Psychological Factors Associated with Perception ... - Semantic Scholar

Journal of Sex & Marital Therapy, 31:285–302, 2005 Copyright © 2005 Brunner-Routledge ISSN: 0092-623X print DOI: 10.1080/00926230590950208

Psychological Factors Associated with Perception of Experimental Pain in Vulvar Vestibulitis Syndrome MICHAL GRANOT and YOAV LAVEE Social Welfare & Health Studies, University of Haifa, Mount Carmel, Haifa, Israel

This study assessed the association between pain perception and psychological variables in women with vulvar vestibulitis syndrome (VVS) by comparing 28 VVS women with 50 healthy women. We assessed non genital systemic pain perception with quantitative sensory testing by administering experimental pain stimuli to the forearm. The VVS women demonstrated a lower pain threshold and a higher magnitude estimation of pain, combined with a higher trait anxiety, increased somatization, and a lower body image. Among the VVS women, nonvaginal pain catastrophizing was significantly related to reported pain during coitus. A cluster analysis revealed four subtypes of VVS women, as characterized by levels of pain and personality variables. I suggest implications for the assessment and treatment of women suffering from painful coitus. Vulvar vestibulitis syndrome (VVS) is characterized by severe pain and tenderness on vestibular touch or attempted vaginal entry, with no obvious local vulvar pathology except for vestibular erythema (Friedrich, 1987; Masheb, Nash, Brondolo, & Kerns, 2000). VVS has been reported to be a major cause of dyspareunia in premenopausal women (Mariani, 2002; Marinoff & Turner, 1991; Masheb et al., 2000; Paavonen, 1995; Pukall, Binik, Khalife, Amsel, & Abbott, 2002). Although the etiology of this syndrome is still obscure, several mechanisms of pathogenesis have been suggested, including infectious diseases, inflammatory changes, alteration of immune responses, and allergic reaction (Baggish & Miklos, 1995; Bornstein, Goldik, Alter, Zarfati, & Abramovici, 1998; Green, Christmas, Goldmeier, Byrne, & Kocsos, 2001; Jeremias, Ledger, & Witkin, 2000; Masheb et al., 2000; Nyirjesy, 2000;

Address correspondence to Michal Granot, Faculty of Social Welfare & Health Studies, University of Haifa, Mount Carmel, Haifa 31905, Israel. E-mail: [email protected] 285

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Schover, Youngs, & Cannata, 1992; Wesselmann, 2001). In addition, altered pain perception (Bohm-Starke, Hilliges, Brodda-Jansen, Rylander, & Troebjork, 2001; Granot, Yarnitsky, Friedman, & Zimmer, 2002; Lowenstein et al., 2004; Pukall et al. 2002, 2004) and psychosocial factors (Danielsson, Eisemann, Sjoberg, & Wikman, 2001; Nunns & Mandal, 1997) have been suggested as contributing factors in the etiology of VVS. In line with the different possible mechanisms underlying VVS, various treatment modalities have been proposed, including electromyographic biofeedback (Glazer, Rodke, Swencionis, Hertz, & Young, 1995), physical therapy (Bergeron et al., 2001; Bergeron, Brown, Lord, Oala, & Binik, 2002), cognitive behavioral therapy (Abramov, Wolman, & David, 1994; WeijmarShultz et al., 1996), and the surgical procedure known as vestibulectomy (Bergeron et al., 2001; Bergeron, Bouchard, Fortier, Binik, & Khalife, 1997; Kehoe & Kehoe, 1999). However, the partial success rates of these treatments suggest that VVS represents a complex pain disorder involving multiple factors in its pathogenesis. Furthermore, it may be suggested that VVS represents a number of subtypes in which different combinations of etiological factors play a role. In order to examine the combined effect of pain and personality factors in VVS, as well as the existence of several VVS subgroups, the present study explores the role of enhanced pain perception together with the effects of various pain-related psychosocial factors in this syndrome.

PAIN PERCEPTION IN VVS Several studies examining the mechanism underlying the pain symptoms in VVS have applied quantitative sensory testing (QST), including mechanical, punctuate tactile, and thermal pain thresholds, as well as magnitude estimation for supra threshold mechanical pressure and thermal pain (Bohm-Starke et al., 2001; Lowenstein et al., 2004; Pukall et al., 2002). Altogether, these studies reveal enhanced pain sensitivity of the vaginal region in VVS women. Using a vulvalgesiometer, Pukall, Binik, and Khalife (2004) also demonstrated that women with VVS have significantly lower vestibular pain thresholds than do controls. On the basis of these findings, some have suggested that mechanical allodynia and increased innervation or sensitization of nociceptors in the vestibular mucosa play a role in the pathogenesis of VVS. The question of whether VVS women suffer from a general hypersensitivity to pain has also been explored. Studies that used quantitative sensory testing by applying pressure and thermal stimuli to areas remote from the genital region (e.g., the forearm or the daltoid) have shown enhanced systemic pain perception in VVS women (Granot et al., 2002; Pukall et al., 2002). These studies indicate that VVS is characterized not only by local pain enhancement but by an augmented systemic pain perception.

Psychological Factors Associated with VVS

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PERSONALITY VARIABLES IN PAIN PERCEPTION AND VVS There is abundant evidence that psychological factors, such as trait anxiety, somatization, and catastrophizing, are involved in pain processing among healthy individuals as well as in a variety of pain syndromes. The association between anxiety and sexual problems and pelvic pain, including VVS, has been suggested by a number of studies (Dunn, Croft, & Hackett, 1999; Granot et al., 2002; Knight, Green, & Hinson, 1997; Low, Edelmann, & Sutton, 1993; McGowan, Clark-Carter, & Pitts, 1998; Nunns & Mandal, 1997). Additionally, higher state anxiety was found among VVS anticipating of experimental painful stimuli applied to a nongynecological area (Granot et al., 2002). One can assume that the fear of pain plays a role in the experience of pain during intercourse among those women. The understanding that anxiety plays a role in VVS pathogenesis and recovery has been incorporated into a variety of therapeutic approaches, such as cognitive behavioral therapy and biofeedback. These approaches focus on the patient’s ability to gain a sense of control over the pain and to decrease the anticipated anxiety in order to create a positive association between pleasure and intercourse (Bergeron et al., 2001; Kandyba & Binik, 2003). Somatization is marked by multiple physical complaints caused by psychological problems (American Psychiatric Association, 1994) and is often associated with anxiety. The complaints may involve any bodily system but most frequently involve problems with the digestive system, the nervous system, and the reproductive system. Somatization is one of the major psychological factors associated with chronic pain syndromes (Hardt, Gerbershagen, & Franke, 2000; Sigmon, Dorhofer, Rohan, & Boulard, 2000; Stuart & Noyes, 1999). High rates of somatization have also been found among VVS women (Danielsson et al., 2001). Moreover, women with VVS have been found to suffer from other types of chronic pain disorders as well (Jantos & White, 1997; Tchoudomirova, Mardh, & Hellberg, 2001). An important predictor of experiencing enhanced pain associated with the cognitive aspect of pain processing is catastrophizing. A theoretical schema suggests that catastrophizers exaggerate their attention to the pain, thus increasing their pain perception via magnification or rumination strategies and negatively evaluating their ability to cope with the painful experience (Rosenstiel & Keefe, 1983; Sullivan, Bishop, & Pivic, 1995; Sullivan & Neish, 1999; Sullivan et al., 2001). The association between catastrophizing and pain has been observed across measures in healthy subjects in response to experimental pain procedures, as well as during aversive diagnostic procedures (Sullivan et al., 1995). It has also been associated with illness behavior, including frequency and duration of hospital stay (Gil, Phillips, & Keefe, 1989), use of over-the-counter medication (Bedard, Molloy, Pedlar, Level, & Stones, 1997), and seeking analgesia after surgery (Jacobsen & Butler, 1996).

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High levels of catastrophizing have been found among patients with chronic pain syndromes, such as low back pain (Flor, Behle, & Birbaumer, 1993), rheumatoid arthritis, burns (Haythornwaite, Lawrence, & Fauerbach, 2001), and whiplash injuries (Sullivan, Stanish, Waite, Sullivan, & Tripp, 1998). Furthermore, catastrophizing has been associated with disability among fibromyalgia patients (Martin et al., 1996; Robinson et al., 1997). A higher level of pain catastrophizing was also found among VVS women in response to intercourse pain as compared to general pain (Pukall et al., 2002). It may therefore be expected that pain catastrophizing will also play a role in the perception of pain among VVS women. Body image is an important dimension of sexual well-being and contributes to how people view their bodies as a vehicle through which they express their sexuality (Strong & DeVault, 1988). Research linking body image to sexual functioning has largely focused on sexual concerns among people with eating disorders (Jagstaidt, Golay, & Pasini, 1996, 1997, 2001; Werlinger, King, Clark, Pera, & Wincze, 1997); cancer survivors (Anllo, 2000; Constant et al., 2000; Lagana, McGarvey, Classen, & Koopman, 2001; Smith & Reilly, 1994), and people with chronic illness and disabilities (Weerakoon, 2001; Whipple & McGreer, 1997). Falck (1996) reported that in a group therapy intervention with women suffering from chronic pelvic and vulvar pain these conditions were often associated with disturbed experiences of body image and sexual dysfunction. Similarly, Jantos and White (1997) found that changes in body image were present in 63% of women with vestibulitis. However, the association between pain perception and body image in VVS patients has not yet been addressed. It may be assumed that a reciprocal relationship exists between symptoms of dyspareunia and low body image. On the one hand, painful intercourse and dysfunctional sexual relationships may increase the subjective perception that one’s body is deficient. On the other hand, low body image may lead to inhibitions in sexual interactions, decreased arousal and lubrication, and the experience of coitus as unpleasant and painful. In sum, previous research indicates that VVS is associated with increased systemic pain perception, anxiety, and somatization. There also is evidence that augmented pain perception is associated with patients’ tendency to catastrophize this experience, suggesting that catastrophizing may play a role in the pathogenesis of VVS. Finally, the link between one’s body image and sexual attitudes and experiences suggests that low body image may also be associated with pain during sexual intercourse. Given that VVS represents a complex pain disorder, with multiple factors assumed to be involved in its pathogenesis, the aim of the present study was to assess the role of psychosocial variables in the perception of experimental painful stimuli among VVS women. More specifically, we examined the differences between VVS and healthy non-VVS women in their perceptions of systemic pain, as well as in their levels of pain-related psychosocial


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variables. Additionally, because of the limited success rate of each of the various treatment modalities, which suggests that not all VVS women are alike, we attempted to determine whether subgroups of VVS women exist with respect to pain perception and psychosocial factors.

METHOD Participants Participants in the study included two groups of women: a VVS group and a control group of healthy non-VVS women. The VVS group consisted of 28 female patients seeking treatment in a vulvar vestibulitis clinic in Haifa, Israel. All were diagnosed with VVS according to the following criteria: (a) pain during intercourse that has lasted for more than 6 months and (b) severe pain during a cotton-swab test in more than one location of six vestibular sites. Patients were not included in the study if they suffered from vaginismus or from other forms of vulvodynia (e.g., vulvar dermatoses, vulvitis, vulvar papillomatosis, or essential vulvodynia). The control group consisted of 50 students recruited by advertising at the University of Haifa. The students were paid approximately US $30 for their participation. Exclusion criteria for both groups were age below 18 or above 40 and a history of systemic disease or hormonal disorders. Mean ages of the VVS and control groups were 22.88 (SD = 2.27) and 24.60 (SD = 4.11), respectively, with no significant differences between them (t = 1.73, p = .09). All of the participants had a high-school education, and all but 8 participants in the VVS group had attended at least some college, as well.

Instruments and Measures QUANTITATIVE

SENSORY TESTING

We performed the quantitative sensory tests with a Thermal Sensory Analyzer (TSA-2001, Medoc, Israel), using a 30 × 30 mm2 contact thermode. All stimuli were applied to the vollar part of the forearm. Pain threshold was defined according to the Method of Limits (Yarnitsky, 1997) by elevating the temperature from 32◦ C at a rate of 1◦ C/s. The women were asked to indicate the point at which the nonpainful warm sensation produced by the thermode became a painful heat sensation. We calculated an average of four stimuli with an interstimulus interval of 5 s to determine the pain threshold. We assessed the magnitude estimation of perceived phasic suprathreshold pain for heat stimuli at 47◦ C for 1 s. Two stimuli were delivered, and the women were asked to report the level of perceived pain intensity after each stimulus by means of a visual analog scale (VAS). The 150 mm VAS ranges from “no pain” at one end to “the worst pain imaginable” at the other end. The average of the two VAS scores was calculated.

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The assessment of tonic pain (46◦ C) was obtained in real time on a Computerized Visual Analog Scale (COVAS, Medoc, Israel). This stimulus lasts for 60 s and provides a measure that reflects pain sensation similar to that evoked under clinical conditions. Similar to the manual VAS, the computerized device consists of an easily moveable horizontal lever on a 100 mm range with an anchor at each end. Participants noted the magnitude of perceived pain at 5, 20, 35, and 50 sec during the tonic stimulus. To determine the tonic pain score, we calculated the mean of the four scores. ANXIETY We assessed anxiety level with the validated Hebrew version (Teichman & Malineck, 1978) of Spielberger’s State-Trait Anxiety Inventory (STAI; Spielberger, 1972; Spielberger, Gorsuch, & Lushene, 1969). The first part of the questionnaire assesses the level of state, or situational, anxiety; the second part assesses the level of trait, or dispositional, anxiety. Each part includes 20 brief statements describing emotional conditions that refer to the present moment for state anxiety and to frequency over time for trait anxiety. Participants were asked to rate their feelings about each statement on a 4-point scale ranging from “not at all” to “very much so.” SOMATIZATION We assessed the level of somatization with the short version of the Brief Symptom Inventory (BSI; Derogatis & Melisaratos, 1983), representing one factor in the Symptom Check List (SCL-90; Derogatis & Cleary, 1977). This multidimensional screening instrument, which is a self-report of psychological distress and multiple aspects of psychopathology, often is included in the evaluation of pain patients (Hardt et al., 2000). The 13-item questionnaire rates the frequency of complaints or symptoms in different areas of the body, including chest pain, headache, low back pain, vomiting, dizziness, flushes, or numbness. In the present study, the internal consistency reliability coefficient (Cronbach alpha) of this scale was .78. PAIN

CATASTROPHIZING

The catastrophizing level was assessed with the Pain Catastrophizing Scale (PCS; Sullivan et al., 1995). This instrument includes 13 items representing the three components of pain catastrophizing: rumination (e.g., “I can’t seem to keep it out of my mind.”), magnification (e.g., “I wonder whether something serious may happen.”), and helplessness (e.g., “There is nothing I can do to reduce the intensity of pain.”). All participants were asked to complete the instrument in response to the tonic stimulus, and the VVS women were also asked to do so in relation to their vaginal pain during coitus (see Study Design section). The internal consistency reliability coefficient (Cronbach alpha) of the PCS scale in this study was .86.


BODY

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IMAGE

Body image was measured with the Body Attitudes Questionnaire (BAQ; Story, 1988). The original scale consists of a list of 49 items for body parts or processes and an additional item for the total body. Respondents are asked to rate their feelings about each item on a 5-point Likert scale ranging from 1 (“I have a strong negative feeling.”) to 5 (“I have a strong positive feeling.”). In the present study, the list included 16 items (hair, face, body hair, thighs, body structure, height, breasts, eyes, skin type, legs, buttocks, hands, skin color, abdomen, vagina, and “how others like my body”). Thus, scores could range from 16 to 80, with high scores representing a morepositive body image. Story reported good face and concurrent validity, as well as a test-retest reliability coefficient of .91 over a 2-week period. The internal consistency reliability coefficient (Cronbach alpha) in this study was .79.

Study Design The present study was approved by the Rambam Medical Center Review Board in accordance with the Helsinki Declaration, and all participants provided written informed consent. The first evaluation conducted with all participants was for anxiety level. In addition, the VVS women were also asked to complete the PCS scale with regard to their vaginal pain during intercourse. Thereafter, we evaluated heat pain threshold and magnitude estimation of perceived suprathreshold phasic and tonic pain stimuli. All tests were conducted during the morning hours by the same investigator. Upon completion of the tests, the women were asked to report the level of catastrophizing in response to the experimental painful stimuli and to complete the somatization and body image questionnaires.

ANALYSES AND RESULTS In order to determine whether personality variables contribute to pain perception, we first compared VVS and pain-free women in personality and pain-related variables. We then conducted an analysis of variables that characterize women with VVS, followed by a cluster analysis in order to delineate subtypes of VVS based on the manifestation of both personality and painrelated variables.

Group Differences We examined differences between VVS and pain-free women using multivariate analyses of variance (MANOVA). Overall differences were found between

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TABLE 1. Means, Standard Deviations, and Group Differences in Study Variables VVS group (n = 28) Variables Pain perception Pain threshold Phasic pain Tonic pain Anxiety State anxiety Trait anxiety Psychological factors Experimental pain catastrophizing Coital pain catastrophizing† Somatization Body image

Control group (n = 50)

M

SD

M

SD

Difference F (d f = 1, 77)

42.35 63.05 61.24

3.47 34.73 19.02

44.95 46.05 62.94

2.24 27.68 21.89

13.14∗∗ 6.33∗ 0.001

40.77 40.68

12.33 8.98

37.21 35.08

8.12 8.33

1.57 5.71∗∗

11.96 27.41 20.27 53.09

9.92 13.01 7.26 10.45

16.85 — 13.81 59.21

13.53 — 8.07 9.45

1.95 11.51∗∗ 7.28∗∗

Note. Coital pain catastrophizing was only measured for the VVS group and was not included in the multivariate analysis of variance. ∗ p < .05. ∗∗ p < .01.

groups in pain perception (F (3,74) = 5.82, p = .001) and in psychological factors (F (3,74) = 5.86, p = .001) but not in anxiety (F (2,75) = 2.88, p = .06). As shown in Table 1, the VVS women demonstrated lower pain threshold and higher magnitude estimation of phasic suprathreshold stimuli than did the women in the control group, but no significant difference was found in tonic stimuli. Additionally, the VVS women demonstrated higher levels of trait anxiety and somatization as well as lower body image. We found no differences between the two groups in their levels of state anxiety or in experimental pain catastrophizing. Further analysis indicated that among the VVS women, there was a significant correlation between the experimental and the coital-related pain catastrophizing scores (r = .46, p < .05). However, the catastrophization scores for coital pain (M = 27.41, SD = 13.01) were significantly higher than were those for experimental pain (M = 11.96, SD = 9.92), t = 6.56, p < .001. The correlations between the study variables show some additional differences between the VVS women and the control group. Most notably, pain perception was negatively associated with body image among the VVS women but not among the non-VVS women. That is, lower body image is related to enhanced systemic pain perception. In both groups, pain catastrophizing was positively associated with a lower pain threshold and higher pain perception. However, only among the VVS women was pain catastrophizing also related to lower body image and greater somatization. Moreover, although somatization was associated with lower body image in both groups, this relationship was found to be considerably higher among the VVS women

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TABLE 2. Correlation Matrix of Study Variables in the VVS Group and the Control Group Variables

1

2

3

4

5

6

7

1. 2. 3. 4. 5. 6. 7. 8.

— −.85∗∗ −.17 −.09 .28 −.27 −.64∗∗ −.22

−.75∗∗ — .25 .17 −.43∗ .34 .61∗∗ .12

−.01 −.07 — .58∗∗ −.18 .38 .27 .23

−.09 .07 .22 — −.31 .40 .21 −.10

−.21 .07 −.48∗∗ −.22 — −.54∗∗ −.45∗ −.19

.07 −.02 .49∗∗ −.01 −.29∗ — .47∗ .38

−.35∗ .42∗∗ .03 .28 .23 .10 — .46∗

Pain threshold Pain perception State anxiety Trait anxiety Body image Somatization PCS–experimental PCS–vaginal

Note. Correlations for the VVS women are below the diagonal; correlations for the control group are above the diagonal. PCS = Pain Catastrophizing Scale. ∗ p < .05 ∗∗ p < .01.

than among the controls (r = −.54 and r = −.29, respectively). The correlations are presented in Table 2.

Pain Perception and Personality Variables Predicting VVS In order to examine the variables that best explain the differences between the VVS and the non-VVS women, we conducted a hierarchical logistic regression analysis. In the first step, the role of pain-related variables was assessed. The findings indicated that a lower pain threshold significantly characterizes VVS women. More than 77% of the subjects were correctly classified by their pain threshold scores. The findings are presented in Table 3. In the second step, we assessed the added contribution of personality variables in predicting VVS. As Table 3 shows, personality variables added 36% to the explained variance and 8.6% to the accuracy of prediction beyond pain-related variables. Higher trait anxiety and somatization and lower catastrophizing were found to play a significant role in predicting VVS. TABLE 3. Hierarchial Logistic Regression Predicting VVS by Pain and Personality Variables

Step 1 Pain threshold Phasic pain perception Step 2 Pain threshold Phasic pain perception Trait anxiety Body image Somatization Catastrophizing

B

SE

Wald

Exp(B)

−.552 −.025

.194 .018

8.077∗∗ 1.861

0.576 0.976

−.829 −.030 .123 −.038 .103 −.174

.287 .025 .055 .042 .053 .061

8.362∗∗ 1.526 4.982∗ 0.825 3.771∗ 8.160∗∗

0.437 0.970 1.131 0.963 1.108 0.840

Note. Exp(B) = odd ratio. For step 1, R 2 = .26, percent correctly classified = 77.1; for step 2, R 2 = .62, percent correctly classified = 85.7. ∗ p < .05 ∗∗ p < .01.

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Thus far, the findings indicate a complex picture of the role that personality variables play with VVS. First, although no significant differences were found between the VVS and the non-VVS groups in their level of catastrophizing in response to the experimental noxious stimuli, catastrophizing does play a significant role in the prediction of VVS. These findings suggest that catastrophizing is not in itself a factor that discriminates between VVS and non-VVS women but it does in combination with other personality and pain-related variables. Second, large variations were found among the VVS women in pain as well as in personality variables, suggesting that not all VVS women are alike.

Classification of VVS Women into Subgroups A cluster analysis was conducted in order to explore whether subgroups exist among VVS women with respect to pain-related and personality variables. More specifically, we conducted an agglomerative hierarchical clustering procedure with squared Euclidean distance and a between-groups linkage. The agglomeration schedule indicated that four clusters best account for the data, with the agglomeration coefficients significantly decreasing afterward. We then conducted a MANOVA with post-hoc tests for differences between the subgroups in personality variables and pain threshold. The findings indicated that the four subgroups are significantly different across the clustering variables: F (12,44) = 19.20, p < .001. Post-hoc tests for group differences in each variable (see Table 4 and Figure 1) revealed that the four types of VVS women were characterized by specific combinations of anxiety and pain perception. Group 1 (19% of VVS women) was characterized by a low pain threshold and a high level of anxiety; Group 2 (19%) was characterized by a high pain threshold and a low level of anxiety; Group 3 (29%) was characterized by a high pain threshold and a high level of anxiety; TABLE 4. Means, Standard Deviations (in Parentheses), and One-Way Analyses of Variance for Differences Between VVS Subgroups in Personality Variables and Pain Perception VVS group

Trait anxiety Somatization Catastrophizing Pain threshold

1

2

3

4

F (d f =3)

47.00a (7.00) 26.33a (3.06) 32.00a (3.00) 38.37a (1.46)

34.40b (7.50) 12.20b (5.76) 0.80b (0.84) 47.10b (1.30)

46.67a (6.44) 16.50ac (4.42) 11.11bc (5.16) 42.58c (2.30)

33.17b (3.87) 24.78bc (4.63) 11.33c (5.82) 40.08ac (1.28)

8.48∗

Note. a,b,c means within each row whose super-scripts differ are different at p < .05. ∗ p < .001.

10.59∗ 28.82∗ 19.69∗


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FIGURE 1. Four subgroups of women suffering VVS classified by anxiety, somatization, catastrophizing, and pain threshold (standardized scores).

and Group 4 (33%) was characterized by a low pain threshold and a low level of anxiety. These findings indicate that there are various manifestations of psychosocial variables and varied sensitivity to pain among women who suffer from VVS.

DISCUSSION The present study assessed whether psychological characteristics are associated with enhanced systemic pain perception in VVS. When compared with healthy women, VVS women were found to have lower pain thresholds, increased somatization, higher trait anxiety, and lower body image. Furthermore, we noted the existence of several subtypes within the VVS group, suggesting that this disorder represents various manifestations of personality and pain-related characteristics. Before discussing the findings and their implications, we should note that the sample in this study was relatively small. Although caution must be exercised in generalizing the findings, this study does allow us to make some useful observations with respect to correlates of personality aspects and perceived pain among VVS women. The findings indicating that VVS women are characterized by enhanced pain perception support the results of previous studies suggesting that greater systemic pain sensitivity accompanies this disorder (Granot et al., 2002; Pukall et al., 2002). Likewise, the finding that VVS women exhibit higher trait anxiety

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than non-VVS women also is in line with past research pointing to the role of anxiety in VVS (Dunn et al., 1999; Granot et al., 2002; Knight et al., 1997; Low et al., 1993; Nunns & Mandal, 1997; McGowan et al., 1998). However, we found that not all VVS women demonstrate greater pain sensitivity and high anxiety, suggesting that pain perception and anxiety play a role in the pathogenesis of VVS among some women but not among others. The present study further expands the understanding of VVS beyond the already documented contribution of pain perception and anxiety by assessing the role of other psychological aspects in VVS: catastrophization, somatization, and body image.

The Role of Catastrophization in VVS The tendency to catastrophize experimental painful stimuli was not found to be significantly different between VVS women and their non-VVS counterparts. At the same time, VVS women reported higher levels of catastrophizing related to vaginal pain during coitus compared with experimental (nonvaginal) pain, thereby supporting previous findings (Pukall et al., 2002). The present study further reveals that, among VVS women, nonvaginal pain catastropization is associated with increased pain during coitus. Furthermore, the results show that pain catastrophizing is associated with enhanced pain perception, as well as with certain personality characteristics, including greater somatization and lower body image. The strong link between catastrophizing and other pain-related and personality characteristics may be attributed to the cognitive component of this tendency. A growing number of studies show that the tendency to catastrophize during painful stimulation contributes significantly to enhancing the pain experience and increasing emotional distress. Possible mechanisms of action for this phenomenon were proposed by Sullivan et al. (2001), who suggested that catastrophizing represents a multidimensional trait in which activation, appraisal, attention, and coping play a role in the experience of pain. Within this framework, the associations between catastrophizing and other personality variables found in the present study may be explained by an activation of emotional components such as somatization and body image. Alternatively, it is possible that these links are explained by a process of appraisal, in which an exaggeration of the threat of a painful stimulus (i.e., during coitus) leads to an enhanced pain experience. This process may explain our findings showing a strong association between catastrophizing and pain perception among VVS women. Additionally, increased attention toward the painful stimuli, by rumination, results in a greater pain experience. As such, VVS women may focus their attention on a variety of pain experiences, thereby explaining their greater tendency towards somatization. However, it must be emphasized that not all VVS women were found to be


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high on catastrophizing. The cluster analysis revealed that although some VVS women were characterized by a high tendency to catastrophize pain experiences, others were not.

The Role of Somatization The findings of the present study show that VVS women tend to be characterized by higher somatization than do non-VVS women. The results of previous research by Jantos and White (1997) also point to a parallel between VSS and somatization, as assessed according to the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; APA, 1994) for somatization disorder. Dannielson and colleagues (2001) further suggested that somatization may play a part in the development of VVS. The present study further emphasizes the role of somatization in VVS in several ways. First, unlike previous studies, we assessed the association between somatization and the response to experimental pain. Second, we demonstrated that although VVS women appear to have higher scores on somatization than do non-VVS women, this is not the case for all women suffering from VSS.

The Role of Body Image Body image is known to play a meaningful role in sexuality, with a positive body image contributing to the perception of oneself as sexually attractive (Crooks & Baur, 1990). In contrast, a negative body image may lead to feelings of inadequacy in sexual relationships and to sexually avoidant behavior (Faith & Schare, 1993; Trapnell, Meston, & Gorzalka, 1997). In the present study, VVS women were found to have a lower body image than were non-VVS women. Additionally, their lower body image was found to be associated with higher pain perception, as well as somatization and catastrophization, indicating that lower body image plays a unique role in this syndrome. Although poorer body image may be a consequence of vaginal pain, the strong associations between body image and other personality traits suggests that it may also serve as a contributing factor in the pathogenesis of VVS. It may further be suggested that VVS women have negative feelings and attitudes toward their bodies, which in turn lead to pain-avoidant behavior.

Conclusions and Implications Two major findings of the present study have important implications for therapeutic intervention. First, the role of psychological factors in the systemic hyperresponsiveness to pain in VVS demonstrates the complexity of the disorder. Second, the existence of several subgroups of VVS women points to

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the unique pattern of the combination of pain and personality variables. These may suggest that the assessment of women presenting with painful coitus should include not only a medical examination but also an evaluation of their pain perception and personality characteristics, including anxiety, somatization, and pain catastrophizing. Such a process will facilitate the emergence of more-comprehensive patient profiles and will enable the application of multimodal therapeutic approaches selected to suit the different subgroups of women with VVS.

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