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University Microrilnns International

300 N /HFB HOAD, ANN ARBOR, Ml 3B100 1K BFDFORD ROW, LONDON WC1R ■IflJ, ( NOLAND 791597!.

FORMAN, MICHAEL ALAN SPECIFICITY OF IRRATIONAL ATTITUDE PATTERNS IN PSYCHOPHYS10LOG1CAL DISORDERS: A DESCRIPTIVE STUDY.

THE OHIO STATE UNIVERSITY, PH.D., 1979

University M icrofilm s International •TOO N / 1 I H H O A O . A N N A H U O H . Ml '1HKM.

@ Copyright hy Michael Alan Forman

1979 SPECIFICITY OF IRRATIONAL ATTITUDE PATTERNS IN PSYCHOPHYSIOLOGICAL DISORDERS: A DESCRIPTIVE STUDY

DISSERTATION

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

By Michael Alan Forman, A.B., M.S.

The Ohio State University

1979 Approved By Reading Committee: Donald J. Tosi Herman J. Peters Peter H. Gwynne adviser Department of Counselor Edfucation ACKNOWLEDGEMENTS

Create ideas with humility knowing that behind the idea he calls his own are thoughts and efforts of many men.

-- W. A. Peterson

I wish to express my indebtedness to all the physicians and their associates who cooperated in this venture, while special thanks are extended to Dr. David R. Rudy, Director of the Riverside Family Practice Center, whose generous assistance in this research endeavor was appreciated. I am grateful for the support of my academic advisor, Dr. Donald J. Tosi, whose wit and guidance has inspired me to believe in myself and to persevere in the face of difficulties. Special thanks goes out to Keith Widaman for hio invaluable statistical consultation; to my friend and colleague, Dr. Dennis Eshbaugh, for his encouragement and enumerable clarifying comments; to Judy Boggs who spent many long hours typing this manuscript. I would also like to thank the many cooperative patients suffering from psychosomatic disorders. Without their participation and interest, the study would not have been possible and I hope this investigation will be helpful to them. I am grateful to all those who have helped, but my deepest appreciation goes to my family for their investment in me. To my parents, Bernard and Lois Forman; grandparents, Henry and Birdie Faye Raff; to my parents-in-laws, William and Dea Brandon and Maurice and Magda Waldman; and of course my wife, Debi, whose patience and love helped to make it all worthwhile.

iii VITA

August 16, 1952. . . Born - Chicago, Illinois 1972 ...... Medical Researcher, Pox River Hospital, Chicago, Illinois

1973-1974...... Psychiatric Team Worker, London Memorial Hospital, Chicago, Illinois

1974 ...... A.B., Psychology, Indiana University, Bloomington

1975 ...... Counselor, University Middle School, Practicum, Indiana University, Bloomington 1975 ...... M.S., Counseling and Guidance, Indiana University, Bloomington

1975 ...... Program Consultant, Council for Retarded Citizens, Columbus, Ohio

1975-197 9 ...... Psychological Intern, Dr. Henry Samuels, Riverside Psychological Services, Columbus, Ohio 1976-197 9 ...... Psychological Intern, Community Agency for Labor and Management, Columbus, Ohio

FIELDS OF STUDY Major Field: Counselor Education Studies in Counselor Education. Professor Donald J. Tosi Studies in Counselor Education. Professor Herman J. Peters Studies in Psychiatry. Professor Peter H. Gwynne,

iv Vita - continued

Studies in Developmental Psychology. Professor Henry Leland Studies in Clinical/Counseling Psychology. Professor Harold J. Pepinsky

v TABLE OP CONTENTS

Page ACKNOWLEDGEMENTS...... ii VITA...... iv LIST OP TABLES...... viii

LIST OF FIGURES...... x Chapter I. Introduction ...... 1 Need For The Study...... 4 Purpose Of The Study...... 8 Hypotheses...... 8 Limitations Of The Study...... 9 Definitions Of Terms...... 11 II. Review Of The Literature...... 14 Historical Remarks: The Mind-Body Problem...... 14 Psychogenesis ...... 20 Cardiovascular System - Migraine Headache ...... o...... 29 Classification...... 29 Pathophysiology...... 32 Personality Attributes...... 34 Musculoskeletal System - Psychogenic Low Back Pain...... 46 Classification and Pathophysiology...... 46 Personality Attributes...... 50 Gastrointestinal System - Duodenal Ulcer...... 66 Classification and Pathophysiology...... 66 Personality Attributes...... 69

vi. Page

III. M e t h o d ...... 82 Selection Of The Instrument...... 82 Selection Of The Sample ...... 85 Procedure ...... 89 Statistical Analysis...... 91 Research D e s i g n ...... 92 Summary ...... 93 IV. Analysis Of The D a t a ...... 95 Factor Analysis ...... 95 Analysis Of Variance...... 100 V. Summary, Conclusions And Recommendations . 117

Summary 117 Discussion And Implications ...... 121 Recommendations ...... 126 APPENDIXES A. Summary Of Conversation Held With The Patients...... 135 B. Cover Letter/Consent Form...... 137 C. Personal Data Questionnaire...... 138

D. Common Beliefs Survey III...... 140 E. Common Beliefs Survey III: Parcel And Factor Membership Of Items. .... 144 LIST OF REFERENCES...... 149

-ii LIST OP TABLES

Table Page 1. Relations Between Stimuli, Persons, and Responses, Described in Different Languages...... 22 2. Sample Characteristics ...... 87 3. Univariate F-Tests of Groups Main Effect for CBS III Factors ...... 101 4. Mean Scores for Ss Performance on Factor V of the CBS III...... 102 5. Univariate F-Tests for the Combined Psychosomatic Groups Versus the Medical Control Group on Six Dependent Factors . . 103 6. Results of Duncans New Multiple Range Test on all Ordered Pairs of Means for Factor I I I ...... 105 7. Results of Duncans New Multiple Range Test on all Ordered Pairs of Means for Factor V ...... 105 8. Univariate F-Tests of Groups Main Effects for Age and Socioeconomic Status . 107

9. Mean Age For Groups...... 107 10. Mean Socioeconomic Status for Groups . . . 107 11. Results of Duncans New Multiple Range Test on all Ordered Pairs of Means for Age...... 108 12. Results of Duncans New Multiple Range Test on all Ordered Pairs of Means for Socioeconomic Status ...... 109

viii Table Page

13. Correlation Matrix For 18 Parceled Variables...... 111 14. Varimax Loadings of 18 Item-Parcels on 6 Factors ...... , . . . 114

15. Promax Loadings of 18 Item-Parcels on 6 Factors ...... , . . . 115 16. Interfactor Correlation Matrix ...... 116

ix LIST OF FIGURES

Page Figure 1 Scree Test For Factors...... 97

x CHAPTER I

INTRODUCTION

"It is more important to know what sort of person has a disease than to know what sort of disease a person has." Hippocrates apparent overstatement is actually quite profound. Once again, the patient as a human being with worries, fears, hopes, despairs, as an individual whole and not merely the bearer of organs - of a diseased liver or stomach - is becoming the legitimate object of medical interest (Alexander, 1950).

From a historical perspective, this renewed psychological interest is nothing more than a revival of old philisophic views in a new and scientific form. Psychosomatic medicine once again has been emerging in the past few decades from the dichotomous fallacies based on Cartesian dualism between the mind and the body into a fertile area of clinical and physiologic research (Wittkower and Warnes, 1977). The physician who treats "disease" without the realization that the disease is merely a reaction of a human "body" and "mind" to the presence of a disturbing factor or factors in the internal and external environment of that body and mind, is slowly becoming outdated (Cantor, 1951).

1 The modern viewpoint is that the terms "mind" and "hody" are artificial separations from the facts of life and useful only for the convenience of discussion. It seems that psychological processes are fundamentally not different from other processes which take place in the human organism. The fact is that the mind and hody are inseparable in the life functions (Cantor, 1951). They are at the same time physiological and differ from other body processes in that they are perceived subjectively and can be communicated verbally to others (Alexander, 1950). They, therefore, can be studied by psychological methods. The great proliferation of scientific knowledge in the past 50 years has brought in its wake the subtle evil of fragmentation and reductionism within the specialized medical fields. As a result, the medical approach has been more mechanistic than psychosomatic (Wittkower and Warnes, 1977). Hence, the medical or surgical specialist may minimize the psychosocial factors of health and illnes or ignore them completely in the management of the patient This failure to achieve integrated psychosomatic care has been referred to as "a collusion of anonymity" (Ballint, 1965) and "a scatter of responsible agents" (Winnicott, 1958) by those who promote a holistic approach. While it is indeed true that the tubercle bacillus "causes" tuberculosis and the treponema pallidum "causes" syphilis and so forth, other etiological factors must be examined. Clearly, not everyone who comes into contact with a bacteria will contract the disease. Other factors in this process may include hereditary constitution, birth injuries, organic diseases of infancy which increase the vulnerability, nature of the infant (i.e., weaning habits, toilet training), accidental physical and/or emotional experiences in infancy and childhood, emotional climate of the family and specific personality traits of parents and siblings, later physical injuries and later

emotional experiences in intimate personal and occupational relations (Alexander, 1950). It is unfortunate that we are too often content with only part of the truth. This is not a fault of medical thinking alone. It is one of the greatest defects of all thinking. Aaron Beck (1967) in devising a typology of cognitive distortions, classifies this common paralogical process as "selective abstraction", and believes that it is one phenomenon associated with the onset of psychopathology. We must avoid the pitfall of single

causation (Cantor, 1951). If we understand psychic phenomena as the subjective aspect of certain physiological (brain) processes, the mind-body dichotomy disappears (Alexander, 1950). Psychosomatic should be used to indicate a method of approach both in research and in therapy, namely, the simultaneous and coordinated use of somatic methods on the one hand (physiological, anatomical, pharmacological, surgical and dietary) and psychological (thoughts, 4 feelings) on the other. Adoption of a psychosomatic approach does not mean that if emotional etiology in a case has been established that somatic-medical management is unnecessary and the patient can be turned over to the behavioral scientists. This error is the reverse of the earlier misconception that if medical- somatic symptoms can be found that the psychologist is not needed. Progress consists of a cooperative effort of the psychologist and non-psychological specialists both in the diagnosis and the treatment of disease.

Need For The Study

The evidence for the usefulness of psychologically based treatment of illness is limited (Kellner, 1967) and the treatment typically administered is usually rather long (Maultsby and Graham, 1974). There is hope that new methods, emphasizing learning principles and cognitions will be more efficient and more acceptable to larger numbers of patients (Maultsby and Graham, 1974). One such method is Rational Emotive Therapy (RET) which is based on the assumption that irrational or unrealistic thinking is associated with emotional, behavioral and visceral disturbances

(Ellis, 1962, 1971, 1974„ 1977; Ellis and Harper, 1975; Tosi, 1974). Numerous experimental studies have shown that an individual can effect emotional and behavioral responses by perceiving themselves and the world more appropriately 5 and accurately (Lazarus, 1971; Velten, 1967, 1968;

Coleman, 1975; Meichenbaum, 1969, 1972, 1974., 1977; Hale and Strickland, 1976; Beck, 1967, 1976; Tosi, 1974; Reardon, Tosi and Gwynne, 1975; Boutin, 1976; Cautella, 1966). A growing number of studies have systematically demonstrated evidence to support the notion that cognitions and perceptions effect physiological conditions (Schacher and Singer, 1962; Grace and Graham, 1952; Graham, Stern and Winokur, 1958; Graham, Kabler and Graham, 1962; Graham, et al0, 1962; Wenger, Jones and Jones, 1956; Burdick, 1972; Gottlieh, Gleser and Gottschalk, 1967). A series of controlled laboratory experiments, for instance, have shown that when subjects are provided with "affective" and "neutral" stimulus words and phrases and are instructed to internalize these stimuli through the use of imagery, their cardiac and respiratory x*ates increase with the perceived activity and valence of the stimulus as measured on the Semantic Differential (Schwartz, 1971; May and Johnson, 1973; Leber and Johnson, 1976; Jones and Johnson, 1978)„

In those studies that have linked cognitions with physiological changes, few have associated cognitions with known visceral disease (Graham, et al., 1962; Grace and Graham, 1952; Ring, 1957). One suspects that if the specificity hypothesis is correct, direct dealing with attitudes will accelerate recovery in patients who have them so strongly or for so long that the associated visceral processes are actually manifest as disease (Maultsby and Graham, 1974). Cognitive-Eehavior Therapy, in general, and Rational-Emotive Therapy, in particular, may he of particular value because it lends itself to specific focusing on the cognitive processes associated with the visceral disease of interest. Hardyck and Moos (1966) concluded that the majority of studies attempting to specify personality types, traits or conflicts associated with psychosomatic disease have compared a group, usually quite small in number, with a particular psychosomatic disease, with a more or less carefully matched control group. Most studies have either ignored or failed to adequately control for such important factors as sex, age, socio­ economic status, the factor of self-referral, intelligence testing conditions, degree of patient knowledge regarding diagnosis and prognosis, severity and duration of the disease or illness. Uncontrolled differences in these factors could importantly effect the results of and, therefore, the conclusions drawn from both intra and inter-psychosomatic disease group comparisons. It is probable that the tendency to overlook these limitations has resulted in many of the disagreements that can be found among different investigations concerned with the relationship between personality characteristics and psychosomatic diseases. 7

The need to systematically measure such attitudes, values and perceptions of the world is, therefore, of paramount importance and the object of this investigation. Purpose Of The Study

Previous attempts to find something in common among persons with any given disease, other than the disease itself, have yielded interesting, yet often confusing and conflicting results. This search has included examination of personality patterns (Dunbar,

1934, 1943, 1959; Wolff, 1948, 1963), personality traits (Gressell, Shobe, Saslo, Dubois, SchrOeder, 1949), early childhood experiences (Halliday, 1943, 1948), unconscious conflicts (Alexander, 1950), stressful life situations (Holmes and Rahe, 1967; Groen, 1947; Dunbar, 1946) and organ infex'iority or weakness (Lacey and Lacey, 1958; Malmo, 1967)o However, as noted previously, few investigators have attempted to directly examine the patients attitudes, beliefs and perceptions (Grace and Graham, 1952; Graham, et al,, 1958, 1962; Ring, 1957; Maultsby and Graham, 1974).

The purpose of this investigation is to explore this approach further using a systematic method of questioning patients about their attitudes while controlling for as many extraneous variables as possible.

Hypotheses

The following null hypotheses were investigated: Main effects: Groups Groups of subjects receiving medical

8 9

treatment for psychosomatic disorders including migraine headache, psychogenic low hack pain, and duodenal ulcer will not differ significantly from each other or a medical control group (separately or as a whole) with respect to mean factor scores reflecting specific attitudes as defined by the Common Beliefs Survey III. Main effects: Sex There will be no significant difference among males and females with respect to mean factor scores reflecting specific attitudes as defined by the Common Beliefs Survey III. Interaction effects:

There will be no significant interaction among combinations of groups and sex with respect to mean factor scores reflecting specific attitudes as defined by the Common Beliefs Survey III. Additional Hypothesis: Groups of subjects receiving medical treatment for psychosomatic disorders including migraine headache, psychogenic low back pain and duodenal ulcer will not differ significantly from each other or a medical control group (separately or as a whole) with respect to their mean age and socioeconomic status.

Limitations Of The Study Several limitations of the present study need to be mentioned at the outset. First, the subjects selected were medical patients referred by physicians affiliated with

Riverside Methodist Hospital in Columbus, Ohio and consequently consisted of white, upper-middle to upper-lower class individuals who presented themselves to their physician. This may not reflect a true sampling of the total population of persons inflicted with migraine headaches, 10 low "back pain and duodenal ulcer. Second, the sample consisted of those who were willing to take the time to respond voluntarily to the inventory and return the results to the researcher. Third, the validity of the Common Eeliefs Survey III and its sensitivity have not yet been experimentally tested, however, it has been shown to have face validity with a theoretical basis and to be a reliable measure in terms of its replicated factor structure. Ey pooling nine existing rationality scales (419 items), discarding those items that were not stated in the form of a belief as opposed to an emotion or symptom, controlling for the acquiescent response biases and revising and refining the items following successive factor analyses with different subjects, Bessai (1977) has px'obably established the best available measure of irrationality based on Ellis’ irrational beliefs system. Fourth, given the problems inherent in clinical data collection of psychosomatic groups, including prevalence rates and voluntary participation limitations encountered by previous investigators, the time needed to secure the numbers to adequately control for such potentially important factors as sex, age and socio­ economic status would far exceed the alloted time for this study. As a result, it was determined that group membership with four levels, and sex with two levels, would be used as independent variables, while age and socio-economic status would be dealt with on a separate 11 descriptive basis.

Definition Of Terms Attitude: An attitude is defined as the perception of the stimulus situation and the response tendency aroused by it; that is, what an individual feels is happening to him and what he wishes to do about it (Graham, et al„, 1962). Attitude Patterns; Attitude patterns are operationalized as that which are measured by the sub­ scales of the Common Beliefs Survey III (CBS III). Elevations on subscale factors, in combination, will be considered indicators of irrational thinking. Rational: Rationality is a non-static concept based upon logically cori*ect thinking relative to a given set of facts (Tosi and Marzella, 1975). Maultsby (1971a) describes five rules for rational thinking and acting. Ones thinking and acting is considered rational when:

1) It is based on objective reality 2) It is life preserving 3) It helps one achieve his immediate and long term goals 4) It minimizes personal stress 5) It minimizes environmental stress

Failure to meet three of these conditions are considered irrational thinking and acting.

Migraine Headache: A migraine headache is defined as a headache, commonly unilateral, associated 12 with nausea, vomiting or diarrhea. Alternatively, fulfillment of any three of the following criteria is considered adequate to make the diagnosis. Occurrence of: anorexia, photophobia, visual symptoms (blurring, teichopsia, or other scotoma), neurologic symptoms with headache, or family history of migraine or frequent severe headaches in the first degree family members. The diagnosis of migraine headache will be determined following an evaluation history and examination and any indicated lab and X-ray tests (e.g., GAT Scan, EEG, Brain Scan) needed to rule out anemia, brain tumor, metabolic causes or hypertension. Psychogenic Low Back Pain: Pain eminating from the lumbosacral region that has no clear cut physiological explanation. Typically, there is no obvious pathological lesion and sensory deficits violate anatomical boundaries. The psychogenic low back pain group is defined as those suffering from low back pain when herniated disc, neoplastic disease, referral pain from the kidney, uterus, duodenum, prostate, skeletal injury or other compressive radiculopathies have been ruled out. This will be done following an evaluation history and examination and any indicated X-ray and lab tests (e.g., EMG, Myelography).

Somatic Low Back Pain: Pain that is thought to be due to identifiable organic pathology in the musculoskeletal or neurologic systems including skeletal injury, herniated disc and other compressive radiculopathies. 13

Duodenal Ulcer: A duodenal ulcer is an ulceration or sore of the first section of the small intestine which, if allowed to continue, can erode the wall of the organ. The ulcer varies from an eighth to three-quarters of an inch. Diagnosis will he made following an evaluation history and examination and positive identification based on at least one X-ray or lab test (e.g., Upper G.I., Gastroscopy). Medical Control Group: Medical patients who present themselves to their physician for such things as routine check-up, upper respiratory infections, pre and post-natal examinations, innoculations, minor trauma.

Chronic: A disorder of greater than three months duration.

Organization

Chapter I has established the purpose and need for the study, the working hypotheses, limitations of the study and a definition of term3. Chapter II contains a review of relevant literature. Chapter III consists of the methodology employed, the collection of the data and the method of analyzing the data. The analysis of the findings are presented in Chapter IV, and Chapter V contains the summary, discussion and recommendations for further research and treatment. CHAPTER II

REVIEW OF THE LITERATURE

Historical Remarks: The Mind-Body Problem Psychophysiology is an old idea, hut a new science. It is a likely assumption that ever since man hegan to experience himself as an object of his own awareness, he had some intuitive notions that bodily changes were, in some measures, related to his moods, his sentiments, his frustrations, his elations (Greenfield and Sternbach, 1972). The general area of interest covered by the term "psychosomatic" coined in 1818 by a German romantic psychiatrist, Johann Christian Heinroth, is intimately associated with the mind-body dichotomy whose psychological and philisophical implications have been debated since antiquity (Ramsey, Wittkower and Warnes, 1976). Wittkower and Dudek (1973) have traced its early origins in Greek, Egyptian, Chaldean, and Indian medicine, then through the periods of Hippocrates (460-375 B.C.) and Galen (131- 201 A.B.). It has been reported that Cicero in Rome showed some reaction against 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?"

14 15

(Ramsey, Wittkower and Warnes, 1976). Plato (427 - 347), 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 diseases 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)." With the surge of primitive religious and metaphysical preoccupation of the Dark Ages and then the reaction against this in the Renaissance period which identified all non-naturalistic explanations as demonological, the acceptance of psychological phenomena was retarded for literally centuries. Reil, in 1803, produced the first systematic treatise on psychotherapy, and clearly recognized the mutual interaction between psychological and physical events in the organism (Alexander and Flagg, 1965). However, it was not well received in the scientific community. Carus, a German obstetrician, discussed the concept of the unconscious in his book Psyche (1841), and considered all physical and mental ailments to be the result of unconscious mental processes. The views of Reil, Heinroth and others in the 19th and early 20th centuries never received acceptance probably because they discovered no method to investigate and substantiate their beliefs. 16

There has been enormous growth of interest in psychosomatic interrelationships in the past half century and the contributions to the field have been representative of a wide variety of disciplines and theoretical orientations (Ramsey, et al„, 1976)„ The important work of Pavlov (1927) and Cannon (1953) with experimental animals demonstrated that needs (hunger) and fear (anticipation of danger) could evoke severe, immediate or long-standing physiological disturbances within the nervous system and its innervated organs. Breuer and Preud (1895) and later Ferenczi (1926) postulated that specific unconscious content could be symbolically expressed in the "body language" of somatic symptoms. Freud, however, did not limit his conceptualization in the psychosomatic field to the conversion mechanism, which many of his followers have failed to realize. In a paper published in 1910, he noted that there were mechanisms, other than conversion operative, namely unconscious attitudes that might alter physiologic functions without symbolizing any definite psychic meaning, In fact, he maintained that no mental process, even "pure" thought, is free from some influence on the body, George Groddeck (1926), a physician, is considered by many as the father of psychosomatic medicine insofar as he saw psyche and soma not as separate entities but as facets of one whole. His treatment of psychosomatic disorders included massage, hydrotherapy, rest, psychoanalytic interpretations and dream analysis. 17

The underpinnings of the holistic approach or

"psychosomatic medicine", as it has been called, seemed to develop as a result of clinical observations and humane concern for the sick individual. Attempts to humanize medicine reached its peak after World War II when hopes were raised that diseases previously regarded to be of unknown or "medical" origin had found a psychological explanation and were possibly amenable to psychotherapy. Confusion about the mind-body problem is a serious obstacle to understanding psychosomatic medicine and has

interfered with its growth (Graham, 1972). The term psychosomatic does not necessarily imply a dichotomy between mind and body. It should be understood that psychic phenomena are the subjective aspect of certain physiological or central nervous system processes (Alexander and Flagg, 1965)o Used in this manner, the term of "psychosomatic" designated merely a method of approach both in research and in therapy which is aimed toward the simultaneous and coordinated use of somatic and psychological methods and concepts. Psychological and Physical cannot be use­ fully thought of as referring to different kinds of states or events; rather they are names of different but "parallel languages" that may be used for describing exactly the same events (Graham, 1967). Thus, for Graham, "mind" and "body" (or psyche and soma, or mental and physical, or psychic and somatic) are merely different languages, similar to Latin and Sanskrit, and do not represent different phenomenon. One however may be more 18

convenient, meaningful or useful than the other, just as one language may he better suited to deal with some phenomena, perhaps because of a more descript way of

differentiating similar things. Consider the following example given by Graham (1972); 1) John Smith was frightened when he saw the cat. 2) When the light rays from the cat reached John Smith's retina, various biochemical processes were set up that resulted in the passage of impulses over the optic nerve to the occipital cortex, with activation of sympathetic hypothalamic nuclei, and increased activity in sympathetic nerves to the heart, leading to tachycardia.

Therefore, in principle both are applicable to the same phenomena although in practice Psychological

tends to be used for the limited class of observations made on the patients speech, including self-talk. Physical is often used to describe the outputs of other organs of the body, although it is important to note that a patients speech can also be understood in terms of Physical language, however more cumbersome.

The mind-body problem, then, can be said to be the question of how the Physical and Psychological languages are related to each other. Statements in one language can be translated into the other, to the extent that present knowledge of the fields permit. This is

i Graham capitalized Psychological and Physical to emphasize the usage of both terms as languages in proper English form. 19 different from the seemingly similar statement: "The mind and "body are two sides of the same coin." Two sides of the same coin, as Graham (1972) notes, does yield different vantage points, the head side and the tails side. Rather than saying that there are two aspects or vantage points, Graham contends that there are not two aspects, but rather two ways of describing the same aspect. The Sapir-Whorf hypothesis in anthropological linguistics postulates that language may not only describe the world we inhabit, but also mold the way we experience it. By using nouns and spatial metaphors rather than verbs to express the idea of illness, we are led to a static view of disease that separates illnesses as distinct entities rather than as ways of describing bodily functioning (Warner, 1976).

Given the above argument against the dualistic view, why then does it persist?

Because it does represent reality; there is a duality of psychic and physical. The duality is however not of the events observed; it is of the language to describe them. Since it seems useful, there is no need to eliminate it. It is nevertheless essential to identify it correctly to avoid countless futile debates (Graham, 1972).

The importance of psychosomatic medicine and psychophysiological research, then, can be seen in terms of helping to bridge the language barrier. 20

Psychogenesis Since psychological and somatic phenomena take place in the same organism and have been considered to be two ways of viewing the same aspect, the term psychogenesis needs to be clarified. The major trouble with the assertion, or its denial, that a given disease is "psychogenic", is that the term can meaningfully refer to causation either by another state of the organism (emotions), or by an external (environmental) stimulus.

If it is the first, the assertion is that a state of the organism, described Psychologically, is responsible for another state, in this case a disease described Physically. This meaning occurs in such statements as "his tension is causing his headache" or "his anger is causing his ulcer". The evidence, however, for such a contention would probably arise from various signals emitted by the patients body, and thus could have also been described in Physical terms (i.e., muscle tension, raised blood pressure). Used in this way, "psychogenic" says nothing about the presence of external stimuli. Actually, then, we would be attempting to determine a causal relationship between two ways of looking at the same phenomenon (Physically and Psychologically) which is bound to be futile. Certainly there would be a correlational relationship, but this could be likened to trying to determine which came first, the chicken or the egg. This kind of specificity is considered Psychological- 21

Physical specificity applied to the organism at the time it is responding, (Graham, 1967, 1972). The etiologic question of most interest and importance is the external stimulus question: which responses of the organism and especially which diseases are responses to psychological stimuli (Graham, 1972)? The fundamental scheme is of a situational stimuli, acting on an organism to elicit a response. The characteristics of the organism as well as the elicited responses can be described in either Psychological or

Physical terms (or Sociological, if desired). The external stimuli can be either psychological (i.e., failing an exam, the death of a loved one) or physical (i.e., bacteria, viruses and drugs). Since this investigation revolves around psychosomatic illnesses, the physical stimuli will not be explored in depth. The effect of the psychological stimuli is mediated through action on peripheral sense organs. Graham (1972) has graphically conceptualized this notion in Table 1. Table 1

RELATIONS BETWEEN STIMULI, PERSONS AND RESPONSES, DESCRIBED IN DIFFERENT LANGUAGES

Persons Responses

Psychological Physical Sociological Psychological Physical Stimuli language language language language language

Streptococcus Passive- Obese Lutheran Anger Asthma X-radiation dependent XYY chromo­ Middle Activation Tachycardia Unresolved somes class of oral Digitalis Oedipus conflict Rise in blood complex Labile Married pressure Wife leaves Paranoid blood pr. Attitude personality Uneducated Tuberculosis Pay decrease Inborn meta­ Schizophrenic Careless bolic error episode Husband shouts Response set

Note: Under each heading are given examples of appropriate items. It is not implied that items on the same horizontal line have any relation to each other. (Graham, 1972) 23

While this table appears to clarify Graham's position, there seems to be at least one internal inconsistency. Eased on his own discussion about the specificity-of-attitudes hypostesis (Graham, 1962, 1967, 1972) which states that there is a specific relationship between the attitudes a person holds toward a stressful stimulus and the physiological changes which occur in response to the stimulus, it would seem more appropriate to classify "attitude" under "Psychological language of the Person." Paranoid personality is correctly classified, for instance, as it can be defined as a set of attitudes, beliefs, and perceptions one has of himself and the world„ The alteration in Graham's schema is supported by Ellis' Rational Emotive Therapy (RET) theory of human disturbance (Ellis, 1962, 1971, 1974, 1975, 1977), which posits that it is not the noxious situation (A), that effects ones mood (C), but rather his interpretations, attitudes, beliefs (B) of that situation that effects the emotional state or response, Lazarus (1966) has noted that if one perceives the same stimulus as either harmful or innocuous, he will feel anxiety or neutral about it respectively. In the past few decades, there has been much evidence to empirically support this notion (Velten, 1967, 1968; Coleman, 1975; Meichenbaum, 1969? Meichenbaum and Cameron, 1974; Hale and Strickland, 1975; Beck, 1967, 1976; Tosi, 1974; Reardon, Tosi and Gwynne, 1975; Boutin, 1976). 24

In summary, statements about psychological causes of physical diseases often confuse these two distinct meanings, resulting in endless debate and misunderstandings. The state question reflects the disputed Jaraes-Lange theory of emotion (e.g., does the anger effect the ulcer or does the ulcer effect the anger). (James, et al„, 1922) This, while interesting, is not the critical question facing psychologists. Scientific interest in the physiology of emotions does not require that it be shown that the "emotion" (in this context, the word usually means a response described Psychologically) causes the peripheral changes rather than the reverse (Graham, 1972). Of seemingly more importance is the stimulus-individual interaction that produces or alters the state. While only prospectivej longitudinal studies can have a decisive bearing on matters relating to etiology, Graham and Stevenson (1963) have divided the existing evidence that physiological changes are responses to psychological stimuli into five categories: the life history approach, the use of experimentally controlled stimuli, real life stimuli, epidemiologic evidence, and prediction and course of the illness. In his review of the literature, Graham (1972) cites numerous studies in each category along with a discussion of their methodological strengths and shortcomings. The reader is referred to that source for exemplary findings. To help support the assertion that a psychological stimulus is etiologic to an illness, one wants evidence 25 that there are circumstances in which given a psychological stimulus of a specific kind, the probability of the occurrence of the disease is increased. Similarly, in Medicine, it is not necessary to prove that exposure to a truly pathogenic virus will lead to disease in all persons at all times. Many other variables, including immunity (Physiological make-up of the Person) influence an individuals response to the virus. However, exposure to a virus increases the likelihood that a disease will develop.

Progress in understanding the onset situation factors has advanced greatly. Evidence for a general association between stressul life events and a number of illnesses has been set forth by several authors (McC.Miller, Ingram and Davidson, 1976? Dohrenwend and Dohrenwend, 1974; Holmes and Rahe, 1967). Hinkle and Wolff (195 7, 1958) studied various groups and found that illnesses of all kinds were more likely to occur when a person was exposed to psychological stimuli to which he had "difficulty in adapting", than when he was not so exposed.

Schmale (1964) concluded that 151 of 190 patients with a variety of diseases experienced an "object loss" whether real or imagined, within months ana many within weeks of the disease onset and that all 151 had reacted to their losses with a feeling of "giving up". Holmes and Rahe (1967) have compiled a list of commonly encountered life changes and have attempted to quantitate the traumatic impact of each event as measured by what they call "life Change Units" (LCU) on the Social Readjustment Rating Scale* According to their findings,, the accumulation of over 200 LCU’ s in a year, regardless of their valence, is associated with a very high incidence of reported illness„ Follow-up retrospective life history investigations on Armed Service personnel tend to support this notion that stress of any kind, or more accurately, having to expend considerable effort adjusting to it, leads to illness (Rahe and Arthur, 1968; Rahe, McKean and Arthur, 1970)* Beck (1976) offers clinical evidence that suggests that stressful life events, in themselves, are less important in the production of anxiety and physical disorders than the way in which they are perceived0 The complicated adaptive inner defense responses and consequences are what makes the difference (Fischer, 1977)« Many other investigators who have utilized various control groups and more adequate methodology (Jacobs, et al„, 1967; Theorell, et al„, 1975; Minter and Kimball, 1978) provides another explanation that suggests that life events affect a person’s threshold of complaint and inclination to adopt the sick role as a coping mechanism. Hans Selye (1956), who for years proposed that individual psysiological reactions to "stressors" were actually coordinated as part of a General Adaption Syndrome of defense regardless of the type of stressor, has 27 apparently modified his position in a more recent publication, Stress Without Distress (1974). He points to the results of objective experiments that have shown both specific as well as non-specific responses to all stimuli. Discussion on psychophysiological research would be incomplete without further mention of the specificity question. Basically, the literature is filled with data to support two types of specificity. The first of these is a statement that there is a predictable relationship in different persons between stimuli and responses described in physiological terms (S-R specificity). Thus, the same stimuli has been shown to elicit the same conditions in different persons. The second kind of specificity is the Individual-Response specificity (I-R) also called stereotypy (Engel, 1960; Lacey and Lacey, 1958; Grinker, 1973; Malmo, 1967). Repoz’ts that support this kind of specificity have shown that a given individual tends to respond to a variety of stimuli in a similar manner either because they have an "inferior organ" (Adler, 1924) or as a result of specific personality type (Dunbar, 1947; Gildea, 1949). Friedman and Rosenman (1974) concluded that the Type A person (hard-driving, competitive) is more susceptible to heart disease than the Type B (relaxed) personality. However, another specificity view, the specificity of attitude hypothesis, was proposed by Grace and Graham

(1952). Based on the hypothesis that a number of illnesses 28 were associated with an attitude expressed by the patient toward a stimulus situation, it has subsequently been tested both experimentally and clinically (Graham, Lundy, et al., 1962; Graham, Stern, Winokur, 1958; Graham, Kabler, Graham, 1962). In one experiment (Graham, Stern, Winokur, 1958) an attitude that was previously determined to be associated with hives was suggested to hypnotized subjects ("being mistreated and helpless to do anything about it."). It caused a rise in body temperature which is what occurs in the natural disease state. When the attitude associated with Raynauds disease was suggested to the same subjects ("The wish to take hostile gross motor action"), their body temperature fell in keeping with that disease state. This viewpoint conceptually merges the S-R and I-R positions by the following formulation; Given exposure to a particular stimulus which elicits a particular response (Psychological and Physical) because of the specific nature of the individual (Psychological and Physical), the probability of occurrence of a disease is increased. In the present study, the patients attitudes (what the person feels is happening to him and what he wants to do about it) will be explored, in attempting to associate a specific attitude or attitudes with a particular disease. 29

SPECIFIC DISEASES .

Cardiovascular System - Migraine Headache

Headache is a phenomenon that has been widely studied. It is a unique syndrome in medicine and has been termed the commonest medical complaint of civilized man, yet severe and especially chronic headache is only infrequently caused by organic disease (Dalessio, 1977).

Although the percentage of patients with severe organic disease is low among chronic recurrent headache, such diseases must be carefully ruled out, as headache can be the presenting complaint of such catastrophic illnesses as brain tumors, lesions, cerebral hemorrhage or meningitis.

For the most part, however, chronic headache represents an inability of the individual to deal in some measure with the uncertainties of life and is symptomatic of an underlying disease of thought or behavior rather than a structural disease of the nervous system

(Dalessio, 1977). Sloane (1964) agrees and stated that pain indicated disease of the patient, sometimes of his body, but more often with his life.

Classification In a busy headache clinic staffed by neurologists, Lance (1969) found that 55% of the patients had migraine and 40% had tension headache. Simultaneous muscle contraction (tension) headaches have been noted during 30 migraine (Friedman, 1976; Grace and Graham, 1952). Although prevalance estimates vary considerably, a recent survey suggests that about 25-29% of women and 10-19% of men have migraine (waters and O'Connor, 1975). Migraine belongs to a broader class of headache termed vascular. In 1962, attempting to encourage uniformity in the diagnosis of chronic headache conditions, the National Institute of Neurological Diseases and Blindness formed an ad hoc committee to classify the varieties of headache. They arranged headache into fifteen divisions. One of the divisions, vascular headaches of the migraine type included classic, common, cluster, hemiplegic, opthalmoplegic and lower-half headache. Since then, others have altered the categories based on experimental and clinical data. For instance,

Dalessio (1977) simplified the diagnosis by separating headache into only three main divisions; vascular, muscle contraction, and traction and inflammatory.

Vascular headaches included migraine of the classic, common, hemiplegic and opthalmoplegic types; cluster (also called Horton's or histamine) headache; toxic vascular and hypertensive. In recent years, cluster headache has been compared with migraine from a clinical (Ekbom, 1970, 1974; Lance and Anthony, 1971; Graham, 1972), biochemical (Anthony and Lance, 1971) and pathophysiological aspect (Horven, et al„, 1972). Ekbom (1974) found that migraine was no more common among cluster headache patients than in the normal population. These studies support the view that cluster headache is an independent entity distinguishable from migraine and should be classified as such.

As early as 1893* Sir W. R. Gowers described migraine as a severe, periodic throbbing headache, frequently unilateral, often preceedea by some sensory disturbance, especially a disorder of the sense of sight, and commonly accompanied by nausea and vomiting. While other features of migraine have been described in the literature, most authors seem to regard Gowers" noted features as being diagnostically most crucial.

The classic form of migraine accounts for less than 20% of all migraine attacks, whereas the majority of migraines are somewhat arbitrarily termed the common type in which no pre-headache phase can be easily identified (Friedman, 1972)„ An attack of migraine may begin at anytime and can last from as long as a day to four or five days (Saper, 1978),, Nocturnal awakening with an intense, pounding headache occurs frequently in some patients (Hsu, Kalucy and Crisp, 1977). This has been found to occur most often during the Rapid Eye Movement sleep stage (Dexter and Weitzman, 1970).

Reports on the course and prognosis of migraine have been wide and varied. Although migraine often begins after puberty, its onset may be at any time from early childhood to late life (Paulson, 1962, 1975; Lancet, 1973). Pearce (1977) calls for more research that accounts for age, as he believes that attacks of migraine 32 are associated with certain emotional reactions that occur at particular times of life. Some have reported that menopause brings relief, while others have suggested that the headaches become more frequent and intense in some post-menopausal women (Klee, 1968; Saper, 1978). The intensity of the head pain can vary from mild and annoying to severe and incapacitating (Lancet,

1973; Saper, 1978). In fact, some believe that an episode of migraine need not be characterized by head pain at all. These attacks, termed "migraine equivalents" consist mainly of abdominal pain, nausea and vomiting, diarrhea, tachycardia, vertigo, cyclic edema and pain in the chest, thorax or pelvis (Friedman, 1976; Crawford, 1961; Lundberg, 1975; Graham, J., 1968). Reports are also conflicting regarding the genetic nature of the disorder. Familial incidence has been estimated between

65% (Friedman) to 90% (Daalsgaard-Nielson, 1965) and both dominant (Allen, 1930) and recessive patterns have been hypothesized (Goodell, Lewontin and Wolff, 1954).

Pathophysiology Migraine is considered to be a primary headache disorder since it has headache as the outstanding clinical feature, as opposed to a pathological process in which headache is secondary (Kudrow, 1978). He explains that unlike a secondary headache that originates intracranially, primary headaches originate extracranially, involving the cranial arteries and scalp muscles. Common 33

to all vascular headaches is a tendency to vascular dilation;, which reportedly represents the headache phase of the migraine attack* Vasodilation and excessive pulsation of branches of the external carotid artery have been observed during these headaches which disappears with the cessation of headache after the administration of medication - usually ergotomine, a vasoconstrictor (Adams and Griffith, 1974)» Others have noted, in addition, a perivascular edema and a "sterile" inflammation around the dilated blood vessels which causes them to become progressively rigid and "pipelike"

(Goltman, 1935; Wolff, 1963)« The concentration of a biologically active polypeptide (neurokinin), found in this area of tissue edema, has been correlated with the intensity of the head pain (Ostfield, et al0, 1957; Chapman, et alop 1960)<, As migraine is considered to be a biphasic phenomenon, the initial expression of vascular activity is the vasocontriction phase* Many believe that this is related to the non-painful sensory experiences found particularly in the "classic" migraine just prior to the head pain (Dalessio, 1977; J. R„ Graham and Wolff,

1938), However the biochemical and pathophysical mechanisms of this reaction are not well understood

(Henryk-Gutt and Rees, 1973). It is believed that a release of amines of uncertain etiology (including epinephrine, norepinephrine and serotonin) causes vasocontriction of the large arteries supplying blood and oxygen to various areas of the brain. This cerebral ischemia in the arterial territory is said to be

characterized by a variety of sensory aberrations, or prodromata, but may be marked by little more than vague uneasiness (Walker, 1976; Anthony, 1967; Mathew,

Hrastnik and Meyer, 1976). The vasoconstriction, in turn, apparently causes a release of vasoactive substances that produce vasodilation of pain-sensitive intracranial

arteries, thus the headache (Walker, 1976). These sensory experiences that are sharply defined in the classic type,

but less so in the common type, may include one or more of the followings visual disturbances (photophobia and/or

zig-zag lines), numbness and tingling of the lips and fingers, transient aphasia, thickening of speech, nausea, vomiting, defects of mobility or vertigo, impairment of consciousness and disorientation (Selby and Lance, 1960; Lance and Anthony, 1966; Lee and Lance, 1977).

Personality Attributes Pain is a universal phenomenon resisting verbal

description (Aring, 1977). Since all pain is subjective, no pain can be measured objectively or effectively. The physician must rely, to a great extent, upon the patients description of his symptoms. To believe that some pain is physical and some emotional is as much a distortion as trying to separate the brain from the mind. Consequently the decision to assign some pain to physiological and some to psychological pathways is often merely a 35

judgmental one. Treatment that ignores the psychiatric

aspect of chronic pain will prolong the problem for more than a few patients. Only rarely will headache

respond to physical measures alone (Aring, 1977). The scientific study of migraine gained great

impetus from the work of Harold G. Wolff (1937B 1963). His work has provided the basis for the prevalent view of the migraine sufferer as a tense, driving, obsessional perfectionist with an inflexible personality, who maintains a store of bottled up resentments which can neither be expressed nor resolved. These characteristics would make him unable to adapt easily to circumstances, but liable to react excessively to environmental and interpersonal stresses sometimes with a migraine attack (Henryk- Gutt and Rees, 1973). According to Wolff, these patients

have a chronic resentful attitude which results from their inability to keep up with compulsively assumed responsibilities to live up to their perfectionistic ambitions. Other investigators have reached similar

conclusions. H„ Selinsky (1939) stressed the significance of "struggle, resentment and anxiety." The attack occurs when the patient faces a task beyond his ability. Using the psychiatric interviews of 500 migraine patients, Alvarez (1947) found that the common temperamental features were hypersensitivity and dislike of change, perfectionism and a tendency to worry and become tense. Sigmund Freud, who has been described as an intense, striving, ambitious, sensitive and moody individual with a tendency to complain a great deal was prone to incapacitating spells of migraine all his life (Jones,

1953). Other notables who allegedly suffered the ill effects of migraine attacks included such intellectually ambitious individuals as Alexander Graham Bell, Frederic Chopin, Charles Darwin, Ulysses S. Grant, Mary Todd Lincoln, Karl Marx, Edgar Allan Poe and George Bernard Shaw (Speer, 1977). Touraine and Draper (1934) described a "constitutional" personality type characteristic of the migrainous individual. These included retarded emotional development but superior intelligence. Their sexual adjustment was unsatisfactory. They first appeared when the patient lost the protection of home and had to face the responsibilities of living alone. They also noted an exaggerated dependence upon their mother from whom they could never emancipate themselves. Olga Knopf (1935) gave a similar description after studying 30 patients, 22 of whom were women. She saw them as being "goody goody", ambitious, reserved, depressed, usually quite dignified, sensitive, at times domineering and void of a sense of humor with poor heterosexual adjustment.

Psychoanalytic aspects of the mechanism of migraine are reviewed by Fine (1969). He observed that many migrainous patients had a great deal of unconscious hostility towards persons who were consciously much loved combined with unconscious fantasies relating to attacks on the head„ Dromm-Re ichman (1937) found in her migrainous patients, hostile, envious impulses that were originally directed against intellectually brilliant persons but were turned against the self through guilt mechanisms., In Denmark, Daalsgaard-Nielson (1965) found 1/3 of his migraine patients to be of "normal" personality, but 2/3 were of "vulnerable psychic constellation" being sensitive, perfectionistic and tending to bottle up emotions. This suppression and repression of aggressive impulses may account fox' Knopf's goody-goody type, Drench and Alexanders nuclear conflict theory

(Alexander, 1950) emphasizes the following specific conflict for those suffering from migraine; Repressed hostile impluses perhaps when the repression or inhibition occurs during the planning and preparation for a hostile attack. They found that an attack will terminate rapidly after the patient becomes conscious of his repressed rage and gives expression to it in abusive words.

More recently, Paulley and Haskell (1975) published a compilation of observations made of more than 800 migrainous patients over a 22 year period. They, too, described the following consistent personality traits: perfectionism, intense striving to succeed, inflexibility, intollerance, clock-boundness, history of travel sickness {15% of migraine sufferers), feelings of guilt and compulsion (inordinate use of "I ought", "I 38 should" and "I must"), provocative hostility and resentment.

Prom a study of a large series of patients followed up for periods of up to ten years* Friedman

(1964) concluded that although there was no specific migraine personality* that migraine sufferers were likely to be sensitive* methodical and perfectionistic which predisposed them to react with marked emotional changes to various forms of environmental stress0 Thus* the consensus of most clinical studies on the psychology of migraine headaches may be understood as reaction formations against or consequences of repressed or suppressed hostile impulses stemming from rigid, perfectionistic goals and expectations. Pearce (1977) critically reviewed earlier clinical studies and stated that the conclusions drawn were the authors subjective biased impressions of selected patients. Besides* repressed hostility is an extremely common feature among many kinds of persons. In order to make a pertinent statement about the migrainous patient* it is necessary to compare their personality dynamics to that of non-headache control groups. To these extensive clinical studies there are a growing number of objective psychological studies utilizing various control groups and standardized psychometric tests. Ross and MeNaughton (1945) used the Rorschach Ink Blot test quanitatively with fifty migraine subjects (16 males) and extensive control groups that included twenty-five non-migrainous headache victims (10 males), fifty acquaintances of the authors without symptoms (25 males), fifty psychoneurotic patients (26 males) including both inpatients.and outpatients, and twenty-four patients (19 males) with brain tumor or injury. The Rorschach was administered and scored according to the system of the Rorschach Institute (Klopfer and Kelly, 1942). They concurred that the migraine subjects were more perfectionistic, inflexible, conventional, intolerant, persistent toward success and had difficulty in sexual adjustment. Harboring of strong resentments was not confirmed. In another study using the Rorschach test to compare fifty migraine with fifty te '.sion headache patients, Cooper and Friedman (1954) found no significant differences. Maxwell (1966) compared the Maudsley Rersonali ty Inventory scores of thirty-two migrainous patients, thirty-two non-migrainous patients who visited their doctor frequently and thirty-two non-migrainous subjects who rarely consulted their doctors. There were 23 females and 9 males in each of the three groups. The migraine patients showed a significant increase in the Neurotic score (N) but there was no difference from the general population in their Extraversion (S) scores. Thus, with a selected headache sample, migraine sufferers appear generally more neurotic than non-migraine headache sufferers. 40

Some have found that those who complain to their doctor have a particular type of personality that differs from those who do not consult a physician. The complainers tend to be more neurotic and more extroverted than those who complain a little or not at all (Bond and Pilowsky, 1966; Phillips, 1976), However the obvious methodological problem is in trying to secure an unbiased sample of those who suffer in silence. In an attempt to demonstrate this, Waters and O ’Connor (1970) interviewed 86% of all women aged 20 - 64 living in a defined area with respect to their health. They determined that 46% of women with migraine never sought medical advice and that there were no significant differences between women with migraine and those with non-migraine headaches on nine items selected from the Cornell Medical Index used to measure psychoneurosis, In another study, Waters (1971) brought into question the earlier claims that migraine was a disease of the intelligent, conscientious, professional classes. He demonstrated that while the consultation rate was higher in Social Classes I and II, equal prevalence rates of migraine were found in Classes III and IV,

In a study of headache in a general practice, postal questionnaires were sent to a sample of approximately 1500 patients chosen randomly from a register (Phillips, 1976), Prom the returns, a sample of 68 headache cases (56 female, 12 male) were given the standardized Personality Questionnaire (PQ) which contained a series of questions yielding scores on Extraversion/Introversion, Neuroticism, Psvchoticism and Lie. The groups consisted of thirty-seven migraine patients, twenty-four tension cases and five mixed migraine/tension cases. She was unable to distinguish headache sufferers in this sample on three of the four personality dimensions as compared to Eysenckian norms (Eysenck and Eysenck, 1976). The only difference to reach significance was an elevated Lie score in the female group. The author recognized the difficulty in explaining this result, but felt that since female migraine patients suffered more severe headaches than the patients in the other groups, the high Lie score perhaps reflected a compensatory coping mechanism. When she additionally compared a clinical group consisting of

"severe" tension and mixed tension-migraine victims (n=17) selected for their self-referral to a doctor, the prevailing view of the neurotic headache sufferer was upheld as they had a significantly higher Neuroticism score consistent with Eysenckian norms for neurotics. Consequently, Phillips argues that doctors and neurologist may have formed their views of headache personalities on the basis of the headache sufferers who seek their help and thus bringing into question the generality of the prevailing view of the "neurotic headache personality. However, she fails to mention the problems associated with generalizing from a postal survey in terms of self-selection, nor does she report the number of 42 questionnaires returned of which sixty-eight were selected.

Henryk-Gutt and Rees (1973) tested the hypothesis that the occurrence of migraine may he a function of a specific predisposition in the form of certain personality traits (the intrinsic predisposing factor) interacting with emotional stress (the extrinsic precipitating factor). Forty-two men and sixty-two women were identified as having classical migraine attacks from a questionnaire that was sent to the entire staff of two government departments in London totalling 1,859 persons. After administering the Eysenck Personality Inventory, the Buss Durkee Hostility/Guilt Inventory and an abridged form of the Minnesota Multiphasic Personality Inventory

(MMPI), they concluded that psychological stresses (overwork, anger, resentment and anxiety) do appear to act as important precipitants of migraine headache. Relief of strain was a precipitant in some. However, they added that the life stresses to which all groups have been exposed (including the control) do not differ insofar as they can be assessed objectively. The authors concluded that in order to experience a greater than average reaction to a given stress, the migraine sufferers need to be predisposed by constitutional factors and not be environmental ones alone. On this basis, they determined that the higher values on Neuroticisra (N) in all migraine groups as compared with the non­ migraine headache and headache free controls are not the 43 result of having migraine* hut the "psychologically predisposing factor" in its development. However, it must be noted that none of the three groups were significantly higher on the N scale than the Eysenckian norms from the general population. Migraine sufferers scored significantly lower on factor E/I (Extroversion/ Introversion) than all other groups and there were no differences among groups on the Lie Scores, The abridged MMPI also failed to differentiate the groups, Rogado and associates (in Kudrow* 1978) reported that migraine patients scored higher on the Hysteria and Hypochondriasis scales of the MMPI than did a carefully matched control group of non-headache patients. In fact9 they indicated that a "conversion V" configuaration was typical of the migraine population. However,, this "conversion V" configuration has also been associate with other disorders including low back pain (Hanvikp 1951; Witse and Roccio* 1975; Spergel* 1978).

Kudrow (1978) found that only those migraine patients who also suffered chronic scalp-muscle contraction headache showed these results whereas migraine patients free from scalp-muscle contraction headache did not score higher on these scales than controls or those with combination headache. There have also been many suggestions of a relationship between migraine headache and depression. Cassidy* et al. (1957), for instance* found headache to be the most common somatic symptom in a group of 100 44 patients with manic-depressive illness* hut did not specify the type of headache, Serry and Serry (1965) noted that migraine was one of the common symptoms of "masked depression",, Couch* Ziegler and Hassanein (1975) studied 236 patients (81,4% female) with migraine headache at a University Medical Center Headache Clinic, Migraine was defined as a headache associated- with gastrointestinal symptoms or with any three of the following; anorexia* photophobia* visual or neurological symptoms or family history. Depression was evaluated with the Zung self rating scale (SES), A weak* hut significant relationship between migraine and depression was demonstrated, A stronger relationship was demonstrated when patients with severe headaches (as measured by a calculated weighted migraine score) were correlated with depression. Also* the results suggested that sensory disturbance* speech disturbance and loss of consciousness occurring in association with migraine headache are strongly related to depression* whereas such migraine symptoms as nausea* vomiting* steady throbbing unilateral pain* photophobia* difficulty thinking and dizziness were not found to be significantly related to depression. They concluded that there may be subgroups of migraine patients in whom depression and migraine are linked. Grace and Graham (1952) discussed the inadequacy of the theories of personality patterns* types* the concept of the nuclear conflict in psychodynamic theories and the attempt to blame everything on early training. Their paper gave the details of a study of 128 patients ■who were given a number of interviews in which every effort was made to discover the patients specific attitudes at the time of the onset of their symptoms. Conventional names of "emotions" such as anger, resentment, sadness were not accepted without further definition. Migraine headache was found to occur when an individual had been making an intense effort to carry out a definite planned program, or to achieve some definite objective. The headache occurred during relaxation after the striving of intense effort whether the activity was associated with success or failure. In a later study, the hypothesis that particular attitudes are associated with particular diseases was tested by determining whether the attitude which judges selected as characteristic of patients were, in fact, attitudes predicted by the hypothesis (Graham, Lundy, et al„, 1962)o The authors agreed that even when a naive interviewer and naive judges were employed, the specificity- of-attitude hypothesis held up. Others have also recognized the importance of the "let down" period

(Wolff, 1963; Ostfeld, 1962; Rees, 1974). Migraine has sometimes been spoken of as "relaxation headaches", "Sunday headaches", "menopausal headaches" and so forth. Contrary to Ostfeld's (1962) conclusions, Kolb (1963) suggests that the periods of 4-8:00 P.M. and 4-8:00 A.M., which are the most frequent times of onset, may not be periods of relaxation for many migraine sufferers. An 46 examination of the patients cognitions at such times may help to support this position. Some, not having work or other activities to absorb their energies may become more tense during these periods as they find it difficult to adjust to "relaxation."

Speer (1977) discovered that some patients recover when they escape from an intolerable situation by changing jobs, getting a divorce, adopting a simpler lifestyle or moving out of a parents home. Others "outgrow" migraines when they learn to "just let some things go" and to refuse to let things upset them. Graham (1972) believes that most investigators neglect to carefully examine the patients thoughts when trying to determine preciptating factors in the development or extinction of this physiological response. This factor is not likely to be properly identified when taking a clinical history. Yet, it may hold great promise in the understanding of the genesis and control of migraine headache.

Musculoskeletal System - low Back Pain

Classification and Pathophysiology According to the recent National Center of Health Statistics, 70 million people have experienced a severe backache more than once in their lives. In fact, over 7 million Americans receive medical treatment of some kind for lower back pain daily (Rubin, 1978). That’s 47

approximately one out of every three Americans - a significant health problem!

The anatomy of the lower back defies easy differential diagnosis because of multiple boney articulations, multiple myofascial planes, complicated neuroanatomical relationships and few laboratory procedures (Ritterhoff, 1975). Nevertheless, low back pain has been roughly classified into three categories: spondylogenic, viscerogenic and psychogenic (Simmons, 1966; Murray, 1966). More recently Macnab (1977) expanded this classification of low back pain to include neuro­ genic and vascular syndromes. He describes viscerogenic back pain as that which is derived from disorders of visceral structures including renal disease, duodenal ulcer, disorders of the pelvic viscera, lesions of the lesser sac and retroperitioneal tumors. Vascular back pain is derived from changes in the aorta and vessels in the lower extremities. Neurogenic back pain is derived from lesions in the central nervous system, spinal cord, and cauda equina excluding extradural compression of emerging nerve roots. Spondylogenic back pain may be defined as pain derived from the spinal column or its associated structures including trauma, lesions, inflammation and neoplasm of the vertebral column or sacroiliac joints or more commonly from traumatic or degenerative changes in the soft tissues such as muscles and ligaments. 48

History taking and careful neurological examination alone have yielded correct preoperative diagnosis of disc hernia in approximately 60% of the cases (Hirsch and Nachemson, 1963). If a positive straight leg raising test is added to the workup, a 70% positive incidence results (Hirsch and Nachemson, 1963). If an EMG is also added, an 80% positive finding results (Shea and Woods, 1956), When a water soluble contrast myelography (e.g., metrizamide) is combined with these other diagnostic procedures, the accuracy of preoperative diagnosis of disc hernia can be improved to at least 90% (Nachemson, 1976). Walters (1961) and Macnab (1977) also differentiate two types of psychogenic response. One is "psychogenic regional pain" in which there is no underlying pathophysiological basis for the patients complaints. Walters contends that the old labels of "functional", "psychogenic", "hysterical" or "psychalgia" pain are misleading and confusing and he suggests that they no longer be utilized. He prefers the term "psychogenic regional pain" for those cases with elusive objective findings as it is more descriptive, accurate and definitive. As these pains have been shown to be associated with emotional disorders, they are considered psychogenic in a broad sense. Since the sites in the body do not conform to the pathophysiological properties of a local physical lesion or of referred pain, the pain 49 is felt in a region contiguous with various as opposed to common innervations; as such, the term "psychogenic regional pain."

while emphasizing the importance of not only arriving at this diagnostic category hy failing to find any obvious pathological lesions, Macnab (1977) presents a number of positive findings that can be noted on examination including severe skin tenderness, sensory deficits that violates anatomical boundaries, abnormal motor weakness that extends beyond the region of pain, unexpected vegetative and reflex changes. Some feel, however, that a purely psychologically induced back pain is not common (Podovnikar, 1977; Jequier and Adams, 1974). One survey in the state of Washington found that only one industrial claim per million was made by outright malingerers (Halliday, 1973). The other psychogenic response, "psychogenic magnification of pain”, is a disability arising from emotionally based exaggeration of pain derived from a relatively minor underlying physical disorder (Macnab, 1977). These patients give in readily to pain. This syndrome is typically characterized by a theatrical display of distress, while being quite animated in describing painful reaction to examination with gross and unreasonable limitation of movements. Interestingly, many patients with this syndrome, on examination, will point to the area of discomfort with his thumb, while never actually touching the skin (Macnab, 1977). 50

Oftentimes, straight leg raising is not relieved by by flexion of the knees and further flexion of the hips with the knees bent aggravates the pain (Macnab,

1977). Walters (1961) introduced the thiopental sodium pain assessment which has aided the clinician in determining the significance of emotional states in the production of suffering and disability presented by the patient. Simply, with the patient maintained at a stage of light anesthesia, allowing the primitive pain reaction to continue, the clinical examination is repeated, 3y observing the patients reaction to previously painful

maneuvers (e.g., leg raises), the clinician can better determine whether this condition has psychogenic features needing psychological intervention before successful physical treatment can be expected. Further investigation is required to determine whether or not the two sub=-categories of psychogenic low back pain reflect a differing psychological constellation.

Personality Attributes Current surgical tools are sophisticated and treatment may be technically successful, however many patients continue to have pain (Seres, et al., 1977). Many clinicians believe that pain i3 not often due to organic pathology (Walters, 1961; Engel, 1959; Dillane, Fry and Kalton, 1966). Sternbach (1974) suggests that there is a difference between organic pain and suffering, 51 as patients complaints of pain often do not correlate with the degree of impairment or, on the other hand, improvement noted in other important aspects of their lives* Seres, et al, (1977) found suffering to he a learned behavior which is often shaped when the secondary advantages of pain and suffering provide important solutions to lifelong problems of dependency, inadequacy, insecurity and the need to control* Similarly, Kraft

(1975) and Fordyce (1973) emphasize the importance of operant conditioning in the development and consequently in the treatment of the reinforced "sick role*" Emotional etiology of low back difficulties has long been suspected* Cabot (1911) stated that back pain may be caused by emotional stress* During World War II, several studies of the relationship of psychological factors and musculoskeletal symptoms were published

(Menninger, 1943; Fox, 1945; Luck, 1946; Sargent, 1946)* Parsons (1968) spoke of the "sick role" and Sullivan (1955) of the "weak spine" as convenient means of escape or coping mechanism in stressful situations where other roles have become too difficult or unrewarding* More -recently other authors emphasized the relationship of the symptoms of back ache to emotional disorders* Pilling, et al. (1967) studied 562 Mayo Clinic medical and surgical patients with and without complaints of pain using clinical interview and the MMPI. In those with presumed psychogenic pain, they found significant differences 52 with respect to depression,, anxiety, phobias, hypochondriasis, childhood fainting spells and conversion reaction. The authors concluded that pain may frequently be substituted for feelings of anxiety and depression. Kessler (1959) concluded from a clinical study of 160 low back cases that 80% of his sample exhibited neurotic patterns and Kieholz (1973) and Levit (1972) documented that pain was a symptom in masked depression.

Retrospective psychoanalytic studies by Engel

(1959), Engel and Schmale (1967), Szasz (1957) and Rangell (1953) have shown that the elements of depression, loss or intropunitive anger preceeded the physical symptoms.

Merskey and Spear (1967) have shown, in an epidemiologic study, that a pre-existing problem of intropunitive hostility distinguished patients with pain from control medical and psychiatric groups. Weinston (1969) points out that before injury, the typical low back patient had significant physical and emotional needs that were not being met. He writes that, in such people, injury or illness serves to convert a nonacceptable problem into one that is justifiable by virtue of the accident or illness. Levine (1971) has gone so far as to postulate a physiologic mechanism by which somatic effects of depression may result in disc protusion. He believes that depression can lead to an increased intra­ cellular sodium content of disc material and then to swelling of the disc, which may additionally cause enough 53 nerve root or spinal cord compression to bring about neurological signs and symptoms. He cited as evidence earlier work with animals that demonstrated swelling of

intervertebral discs in situations of stress, the rise of intracellular sodium concentration in hospitalized depressed patients,, and his own clinical case studies. Patients with this chronic low back pain syndrome frequently and insistently return for additional surgery, which usually does not relieve their symptoms (Levine,

1971)o This presents an especially difficult problem for the orthopedic surgeon. Psychological factors of pain are crucial because they frequently determine whether medical forms of treatment succeed or fail, White (1966) warned that when personality factors are unfavorable, a poor surgical result is almost certain no mattex* how accurate the anatomical diagnosis or how skillful the operator. Objective psychometric assessment has aided in the clarification and understanding of psychosomatic conditions, Wolkind and Forest (1972) investigated fifty male patients attending a physiotherapy department for treatment for back pain. Patients with evidence of intervertebral disc lesions either on X-ray appearances or with signs of local nerve pressure were excluded. The Middlesex Hospital Questionnaire, a self-rating scale of psychoneurotic symptoms and behavior was used to measure the prevalence of psychiatric symptoms. Of 54 the fifty patients in this group, twenty-three had "handicapping symptoms," in that they scored significantly higher on the somatic, obsessive and depressive scales. These investigators were further able to show that the questionnaire scores distinguished between those patients with a good and a poor outcome. In another paper (Forest and Wolking, 1974), the questionnaire scores of eighty patients with low back pain attending a Rheumatology department were compared to the. scores of a normal population of 1288 men employed by the Atomic Energy Authority. Again, only those 1ow back pain patients without objective signs of local nerve pressure or localized X-ray changes were included in the study. After six weeks of physical therapy, the patients showing poor response to treatment, as measured by this self- rating questionnaire, were again, characterized by an obsessional and depressive syndrome, described principally in somatic terms. In these patients, depression was not recognized and hence, back ache was seen as a "depressive equivalent." The good outcome group had scores that closely resembled the normal population. Additional information is needed to determine whether or not the poor responders were a subgroup chosen by their doctors to seek physical therapy because of the severity of or preoccupation with physical symptoms. However, additional information is needed to help clarify this possibility.

Wilfling, Klonoff and Kokan (1973) investigated the relationship between psychological test scores and the result of spine fusion in twenty-six male veterans who had one or more operations. The MMPI scores on the hypochondriasis, depression and hysteria scales were significantly higher for the patients who had had multiple procedures than for the ones who had a single procedure. On the Cornell Medical Index, the E section (musculo­ skeletal) and I section (exhaustion and fatigue) also discriminated between the groups with good, fair and poor results as rated by their surgeons. The Y/eschsler Adult

Intelligence Scale (WAIS) and Mooney Problem Check List bore no relation to the subjective result. The MMPI has been used to compare patients who complain of low back pain but show no evidence of organic pathology and patients with known physiological disorders,

Hanvik (1951) used the MMPI to compare thirty cases of "proved" organic causes of low back pain (i, e,, surgical evidence of protruded invertebral disc) with thirty patients who complained of low back pain, but with no clearcut organic findings on the physical and neurological examinations„ The "functional" group had higher mean T-scores on scales: Hypochodriasis (Hs), Hysteria (Hy), Psychasthenia (Pt), Schizophrenia (Sc), and Psychopathic Deviate (Pd)„ The groups were also significantly different on the Depression (D) scale, though the difference was less pronounced than on the other five scales previously mentioned, creating a "conversion/ psychosomatic V" or "depressive valley" where hypochodriasis and hysteria are both elevated and depression is relatively low. After it was seen that statistically significant differences exist between the MMPI scores for the two clinical groups, a profile sorting experiment with the aid of four clinical psychologists, blind to the nature of the experiment was conducted,, It was found that judges were able to distinguish the profiles of members of the two groups and sort them into appropriate diagnostic categories, Hanvik (1949) also developed a 25-item scale from the MMPI for the identification of the functional cases and checked the utility of this measure on a cross- validational sample. Seventy percent of the organic cases and 90% of the functional cases were accurately diagnosed using an optimal cutting point of 11 on the Low Back Pain Scale (Lb scale). The Lb scale was also found to correlate with surgical outcome significantly in 64 cases with herniated invertebral discs (Dahlstrom,

1954), Esibill (1976), however, was unable to find significant differences between those with psychogenic low back pain and those with somatic low back pain as measured by the Cornell Medical Index and the 16 PF scale. Both groups were strikingly similar to the normal population,

Wiltse and Rocchio (.1975) studied 130 patients with no previous history of back surgery who were admitted to Long Beach Memorial Hospital Medical Center 57 complaining of low back pain with sciatica for which chemonucleolysis was the recommended surgical procedure. Following the complete history and physical examination and appropriate X-ray and laboratory studies, the Cornell Medical Index (a 195-item health questionnaire measuring body symptoms) and the Quick test, (a vocabulary-type test of mental ability or intelligence). In addition, the attending physician rated their patients on three separate occasions. Prior to the chymopapain injection, the attending physician rated the patient not only to determine how good a candida.te the patient was based on the severity and type of objective findings, but also to determine the surgeon®s assessment of the degree to which the patient's symptoms were psychogenic in origin. The surgeon's second rating was made immediately after the injection and estimated how good a candidate the patient was now that additional information had been gained through the discogram. A third rating was completed one year or more after the injection to evaluate the success from both an organic and symptomatic standpoint. The best predictors of the symptomatic result of chemonucleolysis (and in a subsequent study, laminectomy) were the hypochodriasis and hysteria scales on the MMPI. Adding to this the physicians preoperative opinion regarding the psychogenic component of the patients symptoms, increased the correlation significantly. In fact, Wiltse and Rocchio were able to develop a prediction formula by which an accurate estimation could be made as to how a patient is likely to respond to the surgical procedure done for pain relief, Interestingly, there were no statistically significant differences between recovered patients with Hypochondriasis and Hysteria T-scores above 75 and those with T^-scores below 64 regarding number of pre-existing objective deficits, The number of objective defects, therefore, did not discriminate between patients with excellent and those with poor symptomatic relief. They determined that those patients with both MMPI Hypochondriasis and Hysteria T-scores below 54 have a 90% chance of good and symptomatic improvement from surgery, whereas those having both Hypochondriasis and Hysteria T-scores above 85 have only a 10% chance of improvement from surgery, regardless of the number of, or lack of, objective physical findings. They also discovered, retrospectively, that while Hypochondriasis and Hysteria T-scores tend to go up with repeated surgical procedures and prolonged disability, those patients who failed to benefit from treatment had higher Hypochondriasis and Hysteria T-scores to begin with, Hansford, Cairns and Mooney (1976) found that the drawings a patient made of the nature and distribution of his pain were significantly correlated with the Hypochondriasis and Hysteria scales on the MMPI which has been shown to be the best prognosticator to the outcome of treatment for disc disease. The Pain Drawing, scored on the basis of acceptable anatomical distribution of back pain sciatica, was found to predict poor psychometrics in 93% of their patients. In a series of more than 100 consecutive patients in a low back pain clinic with a mean age of 42 years, Sternbach, et al, (1973) identified several diagnostic

characteristics of the, so called, "low back pain loser," These include a history of low back ache for several months with pending litigation or disability claims, minimal or inconclusive objective signs, depression, and hypochodriasis (as measured by the MMPI) with accompanying disturbances of sleep, appetite, libido, and general performance, a life-style of invalidism (as measured by the Cornell Medical Index), and a tendency to engage in "pain gaaes" with the physician ox* more typically physicians. Beals and Hickman (1972) compared men who failed to return to work after back and extremity injuries with a control group of forty employed workers matched with respect to age, education and intelligence, The patients with back injuries were more disturbed emotionally than normals and extremity injured workmen in that those with back injuries had significantly higher scores on Hypochodriasis, Depression and Hysteria* It was also found that as time since injury increased patients tended to exaggerate their physical symptoms, but became less depressed than they were shortly after injury. Also these scores increased with the number of operative procedures on the back.

The majority of investigations have compared those 60 with chronic low back pain with the normal population.

However, somewhat different conclusions may result when those with chronic low back pain are compared with other chronically ill patients (Moos and Solomon, 1964). Recently, Spergel, et al. (1978) concluded in their article that the MMPI profiles of rheumatoid arthritics did not differ significantly from patients with four other chronic illnesses including low back pain, gastric ulcer, pulrainary (didn’t specify), and multiple sclerosis. They found that while chronically ill patients exhibit many neurotic traits, no consistent diagnositic patterns could be isolated for the specific disease entities. This is a crucial concept implying the emergence of a "chronic disease personality" (Spergel, et al., 1978). However, the authors failed to report criteria for groups other than the rheumatoid group and also neglected to provide statistical data to support their conclusion which is based on "inspection alone 0 . . without the application of psychological statistics„"

On the other hand, Sternbach (1973) did find differences when he compared chronic low back pain patients with the similarly disabling condition, rheumatoid arthritis, using a 50-item health questionnaire designed to assess the self concept of invalidism, manifest symptoms of depression and the patient-doctor interaction. The items were taken from Section J of the Cornell Medical Index, the MMPI and Zungs Self-Rating Depression Scale.

He concluded that the chronic low back pain patients had 61

adopted an invalids self-concept and life-style, were more depressed, engaged in "painmanship" with the doctor

to a greater extent (i.e., doctor shopping) and had allowed pain to make a greater difference to them, than the rheumatoid arthritics. Other investigators point not to a "chronic disease personality", but to a "disability" or "litigation" personality0 Each year millions of American workmen are injured in industrial accidents and currently 1,25 million Americans sustain injuries to their back or spine annually. Of those injured, 65,000 have some "permanent disability," At present, approximately 2,5 million Americans have permanent impairment of their* back as a result of injury (Rosse, Cornelius and Lax^son, 1970), In Ohio for 1977, 17,210 low back pain disability claims were filed through the Industrial Commission of Ohio (1978), In Franklin County, Ohio alone, 1,509 claims were filed in 1977,

Titchener, et al0 (1974) determined that the high scores on the hypochondriasis, depression, and hysteria scales

on the MMPI were correlated with chronicity of the physical disorder and litigation, Shaffer, et al, (1972) used MMPI profiles and Wechsler Adult Intelligence Scale quotients to compare a random sample of 1,064 applicants for disability benefits under the Social Security Administration disability insurance program, with medical patients matched by age and sex, treated at the Mayo Clinic. The WAIS intelligence quotients of the applicants did not differ from those of the general 62 populations tut the hypochodriasis, depression and hysteria scales were significantly higher in the

applicants for disability benefits. Collete and Ludwig (1968) compared a group of applicants for social security disability benefits whose chief complaint was low back disorder with a group of applicants with other disorders (e.g., circulatory, neurological, and respiratory disorders). They hypothe­ sized that if the low back stereotype was correct, persons with this complaint would possess the following characteristics: emotional instability, vocational instability, job dissatisfaction, lack of employment motivation and poor job performance. While methods used to collect the data were not provided, those suffering from low back pain did not differ at all from other disability applicants on those examined characteristics. However without additional comparison and control groups, it is difficult to determine whether the noted attributes were characteristic of applicants for benefits alone. In any event, this study suggests that the low back pain stereotype needs to be reexamined, and that there may be a consistent neurotic pattern for all disability applicants.

Reports have shown that those receiving compensation demonstrated 33% less objective evidence of impairment (Krusen and Ford, 1958), remained in the hospital longer (Nordby.ft Lucas, 1973), remained off work longer (Raaf, 1959), received nearly twice as many physical 63 therapy treatments (Krusen and Ford, 1958) and report poorer long term improvement (Shepian, 1966$ Raaf, 1959; Krusen and Ford, 1958) compared vjith private patients or those not receiving compensation,, Mensor (1955), m reporting the results of manipulative treatment for the lumbar disc syndrome, found 64-9) of excellent or good results in private patients as contrasted with 45% similar results in compensated patients. He also reported 59% good or excellent results after laminectomy in private patients compared with 46% in patients receiving compensation, Weinstein (1978) extended Behan and Hischfelds concept (1963) of the disability process to five key features. The first stage, crisis buildup, combines a vulnerable character (depressed, frustrated, insecure, dependent) with job tensions (from promotion, demotion, failure) to lead to increased somatic complaints, marked absenteeism, poor job performance and increased blaming. The injury, the second stage, provides an externally generated event or explanation and sanction for decline in competence and increased dysphoria. The third stage in the disability process is the diagnosis and failure of treatment which reinforces the acceptability of the disability. Crystallization of the disability is the fourth stage wherein the individuals expectation of improvement is decreased, dependency and concern over money and benefits increased, as are defensiveness and anger. Finally, a total loss of expectation of recovery 64 and adoption of a new role, the "honorably disabled," Kraft (1975) and Weinstein (1978) not only describe how the spouses, ^he social system and social agencies reinforce pain behavior by rewarding it, but they also provide suggestions on how ability can be rewarded, not disability.

Most investigators, like Hanvik (1951) and Sternbach, et al0 (1973), have found elevations of the hypochondriasis and hysteria scales on the MMPI with patients complaining of low back pain, particularly when there are few or inconclusive organic findings, and when litigation is forthcoming. However, elevations on these scales (and to a lesser degree on the depression scale) have been shown to be common to most, if not all "psychosomatic disorders „" This has aided the physician or surgeon in determing the course and prognosis of treatment, but the consultation-liaison psychologist may need more information when, and if, the patient comes for therapy0 What othei* dynamics underly this picture?

Ludwig and Adams (1968) have observed that many patients seem to be characterized by "self-defeating" behaviors in which patients are unable to give up their pain because of various psychosocial pressures or conflicts* Oftentimes, these patients feel mistreated at work and are unconsciously seeking revenge (Ross,

1977)* Dorpat and Holmes (1963) found that backache symptoms or increased muscle tension, measured by needle 65 electrodes and EMG readings, appeared in situations in which the individuals were unable to take positive and constructive measures to resolve conflicts for fear that action might add to insecurity and frustration. They either feared retaliation for their angry feelings or their own guilt inhibited their action. While no consistent personality configuration was found, the authors isolated consistent and specific attitudes toward the stressful circumstances namely*. all wanted to perform action involving body muscularture (such as running or fighting) but all were unable to act. In two interview studies with blind and non-blind interviewers and judges, subjects with low back pain, as compared to eighteen other physical disorders, were found to consistently express an attitude of "wanting to run away" (Grace and Graham, 1952; Graham, et al., 1962). With the advent of cognitive-behavior therapy, determining the association of specific attitudes and certain physiological conditions may hold great promise in the multi-disciplinary treatment of bodily. Gastro-intestinal System - Duodenal Ulcer

Classification and Pathophysiology Between 5 and 15% of the world's population has had a peptic ulcer at one time or another (Carbary, 1976),

thus presenting a major health hazzard. a fundamental problem in the study of peptic ulcer concerns the fact that the term itself is not always defined precisely. Generally speaking, peptic ulcer is considered to encompass both gastric (stomach) ulcer and duodenal ulcer. While these syndromes share many features in common, investigators have found significant differences between the two, the least of which being the differing anatomical location of the lesion. Both types require the presence of acid gastric juice (HCL and Pepsin), but duodenal ulcer is characterized by chronic hypersecretion of both acid and pepsin, whereas this hypersecretion is not the case for gastric ulcers, except for those occurring in the immediate prepyloric region (Engel, 1975). Also, unlike the conditions in duodenal ulcer, patients with gastric ulcer have a high incidence of gastric carcinoma which is associated with, or occurs after the onset of the disease (Yager and Winer, 1971).

66 67

The prevalence also differs. Duodenal ulcer is most common in the 25-40 year old age group and has been found in as much as four times as many males as females, occurring more often in people with phenotype "0" blood

(Carbary„ 1976; Buckwalter, et al«, 1956), Gastric ulcers on the other hand is thought to be more common in an older age group (over 40) and is found in only slightly more males than females (Carbary;, 1976; Sturdevant, 1976; Yager and Weiner, 1971)= It is also believed that these syndromes differ significantly in terms of their psychological and emotional correlates, however this awaits further investigation (Yager and Weiner, 1971; Graham, 1972). Based on these considerations, many clinicians believe that the two syndromes are separate entities (Kirsner,

1968; Gregory & Smeltzer, 1977)® However, many publications unfortunately do not distinguish between the two types of peptic ulcer which may, in part, account for differing results o The incidence of duodenal ulcer in the United States and the United Kingdom seems to have reached its peak 10 - 20 years ago and is now declining, as are male predominance of ulcer, operations for perforated ulcer and mortality due to ulcer (Sturdervant, 1976; Mendeloff„ 1974). Various explanations have been set forth ranging from changes in the natural history of the disease, to time trends (Susser, 1967), to the quality and availability of medical care and the emphasis on primary and secondary 68

prevention. Still, duodenal ulcer occurs more frequently than gastric ulcer and as a result will be the prime focus of this investigation.

Gosling (1957) reported a high frequency of peptic (duodenal?) ulcer among alcoholics, but Hagnell and Wretmark (1957) found that peptic ulcer preceeded alcoholism as often as it followed it, Hamilton (1950) determined that there was no correlation of peptic ulcer disease with number of siblings, the patients position in the family, the father8s social group and marital

status, ICelloclc (1951) found no differences in the frequency of death, separation from or remarriage of one or both of the parents, birth order or number of siblings when comparing patients with and without ulcer disease. The physiological conditions that foster ulcer are fairly well understood and there is general agreement that a relatively high rate of gastric secretion is concomitant of the duodenal ulcer syndrome (Ivy, et al,, 1950;

Mirsky, et al„, 1950; Gottschalk, 1978), Thus, most studies have demonstrated that those patients with duodenal ulcer have a greater rate of pepsinogen excretion in the urine (Janowitz, et al,, 1950) and a higher concentration of pepsinogen in the blood (Mirsky, et al., 1952), than do subjects without any gastrointestinal disturbance. As acid secretion has been found to be accompanied by a rise in blood and urine levels of pepsinogen during periods of personal conflict, duodenal ulcer is considered to be a psychophysiological disorder 69

(Mirsky, et al., 1950; Gottschalk, 1978). Symptoms of duodenal ulcer include, gnawing pain localized in the stomach or hack, cold clammy sweating, chronic indigestion, heartburn, nausea, vomiting and loss of appetite. Constipation is common, but diarrhea and weight loss may also occur. Bleeding may occur when an ulcer penetrates a vein or artery, causing stools to be black and tarry or noticeable blood in the vomit. Blood pressure may drop low enough to cause shock and perforation may result in dizziness, faintness and a racing heart beat (Miller, 1976). Diagnosis of peptic ulcer is made after symptom evaluation with information on pain (incidence, location and severity), radiography and/or endoscopy of the stomach and duodenum with barium (Dunn, et al., 1962; Brown, et al., 1973; Spiro, 1974). Strictly speaking, breaks in the mucosa that do not penetrate below the muscularis mucosae are erosions rather than ulcer (Brooks, 1978).

Personality Attributes The gastrO“intestinal tract is considered to be one of the sites whereby a wide range of emotional reactions may be manifested. The psychological factors involved in the development of duodenal ulcer have been increasingly emphasized since the observations of William

Beaumont (1833), regarding the activity of gastric mucosa in his famous fistulous subject Alexis St * Martin,, Subsequent studies of fistulous subjects, including "Tom" (Wolf and Wolff, 1947), clearly established that emotional stressful situations might give rise to either hyper or hypo-function of the stomach, depending on the nature of the circumstances and the subjects interpretation of the evento In these studies and others (Gannon, 1929; Engel, Reichsman and Seigal, 1956), fright, withdrawal, depression and attitudes of being overwhelmed were associated with hypofunction of the stomach whereas anger, resentment, aggression repressed conflict were correlated with hyperfunction.

Also, Kehoe and Ironside (1963) found a decrease in acid secretion during depression and periods of hypnotically induced "giving up0" Anger was associated with the highest rate of gastric secretions. While many have studied the association between emotions, gastro-intestinal function and disease, the claims of clinical investigators that previous experience, personality and current life changes are significant determinants of disease have been difficult to prove (Engel, 1974), In 1859, William Brinton suggested that privation, fatigue and mental anxiety frequently coincided with the presence of gastric ulceration. More recently, Jones (1957) concluded that anxiety, frustration, resentment and fatigue were important factors in the symptomotology of peptic ulceration. On the basis of 71

other clinical studies of ulcer patients, Alvarez (194-3), Draper and Touraine (1932) and Dunbar (1946) concluded that typically these patients led active lives and were

ambitious, efficient and striving, Hartman (1933) characterized the ulcer-prone person as a man who is encountering obstacles that prove to him a trial and handicap which he must, because of his nature, endeavor

to overcome,, Mittleman and Wolff (1942) observed thirty ulcer patients by charting psychological and clinical data

independently» They were able to demonstrate a close association between emotional responses and the onset, recurrence and course of ulcer symptoms. While not being a controlled study, they concluded that sustained anxiety and conflict, feelings of being caught, resentment,

guilt, self-depreciation and helplessness were precipitating events. Gastrointestinal symptoms have also been associated with melancholia, Schwab, Brown and Holzer (1968) found depression (guilt and self-hate) to be highly associated with gastrointestinal disturbances by a margin of 2:1 over other medical patients.

The classical psychodynamic formulation of the peptic ulcer patient was developed by Alexander and his collaborators at the Chicago Institute for Psychoanalysis

(1934, 1950, 1965). In their intuitive observations, Alexander, et al, (1934) found that patients with duodenal ulcer invariably had in common a conflict related to the 72 persistence of strong infantile wishes to be loved and cared for, on the one hand, and their repudiation by the adult ego (shame, pride) or by external circumstances, on the other. To avoid this conflict, the patient employs various mechanisms to defend himself against the emergence of these oral motives resulting in such defense mechanisms as repression, overcompensation, and reaction formation. Consequently, the following outward personality traits develop: exaggerated self-sufficiency/ pseudo-independence; driving ambition; and/or excessive displays of strength or acting out. Later, Alexander (1950), and Kapp, et al, (1947) amended this conceptu­ alization to include those who were overtly dependent, meek, disgruntled, passive and "parasitic." In these individuals, oral dependent motives allegedly were not necessarily in conflict with the patient’s ego ideal, but were more prone to other-induced frustrations when persons or objects could no longer be depended upon to satisfy intense, infantile cravings leading to "loss," Rubin and Bowman (1942) supported this correction by demon­ strating two disparate EEG Alpha patterns in ulcer patients. The ulcer group that appeared to show more aggressive, outgoing and independent personality traits had alpha rhythms of low frequency, whereas the ulcer patient who fit the clinical picture of a passive-dependent personality, evidenced high frequency alpha rhythms.

Thus, the Chicago group emphasized the importance of "repressed oral-receptive" tendencies in the development 73 of duodenal ulcer and explained that in appropriate circumstances this same dependency conflict may display different personality types. In any event, it is the conflict resulting from the persistence of severe dependency that was considered basic to the character of duodenal ulcer patients.

In a similar manner, Engel (1975) more recently delineated three characteristic ways in which underlying dependency needs are manifested. The "pseudo-independent" patient satisfies his dependency needs by presenting an opposite facade, which helps him to dominate and control others, and thereby force others to cater to his wants and needs. The "go-getting" executive characatures this type, A second type, the passive-dependent individual, overtly and consciously expresses his dependency by being outwardly compliant, clinging, passive, ingratiating and eager to please others, A third type, the acting-out "I want what I want when I want it" type, satisfies his dependency needs by blatant acting out and insistent demanding, even if it involves a social or even anti­ social behaviors. Substance abuse is common as are vocational and marital maladjustment,

Engel (1975) has found that when ongoing infantile dependency needs are frustrated either by real, perceived or a fear of loss of love or security, activation of duodenal ulcer is more likely to occur, Alexander (1950) postulated that these frustrated oral cravings induce an unconscious desire to be fed, with which is associated the .increase in gastric secretion that normally occurs with the anticipation of food. The increased secretion initiates a sequence of physiological changes which result in the development of the duodenal ulceration. Others have also noted that patients with duodenal ulcer exhibit evidences of the persistence of strong infantile oral-dependent wishes9 marked immaturity and insecurity, tendencies to please and placate and problems revolving about the management of oral incorporative impluses about passivity and hostility (Wolf and Wolff„ 1947, Halliday, 1948)« Stine and Ivy (1952) collected and reviewed over 300 psychoanalytic cases and found, “a virtually unanimous opinion that all patients had a serious conflict related to oral dependency," Investigators who oppose the psychoanalytic concept of a particular psychological constellation or conflict contend that psychosomatic symptoms are casually related to a more nonspecific psychically experienced stress. Draper and his associates (1944) found that chronic fear arising from various stimulating mechanisms wag the dominant emotional force in peptic ulcer patients. Chief fear sources in descending order of frequency included; 1) persistent hold on mother principle and fear of loss of mother surrogates approval, 2) an inner sense of insecurity based on actual or supposed physical inferiority, 3) jealousy and aggression, 4 ) guilt and fear related to sex problems, 5) compensatory striving. 75

Mahl and Karpe (1953) also disputed the importance of Alexander’s contention that hypersecretion is the physiological concomitant of frustrated oral-dependent wishes,, and emphasized instead the importance of "chronic

anxiety" in the formation of peptic ulcer. They measured the gastric secretion of a single parent, seen daily for four weeks in psychoanalysis and found that when the patient was anxious, physiological tests has shown a high level of gastric secretion, whereas, when the patients dependency wishes and their frustration were discussed, his rate was low. Epidemiologic evidence also tends to support the notion that peptic ulcer appears more prevalent at times of hightened anxiety. For instance, Spicer, Stewart and Winser (1944) reported a higher incidence of peptic ulcer following the "bombing of Britain during the second World War, Since dependency traits and anxiety can be found in practically all people to some degree and since most studies prior to 1950 had poor controls, the results are at least suspect without further experimentally controlled investigations, Stembach and his associates (1964) compared prisoners and factory workers with ulcer, A high frequency of reactive depression was present in the prison group whereas the factory personnel were characterized by an ambitious and perfectionistic makeup. They concluded that there was no universally existing emotional process related to duodenal ulcer and that 76 ulcer was an emotional stress disorder whereby any factor that produces a prolonged vagotonic state is capable of producing duodenal ulcer. Navran (1954), however, had found ulcer patients to be more dependent than normals on the 57-item Strength of Dependency scale that he developed from the MMPI. In 1957, Alexander and his collaborators devised a method by which the frequency of oral-dependent conflicts could be evaluated while controllings in part, for experimenter bias and prejudice. Edited transcripts of seven psychosomatic diseases (duodenal ulcer, asthma, rheumatoid arthritis, ulcerated colitis, essential hypertension, neurodermatitis and thyrotoxicosis) were reviewed by a panel of psychoanalysts and internists (who served as control). It was found that the analysts and the internists were equally able to correctly diagnose approximately 34/6 of the ulcer patients overall and approximately 57% of the male patients with ulcer. The results cast some doubt on the specificity of oral- dependent cravings in ulcer patients, Alexander explained that without taking into consideration the presence of a specific organ vulnerability or susceptibility, termed the "X” factor, the specific psychological factors were not sufficient to account for the duodenal ulcer. These authors also point to the importance of a precipitating psychosocial external situation which may be necessary to mobilise the earlier established central psychic conflic t. 'Weiner, et al. (1957) supported a similar formulation in a study of 2,073 healthy army inductees. They administered a battery of psychological tests, including the Rorschach, Blackey Pictures, Draw a Person Saslow Screening Inventory and Cornell Medical Index, to groups of men with high and low serum pepsinogen values. Those who had or later developed duodenal ulcer after several weeks of communal living and intense drilling as shown by an upper gastrointestinal X-ray series, showed more evidence that others of "unresolved psychological conflicts related to emotional dependence.

All those who later developed ulcers during basic training had high serum pepsinogen values (upper 15%) when tested at the outset, prior to basic training. In attempting to predict, on the basis of psychological tests alone, which men would develop ulcer under the stress of the basic training camp, Weiner and his colleagues selected 10 men as most likely to have or develop a duodenal ulcer (based on evidence of intense dependency needs and anxiety). Seven out of the ten subjects either had or developed one during the basic training, two were found to be hyperseeretors without ulcer formation and one was a hyposecretor without ulcer formation. Thus it is important to note that hyper­ secretion, to some extent, may be independent of psychic conflict and that psychic conflict in hyposecretion may not lead to ulcer formation. 78

Engel (1975) also emphasized the following three factors in the formation of duodenal ulcer: the genetically predetermined secretory capacity of the stomach, the ability of the mother to satisfy the oral needs of the infant that would effect ones personality development and psychological status, and current psychosocial factors and the degree to which they are psychologically stressful to the particular individual. The evidence that stressful situations are implicated in the causal sequence is well documented

(Alexander, 1950; Wolff, 1953; Weiner, Thaler, Reiser, and Mirsky, 1957)« Davies and Wilson (1937) found a significant correlation between onset of symptoms of peptic ulcer and domestic upset, financial stress and change in work when compared to 100 men with hernia.

These 11 real11 events and not imaginary problems, usually occurred five or1 six days prior to the onset and were largely concerned with security, independence, and responsibility in 84% of the 205 ulcer patients tested.

However the experiment was not done blindly and one can raise questions regarding the use of a condition that is generally taken care of electively (hernia) as a control for a more acute problem that requires more immediate attention.

Differences found between occupations may indicate a relationship between duodenal ulcer and conflictual work environment. However, Susser (1967) points out that 79 the occupation may not have caused the anxiety but, rather, anxious, conscientious men might incur a higher risk both in accepting a more stressful job and in developing an ulcer, Mirsky (1958) concluded that there was nothing consistently specific about the external social situation which preceeds the onset of the syndrome as similar problems occur in most people, while only a few develop duodenal ulcer. Implicit in such a perspective is the specific meaning of the environmental event or events to the particular individual that determines whether or not the event is responded to as noxious, Graham and his collaborators (1952) lend support to a cognitive approach to human function and dysfunction by examining the special meaning that life events have to the individual. In formulating a specificity~of-attitudes hypothesis, they described an "ulcer attitude" as a feeling that "one has been deprived of what he is due and wants revenge," This attitude was later confirmed in an interview study utilizing a number of techniques including physical measurements during hypnotically induced states and post-diction by blind raters who matched edited recorded interview with specific disease states (Graham, et al,, 1962),

Others have also alluded to the importance of a patient's thoughts and perceptions in the genesis of ulcer formation as Wolf and Wolff (1947) earlier reported that increase in gastric activity could be understood as 80 associated with an unfulfilled desire for aggression and fighting back. Also Castelnuovo-Tadesco (1962) found that perforation of ulcer occurred when patients interviewed had been exposed to situations "which they felt to be grossly damaging to their self-esteem and to which they reacted predominantly with impotent rage„"

Yager and Weiner (1971) enumerated various methodological problems in the study of peptic ulcer disease which may account for confusing and often conflicting results^ pointing out the inherent short­ comings of the clinical psychoanalytic techniques frequently found in the research literature„ They discovered that not only were generalizations often formed on the basis of single case studies^ but subjective inferences and objective observations were intermingled. Other problems included a lack of reported inter-rater or test-retest reliabilities and an obvious void of adequate control groups„ Most striking was that behaviors to be observed were rarely operationally defined and most peptic ulcer studies were not divided into ulcers of the gastric and duodenal variety which recently has been shown to differ pathophysiologically.

There are also studies that indicate that regardless of whether or not it can be shown that psychiatric and social factors "cause" peptic ulceration, certain psychological factors are significant in precipitating complications leading to intractability 81 and poor response to either medical or surgical treatment

(Weiner, Thaler, Reiser, and Mirsky, 1957; Rutter, 1963). Even mild anxiety and depression have been shown to be predictive of poor response to treatment. However, the association between specific cognitive-emotional and physiological factors have most often only been inferred and rarely has it been objectively studied. CHAPTER III

METHODS

This chapter will describe the research methodology

and statistical procedures used in this study and will

consist of several sections. In the first section* the

instrument will be described* with references cited and

a rationale for the use of the instrument. The second

section will refer to sample selection. Other sections will examine the procedure for data collection* the

research design* and statistical procedures used to

analyze the data. Lastly* a summary statement will be

provided.

Selection of the Instrument

Bard (1973) | Lane* Bessai and Bard ( 1975); Bessai

(1976, 1977) worked to construct a self-administered objectively scored diagnositic instrument to be used to measure specific levels of irrational thinking. Based

on Ellis' theoretical framework of irrationality* they pooled and refined nine already existing attitude surveys

into one 54-item inventory, the Common Beliefs Survey III.

These included the Adult Irrational Ideas Inventory

(Eox and Davies, 1971), the Common Perception Scale

82 83

(Maultsby, 1974a), the Common Belief Scale (Maultsby, 1974b), the Common Trait Scale (Maultsby, 1974c), Questions For Rating Reason (Argabrite and Nidorf, 1968), Irrational Beliefs Test (Jones, 1968), Personal Beliefs Inventory (Hartman, 1968), Ellis Scale (MacDonald and Games, 1972), A Self-Rating Scale for Rationality

(Bard, 1973), In reviewing the literature that led to the development of the instrument (CBS III), Bessai (1976) noted several inadequacies with the existing instruments including insufficient number of items, inadequate sample sizes and inappropriate use of items dealing with feelings and symptoms rather than beliefs. The original pool, consisting of 419-items, was reviewed by a panel of judges familiar with the principles of scale construction and/or Ellis' Rational Emotive Therapy (RET), in order to insure that each of Ellis' 12 irrational beliefs were equally represented,, Redundant items were eliminated. Following the evaluation of a factor anaylsis and promax oblique rotation on the selected 189-items comprising the Common Beliefs Survey I (CBS I), that yielded 10 first order factors (6 of which were easily interpretable), the authors set out to test a revised edition, the 100-item Common Belief Survey II (CBS II). The resultant 10 factor solution (9 of which were replicated factors on the CBS I), accounted for 76% of the common variance. The characteristics of these factors were closely examined and four factors were judged artifactual,, either due to similar item wording or based on the non-normal response distributions of the items. Changes were again made resulting in a 49-item matrix which yielded a six factor solution accounting for 82.8% of the common variance. Thus* after a number of revisions, the six replicable first order factors based on Ellis’ irrational ideas included: Importance of the past, Blame proneness; Self-downing, Importance of approval, Perfectionism, and Loss of control of emotions. The replicable second order factors, which accounted for 100% of the common variance included: Evaluation and Locus of control. To obtain the 54 items found on the CBS III, Bessai (1977) added five new equivalent items so that there would be 9 items for each of the six first order factors. The CBS III factor structure was replicated in a recent study (Bessai, 1978).

The instrument consists of 54 items set in a 5-point likert-scale response format ranging from strongly agree to strongly disagree. In order to control for an acquiescent response bias, items are worded so that approximately one-half of the items are stated as rational beliefs (25) and one-half as irrational beliefs (29). The time needed for administration of the instrument is between 15 and 20 minutes. Selection of the Sample The sample consisted of medical patients, most of whom were selected from the Family Practice Center affiliated with Riverside Methodist Hospital in Columbus, Ohio. However, due to the difficulty in securing the number of subjects needed to adequately compare the psychosomatic groups, other referral sources were sought. Staff Physicians of Riverside Methodist Hospital were contacted individually, the nature and purpose of the study explained, and their cooperation in referring outpatients to this investigator was solicited. Six specialists in Internal Medicine, Orthopaedics and Neurology were agreeable. Subjects were chosen on the basis that their presenting physical symptoms conformed to those typically found to be associated with the target psychosomatic groups (low back pain, recurrent headaches, epigastric pain). Thus, of the 152 adult males and females (18 years and older) who initially agreed to participate in the study, 130 returned the test packets, of which 114 met the final diagnostic criteria set forth in this investigation. Fifty-one patients comprised the migraine group, while there were 39 in the psychogenic low back pain group and 24 in duodenal ulcer group. In addition, a medical control group that was drawn from the Riverside Family Practice Center consisted of 150 outpatients treated for such things as upper respiratory infections, routine check-ups, innoculations and minor trauma were used. Thus, all 264 white, upper middle to lower-middle class subjects comprising the to sample were patients of physicians associated with Riverside Methodist Hospital. The sampling took place between February, 1978 and December, 1978 and participation in this study was completely voluntary. Table 2 provides a description of the sample characteristics. Table 2

SAMPLE CHARACTERISTICS

Low Back Duodenal Characteristic Migraine Pain Ulcer Control

1. Age Range 20-60 19-65 26-61 18-71 Mean 37.51 38.31 44.08 32.45 SD 11,84 10.39 9.55 11.94

2. Sex (%) M 21.6 41.0 58.33 41.33 F 78.4 59.0 41.67 58.67

3. Marital Status (%) a) Married 72.6 76.9 91.7 61.3 b) Single 9.8 12.8 4.2 26.0 e) Other 17.7 10.3 4.2 12.7

Socioeconomic Status * (%) a) Upper-middle 76.5 48.7 • 62.5 80.7 b) Lower-middle 19.6 35.9 25.0 16.7 c) Upper-lower 3.9 12.8 8.3 2.7 d) Lower-lower 0.0 2.6 4.2 0.0

Degree of Incapacitation ( a) not at all 39.2 2.6 45.8 b) minimally 19.6 23.1 33.3 c) moderately 19.6 23.1 12.5 d) markedly 39.2 35.9 4.2 e) totally 17.6 15.4 4.2 Table 2 continued

* Adler (1973) used two formal criteria to determine an individuals social position - education level and occupation. Based upon 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. Upper-lower class includes 6 - 9 years or less and laborer occupations^ Lower-lower class includes less than 6 years and unskilled labor or chronic welfare aid. 89

Procedure

Those who participated in the research study were told that they were cooperating in a social- psychological investigation dealing with the common beliefs of patients who present themselves to their doctorso The subjects were assured that all information thus obtained would remain confidential and anonymity

was insured by using a coded number on the answer sheets (see Appendix A). Following the brief conversation, each subject was given a packet containing a consent form (see Appendix B), the personal data sheet (see Appendix G ) requesting information about the person (age, educational level, socioeconomic status) and the Common Beliefs Survey III with accompanying answer sheet (see Appendix D). Those whose voluntary consent was in question as a result of an inability to read and understand the informed consent form and/or the directions of the survey, were excluded from the study.

Initially, it was planned that the testing would be done at each physicians office. However, several problems interfered with this plan including patients previous commitments which prevented their staying for the length of time needed to complete the surveys. In addition, many of the patients had pain severe enough to limit their tolerance to sit. It was therefore necessary to allow some patients to complete their questionnaires at home and to return them by mail. Followup phone calls were made to those who failed to return the test packet within two weeks. Nine subjects indicated that they were no longer interested in participating in the study after giving it some more thought. Seven of those nine were patients with psychogenic low back pain and two were suffering from migraine headaches. Another eight (four migraines, three low backs and one ulcer) stated that they would return it as soon as possible, but didn't; three could not be reached by repeated phone calls and one had heart surgery in the interim and was recuperating. Once the patient had self-administered the questionnaire, the results of any subsequent diagnostic tests (e.g., X-ray, GAT Scan, ESG, EMG) served to separate the patients into appropriate diagnostic groups for statistical analysis and comparison. All physicians who referred patients to this study were provided with copies of the diagnostic criteria (see Chapter I, p. 11) and a final diagnosis was made without the experimenters knowledge or input.

Research Design A 4 x 2, 2-between multivariate analysis of variance with 8 dependent variables was used in analyzing the data. All subjects were assigned to one of the four groups according to their final medical diagnosis: migraine, psychogenic low back pain, duodenal ulcer and 91 medical control group. The 2 betw.een-sub jects variables included group membership and sexs while the dependent variables included mean factor scores 1 - 6, age and socioeconomic status. All subjects received the Common Beliefs Survey III (CBS III) to assess specific levels of irrational thinking.

Statistical Analysis The raw data collected in this study were first analyzed by common factor analysis. For this purpose, a program was selected from the SaS program package (Barr, et al.p 1976). Comrey (1973) describes and encourages the use of Factored Homogeneous Item Dimensions (FHIL) as the basic unit of analysis in factor analytic studies designed to locate the main factors for a taxonomy of personality. This is particularly useful when the items forming a FHID or "parcel" (Cattell and Nesselroade, 1976) have been shown to have both conceptual and demonstrated statistical homogeneity as is the case of an existing factor analysis of items. Two criteria must be satisfied in order to make use of the FHID approach (Comrey, 1973): a) The items must be originally developed and logically conceived as measures of the variable under construction; b) the items must be found to define the same factor in a factor analysis of items. In the present study, both criteria have been met. Factor analysis of the FHID1s themselves forces the production of factors at a higher level in the factor hierarcy and are consequently more likely to represent the broader constructs needed for taxonomy,, The factor structure described by Bessai included nine items for each of six first order factors. As a result, adding every third item within each factor with three items per parcel, produced eighteen parcels or FHIDs, The common factor analysis was performed on all eighteen parcels which represented the six factor, 54-item questionnaire. The SAS program (Barr, et al„„ 1976) was employed to analyze the 18 x 18 intercorrelation matrix. The highest inter­ correlation of a parcel with the remaining parcels was used as the original communality estimate (Harman, 196?; Gorsuch, 1974; Rummel, 1970), A principal axis factor analysis was conducted and the resulting solution was then rotated. As there is much controversy over the proper rotation method, both an orthogonal and an oblique rotation were employed. The Varimax method, first proposed by Kaiser (1956), is now generally accepted as the best analytic orthogonal rotation technique (Harman, 1967; Kirk, 1968; Gomrey, 1973), The orthogonality restriction ensures that factors will dilineate statistically independent variables and consequently are considered by many to be easier to interpret. However, Gattell (1952) argues that since factors in nature are not apt to be orthogonal, a refined oblique rotation is warranted to obtain a more accurate picture of the factor structure. The Promax method (Hendrickson 93

and White, 1964) was used as the oblique rotation in deference to the procedure used by the developers of the inventory used in this investigation. The main purposes of the factor analysis in this study were to replicate the developers factor structure with this heterogeneous sample and to insure that no items (or parcel of items) loaded on alternate factors. Consequently, this will lend additional credence to the use of the inventory. Outputs for the SAS program consists of means and standard deviations, a variable correlation matrix, a matrix of unrotated loadings, communality estimates, variraax and prornax rotated factor matrix, interfactor correlation matrix and tables of the calculated factors for all parcels of items. Significant extracted factors were then analyzed by a 4 x 2 multivariate analysis of variance. P-ratios were transformed from the Wilkes°Lambda criterion for each main effect and interaction using the Components Analysis of Variance program (CANOVA). Followup univariate analysis of variance for each of the dependent variables are provided as are Duncans New Multiple Range tests as the post hoc method to determine where specific pairwise comparison differences lie.

Summary Chapter III has presented the rationale for the selection of the Common Beliefs Survey III and a brief description of the psychometric instrument, citing pertinent references; a description and method of selecting the sample; the process of data collection; the research design, computer program and statistical analysis used to analyze the data. Chapter IV will present the analysis of the data and the findings of the study. CHAPTER IV

ANALYSIS OF THE DATA

The analysis of data will be presented in this chapter. This study was undertaken to test the hypotheses stated in Chapter I. Of primary concern was how mean factor scores on the Common Beliefs Survey III change across three experimental and one control groups. The groups were identified as group one (migraine), group two

(low back pain), group three (duodenal ulcer), group four

(control).

Factor Analysis

In an attempt to replicate the factor structure described by Bessai (1977) for the Common Beliefs Survey

III, a common factor analysis was performed prior to further data analyses. Mean item responses were substituted for missing data, which accounted for less than 2% of the responses for any item. Eighteen packets or "parcels" of items were used as the basic units of the factor analysis. The common factor analysis was performed on all eighteen item parcels. The SAS factor analysis program was employed to analyze the 18 x 18 intercorrelation matrix (see Table 13). Instead of

95 extracting all the factors existing in the data, factoring usually stops at the point where no additional significant or meaningful variance remains. A six factor solution accounting for a variance of 8.74 which was 49?^ of the total variance was chosen as the best resolution of the correlation matrix, based on

Cattell's (1966) scree test (see Figure 1) and the interpretabilitv of the factors. This is the same number of factors previously reported (Bessai, 1977, 97

.2 .1 .0 .9 .8 .7 .6 .5 .4 .3 .2 .1 .0 .9 .8 .7 . 6 M .5 o 5S .4 < .3 h -i .0 o .9 .8 Eh a .7 .6 O .5 .4 .3 .2 .1 .0 .9 .8 .7 . 6 .5 .4 .3 .2 .1 0

1 6 8 10 1 1 FACTORS

Figure 1 Scree Test for Factors Table 14 represents the factor loadings following a varimax rotation. Table 15 represents the factor loadings following a promax oblique rotation with Table 16 showing the interfactor correlation matrix. Both the varimax and the promax rotation methods yielded very similar results in that item-Parcels 1p 2 and 3 contained the highest varimax loadings (.6615, ,7228, .6931 respectively) and promax loadings (.6601, ,7504, ,7000 respectively) on Factor I, This similarity was consistent throughout both tables and since each parcel of items loaded best on the expected factor, the factor structure previously set forth by Bessai (1977) was replicated. An examination of the factor loadings revealed that Bessai's item factor analysis held up for this sampling. Consequently„ her scoring procedure was used for subsequent analyses.

Items comprising Factor I, previously labeled Importance of the Past included such items as: (a) past experiences need not affect present behavior (agree), (b) one can overcome the influence of the past (agree), (c) a person's present behavior must be greatly influenced by his/her past (disagree). Factor II was labeled Blame Proneness and included such items as: (a) Criminals are basically bad people and should be punished (strongly disagree); (b) no one is evil, even though his deeds may be (agree) (c) people are justified in refusing to forgive their enemies (disagree). 99

Factor III was labeled Self Downing and included such items as: (a) If people don't meet their own standards, they are bound to think less of themselves (disagree); (b) a person can’t help feeling guilty about wrongdoings (disagree); (c) people are bound to put themselves down when they fail (disagree). Factor IV was labeled Importance of Approval and ——a ii.nm—m m i w,niT, j hJ?>.uiil.« m i IWUI n in im i i included such items as: (a) Being approved by others is very important (disagree); (b) people do not need to be loved in order to accept themselves (agree); (c) being ignored by friends doesn’t have to be upsetting (agree). Factor V, labeled Perfectionism included such items as: (a) There is a right way to do everything (disagree); (b) it is awful when things are not the way one would very much like them to be (disagree); (c) one must be perfectly competenx, adequate and achieving to consider oneself worthwhile (disagree).

Factor VI, labeled Control of Emotions included such items as: (a) People can control their emotions (agree); (b) how a person interprets an event determines his/her emotions (agree); (c) emotions are not determined by outside events (agree). A complete listing of the items, parcels, and factors is provided in Appendix S.

Following the procedures set forth by Richardson

and Kuder (1939), the internal consistency estimate of reliability was .85 for the Common Beliefs Survey III, while the coefficients of internal consistency for each 100 factor ranged from .50 - .79.

Analysis of Variance The hypotheses were tested hy two between- subjects, multivariate analysis of variance (MANOVa ). The two between-subjects variables consisted of four levels of groups, two levels of sex. The dependent variables consisted of six mean factor scores, based on Bessai' s scoring procedure. Age and socioeconomic status were dealt with separately. F-ratios were transformed from the Wilkes-Lambda criterion for each main effect and interaction using the Component Analysis of Variance program (CANOVA). There were 8 dependent variables included in this study. Each dependent variable was discussed in light of the multivariate analysis of variance. A summary table of each analysis was included and where statistical significance was observed, a table of means was also included.

A 4 x 2 MANOVA. was used to evaluate the null hypotheses of the study. The multivariate difference for the sex main effect can be accounted for by chance alone (F = 1.95; p > .05). This result leads us to fail to reject the null hypothesis. The data suggests that gender is not an important factor in irrational thinking. Both males and females are equally prone to thinking irrationally, as measured by the CBS III. The data also suggests that the multivariate analyses of variance 101 difference for an interaction effect between group and sex could be accounted for by chance alone (F = .82; p .05). Thus, any difference found between groups held up regardless of the patient*s gender. The multivariate analysis of variance for differences in group main effects was found to be significant (F = 2.75; p <*4 .001) by the wilkes-Larabda criterion. Table 3 presents complete univariate F tests for groups across each of the dependent variables following the significant MANOVA F-ratio. These data reveal a significant F-ratio for one of the six CBS III factors.

Table 3 UNIVARIATE F TESTS OP GROUPS MAIN EFFECT FOR CBS III FACTORS (DF - 3,256)

Variable SS MS F P less than

Importance of Past 56,46 18,82 .57 .639 Blame Proneness 70.92 23.64 1.31 .273 Self Downing 177.79 59.26 1.79 .149 Importance of Approval 31.92 10.64 .44 .723

Perfectionism 528.86 176.29 4.76 .003 Control of Emotions 9.72 3.24 .15 .933 102

Factor 5 - Perfectionism The univariate F ratio for Perfectionism was significant "beyond the .01 level across all groups. Table 4 presents the total mean scores for Ss performance

on Perfectionism by groups.

Table 4 MEAN SCORES FOR Ss PERFORMANCE ON FACTOR V OF THE COMMON BELIEFS SURVEY III

Group Means

Migraine 15.12 Low Back Pain 17.44 Ulcer 16.46 Psychosomatic Groups 16.20 Control 13.81

Inspection of these mean scores by groups revealed that the medical control group has the lowest mean scores on Perfectionism as measured by the CBS III (the lower

the score the less perfectionistic) followed by the migraine group, the ulcer group and the low back pain group. One of the hypotheses, #1, compares all three psychosomatic groups, as a whole, with the control. The CANOVA program allows for testing this hypothesis on an apriori basis. a multivariate analysis of variance for differences between the psychosomatic versus the medical 103

control groups was found to be significant (F = 5.78; p < .001) by the toilkes-Lambda criterion; thus the

null hypothesis was rejected. Table 5 presents complete univariate F-tests for the combined psychosomatic groups versus the control for each of six variables following the significant multivariate F-ratio. These data reveal significant univariate F-ratios for two of six dependent variables.

Table 5 UNIVARIATE F TESTS FOR THE COMBINED PSYCHOSOMATIC GROUPS VERSUS THE MEDICAL CONTROL GROUP ON SIX DEPENDENT FACTORS (DF = 1,256)

Variable SS MS F P less than

Importance of Past 33.58 33.58 1 .01 .316

Blame Proneness 60.22 60.22 3.34 .069 Self Downing 164.03 164.03 4.96 .027 Importance of Approval 11.19 11.19 .47 .496 Perfectionism 315.48 315.48 8.51 .004 Control of Emotions 7.47 7.47 .33 .564

Factor 3 - Self Downing The univariate F-ratio for Self Downing was significant at the .05 level when the experimental (psychosomatic) groups were combined and compared to 104

the control. The experimental groups were more prone to Self Downing (x = 20.60) than the control group (x = 16.68),

Factor 5 - Perfectionism The univariate F-ratio for Perfectionism was significant at the .01 level when the experimental groups were combined and compared to the control. The experimental groups were more Perfectionistic (x = 16.20) than the medical control group (x = 13.81).

Factor 2 - Blame Proneness

The univariate F-ratio for Blame Proneness approached significance at the .07 probability level when comparing the combined psychosomatic groups with the control indicating that there is a greater tendency for the psychosomatic patients toward other - Blame Proneness (x = 14.90) than for the control patients

(x = 13.93). while it must be noted that this difference did not reach significance at the standard .05 level, it is a strong trend.

Duncans New Multiple Range tests (1955) were used to determine which contrasting pairs of experimental samples had produced factor scores that differed by more than the least significant and were not, therefore, estimates of the same population. The extension of Duncans New Multiple Range test for the case of unequal n's is discussed by Kramer (1956). 105

Tables 6 and 7 displays the differences among

means where significance was found using the Duncan

procedure.

T ab 1 e 6

RESULTS OF DUNCANS NEW MULTIPLE RANGE TEST ON ALL ORDERED PAIRS OF MEANS FOR FACTOR III

X 2 X 4 X 3 X 1

Control X. . 18.68 --- 1 .47 2.15 2.16* 4

LBP I? ® 20.15 --- .78 .79

Ulcer X 3 = 20.83 --- .01

Migraine X1 = 20.84 ---

* P < .05

Table 7

RESULTS OF DUNCANS NEW MULTIPLE F4NSE TEST ON ALL ORDERED PAIRS OF MEANS FOR FACTOR V

I 2 X 4 *1 X 3

Control X4 = 13.81 1 .31 2.65 3.63**

Migraine X 1 = 15.12 —» 1.34 2.32

Ulcer X, = 16.46 --- .98

LBP X2 = 17.44 — — —

* p < . 0 5 ** p ^ .01 106

Inspection of the Tables 6 and 7 showed that there were no significant differences for the pairwise comparisons of the three psychosomatic groups with respect to the 6 Factors on the CBS III. Differences were detected when each psychosomatic group was compared to the medical control group. While the migraine group seems to have accounted for most of the statistical significance on Factor III and the Low Back Pain group on Factor V9 the other comparisons between each psychosomatic group and the control on those factors yielded very similar mean differences by inspection and approached the adopted level of significance. This seems to be mostly a function of the unequal and relatively small sample size.

Age and Socioeconomic Status Age and socioeconomic status were included in this study as dependent variables in order to help control for their effect. As stated previously* it was not possible to make.age and SES independent variables as originally desired* due to the relatively small number of subjects in each group. Both univariate F-ratios for age and SES were significant beyond the .01 level across all groups* as shown in Table 8. Tables 9 and 10 present the total mean age and SES for subjects by the respective group membership. 107

Table 8

UNIVARIATE F TESTS OF GROUP M a IN EFFECTS FOR AGE AND SOCIOECONOMIC STATUS (DF = 3,256)

Variable SS MSF P less than

Age 3213.80 1071.27 8.12 .001 CD 00

SES 9 2.83 8.40 .001

Table 9

MEAN AGE FOR GROUPS

Group Means

Migraine 37.51

Low Eack Pain 38.31

Duodenal Ulcer 44.08

Control 32.45

Table 10

MEAN SOCIOECONOMIC STATUS FOR GROUPS

Group Means

Migraine .28

Low Back Pain .69

Duodenal Ulcer .54

Control .22 108

Inspection of Tables 9 and 10 reveals that the control group is the youngest, followed by migraine, low back pain and the ulcer group. The control group also had the highest SES (lower number indicates higher SES where 0 = UM, 1 = LM, 2 = UL, 3 = LL) followed by migraine, ulcer, and low back pain. Tables 11 and 12 represent differences among means for Age and SES and the significance levelsbased on Duncans New Multiple Range tests as a Post-hoc measure.

Table 11 RESULTS OP DUNCANS NEW MULTIPLE RANGE TESTS ON ALL ORDERED PAIRS OF MEANS FOR AGE

X4 X 1 X2 X3

Control X4 = 32.45 --- - 5.06** 5.88** 11.63**

Migraine X1 = 37.51 --- .80 6.57* LEP X2 = 38.31 5.77 Ulcer X3 = 44.08 ---

* p < .05 ** p ^ .01 109

Table 12 RESULTS OF DUNCANS NEW MULTIPLE RANGE TESTS ON ALL ORDERED PAIRS OF MEANS FOR SOCIOECONOMIC STATUS

Control .22 .32* .47** X4 " .05 Migraine X 1 = .27 .27 .42**

Ulcer x3 = .54 — .15 LBP X2 = .69

* p 'C ** p v «01

When the three experimental groups were combined and compared to the control group, significant differences were found in Age and SES in that the experimental groups were significantly older (p < .001) and were of a lower

SES (p < .001) than the medical control group. Breaking that down further, when comparing each of the psychosomatic groups to the medical control group, the migrainous patients were found to be significantly older. The psychogenic low back pain patients were not only older than the control but were also of a lower SES. The ulcer group, also, was found to be older and of a lower SES than the medical control patients. Other differences were detected when a psychosomatic group was compared to each of the other two psychosomatic groups in that the migraine group was 110 significantly younger than the ulcer group and were of a higher S2S than the low hack pain group. Table 13

CORRELATION MATRIX FOR 18 PARCELED VARIAELES

1 2 3 4 5 6

1 1.00000 2 0.52339 1.00000 3 0.54374 0.56617 1.00000 4 0.10518 0.05858 0.08879 1.00000 5 0.13840 0.04440 0.13393 0.25485 1.00000 6 0.12004 0.11444 0.17622 0.18406 0.42015 1.00000 7 0.25331 0.25489 0.20817 0.16209 0.07012 0.08958 8 0.26567 0.12052 0.23262 0.22198 0.13551 0.07516 9 0.27853 0.27153 0.32803 0.14824 0.08409 0.12432 10 0.31035 0.29968 0.25785 0.05862 0.09004 -0.10782 11 0.31494 0.15868 0.22323 0.08564 0.13017 0.07345 12 0.33716 0.31490 0.28320 0.11082 0.20339 -0.00405 13 0.14612 0.19243 0.26291 0.16355 0.24577 0.22415 14 0.15345 0.16952 0.26963 0.07897 0.26317 0.30150 15 0.10312 0.17773 0.27043 0.11990 0.27909 0.32397 16 -0.00300 0.04387 -0.01400 0.11579 0.06103 0.05696 17 0.14706 0.10269 0.09500 0.06401 0.16408 0.11408 18 -0.05528 0.01555 0.01323 0.11568 0.16156 0.11345 111 Table 13 continued

Parcel 7 8 9 10 12

1 2 3 4 5 6 7 1.00000 8 0.58424 1.00000 9 0.52845 0.58784 1.00000 10 0.17965 0.23044 0.30346 1.00000 11 0.11153 0.21394 0.26866 0.30468 1.00000 12 0.19001 0.32925 0.26532 0.50345 0.36931 1.00000 13 0.26407 0.41109 0.32501 0.19848 0.25672 0.32188 14 0.31377 0.32152 0.40479 0.13068 0.14232 0.16266 15 0.31100 0.24174 0.35361 0.12296 0.16146 0.15585 16 0.02890 -0.06819 -0.04378 0.12056 0.17804 0.04612 17 -0.02823 -0.02303 -0.04832 0.19557 0.24592 0.13074 18 -0.09379 -0.01783 0.02941 0.08836 0.11430 0.04222 112 continued

13 14 15 16 17 18

1 2 3 4 5 6 7 8 9 10 11 12 13 1.00000 14 0.45884 1.00000 15 0.48365 0.53694 1.00000 16 -0.05817 ■ 0.02701 0.04544 1.00000 17 0.12798 - 0.01848 0.01994 0.41772 1.00000 18 •0.06216 0.03196 0.00529 0.36900 0.41043 1.00000 Table 14 VARIMAX LOADINGS OP 18 ITEM-PARCELS ON 6 FACTORS

FACTOR Criterion Variable I II III IV V VI h2

Parcel 1 0.66149 0.14511 0.16601 0.27648 -0.02543 -0.01189 . 56 2 0.72280 -0.03112 0.10197 0.15513 0.11048 0.05066 .57 3 0.69312 0.08191 0.11302 0.16116 0.21631 -0,00083 .57 4 0.01917 0.39825 0.21678 0.05616 0.00170 0.10835 .22 5 0.03485 0.59060 -0.02759 0.12954 0.25246 0.10897 .44 6 0.14642 0.50859 -0.01234 -0.16557 0.35132 0.10528 .44 7 0.17294 0.03302 0.71370 0.04243 0.18724 -0.02723 .58 8 0.05173 0.16694 0.70149 0.27244 0.16340 -0.09416 .63 9 0.20738 0.01007 0.63912 0.19668 0.29978 -0.01999 .58 10 0.21962 -0.09968 0.15180 0.61196 0.05146 0.14749 .48 11 0.15638 0.08184 0.10655 0.45706 0.11856 0.21257 .31 12 0.21059 0.10403 0.13741 0.66547 0.08499 0.01728 .52 13 0.06306 0.19283 0.19786 0.32124 0.54306 -0.06367 .48 14 0.11349 0.12717 0.23784 0.06088 0.66781 -0.02273 .54 15 0.10553 0.14083 0.17766 0.05354 0.69783 0.02819 .55 16 -0.00378 0.01012 0.00975 0.03950 -0.01993 0.64923 .42 17 0.09059 0.11798 -0.09058 0.19988 0.01088 0.60523 .44 18 -0.03738 0.12775 -0.02033 0.02550 0.00019 0.61234 .39

Variance 1.70 .97 1.69 1.45 1.65 1.27 8.74 PCT Common Variance 19.45 11.10 19.34 16.59 18.88 14.53 100. Table 15 PROMAX LOADINGS OP 18 ITEM PARCELS ON 6 FACTORS

FACTOR

Criterion Variable I II III I V V VI

Parcel 1 .66012 .13433 .08196 .15861 -.18880 -.06770 2 .75039 -.09401 -.00680 .02027 .03056 .03316 3 .70000 .01419 -.01561 .02660 .12400 -.03349 4 -.03102 .42922 .26493 -.00912 -.15215 .06914 5 -.03674 .58894 -.08611 .10725 .13609 .00876 6 .14070 .48263 -.04353 -.25602 .26819 .05559 7 .08130 -.01639 .76419 -.13067 .04398 .04339 8 -.10198 .14012 .71928 .15955 -.01313 -.07382 9 .08285 -.07253 .61530 .05436 .18910 .02814 10 .09121 -.16487 .02300 .62915 .01539 .10377 11 .04347 .02528 .00670 .45584 .06792 .16104 12 .06397 .0646 5 -.01351 .69499 -.00160 -.06914 13 -.08810 .08777 .03700 .30317 .52699 -.10166 14 .00613 -.00909 .10555 -.01827 .68708 -.01049 15 .00046 -.00353 .03546 -.01828 .73332 .03503 16 -.02768 -.04127 .06066 -.00404 -.01328 .66583 17 .04892 .06840 -.10535 .18176 -.00312 .57057 18 -.06410 .09057 .02930 -.01120 -.01213 .60949 Table 16

INTERFACTOR CORRELATION MATRIX FOR 6 DEPENDENT VARIABLES

Variable 1 6 4 5 3 2

1 1.00000 6 .18190 1.00000 4 .33767 .12486 1.00000 5 .42838 .17911 .41201 1.00000 3 .32048 .42073 .42746 .25042 1.00000 2 .07264 .21854 -.11215 .16104 .00173 1.00000 CHAPTER V

SUMMARY, CONCLUSIONS AND RECOMMENDATIONS

This final chapter is divided into three sections: (a) a summary of the research study, (b) a discussion of the findings and their implications, and (c) conclusions and recommendations. The recommendations will be presented in two parts: (1) recommendations for further research and (2) a suggestion for treatment of psychosomatic patients„

Summary This study examined the relationship between various psychosomatic disorders and psychological factors considered to be indicators of irrational thinking. The review of the literature included historical remarks: the mind-body problem; psychogenesis; classifications, pathophysiology and personality correlates of three specific psychophysiological disorders (migraine, psychogenic low back pain, duodenal ulcer). The search of the pertinent literature revealed a need for more accurate measures of irrational thinking and continued exploration into the psychological-personal make-up of patients with psychosomatic disorders. This

117 provided a rationale for the present study. Subjects were 261 white, upper-middle to upper- lower class adults ranging in age from 18-71 years, drawn from referrals of physicians associated with Riverside Methodist Hospital in Columbus, Ohio. Fifty-one subjects comprised the migraine headache group while there were

39 in the psychogenic low back pain group, and 24 in the duodenal ulcer group, in keeping with the varying prevalence rates. The remaining 150 subjects were drawn exclusively from the Riverside Family Practice Center to make up the medical control group. The gathering of data took place between February and December, 1978. All experimental subjects had been symptomatic for at least three months (chronic), were willing to participate in the study, and devote the 20-30 minutes necessary to complete the inventories. First, subjects were asked to complete a Personal Data Questionnaire which included the demographic date (age, sex, educational level, occupation). Secondly, an attitude inventory, the Common Beliefs Survey III (CBS III) was used to assess the level of irrational thinking of the participants. The data were recorded on IBM cards in accordance with the format instructions contained in the selected computer program (SAS, 1976). Common factor analysis with both a varimax and promax solution on all 18 parcels of the 54-items yielded six significant and interpretable factors. Both factor rotation procedures replicated the 119

one previously set forth on the CBS III by Bessai (1977). The six factors were: (1) Importance of the Past (Factor I), (2) Blame Proneness (Factor II), (3) Self-Downing (Factor III), (4) Importance of Approval (Factor IV), (5) Perfectionism (Factor V), (6) Locus of Control (Factor VI). The research design consisted of a 4 x 2, 2 between- subjects multivariate analysis of variance with 8 dependent variables. All subjects were assigned to one of four groups according to their final medical diagnosis. Subjects

were also classified according to their gender. The 8 dependent variables included 6 mean factors scores repre­ senting Importance of the Past, Blame-Proneness, Self- Downing, Importance of Approval, Perfectionism and Locus of

Control, age and socio-economic status. The F-ratios were transformed from the Wilkes-Larabda criterion for each of the two main effects and one interaction using the Components Analysis of Variance program (CANOVA). One way analysis of variance was performed for each of the 8 dependent variables. Duncans New Multiple Range Test a post-hoc analysis was used to locate where significant pairwise comparison differences existed among the groups.

No interaction effect was observed between group membership and sex. A failure to reject the null hypothesis for the sex main effect demonstrates that both males and females were equally prone to irrational thinking as measured by the Common Beliefs Survey III. A significant main effect was found for groups

(P .001). Results of the one-way analysis of variance 1 20 across the four groups on Factor V, Perfectionism, revealed a statistically significant (p < .05) F-ratio. The remaining 5 factors: Importance of the Past, Elame Prone­ ness, Self-Downing, Importance of Approval, and Locus of Control, did not attain a statistically significant F- ratio. The other two dependent variables, age and socio­ economic status, both reached statistical significance (p .01).

The GANOVA program allowed for testing Hypothesis I, which combined the psychosomatic groups and compared them to the medical control group on an apriori basis. Both a significant multivariable F-ratio (p .001) and the follow-up univariate F-tests lead to a rejection of the null hypothesis. The results indicated that the three psycho­ somatic groups as a whole, were not only older (p .001) and of a lower socio-economic status (p O .001) but were also more perfectionistic (p

Statistically significant differences were also found when each of the 3 psychosomatic groups were compared to the medical control group. When applying the Duncan procedure, migraine groups were not only older, but were also more self-downing. The low back pain group was older, of a lower SES and scored significantly higher on Perfec­ tionism. The ulcer group was found to be older and of a 121 lower SES„ Duncan tests failed to find differences among the 3 psychosomatic groups with respect to the 6 CBS III factors. Differences were found with respect to age and SES in that the migraine group was significantly younger than the ulcer group and was of a higher SES than the low back pain group. The ulcer and low hack pain groups were not significantly different on any of the 8 factors.

Discussion and Implications

This study described and compared the attitude patterns of patients with three psychosomatic disorders. Since the study was descriptive,, wherein relationships between variables were examined, any inferences regarding causality drawn here are not intended. The results of this study clearly demonstrate significant relationships between physiological and psychological factors. As migraine, psychogenic low back pain and duodenal ulcer have been presented as a disturbance of the whole person, the findings of this study may, therefore, be meaningful.

Overall, psychosomatic patients were found to be more perfectionistic, self“downing and, to some degree, prone to blame others, than a medical control group, as measured by the CBS III. The fact that the three psychosomatic groups could not be differentiated statistically on the 6 CBS III factors, gives some support to the notion of a chronic disease personality and not the specificity of attitudes hypothesis. The age and socioeconomic status of the patient could not be ignored. 122

At the outset it was desired to control for the effects of age and socioeconomic status by making them independent factors. However, as anticipated, this could not be adequately done within the time constraints of this investigation because of the difficulty in securing the number of subjects needed for a four factor design (group, sex, age, socioeconomic status). In order to account for age and socioeconomic status, as a result it was decided to make them 2 of the 8 dependent variables. Interestingly it was found that the migraine group was significantly younger than the ulcer group and was of a higher socioeconomic status than the low back pain group. Although the numbers in each group were relatively small, these results could suggest the possibility that while irrational attitudes play a role in the development of a psychosomatic disorder, other cultural variables, such as age and socioeconomic status, would in some way describe how the disorder was manifested,

Groen and Bastiaans (1975) conceptualize man as "a social animal living in a human culture „ , . he has to maintain his social and cultural internal homeostasis (i.e,, his health) in a continuous communication with his fellow men and especially with key figures in the social subgroups to which he belongs," As a consequence, the individual may respond to external or internal stress with a disorder specific to what is "acceptable" to his peer/cultural group, in a similar vein as a hysterical or symbolic reaction. 123

One interesting observation was that most of the patients who were resistant to participating in the research were from the low hack pain group* Conversations with them revealed a hesitancy/defensiveness to partake in anything of a psychological nature because as some stated, "my problems are with my back!" Even after reassurance that this investigation was strictly confidential and for research purposes, a few discussed it with the spouse and/or lawyer and withdrew from the study because of pending litigation. For instance, one 1adv with a diagnosis of Psychogenic Low Back Pain told this investigator during the follow-up phone callp "I'd rather not participate . , „ in fact, I can't even tell you if my back still hurts me or not," One young man suffering from the ill effects of migraine refused to return the test packet because * "I am a perfectionist . . * I am a school teaeherp and the way those things are worded * * . I just can't answer them," He added,, "I'm probably the type of person you're trying to study, but I'm sorry, I just can't,"

Perhaps it could thus be argued that given socio­ cultural variables, ones irrational beliefs take on a quantitatively or qualitatively different meaning and the CBS III, by itself, was not a sensitive enough instrument to pick up such differences, toith this in mind, controlling for their effects by selecting a control group that was matched on such variables may have been 1 24 inappropriate. Careful matching of groups according to age and socioeconomic status, for instance, might produce a spurious sample that is not representative of a disorder hut rather of a tail of the distribution. It may very well he important to examine more closely such socio-cultural factors in terms of their predictive power. The problem of suitable control groups for psychosomatic patients continues to be a serious one, Hardyck and Moos (1966) pointed this out as well, in their findings that strikingly different conclusions about personality characteristics of psychosomatic patients were found depending upon the specific subsets of both patients and controls selected for any comparison. The present investigation not only used each psychosomatic group as a control for the others, but also a general medical control group consisting of non-psychosomatic patients who also sought help from a physician. Controversy arises with any control group regarding its appropriateness, and this investigation points out several pitfalls. Most obvious is the fact that the general medical control group differed from the three psychosomatic groups on age and socioeconomic status. While this is indeed a problem, it offers no easy solution in view of the fact that psychosomatic groups also differed from each other on age and socio­ economic status, A control group that matches one psychosomatic group (i.e., migraine) on age and 125 socioeconomic status would not be a suitable control for another group (i.e., ulcer) with disparate demographics. Selecting a mean control group would not match either sample, thus generating further criticism. Several control groups that match a particular characteristic of the disease group also has its problems in that it carries with it the implicit assumption that the various control groups differ only on the variables for which they have been selected and are otherwise homogeneous (Hardyck and Moos, 1966). Further research that carefully compares large samples with a variety of criteria, control groups, and under various conditions is needed. Given that patients with certain diseases share many of the same attitudes with each other, more so than a general patient population, the question also arises, do patients share their psychological traits because they are reactions to the physical illness, through making the psychological manifestation or attitudes reactive. a s Engel (1954) described, a clinician knowing only the diagnosis of a disease (i.e., ulcerative colitis) can give a fairly accurate personality sketch of an individual. On the other hand, however, a description of a personality constellation will not predict a diagnosis of the correct illness or even the event of any illness. Such questions cannot be answered in retrospective or descriptive research and is beyond the scope of this investigation. However, as a side note, this type of question may be completely erroneous 1 26 in light of the multivariate or holistic view of man or given the notion of "parallelism" that mental and physical processes occur concomitantly without influencing each other. Longitudinal experimental studies may help to clarify this problem.

Recommendations Recommendations derived from this study will be presented in two parts. The first set of recommendations are for future research into the psychological correlates of psychosomatic diseases. Secondly, a recommendation will be made for clinicians for possible treatment of such patients. In this dissertations a broad descriptive study has been conducted which5 while providing some answers, has generated a great deal of questions. The following are suggested areas of research. (1) Due to the relatively small number of

subjects in each psychosomatic group, there is a need for replication of the present

study to allow for a better understanding of the importance of a patient's attitudes, age and socioeconomic status. (2) There is a need for further studies utilizing the Common Beliefs Survey III as a measure of irrational thinking, to test its validity and utility in experimental research. 127

(3) Further studies should utilize a variety of criteria (age, socioeconomic status, degree of incapacitation), control groups (medical patients with and without chronic diseases and non-medical controls) and conditions

(in-patient and out-patient) in order to better understand the complexity of psychosomatic disorders. For this, an optimal study with enough subjects in each group to accomodate a multifactor design is required. However, due to the nature and prevalence of psychosomatic disorders and the problems inherent in clinical data collection, future researchers are warned to expect much difficulty (and frustration) in accomplishing this worthwhile task, (4) There is a need to conduct controlled

experiments to establish some "cause-effect" relationship in psychosomatic disturbances. This would necessitate a need for longitudinal studies. The utility of newer statistical techniques such as path analysis

(Kim and Kohout, 1975; Duncan, 1966) should be explored.

(5) Researchers should also turn their attention to the individual’s reaction to illness, seeking out variables affecting the processes of coping and adaption. 128

(6) Migraine headaches,, Psychogenic Low Back Pain and Duodenal Ulcer should he regarded

as a multiphasic clinical problem with a need to determine the relationship between environmental, personal and psychological factors.

It may be desirable for clinicians to adopt a holistic approach in treating the psychosomatic patient. This research indicates that individuals suffering from psychosomatic disorders express more irrationality in terms of their responses on the CBS III than a medical control group. They basically exhibit heightened levels of what Ellis (1974) has termed "the main attitude core" of most human disturbance, perfectionism, self-downing and blame-proneness. Ellis (1974, p. 151) contends that:

"Since blaming yourself and thus becoming anxious will normally lead to the kind of confused thinking that will also quite easily induce one to blame others; and since blaming others for being the way they are will frequently irradiate to similarly irrational, self-defeating blaming thoughts, anxiety and hostility will more often than not tend to go together. The essence of both of these negative emotions is blaming, moralizing or degrading a persons worth when he is behaving in a typically fallable, human manner." These three factors provide the basis for Bessai's second order factor, Evaluation, and suggests that psychosomatic patients in this study, evaluated and rated the self, others and life in general based on 129

their perfectionistic demands. Further clinical and experimental research may help to shed some light on the etiologic signficance of psychosocial factors* but the clinicians major interest is not necessarily whether the duodenum affected the perfectionism* or the perfectionism the duodenum. Whatever the original

cause of his disturbances* the present situation* with accompanying psychological abberations* may best be tackled by concentrating on how individuals with particular personalities cope with a disease process and whether changes in irrational* self-defeating attitudes can affect the course and prognosis of the physical disturbance.

Since* on the whole* the psychosomatic patients exhibit more perfectionism* self-dovming and* to some extent* other blame proneness than the medical control group* a broad spectrum cogn.ltive-behavior therapy approach appears to be a viable treatment modality. Numerous researchers have provided evidence for the value of this approach in modifying a clients self- verbalizations and consequently* his emotional and behavioral disturbances (Meichenbaum and Cameron* 19745 Glass and Smith* 1975; Maultsby and Graham* 1974). Furthermore* other investigations have demonstrated how ones thinking can alter certain physiological processes, including the cardiovascular (Burdick* 1972; Gottlieb* et al., 1967; Grace* Kabler and Graham* 1968), musculoskeletal (Beck* 1967; Goldstein* 1972) and 130 gastrointestinal (Wolf and Wolff, 1947) systems. The present research was undertaken to help discern the irrational attitudes of psychosomatic patients that would lend themselves to the three distinct phases of Cognitlve-Behavior Therapy: problem analysis, confrontation and termination of the illogical self­ statements, and cognitive restructuring of more appropriate, self-enhancing, rational attitudes and beliefs.

While diseases were not found to be attitude specific in this investigation, there were several irrational attitudes that psychosomatic patients as a group endorsed more frequently than the medical control group. Item content reveals the following irrational beliefs: (1) Ferfectionism - "There is a right way to do everything"; "One must be perfectly competent, adequate and achieving to consider oneself worthwhile"; "It is awful when things are not the way one would very much like them to be." (2) Self-Downing - "People really can't help thinking less of themselves when they fail"; "A person is bound to feel awful if he or she makes a stupid mistake"; "A person can't help feeling guilty about wrongdoings." (3) To a lesser degree, Prone to Blame Others - "People who do wrong deserve what they get"; "There is no such thing as bad people, there are only bad deeds (F)." 131

Maultsby (1975) has developed five rules for rational thinking based on scientific verifiable criteria,

long term hedonism, and a minimization of self-defeating emotions and behaviors. An emotional disturbance occurs when an individual's appraisal or interpretation of situational events (internal or external) reflect certain cognitive distortions or irrational beliefs. Beck (1967) classified cognitive distortions as paralogical (arbitrary inference, selective abstraction, and overgeneralization), stylistic (exaggeration) or semantic (inexact labeling). Cognitive Behavior Therapy, in general, and Rational Emotive Therapy, specifically, teaches the client how to discriminate more clearly between sense and nonsense, fiction and reality,

superstition and science (Ellis, 1973),, Arn-old (1960) points out that psychotherapies are successful to the extent that they somehow manage to convince the patient that he is mistakenly and illogically perceiving reality and that to overcome the disturbance and to affect lasting change, he'd better perceive things differently. One of the primary cognitive errors has to do with the language used to describe illness. Some feel that the use of nouns and spatial metaphors rather than verbs to express the ideas of illness has lead to a rigid, static view of disease (Warner, 19671 Whorf, 1973). Consequently, the individual is either hopelessly inseparable from his illness as in the case of: "He is a low back pain loser" or, by contrast, he has or 132 possesses a distinct entity as in the cases of: "He has an ulcer" or "My headache is back." There is no implication that he or his processes have any role in the development of a nonstatic disease. Doctors and patients,, alike, need to challenge and overcome such misconceptions if a multidisciplinary approach to treatment of the disease process is to he successful.

Tosi (1974)9 cites several techniques which may he used within a cognitive framework to analyze, confront and ameliorate emotional disturbances. These

include: rational-emotive modeling based on the work of Bandura and Whalen (1966); utilizing the Premack Principle of reinforcement (Tosi, Briggs and Morley,

1971)? rational emotive-assertive training; thought control (Lazarus, 1972); rational-emotive imagery

(Maultsby, 1972); systematic desensitization and relaxation training (wolpe, 1966); systematic written homework (Maultsby, 1971); the use of tape-listening (Maultsby, 1970). Tosi (1974) and his associates (Tosi and

Moleski, 1975; Tosi and Marzella, 1975) extended and modified Ellis’ Rational Emotive Therapy (1962), according to the following ABODE model: (A) the situational or environmental conditions and events that are associated with, (B) the persons interpretations

(beliefs, ideas, appraisals), (C) his or her emotional reaction, (D) psychophysiological concomitants and

(E) behavioral responses to any of the preceeding events. 133

An experiential, cognitive-behavioral

intervention, Rational Stage Directed Therapy (RSDT), (Tosi, 1974; Tosi and Marzella, 1975) was designed to direct the client through various developmental or growth stages based on this paradigm,. These stages are: self-awareness, exploration, commitment and implementation of rational thinking and acting, internalization, and finally, change and redirection, Basic to RSDT is its potential for developing, rein­ forcing, and maintaining logical-critical thinking relative to affective, physiological, behavioral and situational processes. In each stage, the client is acquiring, developing and refining effective coping skills and becoming more competent in rational self­ management, RSDT makes use of behavioral rehearsal and cognitively induced relaxation or hypnosis (Rational Stage Directed Hypnotherapy) to make clearer the visualization, imagining and experiencing and to help the subject accept the suggestions. Both experimental research and case studies have found RSDT and RSDH to have considerable potential for modifying cognitive, emotive, physiological and behavioral conditions. Boutin and Tosi (1977) found RSDH to be an effective treatment for test anxiety in nurses. Reardon and Tosi (1977) demonstrated the efficacy of this approach in modifying self-concept and emotional stress in delinquent girls. Case studies dealing with the 134 treatment of guilt (Tosi and Reardon, 1976), depression (Reardon, Tosi, and Gwynne, 1977; Tosi, Eshbaugh, 1978), test anxiety (Boutin and Gwynne, 1975), pathological non-assertion (Gwynne, Tosi and Howard, 1978), duodenal ulcer, hypertension, spastic colon (Rudy, Tosi, and

Reardon, 1977), provides further evidence of the efficacy of RSDT and RSDH.

In summary, a broad spectrum approach employing a variety of cognitive-behavioral techniques might be useful in treating patients with migraine, psychogenic low back pain and duodenal ulcer. Rational Stage Directed Therapy, with its utilization of a variety of cognitive, affective, physiological and behavioral techniques would offer a wide range of intervention strategies to reduce emotional stress and pathology associated with psychosomatic disorders as a group.

Such a broad spectrum approach is not considered to be a panacea for the treatment of patients with psychosomatic disorders, but a portion of the multi­ disciplinary treatment of the patient as a whole. Further research is needed to clarify the effects that age and socioeconomic status have on ones irrational beliefs system and on psychosomatic group membership. APPENDIX A

Summary of Conversation Held with the Patient

My name is Michael Forman and I am conducting research in conduction with the Family Practice Center. This is a center-wide project that is aimed at learning more about its patients. We'd like to find out a little more information about you in order to help us meet your needs more efficiently in the future. That is, if you are willing to participate (wait for response). Included in this packet is a questionnaire that I ’d like you to answer as openly and honestly as possible. Read each item carefully. It is important that you answer all items and to avoid using the "uncertain" column whenever possible. However, if for any reason an item is upsetting you may leave it blank. Your name will be removed once all the needed data is in. Neither your name, nor any identifying information will be revealed in any publication document or computer storage.

The results of the investigation will be made available after all the data from all the patients are compiled. Just contact the center in a couple of months. When you are finished, you can return the questionnaires, in this folder, to the receptionist.

If you have any further questions, tell her that you

135 would like to talk with me again. Do you have any questions APPENDIX 3

RIVERSIDE METHODIST H O S P i m

RIVERSIDE METHODIST HOSPITAL RESEARCH FOUNDATION

Dear Patient:

You are being asked to voluntarily participate in a center-wide

social-psychological research study to investigate commonly held beliefs

of the patients that come to this center. There are two instruments that

we would like you to respond to: a) A Common Beliefs Survey and b) a

Personal Data Questionnaire. Together they will require approximately 25

minutes of your time to self-administer. Please answer all items honestly

and to the best of your knowledge as your identity will not be revealed

in any publication, document, or computer storage, or in any other way

which relates to this research. All data will be handled confidentially.

Further information regarding this study will be made available

upon your request.

Finally, you are free to withdraw your consent and discontinue

participation at any time, following the notification of the investigator.

Thank you for your participation.

Michael A. Forman Project Director

David R. Rudy M.D. Director, Family Practice Center

My signiture represents that I understand the above and agree to voluntarily participate in this project. witness: ______signed X______(patient) witness: date: APPENDIX C

PLEASE ANSWER ALL QUESTIONS AFTER YOU DAVE COMPLETED THE CO-WON BELIEFS

SURVEY III. ALL ANSWERS TO THIS QUESTION:!AIRE WILL REMAIN STRICTLY

CONFIDr-TLAL.

1) Male Female

2) Age

3) Married Single Divorced Seperatod Widow

4) Educational Level:

more than 16 years (graduate level college)

13 - 16' years (college)

High School Graduate

9-12 years (some High School)

0 - 8 years

5) Occupation:

(professional, managerial)

(trade)

(laborer)

(not presently employed — housewife, student)

(chronic welfare)

6) Spouses Educational Level:

______more than 16 years (graduate level college)

______13 - 16 years (college)

______High School'Graduate

______9-12 years (some High School)

______0 - 8 years

7) Spouses Occupation:

(professional, managerial)

(trade) not presently employ (housewife, student) (laborer) 138 chronic welfare 139

8) Presenting Problem - (Check the main reason for coming to the doctors office)

headaches stomach pain

back pain other (explain)

9) Your age when you first noticed this problem ______

10) Previous treatment for the above problem (please be specific)

11) How often do you get pain? ______

12) How severe is the pain usually? ______

13) How long does it usually last? ______

14) Degree of Incapacitation (with the above problem)

MARK AN (X) ALONG THIS LINE:

WHEN THE PAIN OCCURS...

I------1------1------1------T

I am able to minimally moderatlev markedly I am totallv carry out all incapacitated incapacitated incapacitated unable to my daily activi­ carry out m ties anyway. daily activ: ties. APPENDIX D

Common Beliefs Survey III

This survey is comprised of a number of statements with which you will tend to agree or disagree. Please indicate on the answer sheet your reaction to each statement by darkening the appropriate space:

SA - Strongly Agree

A - Agree

u - Undecided

D - Disagree

SD - Strong Disagree.

the Undec i ded res ponse

There are no right or wrong answers; this survey is only concerned with your opinions.

Please be sure to answer every item. Use a number 2 pencil and mark your answers only on the answer sheet.

140 141

1. A person's present behavior must be greatly influenced by his/her past.

2. There is a right way to do everything.

3. One can't help getting down on oneself when onefails at something.

4. Being approved by others is very important.

5. Criminals are basically bad people and should be punished.

6. Unhappiness comes from in3ide oneself.

7. If people don't meet their own standards, they are bound to think, less of themselves.

8. No one is evil, even though his deeds may be.

9. Something that once strongly influenced one's life need not determine one's feelings and behavior today because one's past is not all- important.

10. People and things should turn out better than they do, and it is awful if one does not quickly find, good solutions to life's hassles.

11. How a person interprets an event determines his/her emotions.

12. People do not need to be loved in order to accept themselves.

13. It is very important to always handle things in the right way.

14. People are justified in refusing to forgive their enemies.

15. One can overcome the influence of past events.

16. Although approval is enjoyable, it's not a real necessity.

17. Failures just naturally produce guilt feelings.

18. People who are miserable have usually made themselves that way.

19. One can like oneself even when many others don't.

20. Human unhappiness is not externally caused, and people have the ability to control their sorrows and disturbances.

21. Past experiences need not affect present behavior. 142

22. Criticism is bound to make anyone very nervous and anxious.

23. One must be perfectly competent, adequate, and achieving to consider oneself worthwhile.

24. Certain people are bad or wicked and should be severely blamed and punished for their sins.

25. Being ignored by friends doesn't have to be upsetting.

26. If someone does one wrong, then one should think less of that person.

27. If a person wants to, he/she can be happy under most circumstances.

28. A person can’t help feeling guilty about wrongdoings.

29. For most questions there is one right answer.

30. The influence of the past is so strong that it is impossible to really change.

31. People make their own hell within themselves.

32. It is awful when things are not the way one would very much like them to be.

33. Having the respect of others is important but certainly not necessary.

34. People are bound to put themselves down when they fail.

35. There is no such thing as bad people; there are only bad deeds.

36. The past is past and doesn't have to affect one now.

37. The main goal and purpose of life is achievement and success.

38. There is no stronger influence on the present than the past.

39. People who do wrong deserve what they get.

40. One's own deficiencies and short comings are just naturally depressing.

41. People car. control their emotions.

42. It is better to obtain one's own self-respect, rather than securing other people's approval.

43. Something that once strongly influenced one's life determines one's feelings and behavior today because one's past remains all-important. 143

44. People can live comfortably whether other people like them or not.

45. Any job should be done thoroughly and perfectly if it is done at all.

46. 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.

47. People pretty much cause their own moods.

48. It is not a great necessity to be loved or approved by every significant other person.

49. People really can't help thinking less of themselves when they fail.

50. There is invariably a right, precise, and perfect solution to human problems, and it is terrible when this perfect solution isn't found.

51. Emotions are not determined by outside events.

52. A person is bound to feel awful if he/she makes a stupid mistake.

53. A person's deeds may be bad, but that does not mean that the person is bad.

54. Past mistakes must greatly influence the present.

Strongly Agree Agree Undecided Disagree Strongly Disagree

1 2 3-4 5 APPENDIX E

COMMON BELIEFS SURVEY III Parcel^ Fact or 9 Membership of Items

■» Parcel Factor Item Number Item

1 I 21. Past experiences need not affect present behavior. 1 I 15. One can overcome the influence of past events. 1 I 54. Past mistakes must greatly influence the present. 2 I 36. The past is past and doesn't have to affect one now. 2 I 1. A person's present behavior must be greatly influenced by his/her past. 2 I 38. There is no stronger influence on the present than the past. 3 I 9. Something that once strongly influenced one's life need not determine one's feelings and behavior today because one's past is not all-important. 3 I 43. Something that once strongly influenced one's life determines one's feelings and behavior today because one's past remains all- important. 3 I 30. The influence of the past is so strong that is is impossible to really change.

4 II 35. There is no such thing as bad people; there are only bad deeds.

144 145

"¥r Parcel Factor Item Number Item

4 II 46. 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.

4 II 39. People who do wrong deserve what they get.

5 II 8 . No one is evil, even though his deeds may be. 5 II 5. Criminals are basically bad people and should be punished. 5 II 26. If someone does one wrong, then one should think less of that person.

6 II 53. A person's deeds may be bad, but that does not mean that the person is bad.

6 II 24. Certain people are bad or wicked and should be severely blamed and punished for their eins.

6 II 14. People are justified in refusing to forgive their enemies. 7 III 3. One can't help getting down on oneself when one fails at something. 7 III 17. Failures just naturally produce guilt feelings.

7 III 7. If people don't meet their own standards, they are bound to think less of themselves.

8 III 52. A person is bound to feel awful if he/she makes a stupid mistake.

8 III 40. One's own deficiencies and short comings are just naturally depressing. 146

*i$* Parcel Factor Item Number Item

8 III 34. People are bound to put themselves down when they fail. 9 III 22. Criticism is bound to make anyone very nervous and anxious. 9 III 49. People really can't help thinking less of themselves when they fail. 9 III 28. A person can't help feeling guilty about wrongdoings. 10 IV 44. People can live comfortably whether other people like them or not. 10 IV 16. Although approval is enjoyable, it's not a real necessity. 10 IV 12. People do not need to be loved in order to accept themselves. 11 IV 19. One can like oneself even when many others don't. 11 IV 42. It is better to obtain one's own self-respect, rather than securing other people's approval. 11 IV 25. Being ignored by friends doesn't have to be ups<- .ting. 12 IV 48. It is not a great necessity to be loved or approved by every significant other person. 12 IV 33. Having the respect of others is important but certainly not necessary. 12 IV 4. Being approved by others is very important. 147

* Factor Item Number Item

13 V 50. There is invariably a right, precise, and perfect solution to human problems, and it is terrible when this perfect solution isn't f ound.

13 V 10. People and things should turn out better than they do, and it is awful if one does not quickly find good solutions to life's hassles. 13 V 32. It is awful when things are not the way one would very much like them to be. 14 V 2. There is a right way to do everything. 14 V 37. The main goal and purpose of life is achievement and success. 14 V 29. For most questions there is one right answer.

15 V 23. One must be perfectly competent, adequate, and achieving to consider oneself worthwhile. 15 V 45. Any job should be done thoroughly and perfectly if it is done at all. 15 V 13. It is very important to always handle things in the right way. 16 VI 31. People make their own hell within themselves. 16 VI 20. Human unhappiness is not externally caused, and people have the ability to control their sorrows and disturbances.

16 VI 11. How a person interprets an event determines his/her emotions. 148

* Parcel Factor Item Number Item

17 VI 18. People who are miserable have usually made themselves that way. 17 VI 27. If a person wants to, he/she can be happy under most circumstances. 17 VI 41. People can control their emotions. 18 VI 47. People pretty much cause their own moods.

18 VI 6. Unhappiness comes from inside oneself.

18 VI 51, Emotions are not determined by outside events.

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