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AGGRESSIVE BEHAVIOR Volume 29, pages 228238 (2003)

Conict Resolution in Women Is Related to Trait Aggression and Menstrual Cycle Phase
Alyson J. Bond,n D. Gail Critchlow, and Janet Wingrove
Section of Clinical Psychopharmacology, Division of Psychological Medicine, Institute of Psychiatry, Kings College London, London, England

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Twenty-four women with a diagnosis of premenstrual dysphoric disorder (PMDD) and 18 controls took part in a study of patterns of female aggression. They completed a version of the Conict Tactics Scale for a premenstrual and a follicular phase of their menstrual cycle and for the past year. The Life History of Aggression was completed during a clinician interview. The women used more aggressive tactics to solve conicts in the premenstrual than in the follicular phase, but the difference was only signicant for the PMDD group. During the past year, reasoning was the most common strategy used by women to resolve conicts, but verbal aggression was also prevalent. Although physical violence was less common, the prevalence of any act of violence was 33% in the controls and 62% in the clinical group. Women with PMDD used both verbal and physical aggression more frequently than the controls and had a higher lifetime history of aggression. Aggression by women toward partners was associated with a general tendency to act aggressively. Aggr. Behav. 29:228238, 2003. r 2003 Wiley-Liss, Inc.

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Key words: premenstrual dysphoric disorder; menstrual cycle phase; conict tactics; aggression history

INTRODUCTION Women have been shown to demonstrate a different pattern of response to threat than men. When faced with situations involving stress or threat, they are more likely to seek social contact and support, especially from other females, and it has been suggested that they are generally more likely to solve problems in a cooperative way [Taylor et al., 2000]. However, there is evidence that women display as much physical aggression as men in intimate heterosexual relationships [Archer, 2000]. In an argument, either member of a couple may lose control and lash out physically, but, because of their greater physical size and strength, male-inicted aggression results in more injuries [Johnson, 1995]. Female aggressive behaviour may be subject to cyclical variation due to the reproductive cycle, and women

Correspondence to: Dr Alyson Bond, PO Box 48 ASB, Institute of Psychiatry, De Crespigny Park, London, SE5 8AF, UK. E-mail: a.bond@iop.kcl.ac.uk Received 3 October 2001; amended version accepted 14 February 2002 Published online in Wiley Interscience (www.interscience.wiley.com). DOI: 10.1002/ab.10025

r 2003 Wiley-Liss, Inc.

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may nd it more difcult to control their reactions during the late luteal or premenstrual phase of their cycle, especially in an intimate relationship. Premenstrual changes, involving both physical and psychological symptoms, are well documented [Logue and Moos, 1986; Woods et al., 1982]. However, a subset of women complains of severe premenstrual disturbance of mood, which is categorised as premenstrual dysphoric disorder (PMDD) within DSM-IV (American Psychiatric Association, 1994). The diagnostic criteria for PMDD require a minimum of ve symptoms of sufcient severity to impair normal social or occupational functioning. The symptoms must be prospectively rated over at least two cycles. The most frequently reported symptoms are mood symptoms such as depression, irritability, anxiety, and mood swings [Freeman et al., 1985; Hurt et al., 1992], and these symptoms have been shown to have stability across three or more cycles and to correlate highly with functional impairment [Bloch et al., 1997]. Such mood changes are likely to be related to an increase in interpersonal problems, including hostility and aggression, yet these aspects are often neglected [Yonkers et al., 1997], and little work has specically addressed this topic. The relationship between premenstrual symptomatology and aggression has been investigated in two laboratory studies. Both symptomatic and asymptomatic women were found to be more affected by an anger induction in the premenstrual phase than women tested in the follicular phase, but the intensity of the reaction (withdrawal of money) was stronger in the symptomatic group [Van Goozen et al., 1996]. Despite hypothesising a similar effect, a study using the Point Subtraction Aggression Paradigm (PSAP) failed to nd this pattern. Rates of aggressive responding on the PSAP did not differ as a function of menstrual cycle phase in women retrospectively reporting either high or low perimenstrual symptoms [Dougherty et al., 1998]. However, symptomatic women responded more aggressively throughout their cycle. As far as we are aware, no studies have examined partner aggression related to the menstrual cycle, and no experimental studies have been carried out in women with PMDD. The diagnosis of PMDD is associated with a greater likelihood of a history of affective disorders [Pearlstein et al., 1990], and selective serotonin reuptake inhibitors (SSRIs) have been shown to be an effective treatment [Steiner and Born, 2000]. However, not only do PMDD symptoms respond much more rapidly than depressive symptoms to SSRIs, but they also have been shown to respond to intermittent treatment, i.e., administered only during the symptomatic phase [Wikander et al., 1998]. A meta-analysis of 15 randomised placebocontrolled trials found intermittent administration to be as effective as continuous medication [Dimmock et al., 2000]. This evidence indicates that the action is not typically antidepressant and may be due to immediate enhancement of the neurotransmitter serotonin (5-HT). Some support for this comes from a study showing that an acute dose of mchlorophenylpiperazine, a 5-HT receptor agonist, improved symptoms in women with premenstrual syndrome (PMS) [Su et al., 1997]. It has therefore been suggested that it may be more akin to the action of 5-HT on irritability and aggression in other populations [Eriksson et al., 2001]. An inverse relationship between indices of serotonergic function and impulsive aggressive behaviour has been found consistently. Neuroimaging techniques have revealed baseline sex differences in the postsynaptic serotonergic system; higher 5-HT2 receptor binding capacity has been found in men than in women [Biver et al., 1996]. It is possible to manipulate levels of 5-HT acutely by the method of trytophan depletion (TD). This method has been shown to increase aggression in men, but this was restricted to those who reported high trait hostility

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[Cleare and Bond, 1995]. Trytophan depletion lowers the rate of serotonin synthesis in women much more than in men [Nishizawa et al., 1997], and the evidence that oestradiol may regulate both 5-HT receptor density and function [Rubinow et al., 1998] may mean that TD has more effects in women during the premenstrual phase. In fact, when their 5-HT was lowered by TD during the premenstrual phase, healthy women were found to behave more aggressively in response to provocation than after a control drink [Bond et al., 2001]. Several studies have indicated a difference in the sensitivity of the 5-HT system in women with premenstrual disorders [Bancroft et al., 1991; Fitzgerald et al., 1997; Kouri and Halbreich, 1997; Menkes et al., 1994], which may make them more vulnerable to cyclical hormonal changes [Rubinow et al., 1998]. State dependent alterations in the perception of life events have been shown across the menstrual cycle in women with menstrual related mood disorders [Schmidt et al., 1990]. More distress was associated with the same event when it occurred during the premenstrual phase, and the occurrence of negative life events was perceived to be more frequent during this phase. Women with PMDD also report lower social functioning on the social adjustment scale in the luteal compared with the follicular phase of their cycle [Pearlstein et al., 2000]. Their scores in the follicular phase showed minimal impairment but were still found to be signicantly lower than those of a community sample on social/ leisure, parental, and family unit factors. The PMDD sample did not differ from the community sample on work functioning, which is consistent with ndings that symptomatic women report more family related than occupational related stressors [Kuczmierczyk et al., 1992]. Conict can be seen as an inevitable part of all human association, and the crucial element is then not its occurrence but how people deal with it. The Conict Tactics Scale (CTS) [Straus, 1979] represents a technique that was uniquely designed to measure the way in which families attempt to deal with conicts. The CTS investigates three such modes: the use of rational discussion or Reasoning; the use of verbal and nonverbal acts that symbolically hurt the other, known as Verbal Aggression; and the use of physical force or Violence. The CTS was therefore used to analyse patterns of conict resolution both during the past year and during different phases of the menstrual cycle in women with and without PMDD. Although an aggressive act itself may be a state phenomenon, the tendency to act aggressively has been found to be a more stable trait characteristic [Huesmann et al., 1984]. In general, questionnaires have been used to assess habitual aggression in the general population and clinical histories have been used in patient groups. Recently, an attempt has been made to standardise the assessment of a history of actual aggressive behaviour in the development of the Life History of Aggression (LHA) [Coccaro et al., 1997]. The LHA was completed during a clinician interview because the intention was to examine actual previous behaviour rather than reported aggressive tendencies in hypothetical situations. We hypothesised that women would use more aggressive ways of solving conicts during the premenstrual than the follicular phase of their menstrual cycle and that this effect would be stronger in women with PMDD. Second, we hypothesised that using aggression to solve conicts would be associated with generally behaving aggressively. This is the rst study to examine these questions in a sample of women with a diagnosis of PMDD. Self-reports are not blind to cycle phase. However, demand characteristics have been shown not to inuence ratings in a sample of women with late luteal phase dysphoric disorder [Gallant et al., 1992], and the subjects were unaware that the main purpose of the study was to examine aggression.

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Women aged 24 to 45 years were recruited via newspaper advertisements asking for volunteers who suffered from severe premenstrual symptoms and also for healthy volunteers. A telephone interview screened out all those who had irregular or excessively long cycles, had any physical or gynaecological problems, or were taking any medication, including the oral contraceptive. The remaining volunteers were invited to a psychiatric interview. Those who attended gave written informed consent and were then interviewed using the Structured Clinical Interview for DSM-IV (SCID) [First et al., 1997]. Those who fullled the criteria for PMDD but had no other current psychiatric disorder (clinical group) and those who had no current psychiatric disorder (controls) entered the study. All subjects lled in a daily record of symptoms on a visual analogue scale for three menstrual cycles. For a diagnosis of PMDD to be conrmed, the mean symptom score of the ve most severe symptoms in the 5 days premenses had to exceed the mean score in the follicular phase by at least 50%. Both physical and mood symptoms were included.

Measures The CTS [Straus, 1979] is a 7-point, 19-item questionnaire designed to assess individual responses to situations in the family involving conict. It has been shown to have acceptable levels of both internal consistency (Cronbachs alpha 0.420.88) and reliability (kappa 0.320.4 for women) as measured by spousal concordance [Archer, 1999]. It was used to assess aggression toward partners during the past year and during the late luteal and follicular phases of the menstrual cycle. The LHA [Coccaro et al., 1997] has both self-rated and clinician-rated versions to measure lifetime history of aggressive behaviour. Each item is rated from 0 (no events) to 5 (so many events that they cannot be counted). There are ve items on aggression (temper tantrums, physical ghting, verbal ghting, and specic assaults rst on others and then on property), two items on self-directed aggression (specic assaults on self and suicidal attempts) and four items on antisocial behaviour (school disciplinary problems, problems with supervisors at work, and antisocial behaviour that does and does not involve the police). Therefore, a total score and individual sub-scores can be obtained. Psychometric properties have been assessed for the clinician form. The scale has been shown to possess both good internal consistency (Cronbachs alpha 0.88) and inter-rater (0.95) and test-retest (0.91) reliability. It was used as a measure of lifetime aggressive behaviour.

Procedure After the screening interview, a clinician lled in the LHA and the subjects lled in the CTS for events during the past year. The subjects were seen during two subsequent menstrual cycles. They lled in the CTS during the follicular phase of one cycle and the premenstrual phase of another cycle. The order of completion was randomised. Only subjects who had been in a relationship for the previous year were included. This led to the exclusion of 8 subjects, 4 from each group. The study was approved by the institutional ethical committee.

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Analysis Levenes test of homogeneity showed that the error variances for the two groups were signicantly different for verbal and physical aggression. Nonparametric tests were therefore used. The Mann-Whitney U test was used to compare groups, and the Wilcoxon signed ranks test was used to compare phases within groups. Spearmans rho was used for the correlations. Two-tailed tests were used throughout.

RESULTS Twenty-four women with a diagnosis of PMDD (aged 34.575.7 years) and 18 controls (aged 31.776.4 years) completed the study. There was no signicant difference in age between the groups. The mean scores for the two groups and the total sample on the CTS and LHA are shown in Table I. CTS: Late Luteal vs. Follicular Phase Signicant differences were found in conict resolution between the premenstrual and the follicular phase in the total sample of women. There were no differences on reasoning, but the subjects scored higher on the total CTS (z 2.6; Po.01) and on verbal (z 3.3; Po.001)

TABLE I. Mean Score for the PMDDn Group (N 24), the Controls (N 18), and the Total Sample on the Conict Tactics Scale and Life History of Aggression
Measure PMDD Mean Conict Tactics Scale Late luteal phase Reasoning Verbal aggression Physical aggression Total Follicular phase Reasoning Verbal aggression Physical aggression Total Past year Reasoning Verbal aggression Physical aggression Total Life History of Aggression Aggression Self-directed Antisocial Total
n

Controls SD Mean SD

Total sample Mean SD

2.46 2.54 1.08 6.08 2.08 0.67 0.00 2.75 9.62 9.54 4.71 23.87 9.04 0.58 0.87 10.50

2.38 2.39 3.72 6.06 2.02 1.43 0.00 2.62 2.82 5.40 7.35 11.48 6.06 1.14 1.36 7.46

2.72 1.39 0.25 4.36 2.28 0.44 0.11 2.83 9.55 5.83 1.75 16.69 5.22 0.33 0.55 6.11

2.65 2.12 0.73 4.49 3.12 0.98 0.47 4.19 3.58 4.96 4.55 11.71 4.41 0.69 1.10 5.49

2.57 2.05 0.73 5.34 2.17 0.57 0.04 2.79 9.59 7.95 3.44 20.80 7.40 0.48 0.74 8.62

2.47 2.33 2.85 5.45 2.52 1.25 0.31 3.34 3.13 5.48 6.41 11.99 5.69 0.97 1.25 6.97

PMDD Premenstrual dysphoric disorder.

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and physical (z 2.02; Po.05) aggression during the late luteal phase (Fig. 1). When the two groups were examined separately, there were no signicant differences for controls. The patients, however, scored higher on the total CTS (z 2.5; Po.02) and on verbal (z 2.8; Po.01) and physical (z 2.03; P o0.05) aggression during the late luteal phase (Fig. 2). The two groups were compared for their scores on aggressive tactics during the late luteal and the follicular phases. There were no signicant differences during the follicular phase. During the late luteal phase, there was no signicant difference for physical aggression, but there was a trend toward a signicant difference on verbal aggression (z 1.90; P .057). CTS: Past Year The subjects completed the CTS for conicts during the past year. It was found that all subjects (100%) had used reasoning of some sort but that bringing someone else in (asking someone to mediate) was less common (26%). Using verbal aggression was common in the

Fig. 1. Mean scores on the verbal aggression (VA), physical aggression (PA), and total scales of the Conict Tactics Scale in the total sample completed during two phases of the menstrual cycle. Asterisk indicates a signicant (Po.05) difference between phases.

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Fig. 2. Mean scores on the verbal aggression (VA), physical aggression (PA), and total scales of the Conict Tactics Scale in the patients with a diagnosis of premenstrual dysphoric disorder (PMDD) completed during two phases of the menstrual cycle. Asterisk indicates a signicant (Po.05) difference between phases.

total sample, e.g., 78% had insulted or sworn at their partners during the past year, and although using physical aggression such as pushing or grabbing and hitting was less common, it was reported by 28% of the PMDD and 19% of the control groups. When the two groups were compared, no differences were found on reasoning, but the PMDD group scored higher than the controls (Fig. 3) on both verbal (z 2.2; Po.03) and physical (z 2.1; Po.04) aggression and on the total scale (z 2.7; Po.01). Life History of Aggression The two groups were compared on the LHA. The PMDD group scored higher on the total (z 2.1; Po.04) and aggression (z 2.1; Po.04) scales but the groups did not differ on antisocial behaviour or on self-directed aggression.

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Fig. 3. Mean scores on the verbal aggression (VA), physical aggression (PA), and total scales of the Conict Tactics Scale in the total sample completed for conicts during the past year. Asterisk indicates a signicant (Po.05) difference between groups.

Correlations Within and Between Scales The subscales of the two measures correlated signicantly, as would be expected. In the total sample, the LHA total correlated highly with the aggression subscale (r 0.98; Po.01). On the CTS, verbal aggression showed the highest correlation with the total score (r 0.85; Po.01). There were also highly signicant correlations between the LHA aggression and CTS physical aggression (r 0.68; Po.01) and between the total scale scores (r 0.57; Po.01). As expected, reasoning did not correlate with any of the LHA subscales. The two groups were then analysed separately. Many of the relationships remained similar. However, there was a different pattern in the two groups. The relationship between the LHA total and CTS physical aggression was much stronger for the PMDD (r 0.80; Po.01) than the control group (r 0.38; NS). The CTS total and verbal aggression scores were strongly related to LHA self-directed aggression in the PMDD group (r 0.62; Po.01, r 0.61; Po.01, respectively), whereas they showed no signicant relationship in the controls

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(r 0.18, r 0.16). However, both the CTS total and verbal aggression were correlated with LHA anti-social behaviour in the controls (r 0.55; Po.05, r 0.51; Po.05) but not in the PMDD group (r 0.26, r 0.14).

DISCUSSION Women with a diagnosis of PMDD were found to use both more verbal and more physical aggression in solving conicts with their partners during the late luteal or premenstrual phase than during the follicular phase of their menstrual cycle. Control women showed a similar pattern, which was not signicant. There was a trend for the women with PMDD to use more verbal aggression than the controls only during the premenstrual phase. This result conrms work showing that women are generally more susceptible to react emotionally as shown on both physiological (increased blood pressure) and behavioural (withholding money) measures during the premenstrual phase and that this effect is stronger in symptomatic women [Van Goozen et al., 1996]. As we selected women with a denite diagnosis and compared them with asymptomatic women, it may well be that this is a dimensional relationship that becomes stronger according to the severity of the symptomatology. The CTS is commonly used to examine behaviour during the past year. In agreement with other studies [e.g., Bergman and Ericsson, 1996], the most common method of resolving conicts, employed by all subjects, was reasoning. However, some form of verbal aggression was also used by 78%. The prevalence of any act of physical aggression during the past year, as assessed by using the CTS, was found to be 38% in a sample of Swedish psychiatric inpatients [Bergman and Ericsson, 1996]. The prevalence of any act of physical aggression in the current study was 50% in the total sample but was higher in the PMDD group (62%) than in the controls (33%). One reason for the higher rate in our PMDD sample may be the exclusion of a current diagnosis of major depressive disorder as this group of patients had the lowest prevalence of using violence in the Swedish sample. The majority of studies using the CTS have been carried out in the United States, where a large-scale community survey found rates of about 11% for both men and women [Straus and Gelles, 1988]. A very comprehensive review has found prevalence rates to vary considerably [Archer, 2000] and generally to be higher for younger women in less stable relationships. The PMDD subjects were also found to have used tactics involving both verbal and physical aggression more during the past year. This supports work showing that women with PMS report increased conict on the Family Environment Scale compared with asymptomatic controls [Kuczmierczyk et al., 1992] and that women with severe symptoms nd dyadic intimacy and marital satisfaction highly problematic [Siegel, 1986]. Aggression toward intimates by the women was also found to be related to life history of aggression. The total of the LHA scale largely reected aggression in both groups of subjects. However, among those who used aggressive tactics to solve conicts, the controls were more likely to have a history of antisocial behaviour, whereas the patients with PMDD were more likely to have attempted suicide or other acts of self-harm. This may relate to the sensitivity of the 5-HT system in these women [Kouri and Halbreich, 1997]. Central serotonergic dysfunction has been linked consistently to suicidal behaviour [Molcho et al., 1991], and SSRIs have been found to be an effective treatment [Steiner and Born, 2000]. The LHA is considered to be a trait measure of aggression, and a score of more than 12 on the aggression subscale is thought to indicate an abnormally high score [Coccaro et al., 1997].

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Seven subjects scored above this threshold, and six of these had a diagnosis of PMDD. The strong relationship between partner aggression during the past year and general aggression in adult life is consistent with ndings that women reporting moderate to high PMS are more likely to respond aggressively to provocation [Dougherty et al., 1997]. In the latter study, severity of retrospectively reported menstrual symptoms was correlated with aggressive behaviour on a laboratory task. Subjects were not tested at different points of their cycle, but the phase of each subject was determined later. Only 20% were found to have been tested premenstrually, but no difference was found between phases. In the current study, women with a diagnosis of PMDD are also generally more likely to behave aggressively, but the results suggest that this may be related to the increased use of aggressive strategies during the premenstrual phase of their cycle. Using intermittent SSRI treatment to target symptoms during the premenstrual phase may have general benets leading to a reduction in aggression. REFERENCES
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