ناخویشتن داری عاطفی زنان با سندرم قبل از قاعدگی Emotion Dysregulation of Women with Premenstrual Syndrome

The menstrual cycle is a normal physiological process that all women experience and is characterised by tightly orchestrated changes in the levels of ovarian estrogen and progesterone. Researchers have confirmed that diverse body systems (e.g., cardiovascular system1 , central nervous system2 , endocrine system1 , female reproductive system1 , and immune system3 ) are replete with estrogen receptors and that progesterone also acts on numerous tissues. Therefore, cyclically fluctuating levels of estrogen and progesterone have a significant biological effect on the female body, one with both physical and emotional ramifications1 . Studies related to the impacts of the menstrual cycle on women’s emotional changes have been primarily conducted among patients who suffer from premenstrual syndrome (PMS) and its severe predominantly psychological form: premenstrual dysphoric disorder (PMDD)2 . PMS is defined as a group of psychological and physical symptoms that regularly occur during the luteal phase of the menstrual cycle and resolve by the end of menstruation3 . PMDD is characterized primarily by a cluster of mood symptoms, especially depression, tension, anxiety, irritability, and fatigue, with five or more symptoms present during the luteal phase3 . The diagnosis of PMDD can only be made by having women prospectively monitor their symptoms for at least two consecutive symptomatic menstrual cycles4,5. Among Chinese women, the incidence of PMDD and PMS is 2.1% and 21.1%, respectively, and the most common symptoms are irritability, breast tenderness, depression, abdominal bloating and angry outbursts6 . Researchers found that women with PMS or PMDD had more negative mood, depression and irritability, but less positive mood as compared to healthy women during the premenstrual phase7 , made more negative judgements in a facial discrimination task during the premenstrual phase as compared to the postmenstrual phase8 , and had enhanced bilateral amygdala reactivity in comparison with healthy controls when exposed to emotional faces9 . It has been indicated that most of these premenstrual complaints reported by women with PMDD are related to heightened stress-sensitivity10. The aetiology and pathophysiology of PMS remain unclear. Some early studies attributed the cause of PMS to abnormal and excessive secretions of the reproductive hormones11. However, recent studies failed to find any significant difference between women with and without PMS in the concentrations of reproductive hormones9,12, which means PMS does not seem to be due to abnormal concentrations of sex steroids. Some researchers emphasize cognitive factors in the development of PMS. It is proposed that women with PMS may be interpreting physiological changes during the premenstrual phase in a negative way, and regarding them as threatening or depriving so that they feel anxious and depressed13. This hypothesis was supported by the efficacy of cognitive therapy in treating PMS and PMDD2,12,14,15. Furthermore, some researchers even argue that PMS is not a fixed unitary syndrome but an ongoing process of negotiation, and reframing  of symptoms as normal change can effectively reduce premenstrual distress16, thus implying the dysfunction of emotion-regulation based on cognitive change among women with PMS. The process model of emotion regulation17 declaimed that emotion may be regulated at different points in the emotion generative process, and emotion-regulation strategies differ in when they have their primary impact on the emotion-generative process. According to this model, strategies enacted at different stages of the emotion process rely on different skills and have different consequences for emotional experience, physiology, and behavior18. Reappraisal and suppression are two commonly used strategies for diminishing negative emotional reactions, which have been extensively operationalized within the model19. Reappraisal is a type of cognitive change, and it is defined as construing a potentially emotion-eliciting situation in non-emotional terms, while suppression is a type of response modulation, and it is defined as inhibiting ongoing emotion-expressive behavior. Researchers found that habitual emotion regulation may have an impact on individuals’ well-being and performance in emotion experience tasks19. The habitual use of reappraisal was related to greater positive affect, better interpersonal functioning, and higher well-being. By contrast, greater use of suppression was related to a less beneficial profile of emotional functioning20. Previous researches showed that cognitive reappraisal leads to the decreased expression of negative emotions and their behaviors21, decreased startle responses22 and attenuated autonomic responses21. Recent neuroimaging studies also revealed that the greater use of reappraisal in everyday life was related to decreased amygdala activity and increased prefrontal and parietal activity during the processing of negative emotional facial expressions23. Based on these findings, emotion dysregulation has long been thought to be a vulnerability factor for mood disorders24. However, little information is available regarding the impact of the emotion regulation on women with PMS25. Few studies to date evaluated the correlations between PMS and emotion regulation. With 47 papers relating to the influence of the menstrual cycle on the mental health of women, a meta-analysis conducted by Romans and his colleges indicated that 61.7% of the studies reported significant correlations between menstrual cycle and emotion regulation26. However, as far as we know, no study has directly tested emotion dysregulation among women with PMS. According to previous studies, the performance of emotion regulation can be assessed in three ways24: (1) habitual emotion regulation; (2) spontaneous emotion regulation; (3) instructed emotion regulation. The present study adopted the paradigm of Ehring et al.24. We first assessed the relationship between habitual emotion regulation and the severity of PMS via self-report questionnaires to investigate whether the habitual use of maladaptive emotion-regulation strategy was a vulnerable factor of PMS; secondly, we used sad film clips as emotion stimuli to investigate participants’ spontaneous choice of emotion regulation strategy and their regulation efficacy in the emotion-inducing situation; thirdly, we assessed participants’ performance when instructed to use reappraisal to regulate their emotions to reveal the difference in instructed emotion regulation between women with and without PMS. Four hypotheses were tested in the current study: (1) severity of PMS is negatively associated with the habitual use of reappraisal, but positively associated with the habitual use of suppression; (2) women with PMS have higher levels of reported spontaneous emotion suppression and lower levels of reported emotion reappraisal as compared to women without PMS in the spontaneous emotion regulation task; (3) women with PMS have reduced benefit from instructed reappraisal as compared to women without PMS in the instructed emotion regulation task; (4) the difference regarding the performance of emotion regulation between women with and without PMS occurs only in the premenstrual phase. As mentioned, menstruation is governed by estrogen and progesterone. Researchers have found that these two reproductive hormones may have an impact on the amygdala and prefrontal cortex, and thus may have effects on emotion processing and regulation27. In the present study, we collected each participant’s saliva sample on the day of the experiment, from which estrogen and progesterone levels were determined28,29. The hormone levels were used to confirm the phase in which each participant was on the date of the experiment, and we also investigated the relationship between emotion responses and hormone levels. Some researchers have indicated that the emotion dysregulation of individuals with mood disorders may manifest not as the failure in the regulation of self-reported negative emotion, but as the maladaptive physiological responses after emotion regulation30. Thus, in the current study, we used skin conductance level (SCL) as the physiological index of emotion regulation effects, which was widely used in the emotion regulation paradigm with sad film clips as emotion-inducing stimuli31,32.