Theory and methodology in premenstrual syndrome research

Pergamon 0277-9536(95)00046-1

Soc. Sci. Med. Vol. 41, No. 6, pp. 793-800, 1995 Copyright © 1995 Elsevier Science Ltd

Printed in Great Britain. All rights reserved 0277-9536/95 $9.50 + 0.00

T H E O R Y A N D M E T H O D O L O G Y IN P R E M E N S T R U A L S Y N D R O M E RESEARCH

A N N E W A L K E R

Department of Psychology, University of Leeds, Leeds LS2 9JT, England

Abstract--Premenstrual Syndrome (PMS) is a controversial and ill-defined phenomenon, the aetiology of which remains an enigma, despite considerable research effort. In this paper, four meta-theoretical approaches to PMS are described and evaluated. Approaches to PMS can be criticised on three inter-related grounds. They have failed to describe women's experiences in detail before explaining them; they have not placed experience within its socio-cultural context; and they have assumed a linear relationship between biology or culture and behaviour. Future research can address these issues in two ways. Biopsychosocial models of PMS may integrate a variety of approaches and improve our understanding of individual experiences but are unlikely to offer new insights into the phenomenon of PMS. These are more likely to emerge from anthropological and sociological studies which question the cultural and individual meaning of PMS.

Key words--premenstrual syndrome, biopsychosocial models, social construction

INTRODUCTION

The possibility of a link between women's psychological distress and menstruation has been considered by researchers and writers for many centuries. It is only in the twentieth century, however, that such a possibility has been taken seriously by the medical profession. The definition of menstrually related changes in mood and well-being as a dysfunction requiring medical treatment is usually attributed to Frank in 1931, who named the experiences which his patients reported "premenstrual tension" or PMT [1]. This was developed and renamed "premenstrual syn- d rome" (PMS) by Greene and Dalton in 1953 [2], and, by the 1990s Late Luteal Phase Dysphoric Disorder (LLPDD) was controversially rec- ommended for inclusion in the Diagnostic and Statistical Manual of Mental Disorders (DSM) [3].

Research interest in this area has mushroomed in recent years, particularly since the use of PMS as a mitigation in two British murder trials of the early 1980s [4], and the literature is now expanding at a rate of about 100 scientific papers per year. PMS, however, remains an elusive phenomenon, difficult to describe succinctly, troublesome to diagnose and lacking a clear aetiology or therapeutic rationale. Women who can demonstrate a temporal link between their distress and the days before menstruation, and whose medical practitioners are sympathetic, are likely to be treated on the basis of 'trial and error ' in the absence of any coherent management plan (although attempts have been made to help non- specialists through this minefield--e.g. Ref. [5]), and disputes have emerged between medical practitioners about the psychiatric or gynaecological 'ownership'

of specialist PMS treatment [6]. Not surprisingly many women turn to the national self-help organis- ations and the articles published in 'women 's ' magazines for advice and support from other women.

In this paper, the four dominant, but usually implicit, recta-theoretical approaches to PMS will be described and evaluated, in order to address the failure of current research to adequately explain it. Directions for future research are then outlined, which either integrate aspects of the existing recta- theories or adopt alternative epistemologies to develop new insights into the phenomenon.

META-THEORETICAL APPROACHES TO PMS

The biomedical model

In the case of PMS, scientific investigation really began in the 1920s, with the origins of research usually being credited to Frank [1]. Frank was attempting to explain the experiences of a group of women attending his clinic and complaining of " . . . indescribable tension from ten to seven days pre- ceding menstruation . . . . These patients complain of unrest, irritability, 'like jumping out of their skin' and a desire to find relief by foolish and ill-considered actions" [1, p. 1054].

The explanation which he developed provides the basis for the biomedical model of PMS. He attributed the cause of the women's complaints to abnormal and excessive secretions of the female sex hormones and advocated treatment, either by encouraging hormone excretion medically (e.g. by increased consumption of coffee or laxatives) in mild cases; or by ro6ntgen (X-ray) treatment to induce temporary or permanent amenorrhea.

793

794 Anne Walker

In this conceptualisation, hormonal fluctuations which characterise the menstrual cycle result in 'normal' changes in mood and well-being; but abnormal and intolerable moods occur when hormone levels are abnormal or excessive. This has many implications, which can be developed into testable hypotheses, e.g. women with premenstrual symptoms will differ en- docrinologically from women without; premenstrual symptoms will respond to treatment with hormonal agents, and so on, and has provided the basis for much of the research conducted over the last sixty years.

As research has progressed, however, it has become clear that a simple hormonal explanation cannot account for premenstrual symptoms [7], and modifi- cations have been made to Frank's original model. These usually include a mediating step between ovarian hormones and premenstrual symptoms. For example, Reid and Yen [8] suggest that endogenous opioids form a link between ovarian hormones and symptoms. Women with PMS, it is suggested, have normal ovarian cycles but have a deficiency of opioids or a defective feedback sensitivity, resulting in symptoms under normal hormonal conditions. Many other mediating mechanisms have been proposed ranging from peripheral factors such as prostaglan- dins or mineralocorticoids to central factors such as catecholamines or circadian rhythms, but theoreti- cally they all fit the same framework. Symptoms are caused either by a malfunction of the ovarian hormones themselves, or by a malfunction of the inter- vening system in response to normal levels of ovarian hormones.

More recently, theorists have suggested that there may be different mechanisms for different types of symptoms--distinguishing usually between mood symptoms and physical symptoms. For instance, the Systems Model of Premenstrual Symptoms proposed by Bancroft and Backstrom [9], hypothesises a direct relationship between ovarian steroids and peripheral symptoms, such as bloating and breast tenderness, but an indirect one between cyclical hormones and mood change.

Each of these models derives from Frank's original conceptualisation. They all imply a biological dysfunction as a fundamental aetiological factor, and they all require the definition of a dichotomous

phenomenon--PMS is something which is either present or absent. None have been substantially supported, and problems of the operationalization and diagnosis of PMS have made the interpretation of hypothesis testing studies difficult. However, since many physiological systems can be shown to vary in synchrony with the menstrual cycle [lO], there is no shortage of possible intermediary mechanisms to be investigated.

The psychosomatic model

In this model, ovarian hormones are not dysfunctional. Instead, there is something about the woman's temperament or psychology which causes intensification of cyclical changes in mood and well-being through a psychosomatic mechanism (see Fig. 1).

An example of this is seen in Karen Horney's work, published at about the same time as Frank's [11]. She proposes a psychodynamic mediator between hormones and symptoms. The physiological changes prior to menstruation arouse unconscious inner conflicts involving the wish for a child, and hence behavioural and emotional disturbance.

Other writers have suggested that premenstrual symptoms will only occur among women who are experiencing conflict about the female role, or are denying their femininity [12]. Personality characteristics have also been suggested as causal--women who report severe premenstrual symptoms are hypothesised to be more neurotic than women who report mild or un-noticeable symptoms [13]. More recently, it has been suggested that women who are experiencing high levels of stress at work or home or both may experience more severe premenstrual symptoms [14].

These explanations share many characteristics in common with the biological explanations, for instance, a dichotomy is seen between severe and trivial premenstrual symptoms. The distinguishing factor between these, though, is not hormonal or biochemical, but psychological. Women who have severe premenstrual symptoms are psychologically different from those who do not. Treatment is directed towards psychotherapy or stress management, rather than drug therapy. Although, if personality is considered to be the key element, then medical

Normal Hormonal ] Variation 4-

I Normal Changes in ] Mood and Well-Being I

Psychological I Factor ]

JAbnormal Moods orJ 7 Symptoms(PMS'I

Fig. 1. The psychosomatic model.

Theory and methodology in premenstrual syndrome research 795

I Negative stereotypes of menstruation

I Negative Expectations

Cyclical Hormones

-I- Cyclical Arousal

Fig. 2. The social psychological model.

~>J Attribution of

r rousal as symptoms

or surgical removal of the menstrual cycle may be seen as the only therapeutic approach.

Tests of the psychosomatic model, like those of the biomedical model, depend on differentiation between 'sufferers' and 'non-sufferers'. Since all studies vary in this definition, results are difficult to interpret. In addition, psychological questionnaires and measures of cyclical mood change may be confounded. For example, Linda Gannon [15] points out that many items in the Eysenck Personality Inventory (EPI) measure of neuroticism (e.g. "Are you moody?") would be confounded with cyclical change. A difference between 'sufferers' and 'non-sufferers' on this dimension, therefore, is not very illuminating. Like the biomedical model too, the precise mechanism whereby these psychological processes might pro- duce symptoms in advance of menstruation is unclear.

The social psychological model

A third category of explanation applies the classic research on the social psychology of emotions (e.g. Ref. [16]) to premenstrual symptoms [17, 18]. Cyclical hormonal changes are acknowledged and are thought to be related to cyclical changes in arousal. These changes in arousal are in turn associated with sub- jective emotional experiences. Arousal is itself neutral, but becomes labelled as happiness or anger or irritability etc. depending on the attributions made by the person experiencing it. These attributions depend on the cultural beliefs and stereotypes of the individual and their social context (see Fig. 2). The negative beliefs about menstruation in Western societies may lead individuals to develop negative expectations about the premenstrual phase, and hence to label arousal at this time as negative rather than positive (e.g. restlessness rather than creative energy). Individual differences are hypothesised to arise from differences in the strength of negative expectations, which may themselves be related to socialisation, attitudes towards femininity, and so on; and/or differences in the degree of cyclical change in arousal.

This model differs from the biomedical and psychosomatic models in its explicit acknowledge- ment of factors external to the woman complaining of distress. Clearly this model leads to a wide variety

of hypotheses which can be tested; however, the focus for intervention is not just upon the woman as a patient, but also upon the culture and society which has caused her negative expectations of menstruation.

The radical feminist model

Writers such as Parlee [19], Laws [20], Rome [21], and Martin [22], criticise the explanation of women's distress as dysfunctional, citing the historical tendency to medicalize and pathologise behaviour which does not conform to the female stereotype [23-25]. It is argued that the label 'PMS' does not describe a real cyclical syndrome, but is a medicalisation of any behaviour by women (whether in the premenstrual phase or not) which is intolerable within a patriarchal society or interferes with culturally defined womanly functions, e.g. anger. Women's anger and/or depression, may be quite rational responses to the situations in which they find themselves, but are inconvenient to patriarchal society and threaten the traditional status quo. If women, who are believed to be biologically destined for domesticity and mother- hood, fail to accomplish these functions, or rebel against them, then something must have gone wrong in their biology. PMT/PMS gives a dysfunction label to such behaviour, which has convenient biological implications, despite the real social causes of the behaviour. It is popular because it allows the status quo to be maintained. Women, who have internalised these beliefs about femininity and pathology, will tend themselves to blame their individual biology tor their feelings of dissatisfaction, and seek medical help to cure it, rather than threatening the traditions of Western culture (and hence their own status quo) by looking for a political or social solution.

Writers from this perspective also point out that women in general are much less likely to be violent and aggressive than men, citing the striking difference in the numbers of men and women in prison popu- lations, for instance. This raises the possibility that it is only in the premenstrual phase of the cycle that women's anger or violence approximates to the usual male level of antisocial and aggressive behaviour [24]. Perhaps the hormonal milieu in the postmenstrual and ovulatory stages of the cycle acts as a transquil- liser--allowing the passive acceptance of intolerable social circumstances and differentiating women's

796 Anne Walker

behaviour from the masculine model. These argu- ments are used to suggest that whether or not women actually experience cyclical changes in mood and well-being, the experiences which are reported are not dysfunctional and do not represent a 'disease-state'. They are defined as a disease by Western cultures because this serves a particular function for those cultures [26-28]. PMS is not a biologically based disease but a misogynist and culturally defined phenomenon, a social construction. Rodin [26] points out that this argument invalidates traditional biomedical and psychological research into PMS for two reasons. First because " . . . by applying for research funds, proceeding with research, treating patients and maintaining PMS clinics . . . " the medical establishment treats PMS as though it were a legitimate disease category [26, p. 52]. Second, because " . . . women's reports of their menstrual experiences become reproductions of the medical description of PMS. The implication . . . is that the nature of premenstrual bodily and emotional changes cannot be known insofar as the traditional methods of measurement structure the findings" [26, p. 53]. The only way to gain further insight into PMS is to consider it from social, historical and anthropological perspectives.

COMMONALITIES AND CRITICISMS

The theoretical approaches to PMS which have been described arise from different disciplines, and might, at first glance, appear to demonstrate a healthy spread of intellectual approaches to a complex and ill understood phenomenon. However, little interaction is seen between the differing perspectives and the field fails to grow and develop. It is difficult for a researcher with a particular training to fully appreciate the theories and rationales of researchers in a different discipline, and multi or inter-disciplinary studies of PMS are rare. In addition to this, the research emphasis in the last ten years or so has been on the diagnosis and definition of PMS, and LLPDD, leading into complex debates about the minutiae of measurement and assessment, rather than the further development or consideration of theoretical underpinnings. Theoretical approaches to PMS can be criticised on three inter-related grounds. They have failed to describe women's experiences in detail before explaining them; with the exception of the radical feminist approach, they have not placed experience within its socio-cultural context; and they have assumed a linear relationship between biology or culture and behaviour.

Inadequate description

Frank's original paper [1] provides a creative and powerful explanation for female emotional instabil- ity. He asserts that "It is well-known that normal women suffer varying degrees of discomfort preced- ing the onset of menstruat ion. . ." , and goes on to say

that some women suffer "indescribable tension" which is relieved within an hour or two of the onset of menstrual flow. He supports his observations of this latter group by reference to 15 cases from his own clinic, and then immediately develops an explantion for the phenomenon. The association between "tension" and menstruation (or the premenstrual phase of the cycle) is assumed as fact. Several parts of Frank's original observations have remained completely un- questioned-are women of reproductive age variable in temperament? Are men of the same age, post- menopausal women and prepubertal children invari- able? If men and/or women vary in temperament, is this of clinical importance? Do women experience more physical and emotional changes before menstruation than at any other time--or are symptoms at that time selectively recalled or attributed to menstruation? Is premenstrual tension a dysfunction--or are other explanations possible?

These questions essentially represent auxiliary hypotheses to Frank's original explanation [29]. The failure to adequately describe the phenomenon to be explained, before explaining it has distorted the scientific process, meaning that tests of the ovarian hormone hypothesis, whatever their outcome, cannot be properly interpreted. It is always impossible to know whether the experimental hypothesis or one of the auxiliary hypotheses is being tested. For instance, medical ovariectomy may alleviate premenstrual symptoms [30], but if such symptoms can also be experienced by men, or women at other times, or if the ovariectomy disrupts the menstrual function to which symptoms have been attributed, results which appear to support the ovarian hypotheses become unintelligible. Since the psychosomatic and social psychological models are essentially developments of biomedical theories, they are also flawed in this way. Arguably, they are explanations for the idea or stereotype of premenstrual experience, rather than the reality. This failure is also a feature of the radical feminist approach, which is founded in a critique of the dominant ideology rather than investigations of women's experience. This approach too is based on ideas about how women feel rather than descriptions, and as such omits important questions about the meaning that the term PMS has for the women who use it.

The socio-cultural context

One of the reasons for the corruption of the scientific process lies in the failure of researchers and theoreticians to consider their own cultural, historical and ideological background as of relevance to the work in hand. Scientific research and theorising of PMS has been conducted largely without any reflexivity on the part of the researchers concerned. If representations and stereotypes of menstruation or femininity are considered important they are only considered to influence the women who are reporting perimenstrual distress, and not the clinicians or


researchers who work with them. For example, the influence of common-sense views of gender on the design and interpretation of scientific research has long been acknowledged [31, 32], but awareness of this has not been incorporated into PMS research [33].

A major criticism of the positivist approach in social science is the assumption that objectivity can be achieved (e.g. Ref. [34, 35]). The application of natural science methodologies to the understanding of human behaviour has brought many advantages; however, the study of humans by humans will always be a problematic endeavour. Personal values are not left behind in intellectual work. In menstrual cycle research particularly, the questions asked and the interpretations made of results obtained are influ- enced by the personal beliefs, training and intentions of the researcher [23]. The assumption of objectivity allows these influences to remain unexposed, as the illusion of the researcher as a neutral channel through whom 'the truth' will emerge is maintained. The researcher is not required to reflect on their reasons for conducting a particular study in a particular way--and is certainly not expected to share any such reflections with those who choose to read the published results. It has been argued that if objectivity cannot be achieved, good scientific work must be reflexive and acknowledge the subjectivity of the researcher [36, 37].

The assumption of linearity

The model of linearity is one that has dominated theory and research in PMS. The tendency has been to assume that simple one-way causal relationships exist between the substance or factor being studied and the appearance of premenstrual symptoms.

The most common occurrence of this is the assumption that the menstrual cycle is an independent variable [38]. A clear example of this is seen in my own work, conducted with John Bancroft, in which we compared the premenstrual symptomatology of menstrual cycles which were either ovulatory or anovulatory [39]. We assumed linearity between ovulation and symptom occurrence--we also assumed that the direction of causality was from ovary to behaviour and not vice-versa. Our finding of no association between these two variables should (with the benefit of hindsight) be interpreted as no linear relationship between them. The possibility of more complex relationships was not systematically tested.

The assumption of linearity has focused research effort on the dichotomization of women into PMS sufferers and non-sufferers, and the pursuit of the single factor (biological or psychological) which distinguishes the two groups. It is perhaps this endeavour which has been at the same time the most productive (in terms of output) and the most destruc- tive (in terms of understanding) for PMS research. As Ann Oakley [35] points out, the assumption of linear-

ity which may work well in animal research fails if we acknowledge that humans are more than animals. As humans we think and reason, we make sense of our experiences in the social context within which we live. If human beings are not simple, biologically determined and passive organisms but complex, multiply determined and active participants in our own experiences, then attempts to understand those experiences based on simple linear modelling will inevitably fail.

All of the theoretical perspectives (including the radical feminist perspective) outlined in this paper assume a linear and unidirectional relationship between premenstrual symptoms and the purported aetiological mechanism. Increasingly, however, interactive biopsychosocial models of illness are demon- strating greater explanatory power than univariate and unidirectional ones (e.g. Ref. [40]). Premenstrual experiences are extremely variable both between women and between menstrual cycles [41,42]; the menstrual cycle can act as a social cycle as well as a biological one [43,44]; disruptions in mood and circadian patterns can upset the menstrual rhythm [45,46]; and every known physiological and neuro- chemical system fluctuates in synchrony with the menstrual cycle [10]. This complexity suggests that interactive biopsychosocial models may also be of benefit in this context.

FUTURE DIRECTIONS

The purpose of this paper is to address the in- adequacy of the current explanations of PMS. It is suggested that inadequate description of the phenomenon to be explained, the illusion of objectivity, and the adoption of an inappropriate model of linearity have distorted the research process. So where do we go from here? Several possible strategies could be adopted. The first, going back to the radical feminist approach to PMS, is to argue that PMS is an invalid concept and that to continue research in this area is simply to add credence to a patriarchally constructed fantasy. This strategy is ethically difficult because it effectively denies treatment to the many women experiencing distress, which they choose to call PMS [24]. Alternative possibilities are to develop complex and multivariate models of PMS, or to address the phenomenon from outside the framework of traditional science.

Biopsychoso¢ial models of PMS

The criticisms outlined in this paper could be used to develop studies within the traditional scientific paradigm. Studies which investigate the full variety of menstrual cycle related mood change. Studies which base the diagnostic criteria for PMS on representative samples of the female population, and not just on clinically complaining groups. Studies which incorporate men and/or post-menopausal women as control groups. Studies which do not assume unidirectional linear relationships, by using correlational

798 Anne Walker

designs (rather than treating the menstrual cycle as an independent variable) and multivariate analyses. Studies which explicitly acknowledge the meta-theory being tested and use or develop integrated and biopsychosocial theories. As noted above, such models have proved useful elsewhere, and are begin- ning to emerge in the PMS field (e.g. Refs [47-50]). These models, unlike the linear ones, suggest that biological, psychological and social processes interact (see Fig. 3). Theorists usually identify three stages in the process of PMS self-diagnosis. First is the occurrence of particular physical and/or emotional states; second, is the perception and labelling of these as menstrually related by the woman herself; and, third is the interpretation of them as dysfunctional and requiring treatment. An integrated model suggests that biological, psychological and social processes interact at each of these stages.

Research adopting this type of approach addresses some of the inadequacies outlined above-- i t encour- ages full description of women's experiences, and it limits the assumption of linearity and the dichotomi- sation of women into PMS sufferers and non- sufferers. It also acknowledges the sociocultural framework--although PMS is still conceptualised as an individual problem. However, it requires a multi- disciplinary approach to PMS, which may limit its practicality for research (as distinct from intervention), and it does not address the illusion of objectivity.

A social constructionist approach to P M S

Whether or not PMS is a medical concern, it is well-established as a cultural phenomenon and even as a social problem [4]. This suggests that new insights into PMS may be gained by approaching it from anthropological, sociological and social con-

structionist perspectives [26]. The biopsychosocial model of PMS continues the tradition of positivist science in viewing a woman as a relatively passive organism--biological, psychological and social things happen to her. If we know what these biopsychosocial factors are, then we will be able to predict her experience or behaviour. In this case, we will be able to predict whether she will have PMS or not. People, women in this case, can also be seen as agents, however, who interpret their social world and try to make sense of what is happening to them [51]. No matter how much is known about a woman's personality, stress level, hormonal status or mood state, it is not possible to predict with perfect accuracy whether she will complain of PMS because the meaning which PMS has for her is not known. Research from this perspective acknowledges that objectivity is an illusion and therefore does not attempt to separate the knower from what is known. The researcher is not expected to be objective, but is expected to use his or her own subjectivity reflexively in the development and interpretation of the (usually qualitative) research (e.g. Refs [51,52]). Social constructionist approaches are gradually being incorporated into psychology too [53], as are other approaches which adopt a similar epistemological stance (e.g Refs [37, 54]).

A social constructionist approach emphasises that people actively make sense of their experiences and social interactions using the information available to them. This raises a range of new questions to ask about PMS. For instance, what does the term PMS mean to people and why it is so powerful?, what discourses can women use to make sense of premenstrual and menstrual experiences? what function does the existence of PMS (or the stereotype of PMS) have for individuals and for the society as a whole?, when

Fig. 3. The biopsychosocial model.


is it acceptable to attribute experiences to menstruation and when not?, and so on. These questions allow the development of new insights into PMS and address the issue of objectivity. They complement approaches within a biopsychosocial framework by acknowledging the woman herself as an agent rather than as a passive organism.

SUMMARY AND CONCLUSION

PMS is a controversial and ill-defined phenomenon, about which we know remarkably little given the amount of time and effort expended in its study. A major reason for this is the failure of the research to develop clear theories of the phenomenon under study. This is by no means a problem affecting only PMS research. Research into the psychological effects of induced abortion, for example, have been similarly lacking in either explicit theory or conclus- ive findings [55, 56]. The reasons for this may be similar. In the case of abortion studies, explicit theory has not been deemed necessary because it is "so obvious" that abortion must result in trauma and depression [55]. The wider context and the possibility of non-linear relationships are not considered. Simi- larly, PMS has been seen as so obviously hormonally related that explicit theorising is not a requirement for research. In both cases, this failure has resulted in poor integration of findings and inconclusive data. We neither know the psychological outcome of elec- tive termination of pregnancy, nor do we know whether PMS exists. The emergence of multidimensional and biopsychosocial models of PMS is a positive development which may enable researchers and clinicians to understand more clearly the experiences of individual women. The adoption of these models is not sufficient, however, to understand the phenomenon of PMS, which has become a social problem as well as a medical concern [4]. This adds to the complexity of research in this area, and it has been argued that paramenstrual experiences are inevitably viewed through a distorting cultural lens by researchers, clinicians and PMS complainers alike [26]. Scientific approaches which assume objectivity will inevitably fail to develop new insights into women's experiences because the questions which are asked do not challenge the culturally accepted definition of 'normality' . New questions can be asked however, if PMS is approached from a different point of view, using methods which are familiar in anthro- pology and sociology, but relatively new in psychology and biomedicine [26]. Research addressing questions like these requires the investigator to exam- ine his or her own beliefs and practices, as well as those of the research participants, and offers the hope of new insights into the fascinating phenomenon of PMS.

REFERENCES

1. Frank R. The hormonal causes of premenstrual tension. Arch. Neurol. Psychiat. 26, 1053, 1931.

2. Greene R. and Dalton K. The premenstrual syndrome. Br. reed. J. 1, 1007, 1953.

3. Caplan P., McCurdy-Myers J. and Gans M. Should premenstrual syndrome be called a psychiatric abnor- mality. Feminism Psychol. 2, 27, 1992.

4. Rittenhouse A. The emergence of premenstrual syndrome as a social problem. Social Problems 38, 412, 1991.

5. O'Brien P. Premenstrual Syndrome. Blackwell Scientific Press, Oxford, 1987.

6. Robertson M. A survey of multidimensional and inter- disciplinary approaches to premenstrual syndrome. In Menstruation, Health and Illness (Edited by Taylor D. and Woods N.), pp. 129-142. Hemisphere, New York, 1991.

7. Walker A. Premenstrual symptoms and ovarian hormones: a review. J. Reprod. Infant Psych. I0, 67, 1992.

8. Reid R. and Yen S. Premenstrual syndrome. Am. J. Obstet. GynecoL 139, 85, 1981.

9. Bancroft J. and Backstrom T. The premenstrual syndrome. Clin. Endocrin. 22, 313, 1985.

10. Magos A. and Studd J. Effects of the menstrual cycle on medical disorders. Br. J. Hosp. Med. 33, 68, 1985.

I 1. Horney K. Feminine Psychology (Edited and translated by Kelman H.) Routledge, London, 1967.

12. Levitt E. and Lubin B. Some personality factors associated with menstrual complaints and menstrual attitudes. J. Psychosom. Res. I1, 267, 1967.

13. Coppen A. and Kessel N. Menstruation and personality. Br. J. Psychiat. 109, 711, 1963.

14. Woods N. Socialization and social context: influence on perimenstrual symptoms, disability and menstrual attitudes. Hlth Care Women Int. 7, 115, 1986.

15. Gannon L. Menstrual Disorders and Menopause: Biological, Psychological and Cultural Research. Praeger, New York, 1985.

16. Schachter S. and Singer J. Cognitive, social and physiological determinants of emotional state. Psych. Rev. 69, 379, 1962.

17. Ruble D. and Brooks-Gunn J. Menstrual symptoms: a social cognition analysis. J. behav. Med. 2, 171, 1979.

18. Rodin J. Menstruation, reattribution and competence. J. Personality soc. Psych. 33, 345, 1976.

19. Parlee M. Premenstrual syndrome. Psych. Bull. 80, 454, 1973.

20. Laws S. Who needs PMT? A feminist approach to the politics of premenstrual tension. In Seeing Red: The Politics of Premenstrual Tension (Edited by Laws S., Hey V. and Eagan A.). Hutchinson, London, 1985.

21. Rome E. Premenstrual syndrome (PMS) examined through a feminist lens. Hlth Care Women Int. 7, 145, 1986.

22. Martin E. The Woman in the Body. Open University Press, Milton Keynes, 1989.

23. Ussher J. The demise of dissent and the rise of cognition in menstrual-cycle research. In Cognition and the Men- strual Cycle (Edited by Richardson J.). Springer, Berlin, 1992.

24. Ussher J. Women's Madness: Misogyny or Mental Illness? Harvester Wheatsheaf, London, 1991.

25. Showalter E. The Female Malady: Women, Madness and English Culture 1830-1980. Virago, London, 1987.

26. Rodin M. The social construction of premenstrual syndrome. Soc. Sci. Med. 35, 49, 1992.

27. Johnson T. Premenstrual syndrome as a Western culture-specific disorder. Culture, Med Psychiat. I1, 337, 1987.

800 Anne Walker

28. Gottlieb A. American premenstrual syndrome: a mute voice. Anthrop. Today4 (6), 10, 1988.

29. Hempel C. Philosophy of Natural Science. Prentice-Hall, Englewood Cliffs, N.J., 1966.

30. Muse K., Cetel N., Futterman L. and Yen S. The premenstrual syndrome: effects of a medical ovariectomy. New Engl. J. Med. 311, 1345, 1984.

31. Broverman I., Broverman D., Clarkson F., Rosen- krantz P. and Vogel S. Sex-role stereotypes and clinical judgements of mental health. J. Consult. Clin. Psych. 34, 1, 1970.

32. Nicolson P. Towards a psychology of women's health and health care. In The Psychology of Women's Health and Health Care (Edited by Nicholson P. and Ussher J.), pp. 6-30. Macmillan, London, 1992.

33. Fausto-Sterling A. Myths of Gender:Biological Theories about Women and Men. Revised edn. Basic Books, New York, 1992.

34. Harding S. The Science Question in Feminism. Cornell University Press, New York, 1986.

35. Oakley A. Essays on Women, Medicine and Health. Edinburgh University Press, Edinburgh, 1993.

36. Gilligan C. In a different voice: ten years later. Paper presented at Women and Psychology Conference, Uni- versity of Sussex, U.K., July 1993.

37. Hollway W. Subjectivity and Method in Psychology. Sage, London, 1989.

38. Koeske R. Theoretical and conceptual complexities in the design and analysis of menstrual cycle research. In The Menstrual Cycle: Research and Implications for Women's Health (Edited by Komnenich P.), pp. 54-69. Springer, Berlin, 1981.

39. Walker A. and Bancroft J. The relationship between premenstrual symptoms and oral contraceptive use: a controlled study. Psychosom. Med. 52, 86, 1990.

40. Engel G. The clinical application of the biopsychosocial model. Am. J. Psychiat. 137, 535, 1980.

41. Hart W., Coleman G. and Russell J. Assessment of premenstrual symptomatology: a re-evaluation of the predictive validity of self-report. J. Psychosom. Res. 3, 185, 1987.

42. Walker A. Mood and well-being in consecutive menstrual cycles: methodological and theoretical implications. Psych. Women Q. 18, 271, 1994.

43. McFarlane J., Martin C. and Williams T. Mood fluctuations: women versus men and menstrual versus other cycles. Psych. Women Q. 12, 201, 1988.

44. Sommerville S. and Walker A. Social and menstrual cycles: a comparison of men and women. Paper presented at Women and Psychology Conference, Univer- sity of Sussex, July 1993.

45. Dan A., Chatterton R., DeLeon-Jones F. and Hudgens G. Rationale and evidence for the role of circadian desynchrony in premenstrual symptoms. In Menstrual Health in Women's Lives (Edited by Dan A. and Lewis L.), pp. 52-60. University of Illinois Press, Urbana, 1992.

46. Iglesias R., Terres A. and Chavarria A. Disorders of the menstrual cycle in airline stewardesses. Aviation, Space Environ. Med. 51, 518, 1980.

47. Ussher J. Research and theory related to female repro- duction: implications for clinical psychology. Br. J. clin. Psych. 31, 129, 1992.

48. Miota P., Yahle M. and Bartz C. Premenstrual syndrome: a bio-psycho-social approach to treatment. In Menstruation, Health and Illness (Edited by Taylor D. and Woods D.), pp. 143-152. Hemisphere, New York, 1991.

49. Alberts P. and Alberts M. Unvalidated treatment of premenstrual syndrome. Int. J. Mental Hlth 19, 69, 1990.

50. Walker A. PMS research: issues of science and gender. Proc. Br. Psych. Soc. 1, 32, 1993.

51. Sarbin T. and Kitsuse J. Constructing the Social. Sage, London, 1994.

52. Silverman D. Interpreting Qualitative Data. Sage, London, 1993.

53. Gergen K. The social constructionist movement in modern psychology. Am. Psych. 40, 266, 1985.

54. Potter J. and Wetherell M. Discourse and Social Psychology: Beyond Attitudes and Behaviour. Sage, London, 1987.

55. Posavac E. and Miller T. Some problems caused by not having a conceptual foundation for health research: an illustration from studies of the psychological effects of abortion. Psych. Hlth 5, 13, 1990.

56. Wilmoth G., de Alteriis M. and Bussell D. Prevalence of psychological risks following legal abortion in the U.S.: limits of the evidence. J. soc. Issues 48, 37. 1992.

Documents

Theory and methodology in premenstrual syndrome research