Psychosomatics 40:497-502, December 1999
© 1999 The Academy of Psychosomatic Medine
Psychosocial Correlates of Pain Attributions in Women With Dyspareunia
Marta Meana, Ph.D.,
Yitzchak M. Binik, Ph.D.,
Samir Khalife, M.D., and
Deborah Cohen, M.D.
Received August 14, 1998; accepted January 20, 1999. From the University of Nevada, Las Vegas; and McGill University and the Royal Victoria Hospital, Montreal, Quebec, Canada. Address correspondence and reprint requests to Dr. Meana, Department of Psychology, University of Nevada, 4505 Maryland Parkway, Box 455030, Las Vegas, NV 89154–5030; E-mail: meana{at}nevada.edu
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ABSTRACT
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The relationship between patients' causal attributions for pain and biopsychosocial measures was investigated in a sample of 100 women with dyspareunia. Independently of findings from the gynecological examinations, causal attributions were related to adjustment. More specifically, the women who made psychosocial attributions reported higher pain scores, higher levels of psychological distress, lower levels of marital adjustment, more problems with sexual function, and more frequent reports of sexual assault. The relationship between psychosocial causal attributions for pain and psychosocial distress may be clinically useful in the multidisciplinary treatment of this and other pain disorders, regardless of actual physical pathology.
Key Words: Dyspareunia • Causal Attributions • Pain • Women
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INTRODUCTION
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Individuals who experience physical symptoms or disease, serious or not, often develop "theories" about the factors that brought about their current condition, and these "theories" appear to have an impact on affect and behavior. The causal attributions made by patients for their diseases, disorders, and symptoms have been shown, repeatedly, to have a significant relation to psychological adaptation and health behavior.1–8 In one study, it was the causal attributions of myocardial infarction patients, rather than those of their physicians, that predicted subjective rehabilitation.6 In another, breast cancer patients who attributed the cancer to an uncontrollable cause (e.g., genetics) became more actively involved in their efforts to fight the illness.8 In yet another study, lung cancer patients who made psychosocial attributions for their condition had more emotional distress, were less hopeful, and were more depressed than other lung cancer patients.4
Investigating the impact of causal attributions on adjustment and health behavior seems particularly relevant in the case of disorders whose etiology, course, probable outcome, and appropriate treatment are more poorly defined than in the case of heart disease or cancer. Chronic or recurrent acute pain disorders of unknown etiology, such as low back pain, headache, neuralgias, vulvodynia, and chronic pelvic pain, are cases in point. These conditions are rarely associated with distinct disease entities, and patients have received no prior causal explanation from their physicians. Because the patient cannot anchor his/her attributions in medical knowledge passed down from the physician, these "symptoms" are more likely to invoke lay theories of causation.9
The causal attributions made by patients in these cases may be particularly pertinent for three key reasons. First, there is a strong interrelation among pain, affect, and behavior.10 Any factor that will mediate a patient's affect is likely to have an impact on the experience of pain. For example, a patient who has made a causal attribution that is self-recriminating may experience depression, at least in part as a result of the attribution, and this depression could have a significant impact on the experience of pain. Second, since there is no standard treatment for many of these disorders, the consequences of a patient's causal attribution for chronic pelvic pain, for example, may influence or even determine treatment strategies. If a physician is at a loss as to how to treat the pain disorder, he/she may be more willing to bank on a patient's belief about the cause of the pain and align a treatment strategy with that belief. In contrast, it is unlikely that a patient's causal attribution for cancer, for example, would influence standard treatment strategies. Finally, the subjective nature of pain disorders requires that the physician understand the patient's experience so as to negotiate successfully the sometimes difficult physician–patient relationship when no "cure" is forthcoming.11
Dyspareunia, an acute recurrent pain associated with sexual intercourse and prevalent in about 10%–15% of community women, is a chronic problem lasting many years, or even a lifetime, for a significant number of women who report it.12,13 In many cases, no physical pathology can be found to explain the pain. In cases in which pathology is evident, a resolution of the physical problem does not ensure the eradication of the pain, or even a decrease in pain intensity.12 Both in cases with no obvious pathology and in cases in which treatment of the purported cause did not result in pain relief, the default position historically taken by health professionals has been to consider dyspareunia a sexual/relational problem, with its etiology stemming from psychological processes rather physiological ones.14 This dualism is almost always an oversimplified stance on the part of health professionals, but the heuristic power of the physical/psychological dichotomy is one that patients quickly grasp and apply to themselves and others.
This study, conducted in 1995, sought, in part, to investigate the causal attributions of women with dyspareunia and the relation of these attributions to the experience of pain, psychological adjustment, and relationship adjustment. We hypothesized that dyspareunia would be particularly fertile ground for psychosocial causal attributions, because dyspareunia is experienced during sexual activity and, in most cases, in the presence of someone with whom one has a relationship of some complexity. It would seem probable that a substantial number of women would attribute their pain to sexual and relationship issues, regardless of the actual cause of the pain. The specific hypothesis was that women who made psychological attributions would report more pain and poorer adjustment, both personal and relational, than women who made physical attributions, regardless of actual findings from the gynecological examinations.
The reason for hypothesizing that psychosocial attributions, in particular, would relate to maladjustment is twofold: 1) psychosocial attributions would likely involve an element of self-stigmatization (e.g., "I have pain during intercourse because there is something wrong with me psychologically or with my relationship.") and 2) because a "cure" would be perceived as less likely (changing aspects of one's self or relationship is generally perceived to be more difficult than adhering to a medical/surgical regimen). Psychological causal attributions have also been found to be related to maladjustment in other conditions.4,15
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METHODS
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The data used in these analyses were taken from a matched controlled clinical study of the etiology of dyspareunia consisting of a lengthy protocol, which included a psychosocial interview (including questions about causal attributions, sexual function, and history of sexual and physical abuse); self-report measures of pain, sexual attitudes, psychological distress, and marital adjustment; and three gynecological examinations.13,16 Only measures and procedures relevant to this analysis are described in the following section. For details about the entire protocol and procedure, see Meana et al.13
Of the 120 women recruited for that study, 115 were asked to what they attributed their pain during intercourse. Fifteen women (13%) reported that they "had no idea." Because the number of women who had made no causal attributions for their pain was small and not amenable to statistical comparison with the women who had made attributions, the former were excluded from the analyses in this study. Thus, the sample size of women who made attributions was 100.
Subjects
Participants were recruited through the publication of two articles on the topic of dyspareunia, which appeared in two Montreal daily newspapers (one English and one French). Inclusion criteria for study participation were 1) the experience of genital or pelvic pain with penile-vaginal intercourse and 2) fluency in English or French. Exclusion criteria were 1) chronic genital or pelvic pain at times other than during sexual intercourse, 2) pregnancy, and 3) dementia. Participants deemed eligible after a brief telephone screening interview were given an appointment at the Department of Obstetrics and Gynecology of the Royal Victoria Hospital.
The 100 women who had made causal attributions had a mean age of 37.89 (standard deviation [SD]: 12.62). Fifty women were primarily English-speaking and were thus interviewed in English, and 50 were primarily French-speaking and were interviewed in French. Fifteen were single, with no regular sexual partner; 16 had a regular sexual partner; 23 were cohabiting with partners; and 46 were married. Eighty were North American-born, and 70 were raised Roman Catholic (the religious composition of this sample is representative of the population of Montreal, which is predominantly Catholic). The mean number of children was 0.68 (SD: 1.08). The mean years of formal schooling was 14.77 (SD: 3.08), the equivalent of 1 year of undergraduate university.
Upon gynecological examination, 25 of the women in this sample were found to have no pain-related organic findings, 49 were diagnosed with vulvar vestibulitis, 11 were diagnosed with vaginal atrophy, and 15 had organic findings of different varieties that were neither atrophy or vulvar vestibulitis. Vulvar vestibulitis is diagnosed on the basis of three criteria: 1) severe pain on vestibular touch or attempted entry, 2) tenderness to pressure localized within the vulvar vestibule, and 3) physical findings confined to erythema of various degrees. Vaginal atrophy was determined by visually detectable impoverishment of skin elasticity, turgor, and labial fullness, as well as a visible thinning of the vaginal mucosa.
Measures
Causal Attribution.
Causal attribution was determined by asking the following open-ended question: "What do you think is causing you to experience pain with intercourse?" In the literature, this is the first causal attribution question posed using Kleinman's method, although clearly the question is adapted to whatever disorder is the focus of investigation.11,17 Responses were recorded verbatim and then coded by two independent coders as to whether the response constituted a physiological or a psychosocial causal attribution. The percentage agreement for coding causal attributions was 94%.
McGill-Melzack Pain Questionnaire (MPQ).18
The MPQ is both a qualitative and quantitative measure of pain composed of 78 adjectives; 3 scales (sensory, affective, evaluative); and 3 indices of pain (pain rating index, number of words chosen, and present pain index). The pain rating index is considered the global multidimensional measure of pain.
Sexual Arousability Inventory (SAI).19
The SAI is a 28-item self-report inventory measuring perceived arousability to a variety of sexual experiences. The items are descriptions of sexual experiences and situations that are rated along a 7-point Likert scale on the basis of how sexually aroused the respondent feels or would feel when engaged in the described activity.
Sexual Opinion Survey (SOS).20
The SOS is a 21-item measure of the disposition to respond to sexual cues along a negative–positive dimension of affect and evaluation (erotophobia/erotophilia). Each item describes a positive or negative affective-evaluative response to a sexual activity or situation. Respondents indicate agreement-disagreement on a 7-point scale. Scores range from 0 (most erotophobic) to 126 (most erotophilic).
Sexual Function.
As part of the psychosocial interview, women were asked how often they had had sexual intercourse in the past 6 months and how often (percentage of attempts) they had had orgasms resulting from masturbation, partner manual stimulation, oral stimulation, and intercourse in the past 6 months. They were also asked to rate their level of desire, arousal during sexual activity, and aversion to the sexual act on a 10-point scale, where "1" denoted "not at all" and "10" denoted "extremely."
Sexual Abuse.
As part of the psychosocial interview, women were asked whether they considered themselves to have been physically or sexually abused or assaulted during their childhood and as adults. Categorical "yes" or "no" answers were entered.
Brief Symptom Inventory (BSI).21
The BSI is a 53-item measure of state psychopathology composed of nine symptom dimensions (somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, paranoid ideation, psychoticism, phobia, hostility) and a global severity index. Subject scores were computed in reference to female nonpatient norms (a score of 50 on any scale being the norm, and a score of 70 representing the clinical cut-off).
Locke-Wallace Marital Adjustment Scale.22
This is a widely used 15-item general measure of marital adjustment that surveys satisfaction with issues such as "dealing with in-laws," leisure time, sexual relations, etc. Responses were scored as per the system described by Locke and Wallace,22 in which the norm for the total score is 100. For the purposes of this study, we modified the language of the scale to apply to both married and cohabiting couples.
Procedure
Upon arrival at the clinic, the women were interviewed individually by a clinically trained interviewer for about 45–60 minutes and they completed the questionnaires. They then underwent a standard gynecological examination, an endovaginal ultrasound, and a colposcopy. The entire protocol required about 3 hours to complete, including waiting time between examinations.
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RESULTS
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Covariates
We performed a series of univariate tests (analyses of variance, chi-square tests) to determine if there were any significant differences between causal attribution groups (physical and psychosocial) in terms of sociodemographic variables (age, language, religion, marital status, number of children, and educational level) and actual findings from the gynecological examinations. There were no significant differences. Neither socioeconomic nor diagnoses were related to the type of attribution made.
Causal Attributions
Sixty-six of the 100 women attributed their pain to physical causes, and 34 attributed their pain to psychosocial causes (see Table 1 for a list of most common physical and psychosocial attributions).
Pain
The women who made psychosocial attributions for their pain scored higher on the sensory dimension of the MPQ: F(1,96)=6.51, P<0.01. This dimension relates to the temporal, spatial, pressure, and thermal aspects of the pain. These women also scored higher on the evaluative dimension of the MPQ: F(1,96)=6.53, P<0.01. The evaluative dimension describes the subjective overall intensity of the total pain experience. Finally, the women who made psychosocial attributions also scored significantly higher on the total pain rating index, which is considered an overall pain experience rating: F(1,96)=6.12, P=0.02. Qualitatively, the women who made psychosocial attributions for their pain also tended to describe their pain differently. They were more likely to use the words beating:  2=5.94, df=1, N=98, P<0.01; shooting: 2=9.95, df=1, N=98, P=0.002; cutting: 2=4.93, df=1, N=98, P=0.03; aching: 2=6.21, df=1, N=98, P<0.01; heavy: 2=14.28, df=1, N=98, P=0.0002; sickening: 2=8.12, df=1, N=98, P=0.004; punishing: 2=6.31, df=1, N=98, P<0.01; unbearable: 2=5.73, df=1, N=98, P=0.02; and nauseating: 2=4.77, df=1, N=98, P=0.03. There was no adjective that was chosen significantly more often by the group of women who made physical attributions for their pain.
Sexual Attitudes, Function, and Abuse
In terms of attitudes toward sexuality, the women who made psychosocial attributions for the pain scored significantly lower on the SAI: F(1, 72)=5.18, P=0.03, although there were no between-group differences on the SOS. In terms of sexual function, there were no differences between the groups on intercourse frequency, desire, arousal, and orgasm, but the psychosocial attribution group reported more aversion to sexuality: F(1, 98)=19.42, P<0.0001 (see Table 2). They also were significantly more likely to report having been sexually assaulted in their adult lives (2=4.04, df=1, N=100, P=0.04), although there were no differences between the groups in terms of reports of childhood sexual or physical abuse nor of physical abuse during adulthood (see Table 3).
Psychological Adjustment
The women who made psychosocial attributions for their pain scored significantly higher on the Global Severity Index of the BSI: F(1, 99)=10.12, P<0.002. They also had significantly higher scores on the BSI subscales of interpersonal sensitivity: F(1, 97)=5.75, P=0.02; depression: F(1, 97)=5.02, P=0.03; anxiety: F(1, 97)=4.88, P=0.03; phobia: F(1, 97)=9.19, P=0.003; paranoia: F(1, 97)=5.06, P<0.03; and psychoticism: F(1, 97)=12.09, P<0.001. There were no between-group differences on the somatization, obsessive-compulsive tendencies, or hostility subscales (see Table 4).
Marital Adjustment
The women who made psychosocial attributions for their pain scored lower on the Locke Wallace Marital Adjustment Scale than did the women who made physical attributions: F(1, 68)=7.21, P<0.01. The psychosocial attribution group scored very close to the norm mean of 100 (mean: 102.87, SD: 26.04), whereas the psychosocial attribution group scored well below the norm mean (mean: 81.59, SD: 38.94).
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DISCUSSION
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Regardless of actual pathology found in the gynecological examinations conducted in this study, the women who had made psychosocial attributions for their pain differed in some interesting ways from the women who had made physical attributions. The former reported more pain, psychological distress, marital problems, and sexual aversion. They also reported lower levels of arousability and more incidents of sexual abuse or assault in their adult lives. In other words, perceived etiology, rather than actual etiology, was related to adjustment or adaptation.
There are at least three possible explanations for these findings: 1) making a psychosocial causal attribution about dyspareunia has a negative impact on adjustment; 2) premorbidly or otherwise, distressed women who develop dyspareunia are more prone to making psychosocial attributions; and 3) both the attributions and the adjustment are expressions of the same underlying phenomenon (i.e., depression).23,24 The investigation of the direction of the causal relation between attributions and adjustment is important and merits further research attention; however, the results of this study may be clinically relevant no matter which of the aforementioned models is in effect in any one woman.
First, the results alert us to the potential impact of a physician's causal attribution for a disorder on a patient's adjustment. Resorting to the default psychogenic attribution for pain with no obvious pathology has been a common strategy12 but may not be in the best service of patient care. Although this study did not investigate the extent to which women's attributions for dyspareunia were in agreement with previous consultations with physicians, it is likely that physician attributions for a pain of unknown etiology would be taken quite seriously by their patients. The results of this study suggest that there is at least a possibility that these physician attributions can affect patient adaptation (either positively or negatively).
Regardless of the direction of the causal relation of attributions and adjustment, knowing women's attributions for their pain may be clinically useful in the multidisciplinary treatment of dyspareunia and other pain disorders. Asking patients about their causal attributions could be an important part of the assessment process. It could cue health professionals to the level of distress around the problem and possibly identify potential contributors to the pain experience, whether actual or perceived. In the case of maladaptive attributions, cognitive reframing could be integrated into the treatment strategy, in addition to the other indicated interventions (e.g., medical, surgical).
One of the study's limitations is that it did not involve a random sample of women with dyspareunia. The women in this study volunteered because they did not feel that their problem had been adequately addressed by health professionals in the past and were searching for information that would lead to treatment. Thus, women with dyspareunia who felt they had been adequately assessed and treated probably did not participate in this study. This absence may explain why there was such a high percentage of lay theories in this sample. It does not, however, explain the differences between the two attribution groups. Another limitation of this study is the brief assessment of causal attributions. Lay theories of illness are multidimensional, and this study only investigated the causal dimension in the simplest and most direct way. It would be interesting to investigate further elaborations of women's lay theories of dyspareunia and their relation to pain and adjustment.
In the area of chronic pain, clinical signs are rare and subjective symptomatology predominates. Given those parameters, patients' causal attributions for their pain may represent an important resource for the management of these disorders. At best, making the effort to understand patient attributions may help treatment. At worst, it will validate the patient's phenomenological experience of the disorder and enhance the patient–physician relationship.
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This article has been cited by other articles:
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S. Magnuson and S. Collins
Collaboration between Couples Counselors and Physical Therapists when Treating Dyspareunia: An Untapped Partnership
The Family Journal,
January 1, 2002;
10(1):
109 - 111.
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ABSTRACT
INTRODUCTION
