Most health care professionals these days will at least pay lip service to the theory that the mind-body connection exists and has an ongoing impact on virtually all forms of illness and states of well-being.
But when it gets down to practical considerations, this academic awareness may get lost in the shuffle.
There is growing evidence that in the area of women's health, there is still too little attention being paid to the effects of psychological or psychosocial events.
Indeed, according to Dr. Leslie Hartley Gise, a psychiatrist and director of the premenstrual syndrome (PMS) program at the Mount Sinai Medical Center in New York, "basically, the obstetricians are not recognizing psychological dysfunction, and when they do, they are not instructed or equipped to prescribe treatment."
At a special course on "Women's Psychobiology: The Ob-Gyn Interface" conducted during last month's meeting of the American Psychiatric Association, Gise, a specialist on the psychological implications of pregnancy, estimated that young physicians studying obstetrics-gynecology at most medical centers are "unlikely to spend more than 15 minutes at a time with a psychiatric resident.
"That means," she said, "that in all the years of training, the average [obstetrician] never sees a psychiatrist except for a few hours during the entire ob-gyn residency. We were shocked when we considered it that way. There is so little mental health training -- in sensitivity, in awareness."
The woman's "sexual reproductive organs are, more than any other organ system, emotionally charged, existentially inherent to a woman's identity and destiny," said Dr. Elisabeth Herz.
"Therefore," she said, "any dysfunction, disease or loss will by nature have a profound [emotional] impact.
"But it is equally true that psychological stressors can influence and cause their physical malfunction. This circular interrelationship makes it often impossible to distinguish between cause and effect, because effect can become cause."
"For example," she said, "premenstrual syndrome is aggravated by stress -- and PMS also makes it harder to deal with stress, which closes the vicious circle."
On top of all that, she noted, there are the newly confirmed links between reproductive hormones and the chemicals of the brain, which in turn affect behavior, perception and, often, reproductive functioning.
Therefore, said Herz, "it is not only the emotionally charged meaning of the sexual reproductive organs, but also the physiological [effects] which are interlinked."
Herz, who is both a psychiatrist and an obstetrician-gynecologist, teaches a course on the interrelationship of the two fields to ob-gyn residents at the George Washington University Medical Center. It is one of the few such courses in any medical center in this country and prompted Leslie Hartley Gise to note at the APA session that "if every program were like Dr. Herz's, I wouldn't have to make this speech."
The APA course, sponsored by the Institute for Research on Women's Health, concentrated on life events and times when a woman might be especially vulnerable to psychiatric problems.
These included PMS, pregnancies -- planned and unplanned -- abortions, miscarriages, infertility, postpartum problems and menopause or hysterectomy.
Speakers also reminded therapists that men, too, are affected by hormonal upsets, and emphasized to researchers the need to consider sex differences when testing new drugs, especially those that purport to change mood. Their method of activity, some studies have suggested, may be altered in significantly different ways by male or female hormones.
One of the most neglected of the psychologically important events in a woman's life is the miscarriage. For decades, obstetricians have "comforted" a woman with an assurance that she can "always have another." Many still do so today.
And despite the well-documented fact -- referred to by both Herz and Gise -- that miscarriages or stillbirths can trigger the failure of a marriage, only recently has there been the recognition of some of the psychological and psychosocial factors that cause it. It is a classic example of the new recognition of the overlap between medicine and psychiatry, between body and mind.
"Miscarriage," said Herz, "is too often underestimated by those who care for the woman, and by society at large. Lacking support, the woman will find it even harder to work through her painful loss, and it is not infrequent that [psychological and personal] problems remain unresolved.
"The therapist who works with a woman or a couple after a pregnancy loss needs to be aware of the pattern of the grieving process and the features which are unique to it," she said. "Moreover, it is almost a rule that each partner goes through the grief process in a different way, at a different pace, with varying defenses and needs."
"To the woman," said Herz, there is a perception of "inadequacy, frustration and helplessness. Lack of control, envy of successfully pregnant women, fears of losing her husband to a more fertile woman and anxiety about the outcome of her next pregnancy are frequently recurring feelings concomitant with the grief and complicate its resolution.
"As much as the prospective father might want to have a child, he cannot always experience the emotional attachment, however strongly he feels the loss.
"He wants to get the experience behind him and move on. So . . . each of the partners goes through the grief process differently.
"A happy marriage usually pulls closer together during the immediate period, but the grieving process is stressful for many, aggravating preexisting problems, and creating new ones. Each partner's own needs can interfere with the response to the needs of the other. But what helps one partner to cope is expected by him or her to help the other partner as well. Needs are not always directly expressed and resentment builds up when one partner fails to respond. Frequently the woman wants to talk about her feelings over and over again, craves compassion and emotional sharing, looks for reassurance from her partner, and restoration of her diminished sense of self worth and above all needs confirmation of his continued love for her.
"He, on the other hand, would often resist dwelling on the painful memories.
"He may also feel it would be an additional burden to her to focus on his own disappointment. At other times he resents the attention focused on her by friends and family. Often he will withdraw when she doesn't respond favorably to distractions he offers. His lack of emotional expression makes her feel that he was not equally interested in the child. She resents that he seems to get over this grief so easily, and feels that he lacks understanding of what she is going through.
"The more she becomes resentful, the more she withdraws, and the isolation makes her depression worse or the resentment leads to angry outbursts, accusations and destructive arguments that separate them even more.
"His feelings of helplessness to alleviate her depression leads to frustration and anger, and he often withdraws to work, sports or other distractions and avoids her and the steady diet of painful memories."
The need for therapy in these cases may be of crisis proportions. Herz has had many such patients and noted that studies show that these cases -- patients suffering from what the specialists call "habitual abortions" benefit from "more conventional therapeutic work of longer duration." One study showed that in 19 such patients in therapy (matched against a number who had no therapy), the results showed an 84 percent live birth rate for those in therapy as compared with 26 percent for the others.
"Clearly," said Herz, "this is not a scientific proof of the efficacy of therapy in habitual abortion, but in the final analysis, it is the baby in the happy mother's arms that counts."