An investigation of the relationship between emotional maladjustment and infertility

Transcription

1 FERTILITY AND STERILITY Copyright c 1988 The American Fertility Society Vol. 49, No.2, February 1988 Printed in U.S.A. An investigation of the relationship between emotional maladjustment and infertility John D. Paulson, M.D.* Betsy S. Haarmann, M.A. Robert L. Salerno, M.D., Ph.D. Pierre Asmar, M.D. Institute of Reproductive Medicine, Annandale, Virginia The purpose of this investigation was to examine the psychologic test results of women diagnosed with infertility as compared with the general population of women. The infertile group consisted of 150 women, whereas the control group included 50 women. Both groups were similar in regard to age and number of years married. The tests administered were: the 16 Personality Factor, the IPAT Anxiety Scale, the IPAT Depression Scale, the Tennessee Self-Concept Scale, and the Internal-External Scale (locus of control). Scores on a total of 41 test variables did not differ significantly between the two groups. In fact, the means and standard deviations for all variables were remarkably similar. This study concludes that significant emotional maladjustment is no more prevalent in women coping with infertility than for the general population of women. Results from this investigation cast doubt on the historical assumption that stress may be a causal factor in infertility. Fertil Steril 49:258, 1988 The possibility that stress may play an interactive or causal role in infertility has concerned not only physicians and researchers, but the infertility patient as well. The question has been a public one, addressed through medical literature and, more recently, the media. Many patients are concerned that their reactions of loss and frustration may, in some way, contribute to their infertility. There is little doubt among clinicians that the experience of infertility is a stressful one. In addition to the daily life stressors that individuals face, the infertility patient must emotionally adjust to the constantly thwarted hope for a child, coupled with the physical demands of medical treatment. Stress has not been well defined in the infertility literature. We define stress as the emotional fac- Received March 23, 1987; revised and accepted September 28, * Reprint requests: John D. Paulson, M.D., Institute of Reproductive Medicine, 4324-C Evergreen Lane, Annandale, Virginia Paulson et al. Emotional maladjustment and infertility tors or responses that can accompany life's difficulties or crises. This definition is further substantiated within the Diagnostic and Statistical Manual of Mental Disorders (third edition)/ where the diagnosis of adjustment disorder is applied to the individual who displays "a maladaptive reaction to an identifiable stressor." Such reactions include significantly elevated levels of anxiety and/or depression, as well as a variety of behavioral and personality manifestations. Any emotional response to a stressor can therefore be viewed on a continuum from mild to severe or normal to maladjusted. In this light, all infertility patients experience stress. The more important issue becomes that of degree. The use of psychologic tests has provided us with an objective means to quantify this continuum of emotional response. Psychologic tests have been applied in various combinations throughout the research on stress and infertility. Results from these investigations, however, have been inconsistent and controversial. Some studies indicate that infertile women experience higher levels of anxiety,

2 guilt, or neuroticism than do their controls, 2-4 while other studies have shown no relationship on the same or analogous measures. 5 Some of these studies, however, either infer significant relationships when variables compared fall within the limits of the normal range, or base such relationships on the direction of data rather than relying on statistical significance. Studies of greater scope, such as those of Garcia et al. 6 and Freeman et al., 7 have shown clearly that the psychologic test results of infertile women do not differ significantly from those of their controls. However, the general impression that stress interacts with infertility appears to be as strong as ever. The present study was undertaken to further investigate the role of emotional factors in infertility. A group of infertile women and a set of controls were evaluated using state-of-the-art objective psychologic measures. Data from the two groups were compared to determine whether the overall psychologic test results of women diagnosed as infertile would yield more significant levels of maladjustment than those of the population of women in general. Subjects MATERIALS AND METHODS The infertile group consisted of 150 women referred for treatment to the Institute of Reproductive Medicine (Annandale, VA). Patients diagnosed with primary infertility were consecutively included in the study over a period of 1! years. The average age of the infertile group was 31.8 years (standard deviation [SD] = 5.0) and the average number of years married was 5.2 (SD = 3.5). The average number of years attempting conception was 3.5 (SD = 3.1). Each subject received a Personality and Stress Evaluation as part of her medical workup. This evaluation included a clinical interview by a trained psychologist as well as the response to five self-report psychologic inventories. Each infertility patient was offered the option of follow-up counseling services at the end of her evaluation. Counseling was initiated at the request of the patient. The control group consisted of 50 volunteer women who were recruited from college, graduate, and/or nursing programs, as well as from gynecologic practices. There was no remuneration for participation in the study. Each control subject accepted either had children or had no family history Vol. 49, No. 2, February 1988 of infertility and no reported concerns regarding their capacity to conceive a child. The average age of the control group was 28 years (SD = 7.4) and the average number of years married was 4.2 (SD = 6.3). Each control was administered the identical series of psychologic tests. Counseling services were not offered to the control subjects. Psychologic Tests The 16 Personality Factor (16 PF) consists of 16 questionnaire scales arranged in omnibus form. 8 9 Each scale measures a trait that is dichotomous in design. For example, the personality trait of dominance is viewed on a continuum, characterized by submission at one extreme and dominance at the other. Each trait yields standard scores ranging from 1 to 10. In this case, 1 represents submission and 10, dominance. Normal scores fall in the middle range (4 to 7), between both extremes of a given trait, with a mean score of 5.5. Scores are considered clinically significant when they are less than 4 or greater than 7. Depending on the combinations of normal and clinically significant scores on the 16 personality traits, a clinician can determine the presence of either normal or maladjusted personality dimensions. The IP AT Anxiety Scale and the IP AT Depression Scale provide single, global measurements for anxiety and depression, respectively Standard scores for each scale are comparable to the 16 PF and range from 1 to 10, with an average range of 4 to 7. The mean score is, again, 5.5. Scores exceeding 7 on either scale indicate the presence of clinically significant anxiety and depression. The Tennessee Self-Concept Scale provides a global measure of self-esteem as well as measures for specifically defined areas of self-perceptionp Such areas include an individual's concept of their physical self, social self, family self, as well as levels of self-satisfaction and identity formation. The scale consists of 100 self-descriptive statements that each subject rates on a scale of 1 to 5, from completely false to completely true. This test yields percentile scores, with a mean at the 50th percentile. The Internal-External (I-E) Scale measures the extent to which one believes that she is internally or externally controlled.is The subject must select one statement, in each of 20 pairs, that most closely approximates her belief system. A high internal score would indicate a strong sense of self-direction, a take-charge approach to life, while a high Paulson et al. Emotional maladjustment and infertility 259

3 external score would suggest a more fatalistic, "luck-of-the-draw" attitude. This test yields a score equal to the total number of external choices. The range is 0 to 20 and the average score is approximately 9. Lie Scales Scales are built into the 16 PF that determine the degree to which an individual taking the test is "faking good" or "faking bad." A similar category exists for the Tennessee Self-Concept Scale, termed "defensive positive." Test results for a subject showing significant faking good, faking bad, or defensive positive scores were considered invalid. In order to ensure accurate test results, all 150 subjects accepted into this study were within the normal range on these variables. Scoring Tests were scored by two independent statisticians. The t-test was the statistical method employed to compare the infertile group with the control group using pooled and separate variance estimates where appropriate. Data with P < 0.05 were considered significant. 16 Personality Factor RESULTS No significant deviance or maladjustment is evident when comparing the personality profiles of the infertile women with those of their controls (Fig. 1). In fact, the bar graphs for both groups show an almost identical pattern, with means and MEAN STANDARD SCORE 1M a tal CONTROL INFERTILE PERSONALITY TRAITS Figure 1 Scores of 16 PF test. Representation of mean standard scores for infertile and control groups on 16 personality traits; standardized mean = 5.5. The traits were (1) warmth; (2) intelligence; (3) ego strength; (4) dominance; (5) impulsivity; (6) group conformity; (7) boldness; (8) emotional sensitivity; (9) suspiciousness; (10) imagination; (11) shrewdness; (12) guilt proneness; (13) rebelliousness; (14) self-sufficiency; (15) ability to bind anxiety; and (16) free-floating anxiety. MEAN PERCENTILE SCORE SELF CONCEPT VARIABLES 0 CONTROL.INFERTILE Figure 2 Representation of mean percentile scores for infertile and control groups on nine self-concept variables; standardized mean = 50th percentile. The variables were: (1) global selfconcept; (2) identity; (3) self-satisfaction; (4) behavior; (5) physical/sexual; (6) moral/ethical; (7) personal; (8) family; and (9) social. SDs on all 20 variables similar to one another and to the standardization sample. IP AT Anxiety Scale and IP AT Depression Scale The results of these scales demonstrate that no clinically significant levels of anxiety or depression were evident with the infertile group. The means and SDs were similar for both groups: anxiety infertile group mean= 5.5, SD = 2.1; anxiety control group mean = 5. 7, SD = 2.2; depression infertile group mean = 5.1, SD = 2.2; depression control group mean = 5.1, SD = 2.2. Self-Concept Scale No significant differences are observed between the infertile and control groups on any of the selfconcept variables (Fig. 2). When comparing both groups with the mean at the 50th percentile, positions on all clinical variables were remarkably similar, with the infertile group placed slightly higher than the control group. Internal-External Scale The results of the I-E Scale suggest that infertile women tend to believe that they are more externally controlled, while their controls see themselves as slightly more internally controlled: I-E infertile group mean = 10.6, SD = 4.1; I-E control group mean= 9.5, SD = 3.7. This difference, however, did not reach significance (P = 0.09). Counseling Of the 150 women in the infertile group, 27 (or 18%) actively sought counseling during the investigation, forming a subgroup for more in-depth evaluation. 260 Paulson et al. Emotional maladjustment and infertility

4 In order to evaluate more fully the possible role of emotional dysfunction and infertility, we decided to assign the women who sought counseling into one of two groups based on their test scores. Fourteen of these subjects showed evidence of clinical maladjustment, while the remaining 13 showed perfectly normal test profiles. A subject was determined maladjusted if she demonstrated clinically significant scores on three or more of the following scales: IP AT Anxiety Scale, IPAT Depression Scale, 16 PF, or Tennessee Self-Concept Scale. Scores for anxiety and depression had to be greater than 7. Criteria for clinical maladjustment on personality dimensions included significant scores on three or more of the following traits: ego strength (low, <3), dominance (high, >7), impulsivity (high), suspiciousness (high), guilt proneness (high), free-floating anxiety (high), or ability to bind anxiety (low). Criteria for clinical maladjustment and self-concept included a combination of three or more scores falling well below the normal range. Infertility diagnoses also were examined. Diagnoses for the 14 subjects, whose combined test scores reflected maladjustment, included the following: tubal obstruction, endometriosis, scar tissue, and/or adhesions. There was no occurrence of unknown diagnoses or hormonal dysfunction unrelated to endometriosis. DISCUSSION The tests used for this study were selected based on two essential criteria. First, each test had to demonstrate impressive reliability and produce valid research data. Second, each test needed to address the extent to which objective psychologic measures would prove sensitive to a basically normal population sample. This second criterion was particularly important because one would not expect to see consistent levels of severe psychopathology in women treated for infertility. Standardization samples needed to be broad in scope, measuring personality dimensions in less deviant manifestations. Based on the test results and remarkably similar curves for both the infertile and control groups, the time has come to rethink the role of stress in infertility. First, it is quite clear from this study that infertile women do not manifest significantly greater levels of emotional maladjustment than do women in general. If one were to assume that a causal relationship between stress and infertility Vol. 49, No.2, February 1988 exists, then it would follow that infertile women would have, on the average, higher indices of clinical maladjustment. Our study, among others, 6 7 clearly demonstrates that this is not the case. Although maladjustment may not be greater for the population of infertile women than for women at large, could significant stress in individual cases be causally related to infertility? The psychologic history of the 14 subjects in our counseling subgroup, who showed signs of clinical maladjustment, indicate that infertility was a catalyst for pre-existing psychologic sensitivity. If stress does interact with infertility to any degree, then these 14 individuals would certainly be candidates for the examination of such a relationship. Since hormonal dysfunction and/or unexplained infertility is more likely to be associated with stress than other types of organic disorders, we evaluated closely the medical diagnoses of all 14 patients. In each case, organic cause was the basis for diagnosis, i.e., endometriosis, tubal obstruction, scar tissue, and adhesions. It is, therefore, highly unlikely that stress would be a causal factor to their infertility. Finally, if, in fact, infertile women are, on the average, no more maladjusted than women in general, then why is the demand for counseling services and support organizations growing? The near 50/50 split in the adjusted versus maladjusted categories within the counseling subgroup shows clearly that emotional frustration and support need is not necessarily accompanied by clinical maladjustment. The tests employed in this study are some of the best marketed for psychologic testing, and are frequently used to substantiate clinical diagnoses. Furthermore, if we are to view stress as a continuum of emotional factors and responses ranging from normal to maladjusted, then we can indeed assume that a certain amount of observable emotional pain related to any given stressor may be quite normal or mild in clinical definition. In conclusion, the assumption that stress may play a causal role in infertility is called into question by the results of this investigation. While it is not possible to prove unequivocally that such a relationship does not exist for a small percentage of the population, our data nonetheless cast a great deal of doubt on a causal theory. Consequently, we need to re-examine and de-emphasize stress as a causal component to infertility. At the same time, we need to acknowledge that the infertility experience is not without emotional loss and disappointment-loss that can 1 and should, be addressed through counseling support services. Paulson et al. Emotional maladjustment and infertility 261

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