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Maria Puliatti
Psychotherapist – sexologist at the Vulval Pathology Service, AIED, Rome and at the Andromeda Medic Center, Milano
Researcher at the Clinical Psychophysiology Chair (Prof. Vezio Ruggieri) Department of Psychology, “La Sapienza” University, Rome
The role of psychological issues in women with vulvodynia is now established, and several authors have stressed the need of a multi-disciplinary approach for a better understanding of this psychosomatic problem. From 1997 to 1999, AIED Vulval Pathology Service in Rome has conducted several psychodiagnostic studies (Inghirami et al., 1998; Lippa et al., 1999) primarily aimed at identifying these clients’ psychological characteristics as well as the eventual time relation between symptoms onset and critical events in these women’s lives.
The “Psychotherapeutic-rehabilitation” treatment protocol discussed in this paper was prepared in 1999, considering the psychological characteristics and psychosomatic issues of women with painful vulval syndrome. This therapeutic option stems from those clients who do not suffer from known organic causes, but show a time relation between vulval symptoms onset and a stressful event.
The therapeutic approach suggested here is the result of the integration of several models: bodywork, cognitive-behavioral, sexologic, gynecological and urological rehabilitation techniques and protocols for painful syndromes.
Psychotherapeutic treatment
Psychotherapy with women suffering from vulvodynia includes several issues related to symptoms persistence, such as, for instance, the identification of the triggering factors leading to symptoms development, secondary gains (relationships, family) and dysfunctional behaviors (postural changes). Furthermore, the relation between pain and emotional disorders is investigated (Tiengo, 1995).
During the first interview, women are provided with information on:
· the meaning of the genitals as the organ of choice in psychosomatics;
· the formation of psycho-physiological symptoms, i.e., the way psychological tensions can develop into painful symptoms. In fact, psychological factors may cause muscular hyperreactivity in response to psychological stress. This hyperreactivity contributes to muscular spasms and, therefore to the nociceptive effect and pain exacerbation, the pain can, in turn, become an additional stressful factor of its own, and increase muscular tension even more as well as contributing to the formation of trigger points, perpetuating the tension-pain cycle (Barraclough, 2001).
Furthermore a psychodiagnostic personality assessment is conducted through the administration of the following tests:
· MMPI-2 MINNESOTA MULTIPHASIC PERSONALITY INVENTORY (Hathaway, 1951) to assess personality issues
· STAI-Y State-Trait Anxiety Inventory (Spielberg, 1996) to assess state and trait anxiety
· POP PERSONAL OPINIONS PROFILE (Kobasa, 1979) to assess hardiness
· INTERPERSONAL CONTACT QUESTIONNAIRE (Ruggieri, 1995) to study body contact modes
· BODY CATHEXIS (Jourard, 1955) to study the libido investment towards one’s own body
· SEXUALITY QUESTIONNAIRE (Puliatti, 2004) to assess the client’s relationship with sexuality before and after the symptom, as well as the eventual time relationship between symptoms and stressful events.
· STAXI (Spielberg, 1993) to assess state and trait anger
· QUID PAIN QUESTIONNAIRE (De Benedittis, 1993) to assess subjective pain perception
· SEX INDEX (Hendrick, 1987) to assess sexual satisfaction index and sexual attitudes
· GENITALS GRAPHIC REPRESENTATION (Perissinotti, 1995)
· POSTURAL TENSIONS QUESTIONNAIRE (Ruggieri, 2006) to assess body tension subjective perception
An important role is played by the couple, since this symptom often intrudes in a highly disturbed relationship context. The partner is invited to an interview, both individually and with the woman, in order to highlight the couple characteristics. Couple therapy, oriented both to the relationship and communication and to the sexual issues, is suggested, where necessary.
A follow-up interview is conducted 6 months after treatment completion, followed by control interviews 8 months and one year after treatment completion, to monitor results (Puliatti, 2002a).
Protocol for pain
Psychotherapeutic treatment includes a pain assessment protocol, based on chronic pain standard protocols, since vulval pain is exactly similar to other painful syndromes with the same characteristics and maintenance features, the only difference being the body location (Puliatti, 2002b).
Goals:
· Provide information on the relation between pain and psychological factors;
· Acquire and use pain reduction and control techniques (Zoppi, 1991; Warfield, 1993)
· Increase awareness of the relation between psychological and somatic factors of pain
· Identify and modify illness behaviors (postural changes)
· Identify the level of tension in the client’s emotional experiences, related with experiencing pain (Zoppi, 1991)
· Treat the negative consequences of experiencing pain (Biondi, 1988).
· Identify family collusion levels
· Identify the client’s level of functionality (Zoppi, 1991)
· Restore a pleasurable sexual life (Warfield, 1993; Puliatti, 2004)
Rehabilitation treatment
Rehabilitation of clients with chronic vulval pain includes three, initially separated and later integrated, phases related to bodywork.
The first goal with women using their genitals and the whole pelvic area to communicate internal distress is to have them regain control over their body sensations, and especially over the pleasurable ones. Bodywork is an essential preliminary requirement in all cases where the body is the language of suffering. Therefore the first factor to consider is breathing, since awareness of a person’s own breathing, means awareness of the tensions preventing its fluidity.
The second important factor, responsible of reducing pleasure perception and body sensations, is chronic muscular tensions. In these cases, the persistence of emotional conflicts and secondary muscular tensions may end up in the somatization of a constant state of tension, featuring muscular hypertonia, for instance in women with vulvodynia. Continuous tension removes awareness thereof, to the point that subjects think it is “normal” to be so contracted. This involves working on acknowledging tensions, conflicts, and negative underlying feeder emotions, in order to remodulate clients’ baseline tone to appropriate levels. This bodywork uses relaxation techniques, and in particular Jacobson progressive relaxation. This technique trains the client to progressively achieve total muscular relaxation through the following phases: phase 1: muscular tension and relaxation perception training; phase 2: tension location; phase 3: tension release.
Relaxation is one of the most frequently used intervention in pain rehabilitation (Ravazi, 2000), since the main component of pain is the state of tension, the aim is to reduce the somatic modifications induced by the anxiety reaction at a peripheral level (Warfield, 1993) by reducing the activity of the sympathetic system, with a consequent muscular-mental release and the achievement of a dynamic state of the organism.
In the third phase, the techniques acquired are used to focus on pelvic floor control and relaxation, in particular through exercises for pelvic floor rehabilitation, Kegel exercises, contraction and relaxation exercises of pelvic muscles alone (Puliatti, 2004a; Puliatti, 2004b).
The main goals of rehabilitation programs are:
· Restore clients’ awareness of their perineal muscles, allowing them to regain control of some little or poorly used muscles.
· Improve perineal muscles tone and trophism.
· Improve the quality of voluntary contractions and perineal muscle plane strength. (http://www.datamedica.it/percorso-donna/incontinenza.htm)
When working with women suffering of vulval pain, both Kegel and bioenergetics exercises are used, as well as those typically related to urogynechological rehabilitation, since these clients also suffer of urination disorders (urge and urinary tract pyrosis), associated with vulval symptoms. Muscular tension areas involved in vulval pain are mainly the pelvis, glutei, genitals and thighs, therefore, exercises aimed at releasing muscular tension in these body areas are recommended for these clients (Puliatti, 2004 a).
This simple pelvic gymnastics, improving muscle resting tone and reflex contraction when intra-abdomen pressure increases, was slightly modified from a two-phase contraction/release exercise into a three phase contraction/release/ relaxation exercise of the perineal floor, therefore adding an appropriate relaxation maneuver with an outward push, useful in case of muscular hypertonia.
In fact the goal of these exercises is to strengthen the pubic-coccygeal and the other perineal muscles in general; the focus is, therefore, on muscular relaxation rather than on muscular contraction. These exercises can little by little relax the pubic-coccygeal muscle, but require commitment and persistency (Kaplan, 1996).
Pelvic tension increases to limit sexual feelings, therefore any exercise mobilizing the lower part of the body, both in upright position and while lying down, affects the pelvis (Lown, 1977).
A very important role is also played by the gluteal muscles, since their contraction allows forward and backward movement of the sexual organs area, being gluteal tension essential to genital tension. Consider that the lack of reactivity in depressive states can be altered by treating the glutei, since it releases or stimulates a more outward-directed aggressive reaction capability, thus breaking the vicious circle of self-directed aggression (Fissi, 1998).
Most observations on the importance of gluteal muscles contraction equally apply to the thighs, since they involve the same areas of the body (Lowen, 1977); in fact thigh adductors are directly linked to the genitals (Fissi, 1998). Contracting the thighs, therefore, automatically contracts the glutei and genitalia (O’Relly, 1986), therefore an important exercise consists for instance in contracting and relaxing thigh muscles (Lowen, 1977).
Presently, pelvic rehabilitation is no longer considered an optional or alternative therapy to other methods, but an integration thereof, and, therefore, an irreplaceable treatment of choice (according to the dysfunctions) (Miele, 2002).
Treating trauma with EMDR
Another important treatment element is due to a traumatic event in clients with vulval pain.
We have seen that pain is the psychosomatic symptom of choice for people with strong guilt feelings, anger (holding back anger increases muscular tension), and self-punishment mechanisms. Therefore a strong body relation exists between trauma and pain.
Trauma therapy involves use of EMDR (Shapiro 1995; Parnell 2003). EMDR (Eye Movement Desensitization and Reprocessing) focuses on recalling the traumatic experience, and is a complete method using eye movements or other forms (tactile, auditory) of alternate left/right stimulation to treat disorders directly related to past experiences and current disorders. It is a trauma treatment method acting at the neurophysiological level, since it relies on alternate stimulation of the brain hemispheres while the client focuses on the traumatic experience components. It is well-known that the two brain hemispheres have different and complementary functions from a psychological standpoint; Endel Tulving (1994) worked on the asymmetry model of brain hemispheres in memories storage processes. According to this model the left frontal cortex is involved in storing the memories of events and the right frontal cortex in their retrieval. Alternate hemispheric stimulation with EMDR seems to simultaneously stimulate the positive right network while the negative and anxiety-provoking contents of the left are evoked, and this seems to lead to a processing of the traumatic experience-related information by working on the mechanisms related with memory storage (Endel, 2002; Fernandez, 2002; Eschenroder, 2003)
After an abuse, the victims make some negative cognitive assessments on the self, the most frequent of which are:
· I don’t deserve to be loved
· I can’t trust myself
· I am powerless
· I cannot control it
· I should have done something
· I can’t trust anybody
· I am in danger
EMDR breaks down a traumatic event into an image (the worst), negative cognitions on the self, body sensations and emotions. Vulval symptoms generally arise after a triggering event, sometimes long after the abuse, stimulated by any trigger reactivating one of the above mentioned trauma elements, such as an image, a negative cognition, a body sensation or an emotion (such as anger). EMDR focuses on the event, the negative cognitions, the body sensations, which often are the pain and the muscular tension, and the emotions (such as anger) (Puliatti, 2006 a). Sometimes, after processing the trauma of the “abuse”, Grant’s EMDR protocol for pain is used to facilitate changes in the somatic and emotional experiences related thereto, should vulval pain persist, though to a lower level, (Grant, 2000; Puliatti, 2006 b).
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