Self-Awareness and Symptom Evaluation: Observations from the Seattle Midlife Women’s Health Study

Abstract

Approximately 65% - 75% of women experience one or more symptoms during the menopausal transition (MT) (Santoro, 2008), and much research has focused on hot flash (HF) frequency. However, individual women experience hot flashes at different levels of intensity and bother – not every HF is equally problematic. For this reason, examining HF severity is important. HF severity is an evaluation of perceived sensory information (physiologic symptoms) that is a separate and distinct process from physically registering those symptoms (Petersen, van den Berg, Janssens, & Van den Bergh, 2011). A cognitive model of symptom perception has been developed that includes concepts such as anxiety, stress, beliefs, and perceptions about the menopausal transition (Hunter & Chilcot, 2013). However, this model does not include self-awareness. An as yet unexplored and unanswered question is whether self-awareness might have a role in symptom evaluation. Self-awareness is posited as a possible component in symptom evaluation due to its identification as part of what “works” in yoga interventions (Gard, Noggle, Park, Vago, & Wilson, 2014). Yoga has been associated with decreased HF bother and unchanged HF frequency (Booth-LaForce, Thurston, & Taylor, 2007). It seems plausible that self-awareness might have a role in symptom evaluation in settings beyond yoga intervention trials. The purpose of this dissertation project is to explore self-awareness and its potential role in symptom evaluation. Two subscales from the Self-Consciousness Scale (Internal State Awareness and Self-Reflectiveness) are utilized to explore self-awareness. Additional concepts to be tested in a causal model of effects on HF severity are attitudes towards menopause, health perceptions, stages of reproductive aging, anxiety, and stress. The first paper is a concept analysis of self-awareness, differentiating it from interoception, mindfulness, somatosensory amplification, and disassociation. Results include the defining attributes of self-awareness to be self-directed perception, interoception, emotion, and physicality. In all articles reviewed, it was clear that self-awareness always involved self-directed perception. The focus was on the self, not on others or one’s environment. Interoception has been described as “the material me” (Cameron, 2001). The action of perceiving sensations such as coolness, warmth, heartbeat, dyspnea, and thirst are not only physical, somatic experiences. Interoception is both unconscious (the nervous system regulating heart rate) and conscious. Self-awareness is an emotional experience, too. We do not solely perceive coolness or warmth, we also relate to the temperature (coolness feels very differently if we are in the snow or if we are on a sunny beach). Likewise, feeling a sensation of warmth may be very appealing and comforting (an emotional experience) if we have just taken a plunge into cold water on New Year’s Day (Fogel, 2009). Physicality refers to the fact that, literally, a person must be alive, with physical and mental functions intact, in order to be self-aware. Also identified were antecedents (developmental process, age, education, bodily integrity, cognitive functioning, functional capacity of the nervous system to interocept, capacity to perceive and reflect) and consequences (evaluation of symptoms along a continuum from mild to moderate to severe, bothersome, or interfering). Self-awareness may influence subsequent health-seeking behaviors (practicing self-care, seeking healthcare, or pursuing unhealthy behaviors to mask/evade perceived symptoms). Empirical referents indicate how a researcher might test this concept “in the real world” and are indicated by questionnaires that have been designed to measure self-awareness (Self-Consciousness Scale; Somatic Interpretation Questionnaire; Multidimensional Assessment of Interoceptive Awareness). The second paper tested the factor structure of the Self-Consciousness Scale (SCS) using confirmatory factor analysis (CFA). The purpose of this analysis was to ascertain the validity of the SCS in the Seattle Midlife Women’s Health Study dataset. If deemed valid, the SCS data would then be used in building and testing a causal model of HF severity. The SCS was developed by Fenigstein, Scheier, and Buss (1975), and has been used in multiple studies since it was first introduced. A four-factor model was hypothesized to best fit the data. Also hypothesized was that construct validity could be established for ISA and SR subscales with associated psychological concepts such as depression, anxiety, somatic amplification, and coping. ISA has been defined as balanced self-awareness and indicates a positive or neutral state of self-evaluation (Anderson, Bohon, & Berrigan, 1996; Trapnell & Campbell, 1999). SR has been defined as self-oppression, a ruminative type of self-mistrust (Anderson et al., 1996), and is positively correlated with depression, anxiety, and low self-esteem (Anderson et al., 1996; Chang, 1998; Trapnell & Campbell, 1999). The four-factor model displayed poor fit indices (CFI = .81; TLI = .79; RMSEA = .07). However, good fit indices were found for individual subscales ISA (CFI = 1.00; TLI = 1.03; RMSEA ≤ 0.001) and SR (CFI = 1.00; TLI = 1.03; RMSEA ≤ 0.001), and for ISA and SR tested together (CFI = .95; TLI = .94; RMSEA = .05). The ISA and SR subscales appear to validly measure distinctly different concepts and merit use in further studies. The third study built and tested a model of hot flash severity using structural equation modeling. Independent variables of ISA, SR, anxiety, health perceptions, attitudes toward menopause, stages of reproductive aging, and stress were evaluated for effects on HF severity. Maximum likelihood estimation was used to estimate missing data. Results in a trimmed model included significant pathways from ISA (β = .17), stages of reproductive aging (β = .20), and attitudes toward menopause (β = -.15) directly affecting HF severity. SR showed direct effects on stress (β = .51), and stress demonstrated direct effects on anxiety (β = .63) and attitudes toward menopause (β = -.30). Covariance between ISA and SR was significant (β = .62). Results from these papers suggest that ISA and SR are distinct concepts with different effects on HF severity. ISA directly effects HF severity and SR indirectly effects HF severity via a predictive relationship with stress. Stress significantly effects anxiety and attitudes toward menopause, which then demonstrates a significant effect on HF severity. Future studies targeted at carefully defining and testing these concepts are merited. Specifically, perceived stress, attitudes, and anxiety are mutable causes that may be tested in intervention studies to determine efficacy in decreasing symptom severity.