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Article Excerpt
There has been a significant shift in dyspareunia research over the past decade, from mostly uncontrolled investigations and clinical case speculations about psychosocial etiologies to more methodologically sound examinations of the properties of the pain experienced. This recent series of studies has provided evidence that the pain of dyspareunia is comparable to other types of pain in terms of severity (Meana, Binik, Khalife, & Cohen, 1997b), as well as sensory characteristics and neurological processes (Pukall, Binik, Khalife, Amsel, & Abbott, 2002; Pukall et al., 2005). No longer dismissed as a somatic manifestation of deep-seated psychic conflict, dyspareunia is now being discussed as a pain syndrome in its own right, with perhaps only an incidental connection to sex (Binik, Meana, Berkley, & Khalife, 1999; Meana et al., 1997). This momentum has culminated in an appeal to remove dyspareunia from the sexual dysfunction section of the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev [DSM-IV-TR]; American Psychiatric Association, 2000) and have it subsumed under the pain disorder section (Binik, 2005).
With the growing acknowledgment that dyspareunia is a "legitimate" pain, research efforts have increasingly focused on potential physiological etiologies or correlates. This is especially true in the case of what is considered to be the most common type of dyspareunia, vestibulodynia (formerly known as vulvar vestibulitis; Moyal-Barraco & Lynch, 2004). Variables of interest have included recurrent yeast infections, early contraceptive use, pelvic floor hypertonicity, inflammation, and immune system disturbances, as well as genetic variables that may predispose a woman toward developing genital pain (Bouchard, Brisson, Fortier, Morin, & Blanchette, 2002; McKay & Farrington, 1995; Reissing, Brown, Lord, Binik, & Khalife, 2005; Schover, Youngs, & Cannata, 1992; van Lankveld, Weijenborg, & ter Kuile, 1996; Witkin, Gerber, & Ledger, 2002). Fruitful though these research avenues may be, there is some concern that the pendulum in dyspareunia research may have swung too far from the psychosocial and sexual end of the spectrum (Meana, 2005). Investigations into the psychosocial correlates of dyspareunia do not, in and of themselves, signify a dismissal of dyspareunia as a serious pain condition. Many recognized pain syndromes have psychological and social disturbances associated with them. Concurrent treatment of these has long been integrated into pain management programs and been shown efficacious (Gatchel, Peng, Peters, Fuchs, & Turk, 2007).
Recent findings for psychological correlates of dyspareunia have centered on mood disturbances (depression and anxiety), somatization, and attributional styles or personality. Depressive symptoms including anhedonia, fatigue, concentration problems, tearfulness, and negative affect have been found in women who experience pain with intercourse (Brotto, Basson, & Gehring, 2003; Meana, Binik, Khalife, & Cohen, 1997a; Sackett, Gates, Heckman-Stone, Mee-Ran Kobus, & Galask, 2001; Schover et al., 1992). Depressive symptomatology has been associated with more severe pain reports (Meana, Binik, Khalife, & Cohen, 1998). State, trait, and phobic anxiety have also been elevated in comparison to controls in some samples (Granot & Lavee, 2005; Meana et al., 1997a; Nunns & Mandal, 1997). A greater degree of somatization (Granot & Lavee, 2005) and higher scores on the somatization scale of the Minnesota Multiphasic Personality Inventory (van Lankveld et al., 1996) constitute other findings of interest. As many as 42% of women in one sample met criteria for a somatization disorder (Schover et al., 1992). In addition, women with vestibulodynia have scored higher on measures of harm avoidance and reported more somatic symptoms than controls (Danielsson, Eisemann, Sjoberg, & Wikman, 2001; Granot, 2005). Meana et al. (1997a) did not, however, find that women with dyspareunia reported any more non-genital pains than controls.
Recent research has also supported the possibility that certain cognitive styles may be associated with coital pain. Hypervigilance, an attentional bias for pain information (Payne, Binik, Amsel, & Khalife, 2005), as well as a tendency toward pain catastrophization (Granot & Lavee, 2005; Pukall et al., 2002) have all been found in women with dyspareunia. In addition, the causal attributions of one sample of women with dyspareunia were related to pain experience and adjustment. Meana, Binik, Khalife, and Cohen (1999) found that women who attributed their pain to psychological causes rather than to physical causes (prior to obtaining a professional opinion) reported higher pain scores, higher levels of psychological distress, lower levels of marital adjustment, and more sexual dysfunction. Expectations about pain have not yet been directly investigated in the case of dyspareunia, but they have proven to be important in the experience of both chronic and acute pain (e.g., Boersma & Linton, 2006; Boston & Sharpe, 2005).
Only prospective, longitudinal studies can identify predictors of dyspareunia, if indeed any exist. However, cross-sectional investigations remain important in their ability to suggest potential contributors to the etiology of dyspareunia, consequences of its onset, or perpetuating factors that may complicate its resolution. Studies with samples of young women who have only had the pain for a relatively short period of time may be particularly germane to etiological questions. Their lives are less likely to have been complicated by the cumulative damage that dyspareunia can inflict over the years on psychological well-being, sexual function, and relationships. Collegeage women are also the age group with the highest prevalence of pain with intercourse (Laumann, Gagnon, Michael, & Michaels, 1994).
To this end, we embarked on this cross-sectional study with a large sample of college-aged women. We focused our investigation primarily on variables that have been investigated in the context of other pain experiences and disorders and that are amenable to cognitive interventions (expectations, anxiety sensitivity, health-related anxiety, and somatic amplification). These are all constructs characterized by cognitions and appraisals that have been found to impact sensory and affective dimensions of pain. Expectations have been found to influence the experience of both experimentally induced and clinical pain (Gatchel et al., 2007; Price, 1999). A recent brain imaging study confirmed that expectations can shape neural processes involved in the sensory experience of pain and that positive expectations can produce a reduction in perceived pain, similar to that of an analgesic intervention (Koyama, McHaffie, Laurenti, & Coghill, 2005). Anxiety sensitivity (fear of anxiety-related symptoms) has been conceptualized as a risk factor for chronic pain; it has been associated with the experience of both acute, experimentally...
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