Psychological Medicine, 1990, 20, 125-135 Printed in Great Britain

Gender, coping and psychosomatic symptoms AD J. J. M. VINGERHOETS1 AND GUUS L. VAN HECK From the Department of Medical Psychology, Institute for Research in Extramural Medicine, Free University of Amsterdam and Department of Psychology, Tilbury University, The Netherlands SYNOPSIS In this study gender differences in coping were explored, using the Ways of Coping Checklist (WCC; Folkman & Lazarus, 1980). In addition, the focus was on sex differences in the predictive value of coping strategies in relation to psychosomatic symptoms. Males preferred problem-focused coping strategies, planned and rational actions, positive thinking, personal growth and humour, day-dreaming and fantasies. Women preferred emotion-focused coping solutions, selfblame, expression of emotions/seeking of social support, and wishful thinking/emotionality. In spite of the gender differences the results of multiple regression analyses indicated congruous relationships between coping and complaints for both sexes. Stressors and coping factors contributed in much the same way to the explained variance of symptoms and the results were generally similar for males and females. The present data also emphasize the bidirectionality of the coping-symptoms link. This holds especially for self-blame, day-dreaming and fantasizing, and wishful thinking/emotionality. In contrast, distancing was found to be associated with self-reported psychosocial load. Future prospective studies should explicitly pay attention to this bidirectional relationship.

INTRODUCTION It is generally agreed that coping, no matter how defined, is a central issue in theoretical and empirical investigations of the stressor-illness relationship (e.g. Cohen, 1984; Lazarus & Folkman, 1987; Edwards & Cooper, 1988; Miller et al. 1988). In current theoretical approaches, coping is conceived of either as a moderator or as a mediator (Frese, 1986; Folkman & Lazarus, 1988; for a methodological discussion, see Baron & Kenny, 1986). If coping is defined as a moderator, it means that coping is viewed as an antecedent condition that affects the direction and/or the strength of the relation between predictor and criterion variables, as, for example, between stressors and psychosomatic symptoms. When coping is viewed as a mediator, it is assumed that it transmits the influence of an antecedent (in casu, a stressor) to consequences, viz. psychological and/or physical disturbances. ' Address for correspondence: Dr A. J. J. M. Vingerhoets, Department of Medical Psychology, Faculty of Medicine, Free University of Amsterdam, PO Box 7161, 1007 MC Amsterdam, The Netherlands.

This is a functional description of a mediator, but in the literature it is not uncommon to conceive of more structural variables (e.g. the quality of the social network, personality characteristics, etc.) as mediators. It is implicitly assumed that there is a close connection between these structural variables and certain process variables. Although theoretical models often concentrate on coping as a moderator, empirical data seem to support the view of coping as a mediator (e.g. Andrews et al. 1978; Menaghan, 1983; Vingerhoets & Menges, 1989). Though we are gaining more insight into the role of coping in the dynamic processes by which stressors, coping, and health-related outcomes are interrelated, many research questions still remain to be answered. For example, a central question concerns the relationships between short-term and long-term outcomes, and between outcomes across different modes, viz. selfreports, observations, or psychobiological measures (see, e.g. Suls & Fletcher, 1985). A related question concerns the determinants of effective coping, i.e. whether the nature of the stressors, the personality characteristics of the

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encouraging greater awareness of physical symptoms and earlier seeking of professional help; (4) health reporting behaviour; and (5) prior health care. Based on social science Gender and coping styles theorizing and accumulating empirical evidence, In contrast to more situation-specific coping Verbrugge (1985, p. 156) concludes that '...sex efforts, coping styles are considered to be general differences in health are principally the outcome and relatively stable qualities of individuals. The of differential risks acquired from roles, stress, fact that the literature on sex differences in these life styles, and preventive health practices'. more habitual coping strategies is rather limited Men and women differ in terms of their role is the more surprising since there appear to be obligations. In as far as variation in, for instance, good reasons to postulate such discrepancies occupational, marital and parental roles reflects between males and females. The first reason is qualitatively different stressors demanding specithe relationship between coping style and per- fic coping techniques, these distinctive role sonality (McCrae & Costa, 1986; Vingerhoets & patterns can be held responsible for gender Flohr, 1984; Van Heck & Vingerhoets, 1989). differences in attempts to adapt to problematical For instance, Van Heck & Vingerhoets (1989) situations. A consequence of this line of reasonfound that neurotic, socially inadequate, rigid ing is that, for instance, occupational experience and hostile individuals, and to a lesser extent of men and women in similarly responsible and persons with high self-sufficiency scores, tend demanding positions should reduce the subtoward covert, emotion-focused activities, while stantially lower mortality rates ratio among dominant and optimistic persons with high self- women. Some evidence supports this contention esteem are more inclined to use problem- (cf. Detre et al. 1987; see also Rodin & Salovey, orientated coping styles. Several investigations 1989). have shown that the two sexes differ in such There is a growing disbelief that a more personality traits as neuroticism, dominance, frequent exposure to stressors is the major dependency, and trait anxiety (e.g. Maccoby & factor contributing to sex differences in health. Jacklin, 1974; Hoyenga & Hoyenga, 1979). In some carefully designed studies no evidence The second reason is that there are dramatic for such a differential exposure was found (e.g. individual differences in declarative and pro- Holmes & Masuda, 1974; Markush & Favero, cedural social knowledge, partly related to 1974). Furthermore, gender-related differences gender. Canto & Kihlstrom (1987) have recently in stress reactions were obtained in case of made clear that these differences have a profound exposure to the same number of stressors (e.g. effect on the development and the selection of Russo, 1985). In addition, there is ample problem-solving strategies in life tasks. evidence not only for sex differences in stressFinally, there are remarkable discrepancies in induced physiological responses (e.g. Frankenhealth between men and women (e.g. Wingard, haeuser, 1983; Stoney et al. 1987), but also for 1984; Verbrugge, 1985; Strickland, 1988). In differences in the ways individuals adapt cognigeneral, it can be said that women suffer more tively, emotionally, and behaviourally to stressfrom psychological distress and minor somatic ful life circumstances. According to Kessler et disorders, whereas men seem to be especially al. (1985), gender differences in health are to a vulnerable to life threatening diseases such as large extent attributable to differences in the myocardial infarction and cancer (e.g. Rice et al. appraisal of stressors and the selection of coping 1984; Bush & Barrett-Connor, 1985). According . strategies. The same view has been expressed to Verbrugge (1985), there are five categories of recently, by McLaughlin et al. (1988) so that it explanation for sex differences in health: (1) seems worthwhile to scrutinize gender differences intrinsic differences between males and females in coping styles. based on their genes or reproductive physiology In her review, Verbrugge (1985) asserts that which confer differential risks of morbidity; (2) women generally maintain stronger emotional acquired risks from work and leisure activities, ties with more people. When confronted with health-habits, self-imposed stressors and the upheavals they are consequently more inclined reactions to them; (3) psychosocial factors to turn to those people and to medical drugs for individuals involved, or both are crucial. Further, remarkably little is known about the link between gender and coping styles.

Gender, coping and psychosomatic symptoms

relief. In contrast, men tend to opt more often for tension-reducing activities like alcohol consumption, smoking, and drug abuse. Alternatively, they indulge in quiet brooding. In short, Verbrugge concludes that women generally deal more effectively with stressful encounters than men. However, as suggested by Folkman & Lazarus (1980), Schilling et al. (1985) and others, one must take into account the fact that males and females are confronted with stressors of a different nature, requiring coping strategies that fit them best. This may explain why, for example, Pearlin & Schooler (1978) conclude that males use the more effective coping strategies. In a few studies the reported use of coping strategies of both sexes has been compared. For example, Folkman & Lazarus (1980) studied the coping reactions of males and females (aged 45-64 years) in specific situations. Contrary to expectations, they did not find differences in the degree to which both sexes used emotion-focused coping. On the other hand, men exploited more problem-focused coping strategies than women. However, this was only true for work situations and conditions marked by demands of acceptance or a need for further information. A similar lack of overall gender differences was demonstrated by Hamilton & Fagot (1988) for a distinctly different age-cohort, viz. college students. Other studies, however, have shown coping behaviour specific to each sex. In the study by Pearlin & Schooler (1978) correlations were computed between coping strategies and gender for each of four role areas: marriage, parenting, household economics, and occupation. They found many small, but significant correlations with sex. Selective ignoring was the favourite coping style of women, whereas selfreliance appeared to be a typically male coping strategy. Billings & Moos (1981) also paid attention to gender differences in coping. Again, statistically significant, but relatively small, differences were obtained. Men reported a less frequent use of active-behavioural coping, avoidance, and emotion-focused coping than women. Data reported by Astor-Dubin & Hammen (1984) suggest that females employ both cognitive and interpersonal strategies in dealing with stressful conditions, whereas men mainly restrict themselves to cognitive strategies. Stone & Neale (1984) found that men preferred direct action and that women used a variety of other

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coping strategies, focusing on religion, catharsis, relaxation, distraction and, especially, the seeking of social support. Recently, Endler & Parker (1988) developed a new device to measure coping, the Multidimensional Coping Inventory (MCI). When comparing the scores of male and female undergraduates, they found no differences in task-coping. Females, however, had significantly higher scores on the Emotion and Avoidance Coping Scales than males. Finally, studies by Rim (1986, 1987) have shown sex differences in the intercorrelations between coping mechanisms and, consequently, in factor structures of coping styles. To sum up, the picture that emerges is somewhat blurred, not least because every investigator has used his or her favourite questionnaires, which may differ in several relevant aspects. For example, it is quite conceivable that pinpointing one or a few particular events will produce outcomes that differ considerably from those obtained by focusing on coping 'in general'. Moreover, as Schilling et al. (1985) point out in their article on differences in coping strategies between mothers and fathers of a handicapped child, it might be possible that events are appraised very differently by men and women. Consequently, this will contribute to the choice of different coping strategies. It is nevertheless true that there is some correspondence in the results. Most notably, women appear to have a stronger tendency to passive emotion-focused coping, including the expression of emotion and the seeking of social support. In contrast, men seem to prefer problem-focused coping and are less inclined to accept and wait passively. Coping strategies and psychosomatic symptoms: a bidirectional causal flow? In the last fifteen years several investigations have shown a relationship between coping and psychological and/or psychosomatic symptoms (e.g. Andrews et al. 1978; Pearlin & Schooler, 1978; Billings & Moos, 1981; Menaghan, 1983; Vingerhoets & Menges, 1989). In addition, research has been focused on the question of the effectiveness of coping strategies (see Suls & Fletcher, 1985). However, to the best of our knowledge, no attention whatsoever has been paid to sex differences in the effectiveness of coping strategies.

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Though stress theories generally emphasize the importance of coping strategies as major determinants of psychological and physical wellbeing, it may be argued that the relationship between coping and health status is bidirectional, rather than unidirectional. In addition, according to Edwards & Cooper (1988), one should not ignore the mechanisms by which coping strategies affect (or fail to affect) the stressors or how these are perceived. In a recent article, Folkman & Lazarus (1988) show how several feedback loops come into action when a stressful encounter develops, leading to different emotions and reappraisals which, in turn, affect the coping responses. The same line of reasoning can probably be applied to the association between symptoms and coping. When a person realizes that a chosen coping strategy is ineffective, resulting in psychosomatic complaints, this negative feedback may stimulate the employment of other strategies. Second, apart from the ineffectiveness of previously used coping strategies, one may hypothesize that distressed people, by definition, are restricted in their capacity to deal adequately with stressful conditions. Apart from the question of whether men and women have different coping preferences, one may wonder whether the same coping strategy bears the same relationship to a particular outcome variable in men and women. In other words, if problem-focused coping generally proves to be an effective coping strategy, does that then hold equally for both males and females? Aims of the present study

In the present article we have dealt with the three issues raised above. First, comparisons between both sexes were made for the scores on the seven dimensions of the (revised) Ways of Coping Checklist as identified by Van Heck & Vingerhoets (1989). In addition, the scores on the 'original' (Folkman & Lazarus, 1980) Emotion-focused (E) coping and Problemfocused (P) coping scales were compared. Second, it was established to what degree each of the various coping strategies contributed to the explained variance of psychosomatic symptoms and whether these contributions differed between males and females. The latter comparisons were made twice: first, in a multiple regression procedure where coping was entered

first; second, in a multiple regression procedure, with ways of coping entered after life events and daily problems. Finally, the bidirectional relationship between coping and symptoms was explored by applying multiple regression analysis in which predictor variables (WCC factor scores) and the criterion variable (total HSCLscore) were reversed. METHOD Subjects and procedure Four hundred and sixty-five males (mean age is 36-4 years, S.D. = 6-34) and 532 females (mean age is 34-9 years, S.D. = 6-33) took part in this study. All subjects were recruited on a random basis in two relatively small villages (one typically rural and the other more urbanized) in the Province of Brabant in the Netherlands. The original sample consisted of 2500 persons. Men and women were equally represented. The age range was 25-50 years. One-thousand-onehundred and ninety-seven (47-9 %) reacted positively to our invitation, but due to missing data (e.g. because of missing pages in the test booklets) the data of 200 individuals could not be used for the present analysis. Analysis of the occupational and educational levels of the participants revealed that the lower classes were somewhat under-represented. Four to six weeks after the questionnaires were sent out the subjects were approached for the collection of the booklets. If no contact had taken place after two approaches, the subject received a letter with the request to hand in the forms (whether completed or not) at a particular place in their neighbourhood. Instruments and measures

Each potential participant received a booklet containing, among other things, the Everyday Problem Checklist (EPCL: Vingerhoets et al. 1987, 1989), the Recently Experienced Events Questionnaire (REEQ; Van De Willigen et al. 1985), the Hopkins Symptom Checklist (HSCL; Derogatis et al. 1974; Dutch version by Luteijn et al. 1984), and the revised version of the Ways of Coping Checklist (WCC; Aldwin et al. 1980; Folkman & Lazarus, 1980; Dutch version by Van Heck & Vingerhoets, 1989).

Gender, coping and psychosomatic symptoms

Stressors

The EPCL is a 114-item questionnaire containing items from several domains including: (1) family life; (2) living conditions; (3) working conditions; (4) physical appearance and general performance; (5) transactions and business; (6) social life; and (7) confrontation (as witness or object). The subjects are asked to tick the items that describe the situations that occurred in their personal life during the last two months and to rate the gravity of these events. Three scores can be calculated: (1) the number of items checked; (2) an average seriousness rating; and (3) the product of these two scores. In the present analyses we restricted ourselves to the third measure. The REEQ is developed within the tradition of life events research and is mainly based on the Recent Life Changes Questionnaire (Rahe, 1975, 1987). Additional items were derived from life event questionnaires developed by Paykel et al. (1971) and Sarason et al. (1978). It contains 59 items in five domains: (1) health; (2) work; (3) family life and social relations; (4) living and personal conditions; and (5) finances. The subjects not only indicate whether they have experienced the event in the preceding year, but they also rate independently on a five-point scale both the pleasantness and the unpleasantness of each checked event. In the present study we restricted ourselves to the sum of the unpleasantness ratings. Coping Problem-solving and emotion regulating strategies were assessed by means of the Ways of Coping Checklist (WCC; Aldwin et al. 1980; Folkman & Lazarus, 1980). In comparison with the original WCC two major revisions have been made. First, in contrast to the original WCC, subjects were instructed to indicate how they deal with stressful encounters in general. Second, the response format was modified from Yes-No to a six-point scale ranging from 'Not at all characteristic of me' (1) to 'Very characteristic of me' (6). Principal components analysis with oblique rotation yielded seven scales, explaining 36-0% of the variance. The scales were: (1) Planful and Rational Actions (e.g. 'Make a plan of action and follow it'; 'Just concentrate on

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what you have to do next - the next step'); (2) Self-blame (e.g. 'Blame yourself; 'Criticize or lecture yourself); (3) Distancing (e.g. 'Try to forget the whole thing'; 'Wait to see what will happen'); (4) Day-dreams and Fantasies (e.g. ' Have fantasies or wishes about how things may turn out'; ' Daydream or imagine a better time or place than the one you are in'); (5) Expression of Emotion/Seeking Social Support (eg. 'Let your feelings out somehow'; ' Talk to someone about how you are feeling'); (6) Positive Thinking, Personal Growth, Humour (e.g. ' Maintain your pride and keep a stiff upper lip'; 'Rediscover what is important in life'); (7) Wishful Thinking/Emotionality (e.g. 'Wish that you could change what has happened'; 'Wish that the situation goes away or somehow is over with') (Van Heck & Vingerhoets, 1989). As scores for the seven coping dimensions, the individual factor scores were used. Average were calculated for men and women separately. The scores for E-coping and P-coping were based on the raw scores on the items originally identified as belonging to either WCC scale (Folkman & Lazarus, 1980). Symptoms The HSCL is a well-known and widely used questionnaire for the assessment of psychological and psychosomatic disturbances. The Dutch version (Luteijn et al. 1984) contains 57 items and consists of two scales, one for the measurement of psychological symptoms (Psyscale) and one for the measurement of somatic symptoms (Somat-scale). In the present study, only the Total-scores, calculated by summing the scores on the Psy-scale and the Somat-scale, were used. Data analysis For the multiple regression procedures, the total severity (EPCL) and unpleasantness (REEQ) ratings were used as independent variables (together with the coping styles). The total HSCL score was used as the dependent variable. In the second set of analyses, the HSCL scores were used as predictors (together with the stressors), whereas the coping factors were the dependent variables. Thus, subjective evaluations of events and conditions were employed rather than a mere frequency count of both categories of stressors. PSM 20

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A. J. J. M. Vingerhoets and G. L. Van Heck

RESULTS Table 1 summarizes for both sexes the comparisons (/ tests) between mean factor scores for WCC coping styles, average scores on E-coping and P-coping, and average scores on the stressors and symptoms questionnaires. Except for Distancing, all comparisons yielded significant gender differences. Males, on the average, had higher scores on Problem-focused coping, Planning and Rational Actions, Day-dreaming and Fantasizing, and Positive Thinking, Personal Growth and Humour. Females, on the other hand, had a stronger tendency towards Emotionfocused coping, Self-blame, Expression of Emotions/Seeking of Social Support and, finally, Wishful Thinking/Emotionality. Furthermore, there were no significant differences between female and male subjects in average scores on the stressors questionnaires. Finally, women reported more symptoms. Table 2 represents the product-moment correlations of the stressors and coping factors with symptoms, separately for men and women. Comparison of these correlation coefficients did not yield any significant differences between males and females. Regression analyses were carried out to explore whether stressors and coping styles functioned differently for men and women with respect to symptom reporting. The main results (see Tables 3 a and 3 b) can be summarized as follows. When entered first, stressors explained approximately the same amount of the variance in HSCL scores for men (31 %) and for women (30%). The contribution of coping factors to the amount of explained variance in HSCL scores was also significant for both sexes (19 and 15% for males and females, respectively). Except for two coping factors (WCCI, Planning and Rational Actions, and WCC6, Positive Think-

Table 1. Mean factor scores for WCC coping styles, and average scores on WCC Emotionfocused and Problem-focused coping scales, the stressor questionnaires and the symptom checklist Females

Males E-coping P-coping WCCI WCC2 WCC3 WCC4 WCC5 WCC6 WCC7 EPCL REEQ HSCL

131-63 88-82 -0-20 Oil -001 -008 0-28 -008 0-22 22-64 18-24 8000

125-97 90-96 0-23 -0-13 002 0-10 -0-34 010 -0-26 25-21 19-44 76-15

/ values -4-22" 2-48" 6-47** -3-67" 0-46 -2-75* -9-85" 2-78* 7-32" 1-85 1 -31 — 3-30**

• P < 0 0 1 ; *• / > < 0 0 0 1 . E-coping = Emotion-focused coping; P-coping = Problem-focused coping; WCCI = Planning and Rational Actions; WCC2 = Selfblame; WCC3 = Distancing; WCC4 = Day-dreams and Fantasies; WCC5 = Expression of Emotion/Seeking Social Support; WCC6 = Positive Thinking, Personal Growth, Humour; WCC7 = Wishful Thinking/Emotionality; EPCL = Everyday Problem Checklist; REEQ = Recently Experienced Events Questionnaire; and HSCL = Hopkins Symptom Checklist.

ing, Personal Growth, and Humour) all independent variables were positively associated with the HSCL scores. The general pattern of associations was very similar for males and females. The ^-coefficients of the coping factors Expression of Emotion/Seeking Social Support (WCC5) and, for males only, Distancing indicated no contribution. When the coping factors were entered first, the results showed a similar pattern. Stressors still added substantially to the amount of explained variance in the HSCL scores (15 and 17% for males and females, respectively). In addition, a regression analysis was carried out in which Sex was entered as a dummy

Table 2. Pearson correlations between the independent variables (stressors and coping factors) and HSCL scores Stressors

Males Females

EPCL REEQ 0-53 0-47 0-54 0-38

Coping factors WCCI -008 -006

WCC2 0-33 0-35

WCC3 -012 -Oil

WCC4 0-24 0-22

WCC5 -007 -Oil

WCC6 -013 -0-04

WCC7 0-23 0-14

EPCL = Everyday Problem Checklist; REEQ = Recently Experienced Events Questionnaire; WCCI = Planning and Rational Actions; WCC2 = Self-blame; WCC3 = Distancing; WCC4 = Day-dreams and Fantasies; WCC5 = Expression of Emotion/Seeking Social Support; WCC6 = Positive Thinking, Personal Growth, Humour; and WCC7 = Wishful Thinking/Emotionality.

Gender, coping and psychosomatic symptoms

Table 3 a. Summary tables of the multiple regression procedures for male subjects with HSCL scores as the dependent variable and stressors and coping as the independent variables Independent variable Order 1 Step 1

Step 2

Order 2 Step 1 Step 2

R2

Stressors EPCL REEQ Coping WCC1 WCC2 WCC3 WCC4 WCC5 WCC6 WCC7

0-31***

Coping Stressors

0-36*** 0-50*"

Table 3 b. Summary tables of the multiple regression procedures for female subjects with HSCL scores as the dependent variable and stressors and coping as the independent variables

Adjusted R2 R2 change

Independent variable Order 1 Step 1

0 31 0-29*" 019*"

0-50*"

0-49

Step 2

0-19*" -011" 0-37*" 000 0-21"* 001 -0-13*" 0-28"*

0-35 049

015*"

* / > < 0 0 5 ; ** P < 0 0 1 ; * * * / • < 0001. For the explanation of the abbreviations see the footnotes to Tables 1 and 2.

variable. The results indicated that the interaction terms did not substantially add to the explained variance. Moreover, the /?s of the interaction terms did not differ significantly from zero, except for the Sex x EPCL interaction (P = 005). This means that the /3s for all other variables were equal for men and women. Tables A a and 4 b represent the results of the multiple regression analyses with stressors and complaints as predictors and coping style as criterion. Here again, a high degree of correspondence was found for the results of males and females. Summarizing the main results, it can be said that, in particular, Self-blame, and, to a lesser extent, Day-dreams and Fantasies, and, especially for males, Wishful thinking/ Emotionality could be predicted by symptoms. In contrast, stressors were the most important predictors for Distancing and, especially for females, Positive Thinking, Personal Growth, and Humour. Finally, Planning and Rational Actions and Expression of Emotion/Seeking Social Support did not show associations with stressors or HSCL scores.

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Order 2 Step 1 Step 2

Stressors EPCL REEQ Coping WCC1 WCC2 WCC3 WCC4 WCC5 WCC6 WCC7 Coping Stressors

R2

0-30"*

R2 Adjusted R2 change

/?

0-30 0-38*" 0-12"*

0-45*"

0-44

015"* -014** O-35*" 007* 0-18*** 001 -013"* 0-23*"

0-28*" 0-45"

0-27 0-44

017"*

• P < 005; ** P < 001 ; • " / > < 0001. For the explanation of the abbreviations see the footnotes to Tables 1 and 2.

DISCUSSION The aims of the present study were threefold: first, to investigate gender differences in coping styles; second, to examine whether the predictive potential of coping factors varied between males and females; and, third, to explore the bidirectional associations between coping factors and health status. As expected, males were more inclined to active, problem-focused coping, talking problems down, and looking at the bright side of life. In contrast, women seemed to prefer emotionfocused coping, expressing their emotions, seeking social support, and self-blame. These findings corroborate the results in earlier studies by Stone & Neale 1984) and Billings & Moos (1981). The present data, therefore, show once more the consistency of some gender difference in coping, especially with regard to emotionfocusing coping and seeking social support. Furthermore, the data are consistent with the idea that men and women do not differ in terms of the amount of stressful events. Finally, the data lend support to the frequently reported finding (see Verbrugge, 1985; Wingard, 1984) that women have higher scores on symptom checklists. 5-2

A. J. J. M. Vingerhoets and G. L. Van Heck

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Table 4 a. Summary table for male subjects of multiple regression procedures with stressors and symptoms (in two orders) as the independent variables and the coping factors as the dependent variables

Table 4 b. Summary table for females subjects of the multiple regression procedures with stressors and symptoms (in two orders) as the independent variables and the coping factors as the dependent variable

Dependent variable

Dependent variable

WCC1

WCC2

WCC3

WCC4

WCC5

WCC6

WCC7

Independent variable

R* change —0-18***

(1) HSCL (2) Stressors EPCL REEQ (1) Stressors (2) HSCL

001 003**

001 003"

— 0-02"

(1) HSCL (2) Stressors EPCL REEQ (1) Slressors (2) HSCL

011*** 012"*

000

(1) HSCL (2) Stressors EPCL REEQ (1) Stressors (2) HSCL (1) HSCL (2) Stressors EPCL REEQ (1) Stressors (2) HSCL

— 0-04*" 0-12*" 001* 0-07*"

007*" 007***

000 001 — — 000 001

WCC2

(1) HSCL (2) Stressors EPCL REEQ (1) Stressors (2) HSCL

0-12*" 0-12*" — — 0-05*" < 0 0 1 ; • " / > < 0-001. For the explanation of the abbreviations see the footnotes to Tables I and 2.

* P < 005; " P < 001 ; • • • / > < 0001. For explanation of the abbreviations see the footnotes to Tables 1 and 2.

In short, gender differences were found both for the predictors and the criterion of our multiple regression analysis. Nevertheless, no significant differences were found between the standardized /^-weights in both samples. This means that the scores on the various coping

scales contribute in a comparable way to the criterion variance for males and females. The only difference found was related to chronic stressors (EPCL), which had a significant higher weight for females than for males. In other words, chronic stressors appear to be more

Gender, coping and psychosomatic symptoms

strongly associated with symptoms in women than in men. The opposite result was found for life events, but this difference failed to reach statistical significance. A further question is how useful these general findings are for clinical practice? From the /?s one can infer that Planning and Rational Actions and Positive Thinking, Personal Growth and Humour have negative associations with symptoms. Since women generally have lower scores on both factors, one may conclude that it is useful to train women to develop these skills. Moreover, given the relatively high weights for Self-blame and Wishful Thinking/Emotionality, one can recommend unlearning of these coping strategies. The most important male weakness is their use of day-dreams and fantasies. Given the fact that symptom reporting also has predictive value with regard to some coping strategies, the conclusion is warranted that coping strategies also may be determined by how the subject feels at a certain moment. Or, alternatively, both symptoms and maladaptive coping strategies may be connected to a third variable, for instance, neuroticism. In other words, the distinction between predictor (coping) and criterion (health status as measured by symptom checklist) is rather vague and illdefined. To a large extent, these problems are very similar to the confounding between stressors and stress reactions in the Daily Hassles Scale (see Dohrenwend et al. 1984; Dohrenwend & Shrout, 1985; Leventhal & Tomarken, 1987; Vingerhoets & Menges, 1988). Leventhal & Tomarken (1987) put forward some possible solution for this problem, some of which may be useful in this context too. Their proposal is to enhance the quality of measurement of the criterion (health status) and of the predictor (in this case, coping). That is why they recommend using specific diagnoses and exact determination of the duration of the disease episode. They are rather sceptical about the use of so-called generic measures of disease (e.g. symptom checklists) and advocate instead the application of specific measures. To increase the quality of coping assessment, one might further suggest the calling in of experts to judge whether or not the items of coping questionnaires reflect neurotic tendencies or psychopathology (cf. Dohrenwend et al. 1984). The relationship found between self-reports

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of psychosocial load and Distancing is of some interest. People who prefer to employ the latter coping strategy generally reported only a restricted number of stressors. This may reflect their appraisal preferences. These people clearly are not inclined to define situations as stressors. Instead, they seem to hold the opinion that they are all part of daily life, that there is nothing to be worried about, and that problems often dissolve without any real efforts of their own. Several hypotheses can be put forward to explain why women differ from men with respect to coping preferences. For example, it might be possible that men and women generally are exposed to different kinds of stressors that require different coping strategies. Consequently, it may be suggested that the maletypical coping strategies do not fit the femaletypical stressors, and vice versa. Or, alternatively, one could speculate that the differences in coping can be attributed to the different ways in which men and women appraise the situations they find themselves in. For instance, Schilling et al. (1985) mention some striking examples of such different appraisals of stressful conditions. Could it be possible that women generally cope better with stressful situations that demand passive coping, whereas men deal more effectively with stressors that require a direct, active approach? If the answers is 'Yes', then this could be helpful, for instance, in explaining why women cope better with bereavement and divorce than men in terms of health outcomes (e.g. Sterling & Eyer, 1981). The present coping data can partly explain why women have higher scores on symptom checklists. However, it is more difficult to understand the seeming paradox that males generally have more life-threatening diseases, since our data suggest that males cope more effectively, at least in the short run. Given the cross-sectional character of the present study one needs to be cautious in speculating on the specific nature of the relationship between coping and symptoms. Several potential processes may underlie the relationship among personal characteristics (e.g. demographic variables like sex), coping strategies, stressors, and psychosomatic symptoms. One promising line of future research would be to formulate structural equation models corresponding to theoretical models of the dynamic

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stress process leading to psychosomatic symptoms. Such models could be examined using LISREL (Joreskog & Sorbom, 1984). This approach was used successfully in a recent study by Cooper & Baglioni (1988). In addition, there is a need for future research that focuses on prospective designs, in which adequately assessed coping styles are used as predictors for short-term health changes. Only then can valid conclusions be drawn with respect to the exact nature of the association between coping and symptoms. We are indebted to Arjen Jeninga for assistance with data processing, and to two anonymous referees for helpful comments on a previous draft.

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