Evidence Linking Psychological Factors with Vulvodynia

By Marek Jantos Ph.D.

Literature reports on the role of psychological variables in vulvodynia are diverse in their views. Most of the early etiological conceptualizations of dyspareunia were guided by psychoanalytic constructs, focussing on phobic reactions, anxiety conflicts, hostility, aversion to sexuality, abuse and trauma in childhood (Binik et al 1999). Other reports generalizing from findings on chronic pelvic pain to vulvar pain, reported increased hypochondriasis, hysteria and decrease in ego strength (Ranaer et al 1979). A number of them reported unsatisfactory interpersonal relationships with parents, higher incidence of marital conflict, psychosexual problems, and avoidance of close physical contact with their partners (Beard et al., 1977). Typically, many of the studies placed disproportionate emphasis on somatisation issues. More recent studies have sought to assess the psychological profile of vulvodynia patients and focused on emotional states, in particular level of anxiety, depression, illness behaviour, quality of relationships and history of abuse. These studies will be reviewed next.

Negative emotions and vulvodynia
One of the earliest studies, based on non-structured interviews, found that all older patients, and 80% of the younger ones, showed signs of depression (Lynch, 1986). The study found evidence of obsessive compulsive behaviour, as reflected by the degree of personal neatness, a history of fastidious housecleaning, concern about productivity and other perfectionistic tendencies. It was also noted that while patients expressed anger about their medical care, very rarely did they express anger or hostility towards their spouses. In general, relationships appeared to be strong and supportive.

Depression amongst various chronic pain patient groups is estimated to range from 30-54% (Sullivan et al 1992). In vulvodynia, current and lifetime prevalence of major depressive disorder was shown to be 17% and 45% respectively (Masheb et al 2005). These reported prevalence rates are lower than rates in other chronic pain patients and confirm earlier findings that showed vulvodynia women not be different to controls in relation to the level of reported depression (Reed et al., 2000).

A study focussed on the psychosexual aspects of vulvar pain examined the role of stress in vulvodynia (Schrover et al., 1992). The study concluded that psychological stress was the primary trigger of chronic vulvar pain. In spite of the fact that patients disagreed with such a link, the authors attributed the cause of pain onset to stressors that included: severe marital conflict, new relationships, break up of an existing relationship, a patient’s or their partner’s affair, job stress, fear of pregnancy, fear of sexually transmitted diseases, depressive symptoms, or somatisation disorder. However, the findings in this study are problematic in that the results of the psychological tests contradict the conclusions of the authors, and the treatment provided appears to be inconsistent with the assessments made. The study reported that the standardised tests used showed the scores for depression, somatisation and psychological distress to be well within the normal range. The authors acknowledged these discrepancies and sought to clarify this apparent contradiction by stating that “The discrepancy between psychologic testing and the results of interviewer observation is striking,” but “this group of patients is very reluctant to label vulvar pain as related to psychologic stress. These women minimize conflict on questionnaires but cannot conceal problems as easily when interviewed in person by an experienced clinician” (Schrover et al., 1992, p. 632).

It is difficult to draw a clear conclusion from these findings because of the degree of internal inconsistency between standardized objective tests and opinions of the authors. Furthermore, the findings are at variance with earlier studies showing no marital conflict, but strong and supportive relationships (Lynch, 1986). The results are also inconsistent with more recent studies highlighting the supportive nature of the majority of relationships (Reed et al., 2000; Jantos & Burns, 2007). The study is also open to further criticism due to the inconsistency between the suggested psychogenic etiology of vulvar pain and the surgical treatment utilized. The treatment consisted of the surgical excision of purportedly psychologically triggered vulvar lesions. It is widely acknowledged that stress can exacerbate vulvar discomfort in that “…tension or stress can magnify symptoms, particularly when a disorder [vulvodynia] is as mysterious and/or frightening” (McKay, 1985), but a causal relationship between stress and lesions has not been shown.

Other studies also examined the level of psychological distress among patients attending a vulvar health clinic (Stewart & Reicher, 1994). The study found that vulvodynia symptoms interfered more seriously with sexual function than any other forms of pathology seen in non-vulvodynia patients. This conclusion was supported by similar findings in a more recent study (Ponte et al., 2009). Furthermore, the level of disability was found to be related to increased levels of anxiety with patients displaying a heightened awareness of various sensations throughout their bodies, were more likely to attribute serious disease etiologies and consulted more physicians in relation to their pain. The role of anxiety and somatisation was seen as a central issue requiring stress-reduction techniques such as lifestyle changes, exercise, relaxation and psychotherapy. Where anxiety and somatisation were considered to be a manifestation of an underlying depression, antidepressant therapy was recommended (Stewart & Reicher, 1994).

Personality traits, illness behaviour and psychopathology
A study investigating the relationship between medical symptoms, personality traits, illness behaviour, and psychopathology in vestibulodynia patients (in the study referred to as vvs), noted a high prevalence of depression, anxiety and perfectionistic traits (Jantos and White, 1997). The study found insufficient evidence for the diagnosis of somatisation disorder, but patients often reported a history of unconfirmed candidiasis, multiple premenstrual syndrome symptoms, headaches and migraines, urologic and gastrointestinal symptoms and skin allergies. The Illness Behaviour Questionnaire (Pilowsky et al., 1984) showed that, although patients were preoccupied with symptoms, there was no evidence of phobic or hypochondriacal behaviour. Patients did not believe that their pain was of psychogenic origin, but manifested disappointment and anger with a lack of diagnosis. The elevated levels of anxiety and depression were related to chronicity of symptoms and concern about the unknown cause of the pain.

The quasi-experimental study of 105 women with dyspareunia and 105 non-pain controls mentioned in earlier discussion (Meana et al., 1997) highlighted several findings relevant to this discussion. The dyspareunia patients, as a group, presented with more physical pathology and greater psychological distress than the control group. However, when the vestibulodynia subgroup, making up 54% of the dyspareunia group, was compared with control subjects, the vestibulodynia group showed the highest level of sexual impairment, lower frequencies of intercourse, lower sexual desire, lower arousal, and reduced ability to achieve orgasm. Yet, analysis of the psychological data did not show a higher level of psychological impairment. The study found pain related impairment, but the vestibulodynia group were found to be more resilient with no evidence of a link between psychosexual conflict and etiology of vulvar pain.

Psychosexual profiling
Due to the centrality of psychosexual issues in the discussions on vulvodynia, the relationship between pain symptoms and sexual function was studied in more detail (White & Jantos., 1998). A total of 40 vestibulodynia patients (in the study referred to as vvs) sought treatment for painful intercourse. The average duration of pain was 33 months and the average intercourse pain was rated as 7.5 (on a scale of 0-10, where 0 is no pain and 10 is the most severe pain experienced). A large percentage of the patients (83%) also reported experiencing pain with non-intercourse orgasm, and rated non-penetrative pain as 7 on the same scale. When compared with controls, patients experienced the same levels of sexual desire, but reported a higher rate of refusal to sexual advances and sexual intercourse. They also experienced significantly less physiological arousal and reported a more negative attitude towards sexual activity.

The sexual behaviour in patients was most influenced by the experience of pain. The authors commented that “the pain stimuli compete with sexual stimuli, resulting in decreased sexual desire” (p. 784) and the “psychological morbidity noted in the vestibulitis cohort” appeared to be “…most influenced by the actual experience of chronic pain…” and “the psychological morbidity noted in the vestibulitis cohort appears to be secondary and a consequence of the chronic sexual pain” (p. 787). Furthermore, they suggested that “sexually related pain, as reported by vestibulitis patients, can be responsible for recurrent disappointment, anxiety, frustration, depression and loss of self-esteem” (p.785). The authors caution that: "It may be tempting for the physician to view sexual behavioral changes associated with vulvar vestibulitis syndrome as indicative of sexual dysfunction of psychogenic etiology…It is most important to ensure that the pain is not categorized prematurely as of psychological origin or to fall into the dichotomy of seeing sexual pain as either a solely physical or solely psychological problem” (p. 787).

From this study and others, it is evident that the pain ratings for sexual activity fall into the severe range (Jantos, 2008; Bergeron et al., 2001) and the severity of pain is often emotionally and physically disabling, preventing intercourse from occurring and contributing to emotional turmoil and disappointment.

Most studies examining the potential relationship between psychosexual disturbances and vulvodynia omitted to control for the effect of chronic pain itself. A study using a cross-sectional design evaluated psychological traits, marital satisfaction, sexual history and behaviour and somatic characteristics comparing vulvodynia patients with a chronic pelvic pain group without vulvodynia symptoms, and a control group (Reed et al., 2000). The data showed that in terms of the quality of marital relationships, interest in sex, importance of vaginal sex and frequency of sexual activities, women with vulvodynia were not dissimilar to the other two groups. Upon onset of pain, women with vulvodynia and those with pelvic pain rated the quality and quantity of current sexual activities as significantly more impaired when compared to control subjects and to their own premorbid state. The history and incidence of depression was similar for all three groups; however, the severity of depression and of global affective distress, as measured by the Beck Depression Inventory and the Brief Symptom Inventory and Global Severity Index, was significantly higher for the pelvic pain group. There were no significant differences between the vulvodynia and control groups. The pelvic pain group had a significantly higher rate of sexual abuse.

The study highlighted that psychological dysfunction was not a prerequisite of chronic vulvar pain. Likewise, there were no indicators to suggest that vulvodynia patients were sexually averse, rather, the symptoms of vulvodynia significantly interfered with sexual functioning which resulted in a decline in frequency and quality of sexual activity. The study also found that the occurance of somatic complaints among the vulvodynia group did not differ from controls, it notes that the failure to understand the multidimensionality of the symptom of pain and the lack of awareness of how pain impacts on women’s sexuality needed to be addressed. The findings provided no support for a link between vulvodynia and psychological disorders or lack of marital adjustment, sexual or physical abuse, depression or somatic sensitivity. The authors concluded that a primary psychological cause of vulvodynia is not supported and “suggestions that personal choice or psychological weakness of women have caused vulvodynia are unsubstantiated and may add to the patient’s distress” (p. 631). The study emphasizes that “attention needs to continue to be given to the possibility of increased psychological distress in women who are dealing with chronic pain,” especially unpredictable genital pain (Reed et al., 2000, p. 631).

In a recent assessment of a psychosexual profile of vulvodynia patients, the connection between vulvodynia symptoms, relationships, and sexual activity was studied (Jantos & Burns, 2007). Of the 516 patients who were sexually active, 80.3% reported a decrease in sexual desire and a marked reduction in frequency of sexual intercourse. The average weekly frequency of sexual intercourse changed from 3.5 times per week prior to onset of symptoms, to 0.6 times per week post symptom onset. Over 50% of patients experienced some difficulties with physiological arousal, and sexual intercourse was prevented by a dry and tight vagina in 41.2% of the cases. Negative emotional reactions to sexual intercourse were experienced by 39.4%, with only 18.3% of the patients indicating that they still found sexual activity enjoyable. Patients also noted a reduction in the frequency with which their partners initiated sexual activity, due to concern that intercourse would cause pain. Indeed, 74.9% of patients indicated that their partners were supportive, 25.1% indicating that their partners were frustrated, but only 3.5% reported having partners who were angry or did not care. When asked which activities patients would like to increase if pain symptoms abated, the majority expressed a desire to increase sexual activity (87.5%).

The findings confirm that women with vulvodynia experience some negative emotions towards sexual activity because of pain, and concerns about pain lead to lower levels of sexual activity, but generally they enjoy supportive relationships. For those in a marriage relationship, marriage acted as a buffer against emotional distress. The study found no evidence linking vulvodynia with relationship stress or psychosexual conflict.

Incidence of reported physical and sexual abuse
The issue of physical and sexual abuse has often been raised in relation to the etiology of vulvodynia and is pertinent to this discussion. Unlike the earlier findings relating to chronic pelvic pain (Steege, 1998; Reed & Haefner, 2000), research has consistently failed to find any relationship between physical or sexual abuse and vulvodynia. The incidence of sexual abuse in the vulvodynia cohorts was found to be no higher than in the general population (Jantos, 1997; Schrover et al., 1992; Friedrich, 1987). Variations in findings appear to arise on account of different definitions of abuse. In a Canadian study of 300 vulvodynia patients, 9% of women reported non-consensual sexual intercourse (Sandownik, 2000). An Italian study reported non-penetrative sexual abuse in 29% and penetrative abuse in 6.5% of its vulvodynia patients (Graziottin & Brotto, 2004). A US study reported an 8% incidence of reported sexual abuse among its patients (Brotto et al., 2003). In another US study on victimization, 242 patients were compared with 113 controls and the prevalence of victimization was found not to be higher in the patient group when compared with the control group. The authors of the study concluded that “…if anything, there was a trend toward a negative association between vulvar pain and sexual victimization” (Dalton et al., 2002). In a study specifically designed to compare the incidence of sexual and/or physical abuse in women with vulvodynia, questionnaire responses from 89 vulvodynia patients were compared with those of 65 patients with chronic vulvar pain of medical origin and 166 general dermatology patients (Edwards et al., 1997). The analysis showed that there were no differences between the three groups.
In a US study on adult-onset vulvodynia and childhood violence and victimization, a sample of 12,000 women in the Boston area was contacted, and 125 women were identified, who, on the basis of a phone interview, met the ISSVD diagnostic criteria for vulvodynia (Harlow & Stewart, 2005). Through telephone interviews an assessment was made of the medical, psychiatric and sexual histories and of childhood victimization. Results from this non-clinical sample showed that women who never or rarely received family support as children were two to three times more likely to report vulvodynia symptoms. Women who reported severe physical abuse in childhood, and those who experienced severe sexual abuse, were four and six times more likely, respectively, to experience vulvodynia symptoms. The joint effect of severe abuse, childhood endangerment and lack of family support was associated with a 14-fold increased risk of vulvodynia. It is unclear to what extent the strong associations reported in this study may be due to a broader definition of victimization or due to recall bias. However, increased stress during childhood and adolescence and other early life experiences may constitute a risk factor for chronic vulvar pain.
Finally an Australian study assessing the psychosexual profile of 744 vulvodynia patients found that the self-reported incidence of unwanted sexual activity during childhood and adulthood were 11.5% and 12.5%, respectively (Jantos & Burns, 2007). The findings of this study confirm that the incidence of unwanted sexual activity among vulvodynia patients is no higher than among the control groups and the general population.

Somatoform hypothesis
Two recent opinion papers have reactivated discussion of the somatoform hypothesis in relation to the etiology of vulvdynia (Mascherpa et al., 2007; Lynch, 2008). The hypothesis as outlined in the most recent paper (Lynch, 2008), rests in part on a semantic argument stemming from the current wording of the ISSVD terminology and classification of vulvodynia. The author of the opinion paper acknowledges that his is a minority view, but the therapeutic implications of the somatoform hypothesis he sees as “immensely important” (p.395). According to the hypothesis, “medical” (neurological, inflammatory and infectious) causes of vulvar pain preclude the diagnosis of vulvodynia and only “idiopathic” or unexplained non-medical causes can form a plausible basis of diagnosis. It is then assumed that the idiopathic causes are primarily psychogenic in nature. The evidence cited in support of the hypothesis is based on findings of predisposing psychological, sexual and social disturbances among patients, and on the co-existence of other chronic pain syndromes (fibromyalgia, irritable bowel syndrome, interstitial cystitis and other idiopathic pain problems such as headache, lower back pain and pelvic pain). Symptoms of vulvar pain are seen as an expression of personal and/or social distress, not on account of inflammatory and neuropathic processes. As a result patients are non-responsive to commonly used analgesics and anti-inflammatory medications, but responsive to non-medical conservative therapies. According to the hypothesis, the psychosexual and social factors, previously seen as predisposing individuals to the development of vulvodynia, are actual precipitating factors. The pervasiveness of psychosexual dysfunction is seen as far exceeding what might be expected in response to organic pathology. The high levels of depression and anxiety, and lower levels of sexual desire, arousal and frequency, together with high levels of marital conflict provide evidence for the pre-existence of psychosexual and social issues which ultimately find expression in the form of pain symptoms. Furthermore, the argument is put forward that the higher than average incidence of abuse among vulvodynia sufferers is also a possible precipitating factor. However, research evidence supporting such a hypothesis is lacking.

In summary, current studies assessing the psychological profile of vulvodynia patients find no evidence for a psychogenic cause of chronic vulvar pain. Negative attitudes toward sexual activity, fear, phobias, depression and generalised distress appear to arise in response to the association of pain with sexual activity (Meana et al., 1997; White & Jantos, 1997; Reed et al., 2000, Jantos & Burns 2007). It is also important to note that patients consistently continue to reject any suggestions that vulvodynia is symptomatic of personal psychological factors (Schover et al., 1992, Jantos & White, 1997; McKay, 1989).

It would appear that much of the confusion surrounding the classification and management of vulvodynia arises from a lack of understanding of the nature of chronic pain. The next section seeks to briefly review the difference between acute and chronic pain, to assist in recognising vulvodynia as a chronic pain syndrome.