margaret singer - psychological studies of allergic women (1962)

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Psychological Studies of Allergic Women

The Relation Between Skin Reactivity and Personality

BEN F. FEINGOLD, MX).,* FRANK J. GORMAN, M.A./f

MARGAR ET THAL ER SINGER, Ph.D.,J and KU RT SCHLESINGER, M.A.§

1 HE RE HAS BEEN long and con tinuinginterest in the interrelationships betweenpsychological events and the course of al-lergic disease. Both professionals and lay-men believe that psychological factors areimportant in allergic disease, but beyondthe level of gross agreement, opinions differvastly. Yet in spite of a lack of data outlin -ing the basic mechanisms involved in theinteractions between emotional-behavioralresponses and allergic conditions, most clini-cians have observed patients in whom someassociation between psychological eventsand the course of allergic disease was strong-ly indicated. The literature supporting thisview consists of reports of both conditioningstudies and of clinical and psychiatric ob-servations.

The conditioning studies are illustratedby the following. Her xhe ime r5 reportedthat he was able to prod uce asthma tic symp-toms in humans as a function of an environ-ment previously associated with allergensDekker and Groen2 reported similar obser-

vations. By utilizing a techn ique initiallyFrom the Alleigy Department of the Kaiser Foun-

dation Hospitals and the Pennanente NfedicalGroup.

*Kaiser Foundation Hospitals, San Francisco,Calif.

j-Langley Poiter Neuropsychiatric Institute, SanFrancisco, Calif

JAdult Psychiatry Branch, National Institute ofItfental Health, Bethesda, Md.

§Kaiser Foundation Hospital, San Francisco. Calif.Received for publication Mar. 6, 1961.

VOL. xxiv , NO. 2,1962

developed by Ratner et al.,vi Ottenberg et

al.,12 demonstrated that asthma-like symp-

toms could be produced in guinea pigsthrough the use of classic conditioning pro-cedures. In this same contex t, the studies ofLiddell,6 who observed respiratory disturb-ances in many "experimentally neurotic"animals, should be noted.

There are three clinical and psychiatricapproaches. Childhood relations have been

indicated to be important in the precipita-tion of allergic disease by French and Alex-ander,

4in their pioneer studies and more

recently by Miller and Baruch,9 in their em-phasis on mate rnal rejection. Secondly, thesuggestion that certain allergic patients ap-pear to have "emotional disturbances" wassupported by the work of McDermott andCobb,

8 Rogerson,34 and Tuft.15 Exponentsof the third approach report that psycho-therapy seems to have an ameliorative ef-fect upon allergy.7' ]

° .x l

Personality studies tend to emphasizechildhood response patterns carried over in-to adulthood, and traits, conflicts, or emo-tions which characterize persons with an al-lergic con dition are sought. Alt-hough manyinvestigators have suggested personality pat-terns associated with various allergic syn-dromes, no specific personality pattern hasbeen identified with all allergic conditions.On the whole, asthmatic subjects referredfor psychiatric treatment have been mostthoroughly studied. The other allergic con-



196

ditions have been less frequently explored,and allergic persons not undergoing psychi-atric treatment have been studied only rare-ly. Also, there are few overviews of the en-tire group of allergic subjects. Particularlyneglected has been the study, in an individ-ual, of the relationships between level ofskin reactivity to allergens, type of allergicsyndrome, and personality features. The de-gree of skin reactivity, although an impor-

tant part of the diagnostic evalua tion, tendsto be ignored in psychological studies, andlittle is known of the interrelationships, ifany, between skin reactivity, personality,and specific allergic syndromes.

We chose the latter as our area of study.It was thought that the results obtainedwould be enhanced by careful attention tothree aspects of experimental design: (1)more precise differentiation of subjects onthe basis of skin testing, especially sinceWittkower and Petow16 caution against de-scribing true allergic disease and nonreac-

tive allergic disease* as one and the samephenomenon; (2) utilization of psychologi-cal tests which provide both subjective andobjective measures of a wide variety of per-sonality characteristics; and (3) use of moreadequate, sensitive, and powerful statisticaltechniques for evaluating the data. A pre-liminary study was undertaken to explorethree questions of general interest:

Is there a personality pattern typical ofallergic subjects?

Are there different personality patternsfor groups with true allergic disease andwith nonreactive disease?

Are the various true allergic diseases asso-ciated with characteristic personality differ-ences?

Method

Forty patients constituted the initial sam-ple, which included only those patientswhose presenting complaint suggested the

*In this article, the teim "nonreactive allergic" is

applied to individuals presenting the symptomatol-

ogy of allergic disease but lacking confirmation by

positive skin tests Patients who show positive skin

reactions as well as clinical symptomatology are said

to have "true allergic disease."

A L L E R G Y A N D P E R S O N A L I T Y

presence of an allergic disease. These pa-tients had not been under treatment in theallergy department during the precedingyear and were not so acutely ill that hos-pitalization was required . In the interest ofgreater group homogeneity with respect tovariables of possible importance but not ofimmediate interest, only married womenbetween the ages of 20 and 40 were in-cluded. With these exceptions, no other re-

strictions were made, in the hope to achievean unselected sample with respect to diag-nosis, degree of skin reactivity, and thegroup of allergens involved. Th e mean ageof the group was 30.4 (S.D., 3.84). Of thesample, 35 were married and living withtheir first husband , and 5 had been divorcedand had remarried.

A t the initial visit, subjects were inter-viewed by a staff physician seeking an al-lergy-oriented history, and were given acomplete physical examination, at whichthe eyes, nose, throat, lungs, and skin were

examined carefully for findings suggestiveof allergic disease. If the history and physi-cal findings were suggestive of allergic dis-ease and the subject met the other criteriafor inclusion in the sample, she was referredto the psychologist, who requested the pa-tient's cooperation in research studies ex-ploring psychological aspects of allergic dis-ease; only 1 subject refused. The tests usedwere the Minnesota Mu ltiphasic P ersonalityInventory (MMPI) and the Rorschach test.On occasions, the Draw-a-Person test andselected Thematic Apperception Test cardswere used. Biographical data were also ob-

tained in a brief interview after the testing.Conc urrently with the psychological stud-

ies, the patient underwent allergy skin tests.In every instance, the pa tien t was skin-testedwith inhalant factors.* For the initial skin

•In ha lan t factors consisted of: (1) the epidermal

group, includ ing cotton lin ters, chicken feathers,

duck feathers, goose feathers, turkey featheis, cat

hair, cattle hair, dog hair, goat hair, hog hair, horse

hair, rabbit hair, hemp, kapok, sheep wool, jute,

cocoanut fiber, and a pooled sample of house dust;

and (2) the pollen group, including allergenic pol-

lens prevalent in the spring, late spring, and fall, and

those from tree flora of California.

PSYCHOSOMATIC MEDICINE



FEINGOLD ET AL. 19 7

test, the puncture technique, with use of a1:50 dilution (w/v) of 50% glycerolated ex-tract, was applied. Patients who failed toreact were retested by the intradermal tech-nique with use of a 1:1000 dilution (w/v) ofa 50% glycerolated extract diluted in nor-mal saline. Skin tests were performed bytrained allergy technicians, and the reac-tions were read a fter 20 mi n. by a staff physi-cian T he reactions were graded for each offive groups of allergens o n the customary1-4 scale. A ratin g of 1 was app lied to abarely visible local whealing and flare reac-tion, while a Grade 4 reaction indicatedstrong whealing with pseudopods surround-ed by a pronounced flare.

Th e results of skin testing were correlatedwith the history and physical findings. Onthe basis of this evaluation, manag eme nt foreach patient was outlin ed. W hen indicated,hyposensitization with appropriate antigenswas ordered.

The subjects were classified on the basis

of reactivity and diagnosis as follows:Reactivity

1. Reactivity to epidermal factors: afour-point range, from strong punc-ture reactivity to slight or none onintradermal testing

2. Reactivity to epidermal and inhalantfactors: a five-component rating em-bracing reactivity to epidermal factorsand to prevailing spring, late spring,fall, and tree flower pollen, as outlinedin Table 1.

T A B L E I CLASSIFICATION OF GLOBAL RATINCS OF

SKIN REACTIVITY

Response Rating

"Strong" response to any two of the fiveclasses of allergens tested and moderateto the remainder

At least one "strong" response and notmore than one "none" response to anyone of the five classes o£ allergenstested

Not more than one "moderate" responseand at least two "weak" responses

More than three "none" responses

Strong

Moderate

Weak

None

Diagnosis

1. Asthmatic patients were grouped ac-cording to whether they had bronchialasthma, bronchial asthma with otherconcur rent allergic conditions, or non -reactive asthma.

2. Patients with rhinitis were classed ashaving allergic rhinitis, allergic rhini-tis with other concurrent allergic con-

ditions, or nonreactive rhinitis.3. Patients with a sole diagnosis ofbronchial asthma, allergic rhinitis, orseasonal hay fever were compared.

4. Patients with nonreactive asthma werecompared with those with nonreactiverhinitis.

Results

This paper will present only those resultsobtained with the MM P1 test. Other find-ings will be reported in a forthcoming arti-cle.

The MMPI "T" scores without "K" cor-rection on three validity and nine clinicalscales for each group were included in ananalysis of variance for unequal group sizeand nonindependent measures, as outlinedby Collier and Stunkard.1 Two of these sixcomparisons (for Reactivity Groups 1 and2) yielded significant differences. The com-parisons according to diagnostic categoriesdid not yield significant differences.

Difference in Reactivity to Allergens

When subjects were classified by degree of.

epidermal reaction alone, both group and!scale-by-group interaction differences werefound (Table 2). The mean profiles (Fig.1) of the three groups (strong, medium , andweak*) suggest that the group differencesare the meaningful result, that the signifi-cant difference in inte raction (i.e., pro filepatte rn differences) is a by-product of t hegrou p differences Inspection of the th re emean profiles indicates that profile config-urations from group to group tend to be

•There were no subjects who fell into the "noreaction" group for epidermal allergens.

VOL. xxiv, NO. 2,1962



198

TABLE 2 . ANALYSIS OF VARIANCE O F M M P I SCORES

FOR G RO U P S WITH D IF F ERIN G S K IN TES T REA CTIV ITY

TO EPIDERMAL ALLERGENS

Source of varianceSu7ns of Mean

df squares squares F

Erro r (1)M M P I s c o i e s X

epidermal react iv i ty

MMPI scales

Within SsEr ro r (II)

Epidermal react iv i ty

Between Ss

1O1AL

385

2211

418

35

237

455

23,353

3,411

11,994

38,7588,184

2,622

10,846

49,604

61

155 2.54*

234

1,331 5 68f

•Significant beyond the 01 levelfSignificant beyond th e 05 le \e l .

highly similar. Of more impor tance it wouldappear is the fact that the weaker the epi-dermal reactivity the more the mean patternof MMPI responses deviates in an abnormaldirection.*

It was thought useful to utilize all the re-activity data available and, consequently, all

subjects were given over-all reactivity rat-ings based on criteria stated in Table 1.Four groups were compared on these over-all ratings: none, weak, moderate, and

• I t should be noted that deviat ions f rom the mean

do not necessarily imply gross psychological abnor-mali ty .

A L L ER G Y A N D P E R S O N A L I T Y

strong. The analysis of variance (Table 3)indicated that profile pattern differenceswere significant. In order to present thedifferences more clearly the subjects ratedas having weak or no reaction were com-bined and compared with the combinedmode rate and strong groups. The re were 22subjects in the low group, 16 in the high.Again analysis of the data (Table 4) indi-cated significant differences. Mean differ-

ences on each of the scales were evaluatedby Student's "t" technique (Table 5) .There were nonchance mean differences onsix of the scales (Fig- 2). Stronger reactorstended to score lower on the hypochondria-sis psychopathic deviate, psychasthenia, andhypomanic scales. Weaker reactors scoredlower on the K scale. Although these find-ings require further empirical definition,they might be interpreted as indicating thatstronger reactors see themselves as psycho-logically healthy, uncomplaining, conform-ing, sociable, friendly, and ready to interactwith others, and in general, as holding ra-tional control in high esteem. Differencesare small, but weaker reactors tend to ad-mit more impulsive actions and greateranxiety and dissatisfaction with things asthey are.

Th e two sets of ratings (i.e., ratings based

Hs+5K D Hy Pd+4K Mf Pa Pt+IK Sc+IK Ma+2K

Fig . 1. Mean MMPI prof i les of subjects grouped for reactivity to epidemal factors. (X X = weak,

X X = modera te , X X = strong)




FEINGOLD£T AL.

T A B L E 3 ANALYSIS OF VARIANCE OF MMPI SCORES

FOR GROUPS DIFFE RING IN GLOBAL REACTIVITY

RA TIN CS

Source of variance

Er r o r (I )

MM PI scores Xreact ivi ty ra t ing

MMPI scales

Within Ss

Er ro r (II)React ivi ty ra t ing

Between Ss

TOTAL

df

374

3311

4 1 8

343

37

455

Sums ofsquares

23,053

4,995

10,71038,758

9,409

1,437

10,846

49,604

Meansquares

62

151

277479

F

2.43*

17 5

•Significant beyond th e .01 level.

TABLE 4 . ANALYSIS OF VARIANCE OF MMP I SCORES

FO R CROUHS WITH H IG H AND LOW GLOBAL REACTIVITY

RA TIN G S

Source of variance

Erro r (1)

MMPI scores X

react ivi ty ra t ingMMPI scalesWithin Ss

Er ro i (2)

React ivi tyBetween Ss

TOTAL

df

396

11

11

4 1 8

36

1

37

45 5

Sums ofsquares

24,534

2,33111,89338,758

9,771

1,07510,846

49,604

Meansquares

6 2

2 1 2

2 7 1

1075

F

3 4*

3.96

199

on epidermal reactivity only and thosebased on the over-all reactivity rating) areclosely inter-related. Nevertheless 13 of the40 subjects were placed in different cate-gories by the two methods. Consequently,since these seemed somewhat different meas-ures, it was felt useful to explore both. M oreprecise statement about the meaning ofthese findings must await future study.

Comparison of Diagnostic Groups

Four further analyses were performed,utilizing diagnostic criteria as bases forgrouping the subjects. In the first of thesewere compared the mean MMPI patterns(Fig. 3) of subjects who had bronchial

TABLE ."> " t" T E S T ON MMPI SCALES

Scale t P

•Significant beyond the 01 level.

LFK

H s

DH y

P dM£Pa

PtSc

Ma

21 21 998

2.34

2 1 9

3.30

<.O5

< 0 6

<.O5

<.05

<.O5

Fi g . 2 . Mean MMPI prof i les to r combined over-all allergen reactivity (X-

X X = moderate-s trong)

VOL. xxiv, NO. 2, 1962

Pt! IK Sc+IK Ma+.2K

—X = none-weak,



200 A L LE R GY A N D P E R S O N A L I T Y

Pt+1K Sc+IK MJ+2K

Fig. 3. Mean MMPI profiles for asthma, rhinitis, and hay fever groups. [X . . . . X = asthma (n =5 ),X X =- allergic rhinitis (n= 7) , X X = hay fever (ra=4) ]

asthma (n = 5 ), allergic rhinitis (n = 7 ), orhay fever (n = 4 ) , and whose symptom pat-terns were uncomplicated by other allergicdiseases. Next, subjects with nonreactive

asthm a (n = 3) and those with nonrea ctiverhin itis (n = 8) were contrasted (Fig. 4 ).No significant differences were found. How-ever, there are suggestions in the profilesthat nonchance differences might be estab-lished if adequate numbers of subjects arestudied in the two nonreactive categories.

In the next step subjects with asthma-likesymptoms were separated into three groups,those with: (1) bron chial asthma, (2)bronchial asthma combined with other al-

lergic conditions, and (3) those with non-reactive asthma. Their mean profiles werecompared. Finally a similar comparison wasmade of those subjects who manifestedrhinitis-like symptom patterns. The meanMMPI profiles were analyzed for subjectswith allergic rhinitis alone, those with al-

L , F K Hs+ 5K 0 Hy Pd+.4K Mf

Fig. 4 . M ean M MP I prof i les for two nonreact ive groups. [X —

Pa Pt+IK Sc+IK Ma+.2K

:—X = n on-reactive asthma (n = 3

• X = non-reac tive rhiniti s (n = 8)]




F E I N G O L D ET Ah.

lergic rhinitis, and complicating allergicconditions, and with nonreactive rhinitis.The results of these last two analyses couldbe attributed to chance.*

In sum, the analyses based on diagnosticinformation produced chance findings.There were some tentative indications thatdifferences may be found between nonreac-tive categories, i.e., differences betweenthose with asthma and rhinitis but nonreac-

tive to skin tests.

Discussion

The findings indicate that psychologicalfactors are of importance in understandingallergic illnesses. Their precise role or rolesare not yet clear, but the groundwork forfurthe r study seems clearly established. T h ethree exploratory questions posed at the be-ginning of this preliminary study can be atleast partially answered.

First, the question of the existence of a"typical allergy personality p atter n" was notattacked directly. Before we unde rtake thesearch for a typical pattern, it would be ad-visable that we know the appropriate vari-ables regarding which a pattern might bemeaningful. Accordingly, no attem pt wasmade to differentiate allergic patients fromothers, i.e., no control groups were tested.Instead, knowledge was sought which mightprove useful in determining what variablesmight be pertinent and of predictive signifi-cance within the group. On the basis ofthese preliminary results, it appears unlike-ly that any typical allergic pattern will

emerge. Differences were found regardless

•It has been brought to our attention by the edi-torial staff of PSYCHOSOMATIC MEDICINE that Dekker,Barendreght, and De Vries

8published a study bear-

ing on this p oint. Using objective criteria they se-lected two groups each of "allergic" and "nonal-lergic" female asthma patients. These groups werethen evaluated for neuroticism by means of the TwoPart Personality Inventory Allergic and nonallergicgroups were then compared. No significant differ-ences were found, a result which is congruent withthe findings reported above for the three asthmaticgroups However, these authors also compared theirentire sample with a group of normal females andfound the asthmatics significantly more neurotic.

VOL. xxiv, NO. 2,1962

201

of diagnosis on the basis of degree of skinreactivity. Therefore , one must suppose tha tthe allergy sample as a whole is quite hetero-geneous; the greater the heterogeneity with-in a group, the less likely that one can finda pattern typical of that group which is atthe same time precise enough to have usefulmean ing. At this point it would seem moreprobable that one might find patterns typi-cal of specified, carefully defined subgroups

within the total allergic population.The second question dealt with differ-

ences between allergies and nonreactive al-lergies. Our sample did not include non-reactors (i.e., those with non reactive aller-gies) in sufficient number to answer thequestion with finality. Nevertheless, there-are clear psychological differences in a nu m-ber of areas, differences associated with thestren gth of reactivity to allergens. Thesedifferences are at least initially definableand seem to form a consistent whole. Weak-er reactors tend to be more deviant on the

personality inventory. Stronger reactors areable to claim an attitude of closer affiliationwith society and more adequate and satisfy-ing interactions w ith others. T h e less sensi-tive tend to be dissatisfied with things asthey are, more com plaining, and more activein their attempts to do something abouttheir complaints than the strong reactors.These are differences related to the dimen-sion of sensitivity to allergens and suggestthat clear psychological differences may befound between those with allergies andthose with nonreactive allergies.

The third question deals with personality

patterns associated with the various diag-nostic categories. Th e sample which fittedthese requireme nts is extremely small; u ntilthese methods are applied to a more substan-tial number of cases, the conclusion that thegroups do not differ should be consideredonly tentative.

Perhaps the most important finding ofthe study lies in the fact that personalitytest differences can be established when re-activity data are carefully enough defined.It may be that some of the controversy whichexists arou nd this "topic might well have



202 A L L ER G Y A N D P E R S O N A L I T Y

been avoided had more emphasis been givento the precise ways in which allergic subjectstend to differ. Evaluation at less broad levelsof generality has led to useful findings andmay pro vide a clearer view of the operationsof psychological variables.

It seems clear that the preliminary stepshave been taken but the basic foundationhas not been set for further definition ofspecific though complex personality differ-ences until the findings can be generalizedfrom more adequate samples to relevantpopulations. Future studies must continuecareful definitions of classificatory variablesand rigorous analysis of the data as well asexpansion of the application of findings tolarger groups of patients.

Summary and Conclusion

Psychological tests were administered toallergic patients differing with respect todiagnosis and severity of reactivity to skin

testing with allergens.The results indicate that severity of skin

reaction is a significant dimension alongwhich patients differed with respect to per-sonality p atte rn . Type of allergic disease insmall numbers of cases was not found to bea significant dimension in terms of person-ality configuration.

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margaret singer - psychological studies of allergic women (1962)

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