Acute stress disorder and posttraumatic stress disorder following miscarriage

Transcription

1 Archives of Perinatal Medicine 18(3), , 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, 1 st Chair of Gynecology and Obstetrics, Medical University of Lodz, Łódź, Poland

2 158 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 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 Wrocław, Elsevier Urban&Partner Criterion A B C D E F G H Diagnostic criteria for Acute 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. 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). 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. Marked avoidance of stimuli that arouse recollections of the trauma (e.g. thoughts, feelings, conversations, activities, places, people). Marked symptoms of anxiety or increased arousal (e.g. difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness). 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. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event. 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.

3 Acute stress disorder and posttraumatic stress disorder following miscarriage 159 Criterion A B C D E F Table 2. Diagnostic criteria for PTSD according to DSM-IV-TR based on Wciórka J. Kryteria diagnostyczne według DSM-IV-TR Wrocław, Elsevier Urban&Partner Diagnostic criteria for 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. Engelhard et al. (2001) 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) Assessment miscarriage Posttraumatic Symptom Scale Self Report T1 113 (PSS SR) T2 101 T1 1 month 25% PTSD T2 4 months 7% PTSD Walker T.M. Structured Clinical Interview for Dissociative miscarriage 40 3 weeks 15% ASD Davidson K.M. (2001) Disorders (SCID D) miscarriage T1 Stanford Acute Stress Reaction T1 (1 week) 28% ASD Bowles et al. (2006) T1 25 Questionnaire (SASRQ) T2 (5 weeks) 39% PTSD T2 19 T2 Post-traumatic Stress Diagnostic Scale (PSD) T1 time one, T2 time two, ASD Acute Stress Disorder, PTSD Post-traumatic Stress Disorder

4 160 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 (criterion 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.

5 Acute stress disorder and posttraumatic stress disorder following miscarriage 161 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 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. References [1] Lee C., Slade P. (1996) Miscarriage as a traumatic event: a review of the literature and new implications for intervention. J. Psychosom. Res. 40: [2] Kaźmierczak W., Fiegler P., Węgrzyn P. et al. (2004) Przyczyny, etiologia oraz współczesne metody diagnostyki i leczenia poronień. Ginek. Prakt. 12: [3] Lok I.H., Neugebauer R. (2007) Psychological morbidity after miscarriage. Best Pract. Res. Cl. Ob. 21: [4] Athey J., Spielvogel A.M. (2000) Risk factors and interventions for psychological sequel in women after miscarriage. Prim. Care Update Ob/Gyns. 7: [5] Janssen H.J., Cuisinier M.C., de Graauw K.P. et al. (1997) A prospective study of risk factors predicting grief inten-

6 162 M. Murlikiewicz, P. Sieroszewski sity following pregnancy loss. Arch. Gen. Psychiatry 54: [6] Neugebauer R., Kline J., O Connor P. et al. (1992) Depressive symptoms in women in the six months after miscarriage. Am. J. Obstet. Gynecol. 166: [7] Geller P.A., Klier C.M., Neugebauer R. (2001) Anxiety disorders following miscarriage. J. Clin. Psychiatry 62: [8] Engelhard I.M., van den Hout M.A., ArntzA. (2001) Posttraumatic stress disorder after pregnancy loss. Gen. Hosp. Psychiatry 23: [9] Wciórka J. (2008) Kryteria diagnostyczne według DSM-IV- TR. Elsevier Urban&Partner, Wrocław. [10] Ayers S., Pickering A.D. (2001) Do women get posttraumatic stress disorder as a result of childbirth? A prospective study of incidence. Birth 28: [11] Tedstone J.E., Tarrier N. (2003) Posttraumatic stress disorder following medical illness and treatment. Clin. Psychol. Rev. 23: [12] Wijma K., Soderquist J., Wijma B. (1997) Posttraumatic stress disorder after childbirth: a cross sectional study. J Anxiety Disord. 11: [13] Bowles S.V., James L.C., Solursh D.S. et al. (2000) Acute and post-traumatic stress disorder after spontaneous abortion. Am. Fam. Physician 61: [14] Janssen H.J., Cuisinier M.C., Hoogduin K.A. et al. (1996) Controlled prospective study on the mental health of women following pregnancy loss. Am. J. Psychiatry 153: [15] Walker T.M., Davidson K.M. (2001) A preliminary investigation of psychological distress following surgical management of early pregnancy loss detected at initial ultrasound scanning: A trauma perspective. J. Reprod. Infant. Psychol. 19; [16] Engelhard I.M., van den Hout M.A., Schouten E.G. (2006) Neuroticism and low educational level predict the risk of posttraumatic stress disorder in women after miscarriage or stillbirth. Gen. Hosp. Psychiatry 28: [17] Brewin C.R., Andrews B., Valentine J.D. (2000) Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. J. Consult. Clin. Psychol. 68: [18] Engelhard I.M., van den Hout M.A., Vlaeyen J.W. (2003) The sense of coherence in early pregnancy and crisis support and posttraumatic stress after pregnancy loss: a prospective study. Behav. Med. 29: [19] Sheridan C.L., Radmacher S.A. (1998) Psychologia zdrowia. Wyzwanie dla biomedycznego modelu zdrowia. Instytut Psychologii Zdrowia PTP, Warszawa. [20] Łuczak-Wawrzyniak J., Skrzypczak J., Szczepańska M. (2002) Leczenie jest sztuką na podstawie wybranych obszarów działalności szpitala ginekologiczno-położniczego. Ginekol. Pol. 73: [21] Chazan B. (2010) Pomoc lekarza. [In:] Klahs C. Poronienie. Zrozumieć rodziców po stracie. W drodze, Poznań. [22] Sieroszewski P., Suzin J., Bernaschek G. et al. (2001) Evaluation of first trimester pregnancy in cases of threatened abortion by means of Doppler sonography. Ultraschall Med. 22: [23] Feskov A. M., Arbuzov S. B., Grabar V. V. (2009) Genetic aspects of infertility and miscarriage a review of literature. APM 15: [24] Frost M., Condon J.T. (1996) The psychological sequelae of miscarriage: a critical review of the literature. Aust. N. Z. J. Psychiatry 30: J Magdalena Murlikiewicz Department of Fetal Medicine and Gynecology Medical University of Lodz Łódź, Wileńska 37 magdalena-murlikiewicz@tlen.pl