5.4 Working model
As was stated in the introduction of this paragraph PVD is a syndrome diagnosis. This idea was confirmed by the depicted pattern of risk factors, onset variables and pathological substrate. Although there is no clear nosological explanation available yet, there is proven pathology of the vestibulum. The problem with this kind of pathology however is that it can occur as a cause, preceding the disease, but also as a consequence of behavior. This ‘double position in time’ disturbs our normal clinical reasoning and is described as as vicious circle. In PVD a number of vicious circle patterns can be found:
PAIN → Fear/
Pelvic floor muscle hypertonia/
Elevated nerve density → PAIN
In terms of psychosomatic medicine none of these reactions are pathological in itself. Each phenomenon is a sound reaction to physical, psychological or social threat. Pain is a vital requirement for survival because it protects us from being harmed: nociception. However the reactions may become symptoms when they become too intense, too prolonged and or lead to harmful combinations. It is therefore impossible to predict PVD, there is no clear cause-effect relationship. However, when occurring in a certain patient it is a very well understandable phenomenon. Unfortunately this insight is no guarantee for effective treatment. On the contrary, if a reaction or symptom has or had a protective function, it is very difficult to get rid of it. Vicious circle patterns are hard to break, especially if one sticks to traditional clinical (i.c. linear) reasoning. The only way to resolve a ‘chicken-egg priority dilemma’ is symptom prevention by and with all bio-psycho-social means (see paragraph x). However, before starting treatment, PVD has to be diagnosed.