Acta Obstet Gynecol Scand 56: 375-379, 1977
SOME METHODOLOGICAL ASPECTS IN THE PSYCHOSOMATIC GYNAECOLOGY Peter Fedor-Freybergh and Goran Zador From the Department of Obstetrics and Gynaecology (Head: Prof. Axel Ingelman-Sundberg), Karolinska Instituter, Sabbatsberg Hospital, Stockholm, Sweden, and the Medical Department (Head: Ass. prof. Goran Zador), Schering Nordiska AB,Nacka, Sweden
Abstract. Psychosomatic medicine-and thus psychosomatic gynaecology-is presented as an approach to be used by doctors when meeting the patient. At the same time it is a method, a technique, trying to elucidate the mechanisms in the most complicated interplay between the psychological, somatic and social “parts of the whole”. Some diagnostic methods which can be used in this connection are discussed. The basic aim of the paper is to show the necessity and the possibility for the gynaecologist to use new technique from the psychodiagnostic field in his daily practice in order to achieve a better understanding of his patient’s complaints and needs.
The psychosomatic approach is equal to good medicine (J. Apley)
Psychosomatic medicine-and thus psychosomatic gynaecology-cannot be considered as a separate medical speciality. It is much more an approach to be used by doctors, psychologists, etc., when meeting the patient. It is based on the conviction that no patient is disturbed exclusively in “body” or in “mind”, but it is always the whole person who is ill, or otherwise the whole person is healthy. If this be true, we can speak neither about psychosomatic diseases nor about disorders, but only about the psychosomatic approach. As Apley ( 2 ) pointed out, the word psychosomatic is a heritage of Cartesian duality, with its intellectual supermarket; unfortunately it strengthens the idea that the mind and body are separate. We know both from physiology and psychology that in healthy people all bodily processes and changes are associated with psychological ones -especially emotions-and vice versa. This also applies to pathophysiology and psychopathology
concerning people when ill; pathological changes in the body will be associated with sick emotions and again vice versa. This is a highly mechanical view if one, speaking about psychosomatic illnesses, understands only ulcus duodeni, asthma bronchiale, etc. In these diseases most studies have demonstrated the connection between emotions and organic changes. The lack of studies in other diseases does not prove the converse. Following the classical, dialectic way of thinking, we must come to the only acceptable conclusion that there is no possibility of separating bodily from psychological phenomena and that the psychological factors are important in all health and in all disease. In this paper we must nevertheless, for semantic reasons, use the pragmatic sicnetific terminology, which sometimes seemingly will contradict our intentions. The only person to solve this personal dilemma, is the reader himself through his interpretations. How much, then, the psychological factors will influence the particular symptom, syndrome, disturbance, or disease, will depend on the patient’s personality structure, on his reaction patterns, on the special circumstances at the onset of the disease, on the patient’s frustration threshold and on psychophysical maturity and state of development (7). Nevertheless the whole clinical picture will be influenced by the social factors and the whole life situation of the patient. Jores (12) speaks in this connection of “human disorders”-a group of disorders in which not so much physical injury but rather the patient’s problems with life and his human failings are expressed. When trying to explain the tentative mechanisms Actu Obstet Gynecol Scand 56 (1977)
P . Fedor-Freybergh and G. Zador
underlying the psychological influences on bodily changes, we can quote a"psychosomatic model" of Luban-Plozza & Poldinger (17). According to this model, certain emotions give rise to certain autonomic changes. Via the diencephalon and the autonomic nervous system, neurotic and unconscious factors exert an effect on the body which may result in functional impairment and damage to the organs. According to the neurophysiologists, all stress situations lead to an activation of the hypothalamus, which immediately sets protection and defence mechanisms in train along motor, visceral and neurohormonal pathways. At the same time, signals are transmitted to the cerebral cortex so that the emotion is perceived and recognized. If the threat to the organism continues, the forces maintaining the internal equilibrium must remain active longer. This can lead to peripheral functional or even organic disturbances in the system affected. Modem anthropology, which looks at man in terms of his social and interpersonal relationships, emphasizes the conflicts arising out of these relationships and stresses their importance as factors in the causation of psychosomatic disorders. Thus, for example, retirement from an active and highly satisfying occupation can lead to a sudden deterioration in a person's health. In order to understand the complicated multifactorial, polydimensional reciprocal interplay when analysing the psychological mechanisms in a clinical picture as demonstrated by a patient, it is necessary to use methods that enable an individual psychosomatic diagnosis to be established. As von Zerssen (21) stressed, in somatic medicine it has been natural that the clinical investigation of a patient is always complemented by the use of standardized physiological and biochemical examination procedures. In psychiatry this partly became the case with the introduction of the use of psychodiagnostic tests. Very occasionally, however, we can see to it that the diagnostic examination of a patient having a proneness to somatic symptoms is complemented by psychological investigations which could lead to a better understanding of the genesis and the extent of the condition, the choice of therapy, and often the prognosis of the particular disease. It was the immense contribution of Professor Axel Ingelman-Sundberg on whose initiative that the Psychosomatic Research Laboratory at the DeActa
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partment of Obstetrics & Gynaecology was set up in 1973 at Sabbatsberg Hospital in Stockholm. One of the aims and purposes, from the very beginning has been to modify existing methods and elaborate some new psychodiagnostic techniques which can be used by the gynaecologist and by non-psychologically or psychiatrically trained staff and in this way extend the diagnostic instrumentarium of the gynaecologist by one more dimension. A large proportion of patients attending hospitals, particularly gynaecological clinics, have neurotic or psychosomatic symtomatology. In women the reproductive system and emotions are specially very closely related. It is much more important to know what sort of patient has a disease than what sort of disease a patient has. Greater attention to the needs of the person rather than of the disease would do much to advance our understanding of distress and, hopefully, its relief (1). More needs to be known about how people feel and, in order to acquire this knowledge, we require better techniques. A most important rule in the psychosomatic diagnostic approach is the use of an individual centred technique. Any psychodiagnostic test should fulfil the following qualititative criteria: 1. it should be capable of use in the same manner for all individuals. 2. it should be capable of repetition in the same individual on several occasions in order to check on the results and to follow up the development in the individual, for instance during the treatment or under the varying influences of the individual's inner psychic or physical processes (19). 3. some tests should allow a quantitative analysis of the results and use of statistical methods. 4. the test, when used in clinical praxis, must be easy to administer and not too time-consuming. 5. the evaluation of the test should not be too complicated. For example when used in the gynaecologic unit in order to assess psychosomatic disturbances, the administration and evaluation must be practicable even for non-psychologically and non-psychiatrically trained staff. 6. the test must give a reliable orientation of the patient's main problems and conflicts and should also make it possible to detect pathological signs. In the psychosomatic laboratory of the Gynaecologic Department, Sabbatsberg Hospital, we divided the psychodiagnostic methods into seven groups.
Methodological aspects in psychosomatic gynaecology
I. Techniques and inventories focused on case history Here, not only the life events previously experienced but also patients’ attitudes and evaluations and their changes are registered. When looking through these types of scales one gets an immediate impression of the patiznt’s basic needs, wishes, disappointments and even some personality traits, which can all give a very important background to the patient’s present problems. The following are a few examples of the evaluation scales. Mark with X your present attitude to: sexual life: own education: own occupation: choice of partner: own children: own family life: own friends: own economic situation: realization of previous dreams and expectation:
In my present life situation I feel (mark with X ) bitterness: joy: general satisfaction with life: disappointment: happiness: resignation: harmony: love fulfillment:
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
Mark with x in the table below to what ing things are important Very imImportant portant to succeed 0 0 to eat 0 0 to be accepted 0 0 to be perfect 0 0 to be loved 0 0 to have sexual desire 0 0 to be comfortable 0 0 to be secure 0 0 to love 0 0 to be happy 0 0 to make love 0 0 to win 0 0 to have many friends 0 0
degree the followLess Unimimportant portant 0
0 0 0 0 0 0
0 0 0
0 0 0 0 0
to have children to be intelligent to be beautiful
0 0 0
I1 Personality tests The large group of personality tests and questionnaires, many of which can be filled in by the patients themselves and evaluated by doctors in an often not-too-complicated way offers in many cases a fairly good picture of the patients’ basic personality traits. In this way one can understand much better the patients’ complaints, their meaning and symbolic values, and not infrequently also predict their further development. ’ As an example from this group we can mention the Eysenck Personality Inventory (5) which is used for measuring neuroticism and extraversionlintroversion, personality dimensions considered by Eysenck as basic traits. In several of our research projects (8, 9, 10) we have demonstrated the valuable use of this test, both in the diagnosis and in the follow-up of the treatment. 111. The projective techniques This group of tests represents a possibility for the patients to express unconscious conflicts, fears, wishes, etc. The best known and the most perfect test in this group is the Rorschach test (18). A very simple but widely informative projective procedure has been elaborated (10). The test consists of 90 complete sentences with varying degrees of emotional relevancy for the individual patient. Example: a 24-year-old girl with secondary amenorrhea associates as follows: I feel I long to I am most afraid of I dream about A mother Being a woman I wish M y thoughts I t hurts me I dislike M y mother Being a mother I am not afraid of A man
ugly look as I did 3 years ago illness and death freedom I feel sorry for her frightens me I were a child again frighten me to be the way I am femininity I can never be free from is not my dream aggression frightens me
IV. Methods f o r measuring depression In accordance with Kielholtz (14, IS), Kielholtz et al. (16) and Battegay (3) we are also of the opinion that depression is a syndrome with many different etiological causes and represents a reaction of the Acta Obstet Gynecol Scund 56 (1977)
P . Fedor-Freybergh and G . Zador
individual to various somatic, endogenous, psychological and social disturbances. The reciprocal influence between the “cause” and the “effect” is obvious. The hormonal imbalance in the climacteric may bring about depression, but the depression can set in motion the climacteric symtomatology. Depression can evoke a secondary amenorrhea, the amenorrheic state will perpetuate depression. One could find many similar examples in daily gynaecological praxis. There are two possibilities of assessing depression by means of psychodiagnostic tests. The first way includes rating scales which have to be evaluated by a psychiatrist or psychologist. Such scales were developed to be applied mostly in patients with mental illnesses (4,l l , 20). The second way includes the self-rating scales which are to be filled in by the patients themselves. They are easy to use and no psychological or psychiatric expertise is necessary for the evaluation (13, 22, 23). For self-rating of depression, the Sabbatsberg Distress Self-Rating Scale (SDS) in earlier publications also called Sabbatsberg Depression Self-Rating Scale was developed (7, 8 , 9, 10). The degree of depression can be evaluated quantitatively and a phenomenological analysis of the depressive syndrome is also possible (9, 10). A close correlation was found between the findings with the Hamilton Rating Scale for Depression and the Sabbatsberg Distress Self-Rating Scale (9, lo), which suggests that the SDS applied to patients suffering from mental illness can be used instead of the HDS.
toms Rating Scale (9, 10) was used. The test is divided into three sections: 42 items concern neurovegetative symptoms, 32 items evaluate somatic symptoms and 26 items assess psychopathological symptoms. This test can be used in two ways in the same patient: as a rating by the doctor and for self-rating and self-estimation by the patient, both using a five-point scale. Thus not only can a fairly complete initial “psychosomatic” status of the patient be registered (and remembered) but one can also follow and qualify changes during the treatment. With this test it is also possible to reveal the side-effects in connection with the treatment. VII. Information processing ability There are diseases and states such as climacteric in which the information processing ability (“channel capacity”) can be impaired. Consequently the patient’s working capacity, functions such as memory, concentration ability, attention, etc., and the general mental functioning threaten to fail. By using a battery of tests measuring the patient’s performance (6, 9) one can objectize the clinical findings and their possible changes during the treatment. REFERENCES
V. Sabbatsberg Sexual Rating Scale, S S S A special rating scale was developed in order to enable evaluation of both quantitative and qualitative aspects of sexuality, such as libido, activity, satisfaction, experience of pleasure, fantasy, orgasm capacity and sexual relevancy. When speaking about the sexual functions of the individual, one cannot consider them in isolation from the personality as whole, from the relations to her partner and from the partner’s sexual functions, abilities and attitudes. Still, with this scale a good orientation about the patient’s sexual life and its changes during the treatment is possible (7, 8 , 9, 10). VI. Sabbatsberg General Symptoms Rating Scale In order to assess the patient’s psychological and somatic complaints the Sabbatsberg General SympActa Obstet Gynecol Scand 56 (1977)
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Peter Fedor-Freybergh Department of Obstetrics and Gynecology Sabbatsberg Hospital S-113 83 Stockholm Sweden