Relationship of chronic pelvic pain to psychiatric diagnoses and childhood sexual abuse

The reliability and validity of empirically scaled measures of psychological/verbal control and physical/sexual abuse: relationship between current negative mood and a history of abuse independent of other negative life events

A history of psychological, physical, and sexual abuse, and circumscribed negative life events are precursors of current psychosomatic symptomatology. However, it is not known whether a history of abuse predicts current symptomatology, independent of other negative life events. We developed three new abuse scales: Psychological/Verbal; Control; and Physical/Sexual, which emerged when survey evidence of a random sample of the general public (N = 195) was factor analyzed. Test-retest reliabilities conducted on university students (N = 62) were moderate to high: Psychological/Verbal (r = 0.86); Control (r = 0.76); Physical/Sexual (r = 0.74); and Negative Life Events (r = 0.84). A Negative Life Event scale was developed to measure the cumulative effects of events (over the lifespan). A total score was calculated by summing event scores, weighted in proportion to 11 independent judges' ratings of distress for later use (Kendall's W; chi 2 = 183.67, df = 67, p < 0.0001). Thirteen criterion measures of current symptomatology were administered to a subsample of the original sample (N = 92), and collapsed into one factor for use as the criterion in a regression analysis; results showed that, independent of negative life events and respondent demographics, the Psychological/Verbal and Control Abuse Scales predicted current negative mood and psychosomatic complaints, and the association between current symptomatology and the Physical/Sexual Abuse Scale approached, but did not achieve, statistical significance (t = 1.99, df = 71, p < .0501). The present study demonstrates that the three abuse scales may be powerful predictors of current symptomatology, and that they have the potential for further investigating a wider range of current medical, physiological, and psychological problems.

Neuroticism and extraversion as predictors of health outcomes in depressed primary care patients

Depressed primary care patients (N = 217) were assessed to determine if certain personality characteristics predict health domains independent of chronic disease, demographics, depression, and psychiatric diagnoses. Eleven health variables were used to create three outcome factor scores: disability (e.g., days missed work); somatization (e.g., medically unexplained symptoms); and subjective pain (severity, interference). Neuroticism explained significant variance in all health outcomes independent of the other predictors. Depression and neuroticism interacted in the disability and pain models. Depression was related to health in neurotic patients, while in the absence of neuroticism, little relation between depression and health was observed. Neuroticism may explain why persons with similar health problems have differing levels of disability, pain, and somatization.

Surgical treatment of endometriosis

Surgical resection of endometriosis, previously possible only by means of laparotomy, can now be accomplished through laparoscopic techniques. The requirements for surgery, surgical principles, operative techniques, and results are summarized in this article, with emphasis on the laparoscopic approach.

Female adolescent response to childhood sexual abuse

PROBLEM

History of childhood sexual abuse has been linked to fear, anxiety, depression, aggression, anger, hostility, poor self-esteem, substance abuse, and sexual maladjustment, as well as somatic complaints. The purpose of this study was to compare sexually abused adolescent females to adolescent females who have not ben sexually abused with respect to incidence of emotional disorders and somatic symptoms.

METHODS

A convenience sample of females, ages 12-17, included 11 identified victims of sexual abuse and 11 nonabused adolescents. A descriptive design using multiple methods of data collection: interview questions, self-report questionnaires, and projective drawings.

FINDINGS

The sexually abused adolescents scored significantly higher than the adolescents who had no history of sexual abuse on specific sub scales (anxiety, muscle tension, cognitive disorganization) and on the total scale scores of both the SOS and the SCL-90.

CONCLUSIONS

Given the epidemic proportions of childhood sexual abuse, nurses in varied settings are in a position to identify, evaluate, and treat families with adolescents who manifest a wide range of sequelae.

Impact of sexual and physical abuse dimensions on health status: development of an abuse severity measure

OBJECTIVE

Despite the abundant literature showing a relationship of sexual and/or physical abuse history with poor health status, few studies provide evidence about which dimensions of abuse may have a worse impact on health. In female patients with gastrointestinal (GI) disorders, the present study aims to identify which dimensions of abuse history (eg, number of perpetrators, injury) might predict poor current health status, in order to develop an empirically based severity of abuse measure.

METHODS

Of a sample of 239 female patients from a referral gastroenterology clinic, this paper primarily focuses on 121 women with a past history of contact sexual abuse (N = 99), and/or life threatening physical abuse (N = 68).

RESULTS

Among those with a sexual abuse history, 24% of current health status was explained by serious injury during abuse (p = .0006), victimization by multiple perpetrators (p = .03), and being raped (p = .09). Among the physically abused, rape (in addition to life threat) (p = .0001), and multiple life-threatening incidents (p = .002) explained 39% of the variance in overall health. Among the women with a sexual and/or physical abuse history, the experience of rape, serious injury during sexual abuse, and multiple life-threatening incidents explained one fourth of the variance in current health status. Based on these three dimensions of abuse, we created an abuse severity measure which explained about one fourth of the variance in health status among the subgroup with abuse history, and among the entire clinic sample.

CONCLUSIONS

Given the high prevalence of abuse in referral practice, and the potential health impact of previous abuse, it is important that history taking include details concerning the abuse experience. The severity of abuse measure developed in this paper should prove useful for both research and clinical practice.

Painful bladder syndromes in the female: Etiopathogenetic hypotheses

The origins of interstitial cystitis and urethral syndrome are unknown. Epithelial leak, functional disorder of the pelvic floor muscle and reflex sympathetic dystrophy are the most popular etiopathogenetic assumptions. Atypical micro-organisms and psychopathologies should always be carefully excluded.

Sociopsychological factors in chronic pelvic pain: a review

Chronic pelvic pain is a common gynecological problem. There has long been an assumption that social and psychological factors play a part in its genesis in a significant subgroup, but their precise role remains unclear. More recently, childhood sexual abuse has been implicated as a specific risk factor. For this review, PSYCHLIT and MEDLINE searches for relevant publications were supplemented by tracing back through the latter's related reference lists. One hundred thirty-one references directly concerning pelvic pain were identified with varying emphasis on social and psychological aspects. A further 449 references were in related fields. Forty-three were considered to be helpful in directly exploring the link between chronic pelvic pain and sociopsychological factors and 22 of these reported specific studies directly relevant. In common with other research into chronic pain conditions, it appears unhelpful to separate this type of pain into "psychogenic" and "organic" categories. Clear case definition is essential. The specificity of childhood sexual abuse as a risk factor is unclear. It may be helpful to consider clearly defined subgroups with the condition in future studies. An example of such a subgroup with pelvic venous congestion is discussed.

Sociopsychological factors in women with chronic pelvic pain with and without pelvic venous congestion

Social and psychological factors have long been proposed as being of importance in a sizeable subgroup of women complaining of unexplained chronic pelvic pain (CPP). The aim of this study was to examine this in two subgroups of CPP patients, thereby eliminating pain alone as the determining variable. Consecutive attenders at a clinic for CPP were assessed on a range of somatic, historical, social, and psychological variables using detailed interviews and questionnaires. They were subsequently allocated to one of two groups, based on the presence or absence of pelvic venous congestion (PVC). Significant associations emerged between some social arrangements, paternal parenting, and patterns of hostility in the group with pelvic venous congestion. The groups also differed in patterns of family illness, and the congested group tended to report more childhood sexual abuse (CSA). Clear case definition in CPP is important. In the subgroup with pelvic venous congestion early social experience may play an important role. Father-daughter relationships may be particularly relevant. Hostility patterns may influence the development of the condition. CSA does not appear to play a specific role in all unexplained CPP cases, but may have relevance for the subgroup with pelvic venous congestion.

Non-organic symptom reporting in patients with chronic non-malignant pain

Patients with chronic non-malignant pain are often suspected of reporting medical symptoms that have non-organic as opposed to purely organic origins. According to the somatization hypothesis, non-organic reporting occurs when affective or other benign physical sensations are misconstrued as symptoms of physical disease [corrected]. Psychological tests purporting to assess somatization are limited by their self-report format and may be confounded in patients with physical disease or injury. Measures of somatization may also be influenced or biased by underlying differences in depression or anxiety. In order to obtain an unbiased estimate of somatization, therefore, it is necessary to control for the influence of extraneous variables. In the present study, symptom report scales designed to assess somatization, symptom amplification, and disease conviction were administered to a group of 100 patients with chronic non-malignant pain. The strategy was to determine whether any of these tests could account for individual differences in illness behavior. Specifically, the set of dependent measures included: length of disability; frequency of medical visitation; activity level; and level of domestic functioning. The most successful predictor of patient behavior was the Somatization Scale (Derogatis et al. 1974) which correlated positively and significantly with each dependent measure. In order to examine the possibility that scores on this test were biased by differences in organic pathology, three physician pain specialists were asked to rate the morbidity of each item on the scale. A multiple regression analysis was then performed to examine whether differences in symptom morbidity, depression, or anxiety could account for the correlation between symptom ratings and illness behavior. The analysis showed that while depression and anxiety were significantly correlated with measures of illness behavior, the Somatization Scale still accounted for a significant amount of unique variance in three out of five dependent variables. Symptom morbidity was significantly correlated with only one measure of illness behavior (Activity Level). In view of these findings, scores on the Somatization Scale were used to classify 25 patients as Symptom Minimizers and another 25 as Symptom Amplifiers. When compared to Minimizers, Amplifiers were disabled for a significantly greater number of days, reported significantly more impairment in domestic functioning, were significantly less active, visited the doctor significantly more often, and were significantly more distressed. The results suggest that substantial differences in disability and medical visitation may exist among patients who may not differ appreciably in their level of organic pathology. Instead, differences in illness behavior may, to some extent, be mediated by differences in somatization.

Somatic symptoms of distress: an international primary care study

The objective of this study was to examine cross-national differences in somatic symptoms associated with psychological distress. Data from the World Health Organization (WHO) collaborative study of psychological problems in general health care (5438 patients at 15 sites) were used to examine somatic symptoms associated with psychological distress. At each site, a stratified random sample of consecutive primary care patients completed the 28-item General Health Questionnaire (GHQ) and the Composite International Diagnostic Interview (CIDI). At all sites, the number of current CIDI somatic symptoms (whether medically explained or not) was strongly associated with current psychological distress (measured by selected GHQ-28 items). Pearson correlation of somatic symptom count with psychological distress score was .42 for all sites and ranged from .20 to .58 (p < .0001 at all sites). Across all sites, anxiety and depressive symptoms showed roughly the same association with somatic symptom counts, and specific somatic symptoms or symptom clusters did not show differential association with anxiety or depression. Although somatic symptoms did cluster into meaningful groups (gastrointestinal, neurological/conversion, autonomic, and musculoskeletal), these symptom groups did not show differential association with psychological distress. Examination of individual somatic symptoms and symptom clusters across sites did not reveal clear patterns of association according to geography or level of economic development. These data show a strong association between somatic symptoms and psychological distress, which did not vary across disparate cultures and levels of economic development. Cultural factors, however, may influence the meaning attached to symptoms or the likelihood of presentation for health care.

Chronic gynecologic pain

Patients with chronic gynecologic pain are frequently seen by consultation psychiatrists working on gynecologic services. This paper reviews the classification and assessment of chronic gynecologic pain and comments on recent studies of these disorders. The role of the psychiatrist in the multidisciplinary assessment and treatment of these women is discussed.

Gender variations in clinical pain experience

This review is a critical summary of research examining gender variations in clinical pain experience. Gender-comparative pain research was identified through Medline and Psychlit searches and references obtained from bibliographies of pertinent papers and books. Review of this research demonstrates that women are more likely than men to experience a variety of recurrent pains. In addition, many women have moderate or severe pains from menstruation, pregnancy and childbirth. In most studies, women report more severe levels of pain, more frequent pain and pain of longer duration than do men. Women may be at greater risk for pain-related disability than men but women also respond more aggressively to pain through health related activities. Women may be more vulnerable than men to unwarranted psychogenic attributions by health care providers for pain. Underlying biological mechanisms of pain and the contribution of psychological and social factors as they contribute to the meaning of pain for women and men warrant greater attention in pain research.

Urologic sequelae of childhood genitourinary trauma and abuse in men: principles of recognition with fifteen case illustrations

Providing urologic care to men who have been traumatized during childhood may be especially challenging because of the extent, severity, and unusual character of their urogenital problems. Recognition of past trauma entails attentiveness to patients' background and behaviors. As illustrated through these 15 cases, patients who present with too many past surgeries, too many unremitting urologic complaints, too little sexual function and too few genital parts, sexual impulses that are too strong, sexualized conduct in clinical settings, and self-destructive behaviors surrounding sexuality may have experienced trauma in the past. While empirical studies are necessary to demonstrate the ultimate utility of these categories, appreciation of these clinical indications improves the urologic care provided to traumatized men in four ways: by elucidating unusual and unusually recalcitrant urologic complaints, thereby clarifying clinical decisions; by allowing for appropriate use of psychiatric consultation; by promoting a better understanding of the sequelae of trauma in men; and by alleviating the discomfort naturally felt by urologists and their staff when caring for these difficult, multiproblem patients.

Sexual assault history and eating disorder symptoms among White, Hispanic, and African-American women and men

Data from two Epidemiologic Catchment Area Program sites (Los Angeles and North carolina) were analyzed to examine relations of sexual assault history to eating disorder symptoms. In regression analyses controlling for age, gender, ethnicity, income, socioeconomic status, and study site, persons with sexualy assault history (n = 514) were more likely than those not assaulted (n = 5511) to report thinking they were too fat (odds ratio [OR] = 1.6); losing > or = 15 lb (OR = 1.86); weight loss to 85% of normal (OR = 2.08); one or more anorexia symptoms (OR = 1.81); and sudden weight change (OR = 2.32). Ethnicity and income modified the relations. The data support an association of sexual assault history with eating disorder symptoms.

Office gynecology for the primary care physician, part II: pelvic pain, vulvar disease, disorders of menstruation, premenstrual syndrome, and breast disease

Approaches to patients with pelvic pain, vulvar disease, disorders of menstruation, premenstrual syndrome, and breast diseases are addressed. In the great majority of cases, it is appropriate for the primary care physician to initiate evaluation and management of these problems. It is hoped that the brief introductions contained here suggest a diagnostic approach to each disorder and guide referral to consultants as needed.

Psychosocial factors and chronic pelvic pain: a comparison of women with endometriosis and with unexplained pain

Chronic pelvic pain is a common clinical problem, and physical investigation often fails to reveal its cause. For this reason, it has been argued that psychological and social factors contribute to such "unexplained" pain. Few studies to date using well-validated psychometric measures and adequate sample sizes have compared patients with unexplained pain and those with identified physical disease. The present study compared pain severity, mood symptoms, personality characteristics and social adjustment in women with unexplained pain and women with endometriosis. Women with endometriosis were more likely to come from upper socioeconomic groups. No differences in mood symptoms or personality characteristics were identified, but women with endometriosis had somewhat more severe pain and greater social dysfunction than those with unexplained pain. Mood disorder and social dysfunction appear to be at least as important in patients with proven endometriosis as in those with unexplained pain.

Chronic pelvic pain and gynecological symptoms in women with irritable bowel syndrome

Chronic pelvic pain and irritable bowel syndrome are common disorders, yet very little is known about their comorbidity. As part of an epidemiological study of patients with irritable bowel syndrome or irritable bowel disease we inquired about a history of chronic pelvic pain and related gynecological problems, and hypothesized that distress associated with either of these conditions was additive in women with both syndromes. A medically trained interviewer evaluated a sequential sample of 60 women with irritable bowel syndrome and 26 women with inflammatory bowel disease in an urban gastroenterology clinic using the National Institute of Mental Health Diagnostic Interview Schedule, the Briere Child Maltreatment Interview (emotional, physical and sexual abuse), and a structured interview to elicit a lifetime history of chronic pelvic pain that was distinct from the history of bowel distress. Chronic pelvic pain was reported in 21 (35.0%) of the irritable bowel syndrome patients vs. 4 (13.8%) of the inflammatory bowel disease group (p < 0.05). Compared to women with irritable bowel syndrome alone, those with both irritable bowel syndrome and chronic pelvic pain were significantly more likely to have a lifetime history of dysthymic disorder, current and lifetime panic disorder, somatization disorder, childhood sexual abuse and hysterectomy. Logistic regression showed that mean number of somatization symptoms was the best predictor of a history of both irritable bowel syndrome and chronic pelvic pain compared either to inflammatory bowel disease or irritable bowel syndrome alone. Many women with irritable bowel syndrome may have a history of chronic pelvic pain as well. The high rates of psychopathology associated with irritable bowel syndrome and chronic pelvic pain independently are even higher in women with both syndromes, and women who present with either irritable bowel syndrome or chronic pelvic pain should probably be evaluated for both disorders.

The diagnostic value of laparoscopy in 2365 patients with acute and chronic pelvic pain

OBJECTIVE

To discriminate the etiology in 2365 patients with acute and chronic pelvic pain (APP, CPP).

METHODS

Diagnostic laparoscopy was carried out in 736 patients (31.1%) with APP and in 1629 (68.9%) with CPP. In 315 patients (13.3%) the diagnostic procedure was extended to operative laparoscopy.

RESULTS

The most frequent laparoscopic findings in patients with APP were acute salpingitis and pelvic adhesions (22.8%) and ectopic pregnancy (19%), while in patients with CPP the most frequent findings were pelvic adhesions (35.4%) and endometriosis (24.6%). In 7.5% of patients with APP and 24% with CPP, laparoscopy did not reveal any pathological finding in the pelvis. Among the 315 patients in whom operative laparoscopy was carried out, 40% suffered from APP and 60% from CPP. In the 446 patients (18.9%) without laparoscopic findings no treatment was given, while of the remaining 905 patients 40% were subjected to laparotomy and 60% received conservative treatment. The total incidence of side effects reached 4.7% and serious side effects resulting from emergency laparotomy occurred in 0.15% of patients with pelvic pain.

CONCLUSION

Our results in a large group of patients with pelvic pain show that there are discrepancies in the incidence of laparoscopic findings between patients with APP and CPP. Discrepancies between the two groups of patients were also found during operative laparoscopy, the treatment administered after laparoscopic diagnosis and the complications encountered.

Sexual and physical abuse history in gastroenterology practice: how types of abuse impact health status

OBJECTIVE

There is an increasing amount of literature pointing to a relationship between sexual and/or physical abuse history and poor health status, although few studies provide evidence concerning which aspects of abuse may impact on health. In female patients with gastrointestinal (GI) disorders, the present study examined the effects on health status of: 1) history of sexual abuse and physical abuse, 2) invasiveness or seriousness of sexual abuse and physical abuse, and 3) age at first sexual and physical abuse.

METHOD

The sample included 239 female patients from a referral gastroenterology clinic who were interviewed to assess sexual and physical abuse history.

RESULTS

We found the following: 1) 66.5% of patients experienced some type of sexual and/or physical abuse; 2) women with sexual abuse history had more pain, non-GI somatic symptoms, bed disability days, lifetime surgeries, psychological distress, and functional disability compared to those without sexual abuse; 3) women with physical abuse also had worse health outcome on most health status indicators; 4) rape (intercourse) and life-threatening physical abuse seem to have worse health effects than less serious physical violence, and sexual abuse involving attempts and touch; and 5) those with first abuse in childhood did not appear to differ on health from those whose first abuse was as adults.

CONCLUSIONS

The authors conclude that asking about abuse should be integrated into history taking within referral-based gastroenterology practices.

The gynecological care experience of adult survivors of childhood sexual abuse: a preliminary investigation

The gynecological care experiences of 44 adult survivors of childhood sexual abuse and 30 non-abused controls were investigated and compared. On a self-administered survey, survivors rated the gynecological care experience more negatively than the controls, experienced more intensely negative feelings, and reported being more uncomfortable during almost every stage of the gynecological examination than did the controls. Survivors also reported more trauma-like responses during the gynecological examination, including overwhelming emotions, intrusive or unwanted thoughts, memories, body memories, and feelings of detachment from their bodies. Eighty-two percent of the survivors in the sample had never been asked about a history of sexual abuse or assault by a gynecological care provider, despite clear evidence from this study that such information would be relevant to their care. Implications of the study's findings for gynecological care practice and training are explored, and questions for future research are discussed.

Psychiatric diagnoses and sexual victimization in women with chronic pelvic pain

The authors evaluated 100 women scheduled for diagnostic laparoscopy (50 for chronic pain, 50 for tubal ligation or infertility evaluation) using structured psychiatric, family history, and sexual trauma interviews. Laparoscopy reports were blindly rated by a gynecologist. Compared with the nonpain group, the women with chronic pelvic pain had significantly higher current and lifetime rates of psychiatric disorders, as well as childhood and adult sexual victimization. They reported significantly higher mean numbers of somatization symptoms, but no significant differences in objective laparoscopic findings. Psychiatric disorders and sexual victimization are common in women with chronic pelvic pain and should be considered in the evaluation and treatment of these patients.

Do somatic complaints mask negative affect in youth?

The developmental transition between adolescence and early adulthood represents a high-risk period for the onset of somatization. Although research has lagged clinical work in this area, it has long been believed that, for somatizing youth, physical complaints are best conceptualized as a defense against negative affect. Recent adult-oriented research, however, suggests that somatic complaints may be better conceptualized on a continuum, with physical complaints covarying with overt psychological symptomatology. To explore these hypotheses systematically, the authors studied the relationship between multiple dimensions of psychological distress and somatic complaints in undergraduate students. Higher levels of physical symptom reporting were associated with complaints of more overt psychological distress, a finding that was consistent with a continuum perspective. The implications of these results for understanding somatization in college student populations and for university-based healthcare are discussed.

Somatoform and personality disorders: syndromal comorbidity and overlapping developmental pathways

We review the literature on the relationship between somatoform disorders and personality disorders, which reveals that approximately two in three patients with a somatoform disorder meet criteria for a personality disorder. We suggest that the most clinically salient problems presented by patients with somatoform disorders reflect dysfunctions of personality. We also examine research on the childhood antecedents of somatoform disorders and argue for reconsidering somatoform disorders, along with personality disorders, as disorders of development. Our argument involves rejecting the traditional approach to classification in favour of a prototypical polythetic view. We also suggest that the perspectives of developmental psychopathology and life-span research offer more to this field than the search for biological substrates or principles based on descriptive psychopathology, which to date have yielded meagre research findings with limited clinical utility.

Medical and psychiatric symptoms in female gastroenterology clinic patients with histories of sexual victimization

Several recent retrospective reports have associated prior sexual victimization and long-term medical sequelae such as increased medical clinic utilization and reports of physical symptoms. However, methodological constraints have limited the generalizability of these findings. Our study was designed using structured interviews with a sequential sample of 89 female gastroenterology clinic patients, who were classified by severity of sexual trauma and studied for differences in lifetime psychiatric diagnoses, physical abuse, and medically unexplained symptom patterns. Compared with the 46 women who had experienced less severe or no prior sexual trauma, the 43 patients with severe victimization had significantly higher life-time and current rates of several selected psychiatric disorders as well as significantly higher mean numbers of lifetime psychiatric disorders, medically unexplained physical and anxiety symptoms, greater harm avoidance and dissociation scores, and increased functional disability. A logistic regression showed that the main predictors of a history of severe sexual abuse were the number of medically unexplained symptoms, adult physical abuse, and lifetime dysthymic disorder. We concluded that women with prior severe sexual trauma episodes may express medically unexplained physical symptoms as part of the long-term adaptation to their victimization.

Living the coming of memories: an interpretive phenomenological study of surviving childhood sexual abuse

An interpretive phenomenological study was conducted to document the pervasiveness of remembering in the lives of adult women survivors of childhood sexual abuse. Participants in the study shared stories that revealed how these memories emerge, intrusively at times, and permeate their day-to-day lives. A call is made for health care providers to be informed about issues related to childhood sexual abuse. A brief discussion of the current backlash to increasing awareness of sexual abuse is also included. Implications of the findings of this study for the delivery of health care are explored. The importance of listening to and believing survivors of childhood sexual abuse is emphasized.

The reliability and validity of a sexual and physical abuse history questionnaire in female patients with gastrointestinal disorders

Although the literature on the psychological and medical sequelae of sexual and physical abuse has been growing, researchers have made few attempts to standardize the measurement of abuse history. The authors of this article report the first standardization of a screening instrument to identify sexual and physical abuse in a medical population. Reliability was assessed using test-retest methodology, and validity was supported by comparison with an interview (criterion validity). The sample included 139 female patients in a gastroenterology clinic. Data indicate acceptable test-retest reliability of the sexual abuse instrument (81%) and 81% overall agreement between the questionnaire and the interview on any sexual abuse. In comparison, the authors found 77% agreement in test-retest reliability of the physical abuse questionnaire and 70% agreement between the questionnaire and the interview on physical abuse. From their analyses, they concluded that the sexual abuse questionnaire and, to a lesser extent, the physical abuse instrument have acceptable levels of reliability and validity. As a screening tool, the abuse measures could be used to identify women in clinic settings for further study.

Coping with chronic pain. Some patients suffer more

BACKGROUND

A multi-dimensional approach was used to examine coping in chronic pain. The following hypotheses were tested: (a) patients who cope maladaptively also cope generally in a similar way; (b) patients' maladaptive coping is associated with childhood adversity.

METHOD

Cross-sectional and retrospective data were collected from 68 consecutive patients (aged 18-70) at a pain clinic where their disease was non-systemic and the pain had lasted for at least three months. Sixty-one patients were interviewed using the Structured Clinical Interview for DSM-III-R, and the Measure of Parental Care in Childhood. All patients completed questionnaires on their pain and personality.

RESULTS

Two coping styles emerged from factor analysis. One was associated with chronicity, psychiatric morbidity, harm avoidance, immature defence style and reporting parental indifference.

CONCLUSION

Patients may be predisposed to cope maladaptively after the experience of parental indifference in early life. Such coping is likely to reflect more general patterns.

Labor experiences of childhood sexual abuse survivors

This field study used the ethnographic method to describe and analyze the labor experiences of childhood sexual abuse survivors. The sample included seven sexual abuse survivors, five nurse-midwives, and three labor and delivery nurses. Data collection included in-depth interviews, participant observation in labor and delivery over a period of six years, and anecdotal material from the literature. Analysis followed Spradley's Developmental Research Sequence and included domain, taxonomic, componential and theme analysis. Women reported both forgetting and remembering abusive incidents, and described labor sensations reminiscent of sexual abuse. A heuristic for appraising labor styles suggestive of past sexual abuse includes fighting, taking control, surrendering, and retreating. These styles are considered extremes of women's reactions to labor and are directly linked to posttraumatic stress disorder. This study demonstrated that it is important for perinatal caregivers to understand the link between childhood sexual abuse and childbirth so that they can assist women to have a positive birth experience.

Severity of somatization and its relationship to psychiatric disorders and personality

Medical patients' (75 with chronic fatigue complaints, 61 with dizziness, and 88 with disabling tinnitus; N = 224) current and past psychiatric diagnoses and personality characteristics were assessed to determine if they could independently explain the number of medically unexplained physical symptoms that the patients had experienced. Cloninger's Tridimensional Personality Questionnaire (TPQ) and the Diagnostic Interview Schedule based on DSM-III-R were used to assess the personality and psychiatric diagnoses, respectively. The results revealed that the number of lifetime medically unexplained symptoms were significantly, independently, and positively related to increasing numbers of current and past anxiety and depressive disorders and to the harm avoidance dimension of the TPQ. In a second analysis, the "worry/pessimism" and "impulsiveness" subscales were positively related to the number of medically unexplained symptoms. The results suggest that somatization is associated with current and past history of psychiatric illnesses and harm avoidance in this sample of medical patients.

Gastrointestinal tract symptoms and self-reported abuse: a population-based study

BACKGROUND/AIMS

A link between abuse and irritable bowel syndrome (IBS) has been reported in outpatients but remains controversial. No population-based studies have investigated this issue. The aim of this study was to determine the prevalence of abuse and its association with symptoms in a representative community sample.

METHODS

An age- and sex-stratified random sample of residents of Olmsted County, Minnesota ranging in age from 30 to 49 years was mailed a valid self-report symptom questionnaire. Abuse was assessed by standard published criteria.

RESULTS

Of the 919 responders (74%), the age-adjusted prevalence of any abuse was 41% in women and 11% in men, resulting in an age- and sex-adjusted prevalence of 26%. Symptoms of IBS, dyspepsia, and frequent heartburn were reported by 14%, 23%, and 12%, respectively. There was a significant association between IBS and sexual abuse, emotional or verbal abuse, and abuse in childhood and adulthood. Similarly, dyspepsia and heartburn were both significantly associated with abuse. In the population, 31% had visited a physician for gastrointestinal symptoms; the odds of visiting a physician were highest in those reporting abuse in adulthood and childhood.

CONCLUSIONS

Self-reported abuse is common in middle-aged subjects; those who report abuse are more likely to have symptoms consistent with IBS, dyspepsia, or heartburn and to visit a physician for bowel symptoms.

Somatization and pain dispersion in chronic temporomandibular disorder pain

We investigated the relationship between somatic and psychological symptoms and pain reported during a clinical examination for 220 patients with chronic temporomandibular disorder (TMD) pain. The clinical examination involved palpation of the muscles of the face and neck, as well as intraoral sites and non-TMD-related placebo sites. A distinction was drawn between somatization--the tendency to report numerous somatic symptoms--and psychological distress manifested by report of numerous affective and cognitive symptoms. Somatization was assessed with the Somatization scale of the SCL-90-R; cognitive/affective distress was assessed with the non-somatic items of the Anxiety and Depression scales. Heightened somatization and high-intensity pain were strong predictors of widely dispersed muscle palpation pain during the clinical examination. High-somatization patients were 3 times more likely than low-somatization subjects to report having a painful placebo site. Pain dispersion was more closely linked to report of number of somatic symptoms than to report of affective and cognitive symptoms of psychological distress.

Patients with chronic pelvic pain and/or infertility: psychological differences pre- and post-treatment

This study investigated the psychological differences between gynecological clinic attenders with either pelvic pain or infertility, or with both pelvic pain and infertility both before and after laparoscopic investigation with concurrent treatment. Given the differing meaning attached to the procedure by these groups, it was hypothesized that infertility patients would be more anxious but with less evidence of psychopathology in comparison with the pain group prior to laparoscopic surgery. Postsurgery and in the short term, pain reduction was expected to be associated with decreased pathology for the pain group. Contrary to the hypotheses, pain patients obtained higher anxiety scores in comparison with the infertility group both pretreatment as well as post-treatment. The latter group's scores were comparable to normative data. Other results were generally in line with the hypotheses, pain reduction for both pain groups being associated with a reduction in psychopathology. Patients with pain plus infertility resembled pain patients at pretreatment, while at post-treatment, they bore a closer resemblance to infertility patients in their psychological profile. This was despite the fact that for both pain groups, pain relief was similar. This reinforces the notion that in the patient groups studied anxiety is associated with pain rather than with infertility.

Long-term correlates of childhood sexual abuse in adult survivors

Empirical research demonstrates a relationship between history of child sexual abuse and numerous psychological, interpersonal, and behavioral problems in adults. Long-term correlates and theoretical conceptualizations of these sequelae are described.

The combined effects of physical, sexual, and emotional abuse during childhood: long-term health consequences for women

The long-term health effects of physical, sexual, and emotional abuse during childhood were studied in a sample of 668 middle class females in a gynecologic practice who responded to a self-administered, anonymous questionnaire covering demographic information, family history, physical and psychological health, as well as stressful events and abusive experiences as a child. Half (53%) of the sample reported childhood abuse, with 28.9% recounting exposure to one type of abuse, 18.7% to two types of abuse, and 5.4% to all three types of abuse. In comparison to women not abused during childhood, the abused reported significantly more hospitalizations for illnesses, a greater number of physical and psychological problems, and lower ratings of their overall health. The greater the number of childhood abuses, the poorer one's adult health and the more likely one was to have experienced abuse as an adult. Thus, in addition to the deleterious psychological consequences of abuse described in the literature, physical health also appears to be adversely affected in women abused as children.

Child sexual abuse: immediate and long-term effects and intervention

OBJECTIVE

The primary purpose of this review is to highlight the progress made in the area of child sexual abuse during the recent decade and to identify the gaps in our current knowledge about this syndrome.

METHOD

More than 100 articles on child sexual abuse were reviewed, the majority written from 1980 to the present concerning the demographics of child sexual abuse, the psychological effects of child sexual victimization, the psychopathology encountered in adult survivors of child sexual abuse, hypotheses regarding the nature of the trauma, a critique of the research, and approaches to intervention.

RESULTS

Although a wide variety of psychological sequelae have been documented in sexually abused children referred for evaluation or treatment, there appears to be considerable variability in the severity of the symptoms, and we remain ignorant of sequelae in abused children who never enter the mental health system. However, some of these children may become symptomatic in adult life. Validation of sexual abuse is hampered by the lack of specific behavioral markers. Methodological difficulties in child sexual abuse research include problems with definition, failure to measure severity of the abuse, sampling problems, failure to use standardized or appropriate instruments, problems with validation, and failure to use control groups.

CONCLUSIONS

Despite an increased focus on child sexual abuse in the recent decade, many gaps remain in our knowledge. Prospective longitudinal follow-up studies of sexually abused children and treatment outcome studies are urgently needed.

Psychosocial aspects of chronic pelvic pain, with special reference to sexual abuse. A study of 164 women

Patients with chronic pelvic pain attending a tertiary referral centre show certain social, developmental and psychological characteristics. Specifically, they appear to have fewer children and to report more paternal overprotection, and a trend towards low maternal care compared to normals. They also show more depression, free-floating anxiety and somatic anxiety than such populations. The levels are similar to those found in other outpatient populations presenting with migraine or irritable bowel syndrome. Hostility levels are greater than those in normal subjects. Overall the present patient population reports the same degree of childhood sexual abuse as do many other female clinic and community sample populations. Sexual abuse is unlikely to be a specific aetiological factor in the development of chronic pelvic pain though it may yet be found to be important in subsets of the population.