http://informahealthcare.com/gye ISSN: 0951-3590 (print), 1473-0766 (electronic) Gynecol Endocrinol, 2014; 30(5): 377–380 ! 2014 Informa UK Ltd. DOI: 10.3109/09513590.2014.887066
PMS AND ALEXITHYMIA
Association between premenstrual syndrome and alexithymia among Turkish University students Ahmet Hamdi Alpaslan, Kadriye Avc|, Nusret Soylu, and Hanife Uzel Ta¸s 1
Department of Child and Adolescent Psychiatry, 2Department of Public Health, Faculty of Medicine, Afyon Kocatepe University, Afyonkarahisar, Turkey, and 3Department of Child and Adolescent Psychiatry, Faculty of Medicine, Inonu University, Malatya, Turkey
Abstract
Keywords
Premenstrual syndrome (PMS) is a heterogeneous disorder, which includes physical, cognitive, affective and behavioral symptoms. The aim of this study was to determine the factors affecting PMS and the relationship between PMS and alexithymia. The research was performed with 308 students. Data were collected using a demographic questionnaire, the Toronto alexithymia scale (TAS-20) and a premenstrual assessment form (PAF). The prevalence of PMS in our sample was 66.6%. The contributing factors to PMS were having a history of psychiatric treatment and having a smoking habit (p50.05). The PMS group showed higher scores than the non-PMS group on all the items of the TAS-20 which includes the three factors: difficulty in identifying feelings, difficulty in describing feelings and externally oriented thinking (p50.05). The alexithymic students showed higher scores on all PAF subscales (p 0.001). Further studies are needed to determine the probable role of alexithymia in the pathogenesis of PMS.
Alexithymia, high school students, premenstrual syndrome
Menstruation is a physiological event that starts with adolescence, continues until menopause and covers 35–40 years of a woman’s life. Premenstrual syndrome (PMS) is a psychoneuroendocrine disorder, which is associated with cognitive, physical, behavioral and emotional symptoms that emerge during the last week of the menstrual cycle and end a few days after the onset of the follicular period [1,2]. The symptoms include alterations in mood, including nervousness, anxiety, depression and thoughts of worthlessness, as well as depleted energy, difficulty in concentration, swelling/tenderness of the breasts and joint pain. The etiology and the physiopathology of PMS are not completely known, and there are no specific examinations and laboratory findings for diagnosis. The number of women complaining of PMS is increasing. In studies with large samples, the prevalence of PMS was reported to be 31% in USA, 79% in Japan, 75% in Malaysia, 24% in UK and 73% in Spain [3]. A study carried out in Turkey with individuals aged 16–25 years reported that the prevalence of PMS ranged from 17.2% to 67.5% [4]. Studies have reported that the lifelong prevalence of psychiatric disorders, especially depression, is high in women with PMS [5,6]. People with alexithymia have difficulty recognizing, defining and verbalizing emotions, and the condition is accompanied by poor imagination [7]. Research has shown that alexithymia is associated with personality disorders, eating disorders, substance
Address for correspondence: Ahmet Hamdi Alpaslan, Department of Child and Adolescent Psychiatry, Faculty of Medicine, Afyon Kocatepe University, Afyonkarahisar, Turkey. Mob: +90 533 581 66 32. Fax: +90 272 246 33 00. E-mail: [email protected]
Received 29 May 2013 Revised 23 December 2013 Accepted 21 January 2014 Published online 11 February 2014
abuse disorders, depression, sexual dysfunction, anxiety disorders and childhood traumas [8]. The prevalence of alexithymia is 10–18% in the general population and 7.6–39.8% in psychiatry outpatients [9]. De Berardis et al. [10] showed that alexithymic women with PMS have higher rates of poor appearance evaluation and body dissatisfaction. With modern life styles and social changes, women experience lower number of pregnancies and lactation periods and hence lower number of menstrual cycles. PMS may have a substantial influence on the lives, daily activities and academic achievements of young girls. As far as we know, there has been no Turkish study of the relation between PMS and alexithymia. The aim of the present study was to determine the relation between PMS and alexithymia, the prevalence of PMS, and the risk factors associated with the severity of PMS.
Methods
20 14
Introduction
History
Participants The study was conducted with university students aged 19–25 years (N ¼ 328) between January and March 2013 who volunteered to participate in the study. Socio-demographic and menstruation information forms were prepared for the study. While conducting the questionnaires verbal and written consent of the students was obtained after the purpose of the study was explained. The questionnaire forms were completed within 45 min. BMI was calculated using self-reported data on height and weight. Exclusion criteria included: (a) having a metabolic disease or psychiatric disorder, (b) using hormonal contraceptives and (c) using other prescribed medicines (e.g. antidepressants, antipsychotics or mood stabilizers). Twenty students were excluded from the study because of missing data. No participation fees were paid.
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A. H. Alpaslan et al.
Measures
Gynecol Endocrinol, 2014; 30(5): 377–380
Table 1. Comparison of variables in the subjects with or without PMS.
Toronto alexithymia scale The Toronto alexithymia scale (TAS-20) utilizes a 5-point Likert scale. The TAS-20 has three subscales. The cut-off scores for theTAS-20 were those provided by Bagby et al. [11]. The total scores of the TAS-20 were categorized into two groups as follows: a score of at least 61 indicated alexithymic and less than 61 non-alexithymic. We used the validated Turkish version of the TAS-20 [12]. In our study, Cronbach’s value for the TAS-20 was 0.86. Premenstrual assessment form The premenstrual assessment form (PAF), a retrospective selfreport questionnaire, consists of 95 questions [13]. The reliability and the validity of the Turkish version of the PAF have been established [14]. Total PAF scores were divided into the number of questions for each participant. According to the results, symptom severity was assessed as follows: values 51.7 were regarded as ‘‘no PMS’’, over 1.7 were regarded as ‘‘PMS’’. The 18 subscales of the PAF are summarized in Table 3. The Chronbach Alpha coefficient which was calculated in order to determine the internal consistency of the scale was found as 0.83. Statistical analysis Descriptive statistics were used to analyze the demographic data. The differences between subjects were tested by using analyses of covariance (ANCOVA) with alexithymia and PMS positivity/ negativity as factors and age, BMI, smoking and state of regular exercise as covariates. The 2 analyses were used to compare categorical variables. Partial eta-squared statistics was also calculated to estimate effect sizes. Differences were considered significant if the p values were 50.05.
Characteristics Age BMI Age at menarche (year) Menstrual bleeding duration (days) Menstrual cycle duration (days)
PMS Mean ± SD
Non-PMS Mean ± SD
t
p*
20.75 ± 1.83 21.14 ± 2.40 13.78 ± 1.25 5.77 ± 1.36
20.56 ± 2.06 20.88 ± 3.06 13.61 ± 1.06 5.78 ± 1.12
0.812 0.814 1.166 0.074
0.417 0.416 0.244 0.941
29.49 ± 7.43
28.41 ± 7.03
1.219
0.224
N (%)
2
py
3.890
0.049
3.154
0.076
0.202
0.653
3.867
0.049
0.621
0.431
0.140
0.709
0.752
0.386
N (%)
Smoking Yes 35 (17.1) 9 (8.7) No 170 (82.9) 94 (91.3) Dysmenorrhea Yes 169 (82.4) 76 (73.8) No 36 (17.6) 27 (26.2) Status of using analgesic at menstrual duration Yes 115 (56.1) 55 (53.4) No 90 (43.9) 48 (46.6) History of psychiatric treatment Yes 27 (13.2) 6 (5.8) No 178 (86.8) 97 (94.2) State of regular exercise Yes 35 (17.1) 14 (13.6) No 170 (82.9) 89 (86.4) Income level High 42 (20.5) 23 (22.3) Low-middle 163 (79.5) 80 (77.7) Status of school performance Bad-middle 78 (38.0) 34 (33.0) Good 127 (62.0) 69 (67.0) MV, mean value; SD, standard deviation. *Student’s t-test p value. yChi-squared p value.
Results A total of 308 female students with ages ranging from 19 to 25 years (20.7 ± 1.9) were included in the study. Of the cases, 80.5% (n ¼ 248) were from a nuclear family, 18.2% from an extended family and 1.3% from a divorced family. In addition, 211% of the subjects were from a high socioeconomic category, 76% (n ¼ 234) were from a middle socioeconomic category and 2.9% were from a low economic category. A total of 63.6% (n ¼ 196) of the students reported that their school achievement was satisfactory, 33.8% said it was moderate and 2.6% said it was low. Among the subjects, 14.3% smoked and 15.9% took regular physical exercise. The mean age of onset of menarche was 13.72 ± 1.19, menstruation occurred at a mean of 29.13 ± 7.31 days and each menstruation period lasted a mean of 5.77 ± 1.29 days. A total of 79.5% (n ¼ 245) of the participants reported that they experienced pain during the menstruation period, and 55.2% used analgesics during the menstruation period. Table 1 shows some characteristics of the subjects who have PMS according to the PAF and those who do not have PMS. The rate of PMS was higher in those who smoke (p ¼ 0.049) and those who have a history of psychiatric treatment (p ¼ 0.049). Table 2 shows the scores obtained on the TAS-20 of the subjects with and without PMS. The results of ANCOVA controlling for age, BMI, smoking and state of regular exercise showed (effect sizes: ranged from 0.036 to 0.203) that subjects with PMS were more alexithymic (higher scores on the TAS-20 Total, TAS-1, TAS-2 and TAS-3, p50.05). Table 3 presents the scores of those who are alexithymic and those who are not according to the TAS-20. The results of ANCOVA controlling for
age, BMI, smoking and state of regular exercise showed (effect sizes: ranged from 0.055 to 0.144) that alexithymic subjects had higher scores on all subscale scores of the PAF (p 0.001).
Discussion To our knowledge, this is the first study in Turkey to evaluate the relationship between alexithymia and PMS. The prevalence of PMS in our sample was 66.6%. In previous studies in USA and other Western countries, the prevalence rates varied from 24% to 79% [3]. Research conducted in Turkey showed that the prevalence of PMS is between 17.2% and 90% [15]. The variability of PMS rates in the literature may be due to the fact that the studies were conducted with different age groups and with populations from different sociocultural backgrounds. The results of studies investigating the effect of individual, familial and menstrual characteristics on the prevalence of PMS are conflicting [5,16]. In our study, the frequency of PMS was not affected by socio-economic and sociocultural parameters (p40.05). Sezgin et al. [17] reported that PMS was higher in smokers than in non-smokers, and Demir et al. [18] reported a significant relationship between smoking habits and PMS. In our study, the smokers had a higher frequency of PMS than the nonsmokers. Smoking can alter levels of estrogen, progesterone and testosterone, and this may be linked to the development of PMS [16,19,20]. One previous study reported an association between obesity, regular exercise and dietary habits and PMS [19], whereas another reported no association [20,21]. In the present study, there was no
Association between PMS and alexithymia
DOI: 10.3109/09513590.2014.887066
relation between the subject’s Body Mass Index (BMI), exercise frequency and PMS. A similar finding was obtained in the studies of Demir et al. [18] and Lustyk et al. [22]. They found no significant difference in the BMI between PMS and a non-PMS group. The young age of the population in the current study and the paucity of obesity among the participants may explain our findings. In our study, there was no statistically significant difference among the PMS and the non-PMS group in variables related to menstruation (the age of first menses, duration of the menstrual cycle, duration of menstrual bleeding and dysmenorrhea). Conversely, some previous studies reported an association between PMS, the menstrual cycle and dysmenorrhea [16]. A study carried out in Turkey found no relation between the age of first menses, the duration of the menstrual cycle and the prevalence of PMS [5]. In the present study, although the rate of dysmenorrhea was higher in the PMS group, the difference was not statistically significant difference compared to the non-PMS group. In addition, other studies reported no relation between dysmenorrhea and PMS [23,24]. The fact that the subjects were not questioned in detail about the severity of the dysmenorrhea may explain the insignificant difference. In the present study, 52.2% of all the participants used analgesics during the menstruation period. However, the scales used depended on selfreporting, which may have influenced the objectivity of the data. Table 2. Total scores obtained on the TAS-20 and the TAS-20 subscales of those who have PMS and those who do not have PMS controlling for age, BMI, smoking and state of regular exercise.
Variables TAS-20 total TAS-1: difficulty in identifying feelings TAS-2: difficulty in describing feelings TAS-3: externally oriented thinking
PMS (205) Non-PMS (103) (mean ± SD) (mean ± SD)
p*
p2
52.28 ± 8.99 16.98 ± 5.28
44.55 ± 7.37 12.48 ± 3.55
50.001 0.150 50.001 0.203
13.47 ± 3.28
11.52 ± 3.50
0.001 0.062
21.83 ± 3.49
20.55 ± 3.14
0.047 0.036
MV, mean value; SD, standard deviation. *ANCOVA, adjusted for age, BMI, smoking and state of regular exercise, partial eta-squared is effect size for ANCOVA.
379
Many previous studies have demonstrated the association of PMS with psychopathology [9,16,20]. Higher rates of PMS were reported in those who have a history of psychiatric disorders and those whose first-degree relatives have such a history [25]. One study reported that 18% of female college students meeting criteria for PMS had affective disorders during 4 years of follow up [6]. Likewise, in the present study, the rate of PMS was significantly higher among the students who had received psychiatric treatment in the past. The results of our study emphasize the need for a careful assessment of the history of psychiatric disorders in women with PMS. Some studies have examined the relation between PMS and alexithymia [10,26]. To the best of our knowledge, this is the first study to evaluate the relationship between PMS and alexithymia in Turkey. In our study, when we compared the groups, the PMS group showed higher scores on all the rating scales of the TAS-20, which includes three factors. There was a statistically significant difference between the groups. When we divided all the participants into two groups, an alexithymic group (who scored 61 or more on the TAS-20) and a non-alexithymic, the alexithymic group had higher scores on all the PAF subscales even when the results were controlled for age, BMI, smoking and state of regular exercise. Alexithymia reflects cognitive deficits in processing emotions because alexithymic individuals are psychologically poorly equipped. PMS has physical, cognitive, affective and behavioral symptoms. Alexithymia also has cognitive and affective features. Alexithymia may play a modulating role in the expression of symptoms in women with PMS. The probable role of alexithymia in the pathogenesis of PMS should be tested in future studies. The first limitation of our study is the use of a convenience sample of university students. Although our university-based sample was comparable in size and composition to other research studies in this area, future research should consider the strength of using a larger, more generalized sample, such as a communitybased participant pool. As the present study is a cross-sectional one, it does not allow us infer a causality relation between PMS and alexithymia. Another limitation of the present study is that our data (e.g. BMI) are based upon self-reporting by the subjects. Finally, in our study, we did not evaluate potential depressive or anxiety symptoms which are known to be associated with PMS and alexithymia in clinical as well as in non-clinical populations.
Table 3. Scores obtained on the PMS subscales of those with and without alexithymia controlling for age, BMI, smoking and state of regular exercise.
Subscales of PAF 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.
Low mood Endogenous depressive features Instability Atypical depressive features Hysteroid features Hostility/anger Social withdrawal Anxiety Increased well-being Impulsiveness Organic mental discomfort General physical discomfort Sign of water retention Autonomic physical changes Fatigue Impaired social functioning Miscellaneous behavior/mood Miscellaneous physical changes
Non-alexithymic (mean ± SD)
Alexithymic (mean ± SD)
p*
p2
24.32 ± 10.45 11.92 ± 4.59 8.16 ± 3.53 21.47 ± 7.53 12.38 ± 5.31 14.06 ± 7.02 10.34 ± 4.48 11.69 ± 4.29 8.27 ± 3.81 9.31 ± 4.56 13.81 ± 5.96 15.13 ± 5.44 8.67 ± 3.53 16.03 ± 5.91 12.51 ± 4.64 26.57 ± 10.64 28.94 ± 11.15 12.44 ± 4.40
31.23 ± 9.71 15.02 ± 5.28 9.14 ± 3.15 25.66 ± 7.82 14.34 ± 4.96 16.36 ± 5.71 12.39 ± 4.25 13.84 ± 4.20 8.64 ± 3.98 11.30 ± 3.94 17.36 ± 5.50 17.61 ± 5.61 9.68 ± 3.54 18.32 ± 6.65 14.36 ± 4.27 32.14 ± 10.46 34.77 ± 9.92 14.14 ± 5.53
50.001 50.001 50.001 50.001 50.001 50.001 50.001 50.001 0.001 50.001 50.001 50.001 50.001 50.001 50.001 50.001 50.001 50.001
0.144 0.147 0.074 0.098 0.092 0.095 0.120 0.122 0.055 0.109 0.107 0.074 0.072 0.071 0.079 0.126 0.137 0.072
MV, mean value; SD, standard deviation. *ANCOVA, adjusted for age, BMI, smoking and state of regular exercise, partial eta-squared is effect size for ANCOVA.
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Future studies should therefore also consider this factor. However, given the paucity of studies in the literature examining the relation between PMS and alexithymia, the current study may contribute to the knowledge base on PMS, alexithymia and associated factors. In conclusion, the prevalence of PMS was 66.6% in the present study. PMS occurred at higher rates among smokers and those who have a history of psychiatric treatment. There was no significant relation between PMS and menstrual characteristics, BMI, exercise and socioeconomic and sociocultural factors. The rate of alexithymia was significantly higher in the PMS group.
Declaration of interest The authors report no conflicts of interest.
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PMS AND ALEXITHYMIA
Association between premenstrual syndrome and alexithymia among Turkish University students Ahmet Hamdi Alpaslan, Kadriye Avc|, Nusret Soylu, and Hanife Uzel Ta¸s 1
Department of Child and Adolescent Psychiatry, 2Department of Public Health, Faculty of Medicine, Afyon Kocatepe University, Afyonkarahisar, Turkey, and 3Department of Child and Adolescent Psychiatry, Faculty of Medicine, Inonu University, Malatya, Turkey
Abstract
Keywords
Premenstrual syndrome (PMS) is a heterogeneous disorder, which includes physical, cognitive, affective and behavioral symptoms. The aim of this study was to determine the factors affecting PMS and the relationship between PMS and alexithymia. The research was performed with 308 students. Data were collected using a demographic questionnaire, the Toronto alexithymia scale (TAS-20) and a premenstrual assessment form (PAF). The prevalence of PMS in our sample was 66.6%. The contributing factors to PMS were having a history of psychiatric treatment and having a smoking habit (p50.05). The PMS group showed higher scores than the non-PMS group on all the items of the TAS-20 which includes the three factors: difficulty in identifying feelings, difficulty in describing feelings and externally oriented thinking (p50.05). The alexithymic students showed higher scores on all PAF subscales (p 0.001). Further studies are needed to determine the probable role of alexithymia in the pathogenesis of PMS.
Alexithymia, high school students, premenstrual syndrome
Menstruation is a physiological event that starts with adolescence, continues until menopause and covers 35–40 years of a woman’s life. Premenstrual syndrome (PMS) is a psychoneuroendocrine disorder, which is associated with cognitive, physical, behavioral and emotional symptoms that emerge during the last week of the menstrual cycle and end a few days after the onset of the follicular period [1,2]. The symptoms include alterations in mood, including nervousness, anxiety, depression and thoughts of worthlessness, as well as depleted energy, difficulty in concentration, swelling/tenderness of the breasts and joint pain. The etiology and the physiopathology of PMS are not completely known, and there are no specific examinations and laboratory findings for diagnosis. The number of women complaining of PMS is increasing. In studies with large samples, the prevalence of PMS was reported to be 31% in USA, 79% in Japan, 75% in Malaysia, 24% in UK and 73% in Spain [3]. A study carried out in Turkey with individuals aged 16–25 years reported that the prevalence of PMS ranged from 17.2% to 67.5% [4]. Studies have reported that the lifelong prevalence of psychiatric disorders, especially depression, is high in women with PMS [5,6]. People with alexithymia have difficulty recognizing, defining and verbalizing emotions, and the condition is accompanied by poor imagination [7]. Research has shown that alexithymia is associated with personality disorders, eating disorders, substance
Address for correspondence: Ahmet Hamdi Alpaslan, Department of Child and Adolescent Psychiatry, Faculty of Medicine, Afyon Kocatepe University, Afyonkarahisar, Turkey. Mob: +90 533 581 66 32. Fax: +90 272 246 33 00. E-mail: [email protected]
Received 29 May 2013 Revised 23 December 2013 Accepted 21 January 2014 Published online 11 February 2014
abuse disorders, depression, sexual dysfunction, anxiety disorders and childhood traumas [8]. The prevalence of alexithymia is 10–18% in the general population and 7.6–39.8% in psychiatry outpatients [9]. De Berardis et al. [10] showed that alexithymic women with PMS have higher rates of poor appearance evaluation and body dissatisfaction. With modern life styles and social changes, women experience lower number of pregnancies and lactation periods and hence lower number of menstrual cycles. PMS may have a substantial influence on the lives, daily activities and academic achievements of young girls. As far as we know, there has been no Turkish study of the relation between PMS and alexithymia. The aim of the present study was to determine the relation between PMS and alexithymia, the prevalence of PMS, and the risk factors associated with the severity of PMS.
Methods
20 14
Introduction
History
Participants The study was conducted with university students aged 19–25 years (N ¼ 328) between January and March 2013 who volunteered to participate in the study. Socio-demographic and menstruation information forms were prepared for the study. While conducting the questionnaires verbal and written consent of the students was obtained after the purpose of the study was explained. The questionnaire forms were completed within 45 min. BMI was calculated using self-reported data on height and weight. Exclusion criteria included: (a) having a metabolic disease or psychiatric disorder, (b) using hormonal contraceptives and (c) using other prescribed medicines (e.g. antidepressants, antipsychotics or mood stabilizers). Twenty students were excluded from the study because of missing data. No participation fees were paid.
378
A. H. Alpaslan et al.
Measures
Gynecol Endocrinol, 2014; 30(5): 377–380
Table 1. Comparison of variables in the subjects with or without PMS.
Toronto alexithymia scale The Toronto alexithymia scale (TAS-20) utilizes a 5-point Likert scale. The TAS-20 has three subscales. The cut-off scores for theTAS-20 were those provided by Bagby et al. [11]. The total scores of the TAS-20 were categorized into two groups as follows: a score of at least 61 indicated alexithymic and less than 61 non-alexithymic. We used the validated Turkish version of the TAS-20 [12]. In our study, Cronbach’s value for the TAS-20 was 0.86. Premenstrual assessment form The premenstrual assessment form (PAF), a retrospective selfreport questionnaire, consists of 95 questions [13]. The reliability and the validity of the Turkish version of the PAF have been established [14]. Total PAF scores were divided into the number of questions for each participant. According to the results, symptom severity was assessed as follows: values 51.7 were regarded as ‘‘no PMS’’, over 1.7 were regarded as ‘‘PMS’’. The 18 subscales of the PAF are summarized in Table 3. The Chronbach Alpha coefficient which was calculated in order to determine the internal consistency of the scale was found as 0.83. Statistical analysis Descriptive statistics were used to analyze the demographic data. The differences between subjects were tested by using analyses of covariance (ANCOVA) with alexithymia and PMS positivity/ negativity as factors and age, BMI, smoking and state of regular exercise as covariates. The 2 analyses were used to compare categorical variables. Partial eta-squared statistics was also calculated to estimate effect sizes. Differences were considered significant if the p values were 50.05.
Characteristics Age BMI Age at menarche (year) Menstrual bleeding duration (days) Menstrual cycle duration (days)
PMS Mean ± SD
Non-PMS Mean ± SD
t
p*
20.75 ± 1.83 21.14 ± 2.40 13.78 ± 1.25 5.77 ± 1.36
20.56 ± 2.06 20.88 ± 3.06 13.61 ± 1.06 5.78 ± 1.12
0.812 0.814 1.166 0.074
0.417 0.416 0.244 0.941
29.49 ± 7.43
28.41 ± 7.03
1.219
0.224
N (%)
2
py
3.890
0.049
3.154
0.076
0.202
0.653
3.867
0.049
0.621
0.431
0.140
0.709
0.752
0.386
N (%)
Smoking Yes 35 (17.1) 9 (8.7) No 170 (82.9) 94 (91.3) Dysmenorrhea Yes 169 (82.4) 76 (73.8) No 36 (17.6) 27 (26.2) Status of using analgesic at menstrual duration Yes 115 (56.1) 55 (53.4) No 90 (43.9) 48 (46.6) History of psychiatric treatment Yes 27 (13.2) 6 (5.8) No 178 (86.8) 97 (94.2) State of regular exercise Yes 35 (17.1) 14 (13.6) No 170 (82.9) 89 (86.4) Income level High 42 (20.5) 23 (22.3) Low-middle 163 (79.5) 80 (77.7) Status of school performance Bad-middle 78 (38.0) 34 (33.0) Good 127 (62.0) 69 (67.0) MV, mean value; SD, standard deviation. *Student’s t-test p value. yChi-squared p value.
Results A total of 308 female students with ages ranging from 19 to 25 years (20.7 ± 1.9) were included in the study. Of the cases, 80.5% (n ¼ 248) were from a nuclear family, 18.2% from an extended family and 1.3% from a divorced family. In addition, 211% of the subjects were from a high socioeconomic category, 76% (n ¼ 234) were from a middle socioeconomic category and 2.9% were from a low economic category. A total of 63.6% (n ¼ 196) of the students reported that their school achievement was satisfactory, 33.8% said it was moderate and 2.6% said it was low. Among the subjects, 14.3% smoked and 15.9% took regular physical exercise. The mean age of onset of menarche was 13.72 ± 1.19, menstruation occurred at a mean of 29.13 ± 7.31 days and each menstruation period lasted a mean of 5.77 ± 1.29 days. A total of 79.5% (n ¼ 245) of the participants reported that they experienced pain during the menstruation period, and 55.2% used analgesics during the menstruation period. Table 1 shows some characteristics of the subjects who have PMS according to the PAF and those who do not have PMS. The rate of PMS was higher in those who smoke (p ¼ 0.049) and those who have a history of psychiatric treatment (p ¼ 0.049). Table 2 shows the scores obtained on the TAS-20 of the subjects with and without PMS. The results of ANCOVA controlling for age, BMI, smoking and state of regular exercise showed (effect sizes: ranged from 0.036 to 0.203) that subjects with PMS were more alexithymic (higher scores on the TAS-20 Total, TAS-1, TAS-2 and TAS-3, p50.05). Table 3 presents the scores of those who are alexithymic and those who are not according to the TAS-20. The results of ANCOVA controlling for
age, BMI, smoking and state of regular exercise showed (effect sizes: ranged from 0.055 to 0.144) that alexithymic subjects had higher scores on all subscale scores of the PAF (p 0.001).
Discussion To our knowledge, this is the first study in Turkey to evaluate the relationship between alexithymia and PMS. The prevalence of PMS in our sample was 66.6%. In previous studies in USA and other Western countries, the prevalence rates varied from 24% to 79% [3]. Research conducted in Turkey showed that the prevalence of PMS is between 17.2% and 90% [15]. The variability of PMS rates in the literature may be due to the fact that the studies were conducted with different age groups and with populations from different sociocultural backgrounds. The results of studies investigating the effect of individual, familial and menstrual characteristics on the prevalence of PMS are conflicting [5,16]. In our study, the frequency of PMS was not affected by socio-economic and sociocultural parameters (p40.05). Sezgin et al. [17] reported that PMS was higher in smokers than in non-smokers, and Demir et al. [18] reported a significant relationship between smoking habits and PMS. In our study, the smokers had a higher frequency of PMS than the nonsmokers. Smoking can alter levels of estrogen, progesterone and testosterone, and this may be linked to the development of PMS [16,19,20]. One previous study reported an association between obesity, regular exercise and dietary habits and PMS [19], whereas another reported no association [20,21]. In the present study, there was no
Association between PMS and alexithymia
DOI: 10.3109/09513590.2014.887066
relation between the subject’s Body Mass Index (BMI), exercise frequency and PMS. A similar finding was obtained in the studies of Demir et al. [18] and Lustyk et al. [22]. They found no significant difference in the BMI between PMS and a non-PMS group. The young age of the population in the current study and the paucity of obesity among the participants may explain our findings. In our study, there was no statistically significant difference among the PMS and the non-PMS group in variables related to menstruation (the age of first menses, duration of the menstrual cycle, duration of menstrual bleeding and dysmenorrhea). Conversely, some previous studies reported an association between PMS, the menstrual cycle and dysmenorrhea [16]. A study carried out in Turkey found no relation between the age of first menses, the duration of the menstrual cycle and the prevalence of PMS [5]. In the present study, although the rate of dysmenorrhea was higher in the PMS group, the difference was not statistically significant difference compared to the non-PMS group. In addition, other studies reported no relation between dysmenorrhea and PMS [23,24]. The fact that the subjects were not questioned in detail about the severity of the dysmenorrhea may explain the insignificant difference. In the present study, 52.2% of all the participants used analgesics during the menstruation period. However, the scales used depended on selfreporting, which may have influenced the objectivity of the data. Table 2. Total scores obtained on the TAS-20 and the TAS-20 subscales of those who have PMS and those who do not have PMS controlling for age, BMI, smoking and state of regular exercise.
Variables TAS-20 total TAS-1: difficulty in identifying feelings TAS-2: difficulty in describing feelings TAS-3: externally oriented thinking
PMS (205) Non-PMS (103) (mean ± SD) (mean ± SD)
p*
p2
52.28 ± 8.99 16.98 ± 5.28
44.55 ± 7.37 12.48 ± 3.55
50.001 0.150 50.001 0.203
13.47 ± 3.28
11.52 ± 3.50
0.001 0.062
21.83 ± 3.49
20.55 ± 3.14
0.047 0.036
MV, mean value; SD, standard deviation. *ANCOVA, adjusted for age, BMI, smoking and state of regular exercise, partial eta-squared is effect size for ANCOVA.
379
Many previous studies have demonstrated the association of PMS with psychopathology [9,16,20]. Higher rates of PMS were reported in those who have a history of psychiatric disorders and those whose first-degree relatives have such a history [25]. One study reported that 18% of female college students meeting criteria for PMS had affective disorders during 4 years of follow up [6]. Likewise, in the present study, the rate of PMS was significantly higher among the students who had received psychiatric treatment in the past. The results of our study emphasize the need for a careful assessment of the history of psychiatric disorders in women with PMS. Some studies have examined the relation between PMS and alexithymia [10,26]. To the best of our knowledge, this is the first study to evaluate the relationship between PMS and alexithymia in Turkey. In our study, when we compared the groups, the PMS group showed higher scores on all the rating scales of the TAS-20, which includes three factors. There was a statistically significant difference between the groups. When we divided all the participants into two groups, an alexithymic group (who scored 61 or more on the TAS-20) and a non-alexithymic, the alexithymic group had higher scores on all the PAF subscales even when the results were controlled for age, BMI, smoking and state of regular exercise. Alexithymia reflects cognitive deficits in processing emotions because alexithymic individuals are psychologically poorly equipped. PMS has physical, cognitive, affective and behavioral symptoms. Alexithymia also has cognitive and affective features. Alexithymia may play a modulating role in the expression of symptoms in women with PMS. The probable role of alexithymia in the pathogenesis of PMS should be tested in future studies. The first limitation of our study is the use of a convenience sample of university students. Although our university-based sample was comparable in size and composition to other research studies in this area, future research should consider the strength of using a larger, more generalized sample, such as a communitybased participant pool. As the present study is a cross-sectional one, it does not allow us infer a causality relation between PMS and alexithymia. Another limitation of the present study is that our data (e.g. BMI) are based upon self-reporting by the subjects. Finally, in our study, we did not evaluate potential depressive or anxiety symptoms which are known to be associated with PMS and alexithymia in clinical as well as in non-clinical populations.
Table 3. Scores obtained on the PMS subscales of those with and without alexithymia controlling for age, BMI, smoking and state of regular exercise.
Subscales of PAF 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.
Low mood Endogenous depressive features Instability Atypical depressive features Hysteroid features Hostility/anger Social withdrawal Anxiety Increased well-being Impulsiveness Organic mental discomfort General physical discomfort Sign of water retention Autonomic physical changes Fatigue Impaired social functioning Miscellaneous behavior/mood Miscellaneous physical changes
Non-alexithymic (mean ± SD)
Alexithymic (mean ± SD)
p*
p2
24.32 ± 10.45 11.92 ± 4.59 8.16 ± 3.53 21.47 ± 7.53 12.38 ± 5.31 14.06 ± 7.02 10.34 ± 4.48 11.69 ± 4.29 8.27 ± 3.81 9.31 ± 4.56 13.81 ± 5.96 15.13 ± 5.44 8.67 ± 3.53 16.03 ± 5.91 12.51 ± 4.64 26.57 ± 10.64 28.94 ± 11.15 12.44 ± 4.40
31.23 ± 9.71 15.02 ± 5.28 9.14 ± 3.15 25.66 ± 7.82 14.34 ± 4.96 16.36 ± 5.71 12.39 ± 4.25 13.84 ± 4.20 8.64 ± 3.98 11.30 ± 3.94 17.36 ± 5.50 17.61 ± 5.61 9.68 ± 3.54 18.32 ± 6.65 14.36 ± 4.27 32.14 ± 10.46 34.77 ± 9.92 14.14 ± 5.53
50.001 50.001 50.001 50.001 50.001 50.001 50.001 50.001 0.001 50.001 50.001 50.001 50.001 50.001 50.001 50.001 50.001 50.001
0.144 0.147 0.074 0.098 0.092 0.095 0.120 0.122 0.055 0.109 0.107 0.074 0.072 0.071 0.079 0.126 0.137 0.072
MV, mean value; SD, standard deviation. *ANCOVA, adjusted for age, BMI, smoking and state of regular exercise, partial eta-squared is effect size for ANCOVA.
380
A. H. Alpaslan et al.
Future studies should therefore also consider this factor. However, given the paucity of studies in the literature examining the relation between PMS and alexithymia, the current study may contribute to the knowledge base on PMS, alexithymia and associated factors. In conclusion, the prevalence of PMS was 66.6% in the present study. PMS occurred at higher rates among smokers and those who have a history of psychiatric treatment. There was no significant relation between PMS and menstrual characteristics, BMI, exercise and socioeconomic and sociocultural factors. The rate of alexithymia was significantly higher in the PMS group.
Declaration of interest The authors report no conflicts of interest.
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