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Archives of Perinatal Medicine 18(3), 157-162, 2012
REVIEW PAPER
Acute stress disorder and posttraumatic stress disorder
following miscarriage
MAGDALENA MURLIKIEWICZ, PIOTR SIEROSZEWSKI
Abstract
The objective of this paper is to summarize the existing state of knowledge on relationship between early
pregnancy loss and acute stress disorder (ASD) and post-traumatic stress disorder (PTSD). Although, grief,
depression and anxiety symptoms as a result of miscarriage have been explored, this issue received little research
attention. Nevertheless, existing studies suggest that up to 28% of women experiencing early pregnancy loss meet
DSM-IV-TR criteria for acute stress disorder and in around 25% of those patients a diagnosis of posttraumatic
stress disorder should be considered. Factors such as former abuse history, reported attachment to the unborn
child, the feeling of personal responsibility for the loss as well as low educational level and high level of
neuroticism can be perceived as predictors of ASD/PTSD in this population. By contrast, high sense of coherence
and positive perception of received social support around and after the time of an event seem to protect women
from developing traumatic stress.
Key words: miscarriage, psychological morbidity, acute stress disorder, posttraumatic stress disorder
Psychological morbidity following miscarriage
Analysis of epidemiological data shows that among
the early reproductive failures spontaneous abortion,
a pregnancy loss before 22 weeks of gestation, is the
most common problem [1]. The frequency of spontaneous abortion in clinically recognized pregnancies is
estimated to be 10-24%, with most miscarriages occurring in the first trimester of pregnancy [1, 2]. In Poland
the number of spontaneous abortions in clinically recognized pregnancies is assessed to be over forty thousand
per year [2].
Miscarriage is infrequently considered to be a lifethreatening event for women and the medical procedures
involved are comparatively simple. This, however, may
obscure the psychological impact of early pregnancy loss,
making it more difficult for women to seek specialized
support and for medical professionals to properly
address their psychological needs. The very common
assumption that women are unlikely to have become
attached to their pregnancies in the initial stage resulted
in a very few studies investigating psychological
morbidity following miscarriage until the 1990s [3].
Nevertheless, in the past two decades there has been an
emerging indication that early pregnancy loss is related
to significant psychological consequences. It is estimated
that 48-51% of all women who experienced a spontaneous
abortion will suffer psychiatric morbidity [4].
Studies exploring this issue mostly concentrate on
grief, depression and anxiety reactions of women (rarely
of the couple’s reactions). It is reported that about 40%
of miscarrying women suffer from symptoms of grief
shortly after the event [1, 3, 5]. Grief intensity and duration are of comparable nature as observed after late and
perinatal death. However, features of grief that are unique to the loss of miscarriage can also be distinguished.
Some women may perceive themselves as a failure, not
being able to deliver a healthy baby and therefore may
question their feminine identity. Also, the loss of a baby
often means loss of plans and hopes for future life. The
fact that miscarriage is a form of loss not visible for
others and that there are no shared memories of a living
person makes it more complex for a woman to complete
the mourning process, which may result in disorders as:
reversed grief, delayed grief or low unchanged grief [4].
A variety of studies revealed that 20-55% of women
shortly after miscarriage experience elevated levels of
depressive symptoms [3]. It is 3.4 that among pregnant
women and 4.3 times that among community women
[6]. The rates of major depressive disorders following
miscarriage differs among studies from 10 to 51%, with
baseline rates quoted at 3-10% in the community [3, 4].
Elevated anxiety symptoms due to early pregnancy
loss are an issue receiving less research attention. It
was reported that 20-40% of women experience them
Department of Fetal Medicine and Gynecology, 1st Chair of Gynecology and Obstetrics, Medical University of Lodz, Łódź, Poland
158
M. Murlikiewicz, P. Sieroszewski
shortly after early pregnancy loss [3]. Geller et al. report
that 15.7% of women experienced one of the three
anxiety disorders (obsessive-compulsive disorder, panic
disorder and phobic disorder) in comparison to 10.9% in
the community group [7]. They found that early pregnancy loss increased risk for an initial or recurrent episode
of obsessive-compulsive disorder but it did not augmented risk for panic disorder or specific phobia (when
considered separately) [3, 7, 8]. Acute Stress Disorder
and Post-traumatic Stress Disorder have not been perceived as possible consequence and have not been investigated since 2000. The main objective of this paper is to
summarize the existing studies on ASD/PTSD and miscarriage and to outline the possible predictors for these
disorders in the population of women after a miscarriage.
Acute Stress Disorder and Post-traumatic Stress
Disorder – diagnostic criteria
The “text revision” fourth edition of Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV-TR)
defines ASD and PTSD as anxiety disorders that are
triggered by a traumatic event that arouses intense negative emotions in the person involved [9]. The nature
of ASD and PTSD is characterized by symptoms of re-experiencing, avoidance of reminders of the event, numbing and increased arousal. The main 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 continue beyond four
weeks, a diagnosis of PTSD should be taken into consideration. Tables 1 and 2 illustrate diagnostic criteria for
ASD and PTSD according to DSM-IV-TR.
Table 1. Diagnostic criteria for ASD according to DSM-IV-TR based on Wciórka J.
Kryteria diagnostyczne według DSM-IV-TR. 2008. Wrocław, Elsevier Urban&Partner
Criterion
Diagnostic criteria for 308.3 Acute Stress Disorder (DSM-IV-TR)
The person has been exposed to a traumatic event in which both of the following were present:
A
(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.
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,
B
(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 re-experienced 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 2 days and a maximum of 4 weeks and occurs within 4 weeks
of the traumatic event.
H
The disturbance is not due to the direct physiological effects of a substance (e.g. 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.
Acute stress disorder and posttraumatic stress disorder following miscarriage
159
Table 2. Diagnostic criteria for PTSD according to DSM-IV-TR based on Wciórka J. Kryteria diagnostyczne
według DSM-IV-TR. 2008. Wrocław, Elsevier Urban&Partner
Criterion
A
B
C
D
E
F
Diagnostic criteria for 309.81 Posttraumatic Stress Disorder (DSM-IV-TR)
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.
The traumatic event is persistently re-experienced in one (or more) of the following ways:
(1) recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions,
(2) recurrent distressing dreams of the event,
(3) acting or feeling as if the traumatic event were recurring (includes a sense of reliving the
experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on
awakening or when intoxicated),
(4) intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect
of the traumatic event,
(5) physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the
traumatic event.
Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present
before the trauma), as indicated by three (or more) of the following:
(1) efforts to avoid thoughts, feelings, or conversations associated with the trauma,
(2) efforts to avoid activities, places, or people that arouse recollections of the trauma,
(3) inability to recall an important aspect of the trauma,
(4) markedly diminished interest or participation in significant activities,
(5) feeling of detachment or estrangement from others,
(6) restricted range of affect (e.g. unable to have loving feelings),
(7) sense of a foreshortened future (e.g. does not expect to have a career, marriage, children, or a normal life
span).
Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the
following:
(1) difficulty falling or staying asleep,
(2) irritability or outbursts of anger,
(3) difficulty concentrating ,
(4) hypervigilance,
(5) exaggerated startle response.
Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.
The disturbance causes clinically significant distress or impairment in social, occupational, or other important
areas of functioning.
Table 3. Epidemiological studies that have applied standardized psychometric questionnaires
to assess Acute Stress Disorder and Posttraumatic Stress Disorder following miscarriage
Author
Groups (number)
Outcome measure(s)
miscarriage
Engelhard et al.
Posttraumatic Symptom Scale – Self Report
T1 – 113
(PSS – SR)
(2001)
T2 – 101
Walker T.M.
Structured Clinical Interview for Dissociative
miscarriage – 40
Davidson K.M. (2001)
Disorders (SCID – D)
miscarriage
T1 – Stanford Acute Stress Reaction
Bowles et al. (2006)
T1 – 25
Questionnaire (SASRQ)
T2 – 19
T2 – Post-traumatic Stress Diagnostic Scale
(PSD)
Assessment
T1 – 1 month – 25% – PTSD
T2 – 4 months – 7% – PTSD
3 weeks – 15% – ASD
T1 (1 week) – 28% – ASD
T2 (5 weeks) – 39% – PTSD
T1 – time one, T2 – time two, ASD – Acute Stress Disorder, PTSD – Post-traumatic Stress Disorder
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M. Murlikiewicz, P. Sieroszewski
Research on posttraumatic stress is derived from
studies on people involved in the wars, disasters, or
those experiencing violence. PTSD has been officially
introduced in DSM in its third edition in 1980, while
ASD is a relatively new concept, that firstly appeared in
DSM-IV. Nowadays, the occurrence of these disorders in
relation to traumatic medical events, including the
events associated with pregnancy and childbirth receives
more study attention [10-12].
Acute Stress Disorder, Post-traumatic Stress Disorder and miscarriage
The history of research on the occurrence and development of post-traumatic stress disorder (PTSD) in
women with an experience of miscarriage includes a limited number of studies. Initial reports, mainly based on
case and retrospective studies, have been burdened with
methodological flaws, not allowing to formulate generalized conclusions. A comprehensive literature review
dedicated to the psychological consequences of early
pregnancy loss published in 1996 notes the absence of
reports examining the experience of miscarriage as a potentially traumatizing event, associated with the experience of severe stress [1]. A crucial problem in the
diagnosis of ASD and PTSD is the traumatic event
criterion. It is worth outlining that only fourth edition of
DSM allows for diagnosis of ASD and PTSD after miscarriage as it incorporated a subjective trauma criterion
(A2), that was not present in previous versions of the
manual. Therefore, earlier studies essentially based on
DSM-III-R could not fully examine relationship between
PTSD and ASD and miscarriage.
Bowles quotes anecdotal evidence suggesting 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 [13]. Subsequent reports present even higher
rates of these disorders. A careful review of the studies
reveals three prospective studies examining relationship
between ASD/PTSD and miscarriage with the use of
standardized measuring tools (Table 3).
Research conducted by Engelhard on a sample of
113 women who have experienced pregnancy loss has
allowed the observation of post-traumatic stress symptoms in this group [8]. Authors controlled pre-existing
PTSD (at an early stage of pregnancy) as well as depression. Posttraumatic Symptom Scale was used for the
measurement of PTSD symptoms a month and four
months after miscarriage. After one month 77% of women showed signs of re-experiencing the event (cri-
terion B of DSM-IV-TR), 40% displayed symptoms of
behavioral avoidance of stimuli associated consistently
with an experienced miscarriage (criterion C), 42% experienced symptoms of increased arousal (criterion D)
and 25% of women participating in the study met the
diagnostic criteria for PTSD with severity of symptoms
comparable to other populations of people affected by
the trauma [8]. After four months the number of women
who reported PTSD decreased to 7%. Simultaneous measurement of depression showed different nature of those
disorders and confirmed that a careful observation is
needed in order to not account PTSD symptoms for
depression. After one month 36% of women registered
as PTSD cases displayed symptoms of mild to severe depression. In the entire group depression rate was 13%.
Although PTSD symptoms dropped after four months
depression rates reminded invariable (13% for the whole
group and 35% for PTSD cases). This corresponds with
the results presenting elevated rates of depression
during a year after pregnancy loss [14].
Walker and Davidson assessed that 15% of women
within three weeks after early pregnancy loss meet criteria for acute stress disorder [15]. In comparison,
Bowles et al. published a report of the pilot studies,
which showed the existence of symptoms indicating acute stress disorder in 28% of women close after miscarriage and post-traumatic stress disorder in 39% of the
surveyed a month after miscarriage [13]. Despite the
small sample size engaged in a study, a prevalence of
PTSD is comparable to the rates obtained by Engelhard
et al and therefore can be viewed as another argument
for more research attention on this issue.
Risk factors for ASD and PTSD after early pregnancy loss
Studies on predictors of PTSD revealed a number of
factors that make people more vulnerable to this disorder. It was estimated that women are more likely than
men to develop ASD and PTSD symptoms due to potentially traumatic situation [17]. Also, a history of domestic violence, childhood physical, emotional or sexual
abuse and a record of psychiatric disorders may contribute to higher rates of ASD/PTSD symptoms [11].
Another risk factor is low educational level and socioeconomic status. Being a unique kind of loss miscarriage
requires distinctive criteria for predictors of ASD and
PTSD in order to provide effective psychological interventions for the population of miscarrying women that
requires it.
Acute stress disorder and posttraumatic stress disorder following miscarriage
Although, it may seem to be natural predictor, researches did not find direct relationship between gestational age and the risk of traumatic stress symptoms.
The same severity of symptoms was observed after
a loss at different stages of pregnancy [8]. In this case,
the attachment criterion seems to have more predicative
value. Women who feel bounded to their unborn child
(regardless of the gestational age) are more likely to
develop ASD/PTSD symptoms after miscarriage. Also
the woman’s age could not be perceived as a risk factor.
Bowles outlined that women reporting self-perceived
medical problem during pregnancy are more predisposed to ASD. Also, women presenting ASD symptoms
shortly after miscarriage are more likely to develop
PTSD in future [13].
Engelhard et al indicated a statistically significant
dependence of the risk of PTSD after a miscarriage and
the educational level and neuroticism of patients [16].
High levels of neuroticism associated with low educational level led to nearly 70% of predicted risk for PTSD
in the patients after the miscarriage [16]. This resembles with reports from studies of people experiencing
other traumatic events such as participation in hostilities, crimes, traffic accidents and natural disasters [17].
An influential theory states that PTSD symptoms does
not originate directly from the traumatic event but from
negative explanations of the distressing experience and
from the deficiency of integration of traumatic recollections into a structured network of autobiographical
memory. In order to cope better in a difficult situation a
cognitive processing of unexpected sensations is required [16]. If this is not a possibility an individual is
more vulnerable to the consequences of traumatic
stress.
A high sense of coherence (the belief that the world
is meaningful, the individual has sufficient resources to
deal with the requirements of life and that, these requirements are indeed worth the commitment) seems to
have a protective function from developing traumatic
stress. Studies report that a high sense of coherence in
early pregnancy is negatively correlated with PTSD
symptoms (particularly symptoms of criterion C and D)
in the months after miscarriage [18]. A strong sense of
coherence, in accordance with the concept of Antonovsky, assumes that the individual who faced with stressful events is able to mobilize adequate resources for
a better coping. One alternative is to use social support
networks [19, 20]. A negative correlation between positive perception of received social support and the intensity of PTSD symptoms was observed [13, 21]. There
161
is clearly a need for more in-depth observation whether
such variables as a history of abuse, former pregnancy
losses and forms of coping with stress can influence
development of traumatic stress symptoms.
Practice recommendations
On the basis of the data presented it seems to be
crucial that physicians diagnosing and treating women
with early pregnancy loss should be conscious about
strongly distressing consequences of the event and therefore address their patients with empathy and sensitivity [22-24]. Providing patients and their partners with
comprehensive information on potential causes and
repercussions of their spontaneous abortion will help to
reduce anxiety levels and other psychiatric symptoms.
As closely after the event women may experience the
state of shock and a variety of ASD symptoms authors
suggest that next appointment (in two-four weeks’ time)
would be a more appropriate choice for presenting
detailed information and responding to questions.
The risk factors for increased psychological morbidity after miscarriage should be assessed. In terms of
traumatic stress symptoms former history of abuse,
strong attachment to the lost child, a feeling of personal
responsibility for the loss, poor social support as well as
low educational level and high neuroticism should be
taken into consideration as possible predictors. Potential
risk for posttraumatic stress disorder should be assessed
in follow-up visits one month after the initial visit. High
risk patients may be offered psychological or psychiatric
consult for further evaluation or potential treatment.
More prospective and longitudinal research is necessary in order to examine connection between early
pregnancy loss and ASD/PTSD. Also, risk factors should
be assessed and more screening tests ought to be established for more effective diagnosis of psychological morbidity after miscarriage.
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J
Magdalena Murlikiewicz
Department of Fetal Medicine and Gynecology
Medical University of Lodz
94-029 Łódź, Wileńska 37
e-mail: [email protected]