CHAPTER 23
Common Psychiatric Problems
KEY POINTS
1 Depression, anxiety, and other psychiatric disorders are common in general
1197gynecologic practice.
2 Referral to mental health specialists can and must be made in a sensitive manner.
3 Suicidal and homicidal behaviors are absolute indications for psychiatric referral.
4 Alcohol and other substance abuse require prompt recognition and intervention.
5 Some women are vulnerable to mood symptoms at times of hormonal change.
However, menopausal hormone levels are not correlated with depression and
premenstrual syndrome (PMS) should not be diagnosed without 2 months of
prospective daily ratings.
6 Personality disorders and somatic symptom disorders rarely can be cured, but
informed management can improve outcomes and greatly decrease the suffering of
the patient.
7 Withdrawal of successful psychotropic treatment is very likely to lead to relapse.
8 Psychotic disorders should nearly always be managed by psychiatrists.
Psychiatric diagnoses and psychological symptoms are extremely common and
account for considerable morbidity and mortality in the general population (1).
They are a central or complicating factor in many outpatient visits and in inpatient
care. Despite their prevalence, psychiatric disorders are often undiagnosed or
misdiagnosed (2). Clinical depression affects up to one-fourth of women
during their lives, but probably more than half of those women are neither
diagnosed nor treated (3,4). Anxiety disorders, alcohol and other substance
abuse, and somatic symptom disorders are very common among gynecologic
patients. When not detected, these disorders can lead to unnecessary diagnostic
and therapeutic interventions, provider frustration, and ongoing patient suffering.
More than half of the patients who commit suicide have seen a nonpsychiatric
physician during the month prior (5).
PSYCHIATRY IN THE GYNECOLOGY OFFICE
There are several reasons that patients with psychological problems can evoke
negative reactions in physicians (Table 23-1). The expression of strong emotions
like sadness, rage, or anxiety in patients can provoke those same emotions in
physicians and other staff members. Patients who break down in tears, become
angry, or embark on a lengthy tale or list of symptoms can disrupt the flow of a
busy practice or clinic, inconveniencing others who are waiting for care.
Physicians are naturally reluctant to uncover problems for which there seem to be
no solutions. Sometimes the necessary social and medical resources are scarce or
lacking. Although parity laws forbid discrimination by insurers against mental
health care, gynecologists and their patients may have difficulty accessing mental
health services. It is sometimes necessary for the physician and family to advocate
1198strongly for mental health care. By incorporating the management strategies in
this chapter into their practices, gynecologists can reduce clinical frustration and
play a major role in improving the health and well-being of their patients.
Table 23-1 Practitioners’ Negative Reactions Toward Patients with Psychiatric
Problems
1. Social stigma attached to psychiatric diagnoses, patients, and practitioners.
2. Concern that individuals with psychiatric disorders are weak, unmotivated,
manipulative, or defective.
3. Unfamiliarity with the growing scientific basis for psychiatric diagnoses and
treatments. Concern that patients with psychiatric problems will demand and
consume inordinate and limitless time from a medical practice.
4. Precipitation in others, including doctors, of feelings that are complementary to the
strong and unpleasant emotions experienced by patients with psychiatric disorders.
5. Gynecologists’ own uncertainty about their skills at psychiatric diagnosis, referral,
and treatment.
6. Failure to acknowledge psychiatric problems as legitimate grounds for medical
attention.
Psychiatric Assessment
Psychiatric diagnosis, as codified in the Diagnostic and Statistical Manual of
Mental Disorders (DSM-5), published by the American Psychiatric
Association, is based on empirical, valid, and reliable evidence (3). DSM-5
diagnoses strongly correlate with response to treatment. The criteria in DSM-5 are
the basis for the diagnostic entities described in this chapter. Accurate diagnosis is
critical to successful management, whether care is provided by a gynecologist or
through referral to a mental health expert.
Approach to the Patient
Although diagnostic criteria list signs and symptoms, the interaction with a
patient should not be reduced to a series of rapid-fire questions and answers. A
wealth of valuable information can be obtained from the patient’s
spontaneous description of her concerns and from her responses to openended questions. A patient who is encouraged to speak for several minutes
1199before being asked to respond to specific questions will reveal information that is
useful, even vital, to her care: a thought disorder, a predominant mood,
abnormally high anxiety, a personality style or disorder, and attitudes toward her
diagnosis and treatment. Such information may emerge only much later, or not at
all, in a question-and-answer format. As in all medical practice, it is critical
that the gynecologist neither jumps to diagnostic conclusions nor proceeds
directly to therapeutic interventions. Allowing a few moments for open-ended
discussion does not mean that the physician and the other patients awaiting care
are to be held hostage by an overly talkative patient. The clinician can tell the
patient with multiple, detailed complaints how much time is available for the
current appointment, invite her to focus on her most pressing problem, and offer a
future appointment to continue the account.
Diagnosis and treatment recommendations are of no avail unless the patient
adheres to the recommendations. One barrier to adherence is a mismatch between
the patient’s expectations and the proposed diagnostic and treatment regimen. If
there is a mismatch, an explanation of the reason will promote ultimate
adherence. Sometimes allowing time for the patient to consider the
recommendations, confer with friends or relatives, and make a commitment to
treatment at a later visit will improve the likelihood of adherence—or of a trusting
and genuine doctor–patient collaboration.
Psychiatric Referral
Gynecologists may consider referral to a mental health professional, particularly a
psychiatrist, to be a delicate matter. The first question is when to refer, followed
by how to refer, and to whom. Most mild psychiatric disorders are treated by
nonpsychiatric physicians, who are the main prescribers of antidepressants and
anxiolytic medications (6). The factors that determine the decision to refer are:
The nature and severity of the patient’s disorder
The time available in the gynecologic practice
The patient’s preference
The gynecologist’s degree of comfort with the patient and the disorder
The availability of mental health professionals
Patients who are acutely suicidal or psychotic should be referred
immediately to a psychiatrist (7). The primary provider should refer patients for
psychiatric evaluation when the diagnosis is not clear or when the patient fails to
respond to initial treatment. The gynecologist can resume responsibility for
ongoing care of many patients after their initial or periodic assessment by a
psychiatrist.
1200How to Refer
Some clinicians fear that patients will be insulted or alarmed by a psychiatric
referral. Following are techniques that decrease the discomfort of the gynecologist
and the patient and enhance the likelihood of success (7). The referral should be
explained on the basis of the patient’s own signs, symptoms, and level of
distress. For a patient suffering from clinical depression, for example, this might
be difficulty sleeping, loss of appetite, and lack of energy. For a patient with an
anxiety disorder, it might be palpitations, shortness of breath, and nervousness.
For a patient with mild Alzheimer disease, it might be forgetfulness or frightening
episodes in which she finds herself in a neighborhood she does not recognize.
When a somatic symptom disorder is suspected, the gynecologist should
emphasize the difficulty of living with symptoms in the absence of a definitive
diagnosis and treatment rather than the hypothesis that the symptoms have a
psychological basis (7):
1. “It is very stressful to be suffering while we can’t pinpoint the problem. I
would like you to see one of our staff who specializes in helping people cope
with these difficult situations.”
2. “It must be difficult to function when you have been so sickly all your life,
have seen so many doctors, have had so many diagnostic tests and medical
treatments, and still don’t have an answer or feel well.”
It is counterproductive to convey the idea that because the diagnostic
process has not revealed a specific disorder, the problem must be “in the
patient’s head.” It alienates the patient. It is never possible to rule out an
organic cause with absolute certainty; and diseases “in the head” are real
diseases (7).
[3] Although suicidal and homicidal behaviors and psychotic symptoms are
indications for referral, many physicians fear that questioning patients about
these behaviors will precipitate them or offend the patient. That is not the
case (8). These questions can be explained as routine and necessary. The
asymptomatic patient will quickly dismiss them. An open discussion of impulses
to hurt oneself or someone else helps the patient to regain control, recognize the
need for mental health care, or agree to emergency interventions such as
psychiatric hospitalization, whereas avoiding the subject intensifies the patient’s
feelings of isolation. The management of suicidal behavior is addressed later in
this chapter.
Likewise, the possibility of psychosis need not be avoided. [8] Most patients
with psychotic disorders have had previous experience with psychiatric
referral. They can discuss hallucinations and delusions quite matter-of-factly.
1201The rare patient who comes to a gynecologist in the midst of a first episode of
psychosis is likely to be frightened by her symptoms and willing to accept expert
consultation.
Despite increasing public sophistication about mental illnesses and psychiatric
care, some patients believe that any mention of mental health intervention implies
that they are either “crazy” or that the referring physician is convinced that their
physical symptoms are imaginary or feigned. It is helpful to state explicitly that
this is not the case. Making the reason for the referral clear and founded in signs
and symptoms obvious to the patient will nearly always allay anxiety over a
psychiatric referral (7).
It is not acceptable to refer a patient to a psychiatrist without informing
her in advance and obtaining her consent, unless she is functionally
incompetent, or in the throes of a suicidal or homicidal emergency. Even
under those circumstances, it is highly preferable to be straightforward. A referral
that begins with an unexpected clinical encounter with a psychiatrist is unfair to
both the psychiatrist and the patient and is unlikely to result in a satisfactory
outcome (7).
[2] To allay any concern a patient may have that a mental health referral is
an indication of the gynecologist’s disdain or disinterest, and to promote
good patient care in general, the referring gynecologist should make it clear
to the patient that he or she will remain involved in the patient’s care. The
mental health professional should be introduced as a member of the health care
team, and the gynecologist should ask the patient to call after the mental health
appointment to report on how it went. The patient should be given a follow-up
appointment with the gynecologist at the time of the referral (7).
Which Mental Health Professional?
Mental disorders are treated by social workers, psychologists, members of the
clergy (the first consulted by some patients), and various kinds of counselors as
well as by psychiatrists (7). The lay public or even some medical professionals
may not understand the distinctions between types of mental health professionals.
The criteria for membership in each profession can vary by region and institution.
Social workers and psychologists can receive degrees at the bachelor, master, or
doctoral level. In some states, licensure is required. Social workers require a
master’s degree and psychologists receive a doctoral degree, in addition to
supervised clinical experience, to qualify for licensure. The category of counselor
includes a wide variety of practitioners, such as marriage counselors, pastoral
counselors, school counselors, and family counselors. The training of social
workers may focus on social policy, institutional care, psychosocial aspects of
medical illness, or individual treatment (7).
1202Practitioners of all these disciplines may or may not be trained in
psychotherapy. For a patient whose symptoms do not meet the criteria for a major
psychiatric disorder and who is able to eat, sleep, and carry out her regular duties,
supportive psychotherapy provided by any trained mental health professional may
suffice. Supportive psychotherapy calls on a patient’s existing coping
mechanisms to combat a stressful situation. Doctoral-level psychologists and
neuropsychologists can perform testing that can be helpful in establishing a
diagnosis. Such testing is especially useful in identifying and localizing brain
pathology and in defining intelligence levels. Undiagnosed cognitive deficits may
contribute to noncompliance with gynecologic care and other problems (7).
Trained social workers are often knowledgeable about community
resources for patients and their families and about the impact of gynecologic
diseases and treatments on patients. Self-help or professionally led therapy
groups can be helpful for patients reacting to gynecologic problems such as
infertility or malignancy.
Psychiatrists are the only medically trained mental health professionals.
They play a particularly important role in resolving diagnostic dilemmas,
especially when questions arise about the psychological or behavioral
manifestations of medical illness and pharmacologic treatment; when a medical
understanding of the gynecologic condition and treatment is essential to the care
of the patient; and when such issues as drug–drug interactions must be considered
(7). Psychiatrists are the only mental health professionals trained to
prescribe psychoactive medications and other biologic interventions and
provide psychotherapy. The legislatures of several states have conferred
prescribing rights on doctoral-level psychologists with additional training but
have not defined the limits of the prescribing authority. The gynecologist would
have to enquire whether a particular psychologist has completed this training; the
numbers are small. It is highly likely that psychiatrists will continue to treat the
most seriously ill patients and take ultimate responsibility for psychiatric
emergencies (7).
Because psychiatric problems frequently present in gynecologic practice, it
is worthwhile for the gynecologist to develop an ongoing relationship with
one or more local mental health professionals. The state psychiatric society
may have a list of subspecialists in psychosomatic medicine, formerly known as
consultation-liaison psychiatry. This is an official subspecialty for psychiatrists
who focus on collaboration with physicians of other specialties. Many
psychiatrists without specific fellowship training also offer consultative services.
The availability of familiar and trusted resources enhances the likelihood that
problems will be identified and addressed. An ongoing relationship with a mental
health professional allows the gynecologist to familiarize that professional with
1203relevant developments in gynecology. It is important to keep up-to-date
information on local suicide prevention hotlines, domestic violence agencies,
and resources for mothers who may pose a danger to their children. Local
laws may require that physicians report to the authorities their identification of
mothers in this situation (7).
Whenever a patient’s thinking, emotions, or behaviors cause concern, the
gynecologist should first consider a nonpsychiatric medical disorder or a reaction
to prescribed or illicit drugs. Psychiatric disorders frequently coexist with these
conditions (7). HIV/AIDS infection, some malignancies, hypothyroidism, and
other diseases can present with psychiatric symptoms.
Psychiatric conditions are extremely common in gynecologic practice. Some
are primary and some are related to reproductive events. All patients should be
screened for depression, anxiety, intimate partner violence, and substance
abuse (7).
Note: Gynecologists generally limit their prescriptions of psychotropic
medications to anxiolytics and antidepressants; some of these agents serve both
functions. Information about these classes of medications is presented at the end
of the chapter; most of the management described in connection with specific
disorders is nonpharmacologic.
MOOD DISORDERS
Mood is the emotional coloration of a person’s experience. Mood may be
pathologically elevated (mania), lowered (depression), or alternate between
the two. Mood disorders are different from, but frequently confused with, the
inevitable ups and downs of everyday life, such as reactions to difficult situations,
including gynecologic conditions. In the English language, depression is used to
describe both a transient mood and a psychiatric disorder. Because of this
confusion, patients and their loved ones become frustrated when well-meaning
attempts to offer reason, distraction, or thoughtful gestures and interactions in
order to affect a self-limited reaction to a difficult situation, fail to influence what
are protractedly disturbed moods.
DEPRESSION
[1] Depression is the single most common reason for psychiatric hospitalization
in the United States. As many as 15% of individuals with severe depressive
disorders eventually commit suicide (9). Depression is a significant risk factor
for cardiovascular disease and for nonadherence to essential treatments for other
diseases, including diabetes. The overall lifetime prevalence of affective disorders
1204is 20.8%; the 12-month prevalence is 9.5% (10–12). During the reproductive
years, depression is two to three times more common in women than in men
(13). The highest incidence of depression is in the age group of 25 to 44 years, but
depression occurs in every age group, from toddlers to the aged. Women have a
lifetime risk of 10% to 25% and a point prevalence of 5% to 9% (14–16). [7]
Depression is a recurrent disorder; of those who experience a major depressive
episode, 50% have a second one. Of these, 70% have a third, and the incidence
continues to increase with each subsequent episode. In the past diagnostic criteria
were not standardized, so it is difficult to know whether the incidence of
depression has increased over recent years, as has been asserted in the popular
press. The Center for Disease Control and Prevention reported that between 2011
and 2014, one in nine Americans had taken at least one antidepressant in the last
month (17).
Although public understanding and acceptance of mental illnesses has
significantly increased, patients may have difficulty accepting, and telling
others, that they are suffering from depression. If the depression occurs
under stressful circumstances, they may feel it is inevitable and untreatable.
If depression occurs under fortunate circumstances, they may feel guilty
because they are not appreciative of their good fortune. While stress can
precipitate depression, depression can occur under any circumstances and has a
significant genetic contribution. The need to carry out multiple roles in the
absence of adequate social support, as is all too common in women’s lives, is
stressful and can contribute to depression in women (18).
Major depressive disorder, single episode (F32.0) is characterized by the
following (3,7):
Sad mood or irritability
Hopelessness
Helplessness
Decreased ability to concentrate
Decreased energy
Interference with sleep, generally with early awakening, inability to
return to sleep, and failure to feel rested; atypically, with increased
sleep
Decreased appetite and weight; atypically, increased food intake
Withdrawal from social relationships
Inability to enjoy previously gratifying activities
Loss of libido
Guilt
Psychomotor retardation or agitation
1205Thoughts of death or suicide
The patient who has five or more of the signs and symptoms of depression
for most of each day for 2 weeks or more fulfills the criteria for the diagnosis
of clinical depression. Depression may be acute or chronic. Like many
diseases, it is caused by genetic, neurophysiologic, and environmental factors.
Trauma in early life plays a role. The average duration of a major depressive
episode is approximately 9 months (16). Patients must be cautioned to
continue treatment at least that long, even if symptoms remit; relapse is
common.
Concomitant gynecologic or other medical illness can cause signs and
symptoms similar to those of depression—loss of energy, sleep, and appetite
—but does not cause guilt, hopelessness, helplessness, or suicidality. These
observations are helpful in differentiating depression from the malaise associated
with other disease states.
Physical symptoms as an expression of depression are especially common in
Asian and Latino cultures and in the elderly (19,20). Some patients with severe
depression continue to function and can appear normal and cheerful. They may
commit suicide without exhibiting any warning signs to friends, family, or
coworkers. The only way to rule out depression is by asking about symptoms
and using the diagnostic criteria.
Management
Antidepressant medication and psychotherapy are effective treatments for
depression. There is evidence that a combination of the two produces the best
outcomes (21–23). Reports about the efficacy of alternative treatments, the most
common of which is St. John’s wort, are conflicting, but mostly negative (24).
Patients should be specifically questioned about their use of herbal and other
preparations and encouraged to use those whose components are standardized.
Transcranial magnetic stimulation is a promising research intervention (25,26).
There are many forms of psychotherapy. Those that were specifically studied
for efficacy in the treatment of depression are cognitive-behavioral therapy and
interpersonal therapy. These forms of therapy are focused on present thoughts,
feelings, relationships, and behaviors. Therapy continues for a set number of
sessions, usually no more than 16 weekly sessions, in a prescribed, predetermined
progression (27). There is increasing evidence that supportive and
psychodynamic psychotherapies are effective.
It is especially important for the patient to have the opportunity to work
out her feelings about having a psychiatric disorder, understand how it has
affected her life, and feel comfortable taking medication or undergoing
1206psychotherapy. Patients often attribute depression to weakness, laziness, or
immorality, and they often confuse antidepressants with stimulants, tranquilizers,
and other psychoactive drugs. Although written material cannot substitute entirely
for verbal instruction, it is useful to provide the patient with written material
about depression so that she can review it at her leisure and with her family and
friends if they have difficulty understanding her condition. At the same time,
clinicians must be aware that there is widespread difficulty understanding written
information, especially about medicine. Many or most antidepressant
prescriptions are either not filled or not taken as prescribed (28).
Depression in one individual has a powerful effect on other members of the
family, particularly children. This can be a motivating factor for patients who are
reluctant to accept treatment.
BIPOLAR DISORDER (F31.11)
Mania is characterized by the following behaviors (3):
Elevated mood, with euphoria or without irritability
Grandiosity
Accelerated speech and physical activity
Increased energy
Decreased sleep
Reckless and potentially damaging behaviors, such as wild
expenditures and promiscuity
Mania can be acute or subacute (hypomania). Hypomania can produce selfconfidence, ebullience, energy, and productivity that are pleasurable for the
patient and the envy of others, making the patient reluctant to relinquish this
mood by undergoing treatment. It can be particularly difficult to arrest the
condition before it progresses to full-blown mania. Acute mania is a lifethreatening condition; without treatment, patients fail to maintain essential sleep
and nutrition levels and literally exhaust themselves with frantic activity. Patients
with bipolar illness must be taught and encouraged, and often learn from bitter
experience, to recognize the early signs of disturbed mood so that treatment or
treatment changes can be initiated. It is important to remember that patients with
bipolar disorder have more depressive episodes than manic episodes, and
therefore it is important to screen every patient complaining of depression
thoroughly for a family history of bipolar disorder and a personal history of manic
symptoms. Though depression in those with bipolar disorder may present
similarly to that of unipolar depression, it is important to distinguish, as the
1207treatment consists of mood stabilizers and antipsychotics. Giving unopposed
antidepressants can provoke a manic episode (29). One potentially helpful
screening tool in the diagnosis of bipolar disorder is the Mood Disorder
Questionnaire that can be given to patients to fill out (30).
Gynecologic Factors
Connections between female reproductive functions and mood changes have been
posited for centuries. When it first became possible to determine circulating
hormone levels, researchers expected to find specific relationships between
psychological and physiologic changes. These expectations were uniformly
discounted. There is no specific serum hormone level directly associated with
premenstrual dysphoria, postpartum depression, or depression at
menopause (31). There is a subgroup of women who are vulnerable, not to
absolute circulating hormone levels, but to hormonal changes (32–35). There is a
correlation between the degree of hormonal change, pre- and postpartum, and the
incidence of postpartum mood disorder. Women who are vulnerable to
hormonal changes may experience severe premenstrual mood symptoms,
postpartum depression, and, possibly, depression in association with
hormonal influences such as hormonal contraceptive methods, menopause,
and hormone treatments (36).
Premenstrual Syndrome and Premenstrual Dysphoric Disorder
[5] Premenstrual syndrome (PMS), as differentiated from premenstrual
dysphoric disorder (PMDD), has been characterized by more than 100
different physical and psychological signs and symptoms, making it difficult
to define scientifically. Methodologic problems further complicate the situation;
in the United States, the prevalence of attitudes linking the menstrual cycle to
adverse mood and behavioral changes is so high that it skews women’s
perceptions, the way they report symptoms to researchers, and the factors to
which they attribute negative feelings.
Premenstrual Dysphoric Disorder (F32.81)
An estimated 3% to 5% of ovulating women appear to suffer from symptoms so
marked that they qualify for a diagnosis of PMDD (37,38).
DSM-5 criteria for the diagnosis of PMDD are:
In the majority of menstrual cycles, the patient had at least five of the
associated symptoms for most of the time during the premenstrual
week, with symptoms starting to improve within a few days after the
1208onset of menses, and becoming minimal or absent in the postmenstrual
week (38).
At least one of the following symptoms must be present: marked affective
lability, marked irritability/anger/interpersonal conflict, marked depressed
mood/hopelessness/self-deprecating thoughts, marked anxiety/tension.
Additional symptoms include decreased interest in usual activities;
subjective difficulty in concentration; lethargy; marked change in appetite;
hypersomnia or insomnia; a sense of being overwhelmed or out of control;
and physical symptoms such as bloating or breast tenderness.
The symptoms must markedly interfere with work, family, or academic
responsibilities; not be exacerbations of another existing disorder; and must
be corroborated by at least 2 months of prospective daily ratings (38).
Records of emotions and behaviors should be kept separate from menstrual
records to avoid confounding patients’ perceptions. The patient must be screened
for domestic abuse and other life circumstances that may contribute to her
psychological state (39).
No treatment for PMS has been validated by empirical studies (40 studies
of St. John’s wort are contradictory) (40). A number of lifestyle changes and
other benign interventions may alleviate symptoms for patients with PMS
(31):
Elimination of caffeine from the diet
Smoking cessation
Regular exercise
Regular meals and a nutritious diet, consisting of complex
carbohydrates
Adequate sleep
Stress reduction
Stress reduction can be accomplished by reducing or delegating
responsibilities, insofar as that is possible, and devoting part of every day to
relaxation techniques such as meditation and yoga. Many women experience
stress factors over which they have no control (40).
For PMDD, several selective serotonin reuptake inhibitors (SSRIs) have
proven effective in clinical trials. Fluoxetine, sertraline, and paroxetine are FDA
approved (42,43). Although SSRIs and all other antidepressants require about 2
weeks of daily administration to achieve therapeutic effect for other depressive
disorders, it appears that SSRIs are effective for PMDD when taken in the usual
daily doses during the luteal phase, and have even proven efficacious when
1209started at symptom onset. As a result of this quick relief of symptoms, it is
thought that the mode of action of SSRIs, when used in this fashion, differs from
that which alleviates major depression (31). Other medications for the treatment
of PMDD are shown in Table 23-2. There is some interest in the role of oral
contraceptives in the management of PMDD, and for patients interested in
contraception, trials of oral contraceptives are a reasonable approach (31).
Symptoms must be carefully monitored to determine whether the hormonal
intervention improves or exacerbates the problem mood changes.
Table 23-2 Treatment of Premenstrual Dysphoric Disorder
Antidepressants Fluoxetine 20 mg daily
Sertraline 50–150 mg daily
Paroxetine CR 12.5–25 mg daily
Citalopram 5–20 mg daily
Venlafaxine 75 mg daily
Clomipramine 25–75 mg daily
Ovulation suppression Ethinyl 20 mg/drospirenone 3 mg (Yaz)
Transdermal estrogen
Leuprolide 3.75–7.5mg IM monthly
Danazol 200–400 mg daily
Other medications Alprazolam 0.25 mg twice a day during luteal phase
Bromocriptine
Spironolactone
Nonpharmacologic Calcium 600 mg twice daily
Chasteberry
Cognitive behavioral therapy
From Lanza di Scalea T, Pearlstein T. Premenstrual dysphoric disorder. Psychiatr Clin
North Am 2017;40(2):201–216, with permission.
Psychiatric Aspects of Other Reproductive Events
Infertility is described by most women who undergo treatment for it as the
most stressful event of their lives. Each unsuccessful treatment episode is
experienced as the loss of a hoped-for pregnancy (44).
The loss of a fetus or newborn induces grief, with some of the same
symptoms as depression. Depression is associated with guilt, whereas
bereavement is not. However, women who lose pregnancies or infants often do
feel guilty, regardless of whether these feelings are logically justified. Patients
should not be pressed to “put the loss behind them” or expected to be “over it”
1210within several months. Some feelings of sadness may persist for years. However,
their sleep, appetite, and other vital functions and behaviors should begin to
improve after a few weeks (44). Grief that persists and interferes with normal
function is characterized as pathologic. Depression can complicate grief and
should be treated (45).
Induced Abortion
Nearly one-third of the women in the United States will have at least one abortion
in their lifetimes. The distribution of religious affiliation among patients having
abortions parallels that of the United States as a whole; that is, women who report
membership in religious faiths opposed to abortions have abortions as often as
those without such affiliations. There is no convincing evidence that induced
abortion causes clinical depression or any other negative psychiatric
sequelae. Studies purporting to demonstrate negative sequelae fail to take into
account the circumstances under which women conceive unintended pregnancies
and elect to terminate them—abuse, abandonment, poverty, rape, and incest—or
the circumstances in which they occur—familial pressure or disapproval, or the
presence of clinic demonstrators (46). Nevertheless, scientifically unsupported
allegations of physical (breast cancer) and psychological (substance abuse,
depression, suicidality) effects have been used to justify restrictive state
legislation in many parts of the country. Some state laws require that physicians
inform patients of these (nonexistent) risks. Patients may need reassurance, in the
form of accurate information, as they make abortion decisions or reflect upon past
abortions.
Peripartum Psychiatric Disorders
[5] The incidence of depression in women during their reproductive years is
approximately 10%. The incidence of depression does not decrease during
pregnancy; most postpartum depression is a continuation of antepartum
depression (47–49). Although there are some cross-cultural variations,
postpartum depression is found around the globe (50). Risk factors include social
isolation, lack of social supports, history of depression, and past or present
victimization (51). It is important to remember that women without risk
factors may become depressed. Postpartum depression must be distinguished
from the transitory, self-limited, and very common “baby blues,” which are
associated with changes in hormone levels and are better characterized as mood
intensity and lability rather than depression. Mild depression can be managed
with psychotherapy (52). Moderate-to-severe cases often require antidepressant
medications (53). Electroconvulsive treatment acts rapidly and effectively,
appears to be safe during and after pregnancy, and can be a life-saving option for
1211the most severe cases (54). Treatment with artificial light may alleviate milder
symptoms (55). Although no agent can be declared perfectly safe for use during
pregnancy and lactation, older SSRI agents are well studied, yielding little
evidence of adverse effects on the fetus or nursing infant (56,57). Medication
should not be stopped arbitrarily, nor should breastfeeding be prohibited. The
withdrawal of antidepressant medication during pregnancy is very likely to
result in recurrent and persistent depression; both antenatal and postnatal
depression have demonstrable, long-term ill effects for mother and child (58–
65). There is concern about withdrawal syndromes in neonates whose mothers
took SSRIs (66). These concerns arise from anecdotal reports and do not include
data about the number of births from which the reports emerged, nor about
confounding variables. Some observers recommended that pregnant women be
withdrawn from SSRIs some days or weeks before delivery. However, delivery
dates are often uncertain; maternal withdrawal might subject the fetus, rather than
the newborn, to withdrawal symptoms; and the likelihood of postpartum
depression, with its effects on both the mother and the infant, would be greatly
increased. Researchers are exploring ways to prevent postpartum depression, but
thus far nothing has proved effective (67,68).
Sertraline appears to be the safest medication for pregnant and lactating
women, and paroxetine is the cause of most concern. If treatment is begun during
pregnancy or lactation, sertraline is the reasonable choice. Switching a patient
successfully treated with another antidepressant to sertraline is not indicated. The
fetus would be exposed to a second medication, and the patient may not respond
as well to sertraline as to the currently effective antidepressant (56,57).
Menopause
[5] Although menopause was assumed for many years to be associated with
an increased incidence of depression, empirical studies led to conflicting
results and controversy. Menopause appears to have mood effects in some
women that can be differentiated from the hormonal effects, such as hot flashes
interfering with sleep. Historical theories like “empty nest syndrome” implied that
some patients are upset by their loss of fertility or the departure of grown children
from the home, but this has not been validated in studies. Many women find
menopause liberating (60). For some women the return of adult children to the
maternal home, or responsibilities for the care of grandchildren, seems to be a
precipitating factor for depression. Patients who suffered PMS or postpartum
depression may be vulnerable to a recurrence of depression at this new time of
hormonal change. Patients with depression at the time of menopause should be
assessed for psychosocial precipitants and domestic abuse. There are conflicting
reports on the effectiveness of hormones for treatment of mood symptoms during
1212menopause (70–75). Treatment with SSRIs may ameliorate hot flashes (76).
Depression in elderly patients can cause a pseudodementia, characterized
by decreased activity and interest and what appears to be forgetfulness.
Unlike patients with genuine dementia, these patients report memory loss
rather than trying to compensate and cover up for it. The early stages of
dementia can precipitate depression as patients react to the loss of cognitive
abilities (20).
Suicide
The most acute issue in the assessment and referral of depressed patients is
the possibility of suicide (77). Following are the risk factors for suicide:
Depression
Recent losses
Previous suicide attempts, even if seemingly not serious
Impulsivity
Concurrent alcohol or substance abuse
Current or past physical or sexual abuse
Family history of suicide
A plan to commit suicide
Access to the means to carry out the plan
Women attempt suicide more frequently than men, but men complete the
act more frequently than women (78). This is probably because men use more
drastic or irreversible means, such as firearms, whereas women tend to overdose,
which can be treated if discovered. It might seem that someone who repeatedly
makes suicidal gestures is more interested in the responses of others than in
ending her life. However, past attempts or gestures increase the risk of
completed suicide. Patients who made a suicide attempt should be queried
about the following risk factors: the intent to die (rather than escape, sleep,
or make people understand her distress); increasing numbers or doses of
drugs taken in a progression of attempts; and drug or alcohol misuse,
especially if it, too, is increasing. Inquiry about suicidal ideation and
behavior is an inherent part of every mental status examination and is
mandatory for every patient with past or current depression or evidence of
self-destructive behavior. The inquiry can follow from discussion of difficulties
in the patient’s life or mood or be introduced with a comment that almost
everyone has thoughts of death at one time or another. Nonsuicidal patients will
immediately volunteer that they have had such thoughts and that they have no
intention of acting on them. They will often add reasons: they have too much to
1213look forward to, it is against their religion, or it would hurt their family.
It is important to distinguish among thoughts of death, the wish to be
dead, and the intention to kill oneself (77). A patient in a painful life situation—
a chronic, painful, or terminal medical condition, the birth of a severely damaged
child, or a grievous loss—may express a wish to die, and even refuse
recommended medical care but emphatically and honestly disavow any intention
of actively harming herself. The patient must be directly asked.
If the patient previously engaged in impulsive self-destructive behavior,
without a plan or warning, it is wise to consult a psychiatrist. If a patient is
actively contemplating suicide, she must see a psychiatrist immediately
(78,79). Other mental health professionals may be helpful but are less likely to
have dealt extensively with and assumed responsibility for suicidal patients, be
able to determine whether the patient should be hospitalized, and have admitting
privileges. Until she is in the physical presence of a psychiatrist, or in a safe
environment such as a hospital emergency room, a suicidal patient should be
observed and protected at all times—every second—whether she is in the
consulting room or the bathroom. The staff member assigned to remain with her
may not leave to make a telephone call, go to the bathroom, or get a cup of coffee.
Family members may offer to monitor the patient and can sometimes be effective,
but the health care professional is responsible for ensuring that they understand
and implement this level of supervision. It is better to risk inconvenience and
possible embarrassment to both the gynecologist and the patient than to risk
a fatal outcome. When suicide is an immediate consideration, only a
psychiatrist can make the decision that a patient is safe (79). Psychiatric
referral can be useful in less dramatic cases: when the gynecologist lacks
experience or is overloaded with patients, when a first trial of treatment is
unsuccessful or there is uncertainty about the diagnosis, when domestic violence
or substance abuse may be present, and when the depression is recurrent.
Approximately half of suicides are not associated with depression. Suicide
can occur in the context of an anxiety disorder, personality disorder,
psychotic illnesses, or as an impulsive response to an adverse life event (79).
Suicide is not an inevitable consequence of any of these conditions, including
depression. Most people rescued from potentially lethal suicide attempts do not
ultimately commit suicide. That is why barriers on bridges, the elimination or safe
storage of firearms, the careful management of medications dangerous in
overdose, and other approaches to prevent impulsive suicides are necessary.
ALCOHOL AND SUBSTANCE ABUSE DISORDERS
[4] Alcohol and substance abuse are among the most common and most
1214frequently overlooked conditions in medical practice; and are major causes
of morbidity and mortality (80). It is important to note that alcohol and
substance abuse occur in patients of all ages and socioeconomic categories. A
2013 national survey showed that approximately 13% of women in the United
States had used illicit drugs in the past year (81). In the DSM-5, the term
“substance” can mean a prescription medication, a toxin, or an illegal drug. The
essential feature of substance dependence, or addiction, is the continued use
of the substance despite serious resulting problems.
Nicotine is included among “substances.” Women appear to be more
susceptible to nicotine addiction than men. Smoking cessation counseling by
the gynecologist is helpful. Withdrawal from alcohol and drugs can be a clinical
problem; patients often fail to inform clinicians of their alcohol and substance use
before being hospitalized or undergoing procedure (83–85).
Patients frequently use alcohol along with other substances of abuse. The
abuse of prescription medication, especially in younger populations, has increased
(86), and opioid use has been declared a national emergency. Patients should be
advised to take care that their medications are not accessible to others. There are
increasing reports of the deaths of toddlers and young children from the
accidental ingestion of opioids left within their reach. Patients concerned about
the use of opioids by family members or other people with whom they are in
contact may want to obtain opioid antagonists for use in emergencies.
Marijuana can decrease the painful symptoms of some diseases and
treatments. For asymptomatic individuals, it has negative effects on
cognition and behavior. Nevertheless, among some populations, it is regarded
as commonplace. The impact of the recent legalization of marijuana in
several states is unknown.
Alcohol is the most frequent substance of abuse. Legal and accepted by the
society, it nevertheless causes a high proportion of morbidity, mortality, and life
complications. Women’s alcohol abuse is more likely to take place in private
than is men’s; society frowns more on women who are drunk or create
disturbances in public than on men who do the same. Women are more likely
than men to use a substance because an intimate partner uses or abuses that
substance, and to trade sexual behavior for access to the substance (87). The
most successful treatment for substance abuse disorders is a so-called 12-step
program such as Alcoholics Anonymous. Most of the programs for the
treatment of substance abuse were developed for men. Women are less
responsive to the usual confrontational approach (88,89). Many women with
alcohol and substance abuse issues have children. Such women, and women who
are pregnant, are often reluctant to enter treatment for fear of prosecution or
losing custody. These are realistic fears. Treatment programs for women with
1215primary responsibility for children must include arrangements for child care
—but seldom do. Recidivism after treatment is very common, but that does not
mean that treatment is useless. On average, patients require three episodes of
treatment before achieving sobriety (82). The essential obligation of the
primary physician is to ask each patient about substance consumption and
any problems arising from it (87). Using the single screening question: “How
many times in the past year have you used an illegal drug or used a prescription
medication for nonmedical reasons?” is proven to be efficacious in detecting
substance abuse in primary care settings (85). Buprenorphine is a useful adjunct
medication for treating opioid addiction; physicians are required to undergo
specific training in order to prescribe buprenorphine (90).
ANXIETY DISORDERS
Anxiety is a sense of dread without objective cause for fear, accompanied by
the usual physical concomitants of fear. Although every human being has
anxious feelings from time to time, anxiety disorders are diagnosed when anxiety
becomes disabling or so painful as to interfere with an individual’s quality of life.
Anxiety disorders place patients at risk for suicide (91).
Diagnosis
The anxiety disorders include generalized anxiety disorder, panic disorder,
social anxiety disorder, agoraphobia, and specific phobias (3).
Generalized Anxiety Disorder (F41.1)
Generalized anxiety disorder is a condition in which anxiety is excessive and
persistent, pervading many aspects of a patient’s life, and interferes with
normal function. Diagnostic criteria include restlessness, easy fatigability,
difficulty concentrating, irritability, muscle tension, and sleep disturbances.
Whereas depressed patients fall asleep more or less normally and then
awaken earlier than intended, anxious patients tend to have difficulty falling
asleep (3).
Panic Disorder (F41.0)
Panic disorder is characterized by panic attacks: sudden, acute periods of
intense fear, generally lasting about 15 minutes, with at least four of the
following symptoms (3):
Diaphoresis
Trembling
1216Shortness of breath
A choking sensation
Chest discomfort
Gastrointestinal distress
Lightheadedness
A sense of unreality
Fear of going crazy or dying
Paresthesias
Chills or hot flashes
The attacks can recur with or without specific precipitating events. The patient
is preoccupied with them and makes behavioral changes she hopes will avert
future attacks: avoiding specific situations, assuring herself there is an escape
route from certain situations, or refusing to be alone.
The symptoms of panic attacks are often confused with the symptoms of
cardiac or pulmonary disease. They lead to many fruitless trips to the
emergency department and to costly, even invasive, medical investigations. A
careful history can establish the correct diagnosis in most cases (92).
Social Anxiety Disorder (F40.10)
Social anxiety causes the patient to fear and avoid situations in which the patient
anticipates, without rational cause, that she will be perceived in a humiliating
light. Such situations include giving a business-related presentation, making an
announcement at a meeting, and having a casual dinner with friends. Patients may
alter their lives to avoid these anxieties, interfering with their interpersonal
relationships and their ability to carry out their responsibilities, or they may
manage to carry on despite considerable psychological pain (93).
Agoraphobia (F40.0)
Agoraphobia is a marked fear of at least two of the following: using public
transportation; being in open spaces; being in enclosed spaces; standing in
line or in a crowd; being outside of the home alone, leading to avoidance of
these situations. She therefore tends more and more to stay at home or limit her
sphere of activity to an increasingly short list of venues. Agoraphobia and panic
disorder can occur separately or together (94).
Specific Phobias (F40.2)
Specific phobias are irrational fears of certain objects or situations, although
the patient recognizes that the object or situation poses no real danger. Of
particular concern in gynecology are fear of needles and fear of vomiting. Many
1217patients dread certain aspects of care, sometimes on the basis of past experience
or outdated information (95). A simple explanation or alteration in procedure can
alleviate the anxiety. For example, a reassuring family member or friend can be
allowed to stay with the patient during a diagnostic test, sedation can be
administered orally or by inhalation before an intravenous line is inserted, or the
patient can be allowed control over her own analgesia.
Behavioral interventions are extremely useful in managing anxiety
disorders without problematic side effects. They include hypnosis,
desensitization, and relaxation techniques (92–100). These techniques provide
a patient with tools to cope with her own anxiety. Specialists in behavioral
medicine, usually psychologists, are expert in these techniques. A local medical
school department of psychiatry or behavioral medicine is a good source for
referrals. Interested gynecologists can master some of the techniques.
Trauma-Related Disorders
Posttraumatic stress disorder (PTSD) (F43.1) is the result of exposure to an
event that threatens death or sexual violence of the patient or others. At the
time of the trauma, the patient experiences horror, terror, or a sense of
helplessness. Afterward, the patient may lose conscious memory of all or part of
the event, avoid situations reminiscent of it, and become acutely distressed when
she cannot avoid them. She feels numb and detached, without a sense of the
future. She is hyperarousable and irritable and has difficulty sleeping and
concentrating. She re-experiences the event in nightmares, flashbacks, and
intrusive thoughts (96).
Obsessive–Compulsive Disorder (F42)
Obsessive–compulsive disorder (OCD) is characterized by obsessions:
recurrent impulses, images, or thoughts that the patient recognizes as her
own, but dislikes and cannot control; or compulsions: intrusive, repetitive
behaviors that the patient feels she must perform to prevent some dire
consequence (95,98,99). The disorder can be mild or totally crippling; in half of
the cases, it becomes chronic. The term OCD has made its way into popular
parlance to describe people who focus on details and have trouble making up their
minds.
Somatic Symptom and Related Disorders
[6] These disorders are characterized by somatic symptoms associated with
significant distress and impairment. The diagnoses are not made on the basis of
absent physical or laboratory evidence of a gynecologic or general medical
1218condition; it is never possible to definitively rule out another diagnosis, and our
increasing recognition of the powerful intrinsic interactions between the brain and
the rest of the body renders the old mind/body distinction obsolete. When dealing
with this category of disorders, it is particularly important to ask about, and
document, the patient’s previous episodes of care; diagnostic procedures
performed, opinions rendered, treatments administered.
Somatic Symptom Disorder (F45.1)
This disorder is characterized by somatic symptoms that interfere with normal
functioning and are upsetting to the patient. Generally, a patient has several such
symptoms, and at least one is present consistently for at least 6 months. She is
inordinately concerned about the seriousness of the symptoms; anxious about
them; and devotes inordinate time and energy to worrying about them. She may
interpret normal bodily sensations as indications of disease, spend considerable
energy on careseeking behaviors, and frequently check her body for signs of
illness. The disorder is often associated with depressive and anxiety disorders. It
should be noted that, in some cultures, depression and anxiety are more often
expressed in terms of physical than psychological symptoms (3).
Illness Anxiety Disorder (F45.21)
This disorder is not characterized by complaints about physical symptoms, but by
preoccupation with and anxiety about the likelihood of a serious medical
condition. The patient checks her body, seeks or avoids medical visits and
diagnostic tests.
Management
Somatic symptom disorder and illness anxiety disorder can entirely disrupt the
patient’s life, and that of her family. On first encounter with the clinician, the
patient may express relief that she has finally found the doctor who understands
and will diagnose and treat her condition. It is tempting to welcome these
accolades, but they are almost always transitory. Given many physicians’ fear of
missing a serious diagnosis, fear of legal action, and the insistence of these
patients, it is difficult to decide when the cost and time of diagnostic procedures
and office visits is sufficient. There is no easy way out of this dilemma. It is not
worthwhile to inform the patient that there is nothing wrong with her when, in
fact, there is something wrong with her. It is best to be proactive. Rather than
dreading contacts with the patient and attempting to avoid them, schedule calls
and visits at reasonable times and intervals, informing the patient that the clinician
feels the visits are necessary for monitoring her condition. Commiserate with her
discomfort, but spend the contact focused almost entirely on her progress with
1219getting on with her life despite it. Health-promoting behaviors, and successes,
even attempts to carry out her work and family responsibilities and enjoy leisure
activities, should be praised and tracked.
Conversion, or Functional Neurologic Symptom, Disorder (F44.4)
This disorder was traditionally called “hysteria.” The patient has symptoms of
altered voluntary motor or sensory function, in a pattern inconsistent with any
known or likely medical causation. There may be weakness or paralysis; seizures;
sensory loss (blindness); or difficulties with swallowing or speaking. She may or
may not exhibit distress over the symptom or symptoms. The treatment of this
disorder generally requires a mental health professional.
Factitious Disorder, or Munchausen Syndrome (F68.1)
This is a poorly understood condition in which the patient actively causes
physical damage to herself or feigns somatic symptoms that result in
repeated hospital admissions and painful, dangerous, invasive diagnostic,
and therapeutic procedures (3). These patients may introduce feces or purulent
material into wounds or intravenous lines, inject themselves with insulin, or cause
hemorrhages. Given enough diagnostic and therapeutic interventions, significant
iatrogenic conditions, such as adhesions from surgery or Cushing syndrome from
the administration of steroids, may develop in these patients.
These patients are initially engaging but eventually frustrate the medical
staff. Declaring that the patient “only wants attention” is not helpful (101).
Most people want attention, but very few are willing to go to these lengths to get
it. Confirming the diagnosis is a delicate process. When staff members become
suspicious, they will be tempted to validate their suspicions by spying on the
patient or sending her out of her hospital room on a pretext and then searching her
belongings. The latter is illegal, and such actions, followed by a confrontation,
will end the therapeutic relationship and provoke the patient to flee rather than
addressing the problem. Calls for a psychiatric consultation may provoke
resentment in the patient and family. Patients soon reappear in another medical
facility. As a result, there are few data about the etiology, incidence, and
management of this condition. Often these patients are medically sophisticated
through some kind of medical training or knowledge gained during previous care
episodes or hospitalizations. Mothers may enact this disorder through their
children by deliberately making them ill, a condition called Munchausen by
proxy (3). Munchausen by proxy gained some popular notoriety, and it resulted
in accusations and loss of custody for some mothers whose children had serious,
chronic diseases requiring multiple medical interventions. Shared electronic
records might affect the occurrence of these conditions by making it more
1220difficult for the patient to present to multiple treatment venues.
It is critical to remember that patients whose somatic symptoms result
from depression, PTSD and other anxiety disorders, and domestic violence,
frequently seek care from gynecologists. These possibilities must be ruled out
before care is directed to symptom management. In the case of domestic
violence, the gynecologist is often the only human contact the abuser allows
the patient outside the domestic situation (102). Several medical associations
have drawn attention to the need to screen women for domestic violence and
the infrequency with which this is done. It appears that a single screening
does not significantly change outcomes. Acknowledging domestic violence,
identifying, and accessing resources are part of an often prolonged and
incremental process—of which screening can be an important first step
(103). One example of a screening query gynecologists could use is: “Does your
partner insult you, threaten you, scream at you, or physically hurt you?” It can be
helpful to leave domestic violence resource flyers with tear-off tabs in the
restroom for individuals who are not yet comfortable speaking about their abuse
with their physician.
Referral
Patients with somatic symptom disorders may resist mental health referral
more adamantly than any other single class of patients (101). Focused as they
are on physical symptoms, these patients can regard referral as a message that
their symptoms are not being taken seriously and as a sign of contempt and
rejection by the gynecologist. It is particularly useful with these patients to
emphasize that distinctions between the mind and the body are artificial. The
brain is part of the body. Our language expresses this synthesis; anxiety causes
“butterflies in the stomach,” aggravation “gives us a headache,” and unwelcome
news “gives us a heart attack.”
Any referral should be framed as support for the patient’s suffering rather
than as a statement that her problems are “all in her head” (104). The mental
health professional should be introduced as a member of the medical team. Some
medical institutions have dedicated psychiatric consultation, medical psychiatry,
or behavioral medicine services offering expertise in the psychological
complications of disease and in somatization disorders. Because the so-called
somatic and psychological symptoms often coexist and interact, the gynecologist
should work in collaboration with the mental health professional. Patients should
be given a return appointment with the primary physician, or a request for a
telephone contact, at the time of the original mental health referral. This serves to
reassure the patient that they are not being dismissed, maintains their contact with
the primary physician, and confirms that a line of communication exists to inform
1221the primary physician of the results of the consultation (104).
PERSONALITY DISORDERS
Personality disorders are pervasive, lifelong, maladaptive patterns of
perception and behavior (105). They interfere significantly with patients’ ability
to function in work, family, and other social roles, and cause considerable
distress. They are characterized by deficits in a cohesive, persistent sense of
identity; interference with standards of behavior, coping skills, and self-reflection.
They are associated with a lack of empathy: the ability to understand the feelings
of others or the effects of one’s behavior on others and the inability to form
meaningful, mutual intimate relationships. Patients with personality disorders
believe that whatever painful feelings and experiences they have are not the result
of their own attitudes and behaviors, but are caused by the attitudes and behaviors
of others. They view their own behaviors, which can wreak havoc in the health
care setting and in patients’ lives, as normal, expectable, inevitable reactions to
erroneously perceived circumstances. To make matters worse, their behaviors
tend to provoke in others the very responses that confirm their expectations; for
example, a patient who is convinced that people always abandon her will cling
desperately to others, eventually driving them away.
Diagnosis
Patients often manifest characteristics from several disorders.
Paranoid personality disorder (F60.0) is characterized by pervasive
suspicion of the motives and behaviors of others: the belief that others have
hostile or exploitative motives with respect to the individual. The patient
second-guesses the medical team, expects to be cheated and to see other
patients preferentially treated.
Schizoid (F60.1) and schizotypal (F21) personality disorder, as the names
indicate, are on a spectrum with schizophrenia, resulting in odd behaviors
and avoidance of others.
Narcissistic personality disorder (F60.81) is characterized by grandiosity, a
constant need for admiration, and a lack of concern for others. This patient
may insist upon seeing or talking to the clinician, in nonemergent situations,
immediately and in preferential treatment in general.
Histrionic personality disorder (F60.4) is manifest in abnormal
emotionality and attention-seeking. They may be sexually provocative.
Antisocial personality disorder (F60.2) is associated with a lack of respect,
or the absence of social and legal norms. The patient may be skilled at social
interactions, inspiring friendship and trust that are exploited for personal
1222gain.
Avoidant personality disorder (F60.6) results in discomfort in social
interactions, resulting from a sense of personal inadequacy and fear of
negative judgments by others.
Dependent personality disorder (F60.7) leads to a sense that one requires
an inordinate amount of care.
Obsessive–compulsive personality disorder (F60.5) is associated with
perfectionism and a need to order and control people and circumstances.
Borderline personality disorder (F60.3) is the most likely to cause trouble
in gynecologic practice. These patients have difficulty controlling their
impulses and maintaining stable moods and relationships (105). They engage
in self-destructive behaviors. Their effects are unstable; they get upset or angry
easily. They fluctuate between overvaluation and castigation of the same person
or direct these feelings alternately between one person and another. When this
happens on a gynecology service, office, or clinic, it can precipitate significant
tensions among the staff. Research reveals that many women who were abused
are diagnosed as borderline, when PTSD more accurately fits their
symptoms (102,103). PTSD is a less stigmatizing and more treatable condition
than borderline personality disorder.
Assessment
The impact of personality disorders ranges widely. At one end of the spectrum,
the disorder is an exaggerated personality style. At the other end of the spectrum,
the individual suffers terrible emotional pain and is unable to function in work
roles or relationships, spending significant periods of time in psychiatric
hospitals. She characterizes her symptoms of despair as inevitable responses to
abandonment or other mistreatment. As the definition implies, the patient will not
seek treatment for the signs and symptoms listed in the diagnostic criteria but will
have complaints about her treatment by others, their responses to her, and the
unfairness and difficulties of life in general. Taking the history, the clinician
should frame questions in those same terms: How long have these troubles gone
on, and how much do they interfere with her ability to work and relate to others?
Personality disorders do not bring patients to gynecologists’ offices directly, but
they greatly complicate things when patients arrive.
Management
Intense and lengthy psychotherapy is required to effect significant
improvement in patients who have personality disorders (102). Expert,
targeted therapeutic interventions can be successful and that the long-term
prognosis is more hopeful than previously believed. The challenge in the
1223gynecology setting is to minimize contention and drain on medical staff while
maximizing the likelihood of effective diagnosis and treatment of the patient’s
medical problems. The most helpful single step for the gynecologist is the
identification of the personality disorder. Diagnosis enables the gynecologist to
recognize the reasons for a patient’s problem behaviors, to avoid becoming
entangled in fruitless interactions with the patient, and to set appropriate limits.
There is increasing evidence that psychotropic medications are useful
adjuncts in the treatment of personality disorders (103). Treatment should be
provided in consultation with a psychiatrist. The patient’s ability to use the
medication can be compromised by impulsivity, self-destructive tendencies, and
unstable relationships. Low doses of major tranquilizers are sometimes helpful,
especially when the patient has brief psychotic episodes. Minor tranquilizers or
anxiolytics pose significant risk of overdose and physical and psychological
habituation (103). They can be prescribed for temporary stresses, but only in a
quantity sufficient for several days and with no refill allowed. Some patients’
anxiety, demands, and power struggles are eased when they are given control over
their own use of medication. Such an approach requires enough familiarity with
the patient to ensure her safety and should be managed by an expert. Because the
patient with a personality disorder attributes her problems to others, her
symptoms cannot be adduced as reasons for psychiatric referral, but her suffering
can be. Personality diagnoses are particularly stigmatizing. If a diagnosis of a
personality disorder absolutely must be noted in the patient’s chart or on
insurance forms, it is essential that she be so informed. It is useful to review the
diagnostic criteria with her so that she understands the basis for the diagnosis. All
psychiatric diagnoses, but particularly personality disorders, carry a
significant stigma.
ADJUSTMENT DISORDERS
Diagnosis
Adjustment disorders are temporary, self-limited responses to life stressors
that are part of the normative range of human experience (unlike those that
precipitate PTSD) (106). The patient has mood or anxiety symptoms that are
sufficient to lead her to seek medical care but that do not meet criteria of
sufficient quantity or quality to qualify for psychiatric diagnosis. The diagnosis
requires an identifiable stressor, onset within 3 months after the stress begins, and
spontaneous resolution within 6 months after the stressor ends. Obviously the
latter cannot be determined until the symptoms resolve—but they do rule out the
disorder if the symptoms persist beyond that time (106).
Adjustment disorders can be distinguished from normal grieving (106).
1224Grieving produces symptoms similar to those of depression, although depression
is more likely to cause guilt. Interference with function should not persist beyond
several months, but some degree of sadness and preoccupation with the lost loved
one often goes on for years. Patients with persistently disabling grief should be
referred to a mental health professional.
Management
Patients with adjustment disorders can be treated effectively with brief
counseling in the primary care setting (106). The counseling can be provided
by the gynecologist or by a nurse clinician, social worker, or psychologist,
preferably a member of the office or hospital staff who is familiar with the
gynecologist and the practice. The medical setting is sometimes the only place
where the patient can vent her feelings and think through her situation.
Counseling is aimed at facilitating the patient’s coping skills and helping her to
make thoughtful decisions about her situation. The gynecologist should follow the
patient’s progress and facilitate referral to a psychiatrist if symptoms do not
resolve.
EATING DISORDERS
Preoccupation with thinness, sometimes to the point of pathology, is a major
problem for women in North America (107). Only a small number of women
profess to be satisfied with their weights and body shapes. Nearly all admit to
current or recent attempts to limit food intake. Physicians have legitimate
concerns about the health consequences of obesity and often share social
prejudices against overweight patients. However, it is increasingly clear that
weight regulation is not simply a matter of caloric intake and energy expenditure.
There is evidence for genetic and epigenetic causes of obesity (108). No dietary
regimen has proven successful in sustained weight loss. Some patients avoid
physician visits altogether because they anticipate being weighed in view of office
staff and other patients, or being shamed. Negative comments by the physician or
others can precipitate, if not cause, an eating disorder.
The best approach with overweight patients is to acknowledge that being
overweight is detrimental to health but that changing one’s diet and lifestyle,
and losing weight, is very difficult. Primary care physicians should indicate
that they are not going to judge the patient, but are available to provide
support and information at the patient’s request.
Binge-Eating Disorder (F50.8)
1225Binge-eating disorder is defined as at least once a week experiencing a sense of
loss of control over eating, without feeling physically hungry, and consuming
greater than normal amounts of food within a 2-hour period, occurring in private
because of embarrassment over the behavior, which results in feelings of
depression and humiliation.
Anorexia Nervosa (F50.01)
Anorexia nervosa is characterized by severe restrictions on food intake, often
accompanied by excessive physical exercise and the use of diuretics or
laxatives. Clinical features include menstrual irregularities or amenorrhea, intense
and irrational fear of becoming fat, preoccupation with body weight as an
indicator of self-worth, and inability to acknowledge the realities and dangers of
the condition. Some patients seek infertility treatment (108). Anorexia poses
significant risks of severe metabolic complications and death, often from cardiac
consequences of electrolyte abnormalities. Thorough physical and laboratory
examination is critical; immediate hospitalization may be necessary (107–110).
Bulimia Nervosa (F50.2)
Bulimia is characterized by eating binges followed by self-induced vomiting
or purging. Patients’ weights may be normal or somewhat higher than normal.
Patients have drastically low self-esteem, and the condition frequently coexists
with depression (110). Recurrent vomiting can cause erosion of the tooth enamel.
Patients with anorexia or bulimia should be treated by mental health
professionals, preferably those with subspecialization in this area. The
conditions are highly refractory to treatment; patients can resort to
elaborate subterfuges to conceal their failure to eat and gain weight
(110,111). Up to 50% of cases will become chronic, and approximately 10% of
those will ultimately die of the disease. Amenorrhea patients should not be treated
with ovulation induction as it is not protective for bone density, and masks
important indicators of disease severity (108).
PSYCHOTIC DISORDERS
The hallmark of psychosis is the presence of delusions or hallucinations.
Hallucinations are sensory perceptions in the absence of external sensory
stimuli. Delusions are bizarre beliefs about the nature of motivation of
external events. Because there is no reliable definition of “bizarre,” a
physician working with a patient from an unfamiliar culture must determine
whether a given belief is normal in that culture. Delusions and hallucinations
1226are the positive symptoms of schizophrenia. The negative symptoms include
apathy and loss of connection to others and to interests. The negative
symptoms may be more disabling than the positive. Deficits in cognitive
functioning are a core feature of schizophrenia.
Schizophrenia affects approximately 1% of persons worldwide (111). Since
the deinstitutionalization of persons with severe and persistent mental illnesses in
the United States several decades ago, most affected individuals live in the
community. Often health care and other services are inadequate, leaving these
women vulnerable to sexual abuse and involuntary impregnation. Overall, the
fertility of women with schizophrenia approximates that of matched populations.
It is unclear whether indigent status is a precipitating stress or a result of
psychotic illness, but, as extremely few individuals have private or public
coverage for adequate treatment, most people with schizophrenia are indigent.
There is wide variability in the functional impact of psychotic disorders.
Patients must not be assumed to be incompetent to make medical decisions or
lead independent lives, especially if they comply with treatment. Motherhood and
child custody are exceedingly sensitive matters for these vulnerable patients.
A relentlessly downhill course is not inevitable; remissions and recovery
can occur and, with support, most patients can lead satisfying lives in the
community (112). Under the pressures of a busy medical setting, psychotic
illnesses can be overlooked, only to erupt in the labor room, operating room, or
recovery room. Patients who believe that conspiracies or aliens are responsible for
their symptoms can answer yes-or-no medical questions without revealing their
delusions. Open-ended questions (“Tell me about your symptoms”) are more
useful (7).
A primary care practitioner can assume responsibility, in consultation with a
psychiatrist, for a stable patient who complies with treatment. When a patient
expresses delusions, the clinician may indicate that he or she does not share these
delusions, but should not debate with the patient. In the process of referral to a
mental health professional, the primary clinician should be clear, matter-of-fact,
open, and confident of the possibility of successful treatment.
GENDER IDENTITY AND SEXUAL ORIENTATION
Issues of gender identity and sexual orientation continue to be contentious in
the society and relevant to gynecology practice. People who identify as
lesbian, gay, bisexual, transgender, and queer (LGBTQ) report avoiding
essential general and gynecologic care because they are made to feel
uncomfortable and misunderstood by physicians and other staff members,
which explains in part, their suboptimal health outcomes. They are at risk of
1227discrimination and bodily harm, and, as a result, at increased risk of anxiety,
depression, and suicide.
Attitudes toward gender and sexual orientation are inculcated in everyone
throughout their development, including gynecology staff. The practice challenge
is to recognize those attitudes and to avoid the assumptions that go with them.
The assumption should not be made that a heterosexual woman has exclusively
had relationships with men whose birth sex is male, or that a lesbian woman has
exclusively had relationships with women whose birth sex is female.
Registration forms and patient histories should allow for the fullest and most
accurate account of a patient’s legal and preferred names, gender identity,
types of sexual partners, relationships, and, all staff must be cautioned not to
express or imply negative judgments.
Gender Dysphoria (F64.1)
Gender dysphoria is defined as a marked incongruence between an
individual’s assigned gender and the individual’s personal experience of
gender causes clinically significant distress or functional impairment.
Identifying as transgender is not the pathology of this diagnosis, rather it is the
distress that accompanies it. Transgender individuals resent implications that they
are psychiatrically ill, but medical insurance only covers care for diagnoses, and
gender affirming medical and surgical treatment is a financially costly process.
There is evidence that gender dysphoria does not result exclusively from the
discomfort with one’s primary and secondary sex characteristics, negative impact
is derived from the lack of societal acceptance. The largest survey of transgender
people showed that more than half of those who identify as transgender have been
verbally harassed and not allowed to dress in a way that fits their gender identity
and nearly one-quarter have been physically attacked because of being a
transgender (113). Unemployment is three times as high in transgender people as
compared to the general population, and transgender people are twice as likely to
be living in poverty (113). There are many other cultures that acknowledge
nonbinary gender identities, and where they have an accepted place in society,
gender dysphoria is less common. In the United States, 40% of those who identify
as transgender have attempted suicide in their lifetime, nearly nine times the rate
of the general population (113). Transgender youth whose parents who are
supportive of their identity are three times less likely to have depressive
symptoms than transgender youth whose parents are somewhat or not at all
supportive (114).
The mainstay of treatment for gender dysphoria is supporting the person’s
transition to the preferred gender expression through supportive psychotherapy,
hormone therapy, and gender affirming surgery if desired. Symptomatic treatment
1228of depressive and anxiety symptoms is appropriate, though not very effective as
monotherapy. As the time of transition is a period of vulnerability to depression, a
gynecologist can be supportive to transmen patients by using less gendered
terms such as “chest” rather than “breasts” and “internal canal” rather than
“vagina” during a physical examination, and taking special care to screen for
suicidal ideation.
PHARMACOLOGIC TREATMENTS
This section focuses on the conditions most often treated by gynecologists.
The types and characteristics of antidepressants are presented in Table 23-3.
All antidepressants have comparable therapeutic efficacy, and all require up
to 2 to 4 weeks to take full effect. It is not yet possible to identify those patients
who will respond best to certain medications, but patients are more likely to
respond to a medication successful in family members, and there is early evidence
that depression may be related to specific neurotransmitters and respond
differentially to medications affecting a given neurotransmitter (115). Patients
tend to respond to medications that worked for them in the past and to those that
worked for depressed family members. Many patients require successive trials
of two or more antidepressants before the one that is effective for them is
identified. It is essential to continue active management through the usual
duration of a depressive episode—9 to 12 months for major depression, until
the patient has responded sufficiently that she has returned to her previous
level of mood and function. If the patient does not recover completely, she
should be referred to a psychiatrist (116).
Selective Serotonin Reuptake Inhibitors
SSRIs pose few risks of medical complications. Side effects include anxiety,
tremor, headache, and gastrointestinal upset (either diarrhea or constipation), and
usually abate within a few days of the onset of treatment. A more serious side
effect is the loss of libido and interference with orgasm (117). Patients may be
reluctant to report sexual side effects, but they may discontinue treatment because
of them. Some women are willing to accept the sexual side effects of SSRIs as an
acceptable price to pay for recovery, especially considering that depression
already interferes with their sexual functioning. Female patients are frequently
concerned about weight gain. In one study, it appeared that a weight gain of 5 to 7
lb might be attributed to an SSRI; the return of normal appetite may lead to
weight gain. Concerned patients should be advised to watch their diets carefully
while taking the medication. There is some evidence that bupropion causes less
weight gain than SSRIs. SSRIs appear to interfere with the efficacy of
1229tamoxifen, resulting in excess mortality from breast cancer (118).
SSRIs are administered in a once-a-day regimen, with little need for dosage
adjustments in most cases. SSRIs have long half-lives, so occasional late or
missed doses do not constitute a problem. Withdrawal, especially sudden
withdrawal, from SSRIs causes flulike symptoms and sleep problems in a small
proportion of patients (119). Patients should be cautioned not to discontinue their
medications without consulting the physician, and only then by gradually
decreasing the dose. As with most medications, antidepressants were not initially
tested in older women, but several are under consideration by the U.S. Food and
Drug Administration (FDA) for use in this age group. The FDA mandated the socalled black box warnings on SSRIs when used in adolescents and young adults.
This decision is highly controversial. The studies upon which the decision was
based included no subject who had committed suicide. Suicidal thoughts, which
are extremely common, were conflated with serious attempts, all lumped together
as suicidality. SSRI prescriptions decreased after the warning was imposed, and
there is some evidence that suicides have gone up as a result (120–122).
It is sensible to use a more activating agent (fluoxetine) in a lethargic patient
and a more sedating agent (paroxetine) in an agitated patient (116). Nonetheless,
responses vary on an individual basis, even within the same class of medications.
The choice of antidepressant is based on side effects, dosage, cost, and the
physician’s clinical experience (Table 23-4).
Table 23-3 Classes, Side Effects, and Prescribing Considerations for Antidepressant
Treatment
1230Serotonin–Norepinephrine Reuptake Inhibitors
Serotonin–norepinephrine reuptake inhibitors (SNRIs) are a class of medications
1231that include venlafaxine, desvenlafaxine, and duloxetine. They are similar to
SSRIs in their indications, side effects, and mechanism of action at low doses, but
have the pharmacologic property of blocking norepinephrine reuptake at higher
doses, making them most similar to TCAs, without the side effect liability. Of the
three, duloxetine is the most potent norepinephrine inhibitor, which makes it a
first line treatment in patients that have comorbid chronic pain, fibromyalgia or
stress incontinence. Venlafaxine and desvenlafaxine have been shown to be
effective in the treatment of vasomotor symptoms associated with menopause
(123).
One side effect of SNRIs that is unique compared to SSRIs is treatmentemergent hypertension, which may be most likely in venlafaxine and least in
duloxetine.
Tricyclic Antidepressants
Tricyclic antidepressants are the oldest antidepressants still in use and are
available in generic preparations (116–119). They all have significant
anticholinergic side effects that may be problematic in medically ill and elderly
patients. They are associated with some slowing of intracardiac conduction; this
side effect can be tolerated and managed in all but a few patients, and it can be
therapeutic for those with hyperconductibility. The most important drawback
of tricyclic medications is their lethality in overdose, which is especially
important because they are used with depressed patients who are already at
risk for suicide. In the rare event that they must be used by a potentially
suicidal patient, the patient must be given only a few pills at a time (119).
Table 23-4 Pharmacology of Antidepressant Medications
1232Monoamine Oxidase Inhibitors
Monoamine oxidase (MAO) inhibitors are especially effective for atypical
depression, which is associated with abnormally increased, rather than decreased,
sleep and appetite. They require dietary restrictions and can be used only in
patients who are able to understand and comply with those restrictions to avoid
hypertensive crises (115).
Other Agents
Other medications include bupropion, mirtazapine, trazodone, aripiprazole,
lithium salts, and anticonvulsants, which are effective mood stabilizers used for
bipolar disorders (124). Bupropion is available in a once-a-day preparation. It
lowers the seizure threshold slightly more than other antidepressants and should
be avoided or used with caution in patients who have a history of bulimia and
head trauma. It is used, under a separate trade name, for smoking cessation, and is
1233particularly useful for smokers who are depressed. Bupropion seems to cause
fewer sexual side effects than the SSRIs and may decrease these side effects when
added to an SSRI regimen.
Benzodiazepines are most useful in acute situations (123). The use can
quickly become chronic, with escalating dosages, diminishing therapeutic effects,
and increasing demands on the physician. Women taking benzodiazepines may
forget to include them in their medical history. When admitted to the hospital,
they may suffer unrecognized withdrawal symptoms, complicating their
treatment, or may continue to take medications from a personal supply without
informing the medical staff.
There are many patients who could benefit from anxiolytics but who are
inordinately worried about becoming dependent or addicted. A patient with
no history of addictive behaviors is unlikely to get into trouble with a
standard dose of medication (95–98). Given the level of public misinformation
about, and stigma against, psychoactive medications, patients may experience
their own misgivings, and the negative reactions of friends and family members.
It is better to provide written material, or direct the patient to a reputable website,
letting her postpone the treatment decision to the next gynecologic visit, than to
prescribe medication that will not be taken as the patient is not likely to reveal the
nonadherence.
Table 23-5 Compounds Used for Anxiety
1234GENERAL MANAGEMENT REVIEW
Many patients and their families are anxious or resistant because of
misinformation or misunderstanding about a medical problem or treatment. Few
patients can absorb all the information about significant gynecologic conditions at
a single visit, but many feel that asking questions will burden the physician or
make the patient appear stupid. Patients suffer anxiety when there is disagreement
among family members or medical staff about the diagnosis or recommended
treatment (Table 23-5).
It is easy to be trapped into a cat-and-mouse game with an anxious and
needy patient who has an anxiety or personality disorder (93). Faced with an
obsessive or anxious, talkative, and needy patient in the midst of bedside
rounds, clinic, or office hours, the clinician can develop a pattern of
avoidance, sometimes alternating with overindulgence stemming from
feelings of guilt. This kind of behavior results in sporadic, unpredictable
reinforcement of the patient’s symptoms and demands for attention and is
very likely to increase them. Attempting to escape by appearing distracted or
yielding with despair to the destruction of the day’s schedule and the care of other
patients simply heightens the patient’s anxiety (94–99).
It is preferable to develop a prospective approach (93). Gynecologists tend
1235to underrate the power of their personal interactions with patients and their
own ability to structure and appropriately limit those interactions. A patient
with a long list of symptoms can be informed at the beginning of the visit
how much time is available and asked to focus on her most important
problem, with other problems to be discussed at future, scheduled
appointments. Instead of scheduling appointments and returning telephone calls
grudgingly in response to patient demands, the gynecologist should inform the
patient that her condition requires regular, brief scheduled visits. If she is
contacting the office more often than visits can reasonably be scheduled, she
should be asked to call between visits, at prearranged times, to advise the staff of
her progress. There are useful self-help groups for patients with various
psychiatric conditions and their families. Although groups focused only on
victimization can validate patients’ experiences and pain and help them build new
lives, they may interfere with their motivation to find other ways to identify
themselves and obtain gratification (99). The gynecologist can monitor the
patient’s responses to the self-help group interaction.
Medication Overview
SSRIs are effective for a variety of anxiety disorders, sometimes in different
dosage regimens than those used for depression (123). Benzodiazepines are
effective when taken for acute anxiety or during relatively brief, time-limited
(several days) stressful situations. The specific agent should be chosen on the
basis of onset of action and half-life. The patient must be admonished to avoid
concomitant use of alcohol and to exercise extreme care about driving or
engaging in other activities requiring attention, concentration, and coordination.
Tolerance and addiction are serious complications from the use of
benzodiazepines. There are patients who could benefit from short-term use in
particularly stressful situations but who are inordinately and unnecessarily
concerned about addiction.
Patients who fail to respond to a trial of office counseling or medication,
who are unable to fulfill their responsibilities, exhaust the patience and
resources of significant others, pose a diagnostic dilemma, consume
inordinate quantities of medical resources, or whose symptoms are becoming
increasingly worse should be evaluated by a psychiatrist.
In conclusion: psychiatric issues are ubiquitous in gynecology. This chapter
offers the gynecologist the diagnostic and management information that can
decrease clinical frustration and increase patient satisfaction.
RESOURCES
1236American Clinical Social Work Association (ACSWA): http://www.acswa.org/
American Psychiatric Association (APA): http://www.apa.org/
American Psychological Association (APA): https://www.psychiatry.org/
The Complete Mental Health Directory 2018/2019 ed. Gottlieb R, ed., Millerton NY: Grey
House Publishing. Contains descriptions of mental health diagnoses, lists of national
mental health organizations.
Depression and Bipolar Support Alliance (DBSA): http://www.dbsalliance.org/
International Obsessive Compulsive Disorder Foundation
Mental Health America: http://www.mentalhealthamerica.net/
National Alliance on Mental Illness (NAMI): https://www.nami.org/
World Professional Association for Transgender Health (WPATH): http://www.wpath.org
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