Menopause: The Journal of The North American Menopause Society Vol. 21, No. 6, pp. 563/566 DOI: 10.1097/gme.0000000000000242 * 2014 by The North American Menopause Society

EDITORIAL What does it really mean? BWhen I use a word,[ Humpty Dumpty said in rather a scornful tone, Bit means just what I choose it to meanVneither more nor less.[ BThe question is,[ said Alice, Bwhether you can make words mean so many different things.[ BThe question is,[ said Humpty Dumpty, Bwhich is to be masterVthat’s all.[ *** BThat’s a great deal to make one word mean,[ Alice said in a thoughtful tone. BWhen I make a word do a lot of work like that,[ said Humpty Dumpty, BI always pay it extra.[ BOh![ said Alice. She was too much puzzled to make any other remark. VExcerpts from Louis Carroll, Alice in Wonderland, Chapter 6, Through the Looking Glass

n this issue of Menopause, Sassoon et al1 reported a test of Bwhether personality factors and vasomotor symptoms were associated with an insomnia diagnosis concurrent with the menopausal transition.[ The participants were a subset of community-dwelling volunteers in an unreferenced study described as Brigorous,[ suggesting that these women had above-average discretionary time and resources. This comports with their mean smoking rate of 9.5% (about a fifth of that epidemiologically expected)2 and depression level, which has been described as Bminimal.[ Thirty-five women with insomnia that began in perimenopause self-reported greater psychological disturbance than did 28 similar women with subjectively normal sleep. Women in the insomnia group self-reported poorer occupational and social functioning, a higher divorce rate, higher neuroticism, lower agreeableness and conscientiousness, more personality disorders as defined by the standard DSM-IV classification, more past or present premenstrual dysphoric disorders, more depressive episodes, and more vasomotor symptoms. Sassoon et al1 defined neuroticism as Bthe general tendency to experience negative affect such as fear, sadness, anxiety, embarrassment, anger, or guilt.[ Only women with high negative affect scores rated their symptoms as distressing. Sassoon et al1 found the following significant: BOur results show the relevance of personality traits, particularly neuroticism

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and obsessive-compulsive personality, in influencing a woman’s experience of insomnia as she goes through the menopausal transition.[The study results exemplify how research based on self-report questionnaires alone can yield hard-to-interpret results. Perimenopause is a transient event that does not explain personality traits, which are long term and enduring.3 Subjective insomnia is appropriately measured by self-reports; but, as Sassoon et al1 stated in their discussion, self-reports of poor sleep often conflict with results of sleep laboratory monitoring, so it is unclear what participant self-reports mean. A landmark epidemiological study found that the menopausal transition generally does not change objective sleep.4 One study showed that most midlife womenVincluding those with subjectively poor sleepVenjoy objectively good sleep.5 These data and the current study results suggest that perimenopausal women’s self-reported insomnia probably reflects judgments that reflect negative affect rather than objectively poor sleep. Because a high neuroticism score implies a bias toward making negative affectYinflected judgments (affect represents judging the goodness or badness of things),6 the unsurprising results of the current study confirm that women who tend to make negative judgments judge their sleep negatively. The women with insomnia also manifested greater obsessionality, which might help break this tautology. Besides these women’s negatively biased judgments, their obsessionality implies a systematic reason for poor sleep because obsessionality reportedly involves electroencephalography patterns that indicate relatively high arousal levels,7,8 which potentially worsen sleep.

PUZZLING WORDS Use of terms such as Bneuroticism[ and Bimpairing personality traits[ helps focus on a negative affect forest rather than on multiple symptom trees.9 However, these Bsuitcase words[10 are stuffed with meanings that need to be unpacked. As Humpty Dumpty said, the words mean exactly what the researchers want them to mean. The often used NEO Questionnaire Measure of Neuroticism consists of several components: anxiety, depression, impulsiveness, self-consciousness, hostility, and vulnerability to stress. Many might agree with Alice that this is Ba great deal to make one word mean.[ The meaning of the word Bneuroticism[ is arbitrary: It has also been defined in relation to emotional memory, perception/attention, and self-reference,11 or as the opposite of emotional stability.12 Understanding people’s symptoms in ways that will lead to symptom relief depends on the illumination of symptom Menopause, Vol. 21, No. 6, 2014

Copyright © 2014 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.

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mechanisms.13,14 One of neuroticism’s components, depression, is a fuzzy concept that has sparked seven decades of argument over the question of whether menopause causes depression.15 The DSM classification defines depression in relation to mood, sleep, appetite, inability to enjoy, diminished ability to concentrate, energy factors, and disordered sleep. Conversely, insomnia often entails depression16,17; thus, it might have been expected, as reported in the current study, that 43% of women with insomnia felt unhappy or depressed. Some would say that the neuroticism self-reports were validated by their association with insomnia, but insomnia itself, independently of neuroticism, negatively biases a person’s viewpoint.18 A negative judgment is a negative judgment. The words Binsomnia[ and Bperimenopause[ are clearer than the word Bneuroticism[ because these words can be checked by objective means. One cannot know what the word Bneuroticism[ means in the same way one knows what the word Binsomnia[ means. In my head, a word like Binsomnia[ is something that stands for poor sleep,19 but a word like Bneuroticism[ stands for a fuzzy piece of information in researchers’ heads. The routes from their heads to my head are strewn with many biases. Using vernacular terms rather than specialty jargon might have made the article clearer.20 Sassoon et al1 aimed to Bcharacterize[ the symptoms and personalities of women with insomnia, which must have been hard to do because people have been trying to characterize human problems ever since ancient Greeks described delirium, hysteria, and phobia. Unlike neurosis and depression, these Greek words distinguish clearly demarcated types of publically observable behavior. Sassoon et al1 concluded that, BIwomen with insomnia during perimenopause were more sensitive to menopausal symptoms (eg, night sweats, hot flashes, and depression) than were women without insomnia. Furthermore, women who developed insomnia during perimenopause had a higher degree of neuroticism, a higher prevalence of impairing personality traits than those without insomnia, and a history of greater sensitivity to severe premenstrual symptoms than women without insomnia.[ The evidence for the above consists entirely of self-reports unconnected with objective data, leaving researchers suspended in semantic space. The study participants’ increased symptoms might mean that perimenopause aggravates preexisting problems. However, subjective self-reported depression rates vary little across premenopausal, perimenopausal, and postmenopausal groups.21,22 Menopausal transition brings a sharp increase in some hard endpoints of depression, such as mental hospital admissions23 and suicides24; thus, the study participants’ mild depression probably differed from clinical depression. Some might dismiss such Bneurotic[ women as Bworried well,[ perhaps consistent with relatively healthy women who volunteer for a rigorous health study, but their neuroses plausibly amplified the generally health-drenched American consciousness. Some verifiable information might be found in observations that the women with insomnia had a higher rate of divorce, more previous depression and premenstrual syndrome, and lower scores on global functioning. They had

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consulted a doctor for menopausal symptoms more than twice as much as had control women. Using these measures instead of personality traits would have yielded more confident study results. Sassoon et al1 stated that their subjective data permitted no estimation of physiological differences between participant groups. However, they linked neuroticism to somatization, which implies a physiological reason for the Bneurotic[ women’s relatively greater focus on somatic information rather than on external information.25 They perhaps felt some conflict about appealing to a physiological explanation because they cited an article on skin electrical conductance but wrote that it discussed Bpsychological reactivity.[ They also neglected to record the article’s page numbers in the citation.

WHO IS MASTER? Researchers rarely question questionnaires, but questionnaire items represent the most numerous response options originally chosen by other experimental participants in questionnairevalidating studies. No participant-related informant, laboratory data, or anything else has ever objectively verified the DSM personality measures.26 Personality traits are therefore selfreports validated by other self-reportsVa circular method that leaves researchers as puzzled as Alice about their meaning. The article features DSM-IV personality disorder data but nowhere acknowledges the imbroglio that DSM personality disorders incited. By 2011, experience had proven DSM personality disorders so overlapping and unreliable that conferees of 12 research conferences held to determine if these measures should be retained in the DSM classification concluded that they were irremediable.27 Nevertheless, by 2014, the board of trustees of the American Psychiatric Association had rejected calls to abandon DSM personality disorders. It retained DSM-IVYstyle personality disorders Bto preserve the continuity with current clinical practice.28[ As Humpty Dumpty said, the only question is who is master. DSM personality disorders thus represent authoritarian fiat rather than scientific probity. Data show that expert consensus panels, like the ones that chose the DSM-IV diagnostic criteria, tend to make choices inconsistent with empirical reality.29 Study findings based on expert choices might therefore not relate to the real world. The experts had assumed the impossible task of applying arbitrary, formal, public semantics to people’s private, amorphous, emotional states.30 The panel of experts who chose the DSM diagnostic criteria generally had insufficient information on the etiology or the validity of the mental conditions that history had bequeathed them, so they chose diagnostic criteria by reliability rather than by validity.31