Vol.3, No.6, 326-332 (2011)
doi:10.4236/health.2011.36056
C
opyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Health
The role of the self-concept in the relationship of
menstrual symptom attitudes and negative mood
Sibylle Peterse1, Tilman Eckloff2
1Department of Psychology, University of Leuven, Leuven, Belgium;
2Department of Psychology, University of Hamburg, Hamburg, Germany.
Received 6 April 2011; revised 16 May 2011; accepted 18 May 2011.
ABSTRACT
Background: A relationship between symptom
attitudes and negative affect has consistently
been found in a range of different symptom
domains. Little is known, however, about the
role of different aspects of the self-concept in
this relationship. We explored the mediating
role of interferences of symptoms w ith the self-
concept in the association of menstrual symp-
tom report and depressive mood. Methods:
Eighty-one women completed an online survey
on menstrual symptoms, perceived interfer-
ences of symptoms with various self-aspects
and negative mood states. We tested our hy-
pothesis in a mediation analysis. Results: We
found a complete mediation of the relationship
of symptom attitudes and depressive mood by
interferences of symptoms with self-aspects.
However, interferences with self-aspects did not
play a role in the association of anxious mood
and symptom report. Conclusion: The self-
concept should receive greater attention in re-
search on symptom attitudes and psychological
well-being. This would be particularly important
in research on medically unexplained symp-
toms.
Keywords: Self-Concept; Health; Symptom
Perception; Symptom and Illness Attitude Model;
Menstruation
1. INTRODUCTION
Concerns about menstrual symptoms are a common
reason for primary care visits in women and associated
with substantial healthcare costs [1,2]. However, it has
been argued that self-reported menstrual symptoms are
often treated by extensive medical and surgical means
such as hysterectomies despite lack of pathology [3].
Lilford [4] reports that “perceived abnormal bleeding
accounts for 70% of hysterectomies in pre-menopausal
British women, and in most cases of “menorrhagia,”
menstrual blood loss is within the “normal” range.
Public campaigns altering the perception of menstrua-
tion via messages in the mass media were successful to
reduce rates of hysterectomies by 25.8% - 33.2% [5].
These numbers suggest that psychological factors play a
major role in the perception of menstruation and men-
strual symptoms.
The impact of psychological factors such as mood
states, expectations, and personality traits on the percep-
tion of bodily sensations and symptoms in general (not
only with regard to menstruation) has been demonstrated
in a still growing body of research [6-8]. However, in
this research on symptom perception, personal psycho-
logical variables such as negative affect have been in the
focus of attention, while little is known on social psy-
chological variables. However, social groups in which
we are members such as communities, families, neigh-
bourhoods, work teams, and networks of friends are not
mere external factors. Membership in formal and infor-
mal social groups and our roles in these groups are inte-
gral part of our self-concept. We internalise these social
aspects and we derive a sense of meaning, purpose, and
belonging from these groups which has impact on self-
perception and emotional well-being [9].
The evaluation of a bodily experience is based on
physiological norms (which are debated regarding men-
strual loss [10,11]) and personal norms of experience.
However, another important factor in the perception of
symptoms can be the perception of interferences of
symptoms with the self-concept [12]. Changes in psy-
chological and physiological well-being which women
attribute to menstruation might be perceived to be in-
consistent with a favourable self-concept, in particular,
to interfere with social functioning, and to violate social
norms. Symptoms interfering with self-aspects can be
perceived as a burden regardless of their clinically rele-
vance. In other words, the consequences of symptoms
for the self-concept might be as important for symptom

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327327
report and help seeking behaviour as sensory experience
and physiological consequences.
Qualitative studies have shown that menstruation in
its non-clinical, ‘normal’ form can be perceived to be
highly invasive and to affect a broad range of social and
personal self-aspects such as professional life, family life,
and intimate relationships [13]. There is growing evi-
dence that identity-continuity, i.e. the perception of con-
tinuity and consistency of the self-concept, is an impor-
tant factor in psychological well-being and health-man-
agement [14]. Interferences of menstruation with self-
aspects might be perceived as threat for perceived con-
sistency of the self. The impact of menstrual symptoms
on a variety of aspects of social life are one major argu-
ment of supporters for extending menstrual cycles by
continuous use of oral contraceptives [15], although this
continuous suppression can have side effects such as
nausea and breakthrough bleeding, and long-term ad-
verse effects have not been explored yet [16]. However,
studies are missing that explore perceived interferences
of symptoms with the social self-concept.
The importance of the self-concept in symptom per-
ception has been outlined recently in the Symptom and
Illness Attitude Model (SIAM [12]). The SIAM predicts
that mental representations of bodily processes such as
menstruation are influenced by salient aspects of the self.
Furthermore, it predicts that mental representations of
bodily sensations and illness in interaction with the
meaning of these representations for salient self-aspects
will influence mood and behaviour. Following this
model, perceived interferences of symptoms with some
self-aspects might be one of the underlying processes
increasing the strength of the relationship of depressive
and anxious mood and self-report of somatic symptoms
[17]. Personal characteristics such as locus of control
were found to moderate the relationship of symptom
report and depressive and anxious mood in women with
non-clinical menstruation [18]. However, we are not
aware of a study testing whether interferences with the
self-concept might be another underlying process in the
relationship between symptom attitudes and negative
mood. Identifying processes that produces relationships
between variables is essential, because it is a precondi-
tion for designing efficient interventions [19]. We be-
lieve it is essential to include not only personal traits as
moderators and mediators in this research, but also vari-
ables linked to the social and personal self- concept.
In this study we explored symptoms report as well as
symptom attitudes. From a methodological perspective,
to measure symptom attitudes, two aspects need to be
taken into account: 1) beliefs about the symptom, and 2)
the affective evaluation of these beliefs [20]. This con-
ceptualization of mental representations of bodily sensa-
tions as associations of believes about a sensation with
an affective evaluation has also been outlined in the
SIAM [12]. According to this model, we measured the
mental representation of menstruation assessing the be-
lief strength that a symptom was perceived to be linked
to menstruation (symptom self-report) and the affective
evaluation of this belief.
As already pointed out by Wood and Badley [21], a
medical intervention alone might not be efficient if pa-
tients perceive the most urgent problems on social levels
and would not seek help for symptoms alone if they
would not perceive them as interfering with the social
self. This might be especially true for menstruation,
since menstruation is subjected to a number of implicit
social norms and taboos [13,22]. Social interferences
might be the key to understand help seeking for sub-
clinical menstrual symptoms and solving social interfer-
ences might be an important step to support medical
interventions in women with clinically relevant symp-
toms. We believe that social interferences of symptoms
and their relationship with depressive or anxious mood
are not restricted to menstruation, but can be extended to
other disease domains as well.
We hypothesize that symptom report is related to
negative mood as it has been shown on a number of
studies exploring the interaction of negative affect and
health self-report [6-8]. Furthermore, following the
SIAM, we expected that the association of menstrual
symptom report and attitudes with negative mood is me-
diated by perceived interference of menstrual symptoms
with the social self-concept. Because of the lack of re-
search on menstrual symptom attitudes and the social
self-concept, we tested our hypotheses on a sample of
women with mainly non-clinical menstrual symptoms in
a cross-sectional design.
2. METHODS
2.1. Participants
Eighty-one women completed an online survey. They
were recruited at the university and via links at online
forums for sport and lifestyle. Participants were in-
formed about the purpose of the study at the beginning
of the survey and participation was completely anony-
mous. The local ethics committee approved the study.
2.2. Online Research
We took great care to follow recommendations given
in the field of online research [23]. The survey was
server-side programmed (EFS Survey, Unipark). To par-
ticipate, no special browser requirements were necessary.
Furthermore, we assigned each participant a session ID

S. Peterse et al. / Health 3 (2011) 326-332
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328
(“cookie”) to keep the users from participating in the
survey more than once. At the beginning of the study,
participants were informed about the purpose of the
study and gave consent by clicking on a check box. At
the end of the questionnaire people were asked again
whether they would allow us to analyse their data for
scientific purposes in anonymous form. Individuals in-
dicating that they would prefer to be deleted from the
data pool were excluded.
2.3. Instruments
We presented a list of 12 symptoms [24] stereotypi-
cally associated with menstruation including back pain,
abdominal pain, cramps, pain in the breast, headache,
nausea, irritability, fatigue, decreases in physical resil-
ience, decrease in alcohol tolerance, concentration defi-
cits, or mood changes. Participants were asked whether
or not they would typically experience these symptoms
during menstruation (yes = 1/no = 0). Subsequently, par-
ticipants rated on a five-point scale to which extent they
would evaluate these symptom to be a normal aspect of
menstruation and not worrying, or to be rather unusual
and worrying (1 = normal and not worrying/5 = unusual
and very worrying). To control for the influence of
variation in knowledge about the reproductive cycle on
symptom attitudes, we asked participants to answer 15
knowledge questions about the menstrual cycle and
menstrual symptoms.
Furthermore, participants rated how strongly men-
strual symptoms would interfere with ten social self-
aspects such as professional life or being a family mem-
ber (1 = no interference at all/5 = extreme interference)
(Table 1). All items consisted of the phrase “My men-
struation interferes with …” followed by the respective
self-aspect (for example “My menstruation interferes
with my professional life.”). Furthermore, women were
asked how important these social self-aspects were to
them (1 = not important at all/5 = very important). If a
self-aspect did not apply to them, they were asked to
indicate this by clicking on a response button labelled
“not applicable”.
Additionally, participants completed the Hospital
Anxiety and Depression Scale (HADS [25], a self-report
measure of negative mood states that avoids reference to
physical symptoms that are often included in assessment
instruments of anxious and depressive mood. Partici-
pants were instructed to rate their mood regarding the
last four weeks in general and not specifically regarding
their last menstruation. For the two HADS-subscales,
anxious mood (HADS-A) and depressive mood
(HADS-D), a score of 0 - 7 is considered normal, 8 - 10
indicates borderline clinically relevant, and 11 or more
indicates clinically relevant anxious or depressive mood.
A meta-analysis has demonstrated high reliability and
validity of the HADS [26]. Participants completed ques-
tions on demographical, health-related, and cycle-related
variables such as age, body weight and height, typical
length of cycle, regularity of the cycle (1 = irregu la r/ 5 =
very regular), presence or absence of menstruation at the
time of completing the survey, and day of the last onset
of menstruation.
2.4. Data Analysis
We computed a symptom attitude score along the atti-
tude measurement model of Fishbein & Ajzen [20] and
the SIAM [12] in creating a sum score of reported
symptom weighted by reported distress related to symp-
toms. We used an SPSS Mediation Macro commonly
used in social sciences for mediation analysis [27] to test
our hypothesis of a mediation of the relationship of
menstrual attitudes and the depressive mood score by
perceived social interferences, including estimation of
the indirect effect with a bootstrap approach (Figure 1).
According to Baron and Kenny [28] a variable is a sig-
nificant mediator if the paths (c) and (a) as displayed in
Figure 1 are ≠ 0 and the mediator significantly predicts
the dependent variable controlling for the independent
variable (i.e., b ≠ 0 in Figure 1). If the relationship be-
tween independent and dependent variable (c’) is no
longer significant after including the mediator within the
model the mediation is called complete mediation. In
this case, the mediator accounts for the major part of
variance in the relationship of the two other variables.
3. RESULTS
3.1. Participants’ Characteristics
Mean age (± standard deviation) of the eighty-one
participants was 25.7 ± 5.4. Participants reported on av-
erage 5.11 ± 2.96 symptoms in the menstrual phase.
Depressive
mood (Y)
Menstrual
symptom
attitudes
(
X
)
Interferences with
social self-aspects
(M)
c' =
b(
YX.M
)
b =
b(
YM.X
)
a =
b(MX)
Depressive
mood (Y)
Menstrual
symptom
attitudes
(
X
)
c = b(YX)
Figure 1.

S. Peterse et al. / Health 3 (2011) 326-332
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329329
Most common symptoms were mood changes (67.5%),
heightened irritability (66.3%), cramps and abdominal
pain (56.6%), pain in the breast (44.6%), and back pain
(20.5%). 28% of the participants had at least one time in
their life consulted a general practitioner because of
menstrual symptoms. Women evaluated their symptoms
on average to be not worrying (2.35 ± 0.55). However,
they reported that their menstruation would partly inter-
fere with their social life (Table 1). All social-self as-
pects were on average evaluated to be important. Mean
depressive mood scores (HADS-D) were 2.68 ± 2.42 and
mean anxious mood scores (HADS-A) were 5.93 ± 3.28.
Borderline to clinically relevant scores in the HADS
subscales (above eight points) were found for six women
regarding the HADS-D subscale and for seventeen
women regarding the HADS-A subscale.
The majority of women (58%) reported a regular or
very regular cycle. Only 3.7% reported an irregular cycle.
Sixteen women reported menstrual symptoms to be pre-
sent at the time they completed the survey and 44.2%
were within the first half of their cycle. Mean reported
cycle length was 27.3 days ± 3.7. Women had on aver-
age 10.7 points of 15 possible points in the questions on
menstrual cycle. Regarding level of education, 78.3%
had achieved or were pursuing a university degree.
3.2. Associations between Variables
Included within the Mediation Mod
Symptom attitudes were significantly associated with
HADS-D scores, r(81) = 0.25, p = 0.03 (symptom report
not weighted by affective evaluation r(81) = 0.23, p =
0.04, all reported correlations Pearson, two tailed).
Table 1. Mean importance of social self-aspects and mean
interference of menstruation, standard deviation in parentheses.
Self-aspects
My menstruation
interferes with…
Mean
importance
Mean
Perceived
interference
Not
applicable
being a family member. 3.52 (1.28) 1.59 (0.96) 9
being a student. 3.39 (1.10) 2.51 (1.16) 7
my professional life. 4.09 (0.97) 2.72 (1.17) 16
important appointments. 4.20 (0.99) 2.83 (1.26) 1
doing sport. 3.58 (0.97) 2.69 (1.17) 9
being a friend. 3.90 (1.20) 1.55 (0.94) 1
participating in social
events. 3.69 (1.14) 2.78 (1.16) 1
being with friends. 3.90 (1.11) 2.05 (1.05) 1
going out. 3.46 (1.13) 2.71 (1.21) 1
in general when being
in public. 3.43 (1.19) 1.84 (0.93) 0
Furthermore, symptom attitudes were associated with
social interferences r(81) = 0.44, p < 0.01; (symptom
score not weighted r(81) = 0.51, p < 0.01). The associa-
tion between social interferences and HADS- D scores
was also significant, r(81) = 0.38, p < 0.01. The
HADS-A score was only significantly associated with
symptom attitudes, r(81) = 0.22, p = 0.05 (symptom
score not weighted r(81) = 0.20, p = 0.07), but not with
social interferences, r(81) = 0.10, p = 0.40. Because of
this lack of significant association of HADS-A scores
with the mediator, we tested the mediation model for
depressive mood only. The number of correct answers to
questions about the menstrual cycle was not associated
with any of the measures, suggesting that self-report was
not substantially biased by a lack of knowledge about
menstruation. No differences in any of the variables in-
cluded within our model were found between women
reporting to menstruate at the time they completed the
survey (n = 16) and women reporting menstrual symp-
toms retrospectively (n = 63) (all ts ≤ 1.20, all ps ≥
0.24).
3.3. Mediation Analyses
We found a complete mediation of the relationship of
symptom attitudes and depressive mood by perceived
interferences of symptoms with social self-aspects (Ta-
bles 2-4, values for symptom scores not weighted by
affective evaluation in parentheses). The effect of men-
strual symptom attitudes on depressive mood decreased
by a nontrivial amount and was no longer significant
with inclusion of the mediator. Additionally, Table 3
shows the results of the test of the indirect effect with
the Sobel test by comparing the strength of the indirect
effect to the null hypothesis that the indirect effect
equals zero. We found the same result with bootstrap-
ping, a procedure which is not based on the assumption
of normality (Table 4).
Table 2. Indirect effect of menstrual symptom attitudes (X) on
depressive mood (Y) through inferences with social
self-aspects (M).
Direct and total effects
B SE b T p criteria
b (YX)0.22
(0.20)
0.10
(0.09)
2.28
(2.12)
0.03
(0.04) c
b (MX)0.47
(0.50)
0.10
(0.10)
4.44
(5.17)
< 0.001
(< 0.01) a
b (YM.X)0.28
(0.29)
0.10
(0.10)
2.28
(2.83)
< 0.03
(< 0.01) b
b (YX.M)0.09
(0.04)
0.10
(0.10)
0.87
(0.47)
0.38
(0.63) c'

S. Peterse et al. / Health 3 (2011) 326-332
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330
Table 3. Estimation of the indirect effect a/b with a normal
theory approach.
ab SE ab
95%
CI-l
95%
CI-u z p
Sobel 0.13
(0.13)
0.06
(0.06)
0.02
(0.02)
0.24
(0.25)
2.34
(2.21)
0.02
(0.03)
Note: Criteria for mediation: see Figure 1.
Table 4. Bootstrap results for indirect effect.
M SE
95%
CI-l
95%
CI-u
Effect 0.13
(0.13)
0.06
(0.06)
0.06
(0.06)
0.29
(0.29)
Note: Number of bootstrap resamples = 5000. Estimation of the indirect
effect with a bootstrap approach advocated by Preacher and Hayes (2004).
95% CI-l/95% CI-u = lower/upper bounds of a 95% confidence interval for
the bootstrap estimates of ab.
4. DISCUSSION
Although menstrual symptoms were on average not
perceived to be particularly unusual or alarming in our
sample of women with mainly non-clinical menstruation,
women reported that symptoms would partly interfere
with social self-aspects. We found symptom attitudes to
be related to both, social interferences and depressive
mood. Furthermore, our results support the hypothesis
that the social self-concept mediates the association of
symptom report and depressive mood as predicted in
models such as the SIAM [12]. We found no association
of social interferences with anxious mood. In the light of
the complete mediation of the relationship between
symptom attitudes and depressive mood by perceived
social interferences, these interferences can be regarded
as important targets for interventions to reduce negative
impact of symptom perception on psychological well-
being. Social stereotypes related to symptoms and the
perception of an interference of symptoms with social
life should be taken into account when exploring symp-
tom self-report in research and clinical practice.
Interestingly, the mediating role of social interferences
was not found for the relationship of symptom report
and anxious mood. These findings are in line with re-
search showing that social psychological evaluative
processes are more closely related to depressive mood
than to anxious mood. Unfavourable comparison to an
upward social standard has been shown to be linked to
depressive mood, low-self-esteem and uncertainty [29].
Furthermore, it has been found that depressed individu-
als tend to interpret social information more negatively
than non-depressed individuals and to engage in unfa-
vourable social comparison more often and react more
negatively than non-depressed individuals [30]. Fur-
thermore, recent research shows that hiding physical
symptoms (or other aspects of the self-concept) in the
work place is related to depressive mood [31]. Our re-
sults encourage research on potential distinct relation-
ships between perceived social consequences of symp-
toms and anxious and depressive mood.
Sociological studies have shown that women working
in positions that are supervised by others and do not al-
low a flexible reorganisation of work load perceive more
problems with managing symptoms [13]. In turn, these
women might perceive more interference of symptoms
with social life compared to women working in positions
which allow more flexibility. Working on attitudes to-
wards menstrual symptoms to improve psychological
well-being might not be sufficient, as long as the social
setting is characterized by social norms that are very
likely to lead to interferences between the social self and
any kind of clinical or non-clinical menstrual symptoms.
Interventions aiming at improving psychological well-
being should include cognitive intervention targeting the
perception of social interferences of symptom as well as
social psychological interventions, targeting socially
shared stereotypes and misconceptions about menstrua-
tion, coping strategies such as seeking social support and
a re-evaluation of implicit social norms.
The perception of social interferences with non-
clinical symptoms might be especially likely in the do-
main of menstrual symptoms compared to other symp-
tom domains. Qualitative studies show that hiding any
signs of menstruation is a strong implicit social norm in
our society [13,24]. The perception of interferences of
menstruation with the social self might be due to at-
tempts to comply with such implicit rules. However,
although implicit social norms might be especially
strong in the case of menstruation, it can be assumed that
interferences of symptoms with the self-concept are not
limited to menstrual problems. The results presented
here in a non-pathological domain can be assumed to be
relevant for a broader range of symptoms. Most chronic
diseases have their own social stereotypes [32] and
strong informal norms exist on hiding symptoms as well
as medication intake [33]. Thus, we hypothesize to find
a similar mediating role of social interferences in other
symptom domains.
Exploring the role of the self-concept might be espe-
cially promising in the domain of medically unexplained
symptoms (MUS [34]), i.e. symptoms for which no
physiological cause can be detected. MUS has been
found to be associated with negative affect. One poten-
tial underlying mechanism in MUS might be the per-
ceived or feared interferences between ambiguous, but
not pathological bodily sensations and aspects of the
self-concept.
Furthermore, this research on social interferences
could also help to gain a better understanding of delay in

S. Peterse et al. / Health 3 (2011) 326-332
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
331331
help seeking. A lack of perceived social interferences
could reduce help seeking behaviour despite the percep-
tion of symptoms.
We analysed cross-sectional data. Our findings high-
light a social process behind the relationship of depres-
sive mood and symptom report which has received little
attention so far. However, we cannot draw conclusions
about causal relationships between variables. Negative
affect has been identified as possible sources of bias,
increasing the report of bodily sensations and other
variables [6-8]. Women with clinical relevant depression
might interpret symptoms more negatively and perceive
more social interferences. However, because of the sub-
clinical levels of depressive mood in our sample, we
cannot assume that perception of social interferences of
symptoms above the midpoint of the scale found is this
sample was due to depression. However, whether the
nature of the relationship found here is causal or mutu-
ally aggravating, still needs to be clarified empirically.
As a further limitation, we analysed self-report of
symptom, but had no information on the objective sever-
ity and clinical relevance of symptoms themselves.
However, menstrual symptoms are usually not measured
in general practice with means other than self-report,
because of the difficulty of this assessment and dispute
about normative values for clinical relevant menstrual
loss [10,11]. We analysed mainly retrospective report.
However, comparing report of women with menstrual
symptoms present and women with menstrual symptoms
not present at the time they completed the survey, we did
not find any differences in the variables included within
our analyses, indicating that retrospective self-report
bias played only a minor role in this research on men-
strual symptom attitudes.
4.1. Limitations
Although we analysed self-report of women with
menstrual symptoms on a mainly subclinical level,
women did report relevant interferences of menstruation
with aspects of their self-concept. However, future re-
search has to explore whether results can be generalised
to clinical samples. Furthermore, we analysed data from
a homogeneous sample of young women, mainly with
academic background. We cannot generalize our results
to groups with another socioeconomic or cultural back-
ground. As outlined above, women with a higher socio
economic status often have more flexibility to reorganize
work load if they perceive an interference of menstrua-
tion with, for example, work. Interferences of menstrua-
tion with the social self in women with lower socio eco-
nomic status can be expected to be even stronger than in
our sample of young woman with a university degree or
pursuing a university degree.
4.2. Conclusions
Consequences of symptoms for the social self-concept
should receive greater attention in research on symptom
attitudes and psychological well-being. If patients per-
ceive the most urgent problems on a social level and
would not seek help for symptoms if they would not
interfere with social life, intervention to improve well-
being and symptom report need to target personal, social
psychological, and social factors.
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