Biofeedback and Self-Regulation, VoL 3, No. 3, 1978
Case Reports and Training Techniques
Biofeedback-Assisted Relaxation Training for Primary Dysmenorrhea: A Case Study T h o m a s F. Dietvorst and David Osborne' Mayo Clinic and Mayo Foundation, Rochester, Minnesota
Primary dysmenorrhea is a familiar complaint to medical practitioners. Recently, behavior therapy has been shown to be an effective treatment for the symptoms of dysmenorrhea. The present case study offers biofeedbackassisted relaxation treatment as an effective alternative treatment. The Menstrual Symptom Questionnaire was used to classify dysmenorrhea as spasmodic or congestive. This classification provides homogeneous groups of patients. The patient in this study had an 18-year history of primary dysmenorrhea that was resistant to hormonal and analgesic treatment. After two months of baseline observation, she was given eight sessions of skintemperature biofeedback and autogenic training. She reported significant reduction of pain and discomfort with the use of biofeedback-assisted relaxation. Desensitization using visual imagery, an important component of previous therapies, was not used. Further examination o f the efficacy of biofeedback-assisted relaxation training for the treatment of both congestive and spasmodic dysmenorrhea is suggested. Dysmenorrhea is a familiar complaint to the medical practitioner. Primary dysmenorrhea, or dysmenorrhea when no disease of pelvic organs can be demonstrated, has been effectively treated by behavior therapy (Chesney & Tasto, 1975b; Mullen, 1968; Mullen, 1971; Tasto & Chesney, 1974). The present case study offers biofeedback-assisted relaxation treatment as an alternative and equally effective treatment.
'Requests for reprints should be sent to Dr. David Osborne, Section of Psychology, Mayo Clinic, Rochester, Minnesota 55901. 301
0363-3586/78/0900-0301505.00/0
© 1978 Plenum Publishing Corporation
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Chesney and Tasto (1975a) developed the Menstrual S y m p t o m Questionnaire after the model presented by Dalton (1969). Dalton's work suggested that there are two types of dysmenorrhea: spasmodic and congestive.
Spasmodic dysmenorrhea, as described by Dalton (1969), is pain beginning on the first day of menstruation which is felt as spasms of acute pain sometimesso severeas to cause vomiting and fainting. The pain is limited strictly to the parts of the body controlled by the uterine or ovarian nerves, i.e., the back, inner sides of the thighs, and lower abdomen. Congestive dysmenorrhea is a part or variation of the premenstrual syndrome. The woman with congestivedysmenorrhea has advance warning of menstruation for several days during which she may experienceincreasing heaviness and a dull, aching pain in the lower abdomen as well as Other areas of the body including the breasts and ankles. This pain may be accompanied by other premenstrual symptoms such as lethargy, depression and irritability [Chesney & Tasto, 1975b, p. 245]. Since these are two different types of dysmenorrhea, a given treatment m a y not be effective for both types. Chesney and Tasto (1975b) showed that progressive relaxation and imagery was an effective treatment for spasmodic dysmenorrhea. Their treatment was not effective for congestive dysmenorrhea. This case study explores the use of skin temperature biofeedback and autogenic training in treating spasmodic dysmenorrhea. Biofeedback has been shown to be an effective tool in the treatment of stress-related disorders (Birk, 1973; Coursey, 1975; Cox, Freundlich, & Meyer, 1975; Reinking & Kohl, 1975). In this process, an aspect of body functioning is measured and the patient is provided with information concerning changes in that parameter. Skin temperature is a useful variable in stress-related disorders. It is a function o f blood flow in the periphery, which, in turn, is an inverse function of sympathetic activation. H a n d temperature, given constant environmental temperature and control of artifacts, provides an index o f arousal (Forsyth, 1974). Subjects who are able to warm their hands, especially those who are able to w a r m them to between 95 ° and 96°F (35 ° to 35.6°C), report a pleasant state of relaxation. The addition o f Autogenic Training Phrases results in an expeditious and effective treatment tool (Green, Green, & Waiters, 1974). The phrases utilized in autogenic training help the patient to focus upon sensations associated with p r o f o u n d relaxation (Luthe, 1969). Attending to the phrases sets the stage for reduction in sympathetic activation and for an increase in skin temperature. The patient is informed of the changes in temperature by the feedback apparatus, and learning occurs.
SUBJECT The patient was a 29-year-old single, white female with no medical complaints other than dysmenorrhea. This disorder had been present since
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menarche at the age of 11 years. Her menstrual periods lasted an average of 7 days, with spotting for the first 2 days and heavy flow on the third and fourth days. The periods were regular in length and occurrence. The patient completed the Minnesota Multiphasic Personality Inventory before entering treatment. The profile of her scores suggested that she was a reserved person who was mildly depressed at the time of examination. The patient had undergone extensive examinations for gynecologic origins of her dysmenorrhea. None was found, and primary dysmenorrhea was diagnosed. Hormone therapy and analgesics gave no relief; however, the patient continued her use of acetaminophen (Tylenol) during the period of study.
APPARATUS The Menstrual Symptom Questionnaire developed by Chesney and Tasto (1975a) was used to classify the patient's dysmenorrhea. This questionnaire contains 25 statements typical of either congestive or spasmodic dysmenorrhea. The patient rates each statement as typical or not typical of herself along a five-point scale. Symptoms were rated by the patient on the Symptom Severity Scale (Chesney & Tasto, 1975b). This scale measures 15 symptoms on a five-point scale of intensity. Electromyographic assessment was obtained with an Autogen 1700 Feedback Myograph. Hand temperature was obtained with an Autogen 2000 Feedback Thermometer; both pieces of apparatus are manufactured by Autogenic Systems of Berkeley, California.
PROCEDURE
The Symptom Severity Scale was completed after each of two menstrual periods to serve as a pretreatment baseline. Two biofeedback evaluations were also done during this time, one in midcycle and one during her menstrual period when she was experiencing discomfort. Eight 50-minute sessions of hand-temperature biofeedback training were given after the second baseline menstrual period. Twice-daily home practice with the autogenic phrases was emphasized because the authors believe that such practice facilitates the acquisition of hand-warming skills. Training sessions were discontinued when the patient was able to maintain a temperature of 95.5°F (35.3°C). The Symptom Severity Scale was completed at the end of each menstrual period.
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RESULTS The patient had a score of 84 on the Menstrual Symptom Questionnaire (MSQ). The midpoint for the MSQ is 77. Scores greater than 77 suggest that the patient has a spasmodic type of dysmenorrhea, and scores lower than 77 suggest that the patient has a congestive type of dysmenorrhea. Comparing this patient's score with the norms provided by Chesney and Tasto (1975a) classified the patient's dysmenorrhea as spasmodic. During the first 50-minute biofeedback evaluation prior to treatment, which occurred in midcycle, the range of frontalis muscle activity was 1.2-3.3/aV (integral average microvolts, bandpass 100-200 Hz), and the range of hand temperature was 89-94.7°F (31.7-34.8°C). The second 50-minute evaluation, when she was experiencing discomfort, indicated fairly low frontalis activity (1.2-1.5/aV), but skin temperature suggested mild sympathetic activation (88-92°F, 31.1-33.3°C). Hand-temperature biofeedback was used during the eight 50-minute treatment sessions, which were begun at the end of the second baseline menstrual period. No EMG feedback was given after the baseline sessions. At the end of the eight training sessions, the patient was able to maintain a hand temperature above 95.5°F (35.3°C) with her eyes open and no machine feedback. The mean for the two pretreatment scores on the Symptom Severity Scale (SSS) was 38.5 points. The scores for the 2 months of follow-up were 25 and 24 points, respectively, indicating a reduction in menstrual discomfort. (The highest score possible on the SSS is 75 points, and the lowest score possible is 15 points.)
DISCUSSION In addition to the data that indicated relief of menstrual discomfort, the patient reported additional evidence of relief. She has not had to take a day of sick leave during her menstrual period as she had routinely done before treatment. The patient's data compare well with data from Chesney and Tasto (1975b). Their pretreatment mean on the Symptom Severity Scale was 42.3 points, and their posttreatment mean was 28.5 points. These data suggest that biofeedback-assisted relaxation may offer an effective alternative treatment for primary dysmenorrhea. These findings also suggest that one may not need to emphasize reduction of muscle tension in treatment of spasmodic dysmenorrhea. An evaluation of the parameters that reflect anxiety in the patient being treated can suggest the best treatment modality.
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The patient treated in the present study obtained reduction of her menstrual discomfort from hand-temperature biofeedback training and autogenic relaxation. Desensitization using visual imagery of the stimuli surrounding the onset of the menstrual period, an important component of the treatment used by Chesney and Tasto (1975b), was not used. Further research should provide information as to the generality of these findings and address the question as to whether biofeedback-assisted relaxation training would be effective with congestive dysmenorrhea.
REFERENCES Birk, L. Biofeedback: Behavioral medicine. New York: Grune & Stratton, 1973. Chesney, M. A., & Tasto, D. L. The development of the Menstrual Symptom Questionnaire. Behaviour Research and Therapy, 1975, 13, 237-244. (a) Chesney, M. A., & Tasto, D. L. The effectiveness of behavior modification with spasmodic and congestive dysmenorrhea. BehaviourResearch and Therapy, 1975, 13, 245-253. (b) Coursey, R. D. Electromyograph feedback as a relaxation technique. Journal of Consulting and Clinical Psychology, 1975, 43, 825-834. Cox, D. J., Freundlich, A., & Meyer, R. G. Differential effectiveness of electromyograph feedback, verbal relaxation instructions, and medication placebo with tension headaches. Journal of Consulting and Clinical Psychology, 1975, 43, 892-898. Dalton, K. D. The menstrual cycle. New York: Pantheon Books, 1969. Forsyth, R. P. Mechanisms of the cardiovascular responses to environmental stressors. In P. A. Obrist, A. H. Black, J. Brener, & L. V. Di Cara (Eds.), Cardiovascular psycho-
physiology: Current issues in response mechanisms, biofeedback, and methodology. Chicago: Aldine, 1974, pp. 211-225. Green, E. E., Green, A. M., & Waiters, E. D. Biofeedback training for anxiety and tension reduction. Annals of the New York Academy of Sciences, 1974, 233, 157-161. Luthe, W. A utogenic therapy. Vol. 1: A utogenic methods. New York: Grune & Stratton, 1969. Mullen, F. G., Jr. The treatment of a case of dysmenorrhea by behavior therapy techniques. Journal of Nervous and Mental Disease, 1968, 147, 371-376. Mullen, F. G., Jr. Treatment of dysmenorrhea by professional and student behavior therapists. Paper presented at the Fifth Annual Meeting of the Association for the Advancement of Behavior Therapy, Washington, D.C., September 1971. Reinking, R. H., & Kohl, M. L. Effects of various forms of relaxation training on physiological and self-report measures of relaxation. Journal of Clinical and Consulting Psychology, 1975, 43, 595-600. Tasto, D. L., & Chesney, M. A. Muscle relaxation treatment for primary dysmenorrhea. Behavior Therapy, 1974, 5, 668-672. (Revision received March 6, 1978)
