PSYCHIATRY

TO DISCUSS

• Amenorrhea
• Inferility
• Pregnancy
• Pregnancy loss

FUTURE TOPICS

• Gender identity
• Sexual identity
• PMDD
• Sexual Dysfunction

IATROGENIC CAUSES OF AMENORRHEA

• Valproate
• Antidepressants
• Antipsychotics

HYPOTHALAMIC AMENORRHEA

• Rapid weight loss
• Eating disorder
• Cushing's Disease

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HYPOTHALAMIC AMENORRHEA

• Elevated depression scales
• Poorer impulse control
• Perfectionist
• Need for approval

EATING DISORDERED PATIENTS WITH AMENORRHEA

• Drive for thinness
• Interpersonal distrust
• Bulimia
• Feel ineffective
• Body dissatisfaction

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HISTORICALLY

• Frequently assumed to be psychogenic
• Blamed on one or the other member of the couple

MID 20TH CENTURY

• 50% psychogenic
• Unconscious anxiety
• Ambivalence about motherhood
• Unresolved Oedipal conflict
• Gender identity

21ST CENTURY

• Little support for role of personality
• Alleviates guilt of couple
• "Not my fault"

ROLE OF STRESS

• Hypothalamic amenorrhea
• Hypothalamic anovulation
• Catecholamines may reduce gamete transport
• Catecholamines may alter uterine blood flow
• Reducing stress MAY IMPROVE infertility

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INFERTILITY DIAGNOSIS

• Generates feelings of loss and sadness
• Loss so sexual desire
• Eval/tx impacts body image and intimacy
• Financial burden

MYTHS HURT

• Everyone gets pregnant eventually
• Infertility is the woman's fault
• Relax, and you will get pregnant
• Infertility only bothers the woman

WHY WE BOTHER

• Continuance of life cycle
• Immortality
• Genetic heritage continues
• Erik Erikson- generativity

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WOMEN'S FEELINGS

• Women report greater levels of distress
• The cause of infertility did not change distress levels
• Feelings of role failure, diminished self esteem

Men's feelings

• Low self-esteen, guilt, fear
• Loss of self confidence
• Feelings of incompetence
• Feelings of anger shame
• Feelings of frustration and incompetence

Physical Symtpoms

• Increased metabolism
• Elevated HR, BP, RR
• Muscle Tension
• Insomnia

Don't ask. Don't Tell?

• Choose with whom to share
• Decide how much to share
• Who does sharing help?
• Set boundaries with family
• Ask for what you require

THINGS STUPID PEOPLE SAY

• Don't worry you will get pregnant
• God has a plan
• You may be better off without kids
• If you think positively

Fill in the Blank

IF you _______ , it won't be your baby
Sperm/Egg Donation
Adopt

Moving through INfertility

• Dawning
• Movilization
• Immersion
• Resolution
• Legacy

Recognize the New Issues

• Relationship
• Monthly disappointment
• Pregnancy loss
• Pain of treatment
• Financial

Silent Grief

• No recognition by community
• No burial
• No cultural mourning of loss
• Mourning loss of investment

Psychotherapy Helps

• Provides empowerment
• Less isolation
• Validation of issues, feelings
• Discuss alternatives
• Access resources

PSYCHOTHERAPY HELPS

• Reduces anxiety, depression
• Decrease preoccupation
• Understand the role of stress
• Access coping mechanisms
• Find support

Other Options

• Meditation, mindfulness
• Yoga, self-nurture
• Decreased physical complaints
• Decreased depression, anxiety

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THOUGHTS OF PREGNANCY

• Begins long before conception
• Imaginative play
• Playing house
• Societal expectations

Control Issues

• Women have mutliple roles
• Contraception allows us to control fertility
• Couples plan for the future.

EARLIER BONDING

• Modern Technology causes change
• Home pregnancy tests
• Ultrasounds
• 3-D imaging

Pregnancy Psyche

• Fantasy and dreams
• Family of origin
• New Goals
• Change of roles
• Work issues

PREGNANCY LOSS

• May be first experience with death
• Elation followed by grief
• Multiple losses: baby, self, future
• More loss: potential, reproductive capacity

Loss is Multi-Layered

• Individual loss
• Family loss
• Impact on relationships
• Impact on Future Plans

CONFRONTATION WITH MEDICAL WORLD

• Unrecognized loss
• Marriage is seen as "normal"

Grief

• A normal process
• A dynamic process
• Allows healing
• Leads to survival

GRIEF

• Denial
• Anger
• Bargaining
• Depression
• Acceptance

GRIEF"Sh

• Unpredictable
• Cope with triggers
• Shadow Grief
• May reccur without warning
• Little public acknowlegement

GRIEVING A MISCARRIAGECul

• Parents' expectations influence the loss
• Personal belief
• Cultural background of individual
• Gestational age of fetus

Multiple Miscarriage

• 3 or more consecutive pregnancy loss
• Before 22nd gestational week
• 1% of all couples

COMMON FEELINGS

• Each loss followed by new grief
• Increasing ambivalence
• Distance self from a new pregnancy
• Degree of attachment is better predictor of grief than EGA

ADDITIONAL SYMPTOMS

• Self-blame
• Helplessness
• Desire to blame others
• Try to control situation
• Prevent future loss

ADDITIONAL SYMPTOMS

• Fear they disappoint others
• Doubt about reproductive competence
• Marital strain

COPING

• Accepting the reality of loss
• Experiencing the pain
• Adjusting to life without pregnancy
• Make sense of life

Infertility and Psychiatric Illness IN WOMEN

• Overall risk OR=1.85
• Alcohol Use Disorder OR=2.75 
• Agoraphobia OR=4.08
• Dysthymia OR=3.41
• GAD OR=1.61

Infertility and Psychiatric Illness IN MEN

• Overall risk OR=1.8545
• Alcohol Use Disorder OR=1.99
• Dysthymia OR=3.41
• GAD OR=2.30

Suicide

• Greater among women who have never conceived
• Risk remains elevated for secondary infertility
• However, rate is lower than general population