3. no yes, but only occasionally yes, once per week or more often 32. b.) 3. w Uh o (A, U" s 36. 37. When you have to work against a deadline, is the quality of your work 1. better. 2. worse. 3. the same. (Pressure makes no difference.) In school do you ever keep two projects moving forward at the same time by shifting back and forth rapidly from one to the other? 1. no, never 2. yes, but only in emergencies 3. yes, regularly Do you maintain a regular study schedule during vacations such as Thanksgiving, Christmas, and Easter? 1. yes 2. no 3. sometimes How often do you bring your work (or study materials related to your courses) home at night? 1. rarely or never 2. once a week or less often 3. more than once a week How often do you go to the university when it is officially closed (such as nights or weekends)? If this is not possible, circle here: 0. l. rarely or never 2. occasionally (less than once a week) 3. once or more a week When you find yourself getting tired while studying, do you usually 1. slow down for a while until your strength comes back. 2. keep pushing yourself at the same pace in spite of the tiredness. When you are in a group, do other people tend to look to you to provide leadership? 1. rarely 2. about as often as they look to others 3. more often than they look to others Do you make yourself written lists of "things to do" to help you remember what needs to be done? 1. never 2. occasionally 3. frequently IN EACH OF THE FOLLOWING QUESTIONS, PLEASE COMPARE YOURSELF WITH THE AVERAGE STUDENT AT YOUR UNIVERSITY. PLEASE CHECK THE MOST ACCURATE DESCRIPTION. 40. lb IF 1% w N H e s 0 1p 4. HM In the amount of effort put forth, I give . much more effort. . a little more effort. 3. a little less effort. . much less effort. In sense of responsibility, I am 1. much more responsible. 2. a little more responsible. 3. a little less responsible. 4. much less responsible. I find it necessary to hurry 1. much more of the time. 2. a little more of the time. 3. a little less of the time. 4. much less of the time. In being precise (careful about detail), I am 1. much more precise. 2. a little more precise. 3. a little less precise. 4. much less precise. I approach life in general 1. much more seriously. 2. a little more seriously. 3. a little less seriously. 4. much less seriously. Autonomic Nervous System Questionnaire Instructions: Please mark the severity of the symptoms as follows. When you feel ANXIOUS, please mark an ”X": when you feel ANGRY or AGGRESSIVE, mark an ”0" under the appropiate column. For example, when you are anxious, how often do you experience heart burn? There should be both an "X" and an "O" for each symptoms when you are finished. Very Some- Rare or Frequently Often times Never 1. heart burn 2. diarrhea 3. urge to frequent urination 4. one or more muscles feel weak 5. sleeping more than usual 6. flushing of the face 7. waterish mouth 8. excessive appetite 9. feel sexually aroused 10. have difficulty breathing ll. stomach growls 12. dry palms Very Frequently Often Some- times Rare or Never 13. constipation 14. one or more muscles feel tense 15. sleeping less than usual 16. pallor of the face 17. cold feet 18. wet hands 19. wet armpits 20. heart palpitations 21. dry mouth 22. goose pimples 23. butterflies in stomach 24. poor appetite Please make sure you have gone through the questionnaire marking both an "0" under the appropriate headings for when you feel angry or aggressive and an “X" for when you feel anxious. Experience of Anger Questionnaire Adolescence is a time when many children begin to develop a clearer sense of who they are apart from their parents. This normal developmental phase is quite often difficult for families. I would like to ask you some questions about your high school years. . 1. Were you living with both of your parents during most of your high school years? a. yes b. no (please specify who you were living with that was responsible for you ) 2. Who would you turn to most of the time when you had a big problem? a. mother b. father c. sister d. brother e. a friend f. a teacher or counselor at school 9. other (specify ‘ ) h. no one 2a. How many brothers and sisters do you have? 2b. What is your position in the birth order of your brothers and sisters if "1" is the oldest? 3. During incidents when you and your mother disagreed about something that was important to you, which of the following feelings describes how you felt? a. angry b. hurt c. afraid d. sad e. I did not feel any emotions. f. other (please specify ) 13> When it was your father and you disagreeing, how did you feel? angry hurt afraid sad I did not feel any emotions. other (please specify ) H10 010 on: Think of an actual event when you were very angry with someone else (e.g., parent, friend, teacher, etc.) during high school. Answer the following questions about the event. 5. C» Read over the following responses and choose the one which most applies to you during the event. didn't ever get angry during high school. felt disappointed and hurt. felt dissatisfied with the other person. was irritated at the other person. was somewhat angry at the person. was very angry at the person. 141160100111 1—11—11—11—11—11—1 Who was the person? parent other relative person with whom you were having a romantic relationship friend teacher other (specify ) HHDCLOO‘D’ What gender was the person? a. male b. female Briefly describe what it was that you were angry about. 9. Did you let the person know you were angry? a. yes. Briefly describe your interaction. b. no. What were some of your thoughts during the event. 11. Did you feel hurt or sad, too? a. yes b. no 12. What did you do after the event? How did you feel? What emotions were you having? 13. During your high school years were there any patterns to who provoked your anger and who didn't? For example, did you get angry only at one person in particular? One or more groups of people (teachers, parents, siblings, girlfriends, etc.)? Did you never get angry at any person or persons or groups of people? 14. Is there a pattern to who makes you angry now? Please describe it. 15. Do you think it is appropriate to express anger at someone? 1. Yes. Under what circumstances? 2. No. Why not? What should you do instead? 16. Do you NOT get angry when you feel you should? 1. Often 2. Sometimes 3. Never C O 0 0b 0 O 01 o 0‘ Menstrual Questionnaire To the best of your memory, how old were you when you first menstruated? 10 years old or younger 11 years old 12 years old 13 years old 14 years old 15 years old 16 years or older \iONU'itwaH Have you had a gynecological check up within the last year? 1. yes 2. no (when was your last check up? ) Apart from vaginal discharges and infections, did any doctor ever mention any abnormalities in your uterus, ovaries, or fallopian tubes? 1. yes (please specify ) 2. no . Is your cycle about the same length every month from the time of onset of one period to the time of onset of the next? In other words, do they vary in length as little as 4 days from month to month? 1. yes (please specify approximate length of cycle ) 2. no (please specify range of different lengths ) Are you taking oral contraceptives (birth control pills)? 1. yes 2. no, but I have in the past 3. no, I have never taken birth control pills How many full term deliveries have you experienced? . none . one . two . three or more pwuu3w Do you use an intrauterine device as a method of birth control? 1. yes (how long? ) 2. no \l e (I) Premenstrual Syndrome is a set of symptoms that many women experience. The syndrome is characterized by physical symptoms such as water retention, pain, fatigue, feeling of bloatedness and weight gain and psychological or behavior changes such as feelings of depression, irri- tability and lack of concentration. These symptoms occur before the onset of menstrual flow. To what degree do you experience this syndrome? No. I don't experience Premenstrual Syndrome. Yes. Slightly. Yes. To a moderate’degree. Yes. I experience Premenstrual Syndrome to a large degree. IFNNH sees Primary dysmenorrhea is defined as pain when having a period. It is often referred to as cramps. When you first started menstruating, were the first few periods painful (did you have cramps)? 1. yes 2. no 3. I can't remember 9. Did you either experience pain or take medication so that you would not have pain at the time of your period last month? 1. yes 2. no Did you experience pain and/or take medication at the time of your period two months ago? 1. yes 2. no Did you have cramps and/or take medication to prevent cramps during most of your periods during the last year? 1. yes 2. no Did you ever experience menstrual pain in the past? 1. yes (please specify at what ages ) 2. no If you answered ”NO" to both questions 9 AND 10, please skip ahead to questions 23 and 24 on page 25. If you answered "YES" to either questions 10 or 11, please answer the following questions numbered 13 through 24. 13. When does your pain begin in relation to your period? 1. the day before my period begins 2. the day my period begins 3. the second day of my period 4. none of the above 1.1 4. How long does your pain last? 1. less than one day 2. one day 3. two days 4. greater than two days 15. Where does your pain occur most? Please mark the fol- lowing diagram. Shade in the area(s) where you hurt most. 16. 17. 1.1 8. N 0. CD" 0‘ 01 0k (”NH Does the pain usually interfere with the concentration you give to your work or recreational activities? Read through the following responses and check the response that best describes you during the time that you are in pain. 1. I find that my attention span increases during menstruation 2. My concentration is no different. 3. My attention is sometimes carried away from what I am doing. 4. My attention is carried to the pain quite a lot. To what extent does the pain interfere with your activities? Read through the following responses and check the response that best describes you during the time when you are in pain. 1. It does not interfere. 2. I must limit my physical activity. 3. I would like to limit my physical activity, but I don't. 4. I must lie down and rest. How much time from your regular activities must you usually take because of the pain? 1. It does not interfere at all with my activities. 2. less than one day 3. one day 4. two days 5. more than two days What, if anything, do you take for your pain most of the time. Please read over all the responses and choose the one you take most. . I take no medication at all. . Aspirin . Tylenol, or other non-aspirin preparations (e.g., Anacin-3) . Over-the counter medications for menstrual pain/blues (e.g., Pamprin, Midol) Prescription medications for menstrual pain (e.g., Motrin, Naprosyn) . Prescription medications for pain in general (e.g., Darvon, Tylenol #3) I'm not sure what I take. Other (please specify ) 21. 23. 24. Does this medication relieve your pain? 1. The pain goes away completely. 2. The pain is still there but I don't notice it much, and it does not interfere with my activities. 3. I get some relief but the pain is still quite noticeable. 4. I get very little or no relief at all. Do you do anything else to relieve the pain either when it is occurring or as a regular part of your health care? 1. yes (please specify 2. no Which of the following sentences describes your interaction with your doctor regarding the subject of your menstrual pain? 1. The doctor asked me if I ever have pain with my period. 2. I brought up the fact that I have pain with my period. 3. The subject of painful periods was never brought up. What are your ideas, attitudes, or feelings about having cramps?