Thirty years ago, psychiatrist George Engel coined the term “biopsychosocial model” to describe a developing paradigm for patient care (Engel, 1977). As shown in Figure 13-1, the model encourages treatments that consider the mind and body of a patient as two intertwining systems influenced by a third system—society. This was perhaps the first time a distinction was drawn between “disease” and “illness.” Namely, disease is the pathological process, and illness is the patient’s experience of that process. In keeping with this model, psychological factors have two distinct relationships with women’s reproductive health. At times, they are a consequence (infertility has been linked with psychological distress). At other times, they may be an insidious cause of a health problem (increased hysterectomy rates are noted in women with a low tolerance for the physical discomfort of menstruation).
Biopsychosocial model. (Data from Engel GL: The need for a new medical model: a challenge for biomedicine. Science 1977 Apr 8;196(4286):129–136.)
Years before Engel’s work, Erik Erikson (1963) created a model that describes psychological maturation in stages across the life span. Specifically, adolescents are confronted with identity development; reproductive-aged women with intimacy concerns; peri- and early menopausal women with productivity issues; and older women with life review. Combining Erikson’s developmental model with Engel’s psychosocial model provides a dimensional perspective to aid the evaluation, diagnosis, and treatment of any patient.
Not only do women use more health care services in general than men in the United States, but more women approach their physicians with psychiatric complaints, and more women have comorbid illness than men (Andrade, 2003; Kessler, 1994). Because primary care is the setting in which most patients with psychiatric illness are first seen, obstetricians and gynecologists often are the first to evaluate a woman in psychiatric distress. The clinical interview in Table 13-1 provides an example of an assessment that includes all three domains from the biopsychosocial model.
++ Table Graphic Jump Location TABLE 13-1Psychiatric Assessment of Women ||Download (.pdf) TABLE 13-1 Psychiatric Assessment of Women
|Component ||Consideration |
|Present or past psychiatric illness ||Relation to reproductive triggers: pregnancy, menses, menopause, etc. |
|Medications ||All medications and supplements; exogenous hormones |
|Diet ||Abnormal eating patterns; diet pills, laxatives, diuretics |
|Substance use ||Covert use, especially of prescription drugs |
|Family ||Including their premenstrual and postpartum mood disorders |
|Medical ||Autoimmune disease, which can present with psychiatric symptoms |
|Menstrual ||Premenstrual or perimenopausal symptoms |
|Social ||Current or past sexual, physical, or emotional abuse. Note sexual preference and current relationship satisfaction |
|Economic ||Ability to meet ongoing financial needs |
Mood, anxiety, and alcohol or substance use disorders are three families of psychiatric disorders commonly seen and ...