Vulvodynia: a hidden women's health issue.

Vulvodynia, or chronic vulvar pain, is a common problem affecting women. Historically, cases of vulvodynia with no apparent physical explanation were seen as resulting from psychosexual factors. However, we now understand that vulvodynia is a chronic pain disorder that typically leads to problems in many areas of functioning, including sexual and psychological functioning.

In 2004, the International Society for the Study of Vulvovaginal Disease (ISSVD) defined vulvodynia as vulvar pain or discomfort, usually described as burning, that cannot be attributed to any physical problem such as inflammation or infection. (1) The ISSVD further designated two categories of vulvodynia, depending on the location of the pain. Localized vulvodynia refers to pain in a particular part of the vulvar area, such as the vestibule, whereas generalized vulvodynia refers to pain affecting the whole vulvar region. Each category is further divided according to the situation that elicits the pain: provoked (i.e., the pain is elicited by physical contact), unprovoked (i.e., the pain occurs independently of external stimulation, otherwise known as spontaneous pain), and mixed (i.e., the pain occurs in both provoked and unprovoked situations). Provoked pain can result from sexual activities (e.g., penile-vaginal intercourse), leading to pain during sexual intercourse--otherwise known as dyspareunia; it can also result from non-sexual activities (e.g., tampon insertion, gynecological examinations, sporting activities), or it can occur in response to both kinds of situations.

This paper will focus on the two most common types of vulvodynia, vulvar vestibulitis syndrome (VVS) and generalized vulvodynia (GVD). VVS refers to pain localized to the vulvar vestibule (i.e., the entrance of the vagina) in response to physical contact (2), and GVD describes spontaneously occurring vulvar pain affecting the entire vulvar area. When the term vulvodynia is used, it refers to all types of chronic vulvar pain in general. (3)

Recent epidemiological studies indicate that vulvodynia affects approximately 16% of women in the population; VVS affects 12% of pre-menopausal women, and GVD affects 6-7% of women, a large proportion of whom are over the age of 30. (4) Despite this prevalence, many women have never heard of vulvodynia and many health care providers and counselors lack the information they need to explain, diagnose, and treat this problem.

VULVAR VESTIBULITIS SYNDROME

VVS is believed to be the most common cause of dyspareunia in women of child-bearing age.

How is VVS diagnosed?

The most common complaint of a woman with VVS is that of dyspareunia. Many women, however, will not report this during a routine examination, and it is crucial that providers specifically ask about pain during intercourse. The pain should be carefully characterized in terms of location (e.g., at the entrance of the vagina versus the pelvic area), description (e.g., burning versus itching), and temporal pattern (e.g., provoked or unprovoked). Asking questions such as these will serve to both validate the pain experience of the patient and aid in diagnosis. In addition, these questions may allow for the classification of VVS as either primary (i.e., the pain has been present since the first intercourse attempt) or secondary (i.e., the pain developed after a period of pain-free intercourse). Clinical studies suggest that an equal number of women have primary and secondary forms of VVS. (5)

As we know, many women have limited knowledge of their vulvar anatomy; a diagram is often helpful in localizing the pain and assessing its patterns during particular activities. Providers should also ask questions about past treatments, previous diagnoses, and remedies that have helped or exacerbated the pain, as these are key in obtaining a complete picture of the problem. Furthermore, careful questioning about how the pain has affected the patient's relationships, sexual functioning, psychological well-being, and overall quality of life will provide a more thorough understanding of the pain and clarify potential treatment options. (6)

During the physical examination, it is important to search for potential causes for the pain (e.g., infections, dermatological conditions, sexually transmitted diseases). If potential factors are found, they must be treated; however, the pain may remain. The standard gynecological tool for diagnosing VVS is the cotton-swab test, which consists of the palpation of various areas of the vulvar region with a cotton-swab. (7) If the patient reports pain when pressure is applied to the vestibule, then the diagnosis of VVS is made. The cotton-swab test is usually performed in a clockwise manner around the vestibule. Research has shown that pain ratings increase with each successive palpation (8); therefore, clinicians should consider a randomized order of cotton-swab palpation to avoid sensitization of the vulvar vestibule and to avoid causing unnecessary pain to the patient. There are also devices, such as the vulvalgesiometer, that allow for the application of known pressures, which can be useful in a research context. (9)

What causes VVS?

There is no simple answer regarding what causes VVS, although numerous theories have been proposed. (10) One of the most consistently reported findings associated with the onset of VVS is a history of repeated yeast infections. (11) It is not clear, however, whether the yeast itself, the treatments undertaken to remedy the infections, or a combination of both is responsible. (12) It is clear that unnecessary treatment for yeast can aggravate the problem, and it is important that both women and health care professionals understand that treatment should not be undertaken without confirmation of an existing infection. (13)

A second theory posits that altered tissue properties in the vestibule may play a role in the development and/or maintenance of VVS by rendering it more sensitive to stimulation. Research has found that the vestibular tissue of women with VVS has increased inflammatory mediators (14) (although this has been debated (15)), increased nerve fibre innervations (16), increased pain receptors (17), increased blood flow (18), and increased pain-related peptides. (19) These changes could lead to a heightened sensitivity in response to vestibular pressure, as has been shown in recent studies (20), which is consistent with the clinical picture of provoked pain in VVS. Taking a cotton-swab and touching different areas of the vestibule in a non-affected woman is perceivable but not typically painful; however, this same stimulation in the vestibule of a woman with VVS is perceived as highly painful and distressing.

Factors outside the vulvar vestibule have also been suggested as playing a role in VVS. Women with VVS have been found to exhibit an increase in pelvic floor muscle tension (21), possibly representing a protective reaction against, or a conditioned response to, vulvar pain. It is not clear, however, whether the tension leads to the pain, or results from the pain. Other studies examining sensitivity outside the vulvar vestibule have reported that women with VVS are more sensitive to stimulation in general: they are more sensitive to touch, pain, pressure, manual palpation, and heat pain in areas such as the deltoid muscle and forearm (22) and report more non-vulvar pain complaints (23) than non-affected women. These results are consistent with several studies of chronic pain patients, such as those with chronic headache (24), migraine (25), temporomandibular disorder (26), and fibromyalgia (27), in which heightened sensitivity outside the area of primary complaint has been documented. Further supporting the generalized nature of the pain of VVS are findings from a recent brain imaging study, indicating that women with VVS process sensory information in an augmented fashion, as do patients with other pain conditions causing hypersensitivity. (28) These results reveal that a more generalized pain process, involving both local and central nervous system (i.e., the brain and spinal cord) mechanisms, may be involved in the initiation and maintenance of VVS.

One potential explanation for this increase in general sensitivity in women with VVS is that of genetic involvement. (29) Recent studies have found that women with VVS have a genetic profile associated with a severe and prolonged pro-inflammatory immune response. Based on these findings, the authors proposed that, in some women with VVS, there is a genetic susceptibility for the development of a chronic localized inflammation in the vestibule after an initial inflammatory response has been triggered (e.g., after yeast infections). The prolonged and intensified inflammation could then trigger other events that may result in increased pain sensitivity due to chronic inflammation in both genital and non-genital areas of the body.

Hormonal factors could also have systemic effects. Studies have shown that women who used oral contraceptives at a young age have an increased risk of developing VVS later in life. (30) Early menarche and dysmenorrhea were also associated with increased risk. (31) These findings suggest that genetic and hormonal factors may play a role in VVS, but the question of how remains to be answered.

Other theories point to psychosocial (i.e., non-physical) factors such as distress, anxiety, depression, low sexual self-esteem, harm avoidance, somatization, shyness, hypervigilance, and pain catastrophization, (32) which have also been found in women with VVS. It is not clear whether these factors predate or develop after the pain; regardless, it is important to investigate the role of these factors in the maintenance of the pain since they may effect pain perception. (33)

It is surprising that despite the significant impact of VVS on sexual functioning, the examination of relationship factors has been limited. Seventy-four percent of women with VVS report that the pain impacts their relationships (34) although they do not typically report significant levels of couple distress. In addition, high relationship adjustment is related to decreased pain severity in women with dyspareunia. (35) Relationship distress is associated with psychosocial attributions for the pain, suggesting a possible interaction between pain coping style and relationship adjustment. (36) In terms of negative relationships involving sexual abuse, many studies comparing women with VVS to non-affected women show no differences in the prevalence of sexual abuse (37); however, a recent epidemiological study linked vulvodynia with experiences of childhood violence. (38)

How can VVS be treated?

Regardless of the cause of VVS, many areas of these women's lives must be addressed in order to achieve therapeutic success. These areas include pain as well as any muscular, psychological, sexual, psychosocial, and relationship issues. Potential treatment options include medical interventions, pelvic floor biofeedback and physical therapy, and cognitive-behavioral therapies.

Medical Interventions

Medical treatments targeting the vulvar vestibule consist of several options, such as topical, injectable, systemic, and surgical interventions. Topical interventions, such as the application of lidocaine and corticosteroid creams, have led to some success in a subset of women with VVS, but overall, the data are not convincing. Whereas a recent study found that long-term lidocaine ointment application decreased pain scores and re-established sexual activity in a group of VVS sufferers (39), a more rigorous placebo-controlled study of the effectiveness of cromolyn (antihistamine) cream (40) did not reveal any evidence of effectiveness. Other research has shown that the application of capsaicin (the active ingredient in hot peppers) to reduce the response of pain receptors in the vulvar vestibule region led to partial relief in women with VVS. (41) Given both the severe burning experienced shortly after capsaicin application (despite pre-treatment with anesthetic cream) and the long-term nature of this treatment, the authors suggested that this treatment be used as a last resort.

Injections of interferon (42), lidocaine in combination with methylprednisone (43), and botulinum toxin (44) were also found to be of some value in small studies. Systemic medications for treating VVS, although an option, have not been thoroughly investigated in the empirical literature. One recently published randomized trial revealed that oral antifungal medication was ineffective for treating VVS. (45)

Long-term follow-up data and randomized clinical trials are needed to fully assess the effects of these topical, injectable, and systemic medical treatments, as there is some concern that they may cause more harm than benefit. (46) Unfortunately, there is no empirical evidence for the success of any oral medication, such as anti-depressants, for the pain of VVS; however, there is some evidence that low-dose antidepressant medication can be an effective treatment for the pain of GVD (see below).

Surgical intervention has also been proposed for the treatment of VVS. Surgical removal of the vestibule (vestibulectomy) has been the most investigated treatment for VVS to date with more than 20 published outcome studies, yielding success rates ranging from 43-100%, with most of the rates typically surpassing 65-70%. (47) This procedure involves the removal of the sensitive tissue of the vestibule. It is a minor surgical procedure, preformed as a day surgery under general or spinal anesthesia, and consists of the excision of the hymen and of the vestibule surrounding the vaginal opening. There are many variations of the surgery (48), with some involving mobilization of the vaginal mucosa to cover the excised area. Following this procedure, women are generally instructed to abstain from all forms of vaginal penetration for 6 to 8 weeks. Because of its invasive nature and because it does not result in 100% success, many health professionals recommend the surgery only after other less invasive treatment options fail.

Pelvic Floor Biofeedback and Physical Therapy

VVS has been associated with an increase in pelvic floor muscle tension. (49) Targeting the pelvic floor musculature through pelvic floor biofeedback and physical therapy in an effort to reduce this tension has been found useful for the treatment of VVS. In pelvic floor biofeedback training, patients use a vaginal sensor and a monitor that provide a direct measure of their muscle tension. This can be used to promote muscle training with respect to contraction, relaxation, and the acquisition of voluntary control. After approximately four months of biofeedback training, it was reported that vulvar pain decreased and sexual functioning increased in women with VVS. (50)

Physical therapy often combines a biofeedback component with soft tissue mobilization and other techniques. The effectiveness of this approach has recently been evaluated in a retrospective study of VVS. (51) Results indicated that after an average of seven sessions, physical therapy yielded moderate to great improvement in over 70% of participants. Treatment resulted in significant pain reduction during sexual intercourse and gynecological examinations, and led to improvements in intercourse frequency and levels of sexual desire and arousal. These findings indicate that physical therapy is indeed a promising treatment for women who suffer from VVS, although prospective studies are needed.

Cognitive-Behavioral Interventions

Cognitive-behavioral treatments for VVS include cognitive-behavioral pain management and sex therapy to reduce pain and restore sexual functioning. Success rates ranging from 43-86% have been reported in two uncontrolled studies in which sex therapy and pain management were combined. (52) A prospective and partially randomized treatment outcome study investigating the effectiveness of behavioral intervention with or without surgery (53) indicated that women in both groups reported decreases in pain; there were no significant differences between women who had undergone the behavioral intervention alone versus those who underwent the behavioral intervention combined with surgery. The authors suggest that the behavioral approach should be the first line of treatment for women with VVS, and the surgery should be reserved for refractory cases given its invasive nature.

A recently published randomized treatment outcome study of VVS comparing vestibulectomy, group cognitive-behavior therapy, and pelvic floor biofeedback (54) indicated that, at post-treatment and 6-month follow-up, women in all three treatment groups reported significant pain reduction. However, vestibulectomy resulted in approximately twice the pain reduction of the two other treatments. In terms of sexual functioning, there were significant improvements in overall sexual functioning and self-reported frequency of intercourse from pre-treatment to the 6-month follow-up for all three groups; however, means for intercourse frequency remained below those of healthy women in the same age range. These findings indicate that restoring sexual functioning in women with VVS may require attention over and above that of pain reduction. While the vestibulectomy was the most effective at reducing pain, it was not significantly better at restoring sexual functioning. In a two-and-a-half year follow-up of this study (55), women in all three treatment groups continued to improve. Vestibulectomy remained superior to the other two groups with respect to pain ratings during the cotton-swab test, and women who had undergone group therapy reported similar improvements in dyspareunia as those who had undergone vestibulectomy. Changes in overall sexual functioning and intercourse frequency were maintained, with no group differences. These results suggest that while the benefits of group therapy may take longer to appear, it can be just as effective as surgery in reducing the pain of VVS.

Alternative Treatments

Alternative treatments for VVS include acupuncture and hypnotherapy. Although few studies currently exist, there is promising data regarding the effect of acupuncture on pain reduction and overall quality of life. (56) In addition, one study indicated that hypnosis reduced pain and helped re-establish sexual pleasure in a woman with VVS. (57)

GENERALIZED VULVODYNIA

Even though GVD is the second most common form of vulvodynia, there is relatively little clinical expertise in and research on this condition.

How is GVD diagnosed?

The diagnosis of GVD is one of exclusion and is based on the description, quality, and location of the pain. GVD is a non-cyclic, chronic vulvar pain extending to the urethral and rectal area, typically characterized by the patient's complaint of burning. (58) The pain of GVD occurs independently of stimulation, although light touch may exacerbate the pain. Some women with GVD also have VVS, but estimates of comorbidity have yet to be reported. For the diagnosis of GVD, it is important to rule out a dermatological condition called pruritus vulvae, which affects the same region as does GVD, but is characterized by an itching sensation and skin changes, such as excoriation and erythema (i.e., redness). (59) McKay (60) recommends the following evaluation for GVD: examination of the skin for dermatoses and a careful search for infectious agents likely to cause inflammation. This should be followed by a nerve assessment and by a careful anatomic distribution of involved areas, since locations and patterns of discomfort have been shown to be important in differential diagnosis.

What causes GVD?

The onset of GVD is usually acute, without a precipitating event. When such an event is recalled, it is often linked to episodes of local treatments, such as vulvar cream application or laser surgery. (61) Unfortunately, little is known about the cause of GVD. McKay (62) proposed that the pain results from altered skin perception, such as in neuropathic pain syndromes. This perspective has gained support because patients with GVD and those with neuropathic pain both report experiencing spontaneous, burning pain. In addition, GVD patients report symptom reduction when they are treated with medications typically prescribed for neuropathic pain (63), such as amitriptyline, a tri-cyclic antidepressant prescribed at low doses for pain control (64) (see below). Neuropathic pain originates with an injury to the nervous system itself, which leads to the transmission of pain signals even when acute injury is no longer present. Neuropathic pain in the vulva can result from many situations, such as damage to sensory nerves during surgery; damage to the pudendal nerve due to sports trauma, childbirth, or vaginal surgery; referred pain (i.e., when injury in one area causes pain in a different body area) from muscles or joints; and spinal cord injuries. (65)

In terms of other potential causes, as in the case of VVS, women with GVD have been found to exhibit abnormalities in pelvic floor functioning (66), which could potentially play a significant role in the initiation and maintenance of GVD; however, the direction of causation is not known. GVD has not been shown to be associated with clinical levels of depression (67) or with higher than normal instances of sexual or physical abuse (68), although vulvar pain in general may be related to episodes of childhood violence. (69)

How can GVD be treated?

Little information exists with respect to validated treatments for GVD. Oral medications for the treatment of neuropathic pain, such as amitriptyline and gabapentin, have been shown effective in reducing pain in women with GVD. (70) In addition, given the abnormalities in the pelvic floor musculature of women with GVD (71), pelvic floor muscle rehabilitation via the use of biofeedback led to reduced pain and improved sexual functioning in women with GVD. (72) However, no randomized controlled trials have been conducted to date with respect to any treatment for GVD. Despite the lack of knowledge concerning valid treatments for this condition, there is much agreement that it should be multidisciplinary (73), as in the case of VVS.

THE EXPERIENCE OF WOMEN WITH VULVODYNIA

Although common, many vulvodynia sufferers do not pursue treatment because of the embarrassment associated with talking about genital pain and its effects on sexual functioning. Of those who do seek treatment, many unfortunately do not receive adequate care: 40% of women with vulvar pain who sought medical attention did not receive a diagnosis even after multiple consultations. (74) These women may also be told, after several potentially invasive and painful evaluations, that all is well physically, implying that their pain is "not real" and that they suffer from psychological problems. Added to this frustrating situation may be a referral to a psychologist or psychiatrist who may focus on psychosocial functioning without fully addressing the complaint of vulvar pain. (75)

It is important to note that many chronic pain patients present without physical findings, as in the case of back pain (76), and that the diagnosis of vulvodynia can only be made in the absence of physical findings. (77) The lack of physical findings does not mean that the pain is imagined. While sexual, psychosocial, and psychological functioning are negatively affected in women with vulvodynia, they are likely the result of the pain as opposed to its cause, and treatment should address all areas of functioning, with a particular emphasis on pain management. (78)

In addition to problems encountered in the health care system, women with vulvodynia suffer from negative impacts on their psychosocial functioning and quality of life. Psychological distress, including depression and anxiety (79) are often reported. Pain-related changes in self-esteem and self-confidence, body image, and femininity have also been found. (80) Women with vulvodynia, especially those with VVS, also report that the pain significantly affects their sexual functioning and relationship adjustment.

Studies have found that women with vulvodynia report lower levels of sexual desire, and lower intercourse and orgasmic frequency, lower ratings regarding quality of sexual functioning, lower sexual self-concept and marital satisfaction, and more negative feelings about themselves and their sexual partners as compared with non-affected women. (81) Although many women with vulvodynia stated that intercourse exacerbated their vulvar pain, only a minority reported that the pain prevented intercourse. (82) In one study, vulvodynia sufferers who reported engaging in intercourse were found to do so for many reasons: 27.3% cited that they felt obligated to please their partner and 19.2% reported that the emotional and physical pleasure derived from such intimacy with their partner outweighed the pain. (83) Sexual activities outside of vaginal intercourse, such as masturbation and oral sex, do not elicit pain frequently in women with vulvodynia, and one study showed that women with vulvodynia engaged in these activities as often as did control women. (84) However, another study found that women with vulvodynia reported engaging in less non-penetrative forms of foreplay despite their acknowledgement that such activities did not elicit vulvar pain. (85) This suggests that affected women may avoid a large array of "safe" (i.e., non-painful) sexual activities.

Many studies have investigated sexual functioning in women with VVS, likely due to the fact that sexual intercourse is the most frequent and direct cause of the pain. VVS was found to alter sexual functioning to a large degree: 78% of women reported changes in sexual activity and satisfaction after pain onset, with most stating that they felt less able to participate in sexual activity. (86) Indeed, VVS was associated with the lowest overall level of sexual functioning and the lowest frequency of sexual intercourse compared to women with other types of dyspareunia and to control participants. (87) In particular, women with VVS reported lower levels of sexual desire, arousal, satisfaction, and pleasure, less vaginal lubrication, and lower frequencies of orgasm and masturbation. As well, they reported higher levels of erotophobia (i.e., feelings of guilt and fear related to sex) and negative feelings towards sex than control women. (88) Consistent with the high levels of erotophobia, other studies have found that women with VVS were less likely to make sexual advances, more likely to participate in sexual activity without wanting to, and more likely to report feeling guilty or inadequate as a result of not being able to perform sexually. (89) In a study comparing sexual functioning of women with VVS and GVD, no differences were found in frequency or type of sexual behaviors (i.e., sexual intercourse, orgasm frequency, fellatio, and cunnilingus) or the level of importance placed on vaginal intercourse. Pain-related changes in sexual functioning were rated as impaired when compared to the pre-pain levels of sexual functioning in women with VVS and GVD, and to current levels of sexual functioning in a control group. (90)

Women with VVS also reported negative effects on relationship adjustment. Although one study found no differences in relationship adjustment as compared with control women (91), another study reported overall ratings of "poor" regarding relationship quality in women with VVS as compared with controls, who rated their relationship quality as "above average." (92) More than 40% of women with VVS reported severe, negative changes in their sexual relationship with their partners. (93) These findings may be related to feelings, on the part of the VVS sufferer, that their partners are less sexually satisfied (94), that they themselves are less sexually desirable to their partner, and that they feel less able sexually to satisfy their partner. (95) Despite reports of overall increased stress with their partners, women with VVS rate their partner as supportive. (96)

Given the physiological, cognitive, affective, and interpersonal complexity of vulvodynia, it is likely that no one "cure" will be found. A multi-modal treatment approach, tailored to each patient, and including careful assessment of the different aspects of the pain experience is recommended. Clinicians should also educate their patients as to the multidimensional nature of chronic pain so that the treatment of psychological or relationship factors is not experienced as invalidating. (97) Although pain reduction is an important goal, sexual functioning should also be worked on simultaneously through individual or couple therapy, as it has been shown that pain reduction does not necessarily restore sexual functioning. (98) Indeed, vulvar pain can have on negative effects on multiple aspects of life--but there is hope for women suffering with vulvodynia.

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50. Glazer, Rodke, Swencionis, et al (1995).

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60. McKay(1992).

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69. Harlow and Edwards (2005).

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73. Pukall CF, Payne, Kao, et al (2005).; Wesselmann and Reich (1996).; Wesselmann, Burnett, Abramovici, et al (1997).1; McKay (1989).

74. Harlow, Wise, Stewart (2001).

75. Pukall, Payne, Kao, et al (2005).

76. RA Deyo, "Early diagnostic evaluation of low back pain," Journal of General Internal Medicine 1(1986):328-338.

77. Moyal-Barracco and Lynch (2004).

78. Pukall, Payne, Kao, et al (2005).

79. Meana, Binik, Khalife, et al (1997).; S Sackett, E Gates, C Hekman-Stone C, et al., "Psychosexual aspects of vulvar vestibulitis," Journal of Reproductive Medicine 46 (2001):593-598.

80. Sackett, Gates, Hekman-Stone, et al (2001).

81. BD Reed, AP Advincula, KR Fonde, et al., "Sexual activities and attitudes of women with vulvar dysesthesia," Obstetrics and Gynecology 102 (2003):325-331.; RM Masheb, E Brondolo, RD Kerns, "A multidimensional, case-control study of women with self-identified chronic vulvar pain," Pain Medicine 3 (2002):253-259.

82. Reed, Advincula, Fonde, et al (2003).

83. AS Gordon, M Panahian-Jand, F McComb, et al., "Characteristics of women with vulvar pain disorders: responses to a web-based survey," Journal of Sex and Marital Therapy 29 (s) (2003):45-58.

84. Reed, Advincula, Fonde, et al (2003).

85. Gates and Galask (2001).

86. Sackett, Gates, Hekman-Stone, et al (2001).

87. Meana, Binik, Khalife, et al (1997).

88. Reed, Advincula, Fonde, et al (2003).; Gates and Galask (2001).; D Nunns and D Mandal, "Psychological and psychosexual aspects of vulvar vestibulitis," Genitourin Medicine 73 (1997):541-544.; Meana, Binik, Khalife, et al (1997).; Sackett, Gates, Hekman-Stone, et al (2001).; Reed, Advincula, Fonde, et al (2003).; Nunns and Mandal (1997).; Danielsson, Sjoberg, Wikman (2000).; Reissing, Binik, Khalife, et al (2003).

89. Sackett, Gates, Hekman-Stone, et al (2001).; Reed, Advincula, Fonde, et al (2003).; Gates and Galask (2001).; Danielsson, Sjoberg, Wikman (2000).

90. Reissing, Binik, Khalife, et al (2003).

91. Ibid.

92. Gates and Galask (2001).

93. Sackett, Gates, Hekman-Stone, et al (2001).

94. Danielsson, Sjoberg, Wikman (2000).

95. Sackett, Gates, Hekman-Stone, et al (2001).

96. Ibid.

97. Pukall, Payne, Kao, et al (2005).

98. Bergeron, Binik, Khalife, et al (2001); Bergeron, Meana, Binik, et al (2003).

Caroline F. Pukall, PhD

Department of Psychology, Queen's University

Kingston, Ontario, Canada