MENSTRUAL
DISORDERS:
A
PSYCHOSOMATIC
STUDY
CHAPTER I
INTRODUCTION
I INTRODUCTION
II STATEMENT OP THE PROBLEM
PSYCHOSOMATIC DISORDERS
III CLARIFICATION OF THE BASIC TERMS
i) PSYCHOSOMATIC ILLNESS
ii) MENSTRUATION
iii) PSYCHOLOGICAL CORRELATES OF MENSTRUAL DISORDERS
(MOOD CHANGES)
iv) TYPES OP MENSTRUAL DISTURBANCES
a) DYSMENORRHEA
b) AMENORRHEA
C)
MENORRHAGIA
d) METRORRHAGIA
e) OLIGOMENORRHEA
f) THE PREMENSTRUAL SYNDROME
V)
FACTORS AFFECTING MENSTRUATION
a) MOTHER'S ATTITUDES TO MENSTRUATION
b) SOCIAL ATTITUDES TO MENSTRUATION
C)
MYTHS ABOUT MENSTRUATION
d) REACTIONS TO MENSTRUATION OF THE GIRL/WOMAN
HERSELF
e) CONCLUSION
Vi) QUESTIONNAIRE AS A RESEARCH TOOL
Vii) PROJECTIVE TECHNIQUE AS A RESEARCH TOOL
IV PURPOSE OF THE STUDY
V SIGNIFICANCE OF THE STUDY
1
I
INTRODUCTION
Whatever our aspirations to equality,.there is no denying
that, biologically and physically, women are different from men.
Our Jarains may be the same but our reproductive systems are not.
The variations between the sex organs are obvious, but .there is
another difference which is less obvious though probably much
more important because it influences every aspect of a woman's
being - physical, psychological and social - and it affects to
some degree not only the woman herself, but also those who live
or work closely with her. The difference is the woman's menstrual
cycle.
For a modern woman, the. menstrual cycle has become a sign of
the Original
Curse.
Many women now combine physically and
intellectually demanding jobs with caring for homes and families;
this may c r eate
intolerable
t e n sions
that are e v e n t u a l l y
reflected in their ability to be fully effective in either.
Psychologists (SHREEVE, 1983; CQEEMAN, 1956) are of the opinion
that tension and emotional difficulties create physiologically
problematic situations which sometimes even the doctor cannot
diagnose correctly. According to the holistic approach, whenever
there is anxiety or tension that disturbs the woman emotionally,
all her physiological and biological processes are affected.
Menstruation being one of them also comes in this category.
Whether it is stress of modern life combined with greater freedom
of choice amongst women, or simply that they are more yocal about
their problems, there is little doubt that gynaecologists see a
large number of women with complaints that do not have their
origin in recognized forms of pathology.
The present research worker was directed
2
to this problem by
observing certain types
of abnormalities' occurring
in the
menstrual cycle of college going girls. Usually, the menstrual
cycle has a fixed time limit and occurs regularly once in 26 to
30 days
if the woman
is healthy,
normal,
and w i t h o u t any
gynaecological problems. However, the research worker was aware
of the link between gynaecological disease and psychology of
women,
especially
so of the psychological
component
in the
cessation of menstruation accompanying change,in the environment,
or the stress of an examination. Thus, the irregularity was not
because of physical malfunction but because of psychological
stress. This is the. beginning of the present research work.
How far is this true ? And to what extent is the association
strongly established,
is the problem of the present research
work. The present research worker is interested in finding out
whether menstrual disturbances of women can be associated to
psychosomatic disorders. If. this is so, then the entire treatment
of the
gynaecological problem would take a new turn and a new
approach. The degree of association between the psychological
disturbance and menstrual disorders and its outcome would throw a
strong light on the age old mind - body relationship. Basically,
human personality is a complete unit which is divided into the
above mentioned areas for the sake of an easy approach for the
understanding of the scientist.'
Modern science has thrown light on the fact that the human
body is a well integrated
unit,
in which if any problem is
created in one area it is likely to affect other areas as well.
Sometimes,
simple mental tension can create peptic ulcers or
hyper - tension. As psychology and biology are linked together,
each
and
every
disease
has
been
3
diagnosed
to
have
it's
psychological
component.- This means that the origin
of the
disorder has two major variables contributing to it’s development
- physical and psychological. This approach has been called the
psychosomatic approach in modern clinical psychology and now more
and more disorders are included in this category.
Menstrual
disorders have also been included as a part of this unit implying
that there is some stress or emotional tension in the personality
of the patient suffering from this kind of disorder
(CAMERON,
1963;BROOME AND' WALLACE, 1984). If, however, the women are well
adjusted,
they do not complain about such menstrual problems
taking it in their stride thinking of it as a normal,
natural
process. So the patient group must be having some personality
characteristics which differ from the normal group. Which are
they ? This is the problem of the present study.
This kind of study eventhough important, poses many problems
when undertaken for research. Firstly, all past literature does
not seem to have concentrated on the same type of population of
subjects (Ss). In some cases, a random group of volunteer Ss has
been used (BEAUMONT, RICHARDS, AND GELDER, 1975) in others, those
admitted to the hospitals were chosen as Ss (OSBORN, 1981) while
in still
others
it was
nurses and me d i c a l
university courses who were chosen as Ss
AND ROBINSON,
s t u d e n t s doing
(LAMB, ULLETT, MASTERS,
1953; SHELDRAKE AND CORMACK,
1976). As a result,
the final observations cannot be generalized to the overall
population.
Secondly,
every investigator has used different types of
methods for the study of symptomatology.
retrospective
difficulties,
accounts
of
the
Ss
Some have relied on
past
and
their
past
while others have actually collected data from
4
)
women taking treatment for menstrual disorders.
Still others
consider doctor's opinion sufficient to describe this group. Here
tooi results cannot be assimilated, under one heading.
Finally, some gynaecologists are of the opinion that for
this kind of study, self reports should be considered the best
method for the assessment of the situation.
Allow the S to
describe her own symptoms of present or past. This method has
been criticized by other scientists because they are of the
opinion that every S does not have the same
standard of
evaluation. Some would say that they have very painful episodes
which others would just describe as uncomfortable. Therefore,
/
some kind of objective measure is necessary. But, in this case
objective measures are not very appropriate for the, measurement
;,t . of the psychological variables. Under these conditions, medical
reports, patient's past history and her responses on more than
one test may give some idea about the actual situation instead of
using just one method. Use of control group is a must because
only that would prove whether the problem described by the
> ,
^
,
*
patients are really serious or just their own interpretation of'a
very normal situation. This approach has, been undertaken in the
present study.
II
STATEMENT OF THE PROBLEM
MENSTRUAL DISORDERS:A PSYCHOSOMATIC STUDY
"Psychosomatic disorder' is a general label used for any
disorder with somatic (bodily) manifestations that are assumed to
have atleast a partial cognitive and emotional etiology i.e. they
■>'\
are to some degree psychological. For example, asthma, peptic
Ulcers, migraine headache and many others.
;T
As pointed out earlier, menstrual disorders are day by day
.
’
5
•
:
!
increasingly associated to psychological etiology. How far this
is true is the problem of the present study. However, the problem
is not as simple as it appears on paper. Any kind of disorder can
create a psychological disturbance if it is chronic or incurable.
This will
create psychological
disturbance
similar*to
that
existing in the psychosomatic personality. It is very difficult
to draw a clear demarcating line between these two groups. For
the present study, however,
the diagnosis of the psychosomatic
disorder has been done on the following basis:
1. The
patient
cont i n u e s
t a king
treatment
under
a well
experienced gynaecologist who is of the opinion that the origin
of the disease is psychological rather than organic.
2. Normal medical treatment does not prove helpful
in curing
these patients.
3. The patients have a history of psychological disturbance right
from early childhood. Therefore, development of the menstrual
disorder is not simply an organic disturbance but one of the ways
of manifesting their emotional disturbance.
On the
basis
of these
three
variables,
psychosomatic
components in menstrual disorders have been identified for the
present study.
A problem arises as to the conditions responsible for the
development
psychology,
of
psychosomatic
disturbances.
In
clinical
functional maladjustment has been classified into
neurotic, psychotic and psychosomatic categories.
It would be
interesting to note the conditions that lead to the development
of psychosomatic disorders.
6
PSYCHOSOMATIC DISORDERS
Personality
disturbances
determinants of physical
illness.
hav e
been
recognized
as
Now it has been clear that
susceptibility to any illness may be influenced toy emotional
disturbances, either directly or through unconscious neglect and
exposure. Hence, psychosomatic disorder is an illness in which
emotional maladaptation is dominant and may lead to irreversible
organ or tissue damage.
Psychosomatic disorders can threaten the life of a patient.
They always mean some distortion or loss of function, or at the
very least discomfort or disfigurement. However, there are some
adaptive functions of psychosomatic disorders pointed out by
CAMERON (1963) which are as follows:
1. A psychosomatic disorder puts an apparent
or an actual
physical illness in place of an intolerable current situation. It
is more dignified to suffer from a psychosomatic disorder instead
of psychosis or neurosis for as long as the patient believes in
the
2.
physical
origin
of her illness.
The whole process of psychosomatic illness is unconscious and
its sym p t o m s
unavoid a b l e
are those of p h y s i c a l
as any other p h y s i c a l
illness w h i c h
illness.
seem as
A majority
psychosomatic disorders are of mild or moderate degree,
of
and do
not lead to death.
3. Psychosomatic disorders give the patient the privileges of a
sick person, without interfering with her freedom or lowering her
self
esteem.
Secondary
gain,
as
this
is
called,
and
the
relationship of an unconsciously needed dependency of a parent
figure,
the clinician,
can bring valuable gratification to a
basically immature person. These gratifications should not be
7
scorned as they sometimes protect
neurotic
or
meaningful
psy c h o t i c
a person
developments;
and
from disabling
they
often
give
interpersonal relationships to an otherwise empty
life. Many emotionally immature,
their needs,
energetic,
dependent men and Women hide
from themselves as well as from others,
independent
facade.
The need©
are
behind an
still
there,
however, and they are still unsatisfied.
4. Finally, the patient may use her physical illness as a means
of eliciting concern, care and affection, which she has needed
all along, but has been unable to get as long as she remained
well. Life is objectively more difficult and less rewarding for
some people than for the others; and subjectively it may seem
bleak,
eventhough objectively
it is considered fortunate.
To
treat a psychosomatic disorder, it is necessary to bring the need
to verbal expression,
so that,
if this can be done skillfully and safely,
as a patient improves physically,
she also matures
psychodynamica1ly.
Ill
CLARIFICATION OF THE BASIC TERMS
i) PSYCHOSOMATIC ILLNESS
There are several
app r o a c h e s
taken to p s y c h o s o m a t i c
disorders: the one taken dictates the connotations that the term
will have. From one widely held perspective, three sub categories
of psychosomatic disorders can be distinguished:
a) those related to the individual's overall personality
example,
highly anxious people show a higher
(for
incidence
of
respiratory disorders, high rate of peptic ulcers and menstrual
disturbances)
b) those intimately connected to one's life style (for example,
people in high pressure stressful occupations show a higher rate
8
of hypertension and gastric dysfunctions)
c) those manifested
primarily
by heightened
reaction
to
substances and conditions (for example, allergies, which while
stimulated by foreign substances, are differently experienced
depending on psychological factors).
In the present study,
emphasis is given to the first
category and the problem selected is the area of menstrual
disturbances.
In the present day society, psychosomatic disorders have
become the main focus of attention from the medical as well as
the psychological view point because they are associated with
stressful life in which present day human being has to live.
Modern times have put the woman in direct competition with
her male counterpart. A woman herself is motivated to be his
equal. This implies that she should be able to do everything that
the man is capable of doing. This may be directly observed in the
field of sports and any other job where traveling is virtually
continuous. Such requirements put the woman at a greater loss
because many a times her menstrual cycle comes in the way. This
creates a sort of frustration and psychologically a negative
attitude towards the menstrual process itself results.
It is quite possible that this attitude was absent 50 years
ago because women were required to handle only household work.
The woman was allowed to rest during menstruation and there was
no loss of efficiency in the work that goes on in the household
owing to the joint family system. Unfortunately, as soon as women
became independent, all. their responsibilities were equated with
those of men. She starts comparing herself with
khe
Joneses
"others are successful, only I failed". If some consideration is
9
m ade’for her feminity,
the woman thinks that it is her -weakness.
As a result, she does not like to accept any privilege offered to
her
on t h a t
count.
In
t his
condition,
the
stress
t hat
is
generated becomes intblerable. The result is the development of
p s y c h o s o m a t i c problems.
Whether m e n strual
belong to the same category,
and if so,
d i s t u r b a n c e s also
to what extent,
is the
problem of the present study.
GYNAECOLOGICAL PSYCHOSOMATIC DISEASE
- "Gynaecological psychosomatic disease'
is by definition th<*
effect of psychological disturbance on the pelvic organs.
Ir. man
ways,, .future
coromo
developments
in
the
management
of
gynaecological conditions such as d y s m e n o r r h o e a m e n o r r h a g i a
pelvic pain.and vaginal discharge,
lie in a proper understandinc
of the relationship between female psyche and soma.
The cerebra
cortex is known to influence the h y p o t h a l a m u s and hence th
endocrine and a u t o n o m i c
nervous
system of
the body.
suggested that when the pituitary-ovarian axis
It
i,
is disturbed,
anovulation with menstrual- dysfunction is a common consequence
The fact that the recognition of this mechanism has not lead t
the u s e
of w e l l
established
forms
of p s y c h o t h e r a p y
is
a
admission of the paucity of respectable research on the subject
the gap between endocrinology and psychology is narrowing bu
still needs to be bridged. Dysmenorrhoea which is the commones4
of all
compl a i n t s
in
gynaecological
outpatient
clinics,
i
without demonstrable, pathology in 70-80 percent of the case;
This
con d i t i o n
psychosomatic
is a u s e f u l " m o d e l
disease because
of
for
the
the
study
high
10
possib
association
emotional dysfunction in. the majority of the cases
TJALLACE, 1984} .
of
{BROOKE A’
ii) MENSTRUATION
Menstruation is a periodic shedding of blood and the
functional layer of the endometrium from the hon-pregnant uterus
during the reproductive years.
Menstruation
is a p r o c e s s w h i c h
is s u b j e c t
to wide
fluctuations of normal as well as producing symptoms associated
with disease and so it is important to first consider what is
normal.
As wit h all other bodi l y
functions,
n o r m a l i t y means
different things to different people. The range is wide and it is
difficult for any individual woman or doctor to know what it is.
There is no well recognized standard against which a woman can
measure her own pattern. The symptoms that a woman brings to a
doctor will depend on her own previous experience, on information
she may have picked up from relatives,
friends or magazines, and
on other problems she may have at the time.
The first menstruation,
the menarche, generally occurs at
about the age of 13 years and menstruation or the monthly period
continues till the menopause.
Generally, menarche may occur at
anytime between the age of ten and sixteen years, the average age
now being 14 years particularly in India.
better off
The daughter's of
parents tend to start menstruating a little earlier
than those whose parents are poor, but the average difference is
no more than six to nine months.(JONES, 1986).
THE NORMAL MENSTRUAL CYCLE
The menstrual cycle consists of a period of bleeding of
variable length and-amount, followed by a longer time when there
is no bleeding.
The length of the cycle is the time from the first day of
11
one period to one day before the onset of the next menstrual
period. When asked the length of the cycle, most women answer
with the time clear between the periods. The length of the normal
cycle is variable and it may be different at different times. It
is normal for some women to start a period regularly every 28
days. It is equally normal for others to have a regular 50 day
cycle. For some women, the normal cycle is never regular so that
the length may be 25 days on some occasions and 60 on others.
For many women, the pattern changes from time to time. There
may be a temporary change as happens under stress, or long-term
changes
in pat t e r n
may
occur.
These
are
not
symptoms
of
gynaecological disease although they may be evidence of emotional
problems.
It is extremely difficult to measure or describe the amount
of bleeding.
The amount of menstrual
discharge
that
can be
described as normal is 30 ml (1 fluid ounce). A loss of more than
80 ml (2 3/4 fluid ounce) is considered as abnormal. Most doctors
are guided by the number of tampons or sanitary towels used' each
month : 10-15 is common, 30 is a lot. This is not very reliable
as some women change more frequently than the others.
An apparently normal uterus may bleed heavily as a result of
hormonal
influences.
Whether
such
bleeding
is unacceptably
excessive depends upon the w o m a n ’s attitude and life style as
much as on the actual volume of blood loss. Working class women
engaged in physical labour will put up with much heavier bleeding
than will the middle class women doing jobs which require more
mental capabilities.
The length of the period also varies from two to three days
to a week or more. A period that lasts for five to six days is
12
considered to be normal but a length of period beyond that is
considered to be abnormal. Most doctors will consider bleeding to
be excessive if it results in anaemia despite a normal diet, or
if clots
form,
or if it in t e r f e r e s wit h a w o m a n ' s
normal
activities.
Most women accept as normal, a certain amount of cramp-like
lower.abdominal pain or backache during the first day or two of
menstruation.
Such pain should respond to simple medicine and
should not interfere with normal activity.
The only criteria of normality common to all women is that
.
•*
”
*%
i
there should be no bleeding between the periods and each episode
of menstruation should be finite.
iii) PSYCHOLOGICAL CORRELATES OP MENSTRUAL DISORDERS
(MOOD CHANGES)
The POCKET OXFORD DICTIONARY OF CURRENT ENGLISH
(1942)
defines mood as a change in the state,of the mind.
According to the PENGUIN DICTIONARY OF PSYCHOLOGY (1985)
mood is any relatively short-lived,
low-intensity emotional
state.
-MORGAN, KING AND ROBINSON (1979) define mood in the following
way:
,
"A mood has an emotional tone or a background that is
relatively long lasting and colours a person's outlook on the
world."
A CONCISE PSYCHOLOGICAL DICTIONARY (1987) defines mood as a
relatively protracted,
intensity,
stable psychic state of moderate or low
a p p e a r i n g as a p o s i t i v e
or n e g a t i v e
e m otional
background of the individual's mental life.
A c c o r d i n g to the p r e s e n t r e s e a r c h worker,
13
m ood
is a
relatively short-lived, moderate or low intensity mental state
appearing as positive or negative.
Mood states have a dramatic effect on behaviour, and they
can affect the intensity of our reactions to emotion provoking
stimuli. For example,
if a woman is depressed,
relatively mild
set backs can be perceived as drastic. On the other hand,
if a
woman is calm, those*set backs may seem minimal.
The role of hormones in one class of mood changes that has
been studied extensively with respect to endocrine functioning is
the mood changes that occur across the menstrual cycle.
The
'1
present research worker is‘interested to study how far these "mood
cycles affect the behaviour of a woman and whether this influence
is normal or abnormal. If a woman is under stress or, suffers from
chronic low grade misery, then the normal fluctuations of mood
during the menstrual cycle may produce marked depression, anxiety
or
irri t a b i l i t y
menstrually.
during
the. p r e m e n s t r u a l
It seems unlikely
that
w eek
as
well
as
so called premenstrual
tension will produce these symptoms in a woman who is otherwise
well and happy but it does seem to have the effect of making her
less able to cope with stress,
more vulnerable and therefore
exaggerate symptoms .which she already has but can cover up at
other times. Only in some women this creates tension to such an
extent that she requires definite medical help. Many women report
feeling somewhat depressed, anxious and irritable just before
menstruation begins, during the premenstrual period. This pattern
of mood changes is so.pervasive that it has been termed the
premenstrual syndrome (MOOS, 1968 : PARLEE, 1973).
There are two types of women who cannot ,cope with these mood
changes. .The first group,
consists of women whose premenstrual
14
disorders are either serious or become unbearable. Hence medical
treatment becomes a necessity. In the second group, objectively
speaking the gynaecologist is"not able to find any physiological
factors responsible for the menstrual disturbance. However, the
patient keeps on complaining.,Sometimes,
the complaints do not stop.. And
even after medication
sometimes,
the complaints
continue throughout the month. This group of women are included
in the psychosomatic category;
In the present study, the research worker wants to find out
the personality characteristics of this kind of patients. How far
do they differ from the normal personality ? Are they severe or
i
'
-
:
mild ? Does medical treatment help them in the long run ?
iv) TYPES OF MENSTRUAL DISTURBANCES
Gynaecology is a science of disease.peculiar to women,
although sometimes it may seem to be a science of peculiar women
(Me.DONALD, 1979). Modern Obstetrics and Gynaecology is dogged by
the word "abnormal" - from abnormal labour to abnormal uterine
bleeding and abnormal menstruation. The number of women labeled
as abnormal,
is so great.that it must bring into question just
how much of the symptomatology is abnormal or just.a variation of
normal. At any time, women might complain that their periods
are :
too short,
too long,
. ■
, . .
too frequent,
too infrequent,
too light,
too heavy,
too painful,
15
too irregular,
-
'
too awful !
This is excluding.the not too infrequently voiced complain
that it seems unfair that they should have periods at all. The
endFess succession of menstrual cycles to which a woman today is
subjected to is abnormal.
In primitive communities, menstruation
was probably a very infrequent event since a late menarche,
lactational
amenorrhoea
and
poor
nutrition,
as
w ell
as
pregnancies, left the women little time for menstrual cycles.
Today's woman is faced with a much earlier menarche - around the
age of 13 years - probably brought about by improved nutritiop in
childhood - but now occurring several years before she will be
ready in most instances to contemplate a pregnancy.
Furthermore,
the menopause may not come for 40 years beyond the menarche, and
women in this time on average have only two full term pregnancies
and perhaps breast feed with lactational amenorrhoea for two
years at the most. Thus,, a modern day woman in our. society will
probably experience on average 300-400 menstrual cycles in her
reproductive, life. The excesses of child bearing in the past have
been changed for the excesses of menstruation in the present. As
a result, problems associated to menstruation have increased.
ORGANIC MENSTRUAL DISORDERS
< Organic gynaecological disorders are due to some basic
organic malfunction of the sex organs. Or, it may also be due to
some basic physiological disturbances of the biochemistry of the
body.
In both these cases,
normal m e n s t r u a l
there is some disturbance in the
cycle wh i c h
is not cured
by simple home
medication or remedies. Such disorders require medical attention,
operative procedures or -therapeutic measures as suggested by the
16
gynaecologist.
These disturbances are actually physiogenic.
However,
if
they become chronic or if doctors fail to diagnose and cure them,
they do give rise to personality disturbances.
The patient
becomes anxious, worried, even fearful and depressed because she
does not know the outcome of her illness.
Sometimes,
this is
aggravated because there are healthy examples just before her
where no such disturbances exist. This creates further anxiety
regarding her own health and the woman wants to find out what is
wrong with her. As there is no answer to this question, it gives
rise to very serious depressive ideas and pessimistic views
regarding her own future.
In the above mentioned case, one can note that psychological
disturbance is associated with menstrual disorder but it cannot
be labeled as psychosomatic because it is the result of the
illness and not the cause of it.
In psychosomatic disorders,
usually personality disturbances
play a causal
role which
sometimes become difficult for the gynaecologists to separate
from .the former type. In the present, study, a special effort has
been made to exclude the o r g a n i c .gynaecological menstrual
disorders and to include only those cases where the psychological
variables play a dominant role in the development of menstrual
disorders. This implies that basically the personality of women
suffeping■from psychosomatic disorders should be different from
those suffering from organic gynaecological problems.
jn the present study, only women suffering from psychogenic
gynaecological
menstrual
disorders
have been
included.
The
present! research worker is interested in this kind of disorder
only because of its psychological origin and not because of it's
17
psychological consequences.
In short, any chronic disorder is
likely to bring about the .same personality disturbances which
menstrual disorders can develop. Therefore, this should not be
considered a very important problem from the psychological point
of view. For the psychologist, it is important to know only how
far psychogenic variables are responsible f o r ,the development of
menstrual disorders. However, this implies a causal study which
is beyond the scope of the present study. Which Ss will develop
menstrual-disorders cannot be predicted unless actual menstrual
disorder has taken place and becomes resistant to normal medical
treatment. As a result, one has to study the S's childhood and
present day personality and try to find out how far they differ
from the normal personality. In the present study, this approach
has been undertaken.
Any research, on any kind of psychosomatic disorder should
keep in mind that so far as the symptoms of the disease are
concerned,
disorder.
they do not differ much from those of the organic
At the symptom
level,
one does
not find much to
distinguish between the psychogenic.and the organic origin of the
disorder. It is-the development and the causal conditions that
sustain and perpetuate them. They distinguish and bring out the
real difference.between organic.and psychogenic origin.
The most common disturbances associated with menstruation
are the absence of menstruation-i.e. amenorrhea; painful periods
i.e.
dysmenorrhea;
profuse or heavy
loss, with periods
i.e.
menorrhagia;. and exaggerated general body changes which occur
prior to menstruation i.e.' the .premenstrual syndrome,
a) DYSMENORRHEA
Dysmenorrhea simply means' painful menstruation or pain
18
associated with menstruation. Gainful periods are not a sign of
sinister disease but may be any thing from a binor irritation to
.
.
.
.
'
an incapacitating nuisance.
\
It is most commonly found in young
girls within three, or four years after the onset of menstruation.
It may be a constant dull ache, in the abdomen or back, starting
the day before the bleeding starts (congestive dysmenorrhea) or
may be
sharp
intermittent pains or colic on the first day
(spasmodic dysmenorrhea). It may be accompanied
by nausea,
headache, dizziness, or backache. It may be severe which is why a
lot of young women seek medical help.
Dysmenorrhea may be
regarded as a symptom of organic disease i.e. physical,
or as
having emotional undertones i.e. psychological or both physical
and psychological. According to STRUBE (1980) there is often some
a n x iety
with
establishing
sexual
a sexual
connotations
identity,
such
as
difficulty
in
poor relationship with the
father, or fear of pregnancy. However, this is by no means always
the case. Menstruation is affected by any sort of stress and in
many ways,
there is a causal relationship between emotional
stress and dysmenorrhea (STRUBE, 1980)..
Dysmenorrhea may be Primary, when it:dates from, or shortly
follows,
the menarche,
or Secondary when pain appears in the
latter reproductive life after earlier years have been relatively
pain free.
,
Examination of patients suffering from dysmenorrhea reveal
little or no organic fault. The emotional element in menstrual
pain can be strong and the mother may be its source.
General
factors associated to dysmenorrhea include a faulty attitude to
menstruation and sexual matters,
enviornmental and parental
pressures and general ill-health (CHAMBERLAIN AND DEWHURST, 19,84;
'-V-
'
19
‘
-
FARRER, 1979) . The present study is an attempt to find out how
many of these factors are associated with menstrual disturbances
in the population of Giajarat. The present research worker is more
interested in Primary dysmenorrhea where functional factors are
more dominant as pointed out earlier,
b) AMENORRHEA
Amenorrhea means absence or abnormal stoppage of the menses
(DORLAND'S
POCKET MEDICAL DICTIONARY,
1983).
It also means
complete lack of periods during not only the menstrual period but
the whole age
menstruate.
^during which the woman
Mostly,
there
can
be
is expected to
a physiological
factor
associated with this disorder; but of late, gynaecologists and
psychologists have come to regard that extreme emotional tension
is also responsible for the same, particularly where the woman
has to participate in.extremely important physical activities
like International sports or any such event (GADPAILLE, SANBORN,
AND WAGNER, 1987).
When the girl or the woman has never menstruated,
she is
said to have Primary amenorrhea. Absence of menstruation after
the menarche is termed Secondary amenorrhea.
In the present study,the research worker wants to find out
how far amenorrhea is associated with emotional disturbances and
tension.
C) MENORRHAGIA
Menorrhagia means excessive menstrual loss and it is most
commonly described as "it absolutely pours". The flow usually
occurs at n o r m a l
duration.
intervals
but, is incr e a s e d
in a m ount or
POLYMENORRHEA refers to periods that are normal
amount but\ which occur too frequently,
20
in
i.e. at intervals of 21
days or less.
It refers to periods that are both heavy and
frequent.
Chronic excessive menstrual loss eventually leads to iron
deficiency anaemia.
symptoms
This gradually brings on an extra set of
to cause added a n x i e t y and a fear o f .cancer.
An
important aspect here is that as soon as the gynaecologist
explains that everything is all right, the normalcy of the whole
problem affects the menstrual flow tremendously. This shows its
psychological origin..
Compared to o'tftdr disorders of menstruation, menorrhagia has
been considered more serious because the patient becomes nervous
due to actual loss, of blood, which she herself observes.
blood
loss
is top
physiological
much
and
too
frequent,
d e f i ciency, psychological
then
anxiety
If the
added
is
to
equally
evident. The patient becomes nervous and this nervousness becomes
and added factor in the continuation of menorrhagia. This is the
reason
why
it
is considered
as
a
psychosomatic
disorder,
d) METRORRHAGIA
Metrorrhagia refers to irregular and unusual bleeding or
bleeding at times other than those when a period is expected
(BORLAND'S POCKET MEDICAL DICTIONARY,
1983).
It makes a woman
suspect.an abnormality but it'does not always make her seek
advice. The bleeding may be,slight and unaccompanied by other
symptoms. A woman may ignore it and decide to consult a doctor
only if it gets worst. It is a symptom never to be ignored; the
discovery
of
investigated.
abnormal, v a g i n a l
bleeding
The present research .worker
must
is -interested
finding out whether it has some psychological origin.
21
always
be
in
6) OLIGOMENORRHEA
Oligomenorrhea means infrequent menstruation.
problem sim i l a r t o ' s e c o n d a r y amenorrhea.
It presents a
Menstruation
is
irregular and infrequent, with periods occurring one to three
months apart or even
present,are obesity,
usually organic.
longer.
Associated
features
hirsutism and infertility.
However,
it is-
sometimes
The cause is
psychologically
important
because the patient usually has a certain set concept in her mind
about the whole menstrual cycle. Any change that occurs is likely
to arouse doubt,
.
'
.
’
fear and anxiety.
‘
Patients
•'
suffering
from
. .
s
oligomenorrhea usually suffer from nervousness.
How far ./this
influences the normal personality and the positive aspects of
life is the problem of the present study,
f) THE PREMENSTRUAL SYNDROME
The syndrome was first described by PRANK
(1931)
as a
premenstrual feeling of "indescribable tension, irritability, and
a desire to find relief by foolish and unconsidered actions".
Premenstrual syndrome is a group of physical and mental
changes which begin anything between two and fourteen days before
menstruation,
and which are relieved almost immediately the
period starts (SHREEVE, 1983). In many women, mood change is one
of the most prominent.features, usually to a state of extreme
irritability which expresses itself as irrational anger with or
without physical violence at one end of the spectrum and as
impatience and snappiness at the other. In very rare cases,
may lead to homicide and suicide
(DALTON,
it
1964 and SHREEVE,
1983) . The s y m p t o m of te n s i o n w h i c h gave
the old name of
p r e menst r u a l
a whole
ten s i o n
to
the
syndrome
as
is both
inadequate and inappropriate because it represents only one
22
characteristic of a plethora of symptoms, and understates the
case for women who also suffer from depression,
lethargy and
numerous physical complaints. While periods tend to get a lot
tolerable as a woman gets older, the premenstrual syndrome tends
to get more isevere.
, Some of the physical and mental symptoms associated to the
premenstrual syndrome are mentioned below. The present research
worker is interested in mental and emotional symptoms which
include tension and irritability,
reduced powers of concentration,
worthlessness,
intense depression,
loss of confidence,
illogical emotional reactions,
symptoms include swelling of.the abdomen,
lethargy,
feelings of
etc.
Physical
ankles and fingers,
feelings of being bloated and swollen, weight gain of several
pounds; heavy, engorged, painful breasts; headaches, etc. As many
as, eighty percent of the women are aware of some degree of
premenstrual changes; forty percent are substantially disturbed
by them,
and between ten and twenty percent
are seriously
disabled as a result of the syndrome (DALTON, 1964; REID AND YEN,
1981).
Premenstrual syndrome has been added in the category, of
psychosomatic disorders because it is-not universal for all- women
to suffer
from the s a m e ,and women suffering
from menstrual
disorders.do show typical personality characteristics which are
usually associated to anxiety and nervousness. How far is this
true and whether this manifestation
is also the result of
emotional disturbances in personality is the problem of the
present study.
V) FACTORS AFFECTING MENSTRUATION
In the -previous section,
it has
23
been
clarified
that
menstrual disorders can be either the cause or the result of
psychological disturbance.
In the present study, the research
worker is interested in the psychological variables responsible
for the development of menstrual, disorders. Hence, in the present
section, variables that clinical psychologists consider important
in the development of menstrual disorders are discussed. Research
is already going on in this field by both gynaecologists and
psychologists. So far the following factors have been pin pointed
as the major psychological
factors associated with menstrual
disturbances.
a) MOTHER'S ATTITUDES TO MENSTRUATION
The first and the most psychogenic condition associated with
menstrual disturbances is the mother's attitudes to menstruation.
The right* attitude and a healthy approach to menstruation has to
be handed down from mothers or handed across by friends. These
attitudes, largely or totally unconscious, are crucial in shaping
a woman's attitudes and responses to all the events in her life,
including menstruation.
,
DEUTSCH (1944) was the first to describe the psychological
problems of menstruation.
Before the menarche,
girls begin the
preparation for menstruation even if they do not know anything
about menstruation at all. An 'obscure awareness’ of her mother's
monthly indisposition shows up at an early date in the girl's
fantasy life and it is not always possible to discover when and
to what extent she becomes familiar with the real nature of this
process.
garments,
Her mother's
menstrual
discomfort,
and even casual rem a r k s
blood-stained
can make a very strong
impression on her daughter. The younger the daughter and the more
incapable of dealing with these impressions, "the more painful,
24
U ^L\
bloody,
cruel,
and threatening are these manifestations
of
feminity to her fantasy life". Menstruation is often the one
subject w h i c h women c o n s i d e r
as a ma j o r
'secret'
between
themselves and their daughters.
According to SELYE
(1960)
faulty attitude and chronic
anxiety can lead to physical changes. The personality make-up of
the patient appears to be the primary causative
agent.
An
ambitious person with strong dependency needs may react to any
stress related to his goals with sustained anxiety and resentment
until somatic complaints result. In other instances, the stress
situation appears to play a leading role and to elicit similar
emotional reactions in most women exposed to it. In still other
cases,, the conflict pattern may merely serve to precipitate a
psychosomatic disorder (menstrual.disturbances being one of them)
in a predisposed person.
. .Thus, a mother's ambivalent attitudes to menstruation are
passed down from generation to generation.
mother's h e a l t h y or u n h e a l t h y
atti t u d e s
In other words, the
do have a direct
correlation with the attitudes of the daughter to menstruation.
Women who.are educated and aware of the process of menstruation
take it as a normal,
natural process and their daughters too
consider it to be a natural part of life's phenomena..On the
other hand, if the mother is uneducated and unaware and if she is
highly scared, of menstruation,
then the completely normal
menstrual cycle may be regarded as something horrifying by the
daughter.. Therefore^ menstrual disturbances i n ,some cases do not
exist, they are created by the woman.
It may be said that the attitudes of the mother is the
primary factor in shaping the. attitudes of the daughter. In other
25
words, mother is the primary condition for the development of
normal or abnormal
attitudes towards
the whole process of
menstruation.
b) SOCIAL ATTITUDES TO MENSTRUATION
'Throughout the ages, many societies have held the belief
that menstruating women are "unclean and unholy', while others
consider them to be dangerous. The attitude of our own society to
women's periods is reflected in the names that have been used to
refer to that time of the month (SHREEVE, 1983). "THE CURSE" was
the first name to be coined and became firmly established. Other
names include,
The Time of the Month,
The Monthlies,
Taking My Period,
,
Menses,
The Devil's Gateway,
.
Chum.
It is thus
not
surprising
if a young
girl
grows
to
fear
menstruation.
Religion also plays an important role in forming attitude
towards menstruation. One does not know but perhaps, looking at
the different religious approaches towards menstruation, one can
draw
the
conclusion
that
a woman
during
menstruation
is
considered unholy and is not allowed to do either, household work
or any religious activity. The reason may be actually to give her
physical rest but society being uneducated, religion had to step
in to support the medical requirement of rest. That is why in
Jnzfjy : religion?, there are specific instructions for the woman to
follow during this period where she is required to remain away
26
from holy places.
C) MYTHS ABOUT MENSTRUATION
Like so many other areas of life, menstruation too has its
confused mythology.
It is likely that a woman's perception of
menstruation will be strongly influenced by such myths. These are
the subject of extensive documentation aind include socially and
culturally dependent beliefs,
for instance,
that menstruating
women:-will turn milk sour; are unclean; makes hives or bees die;
makes brass and iron rust; stop the bread rising, and so on.
However, as women become more- aware of their own identities,
they develop body’ consciousness and thereby an awareness of, how
their bodies work and with the advancement of Western thinking
and o b j e c t i v e .scientific knowledge,
myths
are
losing their
support for the educated masses. This, we can observe from our
own experiences.
In primitive societies, where women lack education and are
not allowed to come in contact with modern ideology, women still
believe in the old mythology and all the principles are accepted
as principles of God. This is the observation of the present
research worker.
d) REACTIONS TO MENSTRUATION OF THE GIRL/WOMAN HERSELF
Menarche is observed as a. traumatic event by some girls who
are ashamed of menstrual bleeding and if detected feel as if they
have done something unclean. Other girls who grow up receiving
more tender care from their mothers during illness than at other
times, experience a few days in bed during their periods as the
most pleasant days of all. It entitles them to their mother's
care without the attendant feelings of guilt. They resent any
attempt to get them out of bed {PASNAU, 1969).
27
' A girl's reaction to her first menstruation was thought to
be a model for menstrual
reactions throughout her
life.
As
described earlier, a mother's reactions to menstruation are also
important.
Some girls almost inherit dysmenorrhea; the mother
suffered, so does the daughter. She expects it to be bad. The
discomfort of a period is not lessened when that particular
period is unwelcome, as it is when a woman wants to be pregnant.
The period hurts, she resents it, it hurts mofe. According to
FLUHMANN
pain
and
(1956),
the affected women are usually hypersensitive to
ex h i b i t
personality
disorders.
PAULSON
(1961),
hypothesized the primary areas of conflict as involving sexual
feelings,
life experiences and attitudes towards feminity as
important etiological factors in dysmenorrhea.
Excessive menstrual loss!is another symptom which prompts
women to seek medical help.
But how does a woman
judge her
menstrual loss to be normal or heavier than normal? Here too, the
reaction of the woman is of prime importance. Most women do not
have any idea regarding what is considered,as normal. What they
do Understand is the untimely messiness and stickiness .involved
with menstruation.
Some women who are particularly fastidious
regard the normal as excessive .because they cannot bear to feel
messy at all. If the period is a real annoyance to them, in their
work or their social
life,
it may seem to require too much
attention and to go on for too long. On the other hand, are women
who actually have excessive menstrual flow but still put up with
it without any fuss taking
it in their stride.
What, is the
difference in the personality characteristics of these two groups
of women, is the problem of the present study.
The psychological factors for the absence of menstruation
28
(amenorrhea) have been described as due to the shock and horror
of the
first
menstrual
period,
essentially
a defensive,
functional inhibition (DEUTSCH, 1944). Amenorrhea was noted in 73
of the 732 women who had undergone attempted rape
(0'NEILL,
1954)i fifteen .percent of the women in concentration camps in
Manila had amenorrhea
(O'NEILL,
1954).
Other cases have been
described in Hongkong and London during war time crisis
(CHEZ,
PASNAU, LEIKEN AND BATISTE, 1964). Patients with anorexia nervosa
have cessation of menses before the lack of food intake brings on
malnutrition (FLUHMANN, 1956). .
•
CHEZ, PASNAU et al.
amenorrhea who were evaluated
psychopathology.
endocrine
•
n
(1964) reported on, four patients with
Each of the
for endocrine disorders
four were
and
found to have overt
disorders “
and psychiatric diagnosis
ranging
from
neurosis to severe character disorders. Each of them had handled
stress by neurotic
or psychosomatic defense mechanisms.
On
initial examination, there was repeated environmental stress or
emotional symptoms. They underwent a thorough psychiatric and
psychologic evaluation. Common denominators were psychosexual
immaturity,
ambivalence
regarding
the
f e m inine
pregnancy, .conflicts over, heterosexual activity,
role
and
and general
difficulties in inter-personal relationships. Psychologic testing
revealed, isolation and distortion of body image.
Studies of/this kind indicate t h e .clinical spectrum
symptoms,
signs
and
laboratory
of
v a l u e s .in p s y c h o s o m a t i c
amenorrhea, and point out the need for the combined approach to
patients with these disorders..
To what extent
any of these
factors are reflected in the' Indian Culture — specifically in the
population of Gujarat is the problem of the present study.
29
' Thus, the real, purpose of the study is to find, out how far
any disturbance in menstruation is used as a defense against
greater social or personality conflict. Secondly, it is equally
important to find out the percentage of population having this
kind of disturbances and if so whether we can develop
some
instruments .to find out what kind of psychological tests would be
relevant for the study of this kind of disorder,
e) CONCLUSION
It is important■to keep in mind the psychological variables
discussed above because it is important to find out how many of
these are actually revealed by the Ss of the present study. It is
quite p o s s i b l e
that all the v a r i a b l e s may not be equally
important or there may be other variables which play a more
dominant role than those discussed above. This study, therefore,
is an exploratory study where the research worker wants to find
out as many psychogenic variables as, possible that are associated
with menstrual disorders.
vi) QUESTIONNAIRE AS A RESEARCH TOOL
The P E N G U I N D I C T I O N A R Y OF P S Y C H O L O G Y
(1985)
defines
.questionnaire as "broadly any set of questions dealing with any
topic or group of related topics designed to be answered by a
respondent".
SOMMER AND SOMMER
series
of
written
(1986) described a questionnaire as a
questions
on
a topic, a b o u t
which
the
respondent's opinions are sought.
A questionnaire thus is a set of questions designed for a
particular topic to be answered by a respondent.
They are
effective
beliefs,
in giving
information
about
a person's
perception, feelings, motivations, anticipations or future plans.
30
There are two general types of questionnaire: self administered,
which
respondents
fill
out
themselves
and
interviewer
administered, in which the interviewer asks questions and records
the responses. Heavy reliance is placed on the S's verbal report
for information about the stimuli or experiences which she is
exposed and for the knowledge of her behaviour.
The advantages and limitations of the questionnaire method
has, been described in detail in standard text books of Research
Methods (SELTIZ, JAHODA, et al. 1959; FREEMAN, 1955, 1962; MOORE,
1987).
)
In the present study, questionnaires have been used by the
method of semi structured interview in order to validate the
responses of the Ss. All the questions have been read carefully
and properly to the Ss so that they can understand without any
difficulty.
Difficult questions have been clarified without
giving any suggestions.
The Ss have been requested to give their opinion about the
method and were also asked if they wished to give more details
about’themselves.
inspite of this, as SHAFFER AND LAZARUS
out,
the
greatest
limitation
of
(1952) have pointed
a questionnaire
is
the
transparency of the questions and its inability to bring out the
unconscious feelings.
In order to overcome this limitation,
a
semi structured verbal projective technique (ISB) has been used.
vii) PROJECTIVE TECHNIQUE AS A RESEARCH TOOL
Originally, projective techniques were developed to overcome
the limitations of the inventories.
ENGLISH AND ENGLISH
(1958)
defined projective technique as "a procedure for discovering a
person’s characteristic modes of behaviour
■
•
31
(attitudes, motives
and dynamic traits) by observing his behaviour in response to a
situation that does not elicit or compel a particular response".
. According to LINDZEY (i96l) , "a projective technique is an
instrument that is considered especially sensitive to covert or
unconscious aspects of behaviour.
variety of S responses,
It permits or encourages a
it is highly multidimensional,
and it
evokes unusually profuse response data with a .minimum of subject
i
'
awareness concerning the purpose of the test".
In the present study, the Gujarati adaptation of the Rotter
and Rafferty's Incomplete Sentence Blank (BHATT, 1972) has been
used. It contains. 40 sentence "stubs" or "stems" or incomplete
sentences.. The S is not r e s t r a i n e d
completing the sentences.
by a n y t i m e
limit for
The only requirement is,that while
completing a sentence one complete thought must be expressed and
there should be some aspect, of ego involvement.
The S has to
express her own ideas and must complete the sentence with the
first thought that comes to her mind.
There is no fixed time
limit though normal Ss complete within half an hour.
ADVANTAGES OF THE ISB
1 Views that the Ss cannot talk about openly can be expressed in
this test.
2 The Ss can express any idea without.any hesitation, restraint
or control. However, some Ss try to give good responses instead
of- valid ones.
Therefore,
they are to be instructed from the
beginning to express their,own personal feelings. They are made
to u n d e r s t a n d
that .there
is nothing- like
right
or wrong
responses.
3 Most of the sentence stems cover personal,
social and family
life situations of an individual. Therefore, a total personality
32
picture emerges once the test is completed by' the S. .
4 Numerical interpretation and classification is already given by
ROTTER
AND RAFFERTY (1950). Therefore, statistical calculations
as well as clinical interpretation are both easy.
5 It does not require much- time to be trained to use this
instrument on normal.as well as atypical sample.
Inspite, of these advantages, there are certain limitations
which every research worker should bear in mind before using this
test. They are:
1 The S is to be prevented, from giving socially acceptable
responses, proverbs or statements which are the fashions of the
day. They are to be specifically instructed to express their own
views rather than those of someone else.
2 The total test.should be completed. No sentence should be left
incomplete as far as possible.
3 Just, one idea should not be repeated throughout the test.
It
implies that-the S is not co-operative.
4 Interpretation of the responses requires great precaution. It
requires the presence of the S to find out the exact meaning of
any particular response. Otherwise, the possibility of double
projection is likely ?to arise.
5 This
test r e q u i r e s
independent thinking.
a good
IQ level,
Otherwise
i t ,has
some e d u c a t i o n
and
failed to give good
results in the case of.Ss who are highly immature or mentally
retarded. Indirectly, therefore, Ss who fill up the test as per
instructions as quickly as possible can be regarded as Ss with a
good IQ.
All the above mentioned points have been kept in mind while
administering the test to the sample of the present study,
33
especially the patients.
IV
PURPOSE OF THE STUDY
The present study has been undertaken
for the following
purposes:
1. To study the level of self perception of the patients Vs
normal
female population
of Gujarat on the
Self Perception
Questionnaire (SPQ).
2. To study the level of gynaecological problems of the patients
Vs normal
female p o p u lation. of Gujarat
on the Inventory of
Gynaecological Problems (IGP). .
-H.
3. To study the level of general Incomplete Sentence Blank (ISB)
scores of the patients Vs normal female population of Gujarat.
4. To study whether education as a variable shows any significant
difference on the three variables stated above
(
1 , 2 , 3) .
5. To study whether age as a variable shows any significant
difference on the three variables stated above (1,2,3).
6. To study whether marital
status as a variable shows any
significant d i f f e r e n c e -on the three variables
stated above
(1.2.3) .
7. ,To,study whether social background as a variable shows any
significant
difference
on the three variables
stated
above
(1.2.3) .
V
SIGNIFICANCE OF THE STUDY
This study,
if proved successful will be useful to the
following areas:
1 Parents having- daughters' complaining about menstruation.
2 'Clinical psychologists who'are treating patients with menstrual
disturbances.
3 Gynaecologists treating patients with menstrual ’disturbances
34
who do not .respond to medical treatment.
4 Research workers who want to go ahead for extensive research in
this field.
35