Sexual Medicine and Medical Collaboration · Dual Formulation

Both Can Be True

Three presentations, two panels each. One medical contributor to screen for, one psychological contributor that belongs in the formulation, and the recognition that choosing between them is the error.

What this exercise practises

Holding a physiological hypothesis and a psychological one at the same time, and distinguishing the psychological contributor that is driving the presentation from the one that is a consequence of it.

Both panels contain plausible wrong answers. The medical panel is discriminated by age and anatomy; the psychological panel is discriminated by sequence, because the contributor that most resembles the presenting problem is usually the one downstream of it.

Estimated time to complete this exercise: 20 minutes

1Presentation one
2Presentation two
3Presentation three
4Sequencing
5Close

Before you begin

How this one works

Three presentations. For each one you make two selections: one medical contributor you would screen for, and one psychological or relational contributor that belongs in the formulation.
Both panels contain plausible wrong answers. In the medical panel they are the wrong condition for the age or the anatomy. In the psychological panel they are the contributor that is real but secondary.
The point of the exercise is the pairing rather than either half of it. You cannot continue until you have chosen from both panels.
Nothing is graded and nothing is recorded. Reloading starts it again.

Clients presenting with pain, dryness, discomfort or avoidance of sexual activity often carry psychological explanations for their symptoms, either self-generated or attributed by previous providers, when structural, dermatological, hormonal or infectious conditions are present. The explanation they carry is usually not wrong. It is incomplete, and it is the half that keeps the other half from being looked for.

References

  1. Bornstein, J., Goldstein, A. T., Stockdale, C. K., Bergeron, S., Pukall, C., Zolnoun, D., & Coady, D. (2016). 2015 ISSVD, ISSWSH, and IPPS consensus terminology and classification of persistent vulvar pain and vulvodynia. Obstetrics & Gynecology, 127(4), 745–751. https://doi.org/10.1097/AOG.0000000000001359
  2. Harlow, B. L., Kunitz, C. G., Nguyen, R. H. N., Rydell, S. A., Turner, R. M., & MacLehose, R. F. (2014). Prevalence of symptoms consistent with a diagnosis of vulvodynia: Population-based estimates from 2 geographic regions. American Journal of Obstetrics and Gynecology, 210(1), 40.e1–40.e8. https://doi.org/10.1016/j.ajog.2013.09.033
  3. Harlow, B. L., & Stewart, E. G. (2003). A population-based assessment of chronic unexplained vulvar pain: Have we underestimated the prevalence of vulvodynia? Journal of the American Medical Women's Association, 58(2), 82–88.
  4. Kirtschig, G. (2016). Lichen sclerosus: Presentation, diagnosis and management. Deutsches Ärzteblatt International, 113(19), 337–343. https://doi.org/10.3238/arztebl.2016.0337
  5. Portman, D. J., & Gass, M. L. S. (2014). Genitourinary syndrome of menopause: New terminology for vulvovaginal atrophy from the International Society for the Study of Women's Sexual Health and the North American Menopause Society. Menopause, 21(10), 1063–1068. https://doi.org/10.1097/GME.0000000000000329
  6. Pukall, C. F., Goldstein, A. T., Bergeron, S., Foster, D., Stein, A., Kellogg-Spadt, S., & Bachmann, G. (2016). Vulvodynia: Definition, prevalence, impact, and pathophysiological factors. The Journal of Sexual Medicine, 13(3), 291–304. https://doi.org/10.1016/j.jsxm.2015.12.021
  7. Sobel, J. D. (2016). Recurrent vulvovaginal candidiasis. American Journal of Obstetrics and Gynecology, 214(1), 15–21. https://doi.org/10.1016/j.ajog.2015.06.067
  8. The North American Menopause Society. (2020). The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause, 27(9), 976–992. https://doi.org/10.1097/GME.0000000000001609