Psychological Reports, 1990, 67, 43-48. O Psychological Reports 1990
RELATIONSHIP BETWEEN ANXIETY AND PREMENSTRUAL SYNDROME ' LORETTA PICONE
AND
North Eastern Suburbs Workcare Rehabilitation
ROBERT J. KIRKBY
La Trobe Universiiy
Victoria. Australia Summary.-The relationship between symptoms of the premenstrual syndrome and anxiety was assessed for 68 women. The syndrome as measured by a modified version of the Moos Menstrual Distress Questionnaire, was correlated significantly with trait anxiety, as measured by Spielberger's State-Trait Anxiety Inventory. Trait anxiety was correlated with all three subtypes from the questionnaire: behavioral, psychological, and physical, most strongly for the psychological subtype. These findings suggest a role for stress-management training in the treatment of the premenstrual syndrome.
Over half a century ago Frank (1931) introduced the term 'premenstrual tension' to describe the severe negative mood changes reported by some women during the premenstrual (luted) phase of the menstrual cycle. More recent recognition that these mood effects are typically accompanied by physical and behavioral changes has led to these phenomena being relabelled as the 'premenstrual syndrome' or 'PMS' (Greene & Dalton, 1953). Premenstrual syndrome occurs in a high proportion of women. Depending on factors such as the definition of symptoms, sampling procedures, and research strategies, estimates of the incidence of PMS have ranged from 25% to 100% (Moos, 1968; Rausch & Janowsky, 1982). Symptoms such as tension, irritability, depression, headaches, tender breasts, and abdominal swelling are among those most commonly reported by premenstrual women (Clare & Wiggins, 1989; Haskett, Steiner, Osmun, & Carroll, 1980). However, as many as 150 symptoms have been so Iinked (Moos, 1969). The severity of rem menstrual problems has been reported to range from mild irritability to disabilities as severe as psychosis (Rausch & Janowsky, 1982). The last decade has seen increased attention paid to the role of social and psychological factors in the understanding and management of these symptoms (Clare, 1983; Dewitt, 1981; Hart & Russell, 1986; Jacobs, 1979; Morse, Dennerstein, Varnavides, & Burrows, 1988; Morse & Dennerstein, 1988). Many of the studies focussing on psychological components have suggested a relationship between stress and premenstrual disturbances. For example, Woods, Most, and Longenecker (1985) reported that women who
'Address correspondence to Dr. Rob Kukby, La Trobe University, Carlton, Victoria, Ausualia 3053.
44
L. PICONE
&
R. J. KIRKBY
indicated the occurrence of major stressful life events were more likely to suffer from premenstrual symptoms such as negative affect and performance deficit. Although several other investigators have suggested a link between these symptoms and women's ability to cope with stress (Asso, 1978; Awartife, Awartife, Diejomaoh, & Ebie, 1980; Clare, 1983; Dennerstein & Spencer-Gardner, 1983; Morse, Bernard, & Demerstein, 1989; Parlee, 1982) few studies have empirically assessed this potential relationship. One study which objectively evaluated the relationship of anxiety and premenstrual symptoms was that of Giannini, Price, Loiselle, and Giannini (1985), who examined the relationship between the reporting of symptoms and trait anxiety of women with premenstrual symptoms measured by the Peck-Abraham Questionnaire. However, it is difficult to assess the validity of this report as, rather than adhere to the scoring recommended by Spielberger (1983), Giannini, et al. (1985) documented trait anxiety as simply 'present' or 'absent' on the basis of unspecified criteria. In the light of the absence of replicable findings the present study was undertaken to test the association between symptom reporting and trait anxiety. It was predicted that higher trait anxiety would be associated with greater severity of premenstrual symptoms. METHOD
Subject1 and Procedure The subjects were 68 female tertiary students whose mean age was 33 yr. (SD = 6.0). With the permission of the class instructors 81 students in three classes were approached during class time and invited to participate in a 'Premenstrual Health Project.' Students were informed that participation was voluntary and that individual scores and identities would remain confidential. Questionnaire booklets were administered to the 78 (96.3%) students who indicated willingness to participate. The importance of quietness and individual privacy was emphasised by the researcher; the subjects completed the questionnaires in about 30 min., after which the booklets were collected. Of the 78 subjects only 68 completed all items in the test package.
Tests The test booklet was composed of three parts: locus of control measures, a premenstrual symptom questionnaire, and an anxiety measure. Details of the findings concerning locus of control were reported by Kirkby and Picone (1989). The second section of the test booklet consisted of a retrospective premenstrual symptoms test, the 34-item modified (Clare & Wiggins, 1979) Menstrual Distress Questionnaire which was adapted from the Moos (1968) Menstrual Distress Questionnaire, the most widely-used instrument in such assessment (Rubinow & Roy-Byrne, 1984). The validity of
PREMENSTRUAL SYNDROME AND ANXIETY
45
using the Menstrual Distress Questionnaire retrospectively has been reported by Hart, Coleman, and Russell (1987, p. 189). Factor analysis of the adapted questionnaire by Clare (1983) established three subtypes: psychological, behavioral, and physical. Typical symptoms for the behavioral subtype included clumsiness, accidents, decreases in efficiency, and avoiding social activities. Psychological symptoms included crying spells, difficulty sleeping, confusion, tension, and physical symptoms included muscle stiffness, headache, stomach pains, dizziness or faintness. Each item was rated using a 4-point severity score (0 to 3). An individual's score comprised the sum of the severity scores for the 34 items. The final section of the test booklet consisted of the trait questionnaire, Form Y, of the State-Trait Anxiety Inventory (Spielberger, 1983). The STAI has been widely used in stress research and has well-docurnented reliability and validity (Spielberger, 1983). Trait anxiety has been described as a "relatively stable" i d c a t o r of anxiety-proneness. That is, individuals with high trait anxiety "tend to interpret a wider range of situations as dangerous or threatening" (Spielberger, 1983, p. 1). The stability of this measure has led investigators of anxiety to prefer it over the more labile, moment-to-moment, state anxiety (see for example, Hazaleus & Deffenbacher, 1986; Lipsky, Kassinove, & Miller, 1980; Sallis, Trevorrow, Johnson, Hovell, & Kaplan, 1987).
Mean scores and standard deviations were 37.7 and 8.2 on the trait anxiety and 23.8 and 18.2 on the menstrual distress questionnaire. The mean scores and standard deviations for the subtypes were for physical 8.7 and 6.0, for behavioral 4.3 and 4.0, and for psychological 9.9 and 8.4. The relationship between menstrual questionnaire and trait anxiety scores was moderate and significant (Pearson r = 0.41, p < .001). Correlations between trait and subtype scores were physical, r = 0.21 (p < .05), behavioral, r = 0.44, (p < .001), and psychological, r = 0.53 (p < .001). The differences between correlation coefficients by t test (Guilford & Fruchter, 1973) were significant for subgroups and anxiety in all three comparisons: psychological and anxiety versus physical and anxiety (t,, = 3.25, p < .005), psychological and anxiety versus behavioral and anxiety (t,, = 1.74, p < .05), behavioral and anxiety versus physical and anxiety (t,, = 2.91, p < ,005; all tests two-tailed). To analyse the data further, scores for total Menstrual Distress Questionnaire and each of the subtypes were divided at the mean and the anxiety scores of the high and low groups were compared by t tests. The anxiety scores of the group scoring high on premenstrual symptoms were significantly above those of the low score group for all four comparisons (total score: t6, = 3.56, p
RELATIONSHIP BETWEEN ANXIETY AND PREMENSTRUAL SYNDROME ' LORETTA PICONE
AND
North Eastern Suburbs Workcare Rehabilitation
ROBERT J. KIRKBY
La Trobe Universiiy
Victoria. Australia Summary.-The relationship between symptoms of the premenstrual syndrome and anxiety was assessed for 68 women. The syndrome as measured by a modified version of the Moos Menstrual Distress Questionnaire, was correlated significantly with trait anxiety, as measured by Spielberger's State-Trait Anxiety Inventory. Trait anxiety was correlated with all three subtypes from the questionnaire: behavioral, psychological, and physical, most strongly for the psychological subtype. These findings suggest a role for stress-management training in the treatment of the premenstrual syndrome.
Over half a century ago Frank (1931) introduced the term 'premenstrual tension' to describe the severe negative mood changes reported by some women during the premenstrual (luted) phase of the menstrual cycle. More recent recognition that these mood effects are typically accompanied by physical and behavioral changes has led to these phenomena being relabelled as the 'premenstrual syndrome' or 'PMS' (Greene & Dalton, 1953). Premenstrual syndrome occurs in a high proportion of women. Depending on factors such as the definition of symptoms, sampling procedures, and research strategies, estimates of the incidence of PMS have ranged from 25% to 100% (Moos, 1968; Rausch & Janowsky, 1982). Symptoms such as tension, irritability, depression, headaches, tender breasts, and abdominal swelling are among those most commonly reported by premenstrual women (Clare & Wiggins, 1989; Haskett, Steiner, Osmun, & Carroll, 1980). However, as many as 150 symptoms have been so Iinked (Moos, 1969). The severity of rem menstrual problems has been reported to range from mild irritability to disabilities as severe as psychosis (Rausch & Janowsky, 1982). The last decade has seen increased attention paid to the role of social and psychological factors in the understanding and management of these symptoms (Clare, 1983; Dewitt, 1981; Hart & Russell, 1986; Jacobs, 1979; Morse, Dennerstein, Varnavides, & Burrows, 1988; Morse & Dennerstein, 1988). Many of the studies focussing on psychological components have suggested a relationship between stress and premenstrual disturbances. For example, Woods, Most, and Longenecker (1985) reported that women who
'Address correspondence to Dr. Rob Kukby, La Trobe University, Carlton, Victoria, Ausualia 3053.
44
L. PICONE
&
R. J. KIRKBY
indicated the occurrence of major stressful life events were more likely to suffer from premenstrual symptoms such as negative affect and performance deficit. Although several other investigators have suggested a link between these symptoms and women's ability to cope with stress (Asso, 1978; Awartife, Awartife, Diejomaoh, & Ebie, 1980; Clare, 1983; Dennerstein & Spencer-Gardner, 1983; Morse, Bernard, & Demerstein, 1989; Parlee, 1982) few studies have empirically assessed this potential relationship. One study which objectively evaluated the relationship of anxiety and premenstrual symptoms was that of Giannini, Price, Loiselle, and Giannini (1985), who examined the relationship between the reporting of symptoms and trait anxiety of women with premenstrual symptoms measured by the Peck-Abraham Questionnaire. However, it is difficult to assess the validity of this report as, rather than adhere to the scoring recommended by Spielberger (1983), Giannini, et al. (1985) documented trait anxiety as simply 'present' or 'absent' on the basis of unspecified criteria. In the light of the absence of replicable findings the present study was undertaken to test the association between symptom reporting and trait anxiety. It was predicted that higher trait anxiety would be associated with greater severity of premenstrual symptoms. METHOD
Subject1 and Procedure The subjects were 68 female tertiary students whose mean age was 33 yr. (SD = 6.0). With the permission of the class instructors 81 students in three classes were approached during class time and invited to participate in a 'Premenstrual Health Project.' Students were informed that participation was voluntary and that individual scores and identities would remain confidential. Questionnaire booklets were administered to the 78 (96.3%) students who indicated willingness to participate. The importance of quietness and individual privacy was emphasised by the researcher; the subjects completed the questionnaires in about 30 min., after which the booklets were collected. Of the 78 subjects only 68 completed all items in the test package.
Tests The test booklet was composed of three parts: locus of control measures, a premenstrual symptom questionnaire, and an anxiety measure. Details of the findings concerning locus of control were reported by Kirkby and Picone (1989). The second section of the test booklet consisted of a retrospective premenstrual symptoms test, the 34-item modified (Clare & Wiggins, 1979) Menstrual Distress Questionnaire which was adapted from the Moos (1968) Menstrual Distress Questionnaire, the most widely-used instrument in such assessment (Rubinow & Roy-Byrne, 1984). The validity of
PREMENSTRUAL SYNDROME AND ANXIETY
45
using the Menstrual Distress Questionnaire retrospectively has been reported by Hart, Coleman, and Russell (1987, p. 189). Factor analysis of the adapted questionnaire by Clare (1983) established three subtypes: psychological, behavioral, and physical. Typical symptoms for the behavioral subtype included clumsiness, accidents, decreases in efficiency, and avoiding social activities. Psychological symptoms included crying spells, difficulty sleeping, confusion, tension, and physical symptoms included muscle stiffness, headache, stomach pains, dizziness or faintness. Each item was rated using a 4-point severity score (0 to 3). An individual's score comprised the sum of the severity scores for the 34 items. The final section of the test booklet consisted of the trait questionnaire, Form Y, of the State-Trait Anxiety Inventory (Spielberger, 1983). The STAI has been widely used in stress research and has well-docurnented reliability and validity (Spielberger, 1983). Trait anxiety has been described as a "relatively stable" i d c a t o r of anxiety-proneness. That is, individuals with high trait anxiety "tend to interpret a wider range of situations as dangerous or threatening" (Spielberger, 1983, p. 1). The stability of this measure has led investigators of anxiety to prefer it over the more labile, moment-to-moment, state anxiety (see for example, Hazaleus & Deffenbacher, 1986; Lipsky, Kassinove, & Miller, 1980; Sallis, Trevorrow, Johnson, Hovell, & Kaplan, 1987).
Mean scores and standard deviations were 37.7 and 8.2 on the trait anxiety and 23.8 and 18.2 on the menstrual distress questionnaire. The mean scores and standard deviations for the subtypes were for physical 8.7 and 6.0, for behavioral 4.3 and 4.0, and for psychological 9.9 and 8.4. The relationship between menstrual questionnaire and trait anxiety scores was moderate and significant (Pearson r = 0.41, p < .001). Correlations between trait and subtype scores were physical, r = 0.21 (p < .05), behavioral, r = 0.44, (p < .001), and psychological, r = 0.53 (p < .001). The differences between correlation coefficients by t test (Guilford & Fruchter, 1973) were significant for subgroups and anxiety in all three comparisons: psychological and anxiety versus physical and anxiety (t,, = 3.25, p < .005), psychological and anxiety versus behavioral and anxiety (t,, = 1.74, p < .05), behavioral and anxiety versus physical and anxiety (t,, = 2.91, p < ,005; all tests two-tailed). To analyse the data further, scores for total Menstrual Distress Questionnaire and each of the subtypes were divided at the mean and the anxiety scores of the high and low groups were compared by t tests. The anxiety scores of the group scoring high on premenstrual symptoms were significantly above those of the low score group for all four comparisons (total score: t6, = 3.56, p
