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Emotion Regulation Strategies and Trait Meta-Mood in Women with Premenstrual Syndrome

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Emotion Regulation Strategies and Trait Meta-Mood in Women with Premenstrual Syndrome

 

Abstract

The aim of the current study was to test whether women with premenstrual syndrome (PMS) had difficulties in emotion regulation and trait meta-mood. A total of 253 female Iranian college students were assessed by the Premenstrual Symptoms Screening Tool (PSST), Emotion Regulation Questionnaire (ERQ) and Trait Meta-Mood Scale (TMMS). In current Study, we investigated the relationship between the emotion-regulation strategies and the severity of PMS and between trait meta-mood with severity of PMS. The results showed that the severity of PMS was negatively associated with reappraisal, but positively associated with the suppression. Also emotional clarity and repair were negatively associated with severity of PMS. The results showed that women with PMS had trouble with regulating their emotions and didn’t use trait meta-mood strategies adaptively. Emotional interventions and strategies may improve these problems in women with PMS and help to reduce distress caused by this disorder.

Keywords:

Emotion regulation; trait meta- mood; Premenstrual Syndrome; reappraisal; suppression; emotional clarity; emotional repair; emotional attention

Abbreviations

DSM     Diagnostic and Statistical Manual

EI          Emotional Intelligence

ERQ     Emotion Regulation Questionnaire

PMDD   Premenstrual Dysphoric Disorder

PMS     Premenstrual Syndrome

PSST   Premenstrual Symptoms Screening Tool

TMMS  Trait Meta-Mood Scale

Introduction

Premenstrual syndrome (PMS) is a disorder with a group of psychological and physical symptoms which regularly occurs during the luteal phase of the menstrual cycle and remits by the end of menstruation (Sekigawa et al., 2004). The studies has indicated that about 30-40% of reproductive women suffer from PMS, and 3-8% of menstruating women experience more severe symptoms (Ryu & Kim, 2015). Also, approximately 75% of women experience some degree of PMS during their life (Johnson, 1987; Steiner  PhD, FRCPC, Meir, 1997). In this disorder, women experience substantial distress (Jang, Kim, & Choi, 2014) with symptoms such as fatigue, appetite-changes, low energy, irritability, depressed mood, anxiety, and impulsive behavior (Dickerson, Mazyck, & Hunter, 2003; Steiner  PhD, FRCPC, Meir, 1997). Despite symptoms resolve within a few days after the onset of menstruation, they can significantly affects their quality of normal life (Jang et al., 2014).  It is proposed that women with PMS interpret their physiological changes negatively, and regard them as a threatening factor, so they feel anxiety and depressed mood (Ossewaarde et al., 2010) and altogether it can be due to inability of emotions regulation in an adaptive manner (for example see Petersen et al., 2016; Reuveni et al., 2016).

Emotion regulation is the ability to identify and recognize which emotions a person feels, and how those emotions are experienced and expressed (for review see Gross 1998). Emotion dysregulation is related to many other psychiatric disorders, such as affective disorders. For example patients with generalized anxiety disorder (Roemer et al., 2009), attention deficit/hyperactivity disorder (Seymour et al., 2012), major depression (Beblo et al., 2012; Brockmeyer et al., 2012), borderline personality disorder (Carpenter & Trull, 2013; Svaldi, Griepenstroh, Tuschen-Caffier, & Ehring, 2012), anorexia nervosa (Brockmeyer et al., 2012; Svaldi et al., 2012), bulimia nervosa, and binge eating disorder (Svaldi et al., 2012) have deficits in emotion regulation. Reappraisal and suppression are two common strategies that people use for decreasing their negative emotional reactional (Ussher & Perz, 2013). Reappraisal is a type of cognitive change, and it is defined as interpreting a potentially emotion-evoking situation in non-emotional terms. Suppression is a type of response modulation, and it is defined as inhibiting ongoing emotion-expressive behavior. Studies have shown that people who use reappraisal have greater positive affect, better interpersonal functioning, and higher sense of well-being and this strategy leads to the decreased expression of negative emotions and behaviours (Sai, Luo, Ward, & Sang, 2016). By contrast, people who use suppression have less effective property of emotional functioning (Shiota & Levenson, 2009). Based on such findings, emotion dysregulation has a considerable role in developing mood disorders (Gross, 1998). However, regarding the impact of potential deficits in emotion regulation on PMS (Dillon & LaBar, 2005) as a disorder that is a manifestation of underlying depressive disorder, a few studies have been done.

Beliefs that people have about their own moods and emotional abilities are known as trait meta-mood. Emotional attention, emotional clarity and emotional repair are three dimensions of trait meta-mood. Emotional attention refers to the person’s awareness of their mood and emotional experience; emotional clarity refers to person’s ability to discriminate feelings clearly; and emotional repair is the ability of regulating moods (Salovey, Stroud, Woolery, & Epel, 2002).

Studies have shown that Trait meta-mood dimensions have correlation with a number of psychological factors and they predict coping behaviors (for a review see Berrocal & Extremera, 2008). In addition, some studies have shown that high levels of emotional attention and low levels of emotional clarity and repair have association with greater symptoms of depression (Salguero, Palomera, & Fernández-Berrocal, 2012).

People with low clarity may be at risk for psychopathology and they experience decreased well-being (Boden, Thompson, Dizén, Berenbaum, & Baker, 2013). They are often unable to efficiently regulate their emotions and usually they can’t select and implement proper strategies to achieve emotion regulation goals. Instead, people with high clarity use effective strategies to regulate their emotions (Gross & Jazaieri, 2014). Effective strategies that cause regulating emotions may, over time, contribute to increased well-being and decreased psychopathology (Boden & Thompson, 2015). Another dimension of trait meta-mood is emotional repair that is significant predictors of life satisfaction independently of well-known mood state constructs and personality traits (Extremera, Durán, & Rey, 2007; Extremera & Fernández-Berrocal, 2005; Wong et al., 2007). Researchers have found that individuals with low emotional Repair were more likely to visit a health centre when the stress level was high (Goldman, Kraemer, & Salovey, 1996). As dimensions of trait meta-mood are protective factors for stressors and annoying problems, it seems that reinforcing these strategies in people with psychological dysfunctions, such as women with PMS, can help improving their symptoms.

In addition to pathophysiology reasons, it looks psychological reasons are important in developing PMS. Romans and his colleges conducted a meta-analysis about the influence of the menstrual cycle on the mental health of women. They showed that in 61.7% of the studies there were significant correlations between menstrual cycle and emotion regulation (Romans, Clarkson, Einstein, Petrovic, & Stewart, 2012). However, few studies conducted have investigated the correlations between PMS and emotion regulation and as far as we know, no study has directly tested trait meta-mood among women with PMS. So it is necessary to do some research in the field of psychological factors such as emotional factors. By identifying such factors, we can design suitable interventions for them to cope with their annoying symptoms. So in this study, we decided to examine emotion regulation strategies and trait meta-mood in women with PMS, as regards considerable number of women who experience PMS in their life.

Methods

Participants

Subjects were healthy, medication-free, with regular menstrual cycles. They reported no history of psychiatric illnesses, and gynaecological pathology; also, they were more than oneyear post-partum or never pregnant, and do not currently breast feeding.

Table 1 about here

Measures

Emotion regulation questionnaire

The Emotion Regulation Questionnaire is a 10-item self-report measure of two emotion regulation strategies: emotional suppression (four items, e.g., ‘I keep my emotions to myself.’) and cognitive reappraisal (six items, e.g., ‘I control my emotions by changing the way I think about the situation I’m in.’). Items were rated on a 7-point Likert rating scale (1 = strongly disagree, 7 = strongly agree), higher scores reflecting higher use of the emotion regulation strategy. Gross and John (Gross & John, 2003) reported internal consistency of α =.73 for the original English ERQ-derived emotional suppression subscale and α =.79 for the cognitive reappraisal subscale. In this study, we used Persian version of Emotion Regulation Questionnaire (ERQ-P) which was examined by Hasani (2017). ERQ-P has good psychometric properties. The reliability of the two ERQ-P subscales is satisfactory as indicated by the level of internal consistency (.81 to .91) and the high test-retest correlations (.51 to .77) across a 5-week interval (Hasani, 2017).

Trait Meta-mood Scale

The TMMS is designed to assess how people reflect upon their moods, and it assesses the extent to which people believe that their emotions are an important source of information and they can attend to their feelings (emotional attention), believe that they can feel clear rather than confused about their feelings (emotional clarity) and believe that they can use positive thinking to repair negative moods (emotional repair) (Salovey, Mayer, Goldman, Turvey, & Palfai, 1995). Salovey et al. (1995) reported adequate internal consistency as well as convergent and discriminative validity for this scale. We used the well validated Persian version of the TMMS. Reliability of the Persian version of the Trait Meta-Mood Scale is .0.77 and it’s Cronbach’s coefficient alpha is 0.79 (Bayani, 2009).

Premenstrual Symptoms Screening Tool

The PSST is a validated self-report questionnaire that was developed as a screening tool in order to identify women with PMDD (Steiner, Macdougall, & Brown, 2003). Convergent validity was obtained with prospectively assessed premenstrual symptomatology (Bentz, Steiner, & Meinlschmidt, 2012). The instrument fits DSM diagnostic criteria, and its potential utility as a retrospective screening tool was recognized by the International Society of Premenstrual Disorders (Hall and Steiner 2015). The PSST includes 14 premenstrual symptoms and 5 items that measure impairment in five domains: (1) working capacity, (2) relationships with coworkers, (3) relationship with family, (4) social activities, and (5) home responsibilities, in accordance with DSM criteria for PMDD. All items are rated on a four point scale. Psychometric properties of the Iranian version of PSST were assessed by performing reliability (internal consistency) and validity analysis [Content Validity Ratio (CVR) and Content Validity Index (CVI)]. Reliability of the PSST as measured by internal consistency was found to be satisfactory (Cronbach’s alpha coefficient, 0.93). The content validity as assessed by CVR and CVI were desirable (0.7 and 0.8, respectively) (Hariri, Moghaddam-Banaem, Bazi, Malehi, & Montazeri, 2013).

Procedure
All participants were introduced to the study and asked if they were willing to take part in the research “Emotion regulation strategies and trait meta-mood in women with premenstrual syndrome”. The consent forms were given to them and after singing the form, questionnaires were filled by participants. They were assured that the data from questionnaires will not be reported individually, but will be published collectively and there is no need to write the name. The questionnaires were in paper and-pencil format with written instruction All participants completed the PSST, TMMS and the ERQ individually. Participants completed the Emotion Regulation Questionnaire which assesses the typical use of emotion suppression (four items, e.g., “I keep my emotions to myself”) versus reappraisal (six items, e.g., “When I want to feel less negative emotion, I change the way I’m thinking about the situation”); trait meta-mood scale which assesses three facets of emotional intelligence (EI) that are directly associated with emotion-regulation: emotional Attention (e.g., “), emotional clarity (e.g., “) and emotional repair (e.g., “); and PSST that identify women with PMS. Finallyafter collecting the data, scoring was done and process of statistical analysis was started.

Statistical Analyses

To examine emotion regulation and trait meta-mood in women with PMS, multiple regression was calculated. We used enter mode for analyzing our data. The predictors of our study were reappraisal; suppression; emotional clarity; emotional repair and emotional attention and the explanatory variable was PMS. Reported p values are two sided. All analyses were performed using IBM SPSS 25.0 (IBM Corp 2012) statistical software.

Results

 Sample Demographics

Total of 253 female students from the Shiraz University of Medicine Science were included in the study. All students fluent in the Persian language were included in the study aged from 18 to 32. The mean age of the participants was 23.03 (SD = 3.27). 84.2% were single, born in Iran, and were in bachelor’s degree (59.3 %).

Assumptions of multiple regression

Multiple regression was calculated to predict PMS based on emotion regulation strategies and trait meta-mood subscales. There are several assumptions that we need to check our data meet, in order for our analysis to be reliable and valid. The first assumption we can test is that the relationship between the independent variables and the dependent variable is linear. Scatterplots showed that this assumption had been met.

Another assumption we can test is that the predictors are not highly correlated. Correlation coefficients  higher than 0.8 may be problematic. This is not an issue in our research, as the highest correlation is r=0.506 (see table 2). Also we can test this assumption by looking at the coefficientstable. For the assumption to be met we want VIF scores to be well below 10, and tolerance scores to be above 0.2; which is the case in this study (see table 3).

Table 2 about here

We used the Durbin-Watson statistic to test the assumption that our residuals are independent (or uncorrelated). In our study, the value is 1.995, so we can say this assumption has been met. To test the fourth assumption (The variance of the residuals is constant), our plot of standardised residuals vs standardised predicted values showed no obvious signs of funnelling, so that the assumption of homoscedasticity has been met (see graph 1). As we only have a small number of data points in this example, the graph can be difficult to read – but as it generally appears more random than funnelled, this assumption can be acceptable.

Figure 1 about here

The final assumption is that there are no influential cases biasing our model. Cook’s Distance values were all under 1, suggesting individual cases were not unduly influencing the model.

Model summery

The results of the regression indicated the predictors explained 40.1% of variance (adjusted R2 =.401, F (5,247) =34.880, p<.000).

As expected, there was positive relationship between PMS severity and more emotion suppression strategy and negative relationship between PMS severity and emotion reappraisal strategy (table 2). In other word, participants who had more severity of PMS have used suppression strategy to calm themselves down in confronting with disturbing stimulus.

Results showed that emotional clarity and emotional repair have negative relationship with high scores of PMS. On the other hand, there were no relationship between emotional attention and emotional repair with PMS (table 2).

Table 3 about here

Discussion

The results from the current study indicated thatthere was a significant relationship between PMS and emotion regulation strategies. Women with high scores of PMS have been used suppression form of emotion regulation and women with low severity of PMS have been used reappraisal strategy. Our results are consistent with previous studies (e.g. Wu, Liang, Wang, Zhao, & Zhou, 2016). As we mentioned earlier, reappraisal and suppression are two important forms of emotion regulation. Their different consequences have been studied by experimental (Nazari, Birashk, & Ghasemzadeh, 2012) and individual-difference studies (Yonkers, O’Brien, & Eriksson, 2008). These studies suggested that reappraisal is often more effective than suppression and emotion experience, and physiological responding decreases by reappraisal. These studies also indicated, suppression can’t decrease emotion experience, and may even increase physiological arousal for suppressors (for a review, see Gross, 2002). Gross and John investigated the association of habitual use of emotion-regulation strategies with affect, well-being, and social functioning (Shiota & Levenson, 2009). Their research showed that greater positive emotion, better well-being, and better interpersonal functioning were associated with using reappraisal, whereas using suppression was associated with greater negative emotion, worse welling-being, and worse interpersonal functioning. These findings support the idea that reappraisal is an effective emotion-regulation strategy and is beneficial to well-being, whereas suppression is a maladaptive strategy, and impairs well-being.

It seems development of PMS relates to an interaction between cyclic hormonal fluctuations and psychological factors. Probably women with PMS use maladaptive strategies for calming themselves and coming up with their symptoms (Gohm, Baumann, & Sniezek, 2001); so, when they experience emotional and physiological changes in premenstrual period, cannot properly recognize and regulate their negative emotions and this feature leads to premenstrual symptoms more severely and results in distressed and dysfunction.

Another result of our study was negative relationship between emotional clarity with high scores of PMS. Emotional clarity refers to meta-knowledge about emotions. Emotional clarity is one of the core dimensions of emotional and mood awareness, and also emotional intelligence (Boden & Thompson, 2017). Our result is consistent with previous studies. Some studies have found that higher scores on Clarity have been associated negatively with experiencing symptoms, depression (Fernández-Berrocal, Salovey, Vera, Extremera, & Ramos, 2005), social anxiety (Salovey et al., 2002) and personality disorders (Leible & Snell, 2004). In addition, Extremera and Fernández-Berrocal showed that women with high scores on Clarity have higher physical and social functioning, mental health, and vitality (Extremera & Fernández-Berrocal, 2002). It seems that women who have psychological symptoms in premenstrual cycle have not good awareness about their emotions and it causes less clearness of emotions so they can’t identify their emotions properly. They are also less aware and less clear about their psychological needs (Boden et al., 2013) and they can’t use adaptive strategies to calm themselves down and regulate their mood and emotions, because effective emotion regulation is largely dependent upon knowledge of experienced emotions that are targeted for regulation (Barrett & Gross, 2001). These reasons are consistent with studies that have been shown lower scores of emotional clarity have been associated with poorer emotion regulation (Gratz & Roemer, 2008; Tull, Barrett, McMillan, & Roemer, 2007) and lower levels psychological well-being (Montes-Berges & Augusto-Landa, 2014; Saxena, Dubey, & Pandey, 2011).

The last finding of our study was negative relationship between emotional repair with high scores of PMS. This is consistent with previous studies that show higher scores on emotional repair have been associated with psychological problems (Fernández-Berrocal, Salovey, Vera, Extremera, & Ramos, 2005; Leible & Snell, 2004; Salovey et al., 2002). High levels of emotional repair is correlated to greater life satisfaction (Hodzic, Ripoll, Costa, & Zenasni, 2016), role emotional, social functioning, mental health, vitality, general health, and lower bodily pain (Extremera & Fernández-Berrocal, 2002). Individuals who cannot identify well what they are feeling tend to quickly repair negative states and avoid the negative feelings. Some studies mention emotional repair as an substantial factor in managing stress and link it to less physical and psychological symptoms (Salovey et al., 2002). Emotional repair, results in successful stress management by helping people to choose better and more adaptive coping strategies, such as problem-solving strategies or positive evaluation of stressful events (Houghton, Wu, Godwin, Neck, & Manz, 2012). It seems that women with PMS have trouble in repairing their annoying emotions In the other word, women who use negative states and have inappropriate emotional repair can’t manage their stress properly and their coping and problem oriented strategies are not proper. So, when they experience the premenstrual cycle symptoms, respond using maladaptive strategies.

Limitations of the StudyThis study has several limitations. First, the retrospective reporting of premenstrual symptoms may distort remember of the severity and frequency of symptoms. Future studies evaluating premenstrual symptoms prospectively on a daily basis are required. Second, the role of emotional regulation might not be specific to PMS but instead might be a general risk factor for depressive psychopathology in women.

Conclusions for Future Research and Clinical Practice. Future research about the correlation of psychological and biological factors is needed to better understand the nature of PMS and its underlying aetiology. Second, the sample size in the current study was modest. This suggests that these findings should be considered with caution and future studies should include larger samples. Third, for diagnosing previous or current psychological disorders no clinical interview has been done. Therefore, it is possible that some participants were suffering from comorbid disorders, such as anxiety disorders. Future studies should include clinical interview to diagnose comorbid disorders.

The aetiology and pathophysiology of PMS remain unclear. Some studies attributed the cause of PMS to abnormal and excessive secretions of the reproductive hormones (Rubinow, Smith, Schenkel, Schmidt, & Dancer, 2007). However, in recent studies there was no significant difference between women with and without PMS in the concentrations of reproductive hormones (Qiao et al., 2012). Rather than conceptualizing PMS as a pure biological disorder, we suggest that both psychological and biological factors are crucial in developing this disorder. Our study express that women with PMS struggle with emotion regulation and appear to have a trait-like emotion dysregulation throughout the menstrual cycle. Greater use of reappraisal in everyday life is related to less experience of premenstrual symptoms and greater use of suppression is associated to higher possibility of experiencing premenstrual symptoms. These results help design the specific emotion regulation interventions associated with PMS. For example, emotion regulation therapy (Mennin, 2004), with some changes in accordance with premenstrual symptoms may be adapted to treat this disorder. In addition, mindfulness-based therapies have been proposed as a therapeutic approach that can lead to improved emotion regulation (Chambers, Gullone, & Allen, 2009). We propose such therapies may benefit women with PMS.

On the basis of our findings, it seems women with PMS have trouble in emotional clarity and emotional repair and it causes they don’t have enough control on their symptoms in the premenstrual cycle. Women with PMS may become irritable and impatient in this period and express maladaptive, impulsive and emotional reactions to situations and this may causing to negative consequences. Sometimes severity of symptoms is so high that tolerance of conditions becomes difficult for themselves and around people and it may causes mutual reactions and getting complicated problems of this period. With regards to these problems and consequences, by knowing reasons and psychological problems of these women, we should design or use interventions helping them to manage and regulate their emotional dysfunction and tolerate their symptoms properly. By using the interventions focusing on trait meta-mood, we can help women who are in premenstrual cycle to pass this period easily and don’t experience high severity of emotional and mood symptoms.

Compliance with Ethical Standards

 

Conflict of interest

Farzad Nasiri, Shokofeh Sharifi and Ali Mashhadi declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964

Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964

Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

Animal Rights

No animal studies were carried out by the authors for this article.

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 Table 1

Inclusion criteria

Age 18–44 years 

Regular menstrual cycle (4–8 cycles for the last 6 months, cycle lengths 23–32 days)

No major gynecological problems (e.g., hysterectomy, gynecological cancer, infertility)

No clinically relevant mental disorder except PMS

No intake of benzodiazepines or antipsychotic medication

No SSRI medication, psychotherapy or miscellaneous hormonal treatment because of premenstrual complaints

 

Table 2

PearsonCorrelations between predictor variables

Measure 1 2 3 4
Reappraisal
Suppression .177
Clarity .116 -.203
Repair .177 -.083 .418
Attention .506 -.199 .143 .128

Figure 1

Scatterplot of considering the variance of the residual

Table 3

Multiple linear regression results for emotion regulation strategies and trait meta- mood factors as Explanatory Variables

Unstandardized coefficients Standardized coefficients
Predictor variable B Std. Error Beta t Sig Tolerance VIF
Constant 52.468 3.194 16.429 .000
Reappraise -.171 .069 -.150 -2.476 .014 .644 1.552
Suppression .193 .090 .115 2.138 .033 .819 1.221
Attention .098 .055 .108 1.799 .073 .658 1.521
Clarity -.574 .061 -.512 -9.346 .000 .790 1.265
Repair -.212 .070 -.164 -3.029 .003 .807 1.238

Note: dependent variable: PMS



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