Men typically outperform women in spatial navigation tasks, while the advantage of women in verbal fluency is more controversial. Sex differences in cognitive abilities have been related to sex-specific cognitive strategies on the one hand and sex hormone influences on the other hand. However, sex hormone and menstrual cycle influences on cognitive strategies have not been previously investigated. In the present study we assessed cognitive strategy use during spatial navigation and verbal fluency in 51 men and 49 women. In order to evaluate sex hormone influences, all participants completed two test sessions, which were time-locked to the early follicular (low estradiol and progesterone) and mid-luteal cycle phase (high estradiol and progesterone) in women. As hypothesized, men outperformed women in navigation, whereas women outperformed men in phonemic verbal fluency. Furthermore, women switched more often between categories in the phonemic fluency condition, compared to men, indicating sex-specific strategy use. Sex differences in strategy use during navigation did, however, not follow the expected pattern. Menstrual cycle phase, however, did modulate strategy use during navigation as expected, with improved performance with the landmark strategy in the luteal, compared to the follicular phase. No menstrual cycle effects were observed on clustering or switching during verbal fluency. This suggests a modulation of cognitive strategy use during spatial navigation, but not during verbal fluency, by relative hormone increases during the luteal phase of the menstrual cycle. Sex differences in cognitive abilities have been reported most consistently for spatial abilities, with men usually outperforming women , while wIn the spatial domain, a robust male advantage is evoked especially in mental rotation and navigation tasks . Among tSeveral investigations also explain the male advantage in spatial tasks via their high levels of testosterone, since testosterone has repeatedly been related to improved spatial performance . Note, hIn the verbal domain, results concerning sex differences are inconsistent when considering large meta-analytic reviews . One reaSome investigations, however, fail to find a female superiority in verbal fluency at all . InconsiConcerning sex-dependent strategy use during verbal fluency tasks, there is evidence that women produce more clusters and switch more often between categories than men, whereas men generate broader clusters and produce less switches, respectively . ClusterHowever, not all studies investigating sex differences in verbal fluency strategies were able to detect sex differences . This maConcerning sex hormone influences on verbal fluency, testosterone tends to have a blocking effect on verbal abilities in general , and verIn summary, sex hormone or menstrual cycle influences on strategy use during spatial navigation or verbal fluency have not been previously investigated.Therefore, in the current experiment we investigate, whether the application of different strategies in navigation and verbal fluency is dependent on female cycle phases and sex hormone levels. We administered a 2-D map-based navigation task and a phonemic and semantic verbal fluency task to a sample of young men and women at two time-points, which were phase-locked to the menstrual cycle in women. Different instructions modulated strategies in both tasks. We expect to replicate the previously demonstrated male advantage in wayfinding and a female superiority in the overall number of words generated, as well as sex-dependent strategies in the navigation task and sex differences in clustering and switching strategies during verbal fluency. We mainly focused on hormone-dependent hypotheses, expecting associations between sex hormones, and thus, menstrual cycle phases and cognitive strategies. Assuming that navigation performance is related to an allocentric perspective and Euclidian strategy use on the one hand, as well as high testosterone levels and low levels of female sex hormones on the other hand, we hypothesize that women perform better with the egocentric and the landmark-based strategy during the luteal as opposed to the follicular cycle phase. Also, assuming that verbal fluency performance is related to switching on the one hand and high levels of female sex hormones, but low levels of testosterone on the other hand, we hypothesize that women produce larger clusters and less switches in the verbal fluency task during the follicular compared to the luteal cycle phase. Concomitant with this hypothesis is the assumption of a positive association between testosterone and allocentric/Euclidian strategies during navigation, as well as clustering during verbal fluency, as well as a positive relationship between estradiol and progesterone and egocentric/landmark based strategies during navigation, as well as switching during verbal fluency, respectively.Mage = 23.65, SD = 4.06) and 49 women , completed the present study. Age of all participants ranged between 18 and 36 and did not differ significantly between men and women . Participants were students of the University of Salzburg, who received course credits for their participation. They had all completed their A-Levels and were thus at a comparably high level of education.One-hundred German-speaking participants, 51 men (SD = 2.64). All participants were tested twice. While men participated within an interval of around 2 weeks, women participated in two different cycle phases, i.e., the low-hormonal early follicular phase  and the high-hormonal mid-luteal phase (3–10 days after ovulation). Ovulation was calculated based on participants’ self-reports and was confirmed by commercial ovulation tests and by hormone levels analyzed in saliva after testing. Twenty-three women were in their follicular cycle phase during the first session and were tested in their luteal cycle phase in the second session. 26 women were tested in their luteal cycle phase in the first session and in their follicular phase in the second session, respectively.Only participants who reported to be right-handers and had no history of neurological, psychological or endocrinological disorders were included in the study. Women were only allowed to participate, if they reported no use of hormonal contraceptives and a regular menstrual cycle of a duration between 21 and 36 days. The mean cycle length of women in the present study was 29.24 days .1) state in §163 (1) that ethical approval is necessary for research on human subjects if it affects the physical or psychological integrity, the right for privacy or other important rights or interests of the subjects or their dependents. In §163 (2) it is stated that it is the responsibility of the PI to decide, whether (1) applies to a study or not. Therefore, we did not seek ethical approval for this study. Since it was non-invasive and performed on healthy adult volunteers, who gave their informed consent to participate, (1) did not apply. Data was processed in anonymized/de-identified form. Upon arrival at the lab, participants were assigned a subject ID , which was used throughout the study.The institutional guidelines of the University of Salzburg .To evaluate spatial navigation abilities, as well as their preferred perspective and choice of strategy, participants completed a computerized 2D-matrix navigation task. The task was adapted from an earlier paper-pencil version by For each item participants received a short written instruction of three lines, which was presented for 15 s before the matrix appeared. As in Figure 1. For every type of instruction, 4 trials were used, resulting in a total of 16 different trials. All participants received all items and the order of trials was randomized across participants.Instructions were formulated as in Response times and accuracy were recorded for each item. Response times were analyzed only for correctly solved items. Participants needed about 15 min to complete this task.animals). To manipulate strategy use, different instructions were used. While the neutral instruction simply requested participants to name as many words as possible, the clustering instruction required them to write down consecutive words, which should be as similar as possible in the phonemic condition  and should belong to the same sub-category in the semantic condition, respectively . In the switching instruction, consecutive words should be as dissimilar as possible in the phonemic condition , or belong to different sub-categories in the semantic condition. Letters, used in the present phonemic condition were the consonants P, N, M, S, H, L, F, T, D, W, K, and R. For the semantic fluency condition, we used the following categories: animals, fruits, beverages, food, furniture, clothing, jobs, cities, countries, toys, sports, and means of transportation. For each participant, two different letters and two different categories were randomly assigned to each instruction and test session. Thus, altogether, in one session participants received a booklet with six different initial letters and six different categories. For both tasks, we formed letter- or category pairs, respectively, such that the frequency of German words beginning with these letters or belonging to this category, approximately matched across instructions and test sessions .To evaluate verbal abilities, as well as clustering and switching strategies, participants completed a paper-pencil version of the verbal fluency task. For participants, aged 21–29 of all education levels, an average production of 8.33 words per minute is suggested for a written version of the phonemic fluency task . Both seFor completing both conditions participants needed about 20 min. Performance on this task was measured by computing the mean number of words produced for each verbal fluency condition. Additionally, the mean cluster size, and the mean number of switches was measured for every task and instruction, assessing participant’s strategies used in the test. Clusters and switches were counted using the rules suggested by lme function of the lme4 package. Dependent variables were reaction time (RT) in milliseconds and accuracy (percentage of correct responses) for the navigation task, and number of words, cluster size and number of switches in the verbal fluency task, respectively.Statistical analyses were carried out in R 3.3.1. Linear mixed effects models were utilized using the post hoc comparisons unnecessary. (iii) Sex hormone influences can be evaluated across all time-points and conditions at once and are compared between men and women via interaction effects in the model. Thus separate correlation analyses and the post hoc comparison of correlation coefficients are not necessary. To make use of these advantages, we did test the following models:The advantages of the lme approach for the current research questions are threefold: (i) It is possible to control for learning effects by including session as a fixed effect even in the menstrual cycle models, where these within-subjects effects are crossed. (ii) Categorical effects with more than one category are automatically dummy coded, thus comparing each category to a reference category, which renders participant number’ was treated as random factor. In all tasks, the factor ‘session’ was included as a fixed factor to the model in order to control for possible memory or learning effects. For each task, sex differences in strategy use were evaluated, by models including the interactive effects of ‘instruction’ and ‘sex.’ Cycle-dependent changes were evaluated in the female sub-sample by models including the interactive effects of ’instruction’ and ‘cycle.’ Specific models for each task are described in the section “Results.” To evaluate the effect of sex hormones on the dependent variables, ‘progesterone,’ ‘estradiol,’ and ‘testosterone,’ were separately added as additional fixed effects to these models.To control for repeated measurement in the linear mixed effect models, ‘lmerTest package to create minimum models including only the factors and interactions which are relevant to explain the dependent variables. Results of these minimum models are reported.Non-significant interactions were backward eliminated like implemented in the step function of the scale function. Therefore, the coefficients b of fixed effects in the models represent a standardized effect size based on standard deviations, similar to Cohen’s d.In all models, both, the dependent and continuous independent variables were z-standardized using the Sex hormone levels were assessed from saliva samples. Three saliva samples were taken from each participant during each session. The first saliva sample was taken after filling out the informed consent, when participants had time to adjust to the lab environment. The second saliva sample was taken between the tasks, whereas the last one was taken at the end of the study, before participants received debriefing, if requested. Saliva samples were stored at −20°C and centrifuged at 3000 rpm for 20 min prior to hormone assessment. Testosterone, 17β-estradiol and progesterone were assessed for each sample using ELISA kits from DeMediTec. Hormone levels were averaged over the three samples obtained during one session, in order to control for diurnal fluctuations in hormone levels and ensure reliability of hormone assessment. Five women had to be excluded from analyses because of inconsistencies between the self-reported cycle phases and the analyzed hormone values. Additional 2 men were excluded from further statistical analyses because testosterone levels varied highly between the two test sessions, suggesting external factors influencing testosterone levels, like stress. Thus, all analyses were performed on 49 men and 44 women.Additionally, 2 estradiol levels, 7 progesterone levels and 3 testosterone levels were missing as they could not be analyzed due to insufficient sample volume.participant number’ as a random factor and ‘sex’ and ‘session’ as fixed factors were run using the lme function of the lme4 package in R 3.3.1. . As expected, men had higher testosterone levels  and lower estradiol  and progesterone levels  compared to women with no differences between test sessions .To evaluate sex differences regarding hormone levels, separate linear mixed effects models (lmes) for each hormone including ‘cycle phase’ as a fixed factor were run for each hormone in the female sub-sample . Testosterone differed slightly between cycle phases , while estradiol  and progesterone  were significantly higher in the luteal, compared to the follicular cycle phase .To evaluate cycle differences, separate lmes including ‘perspective,’ ‘strategy,’ and ‘sex’ . Non-significant interactions were backward eliminated and results of the final models are reported. Specifically, the threefold interaction was always non-significant and thus removed from the model. Mean response times and the mean number of hits for men and women are presented in Figure 2.Linear mixed effects models were fitted for reaction times and accuracy including participant number (PNr) as a random factor and the fixed effects session, as well as the interactive effects of ‘session’ indicated faster reaction times during the second, compared to the first session . A significant main effect of ‘sex’  indicated that men were significantly faster in solving navigation items, compared to women. Significant main effects of ‘perspective’  and ‘strategy’  indicated that reactions were faster during the allocentric, compared to the egocentric perspective and with the landmark strategy, compared to the Euclidian strategy. All interactions were non-significant and thus removed from the model.A significant main effect of ‘session’ indicated higher accuracy during the second session . The main effect of ‘sex’ was non-significant and therefore removed from the model. A significant main effect of ‘strategy’  indicated higher accuracy with the landmark-based strategy, compared to the Euclidian strategy. The main effect of ‘perspective’ was, however, non-significant , but remained in the model due to a significant ‘perspective’∗’strategy’ interaction . The ‘strategy’ effect was larger with the egocentric perspective, compared to the allocentric perspective, i.e., accuracy was particularly high with the landmark strategy under the egocentric perspective. Neither ‘perspective,’ nor ‘strategy’ interacted significantly with ‘sex.’ Therefore, these interactions were removed from the model.A significant main effect of ‘participant number’ (PNr) as a random factor and the fixed effects ‘session,’ as well as ‘perspective,’ ‘strategy,’ and ‘cycle’ . Non-significant interactions were backward eliminated and results of the final models are reported. Specifically the threefold interaction was always non-significant and thus removed from the model.For female participants, further linear mixed effects models were fitted for reaction times and accuracy including ‘session’  and ‘perspective’  were confirmed. The main effects of ‘strategy’ and ‘cycle phase’  were, however, non-significant. ‘Strategy’ did not interact with ‘perspective’ or ‘cycle-phase’ and was thus removed from the model. However, a significant interaction between ‘cycle phase’ and ‘perspective’ was observed . During the luteal cycle phase reaction times for the allocentric instruction increased, while reaction times for the egocentric instruction decreased compared to the follicular cycle phase .Significant main effects of ‘session’  was confirmed. The main effects of ‘strategy,’ ‘perspective,’ and ‘cycle’ were non-significant. ‘Perspective’ did not interact with ‘cycle’ or ‘strategy’ and was thus removed from the model. The main effects of ‘strategy’  and ‘cycle’  were, however, qualified by a significant strategy∗cycle interaction  and thus remained in the model. During the luteal cycle phase, accuracy for the Euclidian strategy decreased, while accuracy for the landmark strategy increased compared to the follicular cycle phase .A significant main effect of ‘progesterone,’ ‘estradiol,’ and ‘testosterone’ levels were separately added as predictors to the models described above . Since separate models were run for each of the three hormones, the significance level was adjusted to p = 0.016. Non-significant interactions and main effects were backward eliminated. Neither ‘testosterone’ nor ‘estradiol’ or ‘progesterone’ had a significant effect on RT.In order to evaluate, whether sex hormones impacted overall performance or strategy use during navigation, ‘progesterone’ and ‘perspective’ was found . The higher the progesterone levels, the larger was the perspective effect, i.e., the higher was the accuracy for the egocentric perspective and the lower was the accuracy for the allocentric perspective. ‘Testosterone’ and ‘estradiol’ did not affect navigation accuracy.For accuracy, a significant interaction between ‘participant number’ as a random factor and ‘session,’ as well as the interactive effects of ‘instruction’ and ‘sex’ as fixed effects, separately for the phonemic and the semantic condition . Non-significant interactions were backward eliminated and results of the final models are reported. The mean number of words, the cluster size, and the mean number of switches for the phonemic and the semantic task are displayed in Figure 3.Linear mixed effect models were calculated for the number of words, average cluster size, and number of switches, including ‘session’ was non-significant and thus removed from the model. In the phonemic condition, the main effect of ‘session’ was significant, i.e., participants produced significantly more words during the second as opposed to the first session . In both conditions, the main effects of ‘instruction’ were significant, i.e., participants produced significantly more words during the neutral instruction as opposed to the clustering instruction  and switching instruction . In both conditions, the main effect of sex was significant, i.e., women produced significantly more words than men . In both, the phonemic and the semantic condition, all interactions were non-significant and thus removed from the model.In the semantic condition, the main effect of ‘session’ was non-significant and thus removed from the model. In both conditions, the main effect of ‘instruction’ was significant, i.e., participants produced significantly larger clusters during the clustering instruction, as opposed to the neutral instruction  and significantly smaller clusters during the switching instruction compared to the neutral instruction . In both conditions the main effect of ‘sex’ was non-significant, i.e., cluster size did not differ significantly between men and women. The effect was removed from the model, since in both condition, the interactions were furthermore non-significant.In both conditions, the main effect of ‘session’ was non-significant and thus removed from the model. In the phonemic condition, the main effect of ‘session’ was significant, indicating a larger number of switches during the second compared to the first session . In both conditions, the main effect of the switching ‘instruction’ was significant, i.e., participants produced a smaller number of switches in the clustering instruction, as opposed to the neutral instructions , but only in the semantic condition did they produce a larger number of switches during the switching instruction, as opposed to the neutral instruction . The main effect of ‘sex’ was significant in both conditions , indicating a higher number of switches in women compared to men. In the semantic conditions the interaction between ‘sex’ and ‘instruction’ was non-significant and thus removed from the model. In the phonemic condition, the interaction between ‘sex’ and ‘instruction’ was significant for the comparison of clustering and neutral instruction , but not for the comparison of switching and neutral instruction , indicating that women reduced their switches more strongly during the clustering condition as opposed to the neutral condition than men.In the semantic condition, the main effect of ‘participant number’ (PNr) as a random factor and the fixed effects ‘session,’ as well as the interactive effects of ‘instruction’ and ‘cycle’ , separately for the phonemic and the semantic condition. Non-significant interactions were backward eliminated. Main effects of ‘session’ and ‘instruction’ were confirmed as in the analyses of sex differences (compare Sex Differences). No significant results were observed for the main effect of ‘cycle’ and the ‘cycle’∗‘instruction’ interaction, neither for the number of words, nor for cluster size, nor for the number of switches. ‘Cycle phase’ was therefore removed from all models.In the female sample, further linear mixed effects models were fitted for the number of words, the cluster size and the number of switches including ‘progesterone,’ ‘estradiol,’ and ‘testosterone’ levels were separately added as predictors to the models described above. . Since separate models were run for each of the three hormones in two task conditions, the significance level was adjusted to p = 0.008. Non-significant interactions and main-effects were backward eliminated. Under the corrected threshold, neither testosterone, nor progesterone or estradiol had an influence on the total number of words produced, the cluster size or the number of switches in any task condition.In order to evaluate the impact of sex hormone levels on verbal fluency performance and strategies, ‘The main objective of this study was to investigate sex differences and sex hormone influences on overall performance and especially on the use of strategies in a spatial navigation task and in a verbal fluency task. We expected to replicate a male advantage in navigation and the use of allocentric perspectives and Euclidian strategies, as well as a female advantage in verbal fluency and preferred switching between categories. We expected female menstrual cycle phases and sex hormone levels to affect performance and strategy use in both tasks.We were able to confirm a male advantage in mean reaction times of the spatial navigation task and a female advantage in the verbal fluency task.However, menstrual cycle phase did not affect overall performance in either task. While we confirmed sex differences in switching during verbal fluency, there were no sex differences in perspective and strategy use during navigation. Menstrual cycle phase did modulate the effect of strategy and perspective during navigation, whereas no menstrual cycle effects on clustering and switching during verbal fluency were observed. In the following these results will be discussed in further detail.For the navigation task the male advantage was clearly visible, with reference to faster response times, but not with reference to accuracy. Performance differences in reaction times, favoring men have also been described for mental rotation tasks  and discConcerning verbal fluency, the present study revealed that women generated overall more words than men in both fluency conditions. This is in line with the literature, although more studies speak in favor of a female advantage in the phonemic fluency task , while tUnlike previous studies ,b, we weIn the navigation task a general advantage was observed when applying the landmark-based strategy, compared to the Euclidian strategy and with the allcoentric, compared to the egocentric perspective, for both, men and women. These observations are contrary to our hypotheses, as an advantage for the allocentric perspective, compared to the egocentric perspective, was expected only for men, while for women better performance with the egocentric perspective was expected. Furthermore, an advantage with landmark-based compared to Euclidian strategies was expected only for women, while for men an advantage with Euclidian strategies was expected.It has been demonstrated that the perceptual salience of different stimulus aspects can alter processing strategies in other tasks . As the Another problem with the computerized 2D-matrix format, which may have influenced the effect of perspective, is that the egocentric instructions require mental rotation. As the matrix does not rotate if the participant takes a turn, a right turn when facing downward for example requires a left button response. With the allocentric instructions, however, mental rotation is not necessary, since the north of the matrix is always fixed to the top of the computer screen. Thus, sex differences in mental rotation ability may have confounded the sex differences in perspective preference, which is a limitation of the present study.We were thus not able to replicate findings on sex-typical strategies use and perspective preferences .With respect to cycle dependent changes, the landmark-based strategy evoked better accuracy in the luteal phase, compared to the follicular phase and the allocentric perspective evoked faster reactions in the follicular phase compared to the luteal phase in women, as expected. These observations are in line with previous studies demonstrating a stronger focus on stimulus-details or local elements of a stimulus in the luteal phase of the menstrual cycle . LandmarWith the verbal fluency task, we were able to confirm our hypothesis concerning sex differences in strategies, when considering the number of switches. Women switched significantly more often between clusters than men. Analyses of the cluster size, however, did not evoke sex differences, which is contrary to previous results . HoweverAgainst our hypothesis, testosterone levels did not affect performance in the navigation or verbal fluency task. These results are contrary to numerous previous findings suggesting a positive effect of testosterone on spatial performance and a negative effect on verbal fluency . HoweverHowever, as hypothesized, we found progesterone to modulate the perspective effect, which is in line with the menstrual cycle dependent changes observed in the present study. The higher the progesterone, as is the case during the luteal cycle phase, the less allocentric and the more egocentric becomes women’s perspective.Furthermore, neither estradiol nor progesterone affected performance or strategies in the verbal fluency task. This is consistent with the finding of no menstrual cycle influences on verbal fluency performance or strategies and suggests that sex differences in verbal fluency performance are more a result of organizational rather than activational effects of sex hormones. In line with this conclusion, previous studies have demonstrated sex differences in verbal abilities already in children, i.e., before the onset of puberty (Even though all participants were university students with similar education levels, we did not explicitly control for general intelligence in the present study. However, if results of the present study were due to insufficient matching in general intelligence, we would expect one group to perform better in both tasks. We did, however, observe better performance of men in the navigation task and better performance of women in the verbal fluency task, such that potential differences in general intelligence cannot fully explain these effects.A potential confound of the egocentric perspective in the navigation task with mental rotation ability has already been discussed as a limitation for the interpretation of sex differences in perspectives during the navigation task.Another limitation with the navigation task is that participants had to remember the route-descriptions. Individual differences in memory abilities may therefore also have biased possible sex differences.In summary, the present study confirms a robust male advantage, with respect to reaction times in the navigation task, and a robust female advantage, in the phonemic verbal fluency condition. Furthermore, the present study replicates previous reports of sex differences in strategy use in the verbal fluency task, while the interpretation of sex differences in navigation strategies is limited by the current format of the task. These limitations do, however, not affect the interpretation of within-subjects menstrual cycle comparisons in the female sample. An increased preference for the landmark-based strategy was confirmed for the luteal cycle phase, compared to the follicular phase of women. However, menstrual cycle does not affect strategy use during the verbal fluency task.BP designed and made the concept of the study. AS was responsible for data acquisition. Analysis and interpretation of the data were performed by both authors, BP and AS. AS drafted the manuscript, which was critically revised and finally approved by BP. Both authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


No studies illustrating the coping behaviors of mothers experiencing physical and mental subjective symptoms, or the factors that contribute to these behaviors, have been investigated. Therefore, the present study sought to develop a conceptual framework on the coping behaviors and contributing factors of mothers experiencing physical and mental subjective symptoms.This qualitative study involved theoretical sampling and semi-structured interviews of mothers who were raising children under 3 years of age in Japan and had experienced physical and mental subjective symptoms since giving birth. Women who were pregnant, required regular medical exams, or had difficulty communicating in Japanese were excluded. All mothers were recruited via personal contacts, snowball sampling, and posters at a community center and nursery schools. Analysis was conducted using the constant comparative method. The interview data were extracted in contextual units based on analytical themes, and concepts were generated. Relationships between concepts were investigated and categorized. To confirm theoretical saturation and ensure the validity of the data, a study supervisor was appointed, four qualitative researchers examined the results, and the interview respondents underwent member checking.“What do mothers do when raising children under 3 years of age while experiencing physical and mental subjective symptoms?” While experiencing subjective symptoms, mothers raising children under 3 years of age tended to lead a child-centric lifestyle and were hesitant to visit the doctor, not only because of typical reasons such as time and costs, but also because of factors related to their child. Some circumstances occurring while experiencing physical and mental subjective symptoms led mothers to put their own needs first and attempt to cope on their own as much as possible. As a result, most mothers would only visit a doctor after becoming seriously ill.There were a total of 21 participants. Thirteen categories were created from 29 concepts identified from the analytical theme Mothers raising children under 3 years of age in Japan tend to put their own needs on hold when experiencing subjective symptoms. As a result, they attempt to cope on their own and, at times, only visit a doctor after becoming seriously ill.The online version of this article (10.1186/s12905-017-0494-8) contains supplementary material, which is available to authorized users. A survey of 74,000 people by Japan’s Ministry of Health, Labor and Welfare (MHLW) found that the rate of physical and mental symptoms was 1.3 to 1.5 times higher in women of the child-rearing to menopause generation compared with men of the same age span, whereas it was almost equal for men and women in all other age groups –4, as weFactors associated with women’s health have been investigated in terms of socioeconomic conditions , 9. HoweChild-rearing mothers are reported to be at a lower risk of contracting serious life-threatening diseases than are the elderly. However, subjective symptoms or diseases can lead to greater hardships and higher medical costs, and can reduce social productivity resulting from work absenteeism . FurtherThe present study sought to develop a conceptual framework for coping behaviors among child-rearing mothers experiencing physical and mental subjective symptoms, as well as the factors that influence these behaviors. This framework can be expected to serve as a fundamental resource for enabling child-rearing mothers to obtain the appropriate and required care when seeking medical treatment.Qualitative study. Study period: August 2013 to March 2014.In the context of the present study, “any physical and mental subjective symptom” is used to refer to an “unwell or abnormal physical or mental state”; in other words, an unusual physical or mental state. Although “coping behavior” is generally used to describe the process of adapting to stress, in the present study, it is used to refer to “behavior to relieve unwell or abnormal physical or mental symptoms”. Therefore, it describes behavior intended to relieve not only mental, but also physical symptoms. Finally, “Fatigue” in the present study is used to refer to “a condition in which a person is physically or mentally tired.”This study targeted those mothers who were currently raising children under 3 years of age in Japan and who had experienced physical and mental subjective symptoms since giving birth. This population was targeted due to the particularly significant fatigue involved in raising children up to the age of 3 years –8, and tData collection was undertaken by a female qualitative researcher (the first author), who was an assistant professor at the College of Nursing at the time of the study. All interview procedures were practiced several times in advance of the study. Next, semi-structured interviews were conducted in adherence with interview guidelines to clarify the participants’ coping behaviors when experiencing physical and mental subjective symptoms and associated factors. One 1-h interview was conducted with each of the participants and recorded using a digital voice recorder.The interviews were conducted in the participants’ houses or office meeting rooms, or at the community center, university, or nursery schools. The location was chosen by the participants so that they could relax and feel confident that their confidentiality was protected. Upon the participants’ request, their children attended the interviews with them or stayed with babysitters in the same or a different room for the duration of the interviews.Constant comparative method , 19–21. None of the participants dropped out after being contacted by the interviewer. There were a total of 21 participants, 10 of who were stay-at-home mothers (indicated with an “S” in the interview transcripts) and 11 of whom were employed (indicated with a “W”). Nine of the employed mothers were professionals, six of whom were medical professionals . The median age of the mothers was 35 years (range: 24–42 years), and that of their youngest child was 19 months (range: 3–35 months). The median number of children was two (range: one to three). The interviewer had previous contact with three participants prior to study commencement.What do mothers do when raising children under 3 years of age while experiencing physical and mental subjective symptoms?” , went to work (“Working even when feeling unwell”), refused to make time for themselves (“No time to spend on myself”), or found it difficult to ask for help with child-rearing or housework (“Difficult to ask for support”).Even when they were experiencing subjective symptoms while raising a child under 3 years of age, mothers were “Putting my own needs on hold”. This attitude influenced their coping behaviors while in poor health. As a result, mothers attempt to “Cope on their own as much as possible” and, at times, only visit a doctor after becoming seriously ill (“Visiting the doctor with terrible symptoms”). Furthermore, some mothers did “Visit the doctor early”, or “Visit the doctor while accompanying a family member”.The mothers were affected by these interacting circumstances, leading to a feeling of “Predicting the cause, course, and treatment” of their symptoms and the “Use of support”. Mothers attempted to cope on their own when they felt capable, and visited the doctor only when they felt it was necessary. When receiving support, mothers were encouraged to rest and visit a doctor, and when they could not get any support, their visits to the doctor were hindered, leading to changes in their coping methods.Their coping behaviors were influenced by “When my child was hospitalized, I had flu symptoms) but I obviously couldn’t go to the hospital and leave my child, so I just slept with my child in her bed” (W4). As shown in this response, the mother was focused on taking care of her child even when she suspected she had the flu herself. “Each time I would have a fever of about 39°C or 40°C, so I would have to breast-feed the baby between these episodes of fever. (Omitted) Having to breast-feed my child. That was really tough” (S10). This response demonstrated how mothers were focused on taking care of their child despite their unhealthiness.Mothers raising a child under 3 years of age were focused on their child even when experiencing physical and mental subjective symptoms. “(It’s winter so I don’t want (my child) to catch a cold from someone. (Omitted) Even using a baby carrier is physically tiring. When my child cries, it’s a bother to others. When my child cries while we are at the hospital, I am considerate of others, so I tend to hesitate to visit the doctor” (S2). “My child has started crawling lately. (Omitted) It takes longer than usual to get anything done. For example, when paying the bill, I have to put the baby down like this, which is a bother” (W8).This category describes the hesitation that mothers felt in visiting the doctor because of the reluctance to go together with their child, the hesitation to take medication, the reluctance to spend time or money at the doctor’s office, and the hassle of looking for a doctor. Most of the mothers for whom this category applied exhibited a reluctance to visit the doctor together with their child. Reasons for this reluctance included the concern that their child could contract an infectious disease, worry about bothering others if their child was unable to wait quietly during the appointment, and the physical burden of taking their child with them. Even when their child was not old enough to walk or crawl, or when they only had one child, mothers complained of a sense of burden. The longer the doctor’s appointment, the greater the reluctance showed by the mothers. “Mothers showing hesitancy to take medication while pregnant or breast-feeding were concerned that the medication would be transmitted to the fetus or the child via their breast milk. Symptoms that appeared in these situations included cold, fever, and gastroenteritis, and the medications involved included antibiotics, intestinal drugs, and antipyretics.I frequently visit  for my child, but not for myself. I really haven’t been to the hospital for a personal matter. I'm always down the list in terms of priorities” (S5). “I feel that I’m always putting myself last. When I work too hard. I wonder why that is. I’m afraid to ask for a day off” (W3).Mothers put their own issues on hold even when experiencing physical and mental subjective symptoms due to the interaction of their child-centric lifestyle, their hesitation to visit the doctor, the difficulty of asking for support, and their work and/or housework commitments. This in turn influenced their coping behaviors. “I lie down on a mattress here (in the living room), then plead with my child to go to sleep and lay their toys on the floor, and then I lie down while they play” (W6). The second technique was a unique approach that did not involve rest or medication. “(When I suspect that I have mastitis) I massage myself most of the time to relieve the breast engorgement, but when I can’t relieve it on my own (I visit the doctor)” (S9). The third technique was to take medication at home from past prescriptions, including antipyretics, antibiotics, and other antifungal drugs. “I saved the (antipyretic) medication that I had previously been prescribed , which was safe for nursing mothers, so I took it when I suddenly came down with a high fever” (W2). The fourth technique was to use over-the-counter medication. “I thought that going to the hospital (with my child) would be an unnecessary bother if he just caught a cold, so I decided to take over-the-counter medication” (S6). In addition to these four coping methods, some mothers decided to discontinue treatment and cope on their own, even when medical care was required. “I had wanted to go to the dentist but my husband wouldn’t or couldn’t look after our child, so I was reluctant to go. Then our second child was born, so I was too busy to go (to the dentist), so my teeth have been like this (shows untreated teeth) for about a year now. They filed them down as much as possible and removed the gum tissue, and they are still in this condition today” (S1).Because of their tendency to put their own issues on hold, mothers attempted to cope on their own as much as possible without visiting the doctor using four techniques. The first technique was resting. Mothers would focus on resting when taking their child to daycare or receiving support from relatives, or in other cases, would lie down while their child played beside them. “ I couldn’t smell anything. Although my nose wasn’t blocked, even when I took the cap off a bottle of perfume and tried to smell it, I couldn’t. I was concerned so I took the cap off the gasoline tank and tried to smell it, but still couldn’t smell anything. That had me worried. I couldn’t taste what I ate, and I had only had a slight sensation of sweet, spicy, or sour, so I was quite concerned (and I visited the doctor)” (S3). One mother noted her experience with the threat of premature delivery in a previous pregnancy period. “I put (my own needs) on hold. My child is far and away my top priority, and everything else is irrelevant. Even when that  occurred, it was no good. I definitely pushed myself too hard. (Omitted) So I probably could have avoided going to hospital if I had been more careful, but I can’t help myself” (W11).Many of the mothers did in fact visit the doctor when they felt terrible. “In the present study, mothers tried to cope on their own rather than visiting a clinic or hospital when experiencing physical and mental subjective symptoms. As a result, most of the mothers only visited the doctor after their symptoms had worsened. One factor that had a significant demonstrable effect on coping behaviors during times of subjective symptoms was the mother’s feeling of putting her own needs on hold. Factors that influenced this feeling included a child-centric lifestyle, hesitation in visiting a doctor, work and/or housework, and the difficulty of asking for support.This feeling of putting one’s needs on hold was also affected by a reluctance to visit the doctor due to associated time and medical costs, as well as work and housework, so it is possible that this feeling is not exclusive to child-rearing women. However, in the present study, this feeling was largely influenced by factors related to their children. With this in mind, there are four cultural background factors in Japan that make child-rearing mothers tend to put their own needs on hold. The first is that in Japan, the mother is predominantly responsible for raising the children and doing the housework. A government survey has shown that in approximately 70% of married couples aged 20–49 years, the wife is responsible for at least 70% of child-rearing and household tasks, even when both the husband and wife are employed full-time . In JapaA total of seven factors were identified as having contributed to mothers’ “Hesitation in visiting a doctor”. Two of these factors took the form of a hitherto unidentified reluctance to visit the doctor when raising a child. The first was reluctance in visiting the doctor together with one’s child. Mothers were worried about causing a disturbance to others, as most children under the age of 3 years find it difficult to wait quietly. Furthermore, the reluctance of mothers to visit the doctor with their child was grounded in a sense of physical burden and the risk of infection to their child. This finding suggests that if mothers could access public and private support services to meet their needs, they would be less concerned about disturbing others or the risk of their child contracting an infection at the clinic or hospital, which would in turn reduce their hesitation in visiting a doctor. The second factor was the reluctance to take medication while pregnant or breast-feeding, particularly while breast-feeding, even though there were oral medications that the mother could have taken safely to alleviate her symptoms , 29. TheUnder the concept “A unique approach that did not involve either rest or medication”, one participant performed self-care (breast massage) when she suspected mastitis. There is no evidence regarding the efficacy of breast massage for mastitis; however, in Japan, traditionally, and even at present, midwives perform breast massage on breastfeeding mothers, and sometimes teach them simple breast massage as a self-care method. Therefore, we considered that mothers performed self-care through the breast massage method recommended by midwives.Predicting the cause, course, and treatment” of their subjective symptoms consisted of using external information sources via the Internet. This finding is consistent with those from a study by Bouche et al. reporting that mothers obtained medical and health information via the Internet [Methods of gathering information for “Internet . A surveInternet ; women oThe symptoms experienced by mothers who participated in this study ranged from chronic conditions such as arthritis, migraine, and toothache, to acute conditions such as influenza, acute gastroenteritis, mastitis and external injury, as well as hospitalization due to threatened premature delivery. The seriousness of symptoms may have affected their coping behaviors. However, the study participants  tended to focus on their child even when experiencing physical and mental subjective symptoms and feeling unwell, and as a result, were more likely to put their own needs on hold to the extent that they tended to refrain from visiting a doctor until they were seriously ill.This study did have two noticeable limitations. First, we performed sampling in an attempt to prevent bias regarding the participants’ occupations and number of children. However, due in part to the effect of personal contacts and snowball sampling, six of the 11 participants who were employed turned out to be medical professionals. Although their medical occupations varied from nurses to acupuncturists and physiotherapists, the medical knowledge and experience of these participants could have affected how they predicted the cause, course, and treatment of their subjective symptoms, as well as the extent to which they were capable of self-coping and putting off a visit to the doctor. Therefore, in this study, we placed an emphasis on confirming theoretical saturation, including the results of stay-at-home mothers and those with other occupations. The second limitation was that the main investigator (the first author), who conducted the interviews and analysis, had interacted with child-rearing mothers in her capacity as a midwife, and was herself a mother of young children; therefore, her past experiences and attitudes may have influenced the study outcomes. We therefore used a constant comparative methodology, ensured that the study was supervised, requested a review of the study results by qualitative researchers other than the study members, and performed triangulation-based checking of study members in an attempt to preclude any arbitrary analyses. We also used an analytical worksheet to clarify the analytical process and enable valid interpretation of the results based on the data. Although the first author viewed the behavior of “putting one’s own needs on hold” as a matter of course rather than as a hypothetical idea, this result was derived through analysis of the data.In Japan, the number of working mothers is increasing , 33, andThe study findings showed that mothers with children under the age of 3 years in Japan put their own needs on hold when experiencing physical and mental subjective symptoms due not only to common factors, but also to child-rearing-related factors. As a result, mothers attempt to cope on their own as much as possible and, at times, only visit a doctor after becoming seriously ill.


The paper presents a survey study that investigates the self-conscious emotion of feeling offended and provides an account of it in terms of a socio-cognitive model of emotions. Based on the qualitative and quantitative analysis of the participants’ answers, the study provides a definition of offense and of the feeling of offense in terms of its “mental ingredients,” the beliefs and goals represented in a person who feels this emotion, and finds out what are its necessary and aggravating conditions, what are the explicit and implicit causes of offense , what negative evaluations are offensive and why. It also shows that the feeling of offense is not only triggered about honor or public image, but it is mainly felt in personal affective relationships. The paper finally highlights that high self-esteem may protect a person against the feeling of offense and the constellation of negative emotions triggered by it. In social psychology research, the feeling of offense has been viewed so far as typically triggered by a blow to a person’s honor, hence to his/her public “face”; yet this painful emotion, beside nicking the reputation and self-concept of the offended person, is often felt also in interpersonal relationships, that it finally may seriously disrupt.Feeling offended belongs to the so-called “self-conscious emotions” , like shThis paper argues that research on self-conscious emotions should be enhanced; and tries to contribute to this endeavor by presenting a study on the feeling of offense.Our aim is to provide a theoretical definition of this emotion and its necessary conditions, and an empirical analysis of its triggering events, the contexts and situations in which it is felt, and other feelings connected to its occurrence. In doing so, we stress that the feeling of offense does not only dwell in the field of honor and public image, as implied by previous research, but it mainly affects our close relationships, any time an action or omission of others challenges our sense of personal value and disrupts our reciprocal relations. Our primary goals are to obtain a real-life account of the feeling of offense, and to understand its connection with the person’s sense of self and her social and affective relationships.The Section “Related Studies and Research Questions” overviews current research on offense and the sense of honor. The Section “Feeling Offended: Research Goals” lists some still open-research questions, while the Section “A Socio-cognitive Model of Image, Self-Image, and Their Monitoring Emotions” presents a socio-cognitive model of mind and social interaction adopted to frame the research, introducing the notions of emotion, evaluation, image and self-image, shame, and pride, to pave the way for a conceptual definition of the feeling of offense. This top-down characterization is then verified in the empirical study presented in the Section “Feeling Offended: a Research Study,” that investigates contexts, reasons, functions of this emotion, thus contributing to single out its “mental ingredients,” i.e., the beliefs and goals represented in the mind of a person who is feeling offended, and to establish its relations with personal factors like gender and self-esteem. Conclusions follow in the Section “Conclusion.”personal factors  that can modulate it on the basis of different expectations or causal attributions ; but it also involves relational factors that affect the interpretation of the offense, since the “offenders” can be relatives, friends, acquaintances, co-workers, each implying different emotional costs. As to the personal factors, self-esteem plays a crucial role in the feeling of offense, since it can affect self-relevant emotions like shame and pride . Yet, to our knowledge, no studies have analyzed how feeling offended can be caused by implicit acts , nor cases in which the social relationship or personal investment (then the resulting expectations) can exacerbate the emotional reactions following the offense.The quoted works on the feeling of offense have always attributed the causes of this mental state to an explicit action, strictly connected to honor issues, as in the case of insults . Yet somTherefore, the first aim of our work is to provide a more comprehensive definition of feeling offended considering all possible types of offenses, both public and personal, both explicit and implicit: actions, communicative acts, and inferred mental states.Second, specific new questions and ones stemming from the above literature will be addressed: what are the specific effects of different causal attributions or expectations on this emotional state, and do they vary according to different social relationships, namely with relatives, friends, colleagues, or strangers? What are the emotions typically triggered by the “feeling of offense” in different types of social/affective relationships? What is the role of personal factors such as gender and self-esteem in mediating the emotional processing preceding and following the feeling of offense? And what is the role of relational factors in affecting the intensity of this emotion and its possible consequences? A final objective or our study is to deepen the role of self-esteem, as a personal variable working as a possible “buffer”  to negatIn this section we overview the socio-cognitive model of mind, social interaction, communication, and emotions in terms of goals and beliefs that we will adopt to investigate the research questions above.goals: regulatory states that, when not realized in the world, trigger plans, hierarchical structures where each action aims at a goal and possibly to superordinate supergoals. In this framework, power is first defined as a notion concerning a single system, “power of,” the likeliness to achieve one’s goals, which depends on favorable world conditions , and the system’s action capacities and knowledge. If system A lacks capacities or resources to achieve a goal g, while another Agent B is endowed with them, A depends on B and can achieve g only if B adopts A’s goal g, i.e., if B puts one’s actions and resources to the service of A’s goal. The device of adoption multiplies people’s power to achieve goals, thanks to resource exchange; but, in order to decide whose goals to adopt, people need to evaluate others as to their dependence on them and to their capacity and willingness to reciprocate: people form an image – a set of evaluative and non-evaluative beliefs – about others. An evaluation is defined in terms of “power of”: a belief about how much some object, event, person have or provide one with the “power of” necessary to some goal. Evaluations about world conditions, adequacy of actions, respective importance of goals are necessary in both deciding which goals to pursue and making plans to achieve them. People judge others and themselves in terms of various criteria: aesthetic criteria (beauty), but also competence , benevolence , dominance  (According to  skills) .goal of image” – the goal of having others make up an image of us – and a “goal of esteem” (positive image). But different people may want to be evaluated positively against some specific goals – I strive to appear a charming woman, you prefer to look a knowledgeable scholar. Further, we have a self-image, a set of evaluative and non-evaluative beliefs about ourselves, necessary to decide which goals to pursue, leaving aside ones out of our reach; and since having positive self-evaluations (a high self-esteem) gives us confidence in pursuing our goals, we also have a goal of positive self-image. A person’s image and self-image are tightly connected since they determine each other : we have a “ch other , but a pstupid) or claim its belonging to a degrading category (pig).Preserving a good image and self-image are among the most important goals of a person, being a means to gain adoption. Yet, sometimes people cast discredit over us, that is, they try to spoil our image by finding out our  flaws, and spreading negative evaluations about us. Discrediting a person means to spoil her image before some audience, inducing others to believe s/he is not so good, beautiful, smart, powerful as s/he tries to appear , by commIn this framework, emotions are seen as multifaceted subjective states, encompassing internal feelings, cognitive, physiological, expressive, motivational aspects, that are triggered any time an important adaptive goal of ours is, or is likely to be, achieved or thwarted . They arAn important subset of emotions is “social emotions” : those fACTION, PROPERTY, CAUSE, POSITIVE EVALUATION, SELF-IMAGE.The socio-cognitive framework analyses the cognitive aspects of emotions in terms of their “mental ingredients,” that is, the beliefs and goals represented in our mind when we feel a given emotion: e.g., pride entails, among others, the ingredients A relevant issue in pride and shame, both linked to image and self-image, is that generally the sharing of values between Self and Other is a necessary conditions for feeling the emotion, while factual knowledge is not.In Hitchcock’s film “I confess,” father Logan (Montgomery Clift) is suspected by a murderer to have revealed his murder that he had confessed. Logan does know he did not reveal it, but the murderer does not. Notwithstanding this, as beautifully expressed by Clift’s intense interpretation, Logan feels highly painful shame because, though not sharing factual belief, he shares the value that a priest must not reveal the content of a confession.In the remainder of the paper, we present a survey study investigating the feeling of offense with the aim of finding out the “mental ingredients” of this emotion, stating its relationship with the goals of image and self-image, and thus integrating a deeper knowledge of this affective state into the model above.The goal of our work, that we pursue through both a top-down and a bottom-up approach, is twofold: on the theoretical side we want to provide a definition of the feeling of offense in terms of the socio-cognitive model above, singling out its mental ingredients and stating its connection with the goals of image and self-image; on an empirical side, by means of a survey study we want to answer the research questions above, concerning the causes and effects of this feeling, while testing the hypothesis that the tendency to feeling offended is increased by lower self-esteem.We first propose a definition of the feeling of offense in terms of our socio-cognitive model; then, we present an empirical study aimed at testing and deepening our definition.1, an attack to something even more important than the integrity of our body: our image. We feel offended every time we think that someone conceives – and possibly communicates to ourselves or others – an evaluation of us that is worse/lower than one we think we deserve. Yet, this wound is particularly serious since it does not only sully the image that the offender or others have of us, but nicks an even more precious good of ours: our self-image. The offense insinuates the doubt that what others attribute to us is a real flaw of ours.An offense is a wound, an injury to the soulSince the goals of image and self-image are so adaptively important for our life, the moral inury of an offense triggers a very painful emotion: we feel offended.In our hypothesis, the feeling of offense is a negative emotion felt when an action or omission of someone, with whom we have a relevant affective relationship, causes a blow to our image and, possibly, self-image. Our survey study aims at singling out the “cognitive ingredients” of this emotion. Further research questions concern the causes, conditions, social and cognitive mediators of the feeling of offense, the connected emotions, and the relationships between the offender and the offended person; finally, our hypothesis is that the tendency to feeling offended is increased by lower self-esteem.SD = 14.1), the majority with a high school bachelor (54%) or a University degree (26%).To address these issues, we designed a semi-structured online survey on “feeling offended” that investigated the features and the effects of this feeling through the recalling of autobiographical episodes . The surThe survey included 14 closed and 11 open questions, asking how frequently the participants felt offended, for what reasons, who offended them, and in what life domain . To go more into the emotional experience of feeling offended, participants were asked to report one case in which they felt so, the specific reasons why they did, if they believed the other intended to offend, their relationship with the other before and after the offense, and what other emotions they connected to the feeling of offense. We also asked if there was some case in which another wanted to offend them but they did not feel offended, and if so, why they did not; and conversely, if in some cases another person had felt offended by them, but should not have felt so, and why. Finally, we asked to provide a definition of “feeling offended.”After this questionnaire, participants filled in Rosenberg’s test of self-esteem . A conteThe open questions subject to qualitative analysis concerned the definition of feeling offended provided by participants, the typical situations in which one feels offended, and the specific events that are felt as offending. From the analysis, some differences result sometimes between the mental ingredients explicitly mentioned by our participants in their definition of this emotion and those explicitely or implicitly present or implied in their reported examples. Let us start with the participants’ definitions.feri- of verb ferire, adjective ferito, and noun ferita  occurs as much as 41 times]. This wound somehow implies a lack of respect for A (lack of care for his/her image), and the aggression is considered unjust by A, A thinks s/he does not really deserve to be attributed such a property; a misunderstanding or unwarranted assumption by B holds such that A, though sharing the evaluation criterion with B, does not share the same factual knowledge: A and B share the value in terms of which facts can be judged, but not the really occurred facts. The problem with A is that B is relevant for A, since keeping a positive social relationship with B is important for A.Looking for the ingredients that, all in all, are contained  in participants’ definitions, in their words the feeling of offense appears as a negative emotion felt by A, often close to or embedding humiliation, anger, bitterness, sadness, rancor, the feeling of being misunderstood, impotence, and annoyance. It is caused by either a non-communicative or a communicative act by B that results into an aggression to A’s image, since it explicitly points at or implicitly entails a negative property of A: a property worth a negative evaluation of A by B with respect to an evaluation criterion relevant for the image which A wants to project, and shared with B. Being attributed this negative property is seen as a true wound to A’s image  fidati di altri, i quali hanno fornito le mie stesse opinioni.16: .distrust of B for A that is made explicit by B’s not following A’s advice.Here what is offensive for A is a substantive carelessness:Another very offensive mental state, generally implied by an omission, is the other’s Una mia cugina non ha mantenuto la sua promessa di venirmi a trovare, e non mi ha più cercato.52: .prefers someone else over you, you feel betrayed: and betrayal is not only offensive per se but mostly because A finally loses in the comparison between him/her and the rival, who is preferred by B. Like in this example:That the other disregards her own promise means that you are not important for her, she does not care you and your feelings: something highly upsetting. Further, if your low importance for the other is a bad hit to your self-esteem, even more so is the comparison between how important you are for the other as opposed to other people. Thus when the other mia sorella si è sposata e non mi ha voluto come testimone dopo che me l’aveva già chiesto.112: .In these cases B’s preference uncovers A’s relative unimportance; but the extreme case is not being acknowledged at all as a person, for example, not being greeted when meeting others.(b)NON-COMMUNICATIVE ACTIONSOffended by Sometimes, what is offensive is not a particular communicative behavior, but a general attitude of B toward A:Quando frequentavo l’università, una mia insegna[n]te, nonché relatrice, spesso mi faceva sentire un’ignorante.35: .Another offensive behavior is when B “takes advantage” of A: this makes A feel “used” like an object, not credited the dignity of a human person with her personal goals and desires.Finally, injustice is offensive:A lavoro quando non mi è stato riconosciuto il merito di un compito svolto.27: (At work when I was not acknowledged the merits of a task performed).Being subject to injustice is offensive also for an underlying thought: how unworthy am I so as to be treated this way?(c)COMMUNICATIVE ACTIONSOffensive A person can be offended by a criticism, a slander, an unjust accusation; by gossip, insults, mockery, but also by a reproach, a formal negative judgment (like a bad score), a negative prediction:quando a venti anni mi dicevano che non avrei fatto molto nella vita.107: (when at 20 people told me I would not do so much in my life).The bulk of offensive action is exclusionquando un professore mi ha cacciato da un esame orale.29: .which can take the form of a refusal to listen, or of the other’s silence.Figure 2 a physical  inadequacy, plus inadequacy with respect to the criteria of competence (cognitive skill), dominance , and benevolence .Is any and every negative evaluation offensive? Probably not: only those evaluations vis-à-vis criteria that we consider important for our image are felt as attacks to it. From this point of view, the discrediting evaluations mentioned by our participants as offensive, in partial analogy with previous works on the discrediting acts in political communication  can be cPHYSICAL APPEARANCE, based on an aesthetic criterion. But even more offensive it is targeting the functional properties of a person’s physical arrangement: the stygma of handicap makes the person feel humiliated, and when mentioned or alluded to it is offensive, even, surprisingly, when the intention of B is not to offend but, for instance, rather to help (pity is humiliating).A typical case in which people feel offended is when they are teased or criticized for their COMPETENCE, participants mention the attribution of stupidity, but also lack of social skills (like being told you are not able to educate your children).Referred to the criterion of DOMINANCE, the other’s carelessness is offensive since it tells they consider us irrelevant. We feel totally inconsequential when we are considered or explicitly accused to be useless, but also when people ignore us, or they omit those simple acts that credit us with dignity and deem us as worth respect. Further offensive attacks to our DOMINANCE are when others consider us inferior.Concerning BENEVOLENCE, we are offended by attributions of immorality, of cheating or unreliability, of negligence or non-compliance with our duty, and finally of selfishness.Coming to The real examples of our participants provide the mental ingredients of the offense – its sufficient conditions – as drawn from positive cases. Yet, an euristic way to find out the necessary conditions of a phenomenon is to wonder what happens when that phenomenon fails to occur. So we put two more questions to our participants:Did it happen that someone wanted to offend you but you actually did not feel offended? And if so, why didn’t you?n.19: andWere there cases when someone felt offended but actually s/he had no reason to feel so? Report one and explain why did s/he felt offended, and why s/he had no reason to feel so.n.22: From answers to question 19 (someone wanted to offend but you did not feel offended) the following conditions seem necessary for the feeling of offense.(a)No relevance of the flaw for A B’s criterion of evaluation is not considered important by Aper il mio modo differente di agire e pensare.18: (I did not feel offended) due to my different way of acting and thinking.(b)No truth of the event (no fact sharing)the event criticized by B does not hold in factperchè lei voleva entrare nel nostro gruppo di amiche, e pensava che la sua assenza in quel gruppo fosse causa mia.20: .(c)No goal of offending in BB did not really have the goal of wounding A, for instance when simply joking, or when criticism is aimed at advice or benevolent pedagogical goals, or finally when A understands that the reason why B tried to disvalue A was motivated by B’s “self-serving goals”: e.g., out of envy or to establish his superiority over A; therefore, he may “decide” not to get offended as a form of “psychological reactance” : the mor(d)No relevance of B for AB and B’s judgment are not important for A since it is not important for A to maintain a social-affective relationship with B, or, reciprocally, A does not esteem B.(e)No touchiness of ASome participants generally do not attribute a high offensive potential to some kinds of criticism, or they imply that the ease of feeling offended depends on people’s personal sensitivity to others’ judgment, i.e., A’s particular touchiness; others even consider their not being hypersensitive to others’ comments as a matter of moral superiority, often helped by their skills of humor and irony(f)No dependence of A’s self-esteem from others’ esteemThe clearest protection from feeling offended is being so self-confident as not to be too dependent on other people’s judgment: like implied by this answer:Ho capito che ciò che importa è come sono e come mi sento io e non come le persone intorno a me mi vedono.54: (I understood that what is important is how I am and how I feel and not how people around see me).The same conditions drawn from question n.19 pop up from the specular question n.23: if someone felt offended, but in your opinion should have not, why shouldn’t s/he? For some participants, one should not feel offended because the other did not really want to hurt, or was simply joking, or aimed to help . Moreover, a further necessary condition for really feeling offended is the seriousness of the criticism.Since defining an emotion implies finding out the necessary conditions for a person to feel that emotion, we summarize the above analysis in a set of conditions, among which – in a Searle-like manner – we can distinguish (a) preparatory conditions, (b) essential conditions, and (c) aggravating conditions.Preparatory conditionsA has the goal of a positive image before BA has the goal of a positive image before third parties CA has the goal of a positive self-imageA believes that property X is pertinent for his goal of image before B or before third parties CEssential conditionsB perfoms an Action AOr elseB omits to perform Action AA believes that this explicitly communicates or indirectly impliesThat B attributes a flaw X to AX thwarts the image that A wants to project of himselfTo BAnd/or to third parties CAnd/or to him/herselfA believes that X makes him/her inferior to B/COr to the category to which A wants others to believe he belongs to.All of this causes A to feela negative image emotion and/or a negative social emotion toward B (anger or rancor)a negative emotion of affiliation a negative emotion of attachment toward B (disappointment about B)Aggravating conditionsThe negative emotion of A is as more dramatic asThe manifestation of A’s flaw is public, i.e.,A believes that third parties C will come to know about As’ flaw or inferiorityA believes that B’s attack to A’s image is deliberateA has a low self-esteemA’s self-image is strongly dependent on the image that others (B and/or C) have of AFor A the goal of having a positive social (possibly affective) relationship to B is importantA esteems B.Data grouped around the above notions were subject to quantitative analysis, by coding them as follows:(1)Features of feeling offended. Each episode was codified, where explicit enough, as to:(a)Evaluation criterion .(b)Cause .Actions were coded as: omission, betrayal, injustice, unfriendly stance, deception, and misunderstanding;Communicative acts as: increasing level of aggression, silence, refuse, exclusion, negative prediction, detraction, reproaches, negative formal evaluation, criticism, mockery, accusation, slander, aggression, insult.Inferred mental states, as mistrust or carelessness.(c)Personal and relational components: private vs. public, depending on whether the offense was in a personal relationship or before others; and context .(2)Causal attribution. whether the cause of the feeling was oneself, another person, or simply something happened ; stability of the attribution was coded, where possible, from the personal recall of episodes; in case of transitory features the attribution was “unstable,” unlike cases where something cannot be changed, coded as “stable.”(3)5-points Likert scale: 1 = nothing at all, 4 = very much).Emotions associated to feeling offended (on a (4)5-points Likert scale: 1 = nothing at all, 4 = very much).Evaluation of the “offender” and possible forgiveness after the offense (on a (a)Types of evaluationTable 1) concern dominance (37.6%) and competence (35.8%), and to a lesser extent benevolence (14.7%) and physical appearance (11.9%) . The specific evaluations of lack of dominance include dependence, helplessness, inferiority, uselessness, and especially irrelevance, while lack of competence ranges from negligence to stupidity, to social competence (to be a good mother). In our database cases referred to female sexuality or masculinity are quite rare  or inferred (indirect) negative evaluation, conveyed by (1) an action, (2) a communicative act, or (3) the other’s inferred mental state. The evaluations that most likely cause the offence ; p < 0.005]. Differently, when conveying lack of competence and dominance offense causes a pride reaction more likely than when on benevolence and physical appearance .Even if the most frequent type of evaluation conveyed by offenses concerns the dominance criterion, this is not the most emotionally arousing: crossing type of evaluation with emotions, the negative evaluations of physical appearance result to cause (b)Causes of the offense: actions, communicative acts, and mental statesTable 2) are communicative acts (60%), then behaviors (24%), and third the other’s implied mental states (16%). If thus 60% of the offenses are borne through communicative acts, the remaining 40% are simple behaviors and inferred mental states, coded as indirect evaluation . People not only admit they can feel offended by non-communicative actions or even non-actions (as in case of an omission or an unfriendly stance of the offender), but also that in communicative acts too the negative evaluation can be communicated indirectly.The negative evaluations that cause a state of offense are conveyed, in our participants’ autobiographic reports, in three ways: actions or behaviors, explicit communicative acts, and mental states inferred by the offender. The most frequent (see The most quoted communicative acts causing offense are simple criticism (24%), insult (16%), accusation (15%), and reproach (8%), mostly directed toward the target ; other offensive communicative actions are mockery (16%), slander (5%), and calumny (2%). Further possibilities are silence, refuse, or exclusion.Among offensive behaviors participants first include omissions (27%) and betrayals (27%), then injustice (17%), unfriendly stances (13%), deception or taking advantage (10%), and misunderstanding (6%).Finally, the underlying mental states attributed to B that offend A are mistrust and carelessness (48% vs. 52%).shame more then do behaviors or inferred mental states  possibly because they can be heard by other persons, whereas bitterness is significantly caused more by behaviors and inferred mental states than by overt communicative acts . A hypothesis to account for this is that the stronger cognitive work required for inferring indirect evaluations more easily induces the victim to the continuous rumination typical of bitterness Components of feeling offended: a private/personal/relational vs. public injury.personal and private relations (64%), where the presence of other persons looks almost irrelevant; therefore in our study feeling offended is associated to public or honor code (36%) to a much lesser extent than in previous studies  or, to a lesser extent, to “something happened” (3.38), with personal attribution much less frequent (1.95). Furthermore, participants attribute their feeling offended more to the other person’s intention  than to contextual factors (2.98).Participants attribute their feeling offended to others, oneself, or simply the situation (“something happened”). Results highlight that this emotional state is strongly associated with a strong attribution of responsibility to the other person . Fear is an interesting case: it may be associated with a more stable trait that the offended person acknowledges to herself and that she probably recognizes as a cause of future negative experiences. For example, if she acknowledges that her body as a stable source is repeatedly subject to negative evaluation  she may anticipate the fear that this evaluative process will accompany her for the course of her life, thus becoming an emotion associated not only with the image of herself (as in the case of shame or guilt), but even to survival goals. Likewise, shame and guilt are related to an internal attribution of the offense. Furthermore, the external conditions taken as responsible correlate with fear, possibly because they become less controllable by participants, hence potentially threatening (Table 3).The causal attribution of a received offense can affect different types of emotions of both image and self-image (shame and guilt) and even those linked to the goal of survival (fear); if generally when feeling offended a person tends to attribute responsibility to the offender, when an internal attribution is acknowledged, emotions of fear, shame, and guilt significantly increase  referred to physical evaluation (37%). The stable causes in feeling offended are recalled more by women than men . Stable attributions have an important effect on shame and pride: a t-test analysis points out that with negative evaluations attributed to stable causes the offended person feels significantly more shame and less pride than with unstable ones . This can be considered a very strong factor in explaining shame as tested also by a significant regression with gender, self-esteem, and stability of attribution where this last one is the best predictor, thus demonstrating that when the cause of the negative evaluation cannot be changed, one feels more intensely offended .Getting more into the dimensions of causal attribution, feeling offended can be associated mostly to an unstable cause (73% vs. 27%), i.e., something that can be changed in time; unstable causes mainly relate to competence or dominance (37.5% and 41.7%) unlike stable causes, significantly  or to something happened , with co-workers only an external attribution is present , while in family relations people tend to shift responsibility to oneself . So only when the relationship is closer people are likely to make a personal exam of the all possible responsibilities, otherwise the tendency is to attribute one’s own state to an external cause (Table 4).The context of the offense, private or public, and the relationship with the offender can differentiate the internal processes of causal attribution in that, while with friends and acquaintances people tend to attribute the responsibility of the offense mostly to the other  and sense of guilt ; with friends, to fear and sense of guilt; with acquaintances shame can prevail ; just in professional relations feeling offended is associated with anger  and bitterness , both intrinsically connoted by a sense of injustice (Table 5).The relation between causal attribution of the offense and the types of personal relationships can in turn affect the associated emotions of this emotional state; the closer the relation the more inner focused the emotions: in-family offense in fact is mainly associated to sadness , friends (3.03), and to a lesser extent acquaintances (2.30); but the recalling focused on family and friends is more frequent in women than in men , coherently with the expectations of care generally assigned to females (Table 6). females : women, p < 0.05) and bitterness when feeling offended, in men anger and pride prevail (p < 0.05); when men feel offended they react by activating themselves as if being mistreated – directly or not – finally assuming masculine and dominant roles. For males, then, feeling offended looks more associated with a violation of honor rules (Table 7).When relating gender to reported emotions, ones of opposite arousal emerge: while women tend to express mainly sadness  = 148.00; p < 0.000]. However, the positive assessment of the other person is a factor in protecting the relationship, since it is positively correlated to, and increases the possibility of forgiving the offense .r = -0.360; p < 0.000) and with the possibility of forgiving include anger , but clearly also “memory” emotions such as the rumination of bitterness  and rancor ; both anger and bitterness are more frequent in working contexts (Table 5), and presumably the positive evaluation of the other and possibility to forgive after the offense are less likely when the offense is made within working relations.The possibility of forgiving is, however, differently associated with the emotions felt in the offense: emotional experiences that correlate negatively with positive evaluation after the offense , in line with other studies (Table 8).The correlation  studies . The cor∗ type of relation Ftime = 7,145; p < 0.01)] (Table 9).The positivity of the other’s image worsens significantly in relation to the type of relation with the person who offended; basically, in a personal relation the other’s image is comprehensibly more positive, but after the offense positivity strongly decreases, much more than in public contexts. [Interaction effect The second aim of our work was to investigate the role played by personal traits, in particular self-esteem, on the feeling of offense, conceptualized in a comprehensive way, including explicit and implicit causes. While we have seen that offense results in lowering the self-esteem of the offended person, here self-esteem is not considered as a possible outcome but as an antecedent of “feeling offended,” hence as a possible protection factor to support people from aggressive communicative contexts. In this perspective self-esteem is viewed as a buffer , a copinThe Rosenberg Self-esteem Scale  consistsA factorial analysis on the self-esteem scale confirmed a single-factor scale structure whose items saturate greater than 0.40 on a single factor and good internal reliability (Cronbach’s α = 0.82). The self-esteem score  was calculated. For that index, subsequently, the median value was used as discrimination to distinguish high and low levels of self-esteem.(1)Causal attribution – oneself, other, something happened – on a five-points Likert scale, 1 = never, 5 = very often).(2)1 = nothing at all, 5 = very much).Emotions associated to feeling offended 1 = nothing at all, 5 = very much).Evaluation of the “offender” and forgiveness after offense ; χF = 4,147; p < 0.000) and external attribution to an event (something happened)  = 2,813; p < 0.006) are higher in case of low self-esteem; when people give a negative global evaluation of the self (Table 10).Both internal attribution ; differently, people with low self-esteem feel higher levels of negative low arousal emotions, but also fear, showing that their negative global evaluation leads them to experience lack of internal resources to face the received offense (Table 11).Participants with high self-esteem express lower levels of negative low arousal emotions when feeling offended: lower sadness, shame, bitterness, rancor, and sense of guilt . To test the mediational hypothesis, a series of regression analyses was performed following the procedures outlined by T: 1,69; p < 0.05 for sadness and T: 2,33; p < 0.05 for shame).This procedure consists of a three-step series of regression analyses. In the first regression, the independent variable is associated with the dependent variable; in the second regression, the independent variable has to be associated with the hypothesized mediator. The third phase consists of a regression where the effects of both independent variable and mediator on the dependent variable are tested. Mediation is demonstrated when the addition of the mediator variable into the third regression equation substantially decreases or eliminates the previously significant relation between the independent variable and the dependent variable. The relation involved in the mediations was also tested by means of Sobel test  is significantly related to self-esteem, with men showing higher self-esteem (β: 0.018). Self-esteem correlates negatively with sadness and shame in feeling offended : the more self-esteem, the less sadness and shame in feeling offended , and their mediation also lowers the direct relation between gender and sadness and between gender and shame (p: n.s.), being a good moderator. So, women are more likely to have a lower self-esteem than men and the relation between gender and self-esteem makes them more likely to feel sadness and shame when feeling offended.This mediation data highlight the importance of detecting personal features in the feeling of offense, especially when it comes to stable traits like gender and self-esteem, since low self-esteem blatantly contributes to a significant negative reaction in terms of sadness and even shame, by potentially reinforcing a negative evaluation of oneself. Reading this result on the other side, we conclude that self-esteem can be considered a good “buffer,” across different relations, in presence of offensive words, actions, and omissions.Previous literature on the offense has viewed it almost exclusively as an attack to the public image of a person, to her own, or her family’s honor. But the autobiographic episodes told by our participants witness that the attack to the person’s self-image is much more frequent, offensive, and serious than public loss of face, since it can deeply hurt and jeopardizes her relationship with the offender.Moreover, such a blow to a person’s image and self-image is hit not only by explicit statements of a person’s flaws or mistakes (60% of offensive actions), including criticisms, accusations, reproaches, and insults, , whereas with aquaintances and working relations one tends to attribute the cause of the offense to the other.Feeling offended is then mainly an intimate condition in which the offended person, especially in her family relationships, may attribute a part of responsibility to oneself . Two emotions instead which do not favor forgiveness and worsen the other’s image are anger  and rancor . When feeling offended is caused by a sense of injustice, forgiveness may become more difficult, mostly in non-intimate relations where the other’s positive image is generally lower than in intimate ones; but in intimate relations feeling offended can strongly worsen the image of the other (Table 9) and cause deep sadness reactions (Table 8).Like in action that the Target has done in one case but might amend in future, being unstable and controllable, less inhesorable, and permanent, an insult claims a negative property of the Target so stable and out of control as to become definitorial of the Target . This feature distinguishes insult from other acts of discredit: while a criticism or a reproach may concern a single e Target . TellingAs to the relation between feeling offended and self-esteem our data suggest a difference between two types of emotional reaction to the feeling of offense, that we might call a “proud” and a “hangdog” attitude: the former with prevailing emotions of anger and indignation, the latter charaterized by shame, self-blame, sadness, depression. The former tends to occur with unjust criticism or accusation: the Target does share the Offender’s criterion of evaluation, but does not agree that s/he did that wrong action or was the wrong way , so the reaction is a snapshot of pride before the Offender, as if communicating: I am angry and indignant for this unjust accusation, which reveals distrust in me, ruling out the possibility of simply misunderstanding my behavior; it is not worthwhile to depend on such a person who does not acknowledge my worth. In this case the Target prefers to refrain from her possible previous dependence on the Offender, and to give up any relationship with him. The lack of fact sharing is favored by the Target’s confidence in herself, her values, and her reality perception, that make part of her self-esteem.In the other case the Target, besides convincingly sharing the Offender’s criterion of evaluation, ends up sharing factual knowledge too, so she can but acknowledge her wrong. In fact, having a low self-esteem implies a constellation of consequences: on the cognitive side, low confidence in one’s own assumptions (uncertain beliefs about whether she or the Offender were right in their perception); on the affective side, higher dependence on the Other and the relationship with him: hence, more displeasure in breaking the relationship, more sadness both for the mourn of losing the other, and for one’s own further nicked self-esteem.Feeling offended is an adaptively relevant emotion because it monitors the goals of image and self-image, in the same vein as shames does. While you are ashamed when you simply believe or fear others to make up a negative evaluation of you, you feel offended when such evaluation becomes in some way actual and overt, not only when it is publicly claimed in front of others, but also when you think it can be inferred from the other’s behavior or non-behavior.All negative emotions have the function to alert the subject that an important goal is at risk of being thwarted, and to induce immediate reactions aimed at a repair.Here, the very pain of feeling offended alerts us that our goals of image and self-image are challenged by the other, but while in a proud reaction the result may have a function to claim our own personal value (though sometimes at the cost of breaking the relationship), in a person with low self-esteem the wound could remain open by leading to a negative processing finally confirming such low value, hence inducing a more passive emotional reaction.This work has presented a survey study investigating nature, contexts of occurrence, affective, and relational effects of the feeling of offense: an emotion that monitors our goals of image and self-image, that are so basic for the human animal as to make the connected emotions really basic too. Based on a content analysis of participants’ answers, within a socio-cognitive model of emotions that argues for an adaptive function of each of them, the study has singled out the mental ingredients of feeling offended, its necessary and aggravating conditions, the causes of offense, and resulting offensive evaluations.An offense is a blow to our image and our self-image, which makes us feel offended. Feeling offended is a negative emotion caused by a communicative or non-communicative act or omission of another person that explicitly points at or implies a negative property of the Target, who generally shares the other’s criterion of evaluation, cares his/her judgment, and wants or used to entertain a positive relationship with him/her. This triggers emotions of anger, disappointment, bitterness, rancor toward the other, it often causes the break of the relationship, and lowers the Target’s self-esteem. Unlike previous works mainly viewing offense as a blow to a person’s honor and public image, our study has shown that people feel offended more in personal than in public relationships, and that its causes are not only insult or criticism, but also the other’s arrogance or betrayal, carelessness, or distrust, since they imply offensive evaluations ranging from ignorance to lack of skill and stupidity, to immorality or cheating, inferiority, irrelevance, ugliness, or handicap. Responsibility for the offense is attributed not only to the other, but sometimes to oneself, mainly by women, who pay more attention to personal relationships, and by persons with low self-esteem. People may show two reactions to feeling offended: a proud reaction, where one rejects the negative evaluation with anger and indignation, considering the criticism unjust, possibly breaking the relationship; and a “hangdog” reaction, where one takes part of the responsibility for the offense, and feels sadness, guilt, even fear, further lowering one’s self-esteem. Yet, a previous high self-esteem, seen as an antecedent of the offense, works as a protection factor to support people from aggressive communicative contexts, a coping potential against negative emotional reactions to feeling offended.This study can be framed within research on the emotions of image and self-image. The complex field of the relations among self-esteem, gender, and the feelings of offense is here explored only on the personal ground, neglecting its important historical–cultural aspects. Future research might investigate it through cross-cultural comparison. Moreover, the specific emotion of feeling offended might be compared with close but subtly different emotional states like feeling humiliated, demoralized, mortified, and taking it personally. In this connection, two aspects of feeling offended might be distinguished, one more linked to challenge to one’s power and image, and one to one’s attachment relationships.The paper is due to both authors to the same extent, though the order of names mainly recalls responsibility for the very first idea of the research topic.The methodology of the study has been approved by the Ethical Committee of Roma Tre University, in accordance to the Ethical Principles of research involving Human participants.The two authors are responsible for the ideation of the whole article, discussion, and conclusion. FD is in particular responsible for related studies review, quantitative data analysis, and interpretation of results. IP is responsible for topic ideation, introduction and theoretical part, and qualitative data analysis. They both ensure the integrity and accuracy of the work.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The handling Editor declared a shared affiliation, though no other collaboration, with the authors.