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Gebhart, James Edward

THE RELATIONSHIP OF SELECTED PERSONALITY CHARACTERISTICS AND PERSONAL BELIEF SYSTEMS TO MITRAL VALVE PROLAPSE SYNDROME

The Ohio State University PH.D. 1982

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University Microfilms International THE RELATIONSHIP OF SELECTED PERSONALITY CHARACTERISTICS AND PERSONAL BELIEF SYSTEMS TO MITRAL VALVE PROLAPSE SYNDROME

DISSERTATION

Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy in the Graduate School of The Ohio State University

By

James Edward Gebhart, B.A., M.Div.

*****

The Ohio State University 1982

Reading Committee: Approved By

Joseph P. Quaranta, Ph.D.

James Wigtil, D. Ed.

Henry Leland, Ph.D.

U Advisor Faculty of Special Services © C o p y r i g h t by

James Edward Gebhart

1982 In honor of my family

Karen, Jeffrey, Gretchen,

Mother and Father ACKNOWLEDGMENTS

Many persons assist with a study of this nature, and they merit recognition as well as gratitude. Three members of the faculty pro- > vided the exacting scrutiny by which this study was measured: Joseph

Quaranta, Ph.D., James Wigtil, D. Ed., and Henry Leland, Ph.D. Stephen

Schaal, M.D., extended the invitation of the Department of Cardiology of The Ohio State University without which the study would not have been possible. John Monk, a graduate research associate, translated the research design into a distinct program language for the computer analysis. Two classmates spent many hours with the research: Carol

Stuessy was a vital consultant on the research design; and Jan

Schmittauer translated written notes through many revisions into final manuscript. if Finally, deep appreciation is expressed to the MVPS patients who contributed their time and attention to this study, and infused it with enthusiasm of hope; for further understanding of their condition.

.iii VITA

March 29, 1936 ...... Born - Tulsa, Oklahoma

1958 ...... B.A., Westmar College, LeMars, Iowa

1961 ...... M.Div., United Theological Seminary, Dayton, Ohio

1962 ...... Graduate Studies, Columbia University, New York, New York

1962-1967 ...... Pastor, Grace United Methodist Church, Ravena, New York

1964-1967 ...... Clinical Pastoral Education, Albany Medical Center Hospital, Albany, New York

1967-1969 ...... Supervisory Resident and Chaplain, Hartford Hospital, Hartford, Connecticut

1969-1972 ...... Director, Sidney Pastoral Counseling Center, and Director, Shelby County Mental Health Center, Sidney, Ohio

1972-1979 ...... Associate Director, Southwest Community Mental Health Center, Columbus, Ohio

1978-1982 ...... Private Practice, Pastoral Counseling, Columbus, Ohio

PUBLICATIONS

"The Twenty-Four Hour Marathon." The Journal of Pastoral Care, 1971, 27, (4). FIELDS OF STUDY

Major Field: Guidance and Counselor Education

Studies in Counselor Supervision: Professors Joseph P. Quaranta and James Wigtil

Studies in Psychology: Professor Henry Leland

iv TABLE OF CONTENTS

Page ACKNOWLEDGMENTS ...... iii

VITA ...... iv

LIST OF TABLES ...... vii

Chapter

I. INTRODUCTION ...... 1

. Statement of the Problem ...... 3 Rationale for this S t u d y ...... 4 Definition of Key T e r m s ...... 13 Limitations...... 17 S u m m a r y ...... 18

II. REVIEW OF THE LITERATURE...... 20

Introduction ...... 20 Historical Review of the Mind-Body Issue . . 20 Contemporary Theories of Stress ...... 26 Stress and Cardiovascular Disease ...... 30 Personality Factors in Cardiovascular Disease 34 State and Trait Anxiety ...... 37 Locus of Control ...... 43 Mitral Valve Prolapse Syndrome ...... 45 S u m m a r y ...... 51

III. M E T H O D O L O G Y ...... 53

Research Setting ...... 53 Sample Selections ...... 54 Instrumentation ...... 59 Procedures in Data Collection...... 70 Statistical Methodology ...... 71

IV. ANALYSIS OF RESULTS...... 74

Introduction ...... 74 Analysis of the Instruments...... 74 Research Questions ...... 123

v Page

V. SUMMARY AND CONCLUSIONS...... 142

Summary and Conclusions ...... 142 Recommendations for FurtherStudy ...... 161

APPENDIXES

A. Factors in Anxiety ...... 164

B. Schematic Diagram of the H e a r t ...... 165

C. Personal Data Questionnaire ...... 166

D. State-Trait Anxiety Inventory ...... 168

E. Internal-External Locus of Control Scale ...... 170

F. The Rokeach Dogmatism Scale ...... 172

G. The Bessai Common Beliefs SurveyIII ...... 174

REFERENCES...... 176

vi LIST OF TABLES

Selection of the MVPS Sample Population . 55

Demographic Characteristics of Sample Populations ...... 58

Comparative Scores for the State-Trait Anxiety Inventory ...... 64

Summary Demography and Symptomatology Statistics for MVPS and Control Groups . 75

Comparison of Means of Demography and Symptomatology for MVPS and Control Groups 77

Summary Demography and Symptomatology Statistics for Symptomatic and Asymptomatic MVPS Groups ...... 78

Comparison of Means of Demography and Symptomatology for MVPS Symptomatic and MVPS Asymptomatic Groups ...... , 79

Summary Statistics of the State-Trait Anxiety Inventory and Subscales ...... 80

Varimax Rotated Factor Matrix for the State-Trait Anxiety Inventory ...... 81

Sample Items for the State and Trait Subscales of the State-Trait Anxiety Inventory ...... 82

Eigenvalues of the Internal-External Locus of Control Scale ...... 84

Varimax Rotated Factor Matrix for the Internal-External Locus of Control Scale 85

vii 13. Sample Items Exemplifying Higher and Lower Factor Loadings on the Internal-External Locus of Control Scale ...... 86

14. Eigenvalues for the Rokeach Dogmatism Scale ...... 88

15. Varimax Rotated Factor Matrix for the Rokeach Dogmatism Scale ...... 89

16. Typical Items from the Rokeach Dogmatism S c a l e ...... 90

17. Summary Statistics of the Bessai Common Beliefs Survey ...... 92

18. Eigenvalues of the Self-Downing Subscale of the Bessai Common Beliefs Survey ...... 93

19. Initial Varimax Rotated Factor Matrix of the Self-Downing Scale of the Bessai Common Beliefs Survey ...... 93

20. Refined Varimax Rotated Factor Matrix of the Self-Downing Scale of the Bessai Common Beliefs Survey ...... 94

21. Sample Items from the Self-Downing Scale of the Bessai Common Beliefs Survey ...... 95

22. Eigenvalues of Perfectionism Scale of the Bessai Common Beliefs Survey ...... 95

23. Varimax Rotated Factor Structure of the Perfectionism Scale of the Bessai Common Beliefs Survey ...... 96

24. Sample Items from the Perfectionism Scale of the Bessai Common Beliefs Survey ...... 96

25. Eigenvalues for Blame-Proneness Scale of the Bessai Common Beliefs Survey ...... 97

26. Initial Varimax Rotated Factor Matrix of the Blame-Proneness Scale of the Bessai Common Beliefs Survey ...... 98

27. Refined Eigenvalues of the Blame-Proneness Scale of the Bessai Common Beliefs Survey ...... 99

viii Refined Varimax Rotated Factor Matrix of the Blame-Proneness Scale of the Bessai Common Beliefs Survey ...... 99

Sample Items of the Blame-Proneness Scale of the Bessai Common Beliefs Survey ...... 99

Eigenvalues of the Importance of the Past Scale of the Bessai Common Beliefs Survey . 100

Varimax Rotated Factor Matrix of the Impor­ tance of the Past Scale of the Bessai Common Beliefs Survey ...... 100

Sample Items of the Importance of the Past Scale of the Bessai Common Beliefs Survey . 101

Initial Eigenvalues of the Importance of Approval Scale of The Bessai Common Beliefs Survey ...... 102

Initial Varimax Rotated Factor Matrix of the Importance of Approval Scale of the Bessai Common Beliefs Survey ...... 103

Refined Eigenvalues of the Importance of Ap­ proval Scale of the Bessai Common Beliefs Survey ...... 103

Refined Varimax Rotated Factor Matrix of the Importance of Approval Scale of the Bessai Common Beliefs Survey ...... 104

Sample Items of the Importance of Approval Scale of the Bessai Common Beliefs Survey . 104

Initial Eigenvalues of the Control of Emotions Scale of the Bessai Common Beliefs Survey ...... 105

Initial Varimax Rotated Factor Matrix of the Control of Emotions Scale of the Bessai Common Beliefs Survey ...... 106

Refined Eigenvalues of the Control of Emotions Scale of the Bessai Common Beliefs Survey ...... 106

Refined Varimax Rotated Factor Matrix of the Control of Emotions Scale of the Bessai Common Beliefs Survey ...... 106 ix 42. Sample Items of the Control of Emotions Scale of the Bessai Common Beliefs Survey ...... 107

43. Initial Eigenvalues of the Evaluation Scale of the Bessai Common Beliefs Survey ...... 108

44. Initial Varimax Rotated Factor Matrix of the Evaluation Scale of the Bessai Common Beliefs S u r v e y ...... 109

45. Refined Eigenvalues of the Evaluation Scale of the Bessai Common Beliefs Survey ...... 110

46. Refined Varimax Rotated Factor Matrix of the Evaluation Scale of the Bessai Common Beliefs S u r v e y ...... Ill

47. Initial Eigenvalues of the Locus of Control Scale of the Bessai Common Beliefs Survey ...... 112

48. Initial Varimax Rotated Factor Matrix of the Locus of Control Scale of the Bessai Common Beliefs Survey ...... 113

49. Refined Eigenvalues of the Locus of Control Scale of the Bessai Common Beliefs Survey ...... 114

50. Refined Varimax Rotated Factor Matrix of the Locus of Control Scale of the Bessai Common Beliefs Survey ...... 115

51. Eigenvalues of the Total Scale of the Bessai Common Beliefs Scale ...... 116

52. Varimax Rotated Factor Matrix of the Bessai Common Beliefs Survey ...... 117

53. Sample Items from the Bessai Common Beliefs Survey According to a Six Factor Analysis ...... 118

54. Correlation Matrix of Primary Variables ...... 122

55. Means and Standard Deviations for the MVPS and Control Groups on the State-Trait Anxiety Inventory, the Internal-External Locus of Control Scale, the Rokeach Dogmatism Scale, and the Bessai Common Beliefs Survey ...... 124

56. Comparison of Means for MVPS and Control Groups on the State-Trait Anxiety Inventory, the Internal-External Locus of Control Scale, the Rokeach Dogmatism Scale, and the Bessai Common Beliefs Survey ...... 125 x 57. Multivariate Analysis Summaries for the MVPS and Control Groups on the State-Trait Anxiety Inven­ tory, the Internal-External Locus of Control Scale, the Rokeach Dogmatism Scale, and the Bessai Common Beliefs Survey ...... 126

58. Means and Standard Deviations for the MVPS and Control Groups on the State and Trait Subscales of the State-Trait Anxiety Inventory, the Internal-External Locus of Control Scale, the Rokeach Dogmatism Scale, and the Evaluation and Locus of Control Subscales of the Bessai Common Beliefs Survey ...... 129

59. Comparison of Means for MVPS and Control Groups on the State and Trait Subscales of the State-Trait Anxiety Inventory, the Internal-External Locus of Control Scale, the Rokeach Dogmatism Scale, and the Evaluation and Locus of Control Subscales of the Bessai Common Beliefs Survey ...... 130

60. Multivariate Analysis Summaries for the MVPS and Control Groups on the State and Trait Subscales of the State-Trait Anxiety Inventory, the Internal- External Locus of Control Scale, the Rokeach Dog­ matism Scale, and the Evaluation and Locus of Control Subscales of the Bessai Common Beliefs Survey ...... 131

61. Means and Standard Deviations for the MVPS Symptomatic and MVPS Asymptomatic Groups on the State-Trait Anxiety Inventory, the Internal-External Locus of Control Scale the Rokeach Dogmatism Scale, and the Bessai Common Beliefs Survey ...... 133

62. Comparison of Means for the MVPS Symptomatics and MVPS Asymptomatics on the State-Trait Anxiety In­ ventory, the Internal-External Locus of Control Scale, the Rokeach Dogmatism Scale, and the Bessai Common Beliefs Survey ...... 134

63. Multivariate Analysis Summaries for the MVPS Symptomatic and Asymptomatic Groups on the State- Trait Anxiety Inventory, the Internal-External Locus of Control Scale, the Rokeach Dogmatism Scale and the Bessai Common Beliefs Survey ...... 135

64. Means and Standard Deviations for the MVPS Sympto­ matics and the MVPS Asymptomatics on the State and Trait Subscales of the State-Trait Anxiety Inven­ tory, the Internal-External Locus of Control Scale, the Rokeach Dogmatism Scale, and the Evaluation and Locus of control Subscales of the Bessai Common Beliefs Survey ...... 138 xi 65. Comparison of Means for the MVPS Symptomatic and MVPS Asymptomatics on the State and Trait Subscales of the State-Trait Anxiety Inventory, the Internal- External Locus of control Scale, the Rokeach Dogmatism Scale, and the Evaluation and Locus of Control Subscales of the Bessai Common Beliefs Survey ...... 139

66. Multivariate Analysis Summaries for the MVPS Symptomatics and MVPS Asymptomatics on the State and Trait Subscales of the State-Trait Anxiety Inventory, the Internal-External Locus of Control Scale, the Rokeach Dogmatism Scale, and the Evaluation and Locus of Control Subscales of the Bessai Common Beliefs Survey ...... 140 CHAPTER I

INTRODUCTION

Stressful life experience can serve as a positive stimulant to

personal growth and development, a condition termed "eustress" by

Selye (1974). In this sense, stress is construed as an essential

element in the scheme of living organisms, contributing both to basic

self-preservation and procreation, and also eliciting the very challenges

which give much of the joy and meaning to life. However, for most

persons living in post-industrial Western cultures, the extent of stress

has become excessive and deleterious to health, or what Selye (1974)

has termed "distress." Such stress and the complex biochemical mechanisms

that mediate adaptation to a stressful environment, have been associated with a wide variety of diseases, disorders and disabilities in four

primary categories: respiratory, muscular-skeletal, gastrointestinal,

and, for the purpose of this study, cardiovascular (Hinkle, 1974; Holmes

and Masuda, 1974; Theorell, 1974; Wolff, 1968; Pelletier, 1977).

There is continuing controversy whether or not causal inference can

be made from the association of stress and illness, that is, whether one can infer that stressful life events actually play a causal role in-..

the development of a heart disease. However, single causation is a mis­ leading concept in what is actually a complex cognitive-affective-

physiological interactive system. The actual thoughts and feelings of a given experience might well be an appropriate function of a state of

1 physiological arousal; or, on the other hand, physiological arousal might

be the function of the particular emotions and interpretations of a

situation. In fact, in the interactive process, the cognitive-affective-

physiological factors amplify each other in such a way as to cause

progressive degeneration. A migraine attack, for example, might be

triggered by a dietary imbalance, by emotional stress, by an attitude

or assessment of an experience, or by the interaction between these

factors. The end result is that the increased tension aggravates the

pain which exacerbates the tension in a damaging progression.

The development, then, of a psychophysiological disorder often

begins from a baseline of excessive stress, the result of an interaction

of cognitive, affective and physiological factors. As this stress per­

sists in a prolonged and unabated fashion, it produces alterations in

neurophysiological functioning which creates the preconditions for the

development of a disorder (Pelletier, 1977). At a critical point, due

either to an accumulation of life change events (Holmes and Rahe, 1967), or of continued physiological distress and exhaustion (Selye, 1974),

physiological symptoms appear. At this juncture the role of the person­ ality enters the picture. Certain individuals can be expected to manage stress in ways characteristic of their personality formation.

Some have argued that basic personality types can be expected to have specific illnesses (Dunbar, 1954). Others have researched specific personality subsets or "types" which are thought to be prone to cardio­ vascular disease (Friedman and Rosenman, I960; 1974), cancer (Bahnson and Bahnson, 1969), and gastrointestinal and respiratory diseases (Wolff,

1950). Some have contended that only certain characteristics of personality formation, such as locus of control {Kobasa, 1979) or com­ mitment to a belief system {Coehlo, Hamburg, and Adams, 1974) are pre­ cursors to psychophysiological disorders. Still others contend that pathogenic stress derives not from personality, but from specific cognitive processes in which a basic threat to existence is assessed

(Cox, 1978; May, 1950; Lazarus, 1966).

Statement of the Problem

The purpose of this study was to examine differences of selected personality characteristics and operating belief systems between patients suffering from Mitral Valve Prolapse Syndrome (MVPS) and persons of similar.socioeconomic circumstances who manifested no evi­ dence of heart disease, and between symptomatic and asymptomatic MVPS patients.

The specific objectives of this study were as follows:

1. Identify the nature and prevalence of anxiety (state and

trait), perceived locus of control (internal vs. external),

dogmatism (open-minded vs. close-minded), and common beliefs

(rational vs. irrational) among the MVPS and control sample

populations.

2. Evaluate any differences between symptomatic and asymptomatic

MVPS patients with respect to anxiety, locus of control, dog­

matism, and common beliefs.

3. Evaluate the interactive effects of these factors to determine

if a characteristic MVPS profile can be identified. Research Questions

The following questions were pursued within this research:

1. Does the MVPS sample population display a significantly

different profile of selective personality traits and

belief systems than the control sample population of

persons without MVPS as measured by state and trait

anxiety, locus of control, dogmatism, and common beliefs?

2. Does the MVPS sample population which is considered symp­

tomatic display a significantly different profile of

selective personality traits and belief systems than the

MVPS sample population which is considered asymptomatic

as measured by state and trait anxiety, locus of control,

dogmatism and common beliefs?

3. Do significant correlations exist between the selective

personality characteristics, state and trait anxiety and

locus of control, and the belief system, dogmatism and

common beliefs?

Rationale For This Study

Since the Middle Ages, it has been common to divide humans into the separate aspects of body, mind and spirit. Physicians, alchemists (and later psychologists) and the clergy attended to these respective functions.

A few philosophers emerged from these disciplines to speculate on how the three aspects might interact together. However, the polarities persisted until modern times: the idea that healing is primarily a physical process, and psychological and spiritual factors must be dis­

missed; or the idea that illness is the result of psychological short­

comings (or the related view, that i.t derives from a fall from grace),

and health is possible only when there is a psychological and spiritual

wholeness.

Neither of these extremes is adequate to explain illness. Fortun­

ately, in the healing professions today, there are new emphases on

holistic approaches to the human condition which recognize the inextric­

able interaction between the individual and the psychosocial environment.

New concepts of health as mind-body harmony have emerged. Even the term

"psychosomatic" is considered by some as outdated, suggesting an im­

plicit duality which has more often than not been construed as a pair

of opposites. Today the mind and body are viewed as operating inseparably

in life functions, with dramatic interaction being apparent in diseases

of the respiratory, gastrointestinal, muscular-skeletal, and cardio­

vascular systems. Many theories have been presented to explain this

interaction. There are learning and behavioral theories concerned with

the effects of the total environment upon the individual, and the

cognitive processes which occur in response to those stimuli. Develop­ mental, sociological, ethological and neurobiological theorists have all submitted impressive literature to support the importance of such

respective factors as personality development, adaptation, social stress

and neurobiological substrates as they affect health and illness.

One conceptualization which encompasses all the historic factors of the mind, body and spirit interaction is produced by Ross L. Mooney

(1980). His "Self-in-Situation" model of human functioning is an 6

interactive model, describing intrapersonal processes and moving to

interpersonal transactions, and extending beyond to a rhythmic relation­

ship with the universe in both a physical and a metaphysical sense. At

the center of the entire process is a personal willingness to experience

self— body, mind and emotions— and others, and to formulate meanings

from those experiences, which, in turn, refashion the "inner world,"

the actual composition of body, mind and emotions as well as the "outer

world," environment, and universe.

The model is that of microcosm and macrocosm, addressing the

primary cellular-structural integrity of the individual, moving rhyth­

mically "outward" to the world around and the universe beyond, then

back again, then outward again, ad infinitum. The events or activities

which occur at the intersection of the individual moving out into the

world, and the world moving toward the individual, comprise the settings

for interpersonal experience and the meanings derived from such

experiences.

The paradigm accounts for all factors of the human experience:

cognitive, affective, and physical activity at an intrapersonal level,

and the complex interactions of each upon the other; interpersonal

interaction with others; and transcendent experience to the total

universe. It further identifies four specific conditions which must

be met for health to occur. First, there must be an appropriate openness or closedness to the microoosm and to the macrocosm, to the full range of intrapersonal

and inter-personal experience, and to the ultimate source of life and

meaning in the universe itself. Appropriate openness is the natural condition for

any organism: openness to enhance growth, to embrace. This is-the 7

fundamental condition of belonging where the person identifies the very

parameters of his/her existence.

Secondly, there must be a condition of centeredness, or being. By

means of increasing self-consciousness the human organism must come to

grips with itself, knowing and accepting its cognitions, feelings, and

physiological status. Only when this has been established can individ­

uation occur, which is the process by which the unique and integrated

self evolves, establishes personal boundaries, and moves out more

intentionally into the environment.

Thirdly, there must be a condition of ordering in time, or becoming.

Openness and individuation is not enough; the individual must also come

to find his/her position in time as well as space. The life of the self

in the universe is a belonging, being, and becoming. Experiences are

accumulated and integrated in a process called maturation. The future

is welcomed because its unfolding invites further growth.

Finally, there must be a condition of selecting for fit or befitting.

In his analogy of the tree which interknits the earth and sky, root and

leaf, Mooney writes poetically, even mystically, of the fitting of that which is outside to that which is inside the personality. The organism must take in what is healthy and eliminate what is unhealthy. The

person also has a particular kind of belonging, being and becoming which befits in particular places of space and time, in particular

relationships, and in particular idealogies.

For the purposes of psychophysiological theory and treatment, Mooney would argue that illness should be viewed as something happening within

the person in his or her attempt to be open to the world around. Health occurs when the individual is intentionally committed to being more open

to the world, being centered inconcrete experience, being open to time

(past, present and future), and seeking his or her place of fit:

entering into relationships, celebrating existence, pursuing a lively

curiosity and humor, and in quest of the ultimate truth, beauty and

goodness of the universe. Disease occurs when the entire interactive

process beings to fragment. The person begins to become closed to the world and to the natural reciprocity on the intrapersonal-interpersonal

axis. Egocentricity replaces a sense of befitting in the universe.

Materials, politics and techniques become more important than experience

The personality narrows, and a sense of restricted energy occurs. An existential isolation develops. Stressand confusion begin to be

internalized, manifesting in the form of affective disorders such as depression, phobias, anxiety states, or in the form of irrational and unrealistic thinking, and in physical illness. Subsequent interpersonal activities are thus mediated by the "diseasing" personality, and a downward spiral of negative feedback frequently ensues.

Mooney's theoretical position, as a rationale for the study of the

MVPS population, holds that a search should be made for evidence that disease in this population exists, and that it exists as a total existential event in the total experience of the individual, with specific evidence of the following: conflict both within the individual intrapersonally, and without, interpersonally; a loss of personal power, reflected in an increased concern for external resources of control; an increasing closedness to the world, with a subsequent narrowing and restricting personality; and, finally ultimate anxiety, irrational or confused thinking, and physical disease. To assess these variables, the MVPS and control sample populations were studied with four psychometric measurements. These were as follows

1. A state-trait anxiety measurement, determining if anxiety

is present in the sample population, and if so, does it

exist "outside" of the individual in the stressful environ­

ment as a state, or "inside" the individual as a personality

trait.

2. A locus of control measurement, determining whether the

subject is experiencing personal resources from within, or

feels the source of power is located outside in the environ­

ment, and subsequently experiences a sense of helplessness.

3. A measurement of open or closed-mindedness, determining

whether or not there is a narrowing of experience and a

closing to the world outside.

A. A measure of rationality, determining if cognitive disruption

is occurring to the extent of nonreality-based belief systems

with their subsequent debilitating consequences.

With regards to cardiovascular disease, which is the focus of this study, recent investigations of psychosocial precipitants of heart disease have implicated life stress and anxiety and certain mediating personality variables. It is thus hypothesized that high levels of anxiety may constitute a condition of increased vulnerability to pathogens (Manuck, Hinrichsen and Ross, 1975). In addition, certain personality types may prove to be more susceptible to stress and anxiety than others. If it could thus be demonstrated that the inter­ action of selected personality characteristics and belief system 10 variables exist within a sample population suffering from a specific cardiovascular disease, then this would indicate the need for further study in designing a specific psychotherapeutic intervention for remedial purposes.

The cardiovascular disease which appears to be inflicted upon persons characterized by the specific personality traits and belief systems of this research is MVPS. Over the years, there have been many references to the psychoneurotic origin and/or manifestations of MVPS symptoms. Yet surprisingly little research has been reported in this area. Often statements are made without support, such as

"psychological disturbances occur frequently in patients with mitral valve prolapse" (Gome, 1981, p. 438), or "cardiologists have consis­ tently reported impressions that many patients with this disorder have emotional disturbances" (Flannery and Szmuilowica, 1979, p. 740).

Jeresaty (1973) comments broadly Ion the "frequency of mental disturbances" in this population, but in his definitive volume on MVPS (1979) he devotes only one page to the question of the assumption of psychoneurotic characteristics, stating "psychoneurotic manifestations often precede clinical recognition of MVPS and cannot, therefore, be considered reactive or iatrogenic (p. 44." Flannery and Szmuilowica 1979) published four illustrative case histories linking MVPS to inferiority and narcissism, helpless feelings, grief and guilt, and perfectionism; but the anecdotal nature of these reports lends popular support to a prevalent notion that requires more empirical evidence.

Only two studies were found which document standardized personality assessments of persons diagnosed with MVPS. The first, by Shappel, Orr and Gunn (1974), examined 14 MVPS patients by means of the Minnesota

Multiphasic Personality Inventory (MMPI). Seven of the eight symptom- free patients had normal MMPI's. Of the six symptomatic patients, five had abnormal scores for hysteria and hypochondriasis, four had abnormal scores for depression, psychopathic deviate and schizophrenia, and three had abnormal scores for psychasthenia. While the authors did not claim

to have found a personality precursor for MVPS, they did postulate that an abnormal MMPI in a person with MVPS symptoms portends greater risk for a potentially fatal arrhythmia.

In a second study by Young, Kumpuris, et. al. (1978) the SCL-90 symptom check list, the Profile of Mood States, and the hysterical and hypochondriacal scales of the MMPI were quantified around indices of somaticization (SOM), obsessive-compulsiveness (OC), abnormal inter­ personal sensitivity (A-IS), depression (DEP), anxiety (ANX), hostility

(HOS), phobic anxiety (PHOB),.paranoid ideation (PAR), and psychoticism

(PSY). MVPS patients' mean test scores were significantly higher than the normal control group in SOM, OC, A-IS, DEP, ANX, HOS, PHOB, and

PSY. When compared to the same tests given to a heterogeneous group of psychiatric outpatients, the MVPS mean test scores were similar.

One reason for the paucity of research is that many of the patients previously described in medical literature as suffering from cardiac neurosis would now be classified as MVPS. Wooley (1976) traced

DaCosta's "irritable heart," thought to be a functional hysteric dis- • order, through the subsequent "soldier's heart" and the "effort syndrome, also thought to be functional illnesses during World War I, and the more recent neurocirculatory asthenia complex, anxiety neurosis and effort 12 syndrome, and noted the common symptoms: palpitations of the heart, tachycardia, chest pain, fatigue, anxiety and dizziness. He concluded that MVPS is clearly linked with these conditions, all of which were thought to be largely functional disorders.

A second factor in explaining the dearth of research on MVPS or the popular conception that it derives from anxiety and personality disorders is the confusion on the question of agoraphobia and MVPS.

Pariser, Pinta and Jones (1978) speculated on the possibility that

MVPS was an etiology of anxiety attacks, and in a subsequent study

(1979) of 17 patients diagnosed with panic disorder, found that six were discovered to exhibit MVPS symptoms. This raised questions as to whether or not the panic disorder had an MVPS etiology, i.e., whether such persons were misdiagnosed as having panic disorder when, in fact, their anxiety resulted from their physical condition. Crowe and associates (1980) reviewed this question in a familial study of anxiety neurosis, studying families with and families without MVPS.

However, they found that, although family morbidity risk for panic disorder is very high, it is independent of MVPS.

Other agoraphobic studies of note included Venkatesh and associates

(1980) who examined 21 panic disorder patients and found that eight exhibited echocardiographic evidence of MVPS. Kantor, Zitrin and

Zeldis (1980), who discovered that eight of 25 agoraphobic patients had MVPS, suggested that MVPS might well be a significant etiological factor in panic attacks, the reverse of earlier historical conjecture.

Gorman and associates (1981) found that eight of 16 agoraphobic patients revealed MVPS, but contended that panic disorder is a single entity which is "triggered" by MVPS. 13

Two recent studies support the idea that MVPS patients are highly susceptible to stress. Crowe et. al. (1979) found that eight of 21 patients with anxiety neurosis had impaired treadmill exercise ability, and, remarkably, that all eight patients also suffered from MVPS.

Combs and associates (1980) administered psychological stress to 30 subjects, 15 normal controls and 15 with MVPS, and found that, among the MVPS group, increased anxiety was noted as well as increased heart rhythm. This contrasted with no increased anxiety or arrhythmia among controls.

In summary, the self-in-situation paridigm used as the conceptual framework for this study describes the interpersonal and intrapersonal processes in a manner which accounts for cognitive, affective and physiological factors as well as the conditions for living which insure health. From this generalizable theory, health is evaluated in terms of relative openness, a sense of personal power and an ordered and centered personality which is befitting in particular places of space and time, specific relationships, and in specific idealogies. Instru­ ments to assess these variables were then chosen for the study of the

MVPS sample population, about whom there has been little research.

Definition of Key Terms

Mitral Valve Prolapse Syndrome

Mitral valve prolapse is the most common cardiac valve disorder. It is characterized by a midsystolic and associated systolic murmur which is diagnosed by either auscultation (stethescope), echocardiography (visual configuration), or angiocardiography (roentgenography following 14

intravenous injection of an opaque fluid). For the purpose of this

study, MVPS was operationally defined by the diagnosis of a physician

following auscultatory and echocardiography examination which produced

MVPS evidence.

The condition has been known for over a century, although called

by many different names: irritable heart; soldier's heart; systolic

gallop; neurocirculatory asthenia; billowing posterior mitral leaflet

syndrome; ballooning of the mitral valve; and non-ejection click

(Wooley, 1976). While it was long considered a benign curiosity,

extensive research over the last ten years has generated new interest

and redefined the syndrome as one to be taken much more seriously.

Current information is often incomplete, contradictory, and frequently

controversial.

The mitral valve is composed of delicate leaflets which close

tightly as the result of ventricular pressure. They normally resemble

the folds of a parachute. In this syndrome, however, the valve allows

stretching of the leaflet cusps, resulting in a hooded, prolapsed leaf­

let. As the condition progresses, a myxomatous degeneration occurs with a disruption and loss of normal valvular architecture (Jeresaty,

1979).

A more detailed elaboration of this syndrome is provided in the

following chapter pertaining to the review of literature.

Symptomatic and Asymptomatic Mitral Valve Prolapse Syndrome

Among those persons who have been diagnosed as presenting the pro­

lapsed mitral valve, a variety of physical complaints are reported. The

complaints are chest pains, dyspnea (labored breathing), dizziness, 15 fainting, palpitations, and extreme fatigue. These complaints appear in varying degrees and frequency, ranging from persons who have no complaints or only an occasional awareness of palpitations to those who experience all the complaints over many days of the year.

Reference to the symptomatic or asymptomatic MVPS patient appears in the literature, although frequently no clear distinction between the two is given. For this study the researcher created an index of symptomatology by giving equal weight to three factors: evidence of symptoms, that is, the number of complaints reported; the extent or gravity of symptoms, that is, their frequency in terms of days per year and their effect on work attendance and socialization; and the cur­ rent administration of propranolol to control the symptomatology. Persons who had scores above the median for this index were assigned the rating of symptomatic, and persons who had scores below the median for this index were assigned the rating of asymptomatic.

Stress

Stress is defined as an individual's heightened state of physical and emotional arousal in order to cope with increased demands. It is prompted by either physical or psychological stimuli, and is, accordingly, measured by increased adrenergic states in terms of biochemistry, and by various measures of anxiety. For the purpose of this study, stress was operationally defined as the score on the State-Trait Anxiety Inventory

(Spielberger, et. al., 1970).

Anxiety State

This concept refers to a transitory emotional state or condition characterized by subjective feelings of tension and apprehension, and 16 by activation of the autonomic nervous system. Anxiety states vary in intensity and fluctuate over time as a function of the amount of stress that impinges upon an individual. For the purpose of this study, anxiety state was operationally defined as the score on the State-Trait

Anxiety Inventory (Spielberger, et. al., 1970).

Anxiety Trait

This concept refers to relatively stable individual differences in anxiety proneness. Persons who are high in anxiety trait tend to perceive a larger number of situations as threatening or dangerous than do persons who are low in anxiety trait. For the purpose of this study, anxiety trait was operationally defined as the score on the

State-Trait Anxiety Inventory (Spielberger, et. al., 1970).

External Control

This concept is employed by Rotter (1966) in his Internal-External

Locus of Control Scale. It refers to an event or reinforcement perceived by the individual as being controlled by forces outside his/her control, that is, occurring by luck or fate, and independent of the individual's own actions. For the purpose of this study, external control was oper­ ationally defined as the score on the Internal-External Locus of Control

Scale.

Internal Control

This concept is employed by Rotter (1966) in his Internal-External

Locus of Control Scale. It refers to an event or reinforcement perceived by the individual as contingent upon his own behavior or his own relatively permanent characteristics. For the purpose of this study, internal control was operationally defined as the score on the Internal-External

Locus of Control Scale. 17

Dogmatism

This concept is employed by Rokeach (I960) in his Dogmatism Scale.

It refers to the relative degree of openness or closedness in an individual's belief system. For the purpose of this study, dogmatism was operationally defined as the score on the Rokeach Dogmatism Scale.

Limitations

The MVPS subjects under study were medical patients referred to the investigator by physicians affiliated with a large midwestern university hospital in a large midwestern city. They consisted of white, upper- middle class individuals who agreed to the investigation. The subjects composing the control group under study were selected randomly from a list generated by the researcher from persons who presented themselves to physicians for routine health care, and who appeared to exhibit socioeconomic and life-style characteristics resembling the MVPS patients.

Generalizations drawn from the study were limited to sample pop­ ulations of similar characteristics. It was not possible, therefore, to generalize to other populations of MVPS patients where socio-economic and life-style characteristics are dissimilar. In addition, the study was not designed to identify persons who might be asymptomatic but who have never been told of this fact. Apparently many physicians identify a mid-systolic murmur during routine physical examinations, but are reluctant to inform such patients who have no complaints, believing that such information would unnecessarily alarm them.

A second limitation was that all control subjects were chosen on the basis of having indicated no previous history of cardiovascular 18

disease. They were not asked to complete the second page of the Personal

Data Questionnaire where the extent of MVPS symptomatology was assessed.

It is possible that there were persons in the control group without

evidence of MVPS who did periodically suffer from one or more of the

MVPS symptoms: chest pain, dyspnea, dizziness, fainting, palpitations,

and episodes of extreme fatigue.

A similar limitation was that the study was restricted to a comparison

of persons with MVPS to those not known to have MVPS, and a comparison of

persons designated MVPS symptomatic to those designated MVPS asymptomatic.

It was assumed that from this study it would be possible to recommend the subsequent examination of the MVPS asymptomatics in greater detail, taking measurements to specifically compare the MVPS asymptomatics with the control group, and to look at other life style characteristics of the

MVPS asymptomatics for clues as to their success in adapting to their condition without severe and frequent physical distress.

Finally, this study was limited to measurements by the instruments chosen for their applicability to the sample population. A wide range of other characteristics exist in the sample population which could have been examined by the use of other instruments. It was hoped that

the foci of this study would serve as guidelines for subsequent research and treatment.

Summary

Chapter I has provided a brief overview of stress and its association with psychophysiological disorders, with particular attention given to a cardiovascular disorder (MVPS) which appears to be the result of a cognitive-affective-physiological interactive process. The research

problem and questions were posed, followed by a statement of need for

further empirical research in MVPS. The rationale for the study was

established in the context of the historical mind-body dialogue,

building on the specific model of Ross L. Mooney. Terms have been defined and limits stated. Chapter II presents a review of relevant literature. Chapter III describes the methodology employed to execute

the research, the instruments, and the method of analyzing the data.

Chapter IV presents the findings of the research, and Chapter V contains

the summary, discussion and recommendations for further research and

treatment. CHAPTER II

REVIEW OF THE LITERATURE

Introduction

In addressing the relationship of selected personality characteristics and personal belief systems to MVPS, the review of the literature needed to encompass many specific aspects of the mind-body interaction, of the specific personality characteristics and personal belief system constructs, and of MVPS. This chapter, therefore, was developed around the following sections: a historical review of the mind-body issue; contemporary theories of stress; stress and cardiovascular disease; personality factors and cardiovascular disease; state and trait anxiety; locus of control;

MVPS; and a summary.

Historical Review of the Mind-Body Issue

The conceptualization of the mind and body and how the two interact has been considered by all ages of mankind. How to heal depends, to a significant extent, on the resolution of this question.

Historically, the very act of posing the question has tended to create a dichotomy which defied resolution. In primitive societies (prior to 2500 B.C.) a pervasive, unseen spirit was believed to be the prime force determining all events, and disease was simply viewed as an evil

20 21 or enemy spirit entering into the body of the individual, acting against him or her. Trepanation, the boring of holes in the skulls of sick persons to release the evil spirit, has been dated by archeologists to as early as 10,000 B.C. (Kaplan, 1976).

Early Egyptians also viewed disease and death as forces coming into the body from the outside. They thought of the soul, meaning the person's intelligence and emotions, as resting in the heart; and all nerves, mus­ cles, arteries and veins served to connect the heart to all working parts of the body, and to the orifices where the spirit entered and left the body. Egyptian physicians, however, were not totally passive to the will of the spirits; they compiled medical observations and recorded treatments for various illnesses.

The Babylonian and Assyrian civilization was a time when medicine was dominated by religion, and suggestion was the major tool of treatment.

The sick man was the sinner; the ultimate source of disease was the gods; a person in pain was disgraced; and the physician was the priest, who prayed and sacrificed until the sin was lifted and health was restored.

Sigerist (1961) states that disease to this civilization was "psycho­ somatic in all its aspects" (p. 132).

In the early Hebrew civilization, disease was also punishment suf­ fered for the sin of disobedience to God and his laws. For group sin, the consequence was pestilence or plague. Like the Egyptians, the

Hebrews considered the heart to be the seat of the soul, intelligence and will, and the Old Testament is rich in references to the prayers of the people for a new heart or a clean heart. Righteousness was the path to health. The influence of this concept on both Jesus and subsequent

Judaeo-Christian civilization is profound. 22

In classical antiquity, a philosophical interest in the interaction of the mind and body was translated into practical terms. Cicero was reported to have complained about the concentration on purely physical explanations of illness: "Why should the art of curing and preserving the body be so much sought after and why should the medicine of the mind be so neglected?" (Ramsay, Wittkower and Warnes, 1976). Plato, too, was critical of the overly narrow view of patients and illness:

So neither ought you to attempt to cure the body without the soul, and this . . . is the reason why the cure of many dis­ eases is unknown to the physicians of Hellas, because they are ignorant of the whole, which ought to be studied also; for the part can never be well unless the whole is well (Jowett, 1952).

The Greeks were impressed by Egyptian medicine. Although priest- physicians passed proven remedies onto their sons, and even established early medical schools, still it was the gods who brought disease, and the gods who brought healing. With Hippocrates, however, temple medicine was replaced by a new and more naturalistic and rationally-based medicine.

These contemporaries of Plato introduced the dynamic concept of the per­ son as a physical being, infused with an immortal spirit (psyche) and im­ bedded in a metaphysical field. Hippocrates stated it succinctly: "In order to cure the human body it is necessary to have a knowledge of the whole of things." Aristotle wrote at length of the effects of the emotions on the body.

It was Galen, however, who sought to synthesize the Platonic ideal­ ists and the atomistic materialists in a confusing eclecticism that be­ came the foundation of European medicine for the next 1,000 years. In essence, he postulated that disease is caused by humoral disturbances in the fluids of the body, although there was a concomitant problem with 23

the basic physiological principle of life, spirit (pneuma). Thus he would treat a condition as having two causes: the physical cause of over­

balance of black bile, and the psychic cause of inordinate desire (Watson,

1978).

In the middle ages, Galen's holistic interplay between psyche and soma was the accepted view of the nature of things, including health and

illness, in centers of learning. In the world abroad, however, mysticism

and religion returned to dominate medicine. Concurrent with the growth of the Christian church was the common belief that spiritual powers, especially demons, witches and sinful acts, produced disease. The cause was both within and without. Prayers were designed for the inner disease, and the touch of a relic for the outer disease.

With the Renaissance came dramatic new interest in the natural sci­ ences and their application to medicine and behavior. Morgagni studied

tissue from autopsies to demonstrate that a disturbed organ could cause disease and death. As knowledge of the soma proliferated, the psyche fell into scientific disrepute, being discussed only by philosophers. But among philosophers, the old mind and body controversy was resurrected with new vigor and clarity.

It was Descartes who postulated that body and mind were separate entities which could now be interrelated. He saw the mind as being out­ side the physical order of matter and in no way derived from it. However, mind and body did interact, each affecting the other. It was the mind which directed the vital spirits that pass from the heart through the brain to the muscles. The bodily locus, or point of contact, for this interaction was said to be in the pineal gland. Passions— perceptions, 24

feelings and emotions— were the consequence of the body impacting upon

a passive mind.

While Cartesian dualism occupied philosophy for another two centuries,

scientific progress continued in the 19th and into the present century.

Virchow made clear that the origin of disease occurred within the cell.

The somatic or materialistic tenor of the 19th century was characterized

by Thomas Huxley (1900) who believed that mental processes as such had no

causal significance but were simply the product of somatic activity.

Earlier in the century, however, the new voices of psychosomatic inquiry

were to be heard. Reil, in 1803, produced the first systematic treatise

on psychotherapy, clearly addressing the mutual interaction between

psychological and physical events in the organism (Alexander and Flagg,

1965). Carus, a German obstetrician, discussed the concept of the un­

conscious and attempted to bring together physical and mental ailments in

a synthesis of unconscious etiology. And the eminent London physician

Daniel Tuke compiled an exhaustive volume entitled Illustrations of the

Influence of the Mind upon the Body (1884) in which he concluded:

We have seen that the influence of the mind on the body is no transient power; that in health it may exalt sensory functions, or suspend them altogether; excite the nervous system so as to cause the various forms of convulsive action of the voluntary muscles, or repress it so as to render them powerless; may stim­ ulate or paralyze the muscles of organic life, and the processes of Nutrition and Secretion— causing even death (Quoted from Pelletier, 1977, pp. 40-41).

Using Freud's insight, a number of scholars in the early days of the

present century tried to expand the interrelationship of psyche and soma.

Abraham (1927) and Ferenczi (1926) pursued the idea of the conversion

reaction to organs under control of the autonomic nervous system. Franz

Alexander (1950) believed that a specific stress expressed itself in the 25 specific response of a predetermined organ. Flanders Dunbar (1954) took

Alexander's ideas and developed them into theories of the whole person­ ality. Dunbar argued that specific personality profiles were etiological- ly associated with specific diseases.

The important work of Pavlov (1927) demonstrated that needs, hunger and fear could evoke severe, immediate and persistant physiological dis­ turbances within the nervous system and its innervated organs. Breur and

Freud (1895) and later Ferenczi (1926) postulated that specific unconscious content could be symbolically expressed in the "body language" of somatic symptoms. Freud, however, also noted that there were mechanisms relative to unconscious attitudes that might alter physiological functions without symbolizing any definite psychic or "hysteric" meaning. He maintained that no mental process, even "pure" thought, is free from some influence on the body.

At the turn of the century, William James and Carl Lange argued that the actual experience of emotion was secondary to perception of bodily changes. James insisted that "emotion disassociated from all bodily feeling is inconceivable" and that all emotional changes could be accounted for by variation in bodily symptoms, i.e., activity (James, 1891).

Walter Cannon (1927) and Philip Bard (1928) took James and Lange to task, contending that emotions could be experienced without the occurrence of bodily changes. Cannon specified that the thalamus was the central part of the emotional pathway which, if triggered by sensory stimuli or cortical impulses, led to both the experience of emotion and its bodily changes. i The James-Lange versus Cannon-Bard argument has become of renewed interest because of research into the "beta-blockers" and a resulting controversy over the site of their purported antianxiety activity, i.e., being either

local-specific or central-systemic.

In summary, conceptualizations of the mind and body have perpetuated

a dualism from ancient to modern times, with only recent scholarship giving new attention as to how the two work together.

Contemporary Theories of Stress

The notable advances in psychophysiological theory in contemporary

society have resulted from empirical studies which demonstrate the inter­

action of mind and body. Theory has come to be operationalized.

A transitional figure between the recent past and modern times is

Hans Selye, a pioneer in the study of stress for over forty years. He

has employed two definitions for stress: a popular one, "the rate of

wear and tear in the body," and an academic one, "the state manifested by

a specific syndrome which consists of all the nonspecifically induced

changes within a biologic system" (1956, p. 41A). He perceived that all

living things are endowed with innate stress alarms to insure effective

coping with the environment. Not to be confused with nervous tension,

stress was deemed positive (eustress) if it was curative and pleasantly

stimulating, or negative (distress) if it was destructive or unpleasant.

Selye's General Adaptation Syndrome (GAS) states that biological

adaptation is triphasic in nature, providing optimal and effective

response to stress for as long as the organism can tolerate it. The

first stage is the alarm reaction: the organism is activated to counter

a noxious agent, during which time the adrenal cortex is enlarged and

corticoid hormones are increased. If stress continues, a second stage 27

of resistance occurs, providing primary attention of the organism to the noxious stressor with a concurrent decrease of attention to other stimuli. However, if adaptability has not occurred, ultimately a third stage of exhaustion ensues, especially if the stressor has been severe and prolonged. At this stage morbid symptoms appear, and if there is no ultimate relief, death results (Selye, 1980).

Of particular interest to this study is the attention Selye has devoted to the GAS mechanism. It is assumed that the initial alarm is conveyed by the only two coordinating systems which connect all parts of the body with one another, the neurological and vascular systems. It is known that the adrenals activate into the bloodstream at this time which, in turn, triggers the secretion of corticoids. Catecholamines are subsequently liberated to activate mechanisms of general adaptation.

The significance of this biochemical aspect in adaptation to stress is not lost in this research when one considers the recent evidence that

MVPS patients reveal high plasma catecholamine levels (Boudoulas, et. al., 1980).

While on the subject of the adrenocortical mechanism in stress, the work of Mason (1976) should be noted. He demonstrated that continued, prolonged stress led to a gradual attitude of helplessness and loss of control as measured by the excessive urinary excretions of 17-hydroxy- corticosterone (17-0h-CS). By contrast, among volunteers who fully understood the nature of exhausting exercise, there was no change from normal 17-0h-CS excretion. This lends weight to the association of stress and helplessness among MVPS patients, and the biochemical evi­ dence for this association. 28

The basis of holistic approach, or "psychosomatic medicine" developed

as a result of clinical observations and humane concern for the sick

individual. Attempts to humanize medicine reached a peak after World

War II when hopes were raised that diseases previously considered strictly

"medical" were found to have psychological explanations (Forman, 1979).

However, this only served to feed the confusion about mind and body

interaction (Graham, 1972). In the popular mind, the term "psychosomatic"

only reinforced a dichotomy between mind and body. In fact, as Graham

has suggested (1967, 1972), the "psychological" and the "physical" are

the names of different languages that are applied to behavior in persons.

Neither should be construed as more "scientific" than the other.

This position was most recently upheld by Latimer (1979) who pro­

vided classifications for eight various modern theories which attempt

to account for mind and body interaction. The Symptom-Symbol Theory is

the traditional psychoanalytic view that somatic afflictions may be

caused by specific unconscious psychological conflicts that are defen­

sively transformed into symbolically significantly somatic symptoms.

The Personality Profile Theory is the view of Flanders Dunbar (1943)

that specific personalities are prone to specific illnesses. Maternal

Personality Theory is a developmental variant of the Personality Profile

Theory, maintaining that the disorders which ensue in a personal history

derive from the specific interaction which has occurred between the

patient and the mother. The Specific Emotion Theory is based on the work of Alexander (1950), and holds that there is a specific emotional

reaction which elicits specific parasympathetic or sympathic concomitants, which then affect specific visceral organs. The Specific Attitude Theory, 29

a position found in the work of Grace et. al. (1949) and Grace and Graham

(1972), states that a particular attitude held during a. conflict determines

the kind of psychosomatic symptoms that develop. The General Emotional

Arousal Theory contains the work of Selye (1976) and Mason (1975),

previously discussed. In essence, the theory holds that physiological

concomitants of anxiety will be identical regardless of the nature of the threatening situation. The Constitutional Vulnerability (Weak-

Link) Theory posits that the most vulnerable organ of the individual becomes malfunctional or is damaged in response to a stressful situation.

Prototypic studies for this theory were performed by Dovison and Wasserman

(1966). And finally, the Individual Response Specificity Theory synthe­ sizes the General Emotional Arousal Theory and the Constitutional-Vul- nerability Theory, stating that individuals tend to show highly charac­ teristic and consistent physiological patterns of emotional arousal.

These are evoked by a wide range of stimuli but appear in consistent and specific psychophysiological symptoms. Grinker (1966) is considered a leading spokesman for this position.

Levi and Kagan (1971) modified Selye's ideas to give primacy to psychological factors in the mediation of disease. They suggested that life changes evoke a physiological stress response which prepares the body for the physical activity of coping. Holmes and Rahe (1967) have achieved a degree of popularity for operationalizing this notion in a scale to determine an individual's chances to become ill because of current life stress. 30

The person-environment question influenced the issue of mind-body

interaction. In this school of thought, stress is viewed as the result

of a lack of fit between the person and the environment (Cox, 1978; Pine,

1980). Individual perception is posited as a critical factor in the

experience of stress, contingent upon how the individual perceives the

demands of the environment and his/her ability to cope.

References to perceptual factors in stress lead inevitably to the

relationship of cognitive factors in general to the stress experience.

Lazarus and Opton (1966) and Lazarus (1966) contended that cues of a

given situation are interpreted as a threat to the individual by the

cognitive process of appraisal. Such appraisal is made on the basis of

the assessed harm-producing power of the situation, and secondly, on the

"psychological structure" of the individual, meaning his/her motives,

general beliefs about the environment, and intellectual resources. Beck

(1972) argued that the actual stress situation is exaggerated by the

victim of psychophysiological disorders, that is, by the operation of

cognitive factors, which clearly outweigh the realistic external stresses.

It is this overestimation of the individual's coping capacity which

produces such high levels of anxiety and autonomic arousal.

New advances, then, in the identification of the physiology of stress revived the mind-body debate. A number of new and older theories were forthcoming in response to a new interest in psychophysiological disorders.

Stress and Cardiovascular Disease

Although the literature on stress does not usually make the clear

distinction, in fact it refers to stressors which contribute to the "wear 31

and tear" on the organism with concomitant dysfunctions on the one hand, but also to crippling and life destroying diseases as well. The following is a review of the literature pertaining to serious disease which is stress induced.

Actual stress diseases are enumerated in most of the literature as falling into four categories: diseases of the cardiovascular, gastro­ intestinal, muscular-skeletal, and respiratory systems. Pelletier (1977) calls these diseases the major medical problem of post-industrial nations, long surpassing epidemic levels.

Concerning cardiovascular disease, which is the subject of this

study, a general consensus pervades all psychophysiological literature

as to the gravity of stress-induced cardiovascular disease. However,

there are a few specific studies which have examined this issue more

closely.

Harold Wolff (1968) has for years indicted stress in relation to

cardiovascular disease. He has noted the variety of arrhythmias, in­ cluding paroxysmal atrial tachycardia, extrasystoles, atrial fibrillation,

and the more serious paroxysmal ventricular tachycardia which may occur

in association with troublesome events in the day-to-day experience of

individuals who have no other detectable evidence of heart disease.

Stewart Wolf (1958) conducted the provocative study of actual sudden deaths as the result of symbolic stimuli. Such persons were literally so terrified by "voodoo-like" stimuli that their hearts stopped beating and death resulted. The sudden death following the bite of a nonvenomous snake was also indicative of the power of stress to induce massive sym­ pathetic and parasympathic discharges. Manuck (1975) concluded from his 32 review of psychophysiological disorders that high levels of life stress eventuated in corresponding increments in anxiety which, when elevated, created within the organism an augmented vulnerability to pathogens.

Russek and Zohman (1978) set out to study 100 coronary patients.

They found that prolonged stress had preceded the coronary attack in

91% of the coronary group. When compared to controls, it was apparent to these researchers that high stress groups were far more prone to coronary disease than were low stress groups. Hanes (1975) correlated coronary-prone individuals with those engaged in a significant life change.

However, the most comprehensive research to date on this problem has been performed by Meyer Friedman and Ray Rosenman, cardiologists at Mount

Zion Hospital in San Francisco. They began to recognize well-defined behavioral patterns among their heart patients, noting their common tendency to be impatient, aggressive, highly goal-oriented, ambitious, restless, and always under the pressure of time. They termed this pattern

"Type A" behavior, and initiated further research. A "blind" study com­ paring blood lipids and overt behavior patterns enabled researchers to

"predict" that subjects would succumb to heart disease (Rosenman, Friedman et. al., 1964). This, in turn, stimulated further efforts to create a standardized psychological test which might identify coronary-prone behavior (Jenkins, Rosenman and Friedman, 1967).

In parallel developments both in Europe and America, numerous studies were published in the following years pertaining to socio-economic factors and cardiovascular disease. The foci of these studies included personal habits, diet, nature and place of employment, social status, race, level of education, religious affiliation, ethnic background, marital status, and 33

social mobility (Jenkins, 1971). The psychological implications of these

studies were clearly noted.

In research that addressed itself to specific anxiety and stress fac­

tors in cardiovascular disease, the scene was one of proliferation. Ostfeld

and his colleagues (1964) had previously correlated the hypochodriasis (Hs)

and the hysteria (Hy) scales of the MMPI to persons who were soon to have

angina pectoris. Many retrospective studies of patients with coronary

disease revealed elevated scales on the MMPI, usually hysteria (Hy),

hypochodrias (Hs), depression (d ) and hypomania (Ma). It was generally

suggested that before their illness, patients with coronary disease

differ from persons who remain healthy on the "neurotic triad" of the

MMPI: Hy, Hs, and D (Lebovits, et. al., 1967). Cattell’s 16 PF test

was given to Western Electric workers where it was found that those in

whom coronary disease was to develop (angina pectoris and myocardial

infarction) were more suspecting and jealous and had greater feelings of

inner tension (Ostfeld, 1964). Research by Caffrey with Benedictine

monks (1969), Finn and her colleagues with Irish patients (1966) and

Medalie (1968) with Israelis were consistent with previous findings that

coronary disease patients score higher on neurotic indices than do controls.

Most of the above studies have the limitation of being retrospective.

Critics have noted that the anxiety, tension and neuroticism observed may well be reactions to the coronary event rather than the precursors of it.

Paffenbarger and his colleagues (1966), however, found eight significant

precursors of coronary disease among male college graduates. Years before, the men with fatal episodes of coronary disease scored higher

than normals on an anxiety checklist of ten items. This supported the 34 hypothesis that anxiety and tension variables precede as well as follow overt clinical coronary disease.

Other studies in the late 1960's which correlated heart disease with stress factors were performed with attention to the following selective factors: death of a close relative (Rees and Lutkins, 1967; Parkes et. al.f 1969); loss of prestige (van Heijningen and Treurniet, 1966); oc­ cupational stress and work overload (Bruhn et. al., 1968); and persistant life problems and everyday worries (Wynn, 1967); difficulty with relax­ ation (Russek, 1967); and increased adrenergic responses with emotional events (Nestel et. al., 1967; Bellet et. al., 1969; Sigler, 1967).

It was not long until an obvious question arose: is there a specific coronary-prone personality type? The overt behavioral syndrome charac­ terized by extremes of competitiveness striving for achievement, ag­ gressiveness, haste, impatience, restlessness, hyperalertness, explo­ siveness of speech, tenseness of facial musculature, and feelings of being under the pressure of time and the challenge of unending responsi­ bility was quickly received by both popular and scientific audiences as having a kind of intuitive validity (Jenkins, 1971b). It made sense.

Personality Factors and Cardiovascular Disease

Friedman (1969) reviewed the work of Osier, Dunbar and others who have suggested that there was a coronary-prone behavior. He re-examined the results of the Western Collaborative Group Study, the mid 1960's analysis of 3400 men known to be free of coronary disease and who were rated Type A, that is overt behavioral syndrome, hypothetically coronary- 35

prone, and Type B, the opposite behavioral syndrome (Rosenman et. al., 1964;

Rosenman et. al., 1966). He noted that Type A men had 6.5 times the in­

cidence of coronary disease as Type B men in the age decades 39-49 years,

and 1.9 times the incidence of Type B men in the age decades of 50-59.

Behavior Type A was significantly associated with incidences of acute

myocardial infarction and angina pectoris (Rosenman et. al., 1970) as

well as exhibiting a greater tendency for recurrence of myocardial infarc­

tion (Rosenman et. al., 1967). Bortner and Rosenman (1967) developed an

instrument for the measurement and prediction of Type A behavior and

Zyzanski and Jenkins performed and replicated a series of factor analyses

on a series of items created by Jenkins, and found that speed and impatience., job involvement and hard-driving were heavily loaded as discriminate

factors (Zyzanski and Jenkins, 1970; Jenkins, Zyzanski and Rosenman,

1971a).

Friedman and Rosenman (1974) ultimately stated their position that if

there is not, in fact, a personality which is coronary-prone, then at

least it must be said that there is a characterologically predisposed

individual who will react to a stressful situation in a predictable

manner, which is often pathogenic. In their popular book Type A Behavior

and Your Heart, they not only characterized the Type A personality as

competitive, impatient, preoccupied with time, aggressive and extroverted,

and achievement-oriented, but they also noted that serum cholesterol

levels vary directly with the intensity of the Type A behavior pattern.

This was an unequivocal statement of personality characteristics as a

causal factor in organic disease. 36

In more recent studies, Glass (1977) compared Type A college men with

Type B college men and found that Type A men push themselves harder on

treadmill tests, experience loss of control as more threatening, and are

more likely to become passive and surrender when personal control cannot

be re-established.

Kobasa (1979) generalized to a broader cardiovascular population,

suggesting that the individual who has a greater sense of control over

his life will remain healthier when under stress than those who feel

powerless. Coelho, Hamburg and Adams (1974) contended that persons who

feel committed to a belief system will remain healthier than those who are alienated. Moss (1973) noted that persons who feel positively about life change are catalysts in their environment, better motivated for endurance, and experience less stress. In each instance it would-appear

that persons who have a sense of control or understanding of the meaning of their stressors are less likely to suffer than those who feel power­ less and confused by their stressors.

Glass (1977) gave considerable attention to loss of control as a specific characteristic of the Type A personality. He reported negative correlations between the Jenkins Activity Survey, a questionnaire designed for large scale screening of Type A persons (Jenkins et. al., 1967) and the Rotter Internal-External Locus of Control Scale (Rotter, 1966). He suggested that, although Type A subjects may show a need for control, they do not report that they have achieved greater control, and actually display slight decrements in perceived inner control.

Krantz, Glass and Snyder (1974) tested this concept with a controllable stressor, noise. Half of the subjects could terminate the noise with a 37

switch (high control) and half had no control over termination(low-control).

Following this stress, all subjects completed a reaction-time task. Type

A subjects performed better after they were in the low-control stress,

whereas the Type B subjects did better after high control conditions. The

authors reasoned that the uncontrollable stressor motivated the Type A

subjects to work harder in the reaction-time task to reassert control.

Glass (1977) concluded that the crucial ingredient in the process by

which Type A individuals develop greater risk for heart disease is their

struggle to exert control over uncontrollable situations, then to finally

resign themselves to learned helplessness after repeated failures. He

amplified his conclusion with evidence that the cycle of enhanced coping

and subsequent resignation is characterized by extreme fluctuations in

catecholamine secretions, a critical piece of evidence linking this person­

ality type to increased proneness to coronary disease (Goldband et. al., 1979).

It would appear, then, that Type A individuals may be at increased

disease risk because of their hyperresponsivity to stress. The question

of further debate is whether this represents a predisposition of the

individual to manifest anxiety, trait anxiety, or whether the incidence

of beta-adrenergic activity is an appropriate response to a transitory

state, state anxiety.

State and Trait Anxiety

The twentieth century has been termed the age of anxiety. Rollo May

in his classic volume The Meaning of Anxiety (1950) presents a penetrating

analysis of basic historical and cultural trends in Western civilization which have contributed to the emergence of explicit and pervasive anxiety 38

as a salient characteristic of our time. The continuing threat of nuclear destruction, the shock of sociological and technological change, the experience of estrangement and alienation in the new urban society, and

the increasing competitiveness of an achievement-oriented society are but a few of the factors which serve to induce feelings of helplessness, height­ ened vulnerability, and progressive feelings of insecurity— or anxiety.

In 1950 Hoch and Zubin introduced a symposium at the American Psycho- pathological Association with the statement that although anxiety is recognized as the most pervasive psychological phenomenon of modern times, and the chief symptom in neuroses and functional psychoses, there is, nevertheless, "little or no agreement on its definition, and very little, if any, progress in its measurement" (1950, p. v). Subsequent research has led to a more comprehensive view of the nature of anxiety, particularly bringing together the current views of psychologists with the previous work of pioneeers in a state-trait conception.

Freud conceptualized anxiety neurosis as a discreet clinical . syndrome, distinguished from neurasthenia. He regarded anxiety as "some­ thing felt," an unpleasant affective state or condition characterized by apprehension and efferent discharge phenomena (1924). He noted such specific symptoms of the latter as heart palpitation (transitory arrhyth­ mia, tachycardia), disturbances of breathing patterns ("nervous dyspnea"), sweating, tremors, vertigo, and other physiological and behavioral man­ ifestations. He .distinguished this state from anger, sorrow or grief by virtue of particular qualities of dread (1936). There were personality factors involved, deriving from the developmental history of the individual and the unique way he/she repressed libidinal energy. He 39

differentiated between objective anxiety and neurotic anxiety largely on

the basis of whether the source of the danger was from the external world

or from internal impulses. Objective anxiety was regarded as synonomous

with fear, involving a referrent to a perceived danger in the external

world. Neurotic anxiety was often not consciously perceived because it

had been repressed, and was deduced from symptoms of apprehension and

physiological arousal.

Mowrer (1939) published an article in which he formulated Freud's objective or external anxiety in the terminology of stimulus-response learning theory. Mowrer contended that anxiety and fear were synonymous and defined fear as the conditionable portion of the pain reaction. Ac­ cording to classical conditioning, whenever any unconditioned pain stimulus was paired with any number of previously neutral stimuli, a wide range of objectively nondangerous circumstances could evoke condi­

tioned fear reactions. This was consistent with the work of Pavlov

(1927) and, later, with the research of Gant (1942) in his work with dogs, Masserman (1950) in his work with cats, and Liddell's sheep (1944).

The synthesis of psychoanalysis and learning theory was carried forward in the 1950's. Janet Taylor (1951) extended experimental research on anxiety to human subjects by selecting items from the MMPI for the construction of the Manifest Anxiety Scale (MAS). The MAS was the first operational instrument for research in anxiety and was employed in over

2,000 studies in subsequent years (Spielberger, 1975). This led to the

Spence-Taylor theory of emotionally based drive (Spence, K.W., 1956, 1958;

Taylor, 1956). This theory proceeded from the assumption that the strength of a given response is a multiplicative function of the total effective AO drive state and habit strength, that is, the number and strength of the specific habit tendencies that are elicited in a given situation. Among the researchers of the drive theory was Charles Spielberger. Spielberger had been impressed by the work of Schachter (1966) who had presented persuasive evidence that emotional states consist of two major components: physiological arousal and socially determined cognitions, and by the work of Cattell and Scheier (1958, 1961) who, through factor analysis, iden­ tified two distinct anxiety factors: trait, or chronic anxiety, which they defined as a relatively permanent and stable characteristic of people, and state, or acute anxiety, which they defined as a transitory condition which varies from moment to moment.

Spielberger (1966a; 1966b; 1972a; 1972b; 1975) suggested that much of the conceptual and empirical confusion with respect to anxiety results from the failure to distinguish with clarity between trait and state anxiety. He subsequently made important distinctions between these two constructs. He stated that anxiety as an emotional state (A-State) is characterized by subjective, consciously perceived feelings of tension, apprehension, and nervousness accompanied by or associated with activation of the autonomic nervous system. These states may vary in intensity and fluctuate over time as a function of the stresses that impinge upon the organism. On the other hand, trait anxiety (A-Trait) refers to relatively stable individual differences in anxiety proneness, such as the tendency to respond with A-state under stress. A-Trait dispositions are reactive and remain latent until activated by the stress associated with a specific danger situation. In practical terms, persons high in A-Trait are prone to manifest more intense levels of A-State arousal in ego-threatening situations than will low A-Trait individuals. Al

Spielberger supervised the development of the State-Trait Anxiety

Inventory (STAI) which has subsequently been widely employed as a research tool (Spielberger et. al., 1970; Dreger, 1978; Katkin, 1978). There is now more published research on the STAI and more ongoing research with the STAI than on any other commercially available anxiety inventory.

The A-State and A-Trait conception hinges on another factor, however, namely the cognitive appraisal of a situation as being unpleasant or threatening. Through both sensitive and cognitive feedback mechanisms, the A-State reaction serves as a signal to initiate a behavioral sequence designed to avoid or deal directly with the threatening situation. The cognitive process in the A-Trait is the reflection to past experiences that in some way determines individual differences in anxiety proneness, that is, in the disposition to see certain types of situations as danger­ ous and to respond to them with A-States.

Lazarus and Opton (1966) and Lazarus and Averill (1972) have addressed the cognitive mediation of state and trait anxiety. The core of their analysis is that the individual is an evaluating creature, searching the environment for cues for effective coping and adaptation. Any given stim­ ulus is embedded in a context of past experience, environmental (ecological) conditions, and the dispositional variables of the individual, meaning his/ her personality traits, beliefs, attitudes, and coping resources. Anxiety must be viewed as an emotion based on the appraisal of threat, an appraisal which derives from symbolic, anticipatory, and uncertainty factors. Thus the cognitive mediator can be viewed as accounting for the appraisal of a stimulus as fearful or safe, the meaning given to separation and loss,

the appraisal of physiological arousal, the meaning of anticipation and 42

deprivation, and a continuing list of everyday experiences which require

appraisal and response.

Schachter (1966) underscored the physiological arousal and motor

action as the crucial perception from which anxiety is initiated. In

terms of the feedback from physiological changes in the James-Lange

tradition, he stated that these changes are understood and labeled in accordance with perceived social contexts. In his earlier experiment

(1962), subjects who were injected with epinephrine reacted with either anger or euphoria, depending on the social setting in which they were placed. Schachter has interpreted this to mean that individuals label arousal states, depending on how he/she understands or explains them, and it is this labeling process which is at the heart of the anxiety-creating mechanism. So, both cognitive and physiological feedback potentiate the labeling process.

Spielberger (1966a) has constructed a configuration which displays the factors in anxiety (See Appendix A). The complex interaction of

A-State and A-Trait, as distinguished from the external stimulus condi­ tions which evoke such conditions, are cognitively appraised. Both sensory and cognitive feedback influence the appraisal. A subsequent behavioral sequence is initiated, based on all factors.

It is apparent, then, that recent studies by Spielberger and others have addressed the historic ambiguity which has existed on the subject of anxiety. The important differentiation between state and trait anxiety has been widely accepted by scholars. Locus of Control

Locus of control is a major descriptor in social psychology abstracts and indices, revealing that a vast body of research has accumulated around this concept. Simply defined, it refers to whether or not an individual believes he/she has some significant control over personal destiny. Those who believe they have some control are designated "Inter­ nals," that is, the control is within themselves. Those who believe that their destinies are in the hands of fate, chance, luck, or powerful others outside of themselves are called "Externals."

The concept evolves from social learning theory, being formulated

by J.B. Rotter. Social learning theory builds on the belief that social

behavior is clearly learned and purposeful. Rotter made two important

assumptions, summarized in his words: "The unit of investigation for the

study of personality is the interaction of the individual and his mean­

ingful environment" (1954, p. 85); and "The occurrence of a behavior of

a person is determined not only be the nature of importance of goals or

reinforcements but also by the person's anticipation or expectancy that

these goals will occur" (1954, p. 102). Interpersonal relationships and

expectancies are regarded by social learning theorists as prime deter­

minants of behavior; people behave in accordance with their expectations.

Success or failure serves as a reinforcer to this learning.

Locus of control, then, is a situation-specific expectancy. Belief

in personal control is both a general disposition that influences indi­

viduals' behavior across a wide range of situations, and also a rather

specific belief that may apply to a limited number of situations. 44

For purposes of this research, interest is primarily centered in the common conclusion of so many scholars that persons who demonstrate external locus of control are handicapped by their sense of helplessness and are more prone to physical and emotional disorders, behavioral problems, and disrupted interpersonal relationships (MacDonald, 1972). Richter (1951) found external locus of control the most plausible cause of "voodoo" deaths. Bettelheim (1979) deduced that prisoners in Nazi concentration camps who had the most pronounced sense of personal helplessness and lack of control not only became apathetic, but more readily succumbed to death.

In experiment after experiment with animals, it has been demonstrated that aversive events can be tolerated with minimal disturbance if the animal has the advantage of controllability and predictability; but if either of these factors are absent, behavioral disturbance usually ensues (Glass and Singer, 1972; Phares, 1976; Seligman et. al, 1980).

Rotter (1966) defines internal-external locus of control in the following way:

. . . an event regarded by some persons as a reward or reinforcement may be differently perceived and reacted to by others. One of the determinants of this reaction is the degree to which the individual perceives that the reward follows from, or is contingent upon, his own be­ havior or attributes versus the degree to which he feels the reward is controlled by forces outside of himself and may occur independently of his own actions . . . A percep­ tion of causal relationship need not be all or none but can vary in degree. When a reinforcement is perceived by the subject as following some action of his own but not being entirely contingent upon his actions, then, in our culture, it is typically perceived as the result of luck, chance, fate, as under the control of powerful others, or as unpredictable because of the great complexity of the forces surrounding him. When the event is interpreted in this way by an individual, we have labeled this a belief in external control. If the person perceives that the 45

event is contingent upon his own behavior or his own relatively permanent characteristics, we have termed this a belief in internal control (p. 171).

Research in locus of control has evolved with development of tests

used to measure the characteristic of the individual (Phares, 1955;

Rotter, 1966). Results of the research literature consistently support

the early hypothesis of Rotter and colleagues, namely that internals would

be more active, alert, initiating, inquisitive, competent in utilizing

information, more creative in cognitive processing, more willing to take

risks, and generally more adept at attaining mastery over the environment.

To this end, they feel greater fulfillment and contentment. Externals,

by contrast, appear as less confident, less competent, conformist and

other-directed, more prone to prestige manipulation (persuasibility), more

in need of approval, and consequently characterized by a sense of power­

lessness and alienation.

Mitral Valve Prolapse Syndrome

MVPS has been identified as a clinical syndrome for almost twenty years, although not generally recognized until recently. Barlow (1963) published angiographic evidence that systolic clicks and late systolic murmurs were associated with prolapse of the posterior mitral leaflet.

These auscultatory abnormalities had been recognized since the late 1800's, but were considered extracardiac in origin (Come, 1981). Reid (1961) raised the possibility of an intracardiac or intravascular origin for the midsystolic clicks, a hypothesis which stimulated Barlow and his associ­ ates to conduct their study which was then confirmed in further research

(Barlow, 1975). Intracardiac phonocardiography recorded the clicks and 46

late systolic murmur in the left atrium, the appropriate site for events of mitral valve origin. The clicks were ascribed to abrupt tensing of leaflets and chordae (Devereux et. al., 1976).

MVPS has been known by many names over the years. These include: the auscultatory-electrocardiographic syndrome; ballooning of the mitral valve leaflets, billowing posterior leaflet syndrome; Barlow's syndrome; click syndrome; click murmur syndrome; "floppy valve" syndrome; myxomatous degeneration of the mitral valve; and systolic click-late systolic murmur syndrome (Jeresaty, 1979). In addition, patients who throughout the century have been diagnosed as having cardiac neurosis, neurocirculatory asthenia, DaCosta's syndrome» irritable heart, soldier's heart, or the effort syndrome are now thought to have been persons with MVPS (Wooley,

1976).

In terms of functional anatomy, normal function of the mitral ap­ paratus requires delicately coordinated interaction of six anatomic elements: leaflets, chordae tendineae, anulus, left atrium, papillary muscles and left ventricular wall (See Appendix B). Pathological findings of MVPS are specifically documented to include the following: voluminous redundant, scalloped and thickened leaflets; mitral annular (ring-shaped) dilation; myxomatous (a tumor-like development of mucous tissues) trans­ formation of the valve substance; and an absence of inflammatory change

(Devereux, et. al., 1976). The mitral annulus is often sufficiently dilated to cause mitral regurgitation, a condition only seen in MVPS and Marfan's syndrome (Bulkley and Roberts, 1975).

The anxiety, tachycardia, dysrhythmias, atypical chest pain, striking postural change, and electrocardiographic abnormalities in patients with 47 this syndrome clearly suggest a hyperadrenergic state or the activity of other metabolic components. Boudoulas et. al. (1980) investigated this question with twenty MVPS patients, and found higher levels of glucose,

24 hour urinary epinephrine and norepinephrine and plasma catecholamine increase with exercise. Gaffney et. al. (1979) in a study of 35 MVPS women found that the patients had an increased venous and arterial vaso­ constrictor activity following infusion with phenylphrene, suggesting decreased parasympathetic, increased alpha and normal beta-adrenergic tone and responsiveness.

The clinical presentation of MVPS is a broad spectrum which ranges from "silent" asymptomatic patients who are detected only by the presence of auscultatory or electrocardiographic abnormalities or because of a family history of MVPS, to severe holosystolic mitral regurgitation.

Chest pains, dyspnea (labored breathing), dizziness, syncope (sudden weakness and/or fainting), palpitations, dysrhythmias, tachycardia, fatigue and anxiety constitute the range of common symptoms with 75% to 85% of

MVPS patients presenting one or more of these symptoms. Specifically, chest pain has been found in 35-72% of patients, dyspnea in 30-38%, various forms of palpitations in 44-49%, and various psychological disturbances in 15-38% (Malcolm et. al., 1976; Jeresaty, 1979; Hancock and Cohn,

1966; and Jeresaty, 1973).

The general physical examination is frequently normal. However, many patients with MVPS demonstrate an asthenic body build, joint laxity, or abnormalities of the thoracic skeleton (such as straight back, pectus ex- cavatum, and scoliosis). Many think MVPS may be associated with specific diseases of connective tissue, including Marfan's syndrome. 48

The etiology of this condition is the subject of debate. The valvular

theory holds that the mitral valve, having lost its collagenous supporting

structure, allows stretching of the mitral valve cusps, resulting in re­

dundant and prolapsed leaflets. Chest pain results because of excessive

traction on the papillary muscle by the chordae tendonea (the tendonous

chords which connect each cusp of the atrioventricular valves to appro­

priate muscles in the heart). Arrhythmias originate from the abnormally

tensed mitral leaflets, and the characteristic click is due to the sudden

tensing of the everted valve leaflets, like the phenomenon of a sail snap­

ping in the wind.

The myocardial theory is based primarily on angiographic and hemo­

dynamic correlations. This theory holds that abnormal systolic protru­

sion of the inferior wall of the left ventricle results in the elevation

of the papillary muscles and the ballooning of the posterior leaflet into

the left atrium.

Studies on the prevalence of the condition vary with estimates ranging

from 1% to 17% of the general population being afflicted (Come, 1981;

Markiewicz, et. al., 1976). Surveys are confounded by the fact that many persons exhibiting midsystolic click and associated systolic murmur upon auscultatory examination but who otherwise exhibit no symptoms or make no complaints are dismissed as normal variants. The syndrome is most pre­ valent among females (up to 66% of all known incidence) although a pre­ ponderance of males report such gradual deteriorating complications as infective endocarditis and chordal rupture. Familial transmission has been frequently studied and reveals a range of 30% to 47% occurrence in offspring of afflicted parents (Hunt and Sloman, 1969; Jeresaty, 1979)- 49

Four major complications may evolve with MVPS patients: infective endocarditis; progressive mitral regurgitation; spontaneous rupture of chordae tendonae; and malignant ventricular ectopy, causing recurrent syncope, cardiac arrest, and sudden death. Sudden death has been re­ ported in over 25 patients, and there is documentation of another 21 who were successfully resuscitated (Jeresaty, 1979). It is thought that the mortality rate may be much higher once the disease is fully understood, and diagnoses are revised to account for the possibility of MVPS. Con­ gestive heart failure may also complicate mitral regurgitation. Patients with murmurs are often asymptomatic for many years. However, once symptoms of congestive heart failure ensue, rapid deterioration frequently occurs.

Treatment of MVPS patients traditionally begins with reassurance that the outcome is generally manageable. Because bacteria tend to lodge around the extra mitral tissue and can inflame the endocardium, or heart lining, resulting in a serious condition of infective endocarditis, proper instruction on endocarditis prophylaxis is given. It is generally recommended, for example, that the dentist be informed of the MVPS condition so as to prescribe oral penicillin before any dental work, including the cleaning of teeth (Kovalesky, 1981). For patients suf­ fering from chest pain, arrhythmias, severe mitral regurgitation, and dyspnea, propranolol is the current drug of choice.

Propranolol is a beta-adrenergic receptor blocking drug. The mechanism of the antihypertensive effects of this drug has not been established. Among the factors that may be involved are decreased cardiac output, inhibition of renin, and dimunition of tonic sympathetic nerve outflow from vasomotor centers in the brain. It is of unique importance 50

in the management of arrhythmias due to increased levels of circulating

catecholamines or enhanced sensitivity of the heart to catecholamines. In

higher than usual dosage, propranolol also exerts an anesthetic-like mem­

brane action which affects the cardiac action potential and depresses

cardiac function (Baker, 1979).

How propranolol functions to alleviate chest pain is unknown. There

is speculation that increased left ventricular volume and decreased con­

tractility tend to diminish both prolapse and tension of papillary muscle

and adjacent myocardium following administration of propranolol (Devereux,

et. al., 1976).

There are, unfortunately, a number of problems and contraindications

for prescribing propranolol, and many physicians are reluctant to utilize

the drug for these reasons. It is contraindicated for patients suffering

from bronchial asthma and emphysema since it may block necessary broncho-

dilation. It must be withdrawn prior to major surgery since it impairs

the ability of the heart to respond to reflex stimula. It is to be used

with caution with patients suffering from diabetis, hypoglycemia, and

hyperthyroidism since the drug may mask the appearance of premonitory signs and symptoms (pulse rate and pressure changes) and the clinical signs of developing pathology.

In patients where cardiac failure is a possibility, propranolol is particularly problematic. Propranolol can reduce the inotropic action of digitalis at the very time sympathetic stimulation is a vital compo­ nent supporting circulation function in congestive heart failure. Even among patients without a history of cardiac failure, the continued de­ pression of the myocardium over a period of time can lead to cardiac 51

failure. This has been observed in propranolol therapy. Further, in

patients with angina pectoris, there have been reports of exacerbation of

angina and, in some cases, myocardial infarction following abrupt discon­

tinuation of propranolol therapy (Baker, 1979).

In addition to these serious situations which contraindicate the use

of propranolol, the drug also has adverse effects upon patients in many

instances. These include: paresthesia of hands; arterial insufficiency;

lightheadedness; depression, followed by insomnia; weakness and fatigue;

visual disturbances; hallucinations; disorientation for time and place; short term memory loss; emotional lability; nausea; vomiting; epigastric distress; abdominal cramping, diarrhea, constipation, colitis; skin

rashes; and impairment of performance of routine activities.

For these reasons, the search for non-pharmacological interventions for persons suffering from MVPS is a priority concern among many physicians.

Summary

This chapter has been designed to enhance an understanding of the diverse nature of stress and anxiety and its relationship to disease in general, and cardiovascular disease and MVPS in particular. It can be seen how the entire history of the mind-body dialogue is recapitulated in contemporary theories of stress and an understanding of cardiovascular disease. Of particular interest is the current debate as to whether or not specific personality factors are correlated with cardiovascular disease as claimed by several eminent scholars.

Persuasive argument and evidence leads the researcher to the following conclusions germane to this research: 52

First, human emotions do precipitate specific physiological distur­

bances which, in turn, amplify the pathogenic stress in damaging progres­

sion.

Second, adreno-cortical mechanisms of stress and specific neurological

pathways where adaptation to stress is facilitated can be identified.

Third, various mind-body theories which are most appealing to contem­

porary scholars are actually distinguished only by their respective points of emphasis: biochemical, cognitive appraisal, and person-environment interaction.

Fourth, cardiovascular disease has been indicted as being closely related to stress, and often stress-induced.

Fifth, Friedman and Rosenman's "Type A" personality has found solid support in several major studies. It does seem apparent that certain characterologically predisposed individuals will react to a stressful situation in a predictable manner which often leads to increased potential for heart disease.

Sixth, the absence of a sense of personal control is a frequent factor in the exacerbation of pathogenic anxiety which is a central factor in cardiovascular disease.

Finally, MVPS is a cardiovascular disease characterized by a hyper-

adrenergic state similar to that found in persons experiencing high

levels of stress and anxiety.

In the following chapter, the application of this knowledge has

been applied to the research questions of this study. CHAPTER III

METHODOLOGY

This chapter describes the research setting, methodology and stat­

istical procedure used in this study, and consists of several sections.

In the first section, the research setting is defined. In the second

section, the two samples are described. The third section specifies

the procedures used in the study. Finally, the proposed statistical analysis of the data is explained.

Research Setting

The setting for this research centered at University Hospital, Ohio

State University, Columbus, Ohio, and at the office of the researcher in

Columbus, Ohio. The Department of Cardiology of University Hospital worked closely with the researcher in making available a list of persons who had been diagnosed as having MVPS. The office of the researcher is in Upper

Arlington, Ohio, a middle-class to upper-class suburb adjacent to Ohio

State University. Privacy and availability of parking made this office

a preferable place for testing.

Three nurses who helped generate the list of persons for the control group were employed at University Hospital, Riverside Hospital and at the private office of a physician in Upper Arlington, Ohio.

53 5 4

Sample Selections

The MVPS sample chosen for this study was composed of patients refer­ red to the researcher by staff cardiologists at University Hospital, Ohio

State University, Columbus, Ohio. All patients were residents of metro­ politan Columbus. All had been referred by other physicians to University

Hospital, and all had been diagnosed as having MVPS by means of auscultatory and echocardiographic examination during the calendar year 1981.

The list of all patients who had been diagnosed as MVPS during the calendar year totaled 214. From the list, 159 patients were eliminated, leaving a study sample population of 55. Table 1 displays the groups who were eliminated.

One can only speculate what differences were made in the study by the elimination of persons unavailable for testing. The following is submitted as possible effects of those eliminated.

The nine persons considered too ill for testing might well have contributed to more significant effects between the MVPS and the control group, and between the MVPS symptomatic group and the MVPS asymptomatic group. It is probable that they would have weighted results strongly in the direction of significant differences between groups.

The 29 persons who lived outside Metropolitan Columbus might well have added greater weight to the middle socioeconomic class representation.

This would have caused a wider spread on the demographic profile. However, attempts would then have been made to match the control group sample pop­ ulation accordingly, and it is suggested that no significant differences would have been subsequently noted in the statistical analysis. TABLE 1

SELECTION OF THE MVPS SAMPLE POPULATION

Number Category Explanation of Patients

Total number diagnosed with MVPS List provided by Department of Cardiology, during 1981 214 The Ohio State University

Eliminated from study as unavailable . These patients had moved, with no forwardinj for study 84 address; or their physicians had moved with their records.

Eliminated from study as unavailable Repeated efforts were made by telephone and for contact 15 written notification, but without success.

Eliminated from study as living out­ side metropolitan area 29 It was not considered practical to visit these persons or request their coming to Columbus.

Eliminated from study as resistant 22 These persons did not show for scheduled appointments and second appointments, or refused to participate in the study.

Eliminated by medical order 9 Physicians decided these patients were too ill to participate in the study.

Total number of patients participating in the study 55

u " i KJ* 56

Of the 22 patients where some form of contact was made, but where the patients either did not respond at all to the invitation to participate in the research, or where they did not show for their appointment, it can only be assumed that motivation for participation was very low. What this means is uncertain. It is possible that such persons are so asymptomatic as to have little cause for concern. Had they participated in the study, they would have weighted the asymptomatic group, presumably emphasizing the benign nature of MVPS. However, if this group had been combined with the nine persons who were considered too ill for the testing, then the results should not have been significantly different than what occurred with the sample populations who were tested.

Regarding the remaining patients who could not be found either because they had moved, or they had no phone, or because their physician had moved, taking their records, it can be speculated that these were students and persons of a more transient population. The physicians who moved were generally residents at the hospital, and the patients were often clinic patients. This would suggest that they were at the lower end of the economic spectrum. However, because many were presumably university students, they would have ranked higher on the socio-economic scale, being consistent with the sample population that was tested. It does not seem meaningful to speculate whether or not this group would have been highly symptomatic or asymptomatic, or how their inclusion in the study would have affected the results.

In addition, a medical control group was drawn from a list created by the researcher and three nurses. The list consisted of 150 persons who were sufficiently known to be of similar socioeconomic status as the 57

MVPS sample, and likely to agree to participate in the study. These persons were known by virtue of having presented themselves either to the University Hospital Clinic, to Riverside Hospital Clinic, or to the office of a physician engaging in general practice in Upper Arlington,

Ohio, a community which approximates the upper middle-class socio-economic status of the MVPS sample. From the list of 150, a list of 75 was randomly chosen and from this list the first 55 who were available and willing to participate in the study were tested.

Of the 20 persons on the final random control list who were not included in the study, little can be said by way of how this might have influenced the results of the study. All persons were given an equal opportunity for initial contact with calls being made over two weeks.

Some were currently out of town, others had difficulty in scheduling appointments, and others were willing to participate, but by the time they could be scheduled the quota of 55 control members had been scheduled or tested. No common features are found among those on the control list who were not drawn for the final study.

A socio-economic profile was established using Adler's (1973) two formal criteria to determine an individual's social position: education level and occupation. Based on Adler's formal criteria, Upper-Middle

Class includes 13 years of school or over and professional or managerial occupations. Lower-Middle Class includes high school and trade occupations.

Lower-Lower Class includes less than 6 years of school and unskilled labor or employment.

Table 2 provides a description of the MVPS and the control groups.

A comparison of the MVPS and the control sample reveals that the two groups were very much alike in socioeconomic terms. The MVPS group was TABLE 2

DEMOGRAPHIC CHARACTERISTICS OF SAMPLE POPULATIONS

MVPS GROUP CONTROL GROUP Characteristic Frequency Frequency Frequency Per Cent Frequency Per Cent

Sex Female 50 .91 42. .76 Male 5 .09 13 .24

Marital Status Married 34 .62 31 .56 Single 10 .18 15 .27 Divorced 8 .15 8 .15 Widowed 3 .03 1 .02

Socioeconomic Status Upper Middle 34 .62 40 .72 Lower Middle 16 .29 8 .15 Upper Lower 5 .09 7 .13

AgG Range: MVPS = 18-76 Control = 19-62

Mean: MVPS = 35.98 Control = 3A.26

u i co 59

composed of 62% upper-middle class and 29% lower-middle class compared

to the control which was 72% upper-middle class and.-15% lower-middle

class. The age characteristics were almost identical: a mean of

35.98 for the MVPS sample and 34.26 for the control group, with very

similar age ranges. Both groups were quite similar in terms of marital

status: the MVPS sample showing 62% married, 18% single, and 15% divorced,

compared to the control sample of 56% married, 27% single, and 15% divorced.

The only notable difference is that the control group had a higher male representation (24% compared to the 9% case sample) and, as just

described, had 9% more singles than the MVPS sample.

Instrumentation

A personal data questionnaire and four instruments were administered

to all participants in the study. These are described below.

Personal Data Questionnaire

A personal data questionnaire was created to retrieve data necessary for assigning a person to a social class strata, and, among MVPS partici­ pants, for the purpose of retrieving data necessary for the determination of the degree of symptomatology (See Appendix C).

The first page consisted of seven questions: designation of sex, age, marital status, personal education level, category of occupation, spouse's

(if any) educational level, and spouse's (if any) occupation. The second page (for the MVPS sample) consisted of four questions: the designation of any or all of six possible symptoms; a best estimate of days symptomatic, days missed work because of MVPS, and days reduced socialization because 60 of MVPS; the age of onset of symptoms; and the nature of any medication taken for the condition, current or past.

In terms of social status designation, participants who indicated college or college graduate level of education and professional or man­ agerial occupations were assigned an upper-middle class status. Persons with college or high school education and occupations less than profes­ sional or managerial were also assigned upper-middle class status if their spouses indicated college and graduate level education and professional or managerial occupations. Lower-middle class designations were given to persons who designated high school or trade occupations.

Upper-lower class status was assigned to persons who indicated six to nine years of school and labor occupations, and lower-lower class status to those who indicated less than six years of school and unskilled labor or unemployment. If the person being tested was an employed homemaker or student, then in every case the educational and occupational levels of the spouse was used to determine the social status by determining the educational and occupational level of the parents.

In order to establish a specific degree of symptomatology, an index of symptomatology was created by the researcher which gave equal weight to three factors: evidence of symptoms; extent or gravity of symptoms; and the current administration of propranolol to- control MVPS symptoms.

Each factor was assigned a common weight of ten points, but there was a possibility of exceeding this level under certain circumstances. The sum of these three factors constituted the person's symptomatic score, with an expected mean of 15. The specific factor scoring ration was as follows: 61

Question 8: Evidence of Symptoms. Two points were given for each

symptom listed. It was possible for twelve points to be assigned, the

logic being that the presence of all symptoms yielded an unusually high

degree of symptomatology, or a possible bonus score of two points.

Question 9: Extent or Gravity of Symptoms. The total number of

days for 9A (days symptomatic in the last 12 months) and 9B (days of

work missed due to MVPS in the last 12 months) and 9C (days of reduced

socialization due to MVPS in the last 12 months) were added together,

then divided by the coefficient .08 for an estimate which was expected

to yield 10 points for a relatively symptomatic participant. If a

person was unemployed, then to account for factor 9B (days of work missed due to MVPS), the figure of one-half the days estimated as reduced socialization was used, the logic being that the person would have likely

carried on and gone to work at least half of the time he/she was feeling

poor.

Question 10: Current Administration of Propranolol. If the person marked "Yes" for current administration or administration when sympto­ matic, a total of ten points was assigned. If the category of "admin­

istered previously" was designated, then the person administering the

tests determined if this was a brief or trial administration or a routine

regimen of propranolol during an MVPS episode. If it was the latter,

then a full ten points were assigned.

Questions regarding the age of onset of symptoms and other drugs

taken for MVPS were asked for purposes of future research.

The State-Trait Anxiety Inventory

The concepts of state and trait anxiety were first identified by

Cattell and Scheier (1961) on the basis of factor analysis. Spielberger 62

and his colleagues (1966a; 1966b; 1972a; 1972b; 1975) subsequently

refined these concepts and developed procedures for their operational

measurement (Spielberger, Gorsuch and Lushene, 1970). The instrument*

is designed to measure two anxiety states: state anxiety (A-State) and

trait anxiety (A-Trait.)

State anxiety consists of unpleasant consciously perceived feelings

of tension or apprehension aroused within the individual once he has

appraised a situation as physically or psychologically threatening. Trait

anxiety has been described as a relatively stable component of personality which disposes the individual to react to perceived threats with a given

level of A-State. These concepts are discussed at greater length in

Chapter Two of this study.

Spielberger has noted that, in general, persons with high A-Trait

scores will exhibit higher A-State scores than will low A-Trait indivi­

duals. He speculates that this occurs because high A-Trait individuals

respond to a wider range of situations as threatening or dangerous.

This was of direct interest to this study which sought to determine if

MVPS patients were more prone to interpret their world as threatening

because of any unique personality characteristics such as are hypothe­

sized for high A-Traits, or whether the A-State of MVPS patients was

in any way correlated to their degree of symptomatology. Further,

the way in which this factor interacts with other factors being measured (locus of control and operating belief systems) was carefully

analyzed. 63

Development of the State Trait Anxiety Inventory began with three

widely used anxiety scales containing a total of 177 individual items.

Through a series of item analyses using a variety of instructions, these

items were reworded and progressively eliminated until only 20 items

remained to measure state anxiety (Form X-l, "How you feel right now")

and 20 items to measure trait anxiety (Form X-2, "How you generally feel.")

Some items appear in both forms. Responses are made in terms of frequency:

almost never, sometimes, often, and almost always (See Appendix D.)

Either scale can be used by itself, but when the two are given

together, it is recommended that the state anxiety be administered first.

The inventory is self-administering and the directions are self-explanatory.

Completion for both forms seldom requires more than 20 minutes.

In both forms, some of the items are worded in such a way that a response of h indicates little or no anxiety and a response of 1 indicates high anxiety. The latter items must be reversed for purposes of scoring.

On the A-State form, these are items 1, 2, 5, 8, 10, 11, 15, 16, 19, and

20; on the A-Trait form, these are items 21, 26, 27, 30, 33, 36, and 39.

Raw scores can therefore range from 20 to 80, the higher the score being the greater the level of anxiety. For normative scoring, a constant of 50 is added to the A-State form and a constant of 35 is added to the

A-Trait form.

Normative data for this instrument are available for large samples of high school juniors, college freshmen, college psychology students, male neuropsychiatric patients, general medical and surgical patients, and prisoners. Table 3, adapted from the State Trait Anxiety Inventory Manual

(Spielberger, et. al., 1970) demonstrates the comparison of scores. TABLE 3

COMPARATIVE SCORES FOR THE STATE-TRAIT ANXIETY INVENTORY

Category Raw Score State Trait

College Freshmen 30 8 17 35 28 38 AO 52 62 A5 76 82 50 88 91

Undergraduate 30 28 2A 35 50 A6 AO 70 61 A5 83 79 50 91 89

High School 30 26 15 35 A8 3A AO 67 60 A5 79 77 50 89 87

Psychiatric Patient 30 10 11 35 18 19 AO 30 31 A5 A1 A5 50 56 61

Medical Patient 30 21 19 35 33 31 AO A3 A6 A5 68 62 50 75 77

Prisoner 30 7 9 35 17 19 AO 32 3A A5 A7 A8 50 65 67 65

Test-retest reliabilities are reported for A-State (Form X-l) and

A-Trait (Form X-2) scores, separately by males and females. Reliabilities for the A-Trait scale are consistently high, ranging from .79 to .86 in the studies reported by Spielberger, over time intervals from one hour to 104 days. These strong reliability coefficients have also been re­ ported by Katkin (1978) at .73 and .77 over 6 months, indicating that the trait measure is relatively stable. The most modest studies known to the researcher are by Nixon and Steffeck (1977) who found low reliabilities

(.54 to .30) over three, eight and eleven months among medical students.

Reliability studies on the A-State scale are much lower, which is to be expected for a measurement of changing perceptions and experiences.

Coefficients range from .16 to .54 with a mean of .32 for the six groups studied by Spielberger.

Validity studies, however, are strong for both A-State and A-Trait; and it is the validity which should be the important study for the state scale.

Reliability coefficients for the normative samples of the Spielberger study range from .83 to .92 for state scores, and .86 to .92 for trait scores.

The A-Trait scale also correlates highly with the Taylor and IPAT anxiety scales, indicating that it measures essentially the same concept.

In summary, the State-Trait Anxiety Inventory is a convenient, reliable and valid instrument to measure an individual's proneness to anxiety or the individual's transitory anxiety experience. It is well researched, has stood the test of time, and is consistently recommended for research.

The Internal-External Locus of Control Scale

Locus of control constructs have been previously discussed in Chapter

Two of this study. In 1966, J.B. Rotter operationalized the concept of 66

inner control, measuring the extent to which an individual perceives that

events are contingent upon his/her own behavior, and external control, measuring the extent to which an individual perceives that he/she is somewhat powerless or helpless in the face of events which occur by

chance, luck, or by means of the power of others.

The Rotter Internal-External Locus of Control Scale (See Appendix E) consists of twenty-nine forced choice items. Included are six filler items

(items 1, 8, 14, 19, 24, and 27) designed to provide ambiguity. Scores can range from zero (complete internal) to twenty-three (complete external).

Development of the scale began with two instruments used to measure indi­ vidual differences in generalized expectancy or belief in external control.

From the 100 item original, the scale was then item analyzed and factor analyzed to a 60 item scale, and finally refined to the current 29 item instrument.

Normative data as reported by Rotter (1966) for male college students

(N=575) include a mean of 8.15 and an S.D. of 3.88. For female college students (N=605) he reported a mean of 8.42 and an S.D. of 4.06. In three separate studies, Rotter reported reasonable internal consistency with an average reliability coefficient of .69 and a test-retest reliability of .72. However, because of the noncomparability of the items in an additive scale such as this, it is difficult to achieve high estimates of internal consistency.

Other investigators have reported reliability coefficients generally consistent with those of Rotter. Some social desirability is apparent with individuals wanting to present themselves in the most favorable light. As for mean levels of scores, it is very difficult to present a "typical" or "normal" Internal-External Locus of Control Scale score

(Phares, 1955). There appear to be geographic differences to the mean scores as well as differences among social and ethnic groups. Also, in recent years the comparative means have continued to move in the exter-' nal direction at least two to four points, depending upon the specific conditions and populations. Phares, (1976) reported mean external scores for University of Oklahoma students that range from 7.42 in 1966 to 10.38 in 1970. The fact that world events, including the draft and the Viet Nam War, were occurring simultaneous to this study, suggests that an anxiety state can be associated with an increasing loss of personal power and control.

The Rokeach Dogmatism Scale

Deriving from his concern with the organization of a belief and dis­ belief system, Milton Rokeach (I960) set about to construct a theory and measurement of belief systems. He carefully distinguished between an open system (non-rejecting, accommodating, trusting, non-authoritative) and a closed system (rejecting, isolating, mistrusting, authoritative).

From his theory, he constructed his Dogmatism Scale to measure individual differences in openness or closedness of belief systems. Using a Likert- type scale from "I Disagree Very Much" to "I Agree Very Much",the scale went through five editions of which Form E is the most popular and current, and the form used for this research (See Appendix F).

There are sixty items on the scale, twenty of which are fillers. The total score on the scale is the sum of scores obtained on all items, ex­ cluding the fillers. The higher the score, the more closed-mindedness is 68 apparent. Reliability studies for all forms of the scale were measured by Rokeach and coefficients ranged from a low of .68 to a high of .93.

The means ranged from 141.3 to 183.2 with a median of 151.7.

Rokeach (I960) clearly discussed this instrument with the idea of having a full scale score, with three operating subscales. The subscales were as follows:

1. Items involving the belief-disbelief dimension, where disbelief

is seen to be less differentiated, more segregated and more

isolated than open belief systems.

2. Items involving the time perspective, where the more closed

the system, the more it will be organized around future-

oriented and past-oriented events, and the less it will

perceive the present as important.

3. Items involving the central peripheral dimension, which is

the core of the dogmatism theory.

Major problems exist with these subscales, however. Only four items are operationalized for the belief subscale, and only four items are operationalized for the time subscale. The remaining 32 items measure the central dogmatism factor. There were too few items in the belief and time subscales for any meaningful factor analysis to be conducted.

As a result, only the full scale score was utilized for this instrument.

This instrument was chosen because of the scarcity of measurements for belief systems, and because of the initial hypotheses that the MVPS patients, being anxious and prone to feelings of powerlessness, would, as Mooney had said, pull into themselves, be more closed than open to the world around them, more isolated than trusting, and more authoritative than accommodating. 69

The Bessai Common Beliefs Survey III

Bard (1973); Lane, Bessai and Bard (1975); and Bessai (1976, 1977)

worked to construct a self-administered objectively scored diagnostic

instrument to be used to measure specific levels of irrational thinking.

Based on Ellis' (1962) theoretical framework of irrationality, the

authors pooled nine existing attitude surveys into one 54 item inventory,

set in a 5-point Likert scale format, ranging from strongly agree to

strongly disagree. Scoring is the simple calculation of the sum of item

values; on the computer program for this study, the lower score indicates

irrationality. To control for acquiescence, approximately one-half of

the items are stated as rational beliefs and the remainder are stated

as irrational beliefs (See Appendix 6 ).

In addition to the full scale score, eight subscales were designed by

the author of the test. The first six derive from nine item factors

labeled as follows: Importance of the Past; Blame Proneness; Self-downing;

Importance of Approval; Perfectionism; and Control of Emotions. The sub­

scale entitled Locus of Control is comprised of the total scores for Impor­

tance of the Past, Control of Emotions and Importance of Approval.

Although this instrument has earned a face validity as the best

available theoretical measure of irrational and counterproductive belief systems, its empirical sensitivity has not yet been tested experimentally.

There are no standardized norms, and no significant literature on the

instrument. It does reveal reliability in terms of its replicated factor structure. 70

Procedures in Data Collection

After the lists were compiled, it was necessary first to contact all referring physicians for permission to contact the patients, and in many cases, to get addresses and phone numbers of the patients.

Assisting the researcher were two registered nurses, one employed at

University Hospital, Columbus, Ohio, where the MVPS population had been identified, and one in the office of a physician in Upper Arlington, Ohio.

Both were experienced in research methods and knowledgeable of MVPS.

A process of contacting by telephone persons on the MVPS list was

the first collection step. This contact was made, in every case, by the researcher. Patients were told that the research was being conducted in cooperation with the cardiologists who had recently examined them, and their participation was solicited. They were told that a one hour ap­ pointment would be necessary for pencil and paper tests. They were assured of full confidentiality in keeping with the requirements of the Human

Subjects Review Committee of The Ohio State University. They were not told of the purpose of the test nor in any way alerted to the research questions being posed.

Appointments were scheduled at the professional office of the re­ searcher in Upper Arlington, Ohio. The nursing assistants were present to observe the protocol for meeting the patients, giving instructions for the testing, and meeting briefly with the patients after the testing.

The researcher administered 52 of the tests, and the nursing assistants, under the researcher's supervision, administered three tests at the homes of patients. 71

Approximately one hour was required for the administration of the

four tests and the personal data questionnaire. After the testing, the

researcher explained the purpose of the research and volunteered to meet

with the patients either as individuals or as a group at the end of the

research project to discuss results.

The control group was also scheduled on an individual basis for

appointments at the researcher's office. The nursing assistants helped

in the administration of these tests. These persons were only told that

they had been selected at random from a list of hospital and private

physicians' patients for research purposes. After the testing, they were

told that they were part of a control group, and the importance of their

role was emphasized.

Consent for participation forms was given to all participants as required by the Human Subjects Review Committee. Individual protocols were coded in such a way that the participant's name was not identifiable on any answer sheet.

Statistical Methodology

All data obtained in this study were placed on key punch cards and the statistical analysis was performed through the use of an IMB 370 computer at The Ohio State University Data Center. Statistical computa­ tions were performed through the Statistical Package for the Social

Sciences (Nie, et. al., 1975).

All demographic data were organized through the FREQUENCIES subprogram.

This procedure produces frequency tables and descriptive statistics for all variables. Secondly, a correlational table was generated through the 72 utilization of the PEARSON CORR subprogram which computes correlational coefficients between variables including Pearson product-moment cor­ relations and significance probabilities. Thirdly, all scales were subjected to an examination of their reliability through the use of the

RELIABILITY subprogram which provides -a means for evaluating multiple- item additive scales through the computation of widely recognized coefficients of reliability. In this study, the reliability analysis used was Cronbach's (1951) alpha.

A factor analysis of variables on the test instruments was executed through the use of the FACTOR subprogram which considers all factors above the point of discontinuity. The varimax program utilized is an orthogonal rotation to maintain maximum independence of factors. Four steps composed the factor analysis procedure: the preparation of the correlational matrix, and analysis by eigenvalue and scree criteria; the initial varimax rotation to expedite the analysis of initial factors and the exploration of possible data reduction; test refinement, if needed and possible, by data reduction; and a second varimax rotation to expedite the search for more simple and interpretable factors (Kerlinger, 1973).

Finally, the three research questions stated in Chapter One of this study were each addressed by means of multivariate analyses. Because problems exist when univariate significance tests (t-tests or F-tests) are used to compare the differences between groups on a number of dependent, related variables (Tatsuoka, 1971), multivariate analysis is considered a more sensitive method for detecting such differences. Differing from a univariate approach, which compares the differences between two groups by considering each criterion separately, the multivariate method compares 73 the differences in the two groups by considering all criterion variables simultaneously. CHAPTER IV

ANALYSIS OF RESULTS

Introduction

This chapter contains the results obtained in this study. In the first section, an analysis of the demographic data is presented. This, analysis compares the MVPS group with the control group, and the MVPS symptomatic group with the MVPS asymptomatic group, on demographic information and extent of symptomatology. The second section contains an analysis of the instruments, listing reliability coefficients, means, standard deviations, and the factor analyses and suggested instrument refinement. Finally, the research questions posed in the statement of the problem are addressed in terms of the multivariate analyses and correlation analyses of all relevant variables.

ANALYSIS OF THE INSTRUMENTS

The Personal Data Questionnaire

Demography and symptomatology data were collected with the Personal

Data Questionnaire. Table 4 displays the comparison of the control sample population with the MVPS sample population. By definition, there was no information to report on cardiovascular symptomatology for the control group. There were 18% more females in the MVPS group than were drawn for the control group. Since MVPS is more frequently a disorder

74 75 TABLE 4

SUMMARY DEMOGRAPHY AND SYMPTOMATOLOGY

STATISTICS FOR MVPS AND CONTROL GROUPS

MVPS group Control group

Item Mean S.D. Cases Mean S.D. Case:

Sex a .91 • 29 55 .73 .45 55 Age 35.98 12.61 55. 34.26 10.72 55 Marital Status b 1.64 .97 55 1.64 .87 55 Educational Level c 1.91 .70 55 1.73 .80 55 Occupation b 2.87 2.25 55 2.22 1.91 55 c Spouse Educational 1.26 1.06 55 .91 .97 55 Level Spouse Occupation b 1.18 1.49 55 • 91 1.21 55 0 Heart Symptom 1.31 .96 55 Shortness of Breath ® .80 .99 55 Symptom “ > Fatigue Symptom e 1.24 .98 55 Fainting Symptom e .22 .63 55 Chest Pain Symptom e 1.24 .98 55 Dizziness Symptom 6 .87 1.00 55 Days Per Year Symptomatic 77.04 94.53 55 Days Per Year Missed Work 3.73 14.60 55 r Not Employed .27 .45 55 Days Per Year Reduced 14.40 30.23 55 Socialization Age of Onset of Symptoms 26.43 12.69 55 Use of Propranolol ® 2.36 4.29 55

^ h e r e 0=male, l=female bWhere l=married, 2=aingle, 3=divorce, 4=separated, 5=widowed cWhere 0=no spouse, l=graduate study, 2=college, 3=high school, 4=grades 9-12 completed

^Where 0=no spouse, l=professional-management, 2=sales, 3=clerical, 4=skllled trade, 5=laborer, 6=homemaker-student, 7=unemployed eWhere 0=no symptoms, 2=symptoms present f Where 0=employed, l=unemployed sWhere O=propranolol not used, 10=propranolol used 76 of females, this was considered a close match for comparison purposes, and there was no reason to believe that the difference would allow for extraneous factors to influence the results.

A comparison of the means of the two distributions was made by a process of dividing the difference between the two means by the average of the two standard deviations (Minium, 1978). As a general guideline, a coefficient of .10 was held as negligible, and .50 as of some sig­ nificance, or importance. Table 5 displays these values. It is apparent from this table that no significant differences existed between these groups on age, marital status, education or occupation.

Table 6 divides the MVPS sample population into symptomatic and asymptomatic groups.

A comparison of the means of these two distributions was made by the same process used for comparing the MVPS group with the control group. Table 7 displays these values. It is apparent from this table that no significant differences existed between the groups on age, marital status, education or occupation.

Symptomatics and asymptomatics were, then, similar on demographic factors. The major differences appeared when the two groups were compared for extent of symptomatology. This occurred because the median was used to delineate the symptomatic group from the asymptomatic group.

The State-Trait Anxiety Inventory

According to the author of this instrument, it contains two separate subscales: the subscale measuring state anxiety and the subscale measur­ ing trait anxiety. On this and all subsequent statistical analyses, the

SPSS subprogram for reliabilities and the SPSS program for factor analysis TABLE 5

COMPARISON OF MEANS OF DEMOGRAPHY AND

SYMPTOMATOLOGY FOR MVPS AND CONTROL GROUPS

S.D.X+S.D.Y Statistical Factor X-Y S.D. X S.D. Y 2 Difference. xa Ya ------b

Age 35-98 34.26 1.72 10.72 12.61 11.67 0.15

Marital Status 1.64 1.64 0.00 .97 .87 .92 0.00

Educational Level 1.91 1.73 .18 .70 .80 .75 .157

Occupation 2.87 2.22 .65 2.25 1.91 2.08 .313

a Where X=MVPS Group, Y=Control Group b Where X-Y (S.D.X+S.D. Y) 2 78 TABLE 6

SUMMARY DEMOGRAPHY AND SYMPTOMATOLOGY STATISTICS

FOR SYMPTOMATIC AND ASYMPTOMATIC MVPS GROUP

Symptomatic Group Asymptomatic Group

.. Item Mean S.D. Cases Mean ‘S.D. Case

Sex a .96 .19 28 .85 .36 27 Age 38.37 13.86 28. 33.59 10.95 27 Marital Status b 1.71 1.05 28 1.56 .89 27 Educational Level c 1.93 .72 28 1.89 .70 27 28 Occupation d 3.11 2.35 2.63 2.15 27 - 28 1.03 Spouse Educational c 1.36 1.10 1.15 27 Level 28 1.16 1.50 27 Spouse Occupation d 1.18 1.52 Heart Symptom e 1.64 .78 28 .96 1.02 27 Shortness of Breath ® ( 1.21 1.00 28 .37 .79 27 Symptom i' Fatigue Symptom e 1.64 .78 28 .82 1.00 27 Fainting Symptom e .36 .78 28 .07 .39 27 Chest Pain Symptom e 1.71 .71 28. .74 .98 27 Dizziness Symptom e 1.43 .92 28 .30 .72 27 Days Per Year Symptomatic 136.82 100.14 28 15.04 17.43 27 Days Per Year Missed Work 7.29 20.00 28 .04 • .19 27 f Not Employed .36 .49 28 .19 .40 27 Days Per Year Reduced 27.68 38.08 28 .63 2.31 27 Socialization Age of Onset of Symptoms 25.82 15.64 28 27.18 7.99 27 Use of Propranolol ® 4.64 5.08 28 0.00 0.00 27

^Where 0=male, l=female bWhere l=raarrled, 2=slngle, 3=divorce, 4=separated, 5=widowed

°Where 0=no spouse, l=graduate study, 2=college, 3=high school, 4=grades 9-12 completed dWhere 0=no spouse, l=professional-management, 2=sales, 3=clerical, 4=skilled trade, 5=laborer, 6=homemaker-student, 7=unemployed eWhere 0=no symptoms, 2=symptoms present f Where Osemployed, 1 unemployed

®Where O=propranolol not used, 10=propranolol used TABLE 7

COMPARISON OF MEANS OF DEMOGRAPHY AND SYMPTOMATOLOGY

FOR MVPS SYMPTOMATIC AND MVPS ASYMPTOMATIC GROUPS cd

a 1 S.D.X+S.D.Y Statistical^ Factor X * X-Y S.D.X. S.D.Y. 2 Difference

Age 38.37 33.59 4.78 13.86 10.95 12.40 .39

Marital Status 1.71 1.56 .15 1.05 .89 .97 .16

Educational Level 1.93 1.89 .04 .72 .70 .71 .06

Occupation 3.11 2.63 .48 2.35 2.15 2.25 .21

a Where X=MVPS Symptomatics, Y=MVPS Asyraptomatics b Where X-Y (S.D.X+S,.D.Y) 2

— 3 VO 80 with varimax (orthogonal) rotation was utilized. The results are reflected in Table 8 and Table' 9.

TABLE 8

SUMMARY STATISTICS OF THE STATE-TRAIT

ANXIETY INVENTORY AND SUBSCALES

Reliability Scale coefficients Mean S.D. Cases

Total Scale: State and Trait .96 7 A. 43 19.49 106

State Subscale • 94 35.8A 11.50 106

Trait Subscale • 92 38.49 10.04 106

The reliability coefficient used for these and subsequent analyses was Cronbach's Alpha, a measurement of internal consistency which derives from an intercorrelation of items on the instrument, and estimates variance due to the responses of subjects (Cronbach, 1951).

It is a very conservative reliability estimate.

As can be seen, reliability coefficients for the total scale and each of the subscales were high. Variables VARA01 through VARA20 all loaded around or over .AO on Factor 1, with most loadings being quite high; and variables VARA21 through VARA40 performed the same way for

Factor 2. Only item VARA34 appeared weak on the Factor 2 analysis, but this was not considered to be sufficient as to merit an instrument refinement by deleting the item and recomputing a new rotated factor matrix. Sample items, as displayed in Table 10, confirmed that items TABLE 9 VARIMAX ROTATED FACTOR MATRIX OF THE STATE-TRAIT ANXIETY INVENTORY

Scale Factor 1 Factor 2

State-Trait Anxiety Inventory VAHAOI 0.01047 O. 10960 VARA02 0.59597 0.40035 VAnA03 0.72937 0. 14066 VA11A04 0.46033 0. 17790 VA11A05 0.50336 0.14103 VARA06* 0.70523 0.06990 VARA07 0.30974 0.44914 VAtlAOO 0.50622 0.13723 VAIIA09 0.66991 0.21706 VARA10 0.60601 0.23703 VARA11 0.44040 0.46427 VARA12 0.77467 0.21724 VARA13 0.39147 0.26901 VARA14 0.63910 0. 17210 VARA13 0.79437 0.13732 VARA16 0.74237 0.40409 VAIIA17 0.39942 0.40034 VARA10 0.66473 0.20106 VARA19 0.30260 0.20336 VARA20 0.62061 0.27009 VA11A21 0.23439 0.60963 VARA22 0.26090 0.41050 VA11A23 0.20311 0.49351 VARA24 0. 10644 0.40381 VA11A25 0.11933 0.56523 VARA26 0.50984 0.41231 VA11A27 0.33129 0.59965 VARA20 0.12219 0.66349 VARA29 0.10711 0.60734 VARA30 0.37033 0.67394 VARA31 0. 16140 0.59299 VARA32 -0.03333 0.53203 VARA33 0.32407 0.70032 VARA34 0.02923 0.23097 VARA33 0. 19363 0.66712 VARA3C 0.30309 0.72033 VARA37 0.21933 0.43564 VA11A33 0. 19946 0.62642 VAnA39 0.39907 0.30901 VARA40 0.37704 0.66166 State Anxiety Subscale VARA01 0.50001 0.33202 VARA02 0.44222 0.50771 VARA03 0.71600 0.29004 VARA04 0.32321 0.39039 VARA03 0.30369 0.40901 VARA06 0.37070 0.37930 VAIIA07 0.48037 0.27756 VARAOQ 0.24667 0.49032 VARA09 0.70127 0.20007 VARA10 0.43046 0.62629 VARA11 0.27109 0.59300 VA11A12 0.79770 0.31779 VARA13 0.63711 0.27063 VARA14 0.70401 0.22996 VARA10 0.53007 0.50471 VARAI6 0.49731 0.71172 VARA17 0.69014 0.29030 VARAin 0.60631 0.27766 VARA19 0.10077 0.73364. VA11A20 0.25937 d. 73122 Trait Anxiety Subscale VARA21 0.71049 0.21693 VARA22 0.20509 0.34333 VARA23 0.27574 0.47610 VARA24 0.46673 0.23341 VARA23 0.40123 0.39223 VARA26 0.30100 0.30419 VARA27 0.60232 0.29246 VA11A2Q 0.43729 0.47731 VARA29 0.30329 0.69507 VARA30 0.91700 0.13970 VARA31 0.27060 0.63101 VARA32 0.26673 0.40377 VARA33 0.69101 0.30329 VARA34 0.02563 0.32100 VAIIA38 0.40060 0.57163 VARA36 0.70423 0.32937 VARA37 0.22024 0.30022 VARA30 0.37176 0.56600 VARA39 0.64310 0.33772 VARA40 0.54910 0.49C04 TABLE 10 SAMPLE ITEMS FROM THE STATE AND TRAIT SUBSCALES OF THE STATE-TRAIT ANXIETY INVENTORY

Full scale Subscale Item loading loading Concept

Items from the State subscale: "How I feel right now"

VARA01 .818 .588 "I feel calm” VARA03 .730 .442 "I am tense" ' VARA06 .705 .579 "I feel upset" VARA09 .667 .701 "I feel anxious" VARA12 . .775 .798 "I feel nervous" VARA14 .659 .704 "I feel ‘high strung'" VARA15 .79 A .538 "I am relaxed"

Items from the Trait subscale: "How I generally feel"

VARA28 .666 .478 "I feel that difficulties are piling up so that I cannot overcome them" VARA29 .688 .696 "I worry too much over something that really doesn't matter." VARA31 .593 .652 "I am inclined to take things hard" VARA33 .709 .386 "I feel secure" VARA35 .667 .572 "I feel blue" VARA36 .720 .330 "I am content" VARA38 .626 .567 ■ "I take disappointments so keenly that I can't put them out of my mind" VARA40 .662 .491 "I become tense and upset when I think about my present concerns" 83

VARA01 through VARA20 were addressing issues of state anxiety, and items

VARA21 through VARAAO were addressing issues of trait anxiety. Further,

the two factor varimax rotation of each of the subscales substantiated

the author's criteria. Items which could have loaded on factors other

than those expected by the author were items VARA19, VARA22, and VARA3A.

Again, because of all the other strong loadings on the total scale and

each of the subscales, there was no reason to believe that an instrument

refinement by the deletion of these items would significantly improve

the instrument. It was therefore decided to accept this instrument for

study without further refinement.

The Internal-External Locus of Control Scale

This instrument is designed to measure the amount of external locus of control in an individual at a given time. It therefore has no sub­ scales. Summary statistics for this instrument were calculated for the reliability coefficient and the factor analysis. The reliability coefficient was .75, actually higher than the author's earlier studies.

The remaining statistics, based on 99 cases, yielded a mean of 12.63 and a standard deviation of A.06.

Table 11 reflects the eigenvalue spread for this scale, and it is apparent according to the scree criteria that no pure single factor was being measured by this instrument since only 37-4% of the variance was accounted for in a three factor analysis. Instead, a very complex factor was being measured for general locus of control.

When the scale was subjected to a two factor analysis as shown in

Table 12, it became apparent that there were no good loadings on any one 34 factor. One complex factor was apparently being measured, but the factor structure was weak and perhaps measuring many other factors as well.

TABLE 11

EIGENVALUES OF THE INTERNAL-EXTERNAL

LOCUS OF CONTROL SCALE -

Factor Eigenvalue Pet. of var. Cum. pet.

l 4.53097 19.7 19.7 2 2.27461 9.9 29.6 3 1.78781 7.8 37.4 4 1.28878 5.6 43.0 5 1.24437 5.4 43.4 6 1.16276 5. 1 5 '..4 7 1.11541 4.8 Oii. 3 8 1.02902 4.5 62.8 9 0.95601 4.2 66.9 10 0.89524 3.9 70.8 11 0.81351 3.5 74.3 12 0.76695 3.3 77.7 13 0.67992 3.0 80.6 14 0.67095 2.9 83.5 15 0.63436 2.8 86.3 16 0.58525 2.5 80.9 17 0.49891 2.2 91.0 18 0.47489 2. 1 93. 1 19 0.42883 1.9 95.0 20 0.37444 1.6 96.6 21 0.31434 1.4 97.9 22 0.27484 1.2 99. 1 23 0.19776 0.9 100.0

Table 13 displays the items which were loaded the strongest and those that loaded the weakest on the varimax rotation. An examination of these data reveals that some common factor was accounting for the responses around the strongly weighted items VARB20, VARB16, VARB15, and VARB06. The items seem to address the events of daily life, particularly interpersonal relationships, and the role of "luck" in such common events. However, it would appear that other variables were being measured in items VARB17, VARB10, VARB14 and VARB 23.

These items seem to be addressing issues on a much larger scale: influence on government decisions, political and social forces which affect world events, the role of the citizen in national as well as 85

TABLE 12

VARIMAX ROTATED FACTOR MATRIX FOR THE

INTERNAL-EXTERNAL LOCUS OF CONTROL SCALE

Item Factor 1 Factor 2

VAIU501 0.21830 0.05099 VAIU302 -0.21603 0.55796 VARB03 0.30373 0.11700 VARC04 0.45323 0.00519 VARB05 0.40500 -0.03902 VAHB06 0.45177 0.03104 VABB07 0.33099 0.21152 VARBQO 0.44386 0.05313 7AI1C09 0.35469 0.31959 VAI1B10 0.06545 0.63913 VABB1I -0.27100 -0.33010 VARB12 0.35714 0.20730 VARB13 0.19620 0.30416 VARB14 0.07952 0.74106 VAI1B15 0.46706 0.21906 VABD16 0.49294 0.00625 VABD17 0.04006 -0.26946 VAIiDia 0.30201 0.67304 VARB19 0.44435 0. 13700 VAUB2Q 0.54636 0.09990 VAI1B21 0.17360 0.32192 VABB22 0.34902 0.14253 VARii23 0.21226 0.44050

local government, and the "bad" events in human civilization and their

causes. It was inferred, then, that this instrument was very sensitive

to locus of control issues of a routine, highly specific personal

nature such as those one encounters in daily relationships; and that

the construct of good or bad luck was consistently detected in such

experiences. The focus on these high loadings items was the micro­

cosm of life within specific, well-known parameters. In contrast to

this is the macrocosm, the relationship of the individual's experience

to more global issues of national or universal nature. Subjects

confronted with these questions answered in such a variety of ways

that the factor loadings were disparate and quite low. Apparently,

this population was knowledgeable and oriented to microcosmic concepts of locus of control, and whether or not luck plays a 86

TABLE 13

SAMPLE ITEMS EXEMPLIFYING HIGHER AND LOWER FACTOR

LOADINGS ON THE INTERNAL-EXTERNAL LOCUS OF CONTROL SCALE

First Item factor loading Concept

Examples of higher loadings

VARB20 0.546 a. Many times I feel that I have little influence over the things that happen to me. b. It is impossible for me to believe that chance or luck plays an important role In my life. VARB16 0.493 a. It is hard to know whether or not a person really likes you. b. How many friends you have depends upon how nice a person you are.

VARB15 0.468 d. Most people don't realize the extent to which their lives are controlled by accidental happenings. b. There really is no such thing as "luck."

VARB06 0.452 a. No matter how hard you try, some people just don't like you. b. People who can't get others to like them don't understand how to get along with others.

Examples of lower loadings

VARB17 0.048 a. In the long run the bad things that happen to us are balanced by the good ones. b. Most misfortunes are the result of lack of ability, ignorance, laziness, or all three.

VARB10 0.065 a. The average citizen can have an influence in government decisions. This world is run by the few people in power, and there is not much the little guy can do about it.

VARB14 0.080 a. As far as world affairs are concerned most of us are the victims of forces we can neither under­ stand, nor control. b. By taking an active part in political and social affairs the people can control world events.

VARB23 0.212 a. Most of the time I can't understand why politicians behave the way they do. b. In the long run the people are responsible for bad government on a national as well as on a local level.

(Underlined responses represent external locus of control responses.) 87 part in everyday life. But the same population did not relate to macrocosmic issues with any consistency, suggesting that subjects had limited experience, interest or understanding of relating to the world beyond their immediate situation.

It was, therefore, decided to accept this instrument without item deletion and further factor analytic refinement. For the purposes of this study, even though the factor structure was weakened and the test lost some of its power, it did seem to measure the function of locus of control.

The Rokeach Dogmatism Scale

The author of this instrument effectively created a large central dimension which covered his dogmatism construct. Two smaller dimensions, time and beliefs, were on four-item'subscales too small for factor ana­ lysis. This scale yielded a reliability coefficient of .84, a mean of

120.63, and a standard deviation of 20.02 on 102 cases.

A factor analysis was performed on the total scale. It revealed an ambiguous picture: either the instrument was measuring many different things, or it was measuring one concept but without strong loading.

Table 14 reflects the Eigenvalues and Table 15 the varimax rotated factor matrix for this scale. It is apparent that, according to the scree criteria, a gradual curve appears where only 29*1% were accounted for in the first 3 factors. The most likely explanation was that the instrument measured one factor, but was picking up influences of many others.

An examination of the constructs inherent in the items of this test, as reflected in Table 16 revealed that the instrument was assessing the 88

TABLE 14

EIGENVALUES FOR THE ROKEACH

DOGMATISM SCALE

Factor Eigenvalue Pet. of var. Cum. pet.

l 6.47109 16.2 16.2 2 2.79543 7.0 23.2 3 2.38875 6.0 29. 1 4 1.98573 5.0 34. 1 5 1.88351 4.7 38.8 6 1.66069 4.2 43.0 7 1.58380 4.0 46.9 8 1.51108 3.8 50.7 9 1.39076 3.5 54.2 10 1.32922 3.3 57.5 11 1.28173 3.2 60.7 12 1.20233 3.0 63.7 13 1.11925 2.8 66.5 14 1.02895 2.6 69. 1 15 0.94977 2.4 71.5 16 0.92849 2.3 73.8 17 0.85875 2. 1 75.9 18 0.80302 2.0 77.9 19 0.76438 1.9 79.8 20 0.74885 1.9 81.7 21 0.69310 1.7 83.4 22 0.63665 1.6 85.0 23 0.60039 1.5 86.5 24 0.56907 1.4 88.0 25 0.52483 . 1.3 89.3 26 0.52153 1.3 90.6 27 0.46168 1.2 91.7 28 0.42562 1. 1 92.8 29 0.38486 1.0 93.8 30 0.35068 0.9 94.6 31 0.32482 0.8 95.4 32 0.29127 0.7 96.2 33 0.26567 0.7 96.8 34 0.24122 0.6 97.4 35 0.22283 0.6 98.0 36 0.20953 0.5 98.5 37 0.18728 0.5 99.0 38 0.16414 0.4 99.4 39 0.14118 0.4 99.8 40 0.09815 0.2 100.0

presence and function of belief systems and open or closed-mindedness.

The common factor which seemed to be accounted for in the higher factor loadings was the construct of the "right" attitude, idea or opinion that persons are supposed to have. The lowest factor loadings indicated the presence of some other factor, and the items selected for analysis suggested that the other factor influencing the factor analysis had to do with ultimate ideals or causes and belief systems which are more global than particular attitudes, ideas or opinions. TABLE 15 89

VARIMAX ROTATED FACTOR MATRIX

FOR THE ROKEACH DOGMATISM SCALE

Item Factor 1 Factor 2 Factor 3

VARCOl 0.05078 0.45396 -0.36954 VARC02 0.00790 0.00563 0.23093 VARC03 0.10527 -0.04849 0.25409 VARC04 0.17977 0.40798 0.40206 VAIIC05 -0.04146 0.60588 -0.25174 VARC06 -0.00972 0.48432 0.05353 VARC07 0.29765 0.10755 0.29151 VARC08 0.49027 0.07582 0.14149 VAUC09 0.00759 0.47252 0.20429 VARC10 0.02772 0.46032 0.08893 VARC11 0.21101 0.00687 0.25400 VARC12 -0.11406 0.29144 0.44434 VARC13 0.02699 0.14069 0.05273 VARC14 0.47559 0.24052 -0.17720 VARC15 0.40206 0.19403 -0.12494 VARC16 -0.04566 -0.03616 0.46967 VARC17 0.32170 0.33959 -0.10740 VARC10 0.00214 -0.24380 0.24440 VARC19 0.36643 0.13448 0.23683 VARC20 0.30146 -0.04711 -0.06316 VARC21 0.59245 0.02393 0.01514 VARC22 -0.03776 -0.01020 0.17299 VARC23 0.44307 0.36029 0.21614 VARC24 0.27010 0.05620 0. 19902 VARC25 0.03353 0.17883 0.49737 VARC26 0.32093 0.40661 0.00319 VARC27 0.31258 0.30206 0.23238 VARC20 0.32394 0.41412 0.03269 « VARC29 0.32166 0.06258 0.23644 VARC30 0.20310 0.27029 0. 15609 VARC31 0.1S635 0.45718 0.27829 VARC32 0.17224 0.20411 0.40310 VARC33 0.29716 -0.11992 0.42317 VARC34 0.06110 0.29901 -0.10297 VARC35 0.27410 0.24171 0.05256 VARC36 0.44208 0.01953 0.10002 VARC37 0.49504 0.36101 0.24989 VARC33 0.31932 0.27340 0.49536 VARC39 0.27415 0.39702 0.27809 VARC40 0.71708 0.05321 -0.01781

As had been true with the Internal-External Locus of Control Scale, so also the Rokeach was proving to be very sensitive to issues of open and closed-mindedness as'they pertain to the practical matters of every­ day life. The focus of these high loading items was the microcosm of life within specific, well-known parameters. In contrast to this were macrocosmic concepts, reflected in more abstract and ideal questions of life mission, or transcendent cause. Subjects confronted with these 90

TABLE 16

TYPICAL ITEMS FROM THE

ROKEACH DOGMATISM SCALE

Factor Item loading Concept

Higher Factor Loadings

VARCltO .717, When it com es to difleren ces of opinion in religion we must be careful not to compromise with those who believe differently from the way we do. VARC21 • .592 To compromise with our political opponents is dangerus because it usually leads to the betrayal of our own side. VARC08 ’ .490 Of all the different philosophies which have existed in this world there is probably only one which is correct.

VARC37 .495 Most of the ideas which get published nowadays aren't worth the paper they are printed on.

VARC 14 .476 A group which tolerates too much difference of opinion among its own members cannot exist for long.

Lower Factor Loadings

VARC18 .002 If a man is to accomplish his mission in life it is sometimes necessary to gamble "all or nothing at all."

VARC 09 .008 * It is when a person devotes himself to an ideal or cause that his life become meanngful.

VARC02 ..008 ‘ The main thing in life is for a person to do something important.

VARC05 .009 It is when a person devotes himself to an ideal or cause that his life becomes meaningful. VARC16 .046 While I don't like to admit this, even to myself, I"sometimes have the ambi­ tion to become a great man, like Einstein, or Beethoven, or Shakespeare. 91 questions answered in such a variety of ways that the factor loadings were disparate and quite low. Apparently this population was knowledge­

able and oriented to microcosmic concepts of open and closed-mindedness, but had more limited experience, interest or understanding of open

and closed-mindedness as it related to the world beyond the immediate

situation.

Again it was decided that, because of the relatively weak factor

structure, item deletion and further factor analytic refinement would

not aid in further clarification of this instrument. It was seen as

measuring open and closed-mindedness within belief systems.

The Bessai Common Belief Survey

This instrument required the most extensive scale refinement. The

author designed it around six subscales: Self-Downing, Perfectionism,

Blame-Proneness, Importance of the Past, Importance of Approval and Con­

trol of Emotions. The first three subscales were combined into a greater

subscale called Evaluation, and the second three subscales were combined

into a subscale called Locus of Control. The summary statistics for all

these subscales were calculated and are reported in Table 17.

As can be seen, reliability coefficients for the total scale, sub­ scales, and combined subscales ranged from .64 to .87. It was decided to conduct a factor analysis on each of the scales. Each of the six subscales and the two combined subscales were examined to determine if they were germane to the study. Finally, a factor analysis of the total scale was performed. 92

TABLE 17

SUMMARY STATISTICS OF THE

BESSAI COMMON BELIEFS SURVEY

Reliability Scale coefficient Mean S.D. Cases

Total Scale .84 142.52 16.87 110

Self-Downing .87 19.66 5.37 110

Perfectionism .70 31.42 4.87 110

Blame-Proneness .85 23.18 5.16 110

Importance of Past .71 28.44 4.79 110

Importance of Approval .68 20.32 3.49 110

Control of Emotions .64 19.51 3.27 110

Evaluation .87 74.26 11.72 110

Locus of Control .78 68.26 8.48 110

The Self-Downing Scale

The initial analysis of this scale indicated that a relatively strong pure factor was present, accounting for 48.2% of the variance. This was confirmed by use of the scree criteria as is apparent in Table 18.

When this scale was rotated for two factors as shown in Table 19, it was noted that the loadings on Factor 1 were acceptable with two exceptions: item VARD07 ("If people don't meet their own standards they are bound to think less of themselves") which was very weak, and item

VARD22 ("Criticism is bound to make anyone very nervous and anxious") which was just below the acceptable limit of .30. Subjects of this 93

TABLE 18

EIGENVALUES OF THE SELF-DOWNING SUBSCALE

OF THE BESSAI COMMON BELIEFS SURVEY

Factor Eigenvalue Pet. of var. Cura. pet.

1 A.33732 A8.2 A8.2 2 1.01A91 11.3 59.5 3 0.8A225 9.A 68.8 A 0.63956 7.1 75.9 5 0.58335 6.5 82.A 6 0.A7557 5.3 87.7 7 0.A3A28 A.8 92.5 8 0.37299 A.l 96.7 9 0.29973 3.3 100.0

TABLE 19

INITIAL VARIMAX ROTATED FACTOR MATRIX OF THE

SELF-DOWNING SCALE OF THE BESSAI COMMON BELIEFS SURVEY

Item Factor 1 Factor 2

VARD03 0.5856A 0.33816 VARD52 0.63512 0.37665 VARD22 0.259A1 0.59287 VARD17 0.517A8 0.5600A VARDAO 0.A9505 0.36A16 VARDA9 0.75933 0.10A98 VARD07 0.09017 0.3900A VARD3A 0.69278 0.A3791 VARD28 0.60550 0.23017 94

study made disparate inferences from these questions, not consistently

perceiving them to be pure self-downing issues.

With these two items deleted a new factor analysis was conducted

for a refined scale. Table 20 displays the refined factor structure.

It is apparent that one factor was loaded strongly in the structure of

this scale.

TABLE 20

REFINED VARIMAX ROTATED FACTOR MATRIX OF THE

SELF-DOWNING SCALE OF THE BESSAI COMMON BELIEFS SURVEY

Item Factor 1 Factor 2

V M S 03 0.7Q721 0.17896 VARD52 0.509-37 0.54644 VAIID17 0.62951 0.35331 VAUD40 0.24304 0.77164 VAHD49 0.56811 0.41072. VAUD34 0.75209 0.36864 VAHD28 0.55412 0.36452

Sample items reflecting the construct Self-Downing are displayed

in Table 21.

The Perfectionism Scale

An initial analysis of this scale indicated a relatively weak scale with several complexity factor items. As is apparent in Table 22 ac­ cording to the scree criteria only 30% of the variance was accounted for in the first factor. The rotated factor matrix as shown in Table 23 indicated that four of the nine factors were below the minimal .30 coefficient and the loading actually was distributed higher in Factor 2. 95 TABLE 21

SAMPLE ITEMS FROM THE SELF-DOWNING

SCALE OF THE BESSAI COMMON BELIEFS SURVEY

Factor Item loading Concept

VARD34 .752 People are bound to put themselves down when they fail. ' VARD03 .737 One can't help getting down on oneself when one fails at something. VARD17 .630 Failures just naturally produce guilt feelings.

TABLE 22

EIGENVALUES OF PERFECTIONISM SCALE OF THE

BESSAI COMMON BELIEFS SURVEY

Factor Eigenvalue _ Pet. of var. Cum. pet.

1 2.69703 30.0 30.0 2 1.20714 13.4 43.4 3 0.99861 11.1 54.5 4 0.92488 10.3 64.8 5 0.84784 9.4 74.2 6 0.74665 8.3 82.5 7 0.60158 6.7 89.2 0 0.53283 5.9 95. 1 9 0.44342 4.9 100.0 TABLE 23 96

VARIMAX ROTATED FACTOR STRUCTURE OF THE

PERFECTIONISM SCALE OF THE BESSAI COMMON BELIEFS SURVEY

Item Factor 1 Factor 2

VARD50 0.32232 0.30956 VAIIDQ2 0.83173 -0.06629 VARD23 0.09414 0.42005 VARDIO 0.23631 0.30611 VAHD37 0. 16793 0.57407 VARD45 0.36336 0.33311 VAUD32 0.04062 C .46238 VA11D29 0.43422 0.25190 VAIID13 1.41208 0.33234

Sample items reflecting the construct Perfectionism are displayed

in Table 24.

TABLE 24

SAMPLE ITEMS FROM THE PERFECTIONISM

SCALE OF THE BESSAI COMMON BELIEFS SURVEY

Factor Item loading Concept

High Factor Loadings

VARD02 .768 There is a right way to do everything. VARD29 .554 For most questions there is one right answer. VARD50 .425 There is invariably a right, precise, and perfect solution to human problems, and it is terrible when this perfect solution isn't found.

Low Factor Loadings

VARD32 .049 It is awful when things are not the way one would very much like them to be. VARD23 .094 One must be perfectly competent, adequate, and achieving to consider oneself worthwhile. VARD37 .168 The main goal and purpose of life is achievement and success. 97 It was obvious that subjects perceived the high loading items as

addressing the issue of perfectionism, but their response to the low

loading items was disparate, the questions meaning different things to

different persons.

It was decided, therefore, to leave this scale unrefined. To have

deleted all these items for further analysis would have left the scale

weak and heuristically meaningless.

The Blame-Proneness Scale

The initial analysis of this scale revealed the presence of a single

factor, accounting for 41.9% of the total variance according to the scree criteria. Table 25 displays this information.

TABLE 25

EIGENVALUES FOR BLAME-PRONENESS SCALE

OF THE BESSAI COMMON BELIEF SURVEY

Factor Eigenvalue Pet. of var. Cum. pet.

1 3.77385 41.9 41.9 2 1.24059 13.8 55.7 3 0.91990 10.2 65.9 4 0.72628 8.2 74.1 5 0.63071 7.0 81.1 6 0.55007 6.1 87.2 7 0.45785 5.1 92.3 8 0.44449 4.9 97.3 9 0.24624 2.7 100.0

This scale was then submitted to a two-factor analysis. Table 26

displays these data. It can be seen that loadings were very high except

for two items, VARD14 ("People are justified in refusing to forgive their

enemies") and VARD26 ("If someone does one wrong, then one should think 98

less of that person.") These two items were then deleted and a new

.factor analysis was conducted for a refined scale.

TABLE 26

INITIAL VARIMAX ROTATED FACTOR MATRIX OF THE BLAME-

PRONENESS SCALE OF THE BESSAI COMMON BELIEFS SURVEY

Item Factor 1 Factor 2

VARD35 0.84396 0.11364 VARD08 0.73322 0.13025 VARD53 0.53889 0.32910 VARD46 0.52265 0.41398 VARD05 0.47393 0.39403 VARD24 0.58166 0.47521 VARD39 0.56887 0.01627 VARD26 0.08832 0.54485 VARD14 0.03894 0.39538

Table 27 displays the eigenvalues of the refined factor analysis and Table 28 displays the refined factor analysis itself. Some 52.5% of the variance was accounted for in the first factor. The loadings on Factor 1 were actually lower than prior to the refinement, but the distribution was higher in Factor 2. This suggested that one construct was apparently affecting both factors.

Sample items reflecting the construct Blame-Proneness are displayed in Table 29. 99 TABLE 27

REFINED EIGENVALUES OF THE BLAME-PRONENESS

SCALE OF THE BESSAI COMMON BELIEFS SURVEY

Factor Eigenvalue Pet. of var. Cum. pet.

l 3.67596 52.5 52.5 2 0.84481 12. 1 64.6 3 0.71579 10.2 74.8 4 0.58131 8.3 83. 1 5 0.49769 7. 1 90.2 6 0.44284 6.3 96.5 7 0.24158 3.5 100.0

TABLE 28

REFINED VARIMAX ROTATED FACTOR MATRIX OF THE

BLAME-PRONENESS SCALE OF THE BESSAI COMMON BELIEFS SURVEY

Item Factor 1 Factor 2

.VAUD35 0.80171 0.38485 VARD08 0.76612 0.30111 VAIID53 0.37901 0.53955 VAIID46 0.20009 0.62592 VAUB05 0.32960 0.52725 VARD24 0.29115 0.71963 VAUD39 0.42420 0.30668

TABLE 29

SAMPLE ITEMS OF THE BLAME-PRONENESS SCALE

OF THE BESSAI COMMON BELIEFS SURVEY

Factor Item loading Concept

VARD35 .802 There is no such thing as bad people; there are only bad deeds. VARD08 .766 No one is evil, even though his deeds may bi VARD39 .424 People who do wrong deserve what they get. 100

The Importance of the Past Scale

Initial analysis of this scale indicated a weak factor structure.

As shown in Table 30, according to the scree criteria the first factor appeared to account for only 30.6% of the variance, and a second factor added another 19*9% of the variance. Table 31 reveals that, in the rotated factor loadings, four items fell below the minimal .30 coefficient.

TABLE 30

EIGENVALUES OF THE IMPORTANCE OF THE PAST SCALE

OF THE BESSAI COMMON BELIEFS• SURVEY

Factor Eigenvalue Pet. of var. Cum. pet.

l 2.74985 30.6 30.6 2 1.70986 . 19.9 50.4 3 1.00697 11.2 61.6 4 0.84368 9.4 71. 1 5 0.64591 7.2 78.2 6 0.63519 7. 1 35.3 7 0.51690 5.7 91.0 8 0.45018 5.0 96.0 9 0.35643 4.0 100.0

TABLE 31

VARIMAX ROTATED FACTOR MATRIX OF THE IMPORTANCE

OF THE PAST SCALE OF THE BESSAI COMMON BELIEFS SURVEY

Item Factor 1 Factor 2

VAUD21 0.14331 0.74905 VAUD36 0.19375 0.61093 VARD09 0.24251 0.55455 VARD15 -0.14584 0.55139 VARD01 0.34362 O . 11429 VAIID43 0.66786 O . 10357 VARD54 0.77701 0.00018 VARD38 0.59854 -O.C9433 VARD30 0.35549 0.00570 101

VARD 21 ("Past experiences need not affec.t present behavior");

VARD15 ("One can overcome the influence of past events"); VARD36

("The past is past and doesn't have to affect now"); and VARD09 ("Some­ thing that once strongly influenced one's life need not determine one's feelings and behavior today because one's past is not all-important.")

These concepts, which seem rather clear in their reference to an orien­ tation to the past, and which are so similar to the strongly loaded items, were not clearly perceived by the subjects of this study.

It was decided to accept this scale without further factor analytic refinement. To have deleted four items for further analysis would have left the scale weakened and heuristically meaningless.

Sample items do reflect the construct Importance of the Past as indicated in Table 32.

TABLE 32

SAMPLE ITEMS OF THE IMPORTANCE OF THE PAST

SCALE OF THE BESSAI COMMON BELIEF SURVEY

Factor Item loading Concept

VARDbA .777 Past mistakes must greatly influence the present.

VARD43 .668 Something that once strongly influenced one's life determines one’s feelings and behavior today because one's past remains all important.

VARD38 .599 There is no stronger influence on the present than the past. 102

The Importance of Approval Scale

Initial analysis indicated that this scale could possibly be strengthened by instrument refinement. Table 33 displays the eigen­ values and Table 34 the initial varimax rotated factor matrix. Clearly three factors were accounting for 55.5% of the variance, with the first accounting for only 30.1%. The factor matrix revealed several items with relatively high loadings, but three low loading items which could account fdr the complexity of variance: VARD12 ("People do not need to be loved in order to accept themselves"); VARD48 ("It is not a great necessity to be loved or approved by every significant other person"), and VARD25 ("Being ignored by friends doesn't have to be upsetting.")

It was decided to delete these items.

TABLE 33

INITIAL EIGENVALUES OF THE IMPORTANCE

OF APPROVAL SCALE OF THE BESSAI COMMON BELIEFS SURVEY

Factor Eigenvalue Pet. of var. Cum. pet.

1 2.70517 30.1 30.1 2 1.24079 13.8 43.8 3 1.04549 11.6 55.5 4 0.85270 9.5 64.9 5 0.76369 8.5 73.4 6 0.68432 7.6 81.0 7 0.65288 7.3 88.3 8 0.55521 6.2 94.4 9 0.49974 5.6 100.0 103

TA. 'E 34

INITIAL VARIMAX ROTATED FACTOR MATRIX OF THE IMPORTANCE

OF APPROVAL SCALE OF THE BESSAI COMMON BELIEFS SURVEY

Item Factor 1 Factor 2

VARD44 0.54085 0.18061 VARD19 0.55058 0.20923 VARD48 0.12652 0.24340 VARD16 0.56996 0.30550 VARD42 0.30195 0.11695 VARD33 0.43921 0.18140 VARD12 0.01873 0.77219 VARD25 0.24982 0.45101 VARD04 0.52202 0.21060

Item VARD12 was quite clearly a Factor 2 item, referring, perhaps, to a

construct of "love" which subjects did not equate with approval. The decision to delete the other two items was made both because they fell below the .30 minimum coefficient, and also because the remaining items were relatively strong.

With these items deleted, the new factor structure was improved considerably. As shown in Table 35, Factor 1 of the refined instrument could now be seen as accounting for 39% of the variance.

TABLE 35

REFINED EIGENVALUES OF THE IMPORTANCE OF

APPROVAL SCALE OF THE BESSAI COMMON BELIEFS SURVEY

Factor Eigenvalue Pet. of var. Cum. pet.

1 2.34162 39.0 39.0 2 1.02014 17.0 56.0 3 0.80483 13.4 69.4 4 0.68922 11.5 80.9 5 0.62554 10.4 91.4 6 0.51862 8.6 100.0 104

Table 36 displays the factor loadings on the remaining six items

which were generally strengthened by the refinement, and Table 37 lists

sample items which reflect the construct Importance of Approval.

TABLE 36

REFINED VARIMAX ROTATED FACTOR MATRIX OF THE IMPORTANCE OF

APPROVAL SCALE OF THE BESSAI COMMON BELIEFS SURVEY

Item Factor 1 Factor 2

VAIID44 0.31612 0.56646 VAIID19 0.34303 0.55330 VARD16 0.64631 0.21560 VARD42 0.04399 0.23455 VARD33 0.46276 0.23111 VARDQ4 0.55299 0.16124

TABLE 37

SAMPLE ITEMS OF THE IMPORTANCE OF APPROVAL

SCALE OF THE BESSAI COMMON BELIEFS SCALE

Factor Item loading Concept

VARD16 .646 Although approval is enjoyable, it is not a real necessity.

VARD04 .553 Being approved of by others is very important.

VARD33 .463 Having the respect of others is important but certainly not necessary.

The Control of Emotions Scale

The initial analysis of this scale indicated a relatively weak factor structure. As is displayed in Table 38, the first factor 105 '

accounted for only 28.3% of the variance, with the two next factors

only bringing the variance up to a 52.4% level. In the rotated factor

loadings of Table 39, item VARD11 ("How a person interprets an event

determines his/her emotions") was loaded so low that it seemed to have

little in common with either of the first two factors; and items

VARD20 ("Human unhappiness is not externally caused and people have

the ability to control their sorrows and distrubances") and VARD06

("Unhappiness comes from inside oneself") also appeared very low.

TABLE 38

INITIAL EIGENVALUES OF THE CONTROL OF

EMOTIONS SCALE OF THE BESSAI COMMON BELIEFS SURVEY

Factor Eigenvalue Pet. of var. Cum. pet.

1 2.54637 28.3 28.3 2 1.14049 12.7 41.0 3 1.03362 11.5 52.4 4 0.96809 10.8 63.2 ' 5 0.87924 9.8 73.0 6 0.72487 8.1 81.0 7 0.69102 7.7 88.7 8 0.54375 6.0 94.7 9 0.47252 5.3 100.0

It was, therefore, decided to delete these three items and cal- culate a new refined factor structure. Table 40 and Table 41 show how the scale was strengthened through factor analytic refinement.

As is apparent, Factor 1 could now be seen as accounting for

36.7% of the variance and Factor 2 bringing the coefficient to 51.6%. 106

TABLE 39

INITIAL VARIMAX ROTATED FACTOR MATRIX OF THE CONTROL OF

EMOTIONS SCALE OF THE BESSAI COMMON BELIEFS SURVEY

Item Factor 1 Factor 2

VARD31 0.36285 0.24402 VARD18 0.63237 0.05015 VARD47 0.60757 0.17923 VARD20 0.14566 0.74658 VARD27 0.45885 0.12314 VARD06 0.23895 0.15956 VARD11 0.00683 0.04490 VARD41 0.29033 0.37712 VARD51 0.33177 0.36773

TABLE AO

REFINED EIGENVALUES OF THE CONTROL OF EMOTIONS

SCALE OF THE BESSAI COMMON BELIEFS SURVEY

Factor Eigenvalue Pet. of var. Cum. pet.

l 2. 19977 36.7 36.7 2 0.89809 15.0 51.6 3 0.82243 43.7 • 65.3 4 0.78377 ■S. 1 78.4 5 0.72968 *2.2 90.6 6 0.56624 9.4 ,100.0

TABLE 41

REFINED VARIMAX ROTATED FACTOR MATRIX OF THE CONTROL OF

EMOTIONS SCALE OF THE BESSAI COMMON BELIEFS SURVEY

Item Factor 1 Factor 2

VARD31 G.'o3 ,jl 0.23842 VARD18 0.67*,« O . 10594 VARD47 0.44O54 0.48584 VARD27 0.28892 0.32532 VARD41 0.09645 0.57591 'VARD51 0.33006 0.3162«> 107

Overall, factor loadings for the two factors indicated a common influence on both factors.

Sample items reflecting the construct Control of Emotions are displayed in Table 42.

TABLE 42

SAMPLE ITEMS OF THE CONTROL OF EMOTIONS

SCALE OF THE BESSAI COMMON BELIEFS SURVEY

Factor Item loading Concept

VARD18 .674 •People who are miserable have usually made them­ selves that way.

VARD47 .441 People pretty much cause their own moods.

VARD31 .340 People make their own hell within themselves.

The Evaluation Combined Subscale

This scale represents the sum of the Self-Downing, Perfectionism

and Blame-Proneness subscales. It was examined at the time of the

initial factor analysis and again after the refinement of the three

subscales with a second varimax factor rotation with various subscale

items deleted from the Self-Downing and Blame-Proneness subscales.

Table 43 and Table 44 display the results of the initial factor

analysis and Table 45 and Table 46 compare the results of the refined

factor analysis. A comparative study of these scales reveals how

the refined factor analysis improved the factor loadings and how the

combined scale homogenized the three subscales. Factor 1 was loaded 108 TABLE 43

INITIAL EIGENVALUES OF THE EVALUATION

SCALE OF THE BESSAI COMMON BELIEFS SURVEY

Eigenvalue Pet. of var. Cum. Pet.

6.59225 24.4 24.4 2.92878 10.8 35.3 2.07780 7.7 43.0 4 1.42489 5.3 48.2 5 1.29139 4.8 53.0 6 1.16760 4.3 57.3 7 1.10112 4.1 61.4 8 0.93827 3.5 64.9 9 0.91612 3.4 68.3 10 0.82909 3.1 71.4 11 0.79116 2.9 74.3 12 0.73260 2.7 77.0 13 0.68088 2.5 79.5 14 0.62780 2.3 81.9 15 0.62308 2.3 84.2 16 0.56942 2.1 86.3 17 0.51089 1.9 88.2 18 0.47692 1.8 89.9 19 0.45964 1.7 91.6 20 0.42229 1.6 93.2 21 0.36697 1.4 94.6 22 0.32908 1.2 95.8 23 0.30057 1.1 96.9 24 0.25153 0.9 97.8 25 0.24087 0.9 98.7 26 0.19781 0.7 99.4 27 0.15112 0.6 100.0 o n o

X Cd > OS z> CO CO D- ON O NONvOC\J*TOMnOONOMr»M^LOOHOO(r)(r)^'JO>0 M CO on in c^*«—i in_ o _vOvOC\JHHCOHCOONOOvOC\JHvO(r)C^ 2 fj O 05 O o o 00 E-< in CM m c- «—I ON rH CM CO ON o O in vO O vO ON vO co CO CM ON 00 ON CO .p ON C— o o CO ON Cd CO CM CM o ON C— > > > > > > > > > > > > > > > > > > > > > > > > > > 110 TABLE 45

REFINED EIGENVALUES OF THE EVALUATION

SCALE OF THE BESSAI COMMON BELIEFS SURVEY

Factor Eigenvalue Pet. of var. Cum. pet.

1 6.24277 27.1 27. 1 2 2.80941 12.2 39.4 3 2.03275 8.8 48.2 4 1.14894 5.0 53.2 3 1.05550 4.6 57.8 6 1.01418 4.4 62.2 7 0.88253 3.8 66.0 3 0.66031 3.7 69.8 9 0.77205 3.4 73. 1 10 0.75371 3.3 76.4 11 0.69796 3.0 79.4 12 0.63477 2.8 82.2 13 0.58219 2.5 84.7 • 14 0.52629 2.3 87.0 15 0.47244 2. 1 89. 1 16 0.45859 2.0 91.1 17 0.41722 1.8 92.9 18 C.36600 1.6 94.5 19 0.33958 1.5 95.9 20 0;29164 1.3 97.2 21 0.26369 1. 1 98.4 22 0.21414 0.9 99.3 23 0.16320 0.7 100.0

highly on the first seven items, which corresponded with the Self-

Downing Scale; Factor 2 was loaded highly on the next seven items which corresponded with the Blame-Proneness scale; and Factor 3 was loaded highly on the final nine items, which corresponded with the

Perfectionism scale. The combined scale, when viewed from the scree criteria revealed three operating factors with an acceptable primary factor accounting for 27.1% of the variance. This was an approximate replication of the factor structure first described by the author of this instrument. 111 TABLE 46

REFINED VARIMAX ROTATED FACTOR MATRIX OF THE

EVALUATION SCALE OF THE BESSAI COMMON BELIEFS SURVEY

Item Factor 1 Factor 2 Factor 3

VARD03 0.70716 0.02230 -0.02370 VARD52 0.672B0 0.19507 0.23187 VARD17 0.71335 0.13669 0.07235 VARD40 0.54407 0.35375 0.29108 VARD49 0.65458 0.23402 0.04536 VARD34 0.83576 0.17678 -0.04052 VARD28 0.62451 0.07360 0.20490 VAHD35 0.11394 0.81538 -0.11600 VARD08 0.14422 0.71685 -0.00950 VARD53 0.03569 0.667?-’ 0.08035 VARD46 -0.03061 0.63753 0.26950 VARD05 0.08950 0.60504 0.12646 VARD24 0.21923 0.64782 0.14502 VARD39 0.26005 0.48609 0.09807 VARD50 0.29890 0.05217 0.38545 VARB02 -0.00740 -0.00610 0.52683 VARD23 0.34658 -0.04005 0.26460 VAIUMO 0.03690 0.29017 0.36372 VARD37 0.29049 0.30998 0.33697 VARD45 0.11047 0.18036 0.52879 VARD32 0.38999 0.02232 0.22836 VARD29 0.07355 0.11428 0.50916 VARDAS 0. 16360 -0.01694 0,52038

The Locus of Control Combined Subscale

This scale represents the sum of the Importance of the Past,

Importance of Approval, and Control of Emotions subscales. It was examined at the time of the initial factor analysis and again after the refinement of the three subscales with a second factor analysis for the various subscales, accounting for the deletion of three items from two of the subscales.

Table 47 and Table 48 display the results of the initial factor analysis, and Table 49 and Table 50 compare the results of the refined factor analysis. A comparative study of these scales indicated that the initial analysis was ambiguous and inconclusive, and the refined analysis did not eliminate the situation. Interpretation by the scree criteria 112 TABLE 47

INITIAL EIGENVALUES OF THE LOCUS OF CONTROL

SCALE OF THE BESSAI COMMON BELIEFS SURVEY

iCt Eigenvalue Pet. of var. Cum. pet.

1 4.66759 17.3 17.3 2 2.55494 9.5 26.8 3 1.98054 7.3 34.1 4 1.69892 6.3 40.4 5 1.45377 5.4 45.8 6 1.36582 5.1 50.8 7 1.23313 4.6 55.4 8 1.12539 4.2 59.6 9 1.06927 4.0 63.5 10 0.92616 3.4 66.9 11 0.91130 3.4 70.3 12 0.83546 3.1 73.4 13 0.81020 3.0 76.4 14 0.76404 2.8 79.2 15 0.68080 2.5 81.8 16 0.62832 2.3 84.1 17 0.58516 2.2 86.3 18 0.52408 1.9 88.2 19 0.52025 1.9 90.1 20 0.46430 1.7 91.9 21 0.43087 1.6 93.4 22 0.38707 1.4 94.9 23 0.32477 1.2 96.1 24 0.30275 1.1 97.2 25 0.29822 1.1 98.3 26 0.25397 0.9 99-2 27 0.20285 0.8 100.0 113 TABLE 48

INITIAL VARIMAX ROTATED FACTOR MATRIX OF THE LOCUS

OF CONTROL SCALE OF THE BESSAI COMMON BELIEFS SURVEY

Item Factor 1 Factor 2 Factor 3

VARD21 0.52499 0.22148 0.22354 VARD36 0.44435 0.18246 0.26344 VARD09 0.34414 0.10417 0.29664 VARD15 0.48881 0.23600 -0.12029 VARD01 0.27180 -0.17909 0.29562 VARD43 0.24939 0.07071 0.61680 VARD54 0.09861 0.09154 0.70890 VARD38 -0.18876 -0.17444 0.67604 VARD30 -0.00541 0.03950 0.32940 VARDA4 0.36667 0.08868 0.23085 VARD19 0.46319, 0.29085 -0.01903 VARD48 0.42844 -0.00292 -0.08594 VARD16 0.42292 0.17088 0.12951 VARD42 -0.07151 0.45219 0.20909 VARD33 0.30933 0.15678 0.21615 VARD12 0.50890 -0.09977 -0.13551 VARD25 0.47695 0.12427 0.10824 VARD04 0.40222 0.06291 0.33235 VARD31 0.19614 0.43703 0.03704 VARD18 0.13591 0.44781 -0.13607 VARD47 ' 0.13146 0.56178 -0.03093 VARD20 0.29496 0.42514 0.04121 VARD27 0.16764 0.43694 0.01841 VARD06 -0.10742 0.39199 -0.03536 VARD11 -0.20949 0.13673 -0.16016 VARD41 0.05015 0.49897 0.15686 VARD51 0.24179 0.30296 -0.00296 114

TABLE 49

REFINED EIGENVALUES OF THE LOCUS OF

CONTROL SCALE OF THE BESSAI COMMON BELIEFS SURVEY

Factor Eigenvalue Pet. of var. Cum. pet.'

1 4.00539 19.1 19.1 2 2.40931 11.5 30.5 3 1.76796 8.4 39.0 4 1.53538 7.3 46.3 5 1.27258 6. 1 52.3 6 1.09386 5.2 57.5 7 1.05062 5.0 62.5 8 0.97693 4.7 67.2 9 0.83607 4.0 71.2 10 0.80607 3.8 75.0 11 0.70943 3.4 78.4 12 0.63708 3.0 81.4 13 0.62017 3.0 84.4 14 0.56480 2.7 87. 1 15 0.52494 2.5 89.6 16 0.45262 2.2 91.7 17 0.40193 1.9 93.6 18 0.37614 1.8 95.4 19 0.35432 1.7 97. 1 20 0.32869 1.6 98.7 21 0.27567 1.3 100.0

revealed that five factors accounted for the first 52% of the variance.

Factor loadings on the first three factors did not cluster around three subscale items as occurred with the Evaluative Scale. Instead the load­

ings were complex, shifting from one factor to another after the refined analysis, and not forming a clear pattern.

It was decided that the best interpretation of these data was that

the three subscales, Importance of the Past, Importance of Approval, and

Control of Emotions, which had previously shown themselves to have weak factor structures, did not sustain separate factor identity in the

Locus of Control combined subscale. However, the Locus of Control subscale, on its own merits, seemed to be functioning as a reliable scale and should be maintained in subsequent analysis of the MVPS data. 115

TABLE 50

REFINED VARIMAX ROTATED FACTOR MATRIX OF THE LOCUS

OF CONTROL SCALE OF THE BESSAI COMMON BELIEFS SURVEY

Item Factor 1 Factor 2 Factor 3

v,vriD21 0.51649 9.14940 0.23865 VARD3G 0.46015 0.10026 0.21375 VARD09 0.41312 0.19773 0.14071 VARDI5 0.44613 -0.10654 0.33719 VARBOl 0.10660 0.31060 -0.08691 VARD43 0.22462 0.66301 0. 11610 VARD54 0.10036 0.76970 0.10422 VARD3B -0.05966 0.62729 -0.13271 VAIID30 0.05010 0.35953 0.06220 VARD44 0.49540 0.12496 -0.04329 VARD19 0.60400 -0.15229 0.14507 VARD1G 0.49020 0.05941 0.08427 VARD42 0.01065 0.21241 0.30503 VARD33 0.47905 0.05763 0.07568 VARU04 0.40614 0.10636 0.03142 VARD31 0. 16964 0.00116 0.41719 VARDIO 0.00439 -0.07725 0.49446 VARD47 0.02992 -0.02190 0.71583 VARD27 0.26393 -0.11740 0.44920 VARD41 0.07535 0. 16130 0.40471 VARUS 1 0.20221 -0.03696 0.34260

The Total Bessai Scale

A factor analysis was then performed on the total Bessai Common

Beliefs Survey. Table 51 displays the eigenvalues of the instrument, indicating that of the 17 factors which exceeded the 1.00 eigenvalue, nine of these accounted for 52.5% of the variance.

A six factor analysis was performed and the results are shown in

Table 52. A careful evaluation of the higher loadings of each of these scales indicated that six distinct factors were being detected in the analysis. Table 53 indicates the sample items for each factor, which can be summarized as follows: 116 TABLE 51

EIGENVALUES OF THE TOTAL SCALE OF

THE BESSAI COMMON BELIEFS SURVEY

Eigenvalue Pet. of var. Cura. pet.

1 8.17765 15.1 15.1 2 4.58865 8.5 23.6 3 3.42450 6.3 30.0 4 2.59883 4.8 34.8 5 2.35892 4.4 39.2 6 2.03700 3.8 42.9 7 1.85210 3.4 46.4 Q 1.73918 3.2 49.6 9 1.59994 3.0 52.5 10 1.43384 2.7 55.2 11 1.37458 2.5 57.8 12 1.33124 2.5 60.2 13 1.30301 2.4 62.6 14 1.22761 2.3 64.9 13 1.14298 2.1 67.0 16 1.07367 2.0 69.0 17 1.01015 1.9 70.9 18 0.92050 1.7 72.6 19 0.91686 1.7 74.3 20 0.82695 1.5 75.8 21 0.80922 1.5 77.3 22 0.78636 1.5 78.8 23 0.73737 1.4 80.1 24 0.71173 1.3 81.4 25 0.68146 1.3 82.7 26 0.64838 1.2 83.9 27 0.58920 1.1 85.0 28 0.56205 1.0 86.0 29 0.52377 1.0 87.0 30 0.52093 1.0 88.0 31 0.51685 1.0 88.9 32 0.49285 0.9 89.8 33 0.46103 0.9 90.7 34 0.44737 0.8 91.5 35 0.42053 0.8 92.3 36 0.39527 0.7 93.0 37 0.35957 0.7 93.7 38 0.34334 0.6 94.3 39 0.33299 0.6 95.0 40 0.30642 0.6 95.5 41 0.29428 0.5 96.1 0.26458 0.5 96.6 0.25353 0.5 97.0 0.21267 0.4 97.4 0.20605 0.4 97.8 0.18744 0.3 98.2 117

TABLE 52

VARIMAX ROTATED FACTOR MATRIX OF

THE BESSAI COMMON BELIEFS SURVEY

item Factor 1 Factor 2 Factor 3 Factor 4 Factor 5 Factor £

VAJlDOl 0 . 30677 6.00883 . 6.17589 -0.61861 - 0 . 2 2 3 1 5 0 . 1 4 4 2 2 VAIUJ02 -0.04615 0 . 0 3 6 6 8 6 . 1 4 7 3 6 0.52667 - 6 . 6 0 8 6 5 0 . 69166 VAI1003 0.67932 - 6 . 6 0 0 1 1 0.16746 -0.67358 0.66943 0.60781 V A H D 0 4 0 . 22406 0 . 1 2 7 9 6 6 . 3 0 3 3 7 6.68806 0. 0 2 1 4 6 6. 1 3 9 3 3 VAHD03 0.69288 0 . 6 3 2 5 6 -6.61684 6.61212 0.67118 0 . 12480 V A R D 0 6 0 . 17659 - 0 . 0 5 6 4 8 - 0 . 1 1 8 0 7 6 . 15336 0 . 4 7 3 8 8 -6. 1 4 9 1 2 V A H D 0 7 - 0 . 3 3 5 4 0 0.16596 -6.28336 6.66676 0.26051 -0. 0 1 3 9 2 V A i m o a 0. 17359 6.67495 -6.64721 0.64083 - 6.06461 - 0 . 6 2 6 5 8 V A U D 0 9 0. 0 4 0 0 7 - 6 . 1 4 0 0 5 6 . 3 9 0 0 7 • 0.07690 - 6 . 6 0 0 8 0 6.44649 VAIIDIO 0.01154 0 . 3 6 7 4 2 6 . 3 4 3 3 0 0.21429 - 0 . 6 1 7 2 3 - 6 .04505 V A RD11 -0. 2 7 2 1 7 6.66509 -6.17474 0.69700 0. 2 2 7 7 4 -0.04975 VAIW12 0.04694 - 0 . 0 8 6 9 2 6 . 4 3 6 5 6 6.03366 - 0 . 1 7 9 9 0 -0.06435 VAIID13 0 . 1 6 1 0 3 0.01392 6.62037 6.49478 0. 07756 0 . 0 1 7 8 8 VA11D14 -0 . 0 1 7 9 0 -0.23497 6.23019 6.22440 - 0 . 2 6 6 2 0 -0.24231 VATU) 15 -0 . 0 9 3 9 4 0 . 0 2 2 3 2 6 . 5 5 0 9 7 0.61433 0 . 1 4 8 0 4 0.07819 VAnoie 0. 16430 -0.13503 6.43976 6.10666 6.06701 0 . 62134 V A R D 1 7 ' 0 . 7 0 5 3 4 6.12027 6.26163 6.65913 0.67995 - 0 . 0 0 5 5 0 V A R D 1 B 0.04003 0 . 0 4 2 0 6 6.13067 -0.14330 0.46463 - 0 . 6 6 7 2 4 VAJID19 0.03915 -0.19209 6.55334 6.14920 0.17209 - 0 . 1 0 1 0 7 VAIU)20 0.00312 0.22451 6.49076 0.13136 0.22361 -0.12151 V A RD21 0.11756 -6.05112 6.50906 -0.13094 6 . 1 7 9 5 4 0 . 41403 VAI1022 -0. 5 1 1 7 7 -0.13607 -0.11075 -0.18968 -0.11733 -0. 0 6 4 9 2 V A R D 2 3 0.33215 -0.66 232 6.12039 0.27359 0 . 0 9 0 2 4 6.12446 VARD24 0.23797 0.65008 - 6 . 6 1 4 3 0 6.67101 6 . 1 1 8 0 7 0 . 16016 VAIU)25 0.10231 0.06600 6.48276 -6.00573 0.00377 - 0 .02766 V A R D 2 6 - 0 . 0 5 6 7 0 -6.23236 6.66433 -0.01269 - 0 .24451 - 0 .00123 VAIID27 - 0 .21106 6.00050 0.34890 -0.12668 0 . 3 5 7 2 9 0.24049 V A R D 2 0 0.61192 6.60085 0.03932 0.20518 0.61062 - 0 . 0 3 9 6 0 V A R D 2 9 0. 0 4 0 5 2 0.14113 -0.11374 0.43466 0 . 2 0 8 2 6 0. 16578 VAIID30 0 . 12419 0 . 10301 -6.66795 6.23370 0.05069 0 . 33060 VARD31 - 0 .00439 0 . 0 9 6 1 2 6.24207 0.23365 0.36296 -0. 0 0 7 2 4 VARD32 0.30370 6.02703 6.02070 0.12472 0 . 0 3 6 2 5 0.21639 VA11D33 0 . 0 9 1 4 4 -0.09700 0.42301 0.63028 -6.00199 0 . 12119 VARD34 0.03506 0 . 1 6 9 4 9 6 . 1 6 3 4 5 -6.03804 6 . 09466 - 0 . 0 4 9 9 2 VAFID35 0.14152 6.76034 -6.13049 -0.03314 0 . 1 2 1 1 3 - 0 .02887 V A RD36 0.02945 0 . 1 3 6 0 7 6 . 4 4 3 3 3 -0. 6 6 3 9 8 6 . 1 6 2 1 4 0 . 38592 V A R D 3 7 6.32371 0 . 3 1 1 4 7 -6.14179 6.26912 0.62350 6.18179 VAIU)30 6. 3 7 0 3 0 0 . 1 0 7 7 1 -6.26547 6.01668 - 0. 1 2 3 6 6 6 . 49484 VAIID39 6.30043 6.45823 -6.66362 0.68163 -6.13564 6.22579 VAJUMO 0. 5 5 1 4 7 0 . 3 5 6 6 1 -0.05229 6.19446 0 . 1 0 7 7 3 0.23347' V A RD41 0 . 17603 0 . 0 4 0 6 6 6.13442 -0.66666 0 . 4 2 2 1 6 6 . 03960 V A I U K 2 0 . 16157 0 . 6 1 6 6 0 -0.67060 6.29221 6. 4 8 3 8 6 0.15196 118 TABLE 53

SAMPLE ITEMS FROM THE BESSAI COMMON BELIEFS

SURVEY ACCORDING TO A SIX FACTOR ANALYSIS

Factor Item loading Concept

Factor 1

VARD34 .835 People are bound to put themselves down when they fail. VARD17 .705 Failures just naturally produce guilt feelings. VARD03 .679 Che can't help getting down cn oneself when one fails at something. VARD52 .655 A perscn is bound to feel avful if he/she makes a stupid mistake. VARD28 .612 A perscn can't help feeling guilty about wrongdoings. VARDA9 .590 People really can't help thinking less of themselves when they fail.

Factor 2.

VARD35 .761 There is no such thing as bad people; there are only bad deed VARD46 .716 It doesn't make much sense to think that certain people are bad or wicked and should be severely blamed and punished for their sins. VARD08 .675 No one is evil, even though is deeds may be. VARD53 .658 A person's deeds may be bad, but that doesn't mean that the perscn is bad. VARD24 .651 Certain people are bad or wicked and should be severely blamed and punished for their sins. VARD05 .633 Criminals are basically bad people and should be punished.

Factor 3

VARD19 .556 Che can like cneself even when many others don't. VARD15 .551 Che can overcare the influence of past events. VARD21 .500 Past experiences need not affect.present behavior. VARD20 •499 Hunan unhappiness is not externally caused and people have the ability to central their sorrows and disturbances. 119

VARD25 .483 Being ignored by friends doesn't have to be upsetting. VARD36 .444 The past is past and doesn't have to affect cne now. VARD16 .440 Although approval is enjoyable, it's not a real necessity. VARD12 .437 People do not need to be loved in order to accept themselves

Factor 4

VAHD45 .594 Any job should be dene thoroughly and perfectly if it is dene at all. VARDQ2 .526 There is a right way to do everything. VARD13 .495 It is very important to handle things in the right way. VARD50 .472 There is invariably a right, precise, and perfect solution to human problems, and it is terrible when this perfect solution isn't found. VARD29 .435 For most questions there is cne right answer. VARD43 .321 Something that cnce strongly influenced one's life determines cne's feelings and behavior today because one's past remains all important.

Factor 5

VARD47 .542 People pretty much cause their own iroods. VARD42 .484 It is better to obtain one's own self respect, rather than securing other people's approval. VARD06 .474 Unhappiness canes from inside oneself. VARD18 .465 People who are miserable have usually made themselves that way VARD41 .422 People can control their cwn emotions. VARD31 .363 People make their own hell within themselves.

Factor 6

VAHD38 .495 There is no stronger influence cn the present than the past. VARD54 .454 Past mistakes nust greatly influence the present. VARD09 .446 Something that cnce strongly influenced cne's life need not determine cne's feelings and behavior today because cne's past is not aH-important. VARD43 .418 Something that cnce strongly influenced one's life determines cne's feelings and behavior today because cne's past remains all important. VARD21 .414 Past experiences need not affect present behavior. VAHD36 . .386 The past is past and doesn't have to affect cne now. 120

Factor 1 sample items were, without exception, all consistent with the author's Self Downing subscale.

Factor 2 sample items were, without exception, all consistent with the author's Blame-Proneness subscale.

Factor 3 sample items were mixed. Four items, including the one with the highest loading, were consistent with the author's Importance of Approval subscale, making this obviously the construct being measured by this subscale. However, three items from the Importance of the Past subscale were loading on this factor. One item represented the Control of Emotions subscale. As these items were drawn from three distinct subscales, this perhaps helps explain the lower reliability and factor loadings of this subscale.

Factor A sample items were, with the exception of the last item, all consistent with the author's Perfectionism subscale.

Factor 5 sample items were, with the exception of one item, all items which were consistent with the author's Control of Emotions subscale.

Factor 6 sample items were, without exception, all consistent with the author's Importance of the Past subscale.

The factor analysis of the total instrument, then, generally re­ plicated the author's original factor analysis and substantiated the functioning of the six subscales designed by the author.

Summary of the Factor Analysis of the Bessai Common Beliefs Survey

A factor analysis with varimax rotation was performed on each of the six subscales of this instrument, and upon the total scale itself. Re­ fined factor structures were created for the Self-Downing, Blame-Prone- ness, Importance of Approval, and Control of Emotion subscales prior to 121

the final varimax rotation solution. The two combined subscales, Evalua­

tion and Locus of Control, were submitted to a factor analysis. The

Evaluation subscale was a near replication of the author's original

formulation, but the Locus of Control subscale produced an ambiguous

and inconclusive picture, suggesting that it would perhaps be expedient

to use the Locus of Control subscale as a single subscale and eliminate

the three subscales Importance of the Past, Importance of Approval and

Control of Emotions. It was decided to incorporate all six of the Bessai subscales into the two combined subscales for the subsequent study. It was thought that these broader concepts were more germane than the indivi­ dual subscales for both heuristic purposes and for a more accurate analysis of the underlying factor structure of the instrument.

THE CORRELATION OF THE VARIABLES

Prior to the multivariate analyses, a study was made of all variables in a correlation matrix to determine the relative association of these

factors. Table 54 displays this matrix for variables considered of

primary importance for the multivariate analyses. Here it can be seen

that the primary variables are closely associated with only one pair,

State Anxiety and Evaluation, being disparate, and only two others falling just slightly above the .05 level of significance. The highest correlations, of course, were found with a scale and its subscales. It was noted that the Rokeach held a high negative association with the

Bessai, and the I-E Locus of Control correlated well with both the

Bessai and the Locus subscale of the Bessai. TABLE 54

CORRELATION MATRIX OF PRIMARY VARIABLES

Bessai Bessai Trait State-trait Internal-external Rokeach ocmrcn Bessai. locus Variable anxiety anxiety locus of control dqgnatian beliefs evaluation of control

State anxiety .65* .92* -.36* .17 -.23* -.08 -.35* CO & Trait anxiety -.44* .32* .37* -.26* -.38*

State-trait anxiety -.47* .26* -.33* -.18 -.41*

Internal-external locus of control .36* -.47* -.30* -.51*

Rokeach dogmatism -.59* -.61* -.35*

Bessai conrcn beliefs .89* .77*

Bessai evaluation .38*

*p =<.05

ro fNJ 123

RESEARCH QUESTIONS

On the basis of the factor analysis just described, the multivariate analyses on the entire data were conducted. They are summarized by addressing the research questions posed in Chapter One.

Research Question 1: Does the MVPS sample population display a significantly different profile of selective personality traits and belief systems than the control sample population of persons without

MVPS as measured by state and trait anxiety, locus of control, dogmatism, and common beliefs?

The first multivariate analysis was conducted on the four entire scales, which was the most reduced model that could be justified. Table

55 displays the means and standard deviations for each of these scales by

MVPS group and by the control group. Using the same test for comparison of means as was used for the demography and symptomatology comparison and holding .50 as a level of significance, a comparative test of significance was performed. Table 56 displays the results. No significant differences were noted between these means.

Table 57 summarizes the results of the multivariate computation.

It is apparent from these statistics that although there were some differences between means, no persuasive difference actually existed between the group centroids at the minimum .20 level. Although the alpha score of .317 is heuristically promising, statistically it could have resulted by chance three times out of ten measurements.

On the univariate scale, however, the effect of the separate measures on the total variance was quite interesting. The Bessai

Common Beliefs Survey revealed an F score of .042, below the .05 level TABLE 55

MEANS AND STANDARD DEVIATIONS FOR THE MVPS AND CONTROL GROUPS ON THE

STATE-TRAIT ANXIETY INVENTORY, THE INTERNAL-EXTERNAL LOCUS OF CONTROL

SCALE, THE ROKEACH DOGMATISM SCALE, AND THE BESSAI COMMON BELIEFS SURVEY

MVPS GROUP CONTROL GROUP

Scale Means S.D. Means S.D.

The State-Trait Anxiety Inventory 77.83 21.19 70.90 17.17

The Internal-External Locus of Control Scale 12.56 4.06 13.35 4.19

The Rokeach Dogmatism Scale 123.29 19.58 117.96 2 0 . 2 9

The Bessai Common Beliefs Survey 140.31 15.74 144.73 17.79 TABLE 56

COMPARISON OF MEANS FOR MVPS AND CONTROL GROUPS ON

THE STATE-TRAIT ANXIETY INVENTORY, THE INTERNAL-EXTERNAL

LOCUS OF CONTROL SCALE, THE ROKEACH DOGMATISM SCALE, AND THE BESSAI COMMON BELIEFS SURVEY

_ _ Statistical Scale Xa Ya X-Y S.D.X S.D.Y S.D.X+S.D.Y Differenceb 2

The State-Trait Anxiety Inventory 77.83 70.90 6.93 21.19 17.17 19.18 .36

The Internal-External Locus of Control Scale 13.56 13.35 -0.79 4.06 4.19 4.12 -.19

The Rokeach Dogmatism Scale 123.29 117-96 5.33 19.58 20.29 19-94 .27

The Bessai Common Beliefs Survey 140.31 144.73 -4.42 15.74 17.79 16.77 -.26

^here X=MVPS Group, Y=Control Group

bWhere X-Y S.D.X+S.D.Y) TABLE 57

MULTIVARIATE ANALYSIS SUMMARIES FOR THE MVPS AND CONTROL GROUPS

ON THE STATE-TRAIT ANXIETY INVENTORY, THE INTERNAL-EXTERNAL LOCUS OF

CONTROL SCALE, THE ROKEACH DOGMATISM SCALE, AND THE BESSAI COMMON BELIEFS SURVEY

Tests of Significance

Standardized discriminant F Signif­ function Wilkes Method icance coefficient lamba

Multivariate 1.200 .317 . 9A6

Univariate (with 1.87 D.F.)

The state-trait anxiety inventory 2.106 .150* .351

The internal-external locus of control scale 1.622 .206 -.057

The rokeach dogmatism scale 2.038 .157* .110

The bessai common beliefs survey A.263 •0A2** -.722

*p - < .20 **p=< .05 127

of significance. This was confirmed by the follow-up standardized dis­ criminate analysis where the Bessai was found to be highly discriminating between the two groups. Clearly the members of the MVPS group were scoring significantly lower on the Bessai, indicating greater irrationality, that is, a more pronounced tendency to feel helpless because of past events, to be critical of self and others, to feel the need of approval, to be perfectionistic, and to feel a loss of personal control.

The other three variables, however, were also noteworthy. Although the .05 level of significance is commonly established in the social sciences, in medical research significance is often considered at or below a .20 level. Because health and even life can be at stake, a measurement that detects a vital functioning 20% of the time merits further scrutiny for possible remedial purposes. In this light, both the State-Trait Anxiety Inventory and the Rokeach Dogmatism Scale presented themselves at a .15 level of significance, and the Internal-

External Locus of Control Scale was within limits at a .20 level of significance. However, the discriminant analysis failed to support these tests, if .50 is established as a minimum coefficient of discriminate function.

A second multivariate analysis was conducted, this time using the six scales: the two subscales of the State-Trait Anxiety Inventory:

State Anxiety and Trait Anxiety; the Internal-External Locus of Control

Scale; the Rokeach Dogmatism Scale; and the two subscales of the Bessai

Common Beliefs Survey: Evaluation and Locus of Control. This was thought to be the most expanded model which could be justified for a multivariate analysis. 128

Table 58 displays the means and standard deviations for each of

these scales by the MVPS and the control groups. The same test for

comparison of means as was performed for the MVPS and control groups

was conducted. Table 59 displays the results. No significant

differences were noted between the means.

Table 60 summarizes the results of the multivarate computation. It

is apparent from these statistics that any differences in the means did

not find support in the multivariate analysis where no meaningful

difference appeared between the group centroids at the .20 level.

The alpha score of .539 was much higher than the .317 on the four scale multivariate analysis, suggesting the former had more clearly distinguished

between the groups.

The univariate scale also revealed a less clear picture of the inter­ action of variables. None of the scales achieved a significant F coefficient at the .05 level. It was apparent that the increase in the number of scales for the analysis had weakened its power and reduced its heuristic value.

The answer, then, to the first question was that, although a specific MVPS profile did not emerge on the multivariate analysis, the

MVPS sample population did display a significantly different profile from the control population as measured by the Bessai Common Beliefs

Survey. The MVPS sample population would seem to be far more prone to feelings of helplessness, loss of personal control, and criticism of self and others than the control group. Other measures were not within the .05 limits of statistical significance, but the differences TABLE 58

MEANS AND STANDARD DEVIATIONS FOR THE MVPS AND CONTROL GROUPS ON THE STATE

AND TRAIT SUBSCALES OF THE STATE-TRAIT ANXIETY INVENTORY OF THE INTERNAL

LOCUS OF CONTROL SCALE, THE ROKEACH DOGMATISM SCALE AND THE EVALUATION

AND LOCUS OF CONTROL SUBSCALES OF THE BESSAI COMMON BELIEFS SURVEY

MVPSGROUP CONTROLGROUP

Scale Mean S.D. Mean S.D.

The State Anxiety Subscale 37.72 12.33 33.93 10.36

The Trait Anxiety Subscale AO. 35 10.29 36.59 9.A9

The Internal-External Locus of Control 12.56 A.06 13.35 A.19 Scale

The Rokeach Dogmatism Scale 123.29 19.58 117.96 20;29

The Bessai Evaluation Subscale 72.76 11.33 75.75 12.01

The Bessai Locus of Control Sbuscale 67.55 8.26 68.98 8.70 129 TABLE 59

COMPARISON OF MEANS FOR MVPS AND CONTROL GROUPS ON THE STATE AND TRAIT

SUBSCALES OF THE STATE-TRAIT ANXIETY INVENTORY, THE INTERNAL LOCUS OF

CONTROL SCALE, THE ROKEACH DOGMATISM SCALE, AND THE EVALUATION

AND LOCUS OF CONTROL SUBSCALES OF THE BESSAI COMMON BELIEFS SURVEY

S.D.X+S.D.Y Statistical Scale X Y X-YS.D.X S.D. Y 2 Difference. a a b

The State Anxiety Subscale 37.73 33.93 3.79 12.33 10.36 11.35 .33

The Trait Anxiety Subscale AO. 35 36.59 3.76 10.29 9.A9 9.89 .38

The Internal-External 12.56 13.35 -0.79 A.06 A.19 A.13 -.19 Locus of Control Scale

The Rokeach Dogmatism 123.29 117.96 5.33 19.58 20.29 19.9A .27 Scale

The Bessai Evaluation 72.76 75.75 -2.99 11.33 12.01 11.67 -.26 Subscale

The Bessai Locus of 67.55 68.98 -1.43 8.26 8.70 8.A8 -.17 Control Subscale 130 TABLE 60 MULTIVARIATE ANALYSIS SUMMARIES FOR THE MVPS AND CONTROL GROUPS ON THE STATE AND TRAIT SUBSCALES OF THE STATE-TRAIT ANXIETY INVENTORY, THE INTERNAL-EXTERNAL LOCUS OF CONTROL SCALE, THE ROKEACH DOGMATISM SCALE, AND THE EVALUATION AND LOCUS OF CONTROL SUBSCALES OF THE BESSAI COMMON BELIEFS SURVEY

Tests of Significance

Standardized discriminant F Signif- function Wilkes Method F icance- coefficient lamba

Multivariate .844 .539 .942 Univariate (with 1.87 D.F.) The state anxiety subscale .817 .369 -.105 The trait anxiety subscale 3.077 ' .083* .516 The internal-external locus of control scale 1.622 .206 -.037 The rokeach dogmatism scale 2.038 .157* .062 The bessai evaluation subscale 2.818 .097* -.448 The bessai locus of control subscale 2.722 .103* -.375

*p = < .20 **p = < .05 131 132

between the MVPS sample population and the control group were sufficient as to have heuristic value and merit further study.

Research Question 2: Does the MVPS sample population which is considered symptomatic display a significantly different profile of selective personality traits and belief systems than the MVPS sample population which is considered asymptomatic as measured by state and trait anxiety, locus of control, dogmatism and common beliefs?

For this question another multivariate analysis was conducted on the four entire scales for the most reduced model possible. Table 61 displays the means and standard deviations for each of these scales by

MVPS symptomatics and MVPS asymptomatics. The test for comparison of means previously used in the study was conducted and the results are displayed in Table 62. The Internal-External Locus of Control Scale was found to be significantly different at the .50 level of discrim­ ination, meaning that the MVPS symptomatic group mean was significantly more internal than the MVPS asymptomatic group mean. The means for the

State-Trait Anxiety Inventory approached a level of significance at the .50 level.

Table 63 summarizes the results of the multivariate computation.

New findings emerged from these analyses. The multivariate F coefficient of .163 was close to a level of significance. In medical populations it could be interpreted that almost 84% of the time these results would emerge if MVPS symptomatics and MVPS asymptomatics were compared by the use of these scales. The presence of distinctively different centroids suggested that there may well be a distinct symptomatic

MVPS personality as measured by these four instruments. Or, stated TABLE 61

MEANS AND STANDARD DEVIATIONS FOR THE MVPS SYMPTOMATIC AND MVPS ASYMPTOMATIC

GROUPS ON THE STATE-TRAIT ANXIETY INVENTORY, THE INTERNAL-EXTERNAL LOCUS OF

CONTROL SCALE, THE ROKEACH DOGMATISM SCALE, AND THE BESSAI COMMON BELIEFS SURVEY

MVPS Symptomatics MVPS Asymptomatics

Scale Mean S.D. Mean S.D.

The State-Trait Anxiety Inventory 82.63 24.42 73.04 16.23

The Internal-External Locus of 11.52 4.24 13.70 3.60 Control Scale

The Rokeach Dogmatism Scale 126.54 17.38 119.92 21.47

The Bessai Common Belief Survey 141.04 17.79 139.55 13.59 TABLE 62

COMPARISON OF MEANS FOR THE MVPS SYMPTOMATICS AND MVPS ASYMPTOMATICS

ON THE STATE-TRAIT ANXIETY INVENTORY, THE INTERNAL-EXTERNAL LOCUS OF

CONTROL SCALE, THE ROKEACH DOGMATISM SCALE, AND THE BESSAI COMMON BELIEF SURVEY

_ _ S.D.X+S.D.Y Statistical Srale X Y_ X-Y S.D.X S.D.Y 2 Difference^ a 3 ®

The State-Trait Anxiety 82.63 73.04 9.59 24.42 16.23 20.33 .47 Inventory

The Internal-External Locus 11.52 13.70 -2.18 4.24 3.60 3.92 -.56* of Control Scale

The Rokeach Dogmatism 126.54 119-92 6.62 17.38 21.47 19.43 .34 Scale

The Bessai Common 141.04 139.55 1.49 17.79 13.59 15.69 .09 Beliefs Survey

^here X = MVPS Symptomatic Group, Y = MVPS Asymptomatic Group bWhere X-Y (S.D.X+S.D.Y) 2

*p = 7 .50 *7CI TABLE 63

MULTIVARIATE ANALYSIS SUMMARIES FOR THE MVPS SYMPTOMATIC AND MVPS ASYMPTOMATIC

GROUPS ON THE STATE-TRAIT ANXIETY INVENTORY, THE INTERNAL-EXTERNAL LOCUS OF

CONTROL SCALE, THE ROKEACH DOGMATISM SCALE, AND THE BESSAI COMMON BELIEF SURVEY

Tests of Significance

Standardized discriminant F Signif­ function Wilkes Method icance coefficient lamba

Multivariate 1.732 .163* .849

Univariate (with 1.87 D.F.)

The state-trait anxiety inventory 2.906 .096* -.470

The internal-external locus of A.847 .033** .880 control scale

The rokeach dogmatism scale .996 .324 -.125

The bessai common beliefs survey .045 .833 -.618

p = < .20 ** p = < .05 136

somewhat differently, these four instruments accounted for most of the

variance between the symptomatic and the asymptomatic groups.

The univariate analysis also cast new light on the comparison.

Whereas the Bessai Common Beliefs Survey had been the most sensitive

instrument in discriminating between the MVPS sample population and the

control group, it now became totally insensitive for discrimination

within the MVPS sample population. Apparently levels of irrationality

were held in common both by symptomatics and asymptomatics. What

emerged clearly as the instrument to distinguish MVPS symptomatics

from MVPS asymptomatics was the Internal-External Locus of Control

Scale. The F coefficient of .033 was highly significant, and it was

further strengthened by the discriminant coefficient of .880, far

above the .50 minimum level of discrimination. It was clear that

this was a primary variable in distinguishing between MVPS symptomatics

and MVPS asymptomatics. The obvious inference was that a basic

difference between persons in the MVPS sample population who were

symptomatic and those who were asymptomatic centered around the manner

in which MVPS symptomatics were much more internal in their orientation.

The State-Trait Anxiety Inventory also indicated significance, close

enough to have heuristic value. State and trait anxiety could be consider­

ed as having noticeable influence on the variance between MVPS sympto­ matics and MVPS asymptomatics, with the former exhibiting more anxiety

than the latter. 137

A second multivariate analysis was then conducted, using the ex­

panded model for six scales: State and Trait subscales of the State-

Trait Anxiety Inventory; the Internal-External Locus of Control Scale;

the Rokeach Dogmatism Scale; and the Evaluation and Locus of Control

subscales of the Bessai Common Beliefs Survey.

Table 64 displays the means and standard deviations for each of

these scales for the MVPS symptomatics and the MVPS asymptomatics. The

test for comparison of means was conducted and the results are displayed

in Table 65. In addition to the Internal-External Locus of Control

Scale which had previously exceeded the .50 level of discrimination, now the State Anxiety Subscale revealed significance, indicating that

the MVPS symptomatics group mean was significantly more internal locus of control and significantly higher state anxiety than the MVPS asymptomatic group mean.

Table 66 summarizes the results of the multivariate computation.

This time the multivariate F coefficient moved higher from the

.163 on the previous four scale test. It was apparent once again that the increased number of scales had weakened the power of the analysis.

On the univariate analysis, however, new data emerged. On the previous four scale analysis, the State-Trait Anxiety had approached a level of significance with an alpha coefficient of .096. It was noted at that time that this scale merited further study. When this scale was divided into its two subscales, the nature of that influence became apparent. The State subscale emerged significant at a .05 level. This finding was substantiated in the follow-up discriminant analysis where the State subscale was highly weighted as a primary factor which was discriminating between MVPS symptomatics and MVPS TABLE 64

MEANS AND STANDARD DEVIATIONS FOR THE MVPS SYMPTOMATICS AND THE MVPS

ASYMPTOMATICS ON THE STATE AND TRAIT SUBSCALES OF THE STATE-TRAIT ANXIETY

INVENTORY, THE INTERNAL-EXTERNAL LOCUS OF CONTROL SCALE, THE ROKEACH DOGMATISM

SCALE, THE EVALUATION AND LOCUS OF CONTROL SUBSCALES OF THE BESSAI COMMON BELIEFS SURVEY

MVPS Symptomatics MVPS Asymptomatics

Scale Mean S.D. Mean S.D.

The State Anxiety Subscale 40.78 14.76 34.67 8.52

The Trait Anxiety Subscale 42.25 11.26 38.37 8.97

The Internal-External Locus 11.52 4.24 13.70 3.60 of Control Scale

The Rokeach Dogmatism Scale 126.54 17.38 119*92 21.47

The Bessai Evaluation Subscale 73.29 11.87 72.22 10.94

The Bessai Locus of Control Subscale 67.75 10.30 67.33 5.60 138 TABLE 65

COMPARISON OF MEANS FOR THE MVPS SYMPTOMATIC AND MVPS ASYMPTOMATICS ON THE STATE AND TRAIT

SUBSCALES OF THE STATE-TRAIT ANXIETY INVENTORY, THE INTERNAL-EXTERNAL LOCUS OF CONTROL

SCALE, THE ROKEACH DOGMATISM SCALE, AND THE EVALUATION AND LOCUS OF CONTROL

SUBSCALES OF THE BESSAI COMMON BELIEFS SURVEY

S.D.X+S.D.Y Statistical Scale X 7 X-Y S.D.X S.D.Y 2 Differenceb & cl

The State Anxiety AO.78 3A.67 6.11 14.76 8.52 11.64 .52* Subscale

The Trait Anxiety A2.25 38.37 3.88 11.26 8.97 10.12 .38 Subscale

The Internal-External Locus 11.52 13.70 -2.18 4.24 3.60 3.92 -.56* of Control Scale

The Rokeach Dogmatism . 126.5A 119*92 6.62 17.38 21.47 19.43 .34 Scale

The Bessai Evaluation 73.29 72.22 1.07 10.30 5.60 7.95 .13 Subscale

* r = > .50

^here X = MVPS Symptomatic Group, Y = MVPS Asymptomatic Group TABLE 66

MULTIAVARIATE ANALYSIS SUMMARIES FOR THE MVPS SYMPTOMATICS AND MVPS ASYMPTOMATICS ON

THE STATE AND TRAIT SUBSCALES OF THE STATE-TRAIT ANXIETY INVENTORY, THE

INTERNAL-EXTERNAL LOCUS OF CONTROL SCALE, THE ROKEACH DOGMATISM SCALE, AND

THE EVALUATION AND LOCUS OF CONTROL SUBSCALES OF THE BESSAI COMMON BELIEFS SURVEY

Standardized discriminant F Signif- function Wilkes Method icance coefficient lamba

Multivariate 1.44 .225 ' .811

Univariate (with 1.87 D.F.)

The state anxiety suhscale 3.772 .059* .820

The trait anxiety subscale 1.275 .265 .404

The internal-external locus of 4.847 .033** .921 control scale

The rokeach dogmatism scale • 996 .324 .139

The bessai evaluation subscale .003 .957 .143

The locus of control subscale .094 .761 .526

= 4 .20 **

= < .05 07T 141 asymptomatics. MVPS symptomatics were seen to be significantly higher in internal locus of control and state anxiety than were MVPS asymptomatics.

The answer, then, to Research Question 2 was that there was strong evidence that a distinctive MVPS symptomatic personality was being detected by the four instruments of the multivariate analysis. Further, it could be clearly said that MVPS symptomatics were characterized by higher levels of internal locus of control and by higher state anxiety than were MVPS asymptomatics.

Research Question 3: Does a significant correlation exist between the selective personality characteristics, state and trait anxiety and locus of control, and the belief system indices, dogmatism and common beliefs?

As was indicated in Table 54 on page 122, significant correlations exist on 27 of the 30 variables associated. Only the correlation of

State Anxiety with the Rokeach Dogmatism Scale (.09), the correlation of State Anxiety with the Evaluation subscale of the Bessai Common

Beliefs Survey (.42), and the correlation of the State-Trait Anxiety

Inventory with the Evaluation subscale of the Bessai Common Beliefs

Survey (.07) failed to achieve significance at the .05 level. When correlations were conducted between the four full-scale instruments, all correlations were below the .05 level of significance.

The answer, then, to Research Question 3 was that all primary variables were correlated. Most of the-variables were closely related

in such a way that the increased affect of one directly effected the

other. CHAPTER V Summary and Conclusions

This final chapter is divided into three sections: (1) a summary of the research study; (2) conclusions and implications; and (3) recom­ mendations for further study.

Summary

This study was designed to examine differences of selected personality characteristics and operating belief systems between MVPS patients and persons of similar socioeconomic circumstances who manifested no evidence of heart disease, and between symptomatic and asymptomatic MVPS patients.

The rationale for the study derived from a generalizable "self-in­ situation" model which describes the cognitive-affective-physiological processes of intrapersonal functioning as they occur in relation to interpersonal transactions in the environment as well as transcendent meanings which derive from the total experience. The definition of health and disease used as a criterion for assessing the MVPS sample population was based on a model which stresses a functional cognitive- affective-physiological system which exhibits appropriate openness and reciprocity between the individual and the environment.

Four instruments were selected for subsequent measurements. These were the State-Trait Anxiety Inventory to determine if anxiety existed in the MVPS sample population to a significant degree, and, if so, to

142 143

determine if it was state anxiety deriving from a current situation, or

trait anxiety deriving from an anxiety-prone personality, or both; the

Internal-External Locus of Control Scale to determine to what extent

these persons experienced a sense of personal power in life situations,

or to what extent they felt that power to be external to themselves;

the Rokeach Dogmatism Scale, to determine the extent of open or closed- raindedness of the subjects; and the Bessai Common Beliefs Survey, to

determine if cognitive disruption was occurring because of nonreality-

based belief systems.

While it was noted that medical literature made frequent references

to the psychoneurotic etiology of MVPS, or to the concomitant hysterical

or narcissistic personality of MVPS patients, surprisingly little re­

search has been reported on this matter. Many references were anecdotal

or made without support. A review of research revealed that only two

thorough empirical studies have been reported, and these confirmed as

expected that MVPS patients were preoccupied with their physical condi­

tion. It was further noted that the syndrome has often been confused with cardiac conditions thought to be functional or hysteric, and that such confusion persists even among present day scholars.

A review of the literature was conducted in the following areas:

the historic mind-body issue; contemporary theories of stress; stress and cardiovascular disease; personality factors and cardiovascular disease; state and trait anxiety; locus of control; and MVPS. Per­ suasive argument and evidence were found in a number of these areas.

The functioning of a cognitive-affective-physiological intrapersonal system can be identified as it exists in relationship to an inter- 144

personal environment. There is evidence of a strong relationship between

stress and cardiovascular disease. There is a relationship between

the biochemical processes identified in the hyperadrenergic state of

MVPS and other cardiovascular diseases. Finally, external locus of

control seems to exacerbate pathogenic anxiety which is a central

factor in cardiovascular disease.

Subjects of this study were 110 residents of metropolitan Columbus,

one-half of whom had been diagnosed during 1981 as having MVPS, and

the remainder of whom constituted a medical control group with no

history of cardiovascular disease. The MVPS patients had all been

referred by their physicians to University Hospital in Columbus, while

the control group was selected from a list of persons who had visited

a physician or the University Hospital clinic during 1981, and who

appeared to be of similar socio-economic status as the MVPS sample

population. A Personal Data Questionnaire was designed to determine

social class stratum and, among MVPS participants, to determine the

degree of symptomatology for the subsequent comparison of a symptomatic

MVPS group with an asymptomatic MVPS group.

Subjects were tested in the early months of 1982 at the office of the

researcher or at their homes. The data were recorded on IBM cards in accordance with the format instructions contained in the selected SPSS computer program.

The analysis of results took place in the three months following

testing. First, an analysis of the demographic data was conducted, com­ paring the MVPS group with the control group, and the MVPS symptomatic group with the MVPS asymptomatic group. No statistical differences existed 145

between, the MVPS group and the control group on a comparison of means for

age, marital status, education or occupation. Likewise, there were

no statistical differences on these same factors in a comparison of

means for the MVPS symptomatic group and the MVPS asymptomatic group.

An analysis of the instruments used in the study was conducted.

The State-Trait Anxiety Inventory was found to have a high reliability

coefficient of .96, using Cronbach's Alpha as the measurement of internal

consistency. A factor analysis with varimax rotation revealed that two

distinct subscales, state anxiety and trait anxiety, were clearly dif­

ferentiated, each with high factor loadings. This substantiated the

author's claim for the instrument, and it was accepted for the study without further refinement.

The Internal-External Locus of Control Scale revealed a reliability

coefficient of .75, higher than the author found in his studies. A

factor analysis with varimax rotation was performed, revealing the

functioning of one complex factor. The instrument appeared to be

sensitive to locus of control issues of daily life, within well-known

parameters, or, in the microcosmic domain of the subjects. By contrast,

subjects did not relate with any consistency to locus of control issues of a national or global nature, that is, those of the macrocosmic domain.

This instrument was accepted for the study without further refinement.

The Rokeach Dogmatism Scale produced a reliability coefficient of

.84. The factor analysis with varimax rotation revealed an ambiguous

picture which was ultimately interpreted to mean that the instrument was measuring one factor but was giving evidence of the influence of other factors. High factor loadings were found on items pertaining to 146 the "right attitude, idea or opinion about everyday life, while low fac­ tor loadings appeared on items pertaining to ultimate ideals, causes or global belief systems. Once again, subjects seemed to consistently understand references to the microcosm of everyday life, but there was much disparity to references to the macrocosm of life in the abstract, or as an ideal. This instrument was accepted for the study without further refinement.

The Bessai Common Beliefs Survey required refinement prior to its analysis. An overview of the six subscales, the two combined subscales, and the total scale found reliability coefficients ranging from .64 to

.87. Factor analyses with varimax rotation was performed on all the subscales and the total scale.

The Self-Downing subscale was refined and strengthened by the deletion of two loading items which referred to general standards of behavior and anxiety. It was believed these items were not situationally specific for the groups being tested, and consequently disparate percep­ tions of their meaning occurred. The Perfectionism subscale was found to be relatively weak with several complexity factor items. Items with high factor loadings pertained to precise behaviors and activities while items with low factor loadings pertained to life competency, life goals and a sense of ultimate worth. Subjects seemed to be responsive to microcosmic constructs and disparate on macrocosmic constructs. This subscale was therefore accepted for the study without further refinement.

The Blame-Proneness subscale was refined by the deletion of two items which had low factor loadings because of their reference to such broad, general concepts as "forgiveness." This contrasted with the more specific references of the high loading factor items. 147

The Importance of the Past subscale indicated a somewhat weak

factor structure with items having different meanings for subjects.

No clues could be found to account for unknown meanings of the

factor. It was subsequently accepted for the study without further

refinement. The Importance of Approval subscale was refined and

strengthened by the deletion of three items. In this case, the high

loading factor items referred to ideal constructs of love and friend­

ship. Again, subjects seemed in unanimity on microcosmic matters of

daily life, but were disparate on macrocosmic constructs. The Control

of Emotions subscale indicated a relatively weak factor structure. It

was subsequently refined and strengthened by the deletion of three

items. No meaningful clues could be found to account for the unknown

influences affecting this subscale.

The Evaluation subscale revealed that it very effectively homogenized

the three subscales Self-Downing, Perfectionism and Blame-Proneness, and was an approximate replication of the factor structure described by the

author in his original research. The Locus of Control subscale combined

the Importance of the Past, Importance of Approval and Control of

Emotions subscales in a somewhat ambiguous way. It was clear that

factors other than these three constructs were influencing the variance.

It was finally decided to incorporate all six of the subscales into the

two combined subscales for the subsequent study.

Finally, the Total Scale factor analysis confirmed the presence of six distinct factors which, when analyzed by item content, coincided with the six constructs which the author had established for his 148 criteria of common beliefs. It was decided, then, to utilize the total scale as well as the two subscales in the multivariate analyses.

For the sample population of this study, coefficients of correlation for the primary instruments ranged from .61 to .08. High state and trait anxiety was found to correlate positively with internal locus of control and irrationality. High trait anxiety correlated positively with close-mindedness, external locus of control correlated positively with close-mindedness and irrationality, and close-mindedness correlated with irrationality.

The research questions were analyzed by means of the multivariate uijalyses. The first question posed whether or not significant dif­ ferences existed between the MVPS sample population and the control sample population as measured by the respective instruments. No significant differences were noted between the two group means. On the multivariate analysis, an alpha coefficient of .317 was obtained which was considered heuristically promising though not significant at the

.20 level established for medical research. However, on the univariate analyses, the Bessai Common Beliefs Survey proved significant at the

.05 level, indicating that members of the MVPS group were appearing as more irrational, that is, more prone to feel helpless because of past events, to be more critical of self and others, to feel the need of approval, to be perfectionistic, and to experience a loss of personal control. All the other instruments measured at the .20 level, a coef­ ficient of significance often established in medical studies as having heuristic value. 149

The second question sought to determine if a significant difference

existed between MVPS patients who were symptomatic and MVPS patients who

were asymptomatic as measured by the instruments of the study. An im­

mediate difference noted when the means were compared was that the sympto­

matic group was found to be significantly more internal in locus of control

than the asymptomatic group. The symptomatic group was also found to be

somewhat higher in state and trait anxiety than the control group, approach­

ing a level of statistical difference. The multivariate analysis produced

strong evidence that a distinctive MVPS symptomatic personality was being

discriminated from the total MVPS population. The univariate analyses

clearly indicated that the MVPS symptomatic patients were characterized

by significantly greater internal locus of control and higher levels of

state anxiety than were the control group members. In other words, the

MVPS patients were perceiving their life situation as stressful and were

quietly determined to cope with the situation by their own resources.

Conclusions and Implications

The conclusions of this study and the discussion of their implications

are presented in three areas: a general conclusion based upon medical

research pertaining to the origin of MVPS; conclusions and implications of

these phenomena based on the generalizable self-in-situation model used

for the conceptualization of this study.

To preface these remarks, a recapitulation of the self-in-situation model is in order. This model depicted the cognitive-affective-physiological

intrapersonal system as being in continual interaction with both the im­ mediate environment and all that transcends the environment. Intrapersonal-

ly, the self can be assessed in terms of the reciprocal interplay between 150 cognitions, affective states, and physiological responses. At each inter­ face of these three components of self, and at the locus where each com­ ponent is conceived as being linked to the very core of personality, three possible consequences may occur: an opening, or connection, where the components interact with each other; a tentative connection without openness where each component tolerates the stimulus of the other, but no change occurs; and a rejection of the connection , leading to the component being closed to the other at that moment. The effects of this interaction are said to determine the nature of the personality at its core. That personality, then, interfaces with the personalities of others in society with the same possible consequences: openess and acceptance; toleration; and closed rejection.

According to this theory, the functional personality is adept at taking in that which sustains and enhances life, and eliminating or rejecting that which is toxic or life threatening. Thus there is an appropriate time for being open, for toleration, or for being closed.

The healthy personality is appropriately open to the microcosm and the macrocosm, to the full range of intra-personal and interpersonal experience, and to the ultimate source of life and meaning. Such appropriate openness is seen as the natural condition for any organism, the culture for health.

The healthy personality is characterized by clear-mindedness, emotional satisfaction, and a sense of visceral harmony. The same theory suggests, however, that it is not easy to remain open, that even when it is appropriate there will be a tendency to inappropriately become closed at one of the three functional components. This is routinely seen in everyday life.

Persons who are not open in their cognitive function, who do not use their 151

own minds, are stereotyped as dull, foolish, dogmatic, irrational, naive,

and even delusional or psychotic. Persons who are not open to their

feelings, who reject or block the rich, spontaneous, affective dimension

of human experience, are characterized as being labile, flat, uninteresting,

mechanical, distant, and even socially inappropriate or bizarre. Persons

who are not open to their own bodies, who live as if the body were excess

baggage, are characterized as rigid, cold, unsensouous, and unattractive.

By the use of this model, and by the findings of this study, several

conclusions regarding the MVPS personality can be presented.

The first conclusions can be drawn from the medical research reviewed

for this study, namely, that MVPS should not be called, in the strictest

sense, a psychophysiological disorder. This conclusion establishes a

physiological basis for MVPS and a context for possible explanations for

the fact that some persons with MVPS are symptomatic while others with

the same conditions are relatively asymptomatic. Convincing evidence

exists to account for MVPS as a disease of connective tissue with signif­

icant familial transmission. Pathological findings are specifically

documented. Furthermore, the asthenic body structure, joint laxity and

frequent abnormalities of the thoracic skeleton suggest an idiopathy.

Finally, biochemical studies clearly indicate a hyperadrenergic state or

the activity of other metabolic components for persons with this syndrome.

As a result, at some point in time, tissues of the heart around the valves lose their collagenous supporting structure, and the mitral valve leaflets become prolapsed.

A second conclusion which can be drawn from the findings of this study

pertains to the high levels of anxiety, especially state anxiety, which 152

appears to exist among MVPS subjects. This finding can take on specific

meaning when it is considered in the light of the research which states

that unabated adrenergic functioning such as that found in the MVPS

subject is highly stressful and provokes anxiety. This second conclusion,

therefore, is that the altered neurological functioning of the MVPS

subject is stressful and directly related to the elevated anxiety found in

the MVPS sample population.

It does appear that the MVPS personality senses a personal disharmony

in a true existential sense: literally at the heart of the organism.

Whether it is perceived vividly or is consciously imperceptible, a constant

threat seems to be present. Perhaps with each beat of the heart there is a deep

awareness that a valve of the heart remains inappropriately open. One can

then assume that this is perceived as a threat which invokes the

alarm reaction discussed in stress theory, and precipitates increased

levels of both state and trait anxiety. Because this alarm reaction is unabated, the higher levels of anxiety persist as evidenced by the higher scores on the anxiety scales.

One implication from this conclusion would suggest that it would be beneficial for the MVPS patient to develop a broadened awareness of the neurological basis for the stress that is being experienced, and to

subsequently become more public with complaints of the inner distress.

It is conjectured that a large majority of MVPS patients are not aware of the elevated adrenergic basis of their illness, and continue to think that they must be neurotic to be so frightened. It is believed they would find reassurance in a new understanding of their neurological system and how it provokes anxiety. Such self-acceptance of the legitimacy 153 of their condition and the appropriateness of complaints should reduce anxiety over that which was previously unknown, and should serve to elicit public expressions about their personal distress.

A third finding of this study was that persons with MVPS reveal a distinct difference from persons without MVPS on levels of irrational thinking as measured by the Bessai Common Beliefs Survey. It is therefore possible to formulate the third conclusion, that persons with MVPS apparently develop belief systems which are more closed, unrealistic, and irrational than persons who display no evidence of cardiovascular disease.

The evidence from the study indicates that persons with MVPS are more prone to conclude that they are somewhat victimized by their past, that they require the approval of others, that they are somewhat limited in the personal control of their lives, that perfectionism is required of life, and that blame of self or others should be established when an event does not go as planned.

Again the conceptual framework of this study makes it possible to conjecture about the association of a dysfunctional heart valve to a cognitive process. As the symptomatic MVPS personality experiences the inappropriately open valve and musters full attention to the need for closing, this, in turn, can effect the belief system which gives new weight to closing. If the personality desires closure, then closed­ mindedness can ensue. With this can evolve a belief system which is characteristic of persons preoccupied with survival, who feel victimized, are prone to be blame oriented,and who have doubts about their personal power. 154

The implication at this juncture is that these personal beliefs of

MVPS patients need to be challenged. They are directly amenable to change by interventions which can be implemented by family, friends, educators, and a variety of health care professionals. Unrealistic and irrational constructs can be reconsidered. Cognitive distortions can be detected and modified. Persons can be taught to discriminate between sense and nonsense, fiction and reality, superstition and science. Given the synergistic effects of cognitions, affect and physiology, any changes in the belief system which result in greater open-mindedness and realistic thinking can be expected to elicit physiological changes. It should be pointed out, however, that modification of the belief system is only effective as initial entree to the personality. Cognitive restructuring approaches must be linked with approaches which elicit greater affective expression and physiological activities.

In still another finding of this study, the multivariate analyses revealed that the symptomatic MVPS personality was clearly discriminated from the asymptomatic MVPS personality by measures of internal locus of control and high state anxiety. The fourth conclusion, therefore, is that among persons known to have MVPS, a distinct personality can be detected for those who are symptomatic, characterized by internal locus of control and state anxiety.

In the review of studies of coronary-prone personalities, it was noted that there is an unknown characterologically predisposed individual who will react to a stressful situation in a pathogenic manner, that is, by increased aggressiveness, impatience, striving for achievement, hyperalertness, and struggle for personal control. The same can be said of the MVPS sympto­ matic group of this study. While asymptomatic MVPS patients apparently 155 adapt to their physiological disharmony without further cognitive or af­ fective changes or further physiological distress, this is not true of symptomatic MVPS patients. They experience symptoms ranging from great discomfort to severe distress to almost complete incapacitation. The cause of these differences remains unidentified. However, what can be concluded from this study is that a symptomatic personality does apparently develop who is characterized by much more internal locus of control and higher state anxiety than persons with MVPS who remain relatively asymptomatic.

One might surmise that the precursor for the emergence of this personality derives from the struggle to gain control over what must appear to the MVPS patient as an uncontrollable situation. It will be recalled by the study of Glass (1977) that Type-A coronary-prone individuals became ultimately resigned because of their inability to seize control of their lives. Perhaps the MVPS symptomatic personality begins with this same struggle. However, already experiencing anxiety and an unrealistic belief system, the MVPS subject appears to adapt not by succumbing to a sense of helplessness, but by an extraordinary effort to seize personal control of the life situation.

Still another view of this situation derives from the conceptual framework of this study. The cognitive-affective-physiological synergy which detects the inappropriately open valve constrains the personality, with each beat of the heart, to affect closure. It has previously been noted that the closed-mindedness of the MVPS symptomatic patient can be viewed in this light. In can be added, at this juncture, the internal locus of control found in the MVPS symptomatic personality can be interpreted as a 156 \ consistent effort to achieve closure. The MVPS symptomatic personality can be viewed as turning inward in an attempt to close that which will not close.

One immediate implication drawn from this conclusion is that the

MVPS symptomatic personality is the antithesis of the hysteric personality.

In Chapter One attention was directed to the frequent description of the

MVPS as psychcneurotic, with specific suggestions that the profile is one of hysteria. But the hysteric personality is characterized by an external locus of control, with frequent expressions of helplessness. Furthermore, psychotherapy for the hysteric personality minimizes attention to emotions or even ignores outbursts of feelings while giving primary attention to teaching the patient to think more concretely. But such an intervention is obviously contraindicated for the MVPS patient who has already learned that feelings must be suppressed, much to his/her detriment.

A related implication can be drawn from this conclusion, namely that the environment is frequently perceived by the MVPS patient as reinforcing an internalization of thoughts and feelings. Interviews with symptomatic

MVPS patients suggested that they did not believe that help would be forth­ coming from their environment, and that if they complained about their difficulties, they could not be assured of understanding from their families, or even from their physicians. Apparently health care professionals have told them and their families that one must learn to live with the physical distress of MVPS. Often the inference of this advice has been that complaints are unacceptable, being construed as exaggerated manifestations of hysteria. As a consequence, MVPS subjects seem prone to believe that if there is any help for their condition, it must lie deep within the resource­ fulness of the individual. Locus of control must be internally seized. 157

A therapeutic implication of this is the need to provide the MVPS patient with understanding and support, and to encourage a deep and full expression of feelings about the situation. Apparently persons with this condition may be healthy in the sense that they are not denying their experience and are well aware of their conscious suppression as indicated by their high internal locus of control. It is assumed that they are quick to take responsibility for themselves. But they do need to learn that they can be open and public in relating their experience.

Finally, factor analyses of this study presented evidence of the closed personalities of MVPS patients. It was apparent that a large number of the subjects were consistently comprehending references to issues which were of an immediate, local, everyday routine. These were concerns of the microcosm and the behaviors and activities of specific life settings over which the individual might hope to maintain control. However, ' reference to matters of a more global nature, to ideals and universal concepts, were found to be sufficiently confusing that many of those test items were subsequently deleted from the study.

A fifth conclusion which emerged from this finding is that the MVPS symptomatic individual may be restricted in his/her range of personal experience, and subsequently may be prone to be troubled by concerns with personal identity, a lack of a sense of belonging, and a lack of a sense of becoming as a person.

Once again the conceptual model for this study states that the cognitive-affective-physical synergy produces its own wisdom which, among persons with MVPS, is that there is an inappropriate opening. With each beat of the heart comes a call for closure. The physiological dysfunction shapes affective and cognitive processes to the extent that closed-minded- 158 ness and internal locus of control characterize the symptomatic MVPS patient. This fifth conclusion is viewed in this same perspective.

There is little time or energy left for this individual to devote to issues of the macrocosm, to abstractions of the environment, or to enhancing relationships with others.

The MVPS sample population as a whole, and the symptomatic individuals in particular, appear to abhor references to the macrocosm or external situation over which they perceive they have no personal control. To even acknowledge this macrocosm would be to exacerbate the anxiety they already experience. At the very time the individual could conceivably benefit from transcendent experience to cast meaning on a crisis, that possibility is closed. At the very time open reciprocity between the person and the environment could be occuring to facilitate individuation through a broadening of personal boundaries, integration of experience is limited. Consequently the discrepancy increases between what is happening within the person and what is transacting outside, in the environment.

This discussion would not be complete without addressing the question of might be be done to benefit the MVPS symptomatic patient. It should be stated that any psychotherapeutic system would be effective if it addressed itself to the core issues of health and illness as stated by the theoretical framework of this study. Intrapersonally, cognitions must be changed and affective postures must be profoundly challenged if physiological relief, or health, is to occur for the MVPS patient. Interventions which ignore or do not explicate and assist in the integration of these three intrapersonal components are not likely to be as effective as those which address the interaction of all the core components. Further, the social 159 introversion and sense of isolation from transcendent values of the MVPS symptomatic patient must be modified if a more meaningful relationship with the environment and with the universe is to be established. Again, any psychotherapeutic system can be helpful which gives weight to these factors.

Several specific remedial psychotherapeutic interventions appear promising for the symptomatic MVPS patient. One such intervention is frequently referred to as existential psychotherapy, meaning a highly disciplined psychotherapist-client relationship which probes deeply into the fear, the pain, the anxiety, and the existential dread of the client's experience, and seeks to elicit highly expressive and cathartic responses from the client. Physiological conditions, affective states and belief systems are all proper foci for existential approaches which utilize intuitive, metaphorical and abstract interpretations of experience as well as logic. In light of the self-in-situation model of this study with its emphasis on the core of the personality, and the fact that MVPS patients appear to have an intuitive awareness of their inner disharmony which they believe the world does not understand, this approach commends itself as addressing issues in a manner which should have credibility to the MVPS personality.

A second psychotherapeutic intervention with promise for the sympto­ matic MVPS patient would be any of several techniques designed to elicit the expression of feelings in the context of increased physical and cognitive awareness. A variety of interventions can be envisioned at this juncture, either in individual or group settings. Group encounter provides an excellent opportunity for repressed and suppressed individuals to learn 160 more expressive behaviors from other group members who are less inhibited with expression, and to re-evaluate irrational constructs. Psychodrama has a long record of credibility as a procedure for eliciting expression, particularly around life issues and relationships which the subject has considered closed to further assessment and growth. Bioenergetic therapy is a more recent procedure which focuses on body armor, that is, closedness in the joints, restriction in the flexor muscles, and inhibited breathing.

Bioenergetic therapy seeks to release deep expression of personal exper­ ience by giving precise attention to physiological functioning, and suppres­ sion as it is manifested physiologically.

Another promising psychotherapeutic intervention is Rational Stage

Directed hypnosis. Tosi (1974, 1982) extended and modified Ellis' Rational

Emotive Therapy (1962) to the following ABCDE model: (A) the situation or environmental conditions and events that are associated with (B) the person's interpretations, (C) his/her emotional reaction, (D) psycho- physiological concomitants and (E) behavioral responses to any of the preceding events. This experiential-cognitive-behavioral intervention was designed to direct the client through various developmental growth stages as conceived by Quaranta (1979): awareness, exploration, commitment, skill development, and skill refinement. At each stage, the client is taught to acquire, develop and refine effective coping skills for more competent rational self-management. Hypnosis is utilized to enhance visualization and experiencing, and to do so in the context of a very deep physiological stage of stress-free relaxation.

One caution needs to be exercised with Rational Stage Directed

Hypnosis, namely the importance of giving attention to all three aspects 161

of personality functioning, cognitive, affective, and physiological, and

to their interactive effects. While equal importance is stressed in the

conceptual framework of this approach, in its implementation with psycho-

physiological populations the cognitive aspect has sometimes been weighted over the affective or the physiological (Forman, .1979; Reardon and Tosi,

1977). With the MVPS sample population of this study, it would be imper­ ative to remember that the unrealistic belief system like the internal locus of control emerges from a physiological condition, or more accurately, from the synergistic effects of a dysfunctional physiological condition and the associated cognitions and affective states. Remedial interventions would therefore require attention to all three factors. From an induced state of deep relaxation or hypnosis, the patient would be lead to explore new forms of appropriate openness and appropriate closedness both in affective expression and in structure of beliefs.

Recommendations for Further Study

This study has identified several areas which would seem to merit further research.

First, it is recommended that this study be replicated in order to both verify and add to the findings discussed here.

A second recommendation is that a similar study be conducted from a

MVPS sample population drawn from other socio-economic strata than the

upper-middle class stratum of this study. It would be important to know

if these demographic factors effect the variance. Certainly different

environmental stressors might be expected for persons in both lower and

higher socio-economic strata. 162

A third recommendation is that future studies be expanded to take into

account the effects of persons not known to have MVPS but who still might

be suffering from some of the symptoms of MVPS. If such persons were

present in the control group, they could be detected and accounted for in

analysis of variance studies.

A fourth recommendation is that a specific study be made of MVPS

asymptomatics. It would be interesting to see how they compare with a

control group on the measurements utilized in this study, but also on

general life style. A purpose would be to identify factors of personality

and socialization which might account for the success of asymptomatics in

adapting to their condition without severe and frequent physical distress.

A fifth recommendation is that, based on the findings of this study, other instruments be utilized in an array of studies on the MVPS person­

ality. Several specific instruments or procedures are apparent. A life history assessment might be employed in a search for the themes and significant etiological events which might help in an understanding of

the differences between the MVPS personality and the control personality, or the MVPS symptomatic and the MVPS asymptomatic personalities. The developmental, stages as outlined by Erikson (1963) or Loevinger and

Wessler (1970) could be held as theoretical criteria to discriminate

the emergence of the relatively differentiated ego from the ego that is arrested, dependent, or introverted. For a more precise measurement of

the MVPS patient's interaction with the environment, the Thematic Ap­ perception Test (Murray, 1943) could be utilized to discriminate between the individual's perceived needs and the perceived press of the environ­ ment. Persons looking at specific aspects of the person-environment 163

interplay could employ the Fundamental Interpersonal Relations Orientation

(FIRO-B) of Schutz (1967) which measures the desired and expressed aspects

of such interpersonal needs as inclusion, control and affection. The

California Psychological Inventory (Gough, 1957) would provide a distinct

measurement of interpersonal behavior and concepts of social living, and

might shed further light on the preference of MVPS symptomatics for the microcosmic domain. And, of course, for more precise investigations of

the presumed underlying or unconscious personality structures and dynamics of the MVPS population, the Rorschach Technique (Klopfer, et. al., 1954)

could be utilized. The Rorschach would be especially helpful for enhancing

the interpretation of the MVPS subject's propensity for the detailed microcosmic domain.

A sixth recommendation is that comparative studies be made of the family climates of both symptomatic and asymptomatic MVPS patients to determine if those climates might be a significant variable for discrimi­ nating between the two groups.

Finally, studies of pre-MVPS individuals would constitute a major contribution to the field. Since MVPS does appear to be transmitted in families, it would be possible to identify a sample population of children of MVPS parents. These children could be participants in a longitudinal study where, as they develop, specific attention could be.given to the same selected personality characteristics and belief systems of this study. Testing could also be administered to the parents of these children to determine if pathogenic attitudes and behaviors are being reinforced for children becoming symptomatic, or if healthy attitudes and behaviors are being reinforced for children who are likely to remain asymptomatic. APPENDIX A

FACTORS IN ANXIETY

•tm ory tad cognitive fndback

INTERNAL STIMULI Subjective feelings thoughts, feelings, of apprehension, biological needs 'anxious'1 expectation A-STATE Activation (arousal) of the antonomlc nervous system De f e n s e EXTERNAL MECHANISMS STIMULI [COGNITIVE 1 AdJuBtlve processes La p p r a b a lJ (Stressors) highly over-learned for avoiding or responses to reducing A-STATES threatening stimuli responses to stimuli appraised as nonthreatening

A-TRAIT Individual differ­ ences In anxiety proneness

alteration of cognitive appraisal by defense mechanisms

A trait-state conception of anxiety in which two anxiety concepts, A-trait and A-state, are posited and conceptually distinguished from the stimulus conditions which evoke A-state reactions and the defenses against A-states. It is hypothesized that the arousal of A-states involves a sequence of temporally ordered events in which a stimulus that is cognitively appraised as dangerous evokes an A-state reac­ tion. This A-state reaction may then initiate a behavior sequence designed to avoid the danger situation, or it may evoke defensive maneuvers which alter the cognitive appraisal of the situation. Individual differences in A-trait determine the particular stimuli that are cognitively appraised as threatening. 165

APPENDIX B

SCHEMATIC DIAGRAM OF THE HEART

Haad and Arms

unit*

a s 0 fhe ZW.yo/noar Pulmonary Artery J ^Atrium*; Pulmonary Vein

m itral alves 25

. H n n n n . t ) § SI ' W 5M aorticl^>f\ Endocardium J.vjpulmonary V vaKigs&as iVentrlcle RIGHT HEART LEFT HEART m cuspi X V 1 valve receives blood from the receives oxygenated ventricle body and pimps it blood frcrn the through the pulrrmary lungs and pimps it artery to the lungs through the aorta heart muscle where it picks up (myocardium) to the body fresh oxygen Trunk Pericardium and Legs APPENDIX C 166

PERSONAL DATA QUESTIONNAIRE

PLEASE ANSWER ALL QUESTIONS AFTER YOU HAVE COMPLETED THE FOUR INSTRUMENTS. ALL ANSWERS TO THIS QUESTIONNAIRE WILL REMAIN STRICTLY CONFIDENTIAL.

1. Male . Female ______2. Age ______3. Married______Single Divorced______Separated______Widowed______A. Educational Level: A. More than 16 years (graduate level college ) _____ B. 13-16 years (college) _____ C. High school graduate . . . . D. 9-12 years (some high school) _____ E. 0-8 years ______5. Occupation: A. Professional, managerial _____ B. Sales _____ C. Clerical _____ D. Skilled trade _____ E. Laborer _____ F. Homemaker, student, not currently employed _____ G. Unemployed ______H. Other (describe) ______6. Spouse's Educational Level: A. More than 16 years (graduate level college) _____ B. 13-16 years (college) _____ C. High school graduate _____ D. 9-12 years (some high school) _____ E. 0-8 years _____ 7. Spouse's Occupation: A. Professional, managerial _____ B. Sales _____ C. Clerical _____ D. Skilled trade _____ E. Laborer _____ F. Homemaker, student, not currently employed _____ G. Unemployed _____ H. Other (describe)______

ANSWER THE FOLLOWING ONLY IF YOU HAVE EVER BEEN DIAGNOSED FOR CARDIO­ VASCULAR DISORDERS. 8. Difficulty, if any, with mitral valve prolapse: Nature of symptoms (check all that apply) (1) Heart palpitations (rapid or very strong heartbeat) _____ (2) Shortness of breath _____ 167

(3) Fatigue _____ (A) Fainting _____ (5) Chest Pain _____ (6) Dizziness _____ 9. By your best estimate: (1) How many days were you symptomatic in the last 12 months? _____ (2) How many days did yoiU miss work due to MVPS in the last 12 months? 10. Your age when you first noticed these problems ______11. Medication: 1. Propranolol (Inderal) A. Currently administered ______(yes or no) B. Administered when symptomatic _____ C. Has been administered previously _____ 2. Other (identify the drug) ______;______A. Currently administered _____ B. Administered when symptomatic ______C. Has been administered previously _____ APPENDIX D

STATE-TRAIT ANXIETY INVENTORY

SELF-EVALUATION QUESTIONNAIRE Developed by C.D. Splelbergsr, R.L. ftrsuch and R. lushere STAI FORM X-l

DIRECTIONS: A muter of statements which people have used to All AtNot describe themselves are given below. Read each statement and then blacken in the appropriate circle to the rlgit of the statement to Indicate hew you feel right now, that Is, at this nnnent. There are no right or wrcrg answers. Do not spend too much time cn any cne stataasnt, but give the answer which seats to describe your present feelings best. I 1. I feel c a l m ...... 1 2. I feel s e c u r e ...... 1 3. I am t e n s e ...... 1 4. I am regretful...... 1 5. I feel at e a s e ...... 1 6. I feel u p s e t ...... 1 7. I am presently worrying over possible misfortunes ...... 1 8. I feel r e s t e d ...... 1 9. I feel a nxious ...... 1 10. I feel comfortable...... 1 11. I feel self-confident...... 1 12. I feel n ervous ...... 1 13. I am jittery...... ,...... 1 14. I feel "high s trung"...... 1 15. I am relaxed...... 1 16. I feel content ...... 1 17. I am wo r r i e d ...... 1 18. I feel over-excited and "rattled"...... 1 19. I feel j o y f u l ...... 1 20. I feel pleasant...... 1 169

SELF-EVALUATION QUESTIONNAIRE

STAI FORM X-2

NAME DATE

DIRECTIONS: A nuttier of statements which people have used as w sc < to describe themselves are given below. Read each statement and ° § s. ™ then blacken In the appropriate circle to the right of the state- > 2 ™ ^ ment to indicate hew ycu generally feel. There are no right or cr 5> “ c wrong answers. Do not spend too nuch time on any one statement £ rt £, §. but give the answer which seems to describe how you generally feel. ** g>

» 21. I feel pleasant...... '...... 1 2 3 A 22. I tire quickly...... 1 2 3 A 23. I feel like c r y i n g ...... 1 2 3 A 2A. I wish I could be ashappy as others seem to b e ...... 1 2 3 A 25. I am losing out cu things because I can't make up my mind soon e n o u g h ...... 1 2 3 A 26. I feel r e s t e d...... '...... 1 2 3 A 27. I am "calm, cool, and collected"...... 1 2 3 A 28. I feel that difficulties are piling up so that I cannot overcoraq t h e m ...... 1 2 3 A 29. I worry too much over something that really doesn't matter . 1 2 3 A 30. I am h a p p y ...... 1 2 3 A 31. I am Inclined to take things h a r d 1 2 3 A 32. I lack self-confidence . .'...... 1 2 3 A 33. - I feel se c u r e ...... 1 2 3 A 3A. I try to avoid facing a crisis or difficulty...... 1 2 3 A 35. I feel blue- 1 2 3 A 36. I am content...... 1 2 3 A 37. Some unimportant thought runs through my mind and bothers me 1 2 3 A 38. I take disappointments so keenly that I can't put them out of my m i n d ...... 1 2 3 A 39. I am a steady p e r s o n ...... 1 2 3 A AO. I get in & state of tension or turmoil as I think over my recent concerns and interests 1 2 3 A PLEASE NOTE:

Copyrighted materials in this document have not been filmed at the request of the author. They are available for consultation, however, in the author's university library.

These consist of pages:

P. 170-171 Internal-External Locus of Control Scale

P. 172-173 The Rokeach Dogmatism Scale

P. 174-175 The Bessai Common Beliefs Survey III

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