Thirty years ago, psychiatrist George Engel coined a term to describe a developing paradigm for patient care, the “biopsychosocial model” (Engel, 1977). In the years since, this model has also incorporated cultural and spiritual factors. When conceptualizing a woman’s understanding of her reproductive events, this model highlights the distinction between disease, a pathologic process, and illness, a patient’s experience of that process. At times, psychologic health is linked directly with reproductive health. As an example, infertility can lead to mood and anxiety disorders. In contrast, preexisting psychologic distress might be an insidious cause of a health problem. For example, higher hysterectomy rates are noted in women with a low tolerance for the physical discomfort of menstruation.
Years before Engel’s work, Erik Erikson (1963) created a model that describes psychologic 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 a biopsychosociocultural model provides a dimensional perspective to aid evaluation, diagnosis, and treatment of any patient.
Most patients with psychiatric illness are first seen in primary care settings, and gynecologists often are the first to evaluate a woman with psychiatric distress. The clinical interview in Table 14-1 provides an example of an assessment that includes all domains from the biopsychosociocultural model.
TABLE 14-1Psychiatric Assessment of Women ||Download (.pdf) TABLE 14-1 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, particularly prescription drugs |
|Family history ||Including reproductive event–related symptoms/disorders |
|Medical history ||Autoimmune disease, which can present with psychiatric symptoms |
|Reproductive history ||Premenstrual, pregnancy, pregnancy loss, postpartum or perimenopausal context of symptoms |
|Social ||Current or past sexual, physical, or emotional abuse. Note sexual preference and current relationship satisfaction |
|Cultural ||Norms and beliefs of community/family |
|Spiritual ||Rituals, guidelines, and attributes of a “good” life |
|Economic ||Ability to meet ongoing financial needs |
Mood, anxiety, and alcohol or substance use disorders are three families of psychiatric disorders commonly seen and often comorbid with reproductive events. These three groups are defined by specific criteria described by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (American Psychiatric Association, 2013). Each family of disorders is characterized by predominant features, and each disorder within those families is identified by specific symptoms of that feature.
Of these families, mood disorders are categorized as depressive disorders (major depressive disorder, persistent depressive disorder, premenstrual dysphoric disorder, other specified depressive disorder, and unspecified depressive disorder) or as bipolar and related disorders (bipolar I, bipolar II, cyclothymic disorder, other specified bipolar disorder, ...