Acute and Post-traumatic Stress Disorder After Spontaneous Abortion

Am Fam Physician. 2000 Mar 15;61(6):1689-1696.

ACF  This article exemplifies the AAFP 2000 Annual Clinical Focus on mental health.

When a spontaneous abortion is followed by complicated bereavement, the primary care physician may not consider the diagnosis of acute stress disorder or post-traumatic stress disorder. The major difference between these two conditions is that, in acute stress disorder, symptoms such as dissociation, reliving the trauma, avoiding stimuli associated with the trauma and increased arousal are present for at least two days but not longer than four weeks. When the symptoms persist beyond four weeks, the patient may have post-traumatic stress disorder. The symptoms of distress response after spontaneous abortion include psychologic, physical, cognitive and behavioral effects; however, patients with distress response after spontaneous abortion often do not meet the criteria for acute or post-traumatic stress disorder. After spontaneous abortion, as many as 10 percent of women may have acute stress disorder and up to 1 percent may have post-traumatic stress disorder. Critical incident stress debriefing, which may be administered by trained family physicians or mental health practitioners, may help patients who are having a stress disorder after a spontaneous abortion.

Pregnancy is usually considered a special time in a woman's life. Hopes for the future, a sense of fulfillment as a woman, early bonding to the unborn child,1 and the expectations of one's partner and family, are factors that contribute to a complex emotional response to pregnancy. The meaning attached to a pregnancy may assume extraordinary importance for a woman. Besides validating femininity, having a child may be seen as the only way to save a marriage, to please a parent, to make amends for previous “sins” (such as an earlier induced abortion) or even to “replace” a child who has died. A couple struggling with infertility may have an even greater emotional (as well as financial) investment in a pregnancy. Thus, a spontaneous abortion can be extremely stressful for the mother, father, family, physician and others in the social support system.

Spontaneous abortion, or miscarriage, is the naturally occurring “delivery or loss of the products of conception before the 20th week of pregnancy … without induction or instrumentation.”2 Spontaneous abortion occurs in 12 to 24 percent of pregnancies,3,4 leading to an estimated 600,000 to 800,000 spontaneous abortions annually in the United States.5 Although only sparse scientific literature is available on conditions related to fetal loss, such as depression, anxiety and prolonged grief, clinicians6-9 report that, for some women, a miscarriage can be a traumatizing event. Some authors have called for greater attention to the evaluation and treatment of psychologic sequelae after spontaneous abortion.10,11

Acute Stress Disorder and Post-traumatic Stress Disorder

In the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV), acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) are described as consequences of exposure to an extremely traumatic event that arouses intense negative emotions in the person involved.12  Diagnostic criteria for ASD and PTSD include dissociative symptoms, reexperiencing of the trauma, avoidance of stimuli associated with the trauma and increased arousal. These symptoms impair psychologic, social and occupational functioning. The major distinction between the two disorders is that, in ASD, these symptoms are present for at least two days but not longer than four weeks. If the symptoms persist beyond four weeks, a diagnosis of PTSD should be considered (Tables 1 and 2).12

TABLE 1

Diagnostic Criteria for Acute Stress Disorder

A. The person has been exposed to a traumatic event in which both of the following were present:

1. The person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.

2. The person's response involved intense fear, helplessness or horror.

B. Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:

1. A subjective sense of numbing, detachment or absence of emotional responsiveness.

2. A reduction in awareness of his or her surroundings (e.g., “being in a daze”).

3. Derealization.

4. Depersonalization.

5. Dissociative amnesia (i.e., inability to recall an important aspect of the trauma).

C. The traumatic event is persistently reexperienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event.

D. Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people).

E. Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness).

F. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning or impairs the individual's ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.

G. The disturbance lasts for a minimum of two days and a maximum of four weeks and occurs within four weeks of the traumatic event.

H. The disturbance is not due to the direct physiologic effects of a substance (i.e., a drug of abuse, a medication) or a general medical condition, is not better accounted for by brief psychotic disorder and is not merely an exacerbation of a preexisting axis I or axis II disorder.


Reprinted with permission from American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed. Washington, D.C.: American Psychiatric Association, 1994:431–2. Copyright 1994.

TABLE 1   Diagnostic Criteria for Acute Stress Disorder

View Table

TABLE 1

Diagnostic Criteria for Acute Stress Disorder

A. The person has been exposed to a traumatic event in which both of the following were present:

1. The person experienced, witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.

2. The person's response involved intense fear, helplessness or horror.

B. Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:

1. A subjective sense of numbing, detachment or absence of emotional responsiveness.

2. A reduction in awareness of his or her surroundings (e.g., “being in a daze”).

3. Derealization.

4. Depersonalization.

5. Dissociative amnesia (i.e., inability to recall an important aspect of the trauma).

C. The traumatic event is persistently reexperienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event.

D. Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people).

E. Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness).

F. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning or impairs the individual's ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.

G. The disturbance lasts for a minimum of two days and a maximum of four weeks and occurs within four weeks of the traumatic event.

H. The disturbance is not due to the direct physiologic effects of a substance (i.e., a drug of abuse, a medication) or a general medical condition, is not better accounted for by brief psychotic disorder and is not merely an exacerbation of a preexisting axis I or axis II disorder.


Reprinted with permission from American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed. Washington, D.C.: American Psychiatric Association, 1994:431–2. Copyright 1994.

TABLE 2
Diagnostic Criteria for Post-traumatic Stress Disorder

The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication.

Research is needed to accurately quantify the extent to which the diagnostic criteria for ASD and PTSD are applicable to women who have had a miscarriage. Such data could also be used to determine whether particular predisposing factors (such as the meaning and importance a woman attaches to her pregnancy) can predict which women are most likely to develop ASD or PTSD. A history of childhood abuse,13 previous trauma14 or severe trauma15 may be associated with increased vulnerability to PTSD. Conversely, strong social support has been found to reduce later psychologic symptoms in women who have had induced abortions.16

Anecdotal evidence suggests that up to 10 percent of women meet criteria for ASD within one month of having a spontaneous abortion and that up to 1 percent meet the criteria for PTSD four weeks after the event. Only one research study17 in the medical literature concerns the relationship between spontaneous abortion and PTSD. No published studies have examined the association between spontaneous abortion and ASD. Nevertheless, family physicians should be alert to the potential for severe emotional distress in women following a miscarriage.

Illustrative Case

A 23-year-old woman (gravida 1, para 0, aborta 1) who had a spontaneous abortion at 12 weeks' gestation reported a three-week history of feeling “numb and dazed” and emotionally unresponsive. She described frequently being in a dreamlike state in which things did not seem real. On careful questioning, she was unable to recall several aspects of her miscarriage. She was upset about reliving the experience over and over in her mind. She had difficulty falling asleep and was often troubled by nightmares about the miscarriage.

Being present in medical facilities caused intense distress. The patient noted that her job performance had diminished, and she had become irritable at home and at work. She had usually enjoyed reading but now found it hard to concentrate. She was hypersensitive to sounds while trying to concentrate. In fact, she was startled so violently by loud sounds that her husband and coworkers had asked her what was wrong, to which she replied, “I don't know.”

The patient had no other medical problems and took no medications. She denied drug, alcohol or tobacco use. Findings on physical examination were normal except for mild tachycardia and excessive perspiring, consistent with anxiety.

Sequelae of Spontaneous Abortion

Health care workers began to describe the trauma of perinatal loss during the 1970s.18 Many anecdotal reports and theoretic and research articles have been published on the psychologic effects of spontaneous abortion. These have generally focused on aspects of the grief response,9,18,19 depression6,7,20 and anxiety.8,21

The number and variety of distress-response symptoms described in the literature on spontaneous abortion can be grouped into four domains: psychologic, emotional, physical, cognitive and behavioral (Table 3).18 Grief-related behaviors closely match the criteria for the diagnosis of ASD or PTSD. Indeed, the similarities between descriptions of bereavement in spontaneous abortion and those of ASD or PTSD after spontaneous abortion are often striking and only distinguishable by careful review of the diagnostic criteria in the DSM-IV.

TABLE 3

Four Domains of Spontaneous Abortion Symptoms

Emotions/feeling states

Shock*

Numbness†

Guilt†

Anger*‡

Anxiety‡

Depression

Self-blame*

Derealization*§

Depersonalization*§

Isolation*§

Physical symptoms

Empty feeling inside stomach*

Tightness in chest or throat*

Shortness of breath*

Weakness/fatigue*

Sweating*‡

Cognitive effects

Intrusive thoughts about fetus*

Hallucinations of a baby's cry/visual images of baby*

Phantom fetal movement†

Difficulty with concentration and decision making‡

Fantasies about fetus†

Dissociative amnesia†§

Diminished situational awareness†

Behaviors

Difficulty sleeping (nightmares)*‡

Loss of appetite

Social withdrawal§

Substance abuse/use§

Avoiding medical facilities/personnel, pregnant women, children, etc., to prevent reliving the event*§

Impaired social and occupational functioning ∥


The symbols denote the criteria areas of acute and post-traumatic stress disorder characteristics:

*—Reexperiencing the trauma.

†—Dissociative symptoms.

‡—Increased arousal.

§—Avoidance of trauma-producing stimuli.

∥—Poor social and occupational functioning.

Adapted with permission from Moscarello R. Perinatal bereavement support service: three-year review. J Palliat Care 1989;5:14.

TABLE 3   Four Domains of Spontaneous Abortion Symptoms

View Table

TABLE 3

Four Domains of Spontaneous Abortion Symptoms

Emotions/feeling states

Shock*

Numbness†

Guilt†

Anger*‡

Anxiety‡

Depression

Self-blame*

Derealization*§

Depersonalization*§

Isolation*§

Physical symptoms

Empty feeling inside stomach*

Tightness in chest or throat*

Shortness of breath*

Weakness/fatigue*

Sweating*‡

Cognitive effects

Intrusive thoughts about fetus*

Hallucinations of a baby's cry/visual images of baby*

Phantom fetal movement†

Difficulty with concentration and decision making‡

Fantasies about fetus†

Dissociative amnesia†§

Diminished situational awareness†

Behaviors

Difficulty sleeping (nightmares)*‡

Loss of appetite

Social withdrawal§

Substance abuse/use§

Avoiding medical facilities/personnel, pregnant women, children, etc., to prevent reliving the event*§

Impaired social and occupational functioning ∥


The symbols denote the criteria areas of acute and post-traumatic stress disorder characteristics:

*—Reexperiencing the trauma.

†—Dissociative symptoms.

‡—Increased arousal.

§—Avoidance of trauma-producing stimuli.

∥—Poor social and occupational functioning.

Adapted with permission from Moscarello R. Perinatal bereavement support service: three-year review. J Palliat Care 1989;5:14.

Treatment Considerations

Most of the research on ASD and PTSD, especially that on PTSD, has come from studies of veterans of the Vietnam war who were in heavy combat. It was gradually recognized that other traumatic experiences, such as violent crimes, motor vehicle crashes or natural disasters and, more recently, medical conditions such as breast cancer,22,23 could induce similar trauma-response symptoms. Although spontaneous abortion may not seem to be in the same category of traumatic experience, some women are extremely vulnerable in this area and have great difficulty recovering from the loss of their hoped-for baby.

Promptly referring patients with ASD/PTSD symptoms for trauma-related treatment when indicated gives them the best possible chance for early recovery. Critical incident stress debriefing (CISD) has resulted in fewer long-term PTSD symptoms.24 Other researchers25  have not found the same effectiveness after using a debriefing technique. The CISD model (Table 4)26 was developed to accelerate recovery in persons who have normal reactions to abnormal events,27 as some women do after spontaneous abortion. Although we intuitively expect early intervention after spontaneous abortion to hasten the healing process, outcome research is needed to support this assumption.

TABLE 4

Stages of the Critical Incident Stress Debriefing Process

Stage Phase Description

1

Introduction

Explains process, sets expectations

2

Fact

Patient describes traumatic event from a cognitive level

3

Thought

Allows patient to describe cognitive reactions and to make the transition to emotional reactions

4

Reaction

Identifies the most traumatic aspect of the event for the patient and emotional reactions

5

Symptom

Identifies personal symptoms of distress and transfers back to cognitive level

6

Teaching

Educates about normal reactions and adaptive coping mechanisms, i.e., stress management

7

Reentry

Clarifies ambiguities and prepares for termination


Adapted with permission from Mitchell JT, Everly GS. Critical incident stress debriefing. Ellicot, Md.: Chevron, 1995.

TABLE 4   Stages of the Critical Incident Stress Debriefing Process

View Table

TABLE 4

Stages of the Critical Incident Stress Debriefing Process

Stage Phase Description

1

Introduction

Explains process, sets expectations

2

Fact

Patient describes traumatic event from a cognitive level

3

Thought

Allows patient to describe cognitive reactions and to make the transition to emotional reactions

4

Reaction

Identifies the most traumatic aspect of the event for the patient and emotional reactions

5

Symptom

Identifies personal symptoms of distress and transfers back to cognitive level

6

Teaching

Educates about normal reactions and adaptive coping mechanisms, i.e., stress management

7

Reentry

Clarifies ambiguities and prepares for termination


Adapted with permission from Mitchell JT, Everly GS. Critical incident stress debriefing. Ellicot, Md.: Chevron, 1995.

Most women who have a miscarriage deal with their grief through the reassurance of their family and the support of their physician. For some women, there is another important dimension to their response that must not be missed. That is the traumatic element—the fact that occasionally the loss of an unborn child is perceived as an unbearable, life-altering and never-to-be-recovered-from personal catastrophe. The physician working with a woman who has such feelings needs to see her response not as bizarre or exaggerated but as qualitatively different. Some women with these perceptions meet the criteria for ASD and, eventually, PTSD. For them, a different treatment model is needed, such as that used with other trauma victims. For these patients, the best course of treatment is through the intervention of a physician trained in CISD or referral to a similarly trained mental health care provider.

Symptoms of ASD are often viewed as normal reactions to trauma. However, when an increased severity of symptoms and impairment is noted, clinical interventions of the type used in PTSD may be necessary for ASD as well.28 Such interventions may provide a better model than is currently used to treat a woman's emotional distress after spontaneous abortion. Trauma-focused interventions can help such patients to achieve a better understanding of the event, recognize and accept the loss as a traumatic experience and successfully go on with their lives.

Table 5 lists treatment principles and practical suggestions for patients with ASD or PTSD.

TABLE 5

Principles and Practical Tips for the Management of Spontaneous Abortions

Discuss the miscarriage with the parents in a private and comfortable setting. Saying “I'm sorry about the loss” or holding the patient's hand can be helpful.

If the fetus has been named, use the name while talking to the parents to personalize the mourning process.

Offer an ultrasound picture if available.

Discuss the option of seeing the fetus (usually done at 15 weeks or more).

Discuss the option of a memorial service or funeral.

Discuss with both parents the facts about the situation. Inquire about the mother's thoughts and emotions regarding the loss, and educate the parents about any physical and emotional symptoms they may experience. If acute stress disorder is suspected, trained physicians can take the patient through the debriefing process described in Table 4. If the patient desires further support, refer her to a psychologist or a grief counselor.

The father often shows less emotion than the mother and may be torn between supporting the mother and struggling with his own grief. The best approach may be simply to ask the father if he has any questions or if there is anything you can do to help.

When there are other children in the family, advise the parents to discuss the loss with them honestly and openly. Although the children may not grasp the full significance of what has happened, this approach lays the groundwork for openness in future communication.

Some patients will not experience the effects of the miscarriage until after leaving the hospital. Schedule the next appointment or make a follow-up phone call within a week to assess the patient's situation. Refer for follow-up counseling if patient's emotional state is not improving after a month. Consider providing a follow-up call at the one-year anniversary for patients who experienced post-traumatic stress disorder after their loss.

TABLE 5   Principles and Practical Tips for the Management of Spontaneous Abortions

View Table

TABLE 5

Principles and Practical Tips for the Management of Spontaneous Abortions

Discuss the miscarriage with the parents in a private and comfortable setting. Saying “I'm sorry about the loss” or holding the patient's hand can be helpful.

If the fetus has been named, use the name while talking to the parents to personalize the mourning process.

Offer an ultrasound picture if available.

Discuss the option of seeing the fetus (usually done at 15 weeks or more).

Discuss the option of a memorial service or funeral.

Discuss with both parents the facts about the situation. Inquire about the mother's thoughts and emotions regarding the loss, and educate the parents about any physical and emotional symptoms they may experience. If acute stress disorder is suspected, trained physicians can take the patient through the debriefing process described in Table 4. If the patient desires further support, refer her to a psychologist or a grief counselor.

The father often shows less emotion than the mother and may be torn between supporting the mother and struggling with his own grief. The best approach may be simply to ask the father if he has any questions or if there is anything you can do to help.

When there are other children in the family, advise the parents to discuss the loss with them honestly and openly. Although the children may not grasp the full significance of what has happened, this approach lays the groundwork for openness in future communication.

Some patients will not experience the effects of the miscarriage until after leaving the hospital. Schedule the next appointment or make a follow-up phone call within a week to assess the patient's situation. Refer for follow-up counseling if patient's emotional state is not improving after a month. Consider providing a follow-up call at the one-year anniversary for patients who experienced post-traumatic stress disorder after their loss.

The Authors

STEPHEN V. BOWLES, MAJ, MC, USA, is director of USAREC Command Psychologic Operations at the United States Army Soldier Support Institute, Fort Jackson, S.C., and assistant professor of psychiatry at the Medical College of Georgia, Augusta.

LARRY C. JAMES, LTC, MS, USA, is assistant chief of psychology of the adult outpatient service at Walter Reed Army Medical Center, Washington, D.C.

DIANE S. SOLURSH, PH.D., is associate professor of psychiatry and health behavior at the Medical College of Georgia.

MICHAEL K. YANCEY, LTC, MC, USA, is director of perinatal services and the obstetrics and gynecology residency program at Tripler Army Medical Center, Honolulu, Hawaii.

TED D. EPPERLY, COL, MC, USA, is chair of the Department of Family and Community Medicine and director of primary care at Eisenhower Army Medical Center, Fort Gordon, Ga.

RAYMOND A. FOLEN, PH.D., is chief of behavioral medicine and health psychology service at Tripler Army Medical Center.

MARYANN MASONE, CPT, MC, USA, is chief resident in obstetrics and gynecology at Tripler Army Medical Center.

Address correspondence to MAJ Stephen V. Bowles, U.S. Army Soldier Support Institute, RRS, 10000 Hampton Pakway, Fort Jackson, SC 29205 (e-mail: Bowless@Jackson.ARMY.MIL). Reprints are not available from the authors.

The opinions expressed in this article reflect the views of the authors and do not reflect the opinion of the Department of the Army, the Department of Defense or the United States Government.

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