INTEGRATIVE PSYCHOTHERAPY OF BORDERLINE MENTAL DISORDERS IN WOMEN SUFFERING from INFERTILITY!! !!!!V.N.Sgibov - Academician of the Russian Academy of Natural Sciences, Doctor of Medical Sciences, Professor, Chief Psychotherapist of the Penza Region, Director of the Scientific and Practical Center "Psychotherapy", Penza!!!!P.N. Kocherganov - to M.D., Deputy Director of the Scientific and Practical Center “Psychotherapy”, Penza!! Monthly peer-reviewed scientific and practical journal “Psychotherapy”, No. 8. – 2008. – P.39-42 The clinical and psychopathological features of borderline mental disorders in women suffering from infertility are analyzed. Risk factors for the development of borderline mental disorders in these women were identified. A “psychological portrait” of women suffering from infertility is described. The main directions of psychotherapeutic and psychocorrectional measures are formulated. Key words: borderline mental disorders, infertility, risk factors, “psychological portrait”, psychotherapy, psychocorrection. 440008, Penza, Kulakova st., 8/2, tr. (841-2) 68-61-42; fax (841-2) 68-61-95; e-mail: [email protected] Despite the recent interest of doctors in psychology and the tendency to integrate psychological services with general medical practice (Karvasarsky B.D., 2002), infertility treatment is mainly carried out by gynecologists using biological methods [ 2]. Meanwhile, infertility in marriage is not only a physical problem, it causes an intrapersonal conflict for each of the parents (“I can and should”), affects the sphere of interpersonal relationships (with a sexual partner and other family members) and concerns the family as a whole. In addition, conflict situations in the family, dissatisfaction with sexual life, as well as the persistent desire to have a child cause functional disorders in the sexual sphere and, as a result, lead to infertility. Stressful situations induce vegetative disorders, which causes discoordination of the smooth muscle elements of the fallopian tubes with functional uterine obstruction [3]. Infertility in marriage is a particularly significant problem in the social, medical and specifically in the individual psychological terms of the family as a whole. According to official data in Russia, 15-17% of married couples are diagnosed with infertility, and according to experts, this figure will reach 20% in the coming decades [4]. The least studied aspects of this problem are the clinical and psychopathological picture of borderline disorders, risk factors for the development of the disease and individual assessment -personal changes in the psychological state of patients with infertility. Purpose of the study: to study the clinical and psychopathological characteristics of borderline mental disorders in women suffering from infertility and to develop a treatment program for these disorders. Research methods: general clinical, clinical psychopathological, experimental psychological with personality questionnaires and rating scales anxiety and depression. A total of 120 women with infertility, aged from 19 to 40 years (average age 29.6 ± 4.0 years), were examined. Of these, 90 (75%) were women with primary infertility and 30 (25%) with secondary infertility. The duration of infertility ranges from 1.5 years to 16 years. 108 women (90%) were married, 12 patients (10%) were unmarried. Hereditary burden of infertility was noted in 15 families on the mother's side of the patients, which amounted to 12.5%. The study of premorbid personality characteristics based on anamnestic information, personality characteristics, the MMPI technique, the K. Leonhard questionnaire, etc., showed that personalities predominated among the patients asthenic constitution. Of these, the following personality accentuations were identified in 80 women (66.6%): anxious type in 24 patients (30%), hysterical in 18 (22.5%), astheno-neurotic in 16 (20%), labile in 12 (15%), cycloid in 6 (7.5%), psychasthenic in 2 (2.5%), unstable in 2 (2.5%). For the vast majority of women (96 people - 80%)anticipation of pregnancy was an individually significant event, reflecting a woman’s basic psychological and biological need for motherhood. Psychogenic factors for them were conflicts in the family, the collapse of hopes, self-resentment, infringement of dignity, reproaches from relatives, reproaches and accusations of the spouse, the manifestation of increased vulnerability, loss of a leading position in the family, fear of being ridiculed in the service, fears for the stability of the marriage due to the absence of children, fear of infidelity and divorce, etc. Risk factors for the development of borderline mental disorders in our patient population were psychogenic factors that were individually significant for them, premorbid characteristics with personality accentuation, hereditary family history of infertility, complicated obstetric history (especially in secondary infertility ), somatic distress. When examining and analyzing the medical records of our patients, it was found that they suffer from various somatic and psychosomatic diseases much more often than women of this age. Borderline mental disorders in our patients represent a nosologically heterogeneous group. Most of these disorders, 66.7% (80 women) are of the psychogenic nature of the disease and 33.3% (40 women) are somatogenic disorders. Analysis of the psychopathological picture of neurotic disorders in women with infertility when compared with the psychological and typological characteristics of the individual is quite clear showed that syndromic phenomena are caused by the peculiarities of the typological structure of personality. More often, neurotic disorders occurred in patients with an asthenic constitution. We have identified six syndromic types of borderline disorders in women suffering from infertility. These are anxious-depressive, phobic, hysterical, asthenic-depressive, neurasthenic, hypochondriacal types. They are united by the fact that in the clinic the specificity of psychologically significant psychogenic factors is heard - infertility and the associated personality reactions to infertility itself and its “consequences”. Anxious-depressive type developed in accentuated individuals with a “personal” anxious radical in its structure. Thus, in patients with primary infertility (90 patients), this syndrome occurred in 27 people (30%) and in 8 patients out of 30 with secondary infertility (26.7%). Against the background of neurotic depression, an anxious mood was noted with anxiety over unimportant reasons: about the results of the examination and the effectiveness of treatment, the expectation of failure, unhappiness, overvalued ideas of underestimating oneself, fears of deterioration of family relationships and saving the marriage. There were somato-vegetative transient disorders. Phobic syndrome was observed in 23 people (25.6% with primary infertility) and 7 (23.3% with secondary infertility) and occurred more often in individuals with a predominance of astheno-neurotic accentuation. They experienced obsessive fears of a serious gynecological disease, incurability of infertility, failure of therapy, fear of waiting for the next menstrual cycle, fear of miscarriage (with secondary infertility), fear of divorce, fear of being alone. Hysterical syndrome was diagnosed in 21 patients (23.3% with primary infertility ) and in 6 (20% with secondary infertility) in persons with hysteroid accentuation. In the clinic: figurative and emotive reflection of a traumatic situation, the desire to have a child and be “honored”, the demand for sympathy and compassion for her loved ones, affective reactions due to ignoring “suffering”, inappropriate touchiness, tearfulness, capriciousness. Astheno-depressive syndrome in 9 patients (10% with primary infertility) and 2 (6.7% with secondary infertility) in persons with a labile type of accentuation. A clinic with an extremely unstable mood, with unmotivated changes in it, overvalued ideas of low value, a passive-defensive type of reaction, a pessimistic assessment of the present and future, the psychogenic content of experiences and the corresponding coloring of the background mood. Neurasthenic syndrome in 6patients (6.7% with primary infertility) and 2 (6.7% with secondary infertility) without personality accentuation. The disorder manifested itself as increased irritability, touchiness, and emotional instability, which were not previously present to such an extent. Increased sensitivity to the experiences and suffering of others. Reflection of psychogenic experiences in statements and a pessimistic attitude towards one’s future in marriage dominated. Somato-vegetative complaints and somatoform disorders occupied a large proportion. Hypochondriacal syndrome in 3 patients (3.3% with primary infertility) and 5 (16.6% with secondary infertility). The “somatogenic” content of the patients’ complaints, the overvalued attitude to treatment and examination, the insistent demands for additional examinations, the careful implementation of recommendations and the expectation of positive results came to the fore. Hypochondriacal syndrome was observed in patients without personality accentuations, but with somatic pathology (presence of 2- x up to 4 chronic diseases). Our research suggests that the development of one or another neurotic syndrome (hysterical, phobic, anxious-depressive) is an expression of that link of pathogenetic mechanisms that are determined by the psychological-typological structure of the personality. We find it acceptable in this regard to the statements of M.V. Davydovsky that “the probability of a disease is determined by individuality, the latter determines this disease in its specifics” [1]. In contrast to the psychogenic nature, somatogenic disorders arise in case of infertility in women without pronounced accentuations of personality and are caused by pathological somatic manifestations. They are expressed predominantly by asthenic-depressive and hypochondriacal syndromes. Thus, the occurrence of borderline mental disorders in women suffering from infertility is caused by the interaction of external psychogenic, psychological and other environmental factors, and internal biological (constitutional, genetic predisposition, premorbid personality characteristics, its structure, accentuation) and one or another somatic suffering of the patient in their integrative unity. During the study, we found that the prevalence of borderline mental disorders in women suffering from infertility is directly proportional to the duration of infertility and ranges from 1 year to 3 years - 18% (3 people), from 3 to 5 years - 47% (14 people), over 5 years and more - 69% (50 people). These data correlate with the data of our long-term observations of women suffering from infertility. We have compiled a “psychological portrait” of women suffering from infertility. The indicative components were a general low mood, the experience of feelings of depression, helplessness, and “lack of joy.” Typical symptoms were the sensation of a lump in the throat and “unpleasant sensations in the heart area.” There were moderate manifestations of egocentrism in terms of emphasizing their somatic diseases, which, according to the patients, prevented them from becoming pregnant. At the same time, they tried to avoid discussing the state of infertility itself and its possible causes. Often the clinical picture was determined by causeless pessimism, despondency, and lethargy. The reaction to ordinary everyday stimuli and stress was inadequate, usually hyper-emotional. This indicated their existing state of mental disadaptation. The attitude towards other people's children was characteristic: women seemed to transfer their unrealized maternal feelings onto them. This was often followed by a state of depression. Almost always there were somatovegetative manifestations in the form of hand tremor, lability of blood pressure, sweating, and tachycardia. A brief manifestation could be hysteroid reactions. Based on the obtained psychodiagnostic data, the main directions of psychotherapeutic, psychocorrectional andphysiotherapeutic measures: 1. Correction of emotional state. Psychological trainings aimed at deeper awareness of your thoughts, feelings and bodily reactions associated with them; awareness of your desire (unwillingness) to have a child; awareness of cause-and-effect relationships between the characteristics of the perception of the situation and the type of response to it. 2. Increasing motivation for treatment in patients with a favorable treatment prognosis: analysis of needs and attitudes, unconscious motives that may interfere with pregnancy; developing a positive attitude towards treatment. 3. Adaptation to infertility in patients with an unfavorable prognosis for treatment: directing the patient’s vital energy to other areas of activity; searching for alternative ways to have a child (for example, adoption). The leading role in the treatment of patients with the pathology described above was given to individual psychocorrection, family psychocorrection (work on hidden and obvious psycho-emotional stress in the family) and group psychotherapy, which was built on the principle of stages. It was very important to create patients have an attitude to take an active position in overcoming a psychological crisis. All types of psychotherapeutic assistance used were aimed at mobilizing the patients’ own psychological reserves. With the help of a psychotherapist and a medical psychologist, the patient identified his main problem, distinguished it from other accompanying life difficulties and failures, realized the desired outcome of the crisis situation and adequate means to achieve it. As a result of the psychotherapeutic intervention, the patients had the feeling that they were on their own solved their problems rather than receiving ready-made “recipes” for behavior from a specialist. Only in this case, psychotherapy, along with removing the patient from a psychological crisis, strengthened his adaptive capabilities and turned out to be a preventive measure for crisis conditions in the future. During the treatment and work of psychologists and psychotherapists with infertile women, we were able to relieve their neurotic state, doubts in their abilities, decide on the goals and objectives of this important period for a woman. The classes were structured in such a way as to involve as many women as possible, who do not believe in their capabilities, into internal spiritual work, to build trust in themselves, their husbands, and staff, and to get rid of complexes and prejudices. The main goals of psychotherapy for our patients were: filling the gap information about infertility received from treating gynecologists; correction of existing affective disorders, pessimistic mood of patients, numerous fears; eliminating ideas of inferiority (“I’m not like everyone else”) and the associated feeling of guilt before the spouse and parents; work with the immediate environment of patients aimed at improving family relationships; strengthening faith in the possibility of a successful outcome of treatment, as well as the formation of a calm reaction to a series of possible failures, emphasizing the possible duration of this therapy, the need for patience; forming a realistic assessment of their condition and working with patients’ unrealistic and illusory hopes for the possibility of instant miraculous healing. When treating patients with this type of pathology, a whole range of psychotherapeutic techniques is used, among which the most effective are the methods of rational psychotherapy, group psychotherapy, gestalt therapy, transactional analysis, art therapy approaches, auto-training, family psychotherapy, suggestive psychotherapy, traditional healing systems. The inclusion of patients in creative work contributes to the concentration of a person’s volitional and creative resources, programming the positive development of the psyche and adequate emotional reactions of a woman (through color perception; spontaneous drawing; singing; plastic training for a certain music, etc.). Considering the meaning of the problem of infertility that is especially significant for most women, we consider it important to study the essential,existential problems. Multi-level work is carried out with an assessment of one’s own personality. At the same time, metaphors, elements of positive therapy, and psychoanalytic techniques were successfully used. As a result of the use of elements of Gestalt therapy, existing problems and experiences are processed and responded to in the “here and now” plane. Family psychotherapy is an obligatory element of therapy. It is especially useful if there is a conflict situation in a married couple due to the wife’s infertility. During therapy, the necessary advice and recommendations on optimal behavior at home and creating a friendly atmosphere are given. The theme of “the collapse of men’s hopes” is being explored with the husbands. In the event of a prolonged absence of a positive effect from therapy with a married couple, the possibility of fostering adopted children is psychologically explored. We believe that the creation and observance at all stages of treatment of the necessary psychotherapeutic environment and the provision of social support for the patient is the most important in the treatment of borderline mental disorders. For the most effective action, a highly friendly, sympathetic attitude towards patients and their loved ones is necessary. Individual correction made it possible to prepare 86 women (72.4% of those studied) for a group discussion of problems. Support in a group from women with similar problems, advice, and participation can change low self-esteem, do not allow you to remain alone with your inner pain and suffering, improve communication capabilities, often have a positive effect on the psycho-emotional sphere, and return patients to society. Results of psychocorrectional and psychotherapeutic The works are presented in the table. Table Dynamics of some psychodiagnostic indicators in the examined women during treatment Indicator Level in points (before treatment) Level in points (after treatment) Depression (score on the Zunge Depression Scale) 57.0 ± 1.45 1.0 ± 1.9* Personal anxiety (score on the Spielberger-Khanin scale) 47.2 ±1.842.2 ±1.6*Reactive anxiety (score on the Spielberger-Khanin scale) 49.4 ±1.940.9 ± 0.8*Aggression (score on the aggression questionnaire and hostility A. Basho and A. Darka) 28 ± 2.321.8 ± 1.6** - the difference is significant when compared with the corresponding indicator before treatment (P < 0.05). The data presented in the table indicate a pronounced decrease in the level of depression in patients suffering from infertility, a large decline in reactive anxiety and the level of aggression and a slight decrease in personal anxiety after complex psychotherapy. Group classes allow patients to make the myth of their own “inferiority” less significant, allow themselves to be who they are, and prepare the ground for gradual changing attitudes towards this problem, strengthening faith in the possibility of a positive effect from treatment. We believe that an integrated medical and psychological approach to the treatment of infertility will be a significant factor in its optimization. !! !!!! !!!! !!!!LITERATURE!! 1. Davydovsky M.V.// “On the problems of causality in medicine.” – M., 1965. – p.15.2. Karvasarsky B.D. // Clinical psychology: Textbook, ed. B.D. Karvasarsky. – St. Petersburg: Peter, 2002. – 8 p.3. Kocherganov P.N., Sgibov V.N., Lan I.L. The role and place of psychotherapy in the complex therapy of infertile marriage // Psychotherapy in the system of medical sciences during the formation of evidence-based medicine. Collection of abstracts of a scientific conference with international participation. – St. Petersburg, 2006. – 141 p. 4. Sgibov V.N., Rogova S.N., Kocherganov P.N. The role of psychotherapy and psychocorrection in an integrated approach to solving the problem of infertile marriage // Current issues of modern psychiatry and narcology. - Collection of scientific papers. Issue 5. – Penza, 2002. – 72 p. Integrative Psychotherapy of Boundary Psychic Disorders with Women Suffering Barreness Sgibov VN, MD, Professor, Academician of Russian academy of natural science, Head psychotherapist]