Alia Ahmed and Fiona M. Lewis The importance of the psychological impact of physical disease is significantly underestimated and frequently ignored. Being aware of the psychological and psychiatric sequelae associated with vulval disease is vital for healthcare professionals to be able to holistically manage the patient. There is a close relationship between physical disorders and the development of psychological symptoms or frank psychiatric disorder [1], and the importance of addressing the psychological issues as an integrated component of management is well recognised [2,3]. Chronic conditions such as HIV and cancer have a high prevalence of associated depression and anxiety, and treating these problems in addition to the physical condition leads to a better quality of life [4–6]. People with psychiatric conditions are also more likely to seek help in medical settings. They are frequent attenders at general practice, outpatient clinics, and emergency departments with a higher rate of hospital admission [7], consequently creating a significant burden on the healthcare system. Combined clinics utilising clinicians from different backgrounds (e.g., liaison psychiatry, health psychology) are a unique way to address the complex needs of patients presenting with physical and psychological symptoms. This approach has been well illustrated by psychodermatology, which provides a combined approach to skin disease (including vulval conditions) with psychological impact. Clinics commonly follow a consultation model that includes a dermatologist, psychiatrist, and psychologist to adequately address patient concerns. The service model for these services has also been shown to be a more cost‐effective may of meeting the needs of patients with complex conditions [8,9]. Similarly, specialised vulval clinics that utilise a multidisciplinary approach (with dermatologists, gynaecologists, and psychologists) are also well placed to treat the psychological sequalae of vulval disease. As with all psychological reactions to physical illness, several factors contribute to the nature of the psychological response. Psychological distress is not necessarily related to the severity of the condition; for example, mild disease can have a large psychological impact [10]. It is important to consider not only the patient’s reaction to the diagnosis, but also that of their family and close contacts, an important perspective that can be easily missed. The link between physical and psychological symptoms is a complex one. Even when the association seem understandable, causality is not always straightforward. A physical condition can present with psychiatric symptoms (such as when a diagnosis of cancer leads to severe depression), or a primary psychiatric condition can present with medical symptoms (such as panic attacks manifesting as chest pain). In other cases, medical and psychiatric disorders can present together, as in functional somatic complaints or medically unexplained symptoms. The term psychosomatic is applied when psychological conflict, stress, or complex personality traits are thought to be implicated in the aetiology of the disease. There is a definite link between stress and physical disease. The effect of the brain on the skin is mediated by the HPA axis, a neuroendocrine system activated by stressors to up‐ or dysregulate inflammatory pathways and cellular processes to cause or exacerbate skin disease. Stress also activates the autonomic nervous system and, together with HPA axis activation, interacts with the immune system and skin barrier to initiate and maintain chronic inflammation [11,12]. As well as a central HPA axis for the body, there is a peripheral HPA axis in the skin. The skin reacts to psychological stress and external stressors, such as humidity, temperature, pH, changes in the skin microbiome, and skin injury, to produce similar circulating hormones to the central HPA axis [12,13]. When applied to the skin, the central and peripheral pathways affected by stress can collectively drive cutaneous and neurogenic inflammation to cause signs and symptoms of skin disease (e.g., impaired skin barrier function, disruption of wound healing, and increased susceptibility to infection) [12–16]. It is therefore important to consider patients as individuals with different vulnerabilities to stress, and tailor their management to achieve optimal outcomes for both their skin and psyche. The vulva is an organ of sexual function and feminine identity. Disorders that affect the vulva can therefore not only give rise to distressing physical symptoms and visible signs but can also impact sexual identity and function. This can therefore have significant effects on both self‐esteem and intimate relationships. Psychological distress can be heightened in the setting of vulval disease, as in contrast to other cutaneous disorders, which are easily visible to others, the genital area is one of the body sites that is ‘hidden’ but regarded as highly intimate. Women seeking help for vulval complaints, regardless of the aetiology, may also present with symptoms of anxiety, depression, and sexual dysfunction. The severity of the psychological symptoms does not necessarily correlate with the severity of the clinical problem, and women have often been dissatisfied with their previous care. Outcomes for such patients have been shown to improve after attendance at specialist vulval clinics [17,18]. There are multiple factors that can all play a part in how a woman responds to a diagnosis and its treatment. When assessing the psychological impact of a disease, the factors detailed in in Table 48.1 should be considered. Depression is recognised as the leading cause of disability in the world by the World Health Organisation [19]. Depression and anxiety, which often occur together, are the commonest psychiatric conditions seen in any medical setting. However, depression is still underdiagnosed and undertreated [20]. In the context of chronic disease, up to one third of people can suffer from clinical depression. Illnesses that affect the brain, such as multiple sclerosis, Parkinson’s disease, and stroke, are particularly associated with depression. Minor degrees of depression and anxiety are a normal reaction to illness or other life event. If severe, the symptoms can be part of a depressive, anxiety, post‐traumatic stress, or obsessive‐compulsive disorder. A common assumption is that it is understandable for a person to develop depression because of certain events such as cancer, particularly if they are young. This can be rationalised by thinking that ‘anyone would be depressed in those circumstances’. However, these symptoms may need treatment regardless of the understandable reaction, especially if they are severe and persistent. A useful and widely used screening tool for depression is the Beck’s Depression Inventory. This is a 21‐item questionnaire completed by the patient to evaluate the symptoms of depression [21]. In situations of diagnostic uncertainty, an objective measure of depression can direct further management. Once a diagnosis is established, effective treatment of depression can often improve emotional and social function, increase quality of life, and help with physical symptoms. Table 48.1 Factors that can influence the psychological impact in a patient with vulval disease. Clinical depression has features in several domains, and ranges from mild to severe. Psychotic features such as delusions and hallucinations are rare. Perhaps the most important feature, which distinguishes depression from just being upset, is the lack of adaptation to the situation and the persistence of symptoms for several weeks. It is not always clear whether anxiety and depression are consequent or coexistent with a physical diagnosis. Mood disorders can also be complicated by deleterious coping mechanisms that can compromise health such as smoking, taking recreational or prescribed drugs, and increased alcohol intake. Alcohol can be used to modulate feelings of anxiety and depression, but may make the problems worse. The association between pain and depression is particularly important, although again cause and effect is not always clear. Chronic pain, such as vulvodynia, may lead to depression and anxiety, and conversely mood changes can cause pain to worsen, so both the physical and psychological aspects need to be addressed [22,23]. Depression and anxiety are also more prevalent in those with genitourinary syndrome of the menopause and dyspareunia [24]. Severe depression can lead to ideas of deliberate self‐harm and consequent attempted or completed suicide. Suicidal intentions are not normally a reaction to physical illness and can be associated with many other psychiatric or psychological problems. It is important to ask about these thoughts directly, and there is no evidence that asking the question will make the patient more likely to act. If suicidal thoughts are identified as being present, then this allows active intervention and urgent psychiatric referral to prevent harm. Effective treatment for depression will lead to improved mood and fading of suicidal ideation. In the context of terminal illness, suicidal thoughts may be an expression of fear [25], and careful discussion about symptom control can alleviate this. Anxiety describes feelings of unease or worry which may be entirely appropriate and are adaptive reactions that assist problem‐solving. It is only when they become excessive, inappropriate, and difficult to control that they are disabling. These persistent worries do not respond to reassurance or may only do so for a limited period. Anxiety disorders include a range of psychiatric conditions and are characterised by clinically significant levels of worry, apprehension, or panic that occur in the absence of, or out of proportion to, specific causes that are normally associated with such feelings [26]. The physical symptoms associated with anxiety occur with activation of the autonomic system. Common symptoms are sweating, dizziness, and shortness of breath, or more generalised somatic complaints, such as insomnia, restlessness, and muscle aches. A validated and widely used tool for measuring the severity of anxiety symptoms is the Hamilton Anxiety Rating Scale [27]. This 14‐item scale includes measurement of both psychological and somatic symptoms of anxiety. Like depression, anxiety is a normal reaction but can be part of a psychiatric disorder. It is the principal feature of generalised anxiety disorder, characterised by persistent symptoms that are not restricted to a particular situation and accompanied by motor and autonomic overactivity. Anxiety symptoms may also be prominent in panic disorder, agoraphobia, social phobia, obsessive‐compulsive disorders, and post‐traumatic stress disorders (PTSDs). PTSD is associated with recurrent intrusive thoughts or images of a previous traumatic experience, such as sexual assault or rape. In obsessive‐compulsive disorder, there are unwanted thoughts or images, recognised as one’s own, that are difficult to resist. Medical diagnoses, particularly in older patients, can also be associated with anxiety (e.g., neurological conditions, thyroid disorders, and cardiovascular disease), as can drug and alcohol abuse [28]. Psychotic disorders such as schizophrenia and bipolar affective disorder are relatively rare. Delirium is caused by localised or systemic pathology affecting brain function, such as severe infection, inflammation, or systemic disease. Medication such as steroids, recreational drugs, and alcohol withdrawal can also cause delirium. If the underlying cause is treated, the problem should resolve. Psychotic symptoms, such as delusions and hallucinations, may also be associated with delirium, and this is then referred to as acute brain syndrome or confusional state. Women with psychosis may have sexual hallucinations, but these rarely occur in isolation. Delusions and hallucinations are not amenable to rational argument, and the patient refuses to accept explanations that are offered to account for the problem. In the context of vulval disease, patients can present with a fixed belief of infestation of the vulva/vagina (otherwise known as delusional infestation).
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Psychological Aspects of Vulval Disorders
The hypothalamic‐pituitary‐adrenal (HPA) axis
Psychological symptoms and the vulva
Psychiatric presentations
Depression
Previous psychiatric disorders These can impact how the patient copes with the diagnosis; they may also be taking medication for a psychiatric diagnosis that can adversely impact vulval skin (e.g., tricyclic antidepressants can cause mucosal dryness).
Psychopathology Those prone to anxiety, depression, or obsessional tendencies (with or without a formal diagnosis) may react more negatively to their illness, particularly as they are more vulnerable and there may be additional concerns about loss of control or independence, the trajectory of disease, and hypochondria.
Experience of a disease affecting her or her family This will influence her expectations of the current episode. There may be concerns about disease progression, recurrence, or the possibility of malignant change.
Influence of social media Although social media can be helpful about raising awareness of conditions and provide informal support through patient networks, patients can get a negative and pessimistic idea of disease based on other women’s experiences.
Severity of illness It is important to assess both the severity of the condition and the impact on the patient and significant others. Both physical symptoms and the quality of life (including effect on activities of daily living, relationships, sexual activity, ability to work/study, participation in leisure and social activities) are vital to this. The clinician should also remember that the physical signs and symptoms of vulval disease do not always correlate with severity, and minimal physical signs can still cause significant psychological and physical symptoms.
Treatment required Evaluating patient expectations of current or future treatments as well as their previous experiences of treatment is a key factor in creating management plans that are acceptable to the patient. Accepting the burden of treatment can be difficult for some women, especially if their experiences or expectations do not align with the assessment made by the healthcare professional.
Social support The level of support, or indeed the lack of it, from partners or other family members and friends will influence the woman’s ability to adjust to her illness.
Healthcare professional’s attitude Sympathetic physical examination and discussion of the diagnosis and treatment is essential to minimise concerns.
Information Giving the correct information early during the patient journey is vital to be able to reassure and guide the patient in appropriate management of their vulval disease.
Anxiety
Psychotic illnesses, delirium, and drug‐induced states
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