PSYCHOSOMATIC FACTORS
The female generative tract is extremely susceptible to the physiologic expression of emotions. Therefore, a high percentage of gynecologic symptoms have a psychosomatic or a psychogynecic basis. Appropriate hypnotherapy can allay the anxieties and the tensions responsible for the majority of psychogynecic symptoms by altering faulty attitudes concerning femininity and sexuality.
The gynecologist, if trained in hypnosis, can use this modality much as he employs drugs for symptom removal. Symptom removal by hypnotherapy is not harmful, contrary to the belief of some psychiatrists. To assume otherwise is rather ridiculous when one considers that the bulk of gynecologic therapy for functional disorders is directed toward symptom removal. This goal readily can be achieved without an understanding of “psychodynamics.” The author, a psychiatrist and gynecologist, used the psychodynamic approach for years until he realized that his therapeutic results were due to an empathic relationship, reassurance, and reeducation rather than to the “insight” and interpretations.
Modern hypnotic technics employ autohypnosis and sensory-imagery conditioning as described in this chapter. These, together with the rapport, are utilized for most patients in preference to direct symptom removal by authoritarian hypnotic technics. Those for whom superficial therapy is inadequate require an understanding of their neurotic needs for their symptoms. Thus present- and future-oriented psychotherapy shortened by hypnosis is more feasible for most psychogynecic symptoms than searching for causes by uncovering the past through complex psychoanalytic technics. Our hypnotherapeutic technics now will be presented.
AMENORRHEA
Psychic factors30,32 can prevent the release of the proper gonadotrophic hormones to produce functional or “hypothalamic” amenorrhea.40 This form of amenorrhea can be due to fear of pregnancy, guilt feelings over masturbation and other emotional factors. A prerequisite to hypnotherapy of functional amenorrhea is not only a physical examination but also a psychological evaluation of the attitudes toward menstruation and psychosexual functioning.
Amenorrhea has been treated effectively by hypnosis.11,16,20 Dunbar points out:
In many cases amenorrhea can be cured by one hypnotic session. In a patient who had been suffering from amenorrhea for 2½ years, menses were induced by hypnosis, and regulated to occur on the first day of each month at 7:00 A.M. to last for 3 days.11
Heyer has observed:
Numerous authors report results from hypnotherapy in menstrual disturbances, which are beyond question, i.e., relief of pain as well as regulation of the cycle. As a matter of fact, the time of onset for menstruation can be determined in deep hypnosis to the day and hour, as, for example, one may say every 4 weeks or every first day of the month, etc. … In all uses of hypnosis, it is important to give not just colorless commands, but to suggest the whole experience of menstruation forcefully and vividly. Where doubts as to the efficiency of this procedure have risen, faulty technic is responsible.15
Although this method does not always work, the author has on several occasions, dramatically induced the menses by hypnosis.
As mentioned, bleeding seldom can be initiated by direct suggestion. Rather, the technic is to ask the following questions: “Do your breasts get hot and heavy just before you are due to have your period? Do you feel like jumping out of your skin at this time? Is there any pain connected with the onset of the flow? If so, where is it? What is the character of the pain? Do you have a backache, or a feeling of pressure in the pelvic region? Are there any other symptoms associated with the onset of the flow?”
If the answers to the above questions are fed back to the hypnotized patient, one has an excellent chance of reestablishing the menses by this type of sensory-imagery conditioning. The verbalization used is as follows: “In about 2 weeks, you will find it most advantageous to feel all the sensations that you previously described and associated with your periods. Think of the exact place where you have discomfort and pressure. Perhaps you might even imagine how ‘jumpy’ and irritable you felt just before your flow.” In this technic, a “dry run” or a rehearsal of the onset of menstruation under autohypnosis helps to reinforce the appropriate posthypnotic suggestions.
Another technic is to utilize hypnotic age regression. The patient is regressed to her last period and asked to recall the specific sensations associated with it; if she wishes, she can choose the approximate date for the establishment of the menses. Suggestions must be made in a confident manner. However, the physician should never get himself “out on a limb” by guaranteeing that the menses will occur on a specific date. Rather, he can preface his remarks by saying, “If you are able to feel the sensations associated with your period, you have a good chance of having your period. Or, perhaps, you can begin to wonder whether it will be a day or two before the date you chose, or maybe the period will come on a week afterward.”
Check and Le Cron assay attitudes toward menstruation and orient the patient back to the last normal period and then search for a stressful event that preceded the cessation of the menses.7 The patient is informed that efforts will be directed only toward ascertaining if she is free of problems. Also, she will bleed only if she thinks it necessary. After searching for causative factors, the patient is asked if she would like to bleed for only 3 days. If the answer is “yes” with ideomotor finger signaling, she is then asked to select the date for her next period. This does not always work on the first attempt, but repetitive suggestions invariably result in regular menses. This technic is wholly permissive. Furthermore, the responsibility for resumption of her menses is placed upon the patient, and the expectancy level is mobilized in a extraverbal manner, thus providing greater likelihood of success. This fascinating approach should be validated by controlled studies.
PSEUDOCYESIS
Pseudocyesis, or phantom pregnancy, is characterized by some of the signs and symptoms of pregnancy, such as amenorrhea, enlargement of breasts, and change in the body contour. Psychotic states, or a persistent corpus cyst, must be considered when the “pregnancy” persists. This condition convincingly illustrates how psychic factors can influence the endocrine system. Cortical-hypothalamic pathways to the anterior pituitary are utilized, causing release of the corpus luteum hormones and suppression of the follicle-stimulating hormone (FSH).37
One should not forcefully confront the patient with her delusion, but she must be aware of the emotional needs for maintaining the “pregnancy.” Such an individual has to be “unhypnotized” out of ideas that she has “hypnotized” herself into; therefore, permissive hypnotic technics are more likely to uncover the need for the pregnancy fantasy.
Pseudocyesis beautifully illustrates how subcortical structures mediate impulses from the higher sensorium and transmit these repressed emotional forces to appropriate target organs. It also illustrates the astonishing susceptibility of the endocrine apparatus to psychic stimuli. I have noted that the darkened linea alba and other signs of pregnancy often occur in multiparas. This may indicate that the indelible imprint of an “experience” is filed away but is subject to recall at “appropriate” times. Sensory-imagery conditioning under autohypnosis, involving recall of the entire menstrual experience, often can be a valuable adjunctive procedure in relieving pseudocyesis.
DYSFUNCTIONAL UTERINE BLEEDING
Psychic shock may cause profuse vaginal bleeding. Menstruation of a bride on her wedding night often can be a defense against intercourse, or a reflection of fear of pregnancy or responsibility. Irregular bleeding may be the somatic equivalent of the grief and the depression following the loss of a loved one.15
An increase in endogenous adrenalin can cause vasoconstriction of the endometrial blood vessels. Bleeding of psychological origin could conceivably be mediated through the midbrain to the hypophysis with a subsequent alteration in ovarian and adrenal function. Psychotics frequently manifest functional menstrual abnormalities; these are corrected after alleviation of their mental symptoms. Before treatment is instituted, an organic etiology should be ruled out. Hypnotherapy is purely an adjunctive procedure to endocrine and medical treatment of uterine bleeding. Superficial psychotherapy, consisting of education for the correction of faulty sexual attitudes and domestic and social maladjustments, and the utilization of common-sense suggestions for other anxiety-provoking tensions can often be accomplished more rapidly through hypnosis. A high percentage of cases can be helped by a psychotherapeutic approach.
Cheek and Le Cron discuss all the organic factors responsible for abnormal uterine bleeding.7 They have a six-point program for psychotherapy of bleeding dysfunctions:
1. Set up ideomotor responses.
2. Orient to the moment before bleeding starts and ask the “yes” finger to lift.
3. Advance from this moment to some thought or feeling that might be related to the trouble. If the “no” finger lifts, ask what the thought means.
4. Ask: “In the light of what you have discovered, do you think it might be possible to stop this heavy bleeding and return to a normal type of menstruation?”
5. At this point, and no sooner, ask: “Does the deep part of your mind feel that you have a serious or dangerous disease?” Then ask: “Have you identified yourself with any other person who has bleeding like this?”
6. Scanning the thoughts and dreams before the onset of the bleeding may yield significant clues if the questions are confined to daytime activities. Cheek is an experienced gynecologist and he wisely points out that a search for organic factors must be made; they do occur even in the presence of psychological disturbances.
Functional Dysmenorrhea
Dysmenorrhea is a “disease of theories.” Menstruation and “the curse” have been synonymous for centuries. The actual mechanism responsible for the discomfort may be due to a conditioned pain pattern in the cortex, similar to that seen in amputees who complain of phantom limb pain. The absence of gross lesions, the monthly variation in pain according to mood swings, and the frequent relapses in endocrine therapy mark it as a typical emotional disorder.29
It is a serious mistake to minimize pain even if it is emotionally based. Pain is pain, whether physical or emotional. One only mobilizes resentment by such bromidic statements as: “Your discomfort is all in your head. Why don't you relax? Stop worrying about it. It will go away!” In addition to sedation, analgesia, and hormonal therapy, hypnotherapy is a very valuable adjunct. Autohypnosis, glove anesthesia, and autosuggestions to produce a conditioned relaxation for the entire menstrual period definitely can raise the pain threshold.
Hypnosis acts to bind these patients in therapy. As discussed in Chapter 50, the strong dependency helps to overcome the initial resistances involved in yielding the symptom. Later, the dependency is lessened as the patient learns how to control the discomfort by autohypnosis. Whether one employs psychotherapy, hypnosis or just plain common sense in treating functional dysmenorrhea, one should avoid offering such “therapeutic” suggestions as “Get married,” “Have a baby,” or “Find a suitable lover.” These are, at best, unscientific, and, at worst, extremely harmful.
Cheek and Le Cron have developed a unique approach for dysmenorrhea of psychogenic origin.7 First, they train the patient in ideomotor finger signaling. This is used to elicit the factors responsible for the first painful period. Second, they have her relive the feelings associated with this period. Then they ask her to turn off the pain at a subconscious level and allow an ideomotor signal to indicate completion and have her state when she feels comfortable. Third, the hypnosis is deepened, and she is asked if she would like to have scantier periods, and with complete comfort. By asking her to feel like she does when not menstruating, the therapist is giving helpful suggestions in the form of a question. If the next period is painful, search is made for previously undiscovered organic or emotional factors. The patient is informed that if the dysmenorrhea recurs, she should ask herself what psychologic mechanisms are involved. This can remind her how to turn off pain. Direct suggestion has been employed in 17 cases and more complex methods in three with a 20 per cent failure rate.32 These technics and results are astounding.
INFERTILITY
Many factors are responsible for psychosomatic infertility.25,30 The author evaluated a series of infertile patients by psychological tests.19 Behind the outward desire to get pregnant was the deeply repressed wish not to get pregnant, on the basis of emotional immaturity associated with fear of motherhood or feelings of inadequacy. Such conflicting emotions, mediated through autonomic, somatic, behavioral, and endocrine mechanisms, often can affect the physiology of ovulation implantation and, perhaps, even the viscosity of the cervical mucus, to produce the so-called hostile cervix. Other factors are avoidance of coitus during ovulation, transitory or persistent tubal spasm, and conflicts in the male which may affect the fertilizing capacity of the sperm.
About 35 per cent of infertile women get pregnant soon after treatment is begun. Often the enthusiasm with which the infertile patient is investigated is therapeutic;17 diminution of anxiety results in endogenous epinephrine suppression (an excessive amount causes infertility). A similar mechanism operates in women who conceive following the erroneous diagnosis of “blocked tubes.” They stop worrying over their infertility, their tubes relax, and they conceive.
The neural pathways by which emotionally conditioned disharmonic impulses produce tubal spasm have been described.13 As proof of the validity of this hypothesis, selective denervation of the proximal tubes and the cervix often cures this type of infertility. The fallopian tubes, the most “hysterical” portion of a woman's anatomy, also relax following sympathomimetic drugs and hypnosis. Most pharmacologic or psychotherapeutic modalities, including hypnosis, owe a large percentage of their success to the placebo effect. Since infertility often is dramatically alleviated when stress is reduced, it is not hard to see how much more effective specific suggestions would be in achieving relaxation through hypnosis.
Hypnosis can be a helpful adjunct in the treatment of infertility if the physician can understand the psychological conflicts of both partners. Posthypnotic suggestions and autohypnosis, by relaxation and healthful sensory-imagery conditioning, neutralize other anxieties and tensions. The diminution in psychosomatic factors frequently helps establish regular ovulatory cycles and probably a normal pH in the generative tract; the chemistry of the vaginal secretions can be dependent on psychogenic factors.20 Wollman described successful treatment of infertility by hypnosis.41 Increasing libido where there was very little coitus helped overcome several cases of infertility.
The author's technic is as follows: After the patient has been conditioned to enter into hypnosis, she is taught autohypnosis. Posthypnotic suggestions are utilized to induce profound relaxation immediately after coitus. Under hypnosis it is further suggested: “Do not deliberately try to get pregnant. The harder you try, the less chance you have. Just relax. Every time you have intercourse, assume that you cannot conceive.” This type of suggestion, or the reciprocal inhibition therapy, follows the law of reverse effect. By such measures the patient relaxes; harmful endogenous factors are decreased; if tubal spasm is present, it may be alleviated. This reasoning may seem farfetched, but twice the author erroneously diagnosed “blocked tubes.” This achieved relaxation, mental and physical. He was not surprised to find that the patients soon became pregnant. With fear removed, relaxation of the reproductive apparatus occurs. Posthypnotic directions also can be suggested to inculcate a feeling of motherliness and to seek intercourse during the fertile period and, most importantly, to eliminate worry and tensions.
Hypnosis may potentiate the effectiveness of artificial insemination.9 There is no clear-cut explanation as to why it works. However, since the associated tubal spasm is usually anxiety-mediated, it is not surprising that hypnorelaxation procedures are effective.
FRIGIDITY
The physician should emphasize that proficiency and complete gratification are not achieved until “there is a union of one personality with the other,” or until each of the partners is capable of “giving” instead of “getting.” Sexual compatibility is based on mutual respect, liking, and gradually established confidence—the basis for mature love. Many females blame their sexual problems on physical symptoms, particularly those which bring them to the physician. Organic frigidity is rare. Pseudofrigidity due to male ineptness or ignorance of sexual matters can readily be treated by superficial psychotherapy, consisting of discussion and reeducation of the male. True frigidity, including dyspareunia due to vaginismus, is not a distinct clinical entity but a symptom of faulty conditioning during early psychosexual development.18,22,23
Many women feel guilty if they do not have a specific type of pleasure response in the vagina. Sexual satisfaction cannot be reduced to a mechanical response. Kinsey contended that “orgasm is orgasm” regardless of how it is achieved, whether by digital, penile, or lingual manipulation, but less superficial studies do not bear this out. Because some women can achieve an orgasm only after being beaten, it does not follow that this procedure is normal. Orgasm has little to do with the size of the penis, the position, or the posture. What is important is the element of love. This entity is poorly understood and is lacking in many marriages. Since the understanding of love and sex relationships is important to any therapeutic approach, a discussion of these is indicated.
The author has classified the varieties of love.22 Actually, there are four types of love. There is the “I love I” type which is seen in the child. This is primary narcissism and is in reality self-love. The child says, “This is my toy; give me this.” If he doesn't get it, he gets angry, hostile and frustrated, and cries or stamps off. There are adults who have never really emerged from this “I love I” period of their psychosexual development. They are totally incapable of giving in any type of sustaining relationship. Naturally, from the start, such a marriage is destined to failure.
The next type is projected self-love (“I love me—in you”). This, too, is “I love I,” except that these people worship themselves in another person. Like infants, these people “love” only those who do things for them. It is all incoming, not outgoing.
The third type of love is characterized by romantic affection in which sex is paramount. It is the same type of unrealistic, romantic love that is portrayed in our movies, novels, and popular songs. After the initial thrill of the honeymoon, the chill sets in. The sexual ardor begins to wear off, the quarreling begins. Eventually these frustrated individuals discover that they have nothing in common except self-love. They are not willing to give to each other. Since neither gives, neither receives. The last type of love, by far the rarest, is noted in the old married couple celebrating their golden wedding anniversary. They are just as much in love as when they first met. They did not enter this relationship thinking of what they were going to get but, rather, what they were going to give to each other! Their sexual responses may have been weak at first, but increased in intensity as they sacrificed for one another. Briefly, sex is the passionate interest in another body, and love is the passionate interest in another personality! Just as whisky and soda are found together, so are love and sex found together, but they are separate ingredients!
When trying to get at the factors responsible for sexual coldness, one must inquire how the wife feels about her husband. Does she love him? Is she a warm, outgoing person, willing to give of herself to him? What reservations does she have about sex? Has sex been presented to her as wicked, sinful, and dirty? Does the think that only a fallen woman has sexual climaxes?
The following case illustrates my technics:
A couple who were projecting their squabbling over their sexual tensions onto their four children decided to commit suicide! The wife's ignorance and apathy toward sexual matters were pronounced. She was a member of a very devoutly religious sect which frowned upon sex and taught that it was only for reproduction, not for pleasure. Hypnosis and autohypnosis were used. Like most women of this type, she said, “I can get plenty of satisfaction before, during, or after the sex act if my husband plays with my clitoris. However, I feel very guilty about this.”
Her guilt was alleviated by the assurance that any type of sex play precoitally is all right if it meets the approval of both partners and the sex act ends in genital union. (Foreplay exclusively without genital-to-genital union is considered a perversion.)
Sensory-imagery conditioning under hypnosis was then utilized to transfer the sensation of clitoral climax to the vagina. Through posthypnotic directions it was suggested, “You can transfer the pleasurable sensation in the clitoral area to wherever you wish to experience it.” Through hallucinatory intercourse during autohypnosis, she imagined having the pleasant sensation associated with clitoral climaxes transferred to her lower pelvic region. After 3 weeks of intensive psychotherapy, often consisting of 3- or 4-hour sessions, and practice, it was suggested that she have intercourse. “Do not deliberately try to have a vaginal orgasm, but relax and don't press—it will occur eventually. The most important matter is to enjoy sex without guilt. You can wonder whether you will achieve the type of response you wish during the first month or the second month. Perhaps it may even occur earlier. Let me know. The exact pleasure responses which you experienced during the practice sessions will occur when you are least expecting them.” In due time, this patient was having the type of orgasms she wished.
One can also employ time distortion22 by suggesting, “For every minute of friction you receive during the sex act, it will seem like 5 minutes!” Thus, if the female requires prolonged contact and her husband has premature ejaculation, time can be “lengthened” to give them each greater satisfaction. Naturally, this mechanical adjunct, as has already been mentioned, must be combined with the overall relationship and attitudes of mutual love.
HYPNOBEHAVIORAL THERAPY OF FRIGIDITY, VAGINISMUS AND DYSPAREUNIA
Kroger and Fezler review some of the newer concepts in treating nonorgasmic females (primary orgasmic dysfunction) by a hypnobehavioral model.28 They discuss the various classifications of these types of sexual dysfunctions and point out the importance of the relationship between the partners. This is usually the crucial variable in any kind of therapy. They employ specific images for obtaining arousal and hypnorelaxation to neutralize the associated anxiety which is invariably present. The unadaptive or faulty behavioral responses are unlearned, and new healthy patterns of responding are facilitated by hypnosis. Systematic desensitization and counterconditioning are used under hypnosis not only for overcoming anorgasmia, but also for alleviation of dyspareunia and vaginismus. Fuchs and co-workers have reported on desensitization under hypnosis procedures for intractable vaginismus.13 Their approach essentially involves the principles of deconditioning in vivo (actually using vaginal dilators of increasing size to penetrate) or in vitro (imagery or visualizations of penetration by the penis) under hypnotic relaxation. The latter induces a feeling of safety so that the patient can be confronted with the lowest item on a hierarchy of anxiety-evoking stimuli. Each item is presented until eventually even the strongest of the anxiety-evoking stimuli fails to produce any degree of anxiety in the patient. Visualization of the suggested material becomes more vivid and realistic under hypnosis. Improvement of frigidity has been obtained with hypnobehavioral therapy.12 About 60 per cent of 100 women on follow-up were cured of primary and secondary orgasmic dysfunction.6
Other investigators have used hypnotic technics per se for vaginismus,10,40 uncovering the psychodynamic factors responsible for the orgasmic dysfunction.1,35,36 The “allure of the forbidden” has been employed by having the female imagine herself engaging in intercourse with a partner with a white square (representing censorship) over his genitalia.5 The number of orgasmic responses in women with secondary orgasmic dysfunctions has been tripled.39 More sensation in patients having “sexual anesthesia” has been reported.4 Psychodynamic therapy and hypnosis have been recommended for frigidity.2 A search for key or imprint-like experiences in childhood or other inhibiting subconscious factors has been recommended.7
LOW BACK PAIN
This discussion will be limited to low back pain of psychosomatic origin. There is an “organ language” which the body uses to voice its protests, and the choice of the organ system is determined by the focal area in which the emotional conflict occurs. To some of these individuals, worry is “a pain in the back,” and their back symptoms only express the language of the body, saying, “I am carrying a load on my back—I cannot carry on. Can't people see how I am suffering? Why doesn't someone help me?”
If these and other questions can be answered, the emotional basis for the backache can be determined readily. A personality appraisal is generally necessary in refractory patients. Naturally, the signs and the symptoms of organic disease must be ruled out.
Low back pain of emotional origin, if its function is determined, can be treated hypnotically by symptom-transformation—switching the symptom to another less incapacitating one—but this must be only with the patient's permission. Through the induction of an artificial conflict, another target organ can be suggested for an equivalent symptom to replace the original conversion reaction. For example, it can be suggested that the low back pain be transferred to the stomach. This is not done by direct suggestion but by suggesting a conflict associated with deprivation and fear. If the patient develops the new symptom, it is indicative that she is willing to yield the old one. The fact that the symptom can be manipulated indicates a favorable prognosis. Of course, the newly acquired symptom can be removed, either by hypnosis or autohypnosis, more readily than the long-standing one. In order to use this approach one must be familiar with the hypnoanalytic technics described in Chapter 50.
PELVIC PAIN
The same factors described above apply to the diagnosis of pelvic pain. However, there can be no question of “real” versus “psychic” pain. The reproductive organs reflect the effects of emotions. Pelvic pain is treated in a manner similar to that described for backache. The cases below are typical. Many individuals with pelvic pain are “polysurgical addicts,” who are making the rounds of physicians' offices seeking another operation.
Previous operations usually include an appendectomy, the removal of “ovarian cysts,” “straightening of the womb,” and the removal of “adhesions.” Patients with polysurgical addiction are not aware of their deep-seated need for an operative assault. Such women have deep-seated guilt feelings for which the surgery serves as punishment, atonement and, finally, license to commit new offenses. As a rule, there is improvement for several months following such obtuse “therapy,” after which the patient again produces symptoms and demands for further surgery.
The author discusses in detail the use of hypnosis for pelvic pain of functional origin.26 The psychophysiologic mechanisms are explored, and the differential diagnosis and contraindications to hypnotherapy are described. He cites cases treated by brief hypnotherapy through symptom removal, symptom substitution, symptom transformation and amelioration, as well as other types of treatment, such as reciprocal inhibition therapy, the Y-state of Yoga, hypnosis, suggestive sleep, and hypnosynthesis. Direct symptom-eliminating suggestions are valuable. For example, telling the patient, “What you have suffered belongs to the past” represents an inhibitory conditioned mechanism directed toward suppression of excitatory “trigger zones” in the cortex. Extensive probing for traumatic events is never used, and often only a light state is necessary for posthypnotic suggestions to provide pain relief. On the basis of the author's empirical observations, it seems that a high percentage of patients with pelvic pain can achieve symptom control by hypnotherapy. The technics should be adapted to the needs of the patient. Hypnosis may act by breaking up noxious and well-established pain reflexes through “synaptic ablation”—a sort of “psychological lobotomy.”
PREMENSTRUAL TENSION
Women with premenstrual tension suffer from emotional symptoms such as irritability, proneness to domestic friction, crying, and depression. The symptoms of physical discomfort, such as backache, headache, and varying degrees of edema of the breasts, the abdomen, and the legs, are not as important as the emotional concomitants which often disturb the patient's interpersonal relationships. In some instances, compulsive behavior, suicide, and unpremeditated criminal acts are due to the breakdown of defenses and the resultant lowering of the general sensory threshold coincidental with the premenstrual phase.
Excessive estrogens, progesterone, and the overproduction of antidiuretic hormones have been held responsible for the excess sodium and water in the tissues. A lowered blood sugar, following the hyperinsulinism secondary to emotional factors, was thought to increase the irritability of the nervous system. However, the use of hormones or diuretics per se cannot correct the emotional factors contributing to the difficulties.
The lack of uniformity of opinion as to what constitutes premenstrual tension, the varied methods and results reported in regard to treatment, and the frequent relapses after “cure” all indicate that there is no single causative factor. Therefore, an interdisciplinary approach directed to psychosomatic factors is indicated. Failures result if therapy is directed to only one portion of the syndrome.
The multifaceted approach should consist of antidepressants to elevate the mood, analgesic agents for the discomfort, diuretics and ammonium chloride for the edema, and the correction of the electrolyte imbalance—specific therapy, however, depends on the symptomatology. Hypnosis can be used to potentiate all these approaches.
The noncritical attitude of the physician, his empathy, and his acceptance of the validity of the patient's complaints are other important factors which aid in helping to correct the psychological symptoms. Supportive psychotherapy, consisting of reeducation, reassurance, and the development of strong rapport, through hypnosis, will enable most patients to face their life problems and not succumb to real or fancied symptoms, which often are used for secondary gain purposes—to master the world around them in an immature manner. Experience indicates that the symptoms of premenstrual tension disappear to a significant degree when understanding of the need for the symptom is achieved.
MENOPAUSE
Menopausal symptoms are attributed by the majority of clinicians to estrogen deficiency. This is reflected by the large number of patients treated with estrogens and by the numerous papers reporting the success of this therapy. Severe menopausal symptoms are unknown in some cultures, and the clinical picture is confusing in our society. The cause of the flushing is a failure of the heat-regulating mechanism of the body to dissipate heat properly. There are no correlations between clinical findings and vaginal smears. Women who have the worst symptoms may have smears indicating adequate estrogen stimulation. Others, who have no symptoms, show a complete absence of vaginal cornification. Evidence exists that a “third gonad” in the adrenal gland functions long after the ovaries atrophy.
Good results have been obtained in treating numerous patients with supportive hypnotherapy, oral estrogens, and sedatives.24 Substantial improvement occurs after the ventilation of personal problems. Eradication of popular fallacies by reeducation, together with reassurance and the judicious use of hormones and tranquilizers, will often prove helpful. Such a psychosomatic approach serves to eliminate the “buttock syndrome,” making the patient less dependent on “shots” and less cancer prone.
MISCELLANEOUS PSYCHOGYNECIC CONDITIONS
The author frequently sees women who demand urethral and vaginal treatments for nonexistent diseases. These are masturbation equivalents, and sexual gratification is obtained in the guise of the physician's treatment, whereas self-manipulation of the genitals is taboo.
Retroversion of the uterus is frequently held responsible for pelvic pain. However, it has been said that the patient whose genital organs seem to be “wrong” is likely to be a patient whose psychological processes relating to sex are “wrong”!21 The latter can definitely influence the former.
Pelvic Examination
Frequently hypnosis may be of considerable value when a pelvic examination is necessary in an obese patient. Merely having the patient enter into hypnosis usually produces adequate relaxation.
Minor Gynecologic Surgery
Hypnosis may be used as an anesthetic agent in suitable patients for performing a dilatation and curettage, a biopsy of the cervix, or a culdoscopy. It can also be employed to reduce analgesia and anesthesia for major operative gynecologic procedures (see Chap. 34).
Laparoscopy and Hysterosalpingography
Hypnosis can be used to relax a tubal spasm in an infertile patient when performing a diagnostic procedure such as a hysterosalpingography, a tubal insufflation, a hysterogram, or a laparoscopic examination.
Pruritus Vulvae
Pruritus vulvae will be discussed in the next chapter.
Sterilization
Pseudo-orientation in time can be used on selected women requesting sterilization. Under hypnosis, the patient is projected “several years ahead” and asked how she feels now that her tubes were tied several years ago (the date suggested should be at least 2 years ahead). Any feelings of guilt, remorse, or selfrecrimination indicate the need for further investigation. Many women develop emotional disorders after sterilization; these can be obviated by projecting the patient into the hallucinated future.
MAMMARY AUGMENTATION
Breast enlargement through visual imagery and hypnosis was recently reported by Williams.43 He used age regression to the time the breasts were growing to recapture the feeling and sensation of the breasts enlarging. He also age progressed the subjects to a time when the breasts would be the size desired. Results indicated that at the end of 12 weekly sessions, 13 subjects averaged an increase in the circumference of the breasts of 2.11 inches. No follow-up data were reported to see if these gains were retained. Others41 replicated these findings and noted that during the three months after the cessation of treatment, 81 percent of the gains were retained.
Willard,42 using a taped cassette program, observed that 20 of 22 subjects were able to use visual imagery for breast enlargement. All had some increase in breast size. Eighty-five per cent were aware of a significant increase in breast size, and 46 percent required a larger brassiere size due to the enlargement which occurred.
Though these measures do not equal what can be done with surgical augmentation, further refinement of these procedures might equal the results obtained by surgical methods.
SUMMARY
Any physician trained in hypnotherapy who utilizes an interdisciplinary approach can obtain gratifying results in many difficult gynecologic cases. Naturally, hypnosis here, too, is not a cure-all; there are many failures and relapses. However, autohypnosis, sensory-imagery conditioning, and posthypnotic suggestions directed toward the patient's emotional needs speed up any type of psychotherapy.
Dependency is not fostered when autohypnosis is used. Since the patient, to a degree, controls the therapy, her self-esteem is enhanced. Motivation, rapport, and confidence are more readily established when permissive technics that are noncritical are employed.
Dramatic symptom removal by a doctordirected approach is outmoded. Symptom substitution or symptom transformation, as discussed more fully in Chapter 50, are valuable for achieving relatively permanent results.
It is not necessary for the patient to understand the origin of the symptoms, but how she reacts to them and how she deals with her emotional problems are of the utmost importance. Greater therapeutic leverage can be obtained by revivification, posthypnotic suggestion, time distortion, and other hypnotic phenomena.
Hypnotherapy for psychogynecic conditions helps many emotionally disturbed females to face their problems on a more mature level by developing healthier behavior patterns. Thus anxiety-provoking tensions can be dealt with more realistically. Such psychotherapy usually should be combined with a medical approach for optimal results.
REFERENCES
1. Abraham, G.: Possibilities of hypnosis in the treatment of frigidity. Minerva Med., 63:962, 1972.
2. Alexander, L.: Treatment of impotency and anorgasmia by psychotherapy aided by hypnosis. Am. J. Clin. Hypn., 17:33, 1974.
3. August, R.V.: Hypnosis: an additional tool in the study of infertility. Fertil. Steril., 11:118, 1960.
4. Beigel, H.G.: The use of hypnosis in female sexual anesthesia. J. Am. Soc. Psychosom. Dent. Med., 19:4, 1972.
5. Brady, J.P.: Brevital relaxation treatment of frigidity. Behav. Res. Ther., 4:71, 1966.
6. Cheek, D.B.: Short-term hypnotherapy for frigidity using exploration of early life attitudes. Am. J. Clin. Hypn., 19:20, 1976.
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9. Crasilneck, H.B., and Hall, M.D.: Clinical Hypnosis: Principles and Applications. New York, Grune & Stratton, 1975.
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15. Heiman, M.: Psychosocial influences in functional uterine bleeding. Obstet. Gynecol., 7:3, 1956.
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19. __________: Evaluation of personality factors in the treatment of infertility. Fertil. Steril., 3:542, 1952.
20. __________: Hypnotherapy in obstetrics and gynecology. J. Clin. Exp. Hypn., 1:61, 1953.
21. __________: Psychosomatic aspects of obstetrics and gynecology. Obstet. Gynecol., 3:504, 1954.
22. __________: Psychosomatic aspects of frigidity and impotency. Int. Rec. Med., 171:469, 1958.
23. __________: Psychosomatic aspects of frigidity. J.A.M.A., 143:56, 1950.
24. __________: Hypnotherapy in obstetrics and gynecology, J. Arkansas Med. Soc., 55:412, 1959.
25. __________: An integrated approach to infertility. J. Psychosomatics, 3:1, 1962.
26. __________: Hypnosis for relief of pelvic pain. Clin. Obstet. Gynecol., 6:763, 1963.
27. __________: Sexual frustration. Sexual Behav., 2:41, 48, 1972.
28. Kroger, W.S., and Fezler, W.D.: Hypnosis and Behavior Modification: Imagery Conditioning, Philadelphia, J.B. Lippincott, 1976.
29. Kroger, W.S., and Freed, S.C.: Psychosomatic treatment of functional dysmenorrhea by hypnosis. Am. J. Obstet. Gynecol., 46:817, 1943.
30. __________: Psychosomatic aspects of sterility. Am. J. Obstet. Gynecol., 59:867, 1950.
31. __________: Psychosomatic factors in functional amenorrhea. Am. J. Obstet. Gynecol., 59:328, 1950.
32. __________: Psychosomatic Gynecology: Including Problems of Obstetrical Care. Philadelphia, W.B. Saunders, 1951.
33. Leckie, F.H.: Hypnotherapy in gynecological disorders. Int. J. Clin. Exp. Hypn., 12:121, 1964.
34. __________: Further gynecological conditions treated by hypnotherapy. Int. J. Clin. Exp. Hypn., 13:11, 1965.
35. Levit, H.I.: Marital crisis intervention: hypnosis in impotence/frigidity cases. Am. J. Clin. Hypn., 14:56, 1971.
36. Power, E.: Hypnosis as a diagnostic auxiliary medium in internal medicine, gynecology and obstetrics. Am. J. Clin. Hypn., 4:127, 1961.
37. Rakoff, A.E., and Fried, P.: Pseudocyesis: a psychosomatic study in gynecology. J.A.M.A., 145:1329, 1951.
38. Reifenstein, E.C.: Hypothalamic amenorrhea, Med. Clin. North Am., 30:1103, 1946.
39. Richardson, T.A.: Hypnotherapy in frigidity. Am. J. Clin. Hypn., 5:194, 1963.
40. Schneck, J.M.: Hypnotherapy for vaginismus. Int. J. Clin. Exp. Hypn., 13:92, 1965.
41. Staib, A.R., and Logan, D.R.: Hypnotic stimulation of breast growth. Am. J. Clin. Hypn., 19:201, 1977.
42. Willard, R.D.: Breast enlargement through visual imagery and hypnosis. Am. J. Clin. Hypn., 19:195, 1977.
43. Williams, J.E.: Stimulation of breast growth by hypnosis. J. Sex Research, 10:316, 1974.
44. Wollman, Leo: The role of hypnosis in the treatment of infertility. Br. J. Med. Hypn., 2:38, 1961.