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Justo, João The psychological interpretation of clinical in : a continuity hypothesis Revista Portuguesa de Psicossomática, vol. 4, núm. 1, jan/jun, 2002, pp. 109-130 Sociedade Portuguesa de Psicossomática Porto, Portugal

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João Justo*

Abstract can describe the onset and process of the This paper focuses on the psychologi- specific obstetric dysfunction each woman cal interpretation of obstetric pathology. suffers. It remains unexplained why some Several investigations have demonstrated women submerge under pathology at the the existence of important links between beginning of pregnancy, some in the emotional functioning of pregnant middle and, some only near the end of women and different , as well pregnancy. There is a strong probability as problems during delivery. The psycho- that the best answer to this question lies logical understanding of such phenomena in the patient's resources for dealing with often points to inner conflicts that preg- the distinct demands of psychological nant women are unable to deal with or to development that parallel pregnancy. express. Key-words: Obstetric pathology; We are raising a continuity hypothe- Psychological interpretation. sis underlining the observation that women suffering from different obstetric pathologies may be considered as psycho- INTRODUCTION logically similar and suffering from a con- tinuum of related emotional factors, ha- Over the past decades, psycho- ving difficulty in expressing their prob- logical research on female reproduc- lems. According to this hypothesis, what tive life has repeatedly demonstrated characterizes the different pathologies is that obstetric pathology is often mo- the moment when the emotional burden tivated and stimulated by emotional becomes too heavy and psychological con- factors. This conclusion was validated flicts are expressed by current physiologi- in a good number of cases affected by cal functioning. and , hiperemesis Obstetric problems occur at distinct gravidarum, spontaneous interrup- moments in the course of pregnancy. We tion of pregnancy, pre-eclamptic and eclamptic toxemia, premature onset of delivery, premature delivery, as well as several problems of the delive- ry process. * Full Professor at Faculdade de Psico- logia e de Ciências da Educação da Research in this area usually Universidade de Lisboa. points to some kind of psychological

Vol. 4, nº 1, Jan/Jun 2002 João Justo 110 weakness affecting the personality of ing the first weeks, arriving at the top the pregnant woman. The aim of this by the 14th week and decreasing from article is, not only, to explore the most then on [2]. It has also been found that important psychological findings re- women vomiting in early pregnancy lated to obstetric problems, but also show a significant, although slight, to point out the similarities among the trend to androgyny in their body psychological characteristics of measurements (as already referred by women affected by them. Women af- Coppen, [3]). Biological explanations fected by different obstetric patholo- of pregnancy vomiting have stimu- gies may be very much alike from a lated medical interventions like di- psychological point of view, the ap- etary changes, , vitamin parent diversity being related to the B6, etc. [4]. The association of anticho- moment of onset of the obstetric prob- linergic and medication lem. Possibly, this association is in- with vitamin B6 reduces the number fluenced by environmental variables of days with nausea, as well as nau- such as family development, social sea severity [5], while vitamin B6 alone and economical resources, quality of seems to have better results among relationship to the doctor, and so on. patients with severe nausea than Nonetheless, we have to deal with the among patients with mild to moder- question, why some women feel in- ate nausea [6]. capable of psychological manage- As Klebanoff et al. [7] observed in ment so soon, others so late, and o- a large American sample of pregnant thers will experience crisis in the women, vomiting is more frequent middle of this long coping process of among women who are: a) pregnant psychological accommodation to the for the first time; b) younger; c) have demands of gestation. less than twelve years of education; d) are non-smokers; and e) weigh more than 77 Kg. It has also been ob- NAUSEA, VOMITING AND served that women who vomited du- ring pregnancy had: a) better chances to escape or ; b) Nausea and vomiting are quite less probability of premature delivery common during the first three months and, c) higher probability of vomi- of pregnancy. According to Huxley [1], ting in a future pregnancy. morning sickness (nausea with or Positive relationships between without mild vomiting) is present in morning sickness and pregnancy out- the early stages in 50% to 70% of all comes have been noticed since the fif- , and plays an important ties [8,9], and these results were con- role in placenta development. Usu- firmed more recently [10,11]. On the ally, during pregnancy nausea evolu- other hand, Klebanoff and Mills [12] tion is very similar to that of the cho- have demonstrated that vomiting in rionic gonadotropin curve, rising dur- pregnancy is not associated with in-

Revista Portuguesa de Psicossomática Revista Portuguesa de 111 Psicossomática The psychological interpretation of clinical pathology in pregnancy creased risk for congenital malforma- doubts and worries about pregnancy, tions. A significant trend for alcohol as well as with the lack of informa- and tobacco consumers not to vomit tion about pregnancy development, during gestation was reported by Little delivery onset and progress, and and Hook [13], especially in women about the foetus’ health. Furthermore, whose consumption started before Musaddiq [19] states that stressful life pregnancy. According to Little [14] the events can play a part in the genesis relation between birth weight and nau- of vomiting during pregnancy, as can sea and vomiting in pregnancy is al- the general emotional functioning of ways a positive one, independently of the pregnant women [20]. smoking or drinking status. Some pregnant women don’t This clinical problem has long show a decrease in vomiting, not even been interpreted as a result of psycho- by the end of the third month. If vomi- logical variables or pregnant ting increases to severe levels, health women’s mental functioning. Best problems of all kinds are expected known was Helen Deutsch’s [15] "am- (disturbance of dietary patterns, elec- bivalence hypothesis" claiming that trolyte imbalance, ketosis, acetonuria, vomiting at the beginning of preg- severe loss of weigh, etc.). This clini- nancy is a consequence of emotional cal picture is classically designated as ambivalence towards pregnancy and "Hyperemesis Gravidarum" and wor- towards the future baby. Chertok, ries the medical staff because of po- Mondzain and Bonnaud [16] tested the tential consequences for the mother ambivalence hypothesis, interview- (dehydration, pulse irregularities, fe- ing 100 primiparous women at the ver, jaundice, neurologic disorder, third month of pregnancy, and classi- retinal problems, renal damage, liver fying them according to conscious damage, etc.) and for the child (in- verbally expressed attitudes. Those creased risk for child malformations authors confirmed that vomiting in [21,22], or lower birth weight [23]). the beginning of pregnancy is much Some cases are so severe and start more frequent among emotionally so early in pregnancy that total ambivalent women (75%) than parenteral nutrition must be used [24]. among women with clearly defined Fortunately, this condition is ex- attitudes (61%), based upon outside tremely rare [25]. Hyperemesis is said judges' criteria. But, Macy [17] argues to be diminishing during the second that the affective ambivalence works half of the XX century. This change is together with the relationships of the attributed to ease in obtaining preg- pregnant women to her husband and nancy interruption and it is inter- to her mother to produce the morn- preted as a confirmation of the psy- ing sickness of the early pregnancy. chological aetiology of vomiting [2]. According to Iatrakis et al. [18], those Also seen as confirmation of the psy- factors should be associated with the chological aetiology of this syndrome relationship to the doctor, with the is the fact that during war times the

Vol. 4, nº 1, Jan/Jun 2002 João Justo 112 number of such hospital admissions The observation that pregnant drops significantly [26]. women suffering of hyperemesis tend While the cause of hyperemesis re- to be nulyparous, younger and fatter mains unknown, several medical theo- than controls [21] may be concealed by ries have been raised: a) temporary the data mentioned above. According depression of the adrenal function [27]; to these authors, the aggregation of b) elevated levels [21], etc. data easily lead to the hypothesis that Hyperemesis Gravidarum starts hyperemesis (excessive vomiting) is by an emetic phase and evolves into a result of the psychological mecha- a phase of undernutrition and exces- nism of conversion [36]. sive weight loss [28], requiring hospi- Due to resistance to medical treat- tal admission and intensive medica- ment, pregnant women with hyper- tion. Medical intervention of this kind emesis have been submitted to psy- is generally enough to restore the chological therapies. The oldest psy- physiological equilibrium of patients, chotherapeutic approach to this prob- but it is also current that vomits per- lem was based on hypnosis. Several sist, or relapse, despite the fact that researchers have found that the hyp- the health condition of those patients notic procedure produces symptom is getting better. relief in an easy, effective and short To explain the origin of hypereme- way [37,38,39]. Specifically, Kroger based sis and its resistance to medical treat- his work on the fact that during deep ment, authors writing in the psycho- hypnotic states it is possible to induce analytical tradition posit that patients nausea, vomits and with this problem have: a) an uncon- [40]. In those early experiences, the ba- scious rejection of femaleness [29]; b) a sic approach consisted in inducing a general difficulty in dealing with the deep hypnotic state and producing attributes of feminine personality and strong post-hypnotic suggestion that exhibit an overall infantile attitude [30]; symptoms would cease. Another al- c) a higher probability of being a hys- ternative technique uses hypno- terical personality [31]; d) present no- analysis and age regression. The table difficulties of sexual adjustment therapist induces the patient to re- [32] and, e) higher levels of psychologi- gress to a preadolescent age and af- cal immaturity, depression and anxie- terwards leads her to slowly progress ty [33]. to her real age. With this procedure it Caruso et al. [34] suggest that these becomes easy to identify the psycho- patients have a pathological relation logical conflicts that burden a preg- with their husbands based on mutual nant woman’s emotional life and that denial, and Apfel et al. [35] state that are, possibly, responsible for patho- they are significantly more hypnotiza- logical vomiting, as present in hypere- ble than pregnant women with only mesis gravidarum. Grounded in those mild to moderate symptoms of nau- data, researchers may have access to sea and vomiting. a general understanding of interven-

Revista Portuguesa de Psicossomática Revista Portuguesa de 113 Psicossomática The psychological interpretation of clinical pathology in pregnancy ing inner conflicts: a) lack of desire has also proven effective in controlling for pregnancy because of material dif- vomit crises in a patient who started ficulties; b) marital unhappiness and her symptoms during a pregnancy divorce becoming inevitable; c) preg- and remained vomiting for several nancy leading to the loss of a profes- years after giving birth [42]. A different sional career; d) marital relations ex- psychotherapeutic approach to hype- perienced with huge frigidity, along remesis gravidarum is the ABC (ante- with passionate extra-marital rela- cedents, behaviour and consequences) tions producing the present preg- intervention proposed by Callahan et nancy and, e) preference for mascu- al. [43]. In a first stage, patients are in- line personality and total unaccep- volved in identifying factors functio- tance of pregnancy, maternity and nally associated with vomiting, before sexual issues. (releasing factors) and after (reinforc- Looking at the clinical material pro- ing factors) the symptom is produced. duced by the use of hypnotic proce- Usually these factors are events taking dures, one may argue that the data, per place in the patient’s life. In the se- se do not explain hyperemesis gravi- cond stage, and using this information, darum, because a great number of the therapist will try to reorganize the pregnant women share many of those patient’s life so that such events won't problems, as described, but don’t share take place or won't be so stressful, lead- the symptoms of the disease. ing to significant improvements in the In fact, conflictual inner experien- patient’s condition. ces seem to lead to symptom forma- Among all psychological interven- tion in such cases in which the preg- tions used with hyperemetic pregnant nant women’s personality is capable patients the most consistent remains and willing to enact them. According the use of hypnosis according to to the professionals that have been Fuchs et al. [44]. These authors used involved in relieving this condition, hypnosis on an individual and on a the underlying personality structure group basis. According to their re- is of hysterical type. This would also sults, patients hypnotized in a group be the best explanation for the imme- situation responded better, quicker diate effect obtained in a good num- and avoided hospitalisation more ea- ber of cases. sily than patients treated individually. Hypnotic procedures for the re- duction of hyperemesis gravidarum have also been administered together SPONTANEOUS INTERRUP- with supportive psychotherapy and TION OF PREGNANCY behaviour modification [41]. This col- laborative approach has proven effec- Spontaneous interruption of preg- tive and induced faster recoveries nancy is defined as the uterine expul- than medical intervention alone. sion of the embryo or of an unviable Behavioral intervention on its own foetus and, usually happens between

Vol. 4, nº 1, Jan/Jun 2002 João Justo 114 the beginning of pregnancy and the with their repetition, needs to be 20th week of gestation. Despite all called to the attention of psycholo- medical advances, one fifth of all ges- gists who may help to induce better tations confirmed by clinicians ends levels of adaptation and, wherever spontaneously [45]. Identifiable medi- possible, to ensure better conditions cal factors for this problem usually for the development of a new preg- fall into one of four categories: 1) chro- nancy. mosomal abnormalities of the foetus; As can be expected, most women 2) uterine abnormalities; 3) immuno- affected by miscarriage experience logical problems and, 4) endocrine grief and sorrow, and a good number problems [46]. During the ten first among them suffer from anxiety and weeks of gestation chromosomal ab- depression [50-58]. Guilt may be the normalities are responsible for about most difficult aspect to deal with, for half of the cases of spontaneous mis- both men and women after the loss carriage, while after the eleventh of pregnancy [59]. In some cases, psy- week there are 2.9 to 3.5 more cases chological suffering following miscar- of chromosomally normal cases than riage can be observed more than one the opposite [47]. From a classical point year later and may reach the level that of view, the repetition of spontaneous we observe in persons who are interruption of pregnancy induces a mourning the death of relatives or huge decrease in the probability of a dear ones [60]. However, a large majori- woman successfully carrying a future ty of cases (75%) is capable of over- pregnancy to the end [48]. Even nowa- coming the situation of grief one days, the repetition of miscarriage month after miscarriage, very few induces a negative probability on ob- cases will report no reaction at all (4%) stetrical expectations since a women and, only about one fifth (21%) will with three or more spontaneous abor- proceed into the second month with- tions presents problematic outcomes out overcoming the grief reaction for a future pregnancy. Said in cold (Turner et al., 1991). Nevertheless, numbers: a) 30% of viable babies are four months after miscarriage, there small-for-gestational-age; 28% are is a significant decrease in anxiety, born pre-term and, c) perinatal mor- depression, grief, self-blame and tality rounds 16% [49]. worry [61]. At this point a difficult problem Women with threatened arises because, as medical experience show higher levels of depression, states, a good number of pregnant anxiety, anger and of other emotional women dealing with own and with and stress related variables, when foetal problems do carry their preg- compared with pregnant women af- nancies to term regardless of their and fected by vomiting, or when com- their offspring’s disturbances. The pared with normal pregnant women psychological suffering associated [20]. with these conditions, and specially According to Conway [62], evidence

Revista Portuguesa de Psicossomática Revista Portuguesa de 115 Psicossomática The psychological interpretation of clinical pathology in pregnancy gathered from scientific literature ly see the foetus there seems to be no points to seven major aspects capable regret [65]. Relief relief from having of influencing the grief reaction: so- survived the traumatic event has been cial support; professional support in- pointed out by some authors [65,70,71], cluding explanation on the cause of and it may be considered positive if miscarriage; seeing the foetus upon one is reminded that this attitude pre- request of the woman; relief from ha- sents the need to test reality immedia- ving survived the traumatic event; tely after the occurrence of a very lack of community support; low self- stressful event. A temporary reaction, -concept; and excessive worries about this feeling diminishes the severity of a future pregnancy. Speaking of so- the emotional crisis until other inter- cial support, there seems to be a con- nal capabilities are set in motion to sensus that husband [63], relatives and help women face the real conse- friends [64] are the most important quences of the traumatic event [62]. sources, and by that order of prefe- Lack of community support in the rence [65]. The role of female support, sequence of spontaneous abortion is specially of meaningful ones like the unfortunately common in our days, mother or those who have suffered and one of its most sad expressions is miscarriage themselves must also be the lack of mourning rituals, probably stressed [66]. Concerning professional linked to feelings of shame related support, we must realize that many with talking in public about personal health professionals are not trained to traumatic events [65]. Although not deal with the psychological conse- universal, lowered self-concept is a quences of miscarriage and, therefore, natural response to such a serious need to be assisted by mental health event as miscarriage. This change of experts on the ways chosen to talk the feeling of worth in one’s self and explain the nature of the situa- evaluation may be due to doubts re- tion to women who suffered this loss lated to reproductive capability [72], [67]. This is most important, as we but is also related to the negative side know that women informed about the of social interactions which so easily cause of miscarriage are less stressed reinforce guilt feelings in suffering by feelings of self-blame than women women [73]. Another element of these who are given no identifiable cause feelings is the notion that she cannot [61]. Although still controversial, the trust her body [70], or the fact that in possibility of seeing the foetus after many couples sexual intercourse may miscarriage is regarded by some cli- become a difficult situation after mis- nicians as a positive first step towards carriage, either resulting from doubts mourning [66,68,69]. In truth, only one about a future pregnancy or doubts third of women in this condition about sexuality itself [65]. spontaneously stated their wish to see Finally, excessive worries about a the foetus [50]; but, it is equally ob- future pregnancy are able to impair served that among those who actual- the psychological life of these women.

Vol. 4, nº 1, Jan/Jun 2002 João Justo 116

A simple but extremely negative im- an association between vivid imagery pairment is the denial of anxiety du- and higher levels of grief [76]. Surpri- ring the next pregnancy [65]. This may singly, Conway and Russell [77] have impair the psychological develop- found that during the first three ment inherent to gestation itself, in- weeks after miscarriage men exhibit ducing changes in day to day activi- significantly higher levels of grief ties [73] and, enhancing natural am- than women, but four months after bivalence towards pregnancy to grow the event the difference is not signifi- to levels which are disturbing for a cant anymore. couple's life [73]. In those cases, it The possibility that some cases of would not be surprising to find bond- repeated spontaneous abortion have a ing difficulties between mother and psychological aetiology has been sus- baby after birth [73-75]. pected for long time, and was firmly The recognition of psychological stated by Mann [78], based on experi- suffering after spontaneous abortion mental evidence that uterine contrac- leads to an easy comparison with tions may happen in response to stress- other mourning situations. Neverthe- ful stimulus, as formerly found by less, grieving after the loss of preg- Alvarez and Caldeiro-Barcia [79]. nancy during its earliest stages tends In order to prove that a good num- to be a solitary situation, viewed by ber of could be the re- other people as a private problem, sult of pregnant women's emotional resolved within hospital services (the reactions, Mann [78] presents the re- quicker the better), and with a very sults of systematic interviews to a positive and simple life solution: a group of women with a history of re- new pregnancy in the near future [74]. peated abortion and who, after Unfortunately, when things are taken gynaecological diagnosis, were con- in this easiest way, and a new preg- sidered "to be free of gynecologically nancy is seen as the best cure for a discernible abortigenic conditions". former pregnancy loss, it is very pro- According to his data, these women bable that the mourning process does were: a) very similar, to one another, not take place, or does not get to the specially in their proneness to react end. If so, one might expect that the somatically to psychic situations; b) baby born at the end of the new ges- they were somatic reactors since tation will be affected by the psycho- childhood and until adult life (for ex- logical relation that the mother (and ample, as children they developed possibly the family) still maintains nausea and vomiting while facing with the dead foetus. family stressful situations; or they Investigation about men’s reaction developed colitis after becoming en- to miscarriage shows a relationship gaged with their husbands; or they between the observation of the baby’s developed after quarrel- ultrasound scan and the vividness of ling with their mothers-in-law); c) visual imagery of the baby, and also they were delayed in their sexual de-

Revista Portuguesa de Psicossomática Revista Portuguesa de 117 Psicossomática The psychological interpretation of clinical pathology in pregnancy velopment and came from families psychological treatment, in the obstet- with a typical structure (dominant rical life of those women there were mother with overprotective tenden- 91% of pregnancies ending in abor- cies and, incompetent father as a con- tion, while, after treatment, only 19% sequence of death, desertion, divorce, ended the same way. Similar results alcoholism or passivity); d) they re- were also found by Bevis [80] and by garded themselves as poor achievers Berle and Javert [81], applying the dy- in womanly status, regarding mother- namically oriented psychotherapeu- hood as a property of ideal women tic intervention described by Javert [82]. far beyond their adaptive capabilities; Women investigated by Mann were e) always victimized by anxiety also submitted to psychometric diag- whenever pressured to achieve suc- nosis and compared on the one hand cess in any kind of performance. In with women without habitual abor- this context, Mann observes that tion and,on the other hand, with ha- nearly 50% of his sample seems to bitual aborters having an identifiable react psychosomatically in a big range organic cause for miscarriage [83]. of upsetting circunstances, the other When comparing patients with and part of the sample seems to react this without repeated miscarriage it was way only to specific kinds of emo- found that: a) when tested with the tional conflict. In these last cases, the Wechsler-Bellevue test, habitual interesting aspect is the existence of aborters perform less well on the Pic- premarital pregnancy or illegal abor- ture Arrangement subtest; b) when tion. As one can easily guess, guilt tested with the Rorschach Procedure, feelings are very powerful in these a good number of habitual aborters women's psychological lives and the produced much more color-form than occurrence of spontaneous abortion form-color responses, a high number can be seen as the easiest way to self- of popular responses, a high percent- -punishment and emotional relief. age of hostility responses, more indi- According to this author, women suf- rect hostility responses than direct fering from repeated abortion re- hostility ones, and used oral depen- spond to the emotional changes of dent symbolism more frequently than pregnancy by developing uterine con- the norm; c) when tested with the tractions which, in turn, generate de- TAT, a good number of habitual abor- cidual haemorrhage and, finally, mis- ters produced more stories with help- carriage. Independently of the mecha- ing themes and guilt themes, and also nism, the strongest argument for the they had longer reaction times to card psychological aetiology of spontane- 8BM and to card 18GF. Attributing ous and repeated abortion is Mann's one point to each indicator, and tak- [78] report on the success of psycho- ing a score of 5 as the cut point, it was therapeutic psychodynamic interven- found that only 11% of the compari- tions with habitual aborters without son group was at or above this limit, identifiable medical factors: before the while the same happen to 70% of ha-

Vol. 4, nº 1, Jan/Jun 2002 João Justo 118 bitual aborters. In this way, more than ing situations and consequently, d) 75% of the subjects could be classified reveal a repressive type of psychologi- correctly according to psychometric cal functioning, with growing emo- data. When comparing habitual tional tension and psychosomatic re- aborters with an identifiable organic actions being expected. cause and habitual aborters without A reasonable doubt exists in ap- an identifiable organic cause, and us- preciating the above data. An alter- ing again 5 as the cut point, it was native hypothesis is that differences observed that the former are much mentioned between women with and more alike women without abortion without identifiable organic cause repetition. In this sense, it is easy to may be generated by the acquain- understand that the repetition of mis- tance with diagnosis (felt with relief) carriage per se is not enough to pro- or by the lack of that information (felt duce the psychological signs that as a source of anxiety about unknown characterize women suffering miscar- events taking place deep in patients' riage and not having an organic cause reproductive life). to blame. It is interesting to compare Other projects have defended the habitual aborters before and after suc- psychosomatic aetiology of spontane- ceeding to carry a new pregnancy ous abortion, proposing other inter- until the 35th week. Some of the psy- vening mechanisms: 1) in situations chological signs identified as typical of great stress, increased secretion of of these women have changed in the adrenalin may induce dramatic direction of the comparison group, changes in the contractility, meaning that pregnancy, psycho- giving start to delivery of the foetus therapy, or a combination of the two [81] and, 2) extreme hormonal (namely factors has turned these patients into chorionic gonadotrophins) variations much more healthy people. Too little due to emotional problems of the pa- attention seems to have been paid to tient [84-88] may induce the same result. the basic research here summarized, Several investigations have shown though psychotherapeutic endea- the existence of an association be- vours should be grounded on those tween spontaneous interruption of findings. pregnancy and stressful life events [89, These results form the basis of 90], particularly after the 10th week of Elaine Grimm’s [83] statement that gestation [91]. It has been argued that women with repeated abortion and high levels of stress, among other con- without conclusive medical diagno- sequences, induce significant rises of sis are markedly: a) over reactive from ß-endorphin, which have a negative an emotional point of view; b) prone effect on the -flow between the to compliance in social relations; c) uterus and the placenta [92]. It has also impaired by fear of rejection or guilt been stated that stress has a negative that limits the open and direct expres- influence upon pregnant women's sion of hostility generated by frustrat- behaviour as reflected by substance

Revista Portuguesa de Psicossomática Revista Portuguesa de 119 Psicossomática The psychological interpretation of clinical pathology in pregnancy abuse, food intake and also the way spite increasing progress in medical medical help is looked for [93]. Possi- intervention, pre- remains bly linked with those observations is a good predictor of severe maternal the fact that Ancel et al. [94] found a disease as well as a good predictor of much higher risk of late abortion (14- pre-term birth and small for gesta- -21 weeks of gestation) among preg- tional age infants [100], intrauterine nant women living alone. growth restriction and low birth- -weight [101], and of neonatal death [102] and perinatal death [103]. The risk of PRE-ECLAMPSIA AND EC- small-for- infants LAMPSIA seems to be higher among multipa- rous pre-eclamptic women than Pre-eclampsia and eclampsia con- among nuliparous pre-eclamptic stitutes one of the major causes of women [104]. Uncomplicated chronic medical concern during pregnancy. hypertension is also related to a Usually high blood pressure and pro- higher risk of having a small for ges- teinuria are seen as the most impor- tational age, and this association tant symptoms of pregnancy hyper- tends to rise with age [105]. According tensive disorders [95]. The usual con- to Naeye [106], it is only after the hy- sensus for these symptoms evaluation pertensive range is achieved that in- is around >90mmHg for diastolic creased levels of blood pressure be- blood pressure, >140 mmHg for sys- come responsible for birth-weight tolic blood pressure and, >300mg/24 decrements. As argued by Misra [107], hours for . studies that have failed to find a rela- In cases where blood pressure tionship between foetal growth and continues to rise convulsions may pre-eclampsia should be questioned appear, and then we speak of eclamp- due to lack of control upon variables sia. Nonetheless, problems like such as smoking. This habit has a re- oedema, activation of the coagulation cognized negative effect on foetal de- cascade, changes in sensitivity to va- velopment but, at the same time, a sopressors, higher vascular permea- protective effect on gestational blood bility [96], and trombophilia [97] should pressure has been suspected [108]. not be forgotten. The current defini- Among the most important predic- tion brings about the problem of the tors of pre-eclampsia we have second validity of blood pressure measure- trimester mean arterial blood pressure ments due to the lack of standardized [109,110], serum urate [111], nulliparity [112,113], criteria and also to personal variables pre-eclampsia in a previous preg- of the observer [98]. Recent research nancy, high body mass, working du- suggests that pre-eclampsia is a multi- ring pregnancy, and having a family -system clinical problem involving history of hypertension [112]. placentary dysfunction as well as le- Several medical theories have sions of the endothelial cells [99]. De- emerged to explain pre-eclampsia as

Vol. 4, nº 1, Jan/Jun 2002 João Justo 120 a consequence of: immunological dis- exhibit a higher number of psychiat- function [114, 115]; an increase in sympa- ric symptoms while pregnant, re- thetic nervous vasoconstrictor acti- member a more disturbed response vity [116] or an increase in sympathetic to menarche, report higher premens- nervous tone [117]; low gluthatione le- trual tension and poorer sexual ad- vels [118]; high testosterone levels [119]; ri- justment, experience more disturbing boflavin deficiency [96]; genetic predis- events during pregnancy and express position to trombophilia [97] and, ge- attitudes not as favourable to the fu- netic variability in biotransformation ture child as those shown by women enzymes [120]. However, as stated by in a control group [126]; c) have a higher Dekker and Sibai [121], medical hypo- chance of being employed in high- thesis about pre-eclampsia should be -stress jobs and also a higher chance regarded as interactive and not as mu- of being found working during preg- tually exclusive; besides that pre-ec- nancy [127]. Comparing these conclu- lampsia aetiology is not yet fully un- sions to those drawn from prospec- derstood. Despite all medical theoreti- tives studies (i.e., when the psycho- cal and practical efforts, pre-eclamp- logical interview occurs before the sia prevention is still far from effec- onset of pre-eclampsia), different but tive [122]. Since blood hypertension is complementary information can be notably influenced by psychological found. More frequent among pre-ec- functioning [123,124], and since psycho- lamptic women, than among control logical functioning is associated with women who don’t develop this con- the of pregnancy, it is easy dition, we have: a) abnormal results to understand the interest that pre-ec- in MMPI protocols [128]; b) behavioral lampsia has raised among psycho- symptoms in childhood (enuresis, logy researchers. Searching for the disturbance in mood control, insom- aetiological contribution of psycholo- nia, delinquency and repeated psy- gy to this problem, there are two dif- chiatric consultation), marital prob- ferent approaches, the retrospective lems (being single, divorced, wid- and the prospective one. According owed or separated during preg- to the retrospective examples (i.e., nancy), accident proneness and spon- when psychological interviews take taneous [129]; c) lower scores place after the diagnosis of pre-ec- in intelligence assessment, presenta- lampsia) we may observe that pre- tion in personality tests as more in- -eclamptic women: a) describe a trospective, depressed and uncom- greater amount of stress (interper- municative, and less desire for preg- sonal, economic and occupational) nancy [130]; d) when compared with during their pregnancies when com- husbands of control women, hus- pared with a control group, and de- bands of women who develop pre- scribe themselves as more rejecting of -eclampsia show a tendency for de- pregnancy and making a negative pendence, immaturity and difficulty evaluation of their husbands [125]; b) in coping with problematic situations

Revista Portuguesa de Psicossomática Revista Portuguesa de 121 Psicossomática The psychological interpretation of clinical pathology in pregnancy

[130]; e) emotion suppression plays an PSYCHOLOGICAL LINKS important role in the onset of preg- nancy-induced hypertension [131]; f) Psychological research has tried to surprisingly enough, thought not sig- demonstrate that patients prone to nificant, Nisell et al. [132] found preg- exhibit excessive vomiting, sponta- nant women with low life stress to neous abortion or pre-eclampsia du- have higher blood pressure than those ring pregnancy are psychologically with high life stress; g) anxiety and different from women not presenting depression measured in early preg- such obstetric pathologies. The simi- nancy are associated with increased larity between those psychological risk of later pre-eclampsia onset [133]. factors associated with the three dif- Also important is the fact that war ferent pathologies has not been suffi- stress seems to be associated with ciently urderlined. The question is higher levels of pregnant women's raised about how to understand the blood pressure, especially among distribution of physiological patho- younger women [134]. logy along time among pregnant According to those data, one women, given their similarities from should expect that psychological inter- a psychological point of view? vention with pregnant eclamptic The first and easiest answer is the women would be a positive contribu- classical assumption of psychoso- tion for blood pressure decreases, matic medicine; the development of when carefully articulated with medi- psychosomatic diseases depends cal care. Inside the world of psycho- upon organic propensities of the in- therapies, hypnotic procedures would dividual: fragility in the organism of be one of the first options, not only some patients making it easy for cer- because of the possibility of obtai- tain illnesses to emerge, while organic ning results in a short time, but also resistance makes it harder for the because of their recognized impact same diseases to progress in other pa- with hypertensive patients. Surprisin- tients. gly, published data on this matter is In spite of the fact that this prin- extremely difficult to find. More than ciple is still largely accepted by all cli- that, when pregnant women are forced nicians, and in spite that physiologi- to stay in hospital because of pre-ec- cal factors of pregnant women do lamptic complications, the most re- play a role in the establishment of markable aspect to a clinician's eye is obstetric pathologies, we are here rai- the fact that physical exhaustion is of- sing a different hypothesis. ten associated to psychological suffe- This hypothesis is a developmen- ring and despair, making it hard to un- tal one, in the sense that it is based derstand why this condition does not upon the theoretical stance that the push hospitals to provide psychologi- psychological experience of preg- cal help. It is equally hard to accept that nancy follows a sequence of develop- data on this matter should be so sparse. mental stages, with psychological

Vol. 4, nº 1, Jan/Jun 2002 João Justo 122 tasks to be performed and goals to be usual consensus about a rough corre- achieved at each stage. Thus, once a spondence between each of those development task is reached, there is three phases and each one of the three no returning to previous stages [135-138]. trimesters of pregnancy. According to this principle, pregnant Keeping the mentioned stages in women experience stress in accor- mind, and understanding the se- dance to changes (anatomical, hor- quence of coping demands expected monal, etc.) taking place at different during gestation, we can think that it moments of gestation, and having is the failure to perform tasks and distinct timetables. To integrate the achieve goals that prompts the preg- meanings of those changes, the psy- nant women’s organism to produce chological functioning of the child- the kind of obstetric pathology related bearing women will also be submit- to the emerging stage. Possibly, wor- ted to changes. It follows that the abil- king-through the psychological ity to undergo this process will enable meaning of those critical relationships the global balance required to master with the most important persons of the inevitable reality of pregnancy, their lives, as they fulfil the task re- one of the best known and specific of quired by mainstream goals, gener- all life crises. ates a feeling of relief and overall From a psychological point of wellness. Thus, the required balance view, each stage in the gestational may be achieved in the process. In process carries with it a task: a) the cases when adequate working- goal of pregnancy's first phase is to -through flops and goals are not accept gestation, and the proper task achieved, the probable result is a high is to work-through former childhood level of anxiety. This experience is relationships with the pregnant known to play a very negative role in women's mother; b) the goal of pre- respect to all levels of obstetric con- gnancy's second phase consists in dif- cern. In this sense, the display of ob- ferentiating the mother's self from the stetric pathology would be a possible baby's self, for which the proper task psychosomatic expression of unbear- is to work-through the pregnant able psychological conflict. Conse- women’s relationship with the father quently, the moment for its emer- of the future child and, c) the goal of gence in some pregnant women pregnancy's third phase consists in would be understood as a result of preparing the separation between the psychological withdrawal from ef- mother's and child's bodies, and the forts to cope with the task at hand proper task is to work-through the demanded by a gestational process. pregnant women's relationship with If this hypothesis is accepted, one the identity of the baby to come (135- must still face the initial question: -138). Though one cannot state with cer- why are these women so similar psy- tainty the beginning and end of each chologically, and their pathologies are of these stages, we must rely on the so different?

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We are highlighting the associa- jective demonstration of not being tion between the moment of psycho- able to carry pregnancy to its end (and logical inability to cope with gesta- the progressive separation between tional demands and the possible oc- mother and child is the task attributed currence of certain kinds of obstetri- to the third phase). cal problems. Thus: a) severe vomit- According to this sequence, we ing and hyperemesis are much more would say that: a) the onset of hyper- likely to take place from the middle emesis happens when pregnant of the first trimester into the second women are not able to initiate the psy- trimester, than at other moments; b) chological development involved in spontaneous abortion in the absence the first phase; b) spontaneous abor- of chromosomal abnormalities is tion (in the absence of chromosomal much easier to happen during the se- abnormalities) takes place when the cond trimester of pregnancy; c) pre- of the first -eclampsia is much more frequent phase is not accomplished; c) pre-ec- from the middle of the second trimes- lampsia occurs if psychological evo- ter on, than before that period and, lution of the second phase is not d) premature delivery is typical of the achieved and, d) premature delivery third trimester. will end pregnancy when require- From a psychological point of ments of the third phase are not met. view, we have here an interesting re- None of those relations is a mathe- lation between the mentioned clini- matical one. First of all, we must state cal problems and the meaning of the that we are not speaking of all women psychological stages of gestation: who suffer one of those clinical prob- I - severe vomiting is a symptom lems. We are only speaking of women carrying a symbolic meaning of am- for whom medical factors have been bivalence (the natural feeling when considered insufficient for etiological the need for working-through the re- purposes. Secondly, we don’t expect lations with the mother emerges, a that psychological factors per se will task attributed to the development of cause obstetric pathology. We only the first stage); expect that psychological factors may II - spontaneous abortion is an ob- empower physiological ones, thus jective demonstration that pregnancy producing the symptomatic problems cannot be accepted (and acceptance we are worrying about. Thirdly, we is the goal of the first phase); should believe that a good number of III - pre-eclampsia is characterized crisis prone women will not suffer by high levels of blood pressure (pos- such problems because external fac- sibly induced by difficulties related tors (marital, family and social sup- with working-through the actual re- port, etc.) play a positive role, coun- lation with the husband, the task of teracting some of the physiological the second phase) and, consequences enabled by their emo- IV - premature delivery is an ob- tional upset.

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