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Psychological factors related to spontaneous and therapeutic abortion
Psychological factors related to spontaneous and therapeutic abortion NATHAN
M.
DAVID JAN
St.
ROTHMAN, T.
AUDREY Louis,
SIMON,
GOFF, G.
M.D. M.D.
M.D. SENTURIA,
A.B
Missouri
Thirty-two women who had spontaneous abortions were studied by interviews and psychological testing and were compared to a group of 46 rvomen who had therapeutic abortions. In contrast to the therapeutic abortion group, the spontaneous aborters demonstrated little in the way of serious psychopathology. However, in the spontaneous group those women who developed clinically significant depressive reactions did so at the time of the abortion, which was not the case in the therapeutic abortion group. Psychological tests indicated conflicts around sexual identity and sadomasochism in spontaneous aborters resembled but were not as severe as in the therapeutic abortion group. The evidence suggests that the pregnancy and abortion itself may be seen as a primary way of acting out unconscious sadomasochistic conflicts in spontaneous aborters.
1 N A P R E v I o u s publication1 the authors reported a study of 46 women who had therapeutic abortion and were followed for up to 10 years. The earlier study demonstrated that in this group of women who had therapeutic abortions for a variety of indications (medical illness, psychiatric illness, possibly fetal damage) two thirds had diagnosable psychiatric illness prior to the time they came for abortion. Transient, selfwas the characterislimiting depression tic response to the abortion, especially of healthier women in the study; but a number of women in the study experienced little in the way of depression or guilt following the abortion and, in fact, experienced feelings of relief. Sadomasochistic conflicts and rejection of feminine biologic role were important unconscious dynamic factors in From the Departments of Psychiatry Obstetrics and Gynecology, The Jewish Hospital.
these women and appeared to be important in determining the sequence of events leading to the therapeutic abortion. Nine of the 12 women who developed psyschiatric illness in the follow-up period had exacerbations of pre-existing psyschiatric illness that were not related to the therapeutic abortion. In the study described above, it became clear that we were examining a very complicated process. One element in this process that seemed important to us was the response to the actual loss of the fetus. Our interview data revealed that for some women, at the conscious level, the loss of the fetus was relatively unimportant, although there was evidence that unconsciously this loss had great meaning. The loss of the fetus via therapeutic abortion provided an excellent opportunity to act out the sadomasochistic conflicts that were so prominent in this group of women. It was possible for the women to use the fetus both as an object for projected hostility and also to identify with the fetus in a masochistic way. Some women saw themselves as consciously involved in
and
Presented at the Thirty-sixth Annual Meeting of the Central Association of Obstetricians and Gynecologists, Oklahoma City, Oklahoma, Sept. 26-28, 1968. 799
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the whole process of obtaining the abortion and being instrumental in bringing about the termination of the pregnancy. Other women consciously saw themselves in a passive role in relation to this, In this latter group, however, there was evidence to make us believe that unconsciously these women also felt involved in the process in other than passive ways. This suggested to us that these unconscious conflicts might also play an important role in women who aborted spontaneously. Since psychological factors are so important in spontaneous abortions,“+ we felt it would be valuable to look at spontaneous aborters in order to compare them with women who had therapeutic abortions to see what similarities and differences might exist in terms of underlying dynamic conflicts. In addition, we felt it would be valuable to study the response of women to spontaneous abortion to try to understand specifically what these responses were and also to see if there was any relationship between spontaneous abortion and the onset of psychiatric illness that occurred after the abortion. Therefore, we studied a group of women who had spontaneous abortions in the same way in which we had previously studied women who had therapeutic abortions and compared the two groups. Method
Women who had been hospitalized for spontaneous abortion in The Jewish HospitaI were selected as follows: The first 5 women admitted with a diagnosis of spontaneous abortion in the month of December were selected for the index years 1955, 1957, 1959, 1961, and 1963. This was done in order to cover the same 10 year period that was used in the study of women with therapeutic abortion. The women were contacted by letter and telephone and invited to participate in the study. Those who participated were interviewed by one of the authors in an semistructered interview that open-ended, lasted from one to 2 hours. Each woman completed a special questionnaire and battery of psychologica1 tests (MMPI and Loe-
Table I. Characteristics of women with spontaneous and therapeutic abortions Therapeutic (32 women)
Average age at time of abortion
28.8
Age range
19-43
Religion Protestant Catholic Jewish Unknown
or none
Spontaneous (46 women)
19 i 10 3
Race
Social
White Negro
30 3
class I, II, and III IV and V Unknown
23 9 --
Education Less than high school High school More than high school
5 16 11
Interval between abortion and follow-up Less than 1 year 1-3 years 3-5 years 5-7 years More than 7 years
1;
Marital status follow-up Married Divorced Single Widowed
31 1 --
9 2 6
at
vinger Family Problems Scale). charts were also examined,
-
The hospital
Sample
Thirty-two women participated in the study. Five women refused to participate and 9 had either moved out of town or were not located. Table I contains a summary of descriptive data about the women studied. Table II shows the data on abortions and pregnancies in women with both spontaneous and therapeutic abortions. There were 3 women among the spontaneous aborters and one woman in the therapeutic abortion group
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Table II. Rates of abortion spontaneous
in women abortions
and therapeutic
Therapeutic (32 women) No.
1
of pregnancies 3
4 5 or more Total pregnancies No. of abortions Spontaneous 0
-
3’ 4 5 or more Total spontaneous abortions Total induced abortions Spontaneous rate Induced Total
abortion
rate rate
61
33
-
54
45 %
17%
-
28%
45%
45%
who were habitual aborters, e.g., having 3 consecutive spontaneous abortions. The total abortion rate (spontaneous plus induced) for both groups was identical-45 per cent. Major psychiatric illness and following abortion
Neurotic reactions Personality trait disturbance Psychotic reaction (schize phrenic) Other No diagnosis made Total
Spontaneous f%)
Therapeutic (%I
47 16
15 33
37 100
15 7 30 100
-
28 11
15 10 4 2 1
abortion
abortion
4 5 6 10 21 194
6 4 12 136
801
Table III. Psychiatric diagnoses at follow-up in 32 women with spontaneous and 46 women with therapeutic abortion
with
Spontaneous 146 women
factors in abortion
preceding
Table III shows the psychiatric diagnosis at the time of follow-up. Fifteen cases were diagnosed as neurotic reactions, 5 as personality trait disturbances, and no psychiatric diagnosis was made for the remaining 12. No women in the spontaneous abortion group evidenced major incapacitating psychiatric illness prior to the spontaneous abortion. None had been hospitalized in psychiatric hospitals or on psychiatric wards prior to the spontaneous abortion. One woman was hospitalized in a psychiatric ward 5 years after the spontaneous abortion, with a severe neurotic depressive reaction. This hospitalization was related to
the birth of her last child. When seen 3 years after the hospitalization, she had symptoms of a depressive reaction. Six other women developed neurotic reactions which began at the time of the abortion and persisted after the immediate postabortion period. In 3 women the neurotic depressions were still present at follow-up (2 at 4 years and 1 at 2 years postabortion). In the other 3 women, the depression lasted several months postabortion but was not in evidence at follow-up, 5, 7, and 9 years postabortion. In 20 women there was no evidence of new psychiatric symptoms relating to the spontaneous abortion after the immediate postabortion period. Immediate response fo the spontaneous abortion Thirteen women reported they experienced depressed feelings at the time of the spontaneous abortion. In most of these cases, these feelings began prior to the completion of the abortion, when the patients were told by their obstetricians that the abortion was inevitable. Another 9 women reported feelings of disappointment, but did not report feeling appreciably depressed at the time of the abortion. Six women had open and outright feelings of relief and were glad the abortion had occurred. Two women reported mixed feelings of disappointment and relief. The responses of two other women could not be categorized. Eight of the 13 women who were depressed at the time of the spontaneous
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abortion had diagnosable psychiatric illness at follow-up. Only 1 of the 9 women who were disappointed had a psychiatric diagnosis at follow-up. Depression at the time of abortion was also more common in those women who had planned pregnancies (6 of 13) and less common in those who did not (3 of 9). Guilt
following
spontaneous
abortion
Twenty-five (78 per cent) of the 32 women included in this study reported either very little or no feelings of guilt related to the spontaneous abortion. Seven (22 1x1 cent) of the women did report feelings of guilt that were quite conscious and concerned them for periods up to many months follolving the abortion. In the spontaneous abortion group only one of the 12 women who did not have a psychiatric diagnosis made at the titncs of the evaluation reported conscious feelings of the 20 women with of guilt. However, psychiatric diagnoses, 6 (30 per cent) rrported moderate to marked conscious guilt feelings (Table IV). There appears to hp a relationship between the presence of psychiatric illness and the appearance of moderate to marked conscious guilt following :I spontaneous abortion. It should be added that in all of these cases in which guilt feelings of signific.ant intensity were reported, the women had not made attempts to induce an abortion. Seven of the 26 women with living children reported conscious guilt, while none of the 6 women without living childrrn reported guilt feelings. The women who did experience conscious guilt tverr, as ;I
Table IV. Psychiatric and conscious abortion
guilt
diagnoses at follow-ul) after spontaneous
Moderate to marked conscious guilt
group, slightly older than those who did not (an average of 30.0 years versus an average of 28.3 years). Psychological
dOC!S.
For one woman (3 per cent) the ‘1‘ score on the D scale was over 70. This compares \vith I.? won~en (28 per cent) in the therapeutic abortion group who had T scores above 70. PD arid MF sca1c.r. The PD scale measures trends toward psychopathy and acting out behavior. The average raw score for the 32
Table V. MMPI with -~-
raw scores for women spontaneous and therapeutic abortioll .~-~...~-~-Hatha- .-.-- ---..-- .-__ __
D scale
Average Raw score Range S. D. PD
6
14
20
1
11 --___.
12
Total
7
25
32
\ way and / Briggs
19.3
Spontaneous
Therapeutic
20.7
24.6 t 5-37 5.70
1 I-3.5 5.18
4.20 (N.S.)
(P-
O.OOlj
and 0.4K
S.D.
Psychiatric diagnoses No psychiatric diagnosis
data
D .scale. The D scale on the MMPl is a measure of depressive mood. The average raw score on the D scale for the 31 women Ivho completed the MMPI was 20.7. These scores can bc compared with the data obtained in the group of women studied previously who had therapeutic abortion and also with Hathaway and Briggs”” results from a study of a large normal population of woman (Table V) . The spontaneous ahortion group does not differ significantly from Hathabvay and Briggs’ normal population of women? but the therapeutic abortion group
Range
Total
test
MMPI.
Average Raw score Little 01 no conscious guilt
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18.4 4.40
21.5 13-29 4.35 rP=O.oolj
24.3 14-34. (P=O.o01i
38.5 30-46 4.76 (Pm-0.05)
38.7 29-49 5.15 (P-0.01)
5.18
MF .4verage Raw score
36.5
Range S.D.
4.83
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women with spontaneous abortions was 21.7 for the PD scale. Both the spontaneous and therapeutic abortion groups differ significantly from Hathaway and Briggs’ normal women (Table V) . When the raw scores are converted to the T scores, only 2 women (6 per cent) of the group had scores of 70 or greater. In the therapeutic abortion group 17 women (37 per cent) had T scores greater than 70. The MF scale is related to concerns about sexual role. High raw scores (or low T scores when the data are converted) indicate trends toward resolving conflicts about sexuality by exaggeration of “typical feminine attitudes.” The raw score on the MF scale for the spontaneous abortion group was 38.5. Both the spontaneous abortion group and the therapeutic abortion group differ from Hathaway and Briggs’ normal No woman in the spontaneous women. abortion group had a T score lower than 30, but 8 (25 per cent) had T scores between 30 and 39. Only 12 women (38 per cent) had T scores above 50 on the MF scale. In the therapeutic abortion group 5 women (11 per cent) had T scores below 30, 6 women (13 per cent) between 30 and 39 and 16 (35 per cent) over 50. The combination of low MF scores and high PD scores is consistent with sadomasochistic conflicts in character structure. Four women (13 per cent) in the spontaneous abortion group had a combination of low MF (T score less than 39) and high PD (T score over 60). An additional 2 women (6 per cent) had differences of greater than 20 between their MF and PD scores. In the therapeutic abortion group 20 women (43 per cent) had this type of MF/ PD configuration. Table VI relates scores on the PD and MF scales to the number of abortions. Women with three or more abortions have scores on the MF scale higher than the group as a whole and have scores on the PD scale lower than the group average. Attitude toward feminine biologic role. Thirty-one women completed the Loevinger Family Problems Test. The Feminine Biolog-
Psychological
factors
Table VI. MMPI raw of spontaneous abortions
in abortion
scores
No. I
of
I
and
803
number
abortions 2
I
2:
PD + 0.4K
Average raw score Range
21.3
23.2
20.6
13-27
17-29
17-26
38.7 30-46
37.0 32-45
39.6 31-43
MF
Average raw score Range
Table VII. Attitude toward feminine biologic role in 31 women with spontaneous and 40 women with therapeutic abortion Spontaneous f%)
Therapeutic (%)
Rejection of feminine biologic role
32
40
Normal range, feminine biologic role
68
50
High positive feminine biologic role Total
100
10 100
ical Role scale in this test measures attitudes toward feminine functions such as nurturing, childbearing, etc. Ten women (32 per cent) had scores on this scale which indicated rejection of feminine biologic role. The remaining 68 per cent scored within normal range (Table VII). Of the 10 women who had scores which indicated significant rejection of feminine biologic role, 6 had psychiatric diagnoses made at the time of interview (5 neurotic reactions and one personality trait disturbance). Comment We embarked upon this study of women who had spontaneous abortions in order to compare them with women who had undergone therapeutic abortion. The group of spontaneous aborters studied appears to be a representative group of middle class, white,
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married, American women. In the spontaneous abortion group, 62.5 per cent had diagnosable psychiatric illness at the time they were interviewed. This compares with 70 percent of the therapeutic abortion group who had diagnosable psychiatric illness at the time of follow-up. While the numerical difference is not statistically significant, qualitatively there was a marked difference. In the spontaneous abortion group, the psychiatric illness was strikingly less severe. There were no psychotic reactions diagnosed in the spontaneous abortion group, while there were 7 (15 per cent) schizophrenic reactions in the therapeutic abortion group. Since one third of the therapeutic abortion group was aborted for psychiatric indications the differences in severity and extent of psychiatric illness are not surprising. Yet this is not the whole story for there was more extensive and serious psychopatholo
July 15, 1969 Am. J. Obst. Sr Gynec.
abortion group on these two scales, some important qualitative and quantitative differences must be noted. There were many high scores on the PD scale, but not as many of these women peaked at T scores over 70 as did the therapeutic abortion group. Only two women in the spontaneous abortion group had T scores on the PD scale over 70, while 17 of the therapeutic abortion group had T scores over 70. Similarly, the strikingly low MF scores seen in the therapeutic abortion group were not present. The therapeutic abortion group included 5 women with T scores on the MF scale of less than thirty. Thirty was the lowest score in the spontaneous abortion group and leas present only in one case. While there were 6 women with MF/PD differences of greater than 20, there were fewer of the very dramatic differences which were seen in the therapeutic abortion group, which had 5 women with differences of over 40 between the MF and PD scales and another 15 women with differences of greater than 20 points in the T scores on these scales. ‘l’his information, coupled with the data from the clinical interviews, which reveals much less evidence of acting out sociopathic behavior, leads to the conclusion, that while these trends are present in the spontaneous group, qualitatively, they are not so intense, are dealt with in different ways, and cause less apparent difficulty in the lives of the women studied. Twenty-two per cent of the spontaneous abortion group had feelings of conscious guilt that appear to be important to them and lasted for some time. This compares with 35 per cent in the therapeutic abortion group who experienced moderate to marked conscious guilt following the abortion. A not unexpected finding for the spontaneous abortion group is that those women with no psychiatric diagnoses had little guilt about the abortion and seemed to deal with the loss of the fetus in adaptive ways. Characteristically, there was transient grief, and a sense of loss and unhappiness which usually lifted in a few days. The women with positive psychiatric diagnoses experienced the most
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conscious guilt about the spontaneous abortion, In addition, the women with psychiatric diagnoses were the most equivocal about being pregnant or, once pregnant, had not accepted the idea of being pregnant. Fairly short periods of disappointment were most characteristic for those women who did not have diagnosable psychiatric illness. The women with psychiatric diagnoses tended to be depressed immediately following the spontaneous abortion. There were 29 cases in which enough time had elapsed SO the process could be understood. In 22 women there were no persistent psychiatric symptoms directly related to the spontaneous abortion itself. In 6 cases the feeling of depression continued for an appreciable period following the spontaneous abortion. Our data would indicate a marked difference in the amount of psychiatric illness following abortion in the spontaneous abortion group as compared to the therapeutic abortion group. In the therapeutic abortion group, 6 women had psychiatric hospitalization subsequent to their abortions; 4 developed depressive reactions and 2 developed duodenal ulcers. The amount of psychopathology seen following spontaneous abortion over the same 10 year follow-up period is minor when compared to the therapeutic abortion group. However, the data indicate a rather surprising difference. In the therapeutic abortion very little of the subsequent psygroup, chiatric illness appeared related to the therapeutic abortion. It was, instead, seen as part of chronic psychopathology that existed prior to the therapeutic abortion and appeared in time sequences that were, in most cases, unrelated to the abortion. This was true in 9 of 12 cases of psychiatric illness after therapeutic abortion. In the spontaneous abortion group, while the amount and extent of the psychopathology were much less, that which does appear seems to be much more closely related to the abortion. In 6 women neurotic reactions (predominantly depressive) developed at the time of the spontaneous abortion and persisted for periods ranging from several months to 4 years.
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Our data tend to confirm some of the findings from our first study. The women who come to therapeutic abortion appear to be a selected group in terms of their psychodynamics and psychopathology and there is a strong suggestion of a similar selection in spontaneous abortion. That is to say, our data would indicate that pre-existing conflicts appear to be a very important determinant, no matter whether the abortion is spontaneous or induced, even though flagrant sadomasochistic behavior, so characteristic of the therapeutic abortion group, was not present. The MMPI and Loevinger Family Problems Scale indicate that conflicts around acting out, psychopathic behavior, exaggerated feminine attitudes, sadomasochism, and feminine biologic role are of considerable importance in the dynamics of the spontaneous abortion group. However, the data we have available indicate that the pregnancy itself appears to be one focus for the acting out of sadomasochistic conflicts. Women whom we found to have greater conflicts around sadomasochism were also those who had more unplanned pregnancies and pregnancies which were not accepted once they occurred and also appeared to experience greater relief at the time of the abortion and had less depression following the abortion. Finding sadomasochistic conflicts and rejection of feminine biologic role present in a significant number of the spontaneous aborters underlines the rather obvious fact that there may be more than one way to skin a cat. That is, previous work2mg has indicated that psychological conflicts can play a very important part in spontaneous abortion. The spontaneous abortion itself may represent an alternative way of dealing with and acting out sadomasochistic impulses and conflicts around feminine biologic role. Our data have led us to speculate about two issues. The first speculation grows out of the findings that the total abortion rate for both spontaneous and therapeutic abortions was identical. We feel data should be gathered on a much larger sample to see if this can be replicated. From our experi-
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ence we would predict that larger samples will show similar findings. Our material suggests that there are women who wish either consciously or unconsciously to get rid of the pregnancy, and they seemto accomplish this in one way or another. The cycle of pregnancy and abortion (whether spontaneous os induced) seemsto us an important avenue of discharge for pressingunconsciouspsycholo,gical conflicts. Our second speculation grows out of our finding of significantly more guilt in women with living chiIdren than in women without children. We believe that the unconscious meaning, i.e.. the transference meaning, of the
REFERENCES
1. Simon, M., Senturia, A., and Rothman. D.: Am. J. Psychiat. 124: 59, 1967. 2. Grimm, E. R.: Psychnsom. Med. 24: 369, 1962. 3. James, W. H.: A~I. J. ORST. & GYNEC. 85: 38, 1963. ‘1. Javert, C. T.: Spontaneous and Habitual Abortion, New York, 1957, McGraw-Hill Book Company, Inc. 5. Mann, E. C.: S. Clin. North America 37: 447, 1957.
Discussion DK. JOHN I’. HARROL), Chicago, Illinois. ‘I‘hc authors have presented a very timely and intert:sting article which scientifically confirms what some have proposed for years, that there is a relationship between women who have therapeutic absortions and those who abort spontaneously. I dislike the restricting of the term “therapeutic absortion” to those done in the hospital as I believe some illegal absortions are also therapeutic. Therese Benedek has stated that therapeutic abortions are motivated not only by social, ethical, and economic factors but also by unconscious fears in women, which in those of lesser fertility may cause sterility or spontaneous absorti0n.l The authors have interviewed each patient for one to 2 hours and have been able to probe their unconscious levels. I wonder if some of this might be conjecture, since the gynecologist may require four or five visits before the conscious reason for the first visit is discerned.
fetus to the mother is critical in determining this response.Two possibilitiessuggestthemselves; the first is that undischarged or poorly neutralized hostility to the living children could be involved. The pregnancy could mobilize resentment and anger and malit> consciously experienced guilt an important mechanism in dealing with the abortion which may have been unconsciously desired. Another possibility would involve identitication of the fetus with siblings in the mother’5 family of origin. Again unconsciousjealous) :tnd resentment stimulated by the transferrnce meaninp of the fetus could produc’tu more conscious guilt.
6. Rothman, D., Kaplan, A. H., and Nettles. E.: AM. J. OBST. & GYNEC. 83: 383, 1962. 7. Mann, E. C.: Obst. & Gynec. 7: 589, 1956. 8. Tupper, C., and Weil, R. H.: AM. J. OHSI-. & GYNEC. 83: 421. 1962. 9. Rothman, D., and Kaplan, A. H.: .4m. CIIII. Obst. & Gynec. 25: 457, 1965. 10. Hathaway, S., and Briggs, P. F.: J. Clin. Psychol. 13: 364, 1957. 216 South Kingshighwq St. Lmks, Missouri 631 IO
Was there a reason for selecting December for obtaining the cases? I would think, that with holidays in December basically devoted to children, this would favor the occurrence of mild psychiatric disturbances. Fifteen out of the 32 spontaneous aborters had neurotic reactions and 5 had personality trait disturbances. Doesn’t everyone have a personality trait disturbance? Thirteen of the spontaneous aborters expcrienced moderate depression and another 9 disappointment. I wonder how one differentiates the two, especially since interviews were conducted 3 months to 10 years after the absortion occurred. Could this not be retrospective falsification on the part of the patient in that society expects these emotions of them. All of us, I believe, experience disappointment daily. In my own practice I frequently see disappointment after spontaneous absortion but seldom what I call true depression. Were the investigators looking for depression?
Vchne 104 Number 6
The Christian influence that has so strongly affected our morals and emotions for the past 100 years has taught actively or passively that life entered the fetus at conception and any interruption was murder, hence, I’m surprised that only 22 per cent had guilt feelings. Society must bear the blame for all psychiatric residuals after any type of abortion. In Switzerland, where the influence of John Calvin still thrives, over 50 per cent had psychiatric disturbances after abortion.2 In Norway, where sexual matters and morals are much more logical, Bard Brekke in a study of 400 abortions found only 2 cases of mild psychiatric disturbance. This certainly indicates the psychological disturbances are not intrinsic3 Concerning the psychological data (MMPT and Leovinger Family Problems Test) I would like to ask the authors if they found a correlation between the findings on the test pertaining to psychopathy and the rejection of the feminine biologic role and the clinical findings of the same. My understanding is that no correlation exists. REFERENCES
Benedek, T.: In Arieti, S.: American Handbook of Psychiatry, New York, 1967, Basic Books, vol. I. Chap. 37, p. 727. Simon, N. M., and Senturia, A. G.: Arch. Gen. Psychiat. 15: 378, 1966. Brekke. B.: In Calderone. M. S.: Abortion in the United States, New York, 1958, Hoeber Medical Division, Harper & Row, p. 134. DR. GEORGE J. L. WULFF, St. Louis, Missouri. The authors have made a psychiatric study of a group of women who had spontaneous abortions and have compared the findings with those in women who had had therapeutic abortions. Aside from confirming their own statement that their conclusions have been drawn from a very small group of patients, my comments about this paper will relate to the problem of trying to compare apples and oranges. The authors attempt to compare two very dissimilar groups of pregnant patients, pointing out, in one instance, that 65 per cent of the therapeutic aborters had psychiatric illness antedating their abortion, but that none of the spontaneous aborters showed such earlier illness. I would like to call your attention to other areas of dissimilarity. In almost all cases of therapeutic abortion the conceptus must be considered normal, and the termination of such pregnancy, therefore, involves the destruction of
Psychological
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807
a potentially normal human being. We are all aware of the emotional conflicts arising in these women as they struggle to make this decision. Having taken the step, many patients, therefore, will develop guilt feelings and/or psychiatric illness undoubtedly related to this destruction of a normal conceptus. Spontaneous aborters on the other hand have an entirely different pregnancy. It is usually a desired one, and its termination usually does not involve a normal embryo. Unfortunately, the authors do not mention either of these facts. Neither do they evaluate the role of the attending physician in his management of the spontaneous aborter. These patients frequently exhibit warning symptoms for days or weeks; vaginal spotting or bleeding and failure of the uterus to enlarge properly. These symptoms afford the physician and his patient time to suspect and prepare emotionally for a possible unfavorable outcome. These patients can be oriented as to the inevitable outcome and its actual desirability. They can be reassured that the pregnancy was probably an improperly developing one, and that its rejection was a normal physiologic process. Obstetric literature is filled with evidence to support this thesis, and there is ample evidence that a high percentage of these spontaneous aborters have abnormal pregnancies. Nayak showed that of 417 cases of spontaneous abortions, 65 per cent were doomed because of faulty conceptus or faulty placental development and implantation. In their cases of spontaneous abortion, Dr. Simon and his co-workers have noted that 63 per cent developed a diagnosable psychiatric illness during the follow-up and infer that these are related. I cannot believe these same figures would have been obtained if the nature of the abortion itself had been determined prior to the study, and if the orientation by the patient’s physician had been properly evaluated. If they had, I believe that little or no relationship would be found between spontaneous abortions and subsequent psychiatric illness. Finally, it seems illogical to me to compare patients having spontaneous abortions with those having therapeutic abortions-they are as dissimilar as apples and oranges. REFERENCE
1. Nayak, S. K.: Obst. & Gynec. 32: 316, 1968. DR. SIMON (Closing). I would like to turn first to Dr. WulfT’s comments because they touch
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on what was for us the most surprising and critical issue, i.e., Dr. Wulff’s comments about the apples and oranges. We originally embarked on this study when, as part of our study of therapeutic abortion, we thought we would get a control group, and we entertained the apple and oranges hypothesis, too. We thought if we compared our therapeutic aborters with women who aborted spontaneously that would be holding the element of pregnancy itself constant, that is, two groups-both of whom became pregnant, both of whom lost the fetus, but in quite different ways. Now I would say that the dissimilarities are perhaps more superficial than real and more apparent than real. We were quite surprised by our findings. We had no idea that when we examined the spontaneous aborters closely that they would turn out on several parameters to resemble the therapeutic aborters. Those parameters were conflicts about feminine role and sadomasochism. In these respects, we think these two groups are very much alike, although there is some difference in degree. We don’t quibble about that. There is a difference in degree, but we think that in terms of basic conflicts they arc very much alike and much more like each other than groups of normal women who have been studied in this same way. So, I must differ with Dr. Wulff’s comment about the dissimilarities between women who have had spontaneous and therapeutic abortions. I think the important thing is from a psychological standpoint, that what looks so dissimilar can be quite similar inside somebody’s head, and sometimes the most important thing for the woman is not actually how the pregnancy MGIS lost but the fact that the pregnancy was lost, and what the meaning of the pregnancy was to her in the first place. I agree with Dr. Wulff on one point completely. Our sample is a very small one. We are in the process of studying a much larger group of women to see if we can replicate our own findings. In reference to Dr. Wulff’s comments about
July 15, 1969 Am. J. Obst. & Gym.
psychiatric illness after abortion, either we have not made this point clearly or have been misread. For one thing, we do not say at any point in our paper that the appearance of the neurotic illness in either group of women is always related to the abortion in a causal way. We do not say that there is a one-to-one relationship generally. Only in those cases that WC can really establish a hard and fast relationship do we say that. As a matter of fact, for the therapeutic abortion group, we found, for example, that out of 6 women who are hospital&d after thcrapcutic abortion, in only one of those women did we think the therapeutic abortion had anything 10 do with her hospitalization. In the group we stltdied for spontaneous abortion, there was one lvornan hospitalized. She was hospitalized following the birth of a child 5 years after the spontnncous abortion. i\ftcr my evaluation of the &(a on that woman, I thought that it ~vas not the spontaneous abortion that was really critical IO her illness. As a matter of fact, it has been established fairly clearly that there is a higher rate of psychiatric illness growing out of the postpartum prriod than there is out of thr postabortion period, and that having a living child may be more psychologically stressful than abortirl,q for some wompn. I also differ with Dr. Wulff about his feelin? aboul normal conceptions and abnormal cone-cptions and how women arc able to handle them. In our csxpcricncc that did not scrm to bc so (.ritic.al. The question is not that you can rcassure the ~von~an that it ~YIS an nhormal pt-rgnanny and would have been lost anyhow. bllt what that pregnancy meant to her. I would say that WC recognize very well that w-omen begin to mourn the loss of a fetus clue-ing the period of time before the spoutaneous abortion goes to completion. That is a vc~y unclcrstandable thin,q, and we know that. Mourning hegins ahead of time just like mourning begins for a spouse or parent who is dying, but not yrt dead. ‘These women begin the same way, and so the depression begins before the pregnancy is actually terminated.
M.
DAVID JAN
St.
ROTHMAN, T.
AUDREY Louis,
SIMON,
GOFF, G.
M.D. M.D.
M.D. SENTURIA,
A.B
Missouri
Thirty-two women who had spontaneous abortions were studied by interviews and psychological testing and were compared to a group of 46 rvomen who had therapeutic abortions. In contrast to the therapeutic abortion group, the spontaneous aborters demonstrated little in the way of serious psychopathology. However, in the spontaneous group those women who developed clinically significant depressive reactions did so at the time of the abortion, which was not the case in the therapeutic abortion group. Psychological tests indicated conflicts around sexual identity and sadomasochism in spontaneous aborters resembled but were not as severe as in the therapeutic abortion group. The evidence suggests that the pregnancy and abortion itself may be seen as a primary way of acting out unconscious sadomasochistic conflicts in spontaneous aborters.
1 N A P R E v I o u s publication1 the authors reported a study of 46 women who had therapeutic abortion and were followed for up to 10 years. The earlier study demonstrated that in this group of women who had therapeutic abortions for a variety of indications (medical illness, psychiatric illness, possibly fetal damage) two thirds had diagnosable psychiatric illness prior to the time they came for abortion. Transient, selfwas the characterislimiting depression tic response to the abortion, especially of healthier women in the study; but a number of women in the study experienced little in the way of depression or guilt following the abortion and, in fact, experienced feelings of relief. Sadomasochistic conflicts and rejection of feminine biologic role were important unconscious dynamic factors in From the Departments of Psychiatry Obstetrics and Gynecology, The Jewish Hospital.
these women and appeared to be important in determining the sequence of events leading to the therapeutic abortion. Nine of the 12 women who developed psyschiatric illness in the follow-up period had exacerbations of pre-existing psyschiatric illness that were not related to the therapeutic abortion. In the study described above, it became clear that we were examining a very complicated process. One element in this process that seemed important to us was the response to the actual loss of the fetus. Our interview data revealed that for some women, at the conscious level, the loss of the fetus was relatively unimportant, although there was evidence that unconsciously this loss had great meaning. The loss of the fetus via therapeutic abortion provided an excellent opportunity to act out the sadomasochistic conflicts that were so prominent in this group of women. It was possible for the women to use the fetus both as an object for projected hostility and also to identify with the fetus in a masochistic way. Some women saw themselves as consciously involved in
and
Presented at the Thirty-sixth Annual Meeting of the Central Association of Obstetricians and Gynecologists, Oklahoma City, Oklahoma, Sept. 26-28, 1968. 799
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the whole process of obtaining the abortion and being instrumental in bringing about the termination of the pregnancy. Other women consciously saw themselves in a passive role in relation to this, In this latter group, however, there was evidence to make us believe that unconsciously these women also felt involved in the process in other than passive ways. This suggested to us that these unconscious conflicts might also play an important role in women who aborted spontaneously. Since psychological factors are so important in spontaneous abortions,“+ we felt it would be valuable to look at spontaneous aborters in order to compare them with women who had therapeutic abortions to see what similarities and differences might exist in terms of underlying dynamic conflicts. In addition, we felt it would be valuable to study the response of women to spontaneous abortion to try to understand specifically what these responses were and also to see if there was any relationship between spontaneous abortion and the onset of psychiatric illness that occurred after the abortion. Therefore, we studied a group of women who had spontaneous abortions in the same way in which we had previously studied women who had therapeutic abortions and compared the two groups. Method
Women who had been hospitalized for spontaneous abortion in The Jewish HospitaI were selected as follows: The first 5 women admitted with a diagnosis of spontaneous abortion in the month of December were selected for the index years 1955, 1957, 1959, 1961, and 1963. This was done in order to cover the same 10 year period that was used in the study of women with therapeutic abortion. The women were contacted by letter and telephone and invited to participate in the study. Those who participated were interviewed by one of the authors in an semistructered interview that open-ended, lasted from one to 2 hours. Each woman completed a special questionnaire and battery of psychologica1 tests (MMPI and Loe-
Table I. Characteristics of women with spontaneous and therapeutic abortions Therapeutic (32 women)
Average age at time of abortion
28.8
Age range
19-43
Religion Protestant Catholic Jewish Unknown
or none
Spontaneous (46 women)
19 i 10 3
Race
Social
White Negro
30 3
class I, II, and III IV and V Unknown
23 9 --
Education Less than high school High school More than high school
5 16 11
Interval between abortion and follow-up Less than 1 year 1-3 years 3-5 years 5-7 years More than 7 years
1;
Marital status follow-up Married Divorced Single Widowed
31 1 --
9 2 6
at
vinger Family Problems Scale). charts were also examined,
-
The hospital
Sample
Thirty-two women participated in the study. Five women refused to participate and 9 had either moved out of town or were not located. Table I contains a summary of descriptive data about the women studied. Table II shows the data on abortions and pregnancies in women with both spontaneous and therapeutic abortions. There were 3 women among the spontaneous aborters and one woman in the therapeutic abortion group
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Table II. Rates of abortion spontaneous
in women abortions
and therapeutic
Therapeutic (32 women) No.
1
of pregnancies 3
4 5 or more Total pregnancies No. of abortions Spontaneous 0
-
3’ 4 5 or more Total spontaneous abortions Total induced abortions Spontaneous rate Induced Total
abortion
rate rate
61
33
-
54
45 %
17%
-
28%
45%
45%
who were habitual aborters, e.g., having 3 consecutive spontaneous abortions. The total abortion rate (spontaneous plus induced) for both groups was identical-45 per cent. Major psychiatric illness and following abortion
Neurotic reactions Personality trait disturbance Psychotic reaction (schize phrenic) Other No diagnosis made Total
Spontaneous f%)
Therapeutic (%I
47 16
15 33
37 100
15 7 30 100
-
28 11
15 10 4 2 1
abortion
abortion
4 5 6 10 21 194
6 4 12 136
801
Table III. Psychiatric diagnoses at follow-up in 32 women with spontaneous and 46 women with therapeutic abortion
with
Spontaneous 146 women
factors in abortion
preceding
Table III shows the psychiatric diagnosis at the time of follow-up. Fifteen cases were diagnosed as neurotic reactions, 5 as personality trait disturbances, and no psychiatric diagnosis was made for the remaining 12. No women in the spontaneous abortion group evidenced major incapacitating psychiatric illness prior to the spontaneous abortion. None had been hospitalized in psychiatric hospitals or on psychiatric wards prior to the spontaneous abortion. One woman was hospitalized in a psychiatric ward 5 years after the spontaneous abortion, with a severe neurotic depressive reaction. This hospitalization was related to
the birth of her last child. When seen 3 years after the hospitalization, she had symptoms of a depressive reaction. Six other women developed neurotic reactions which began at the time of the abortion and persisted after the immediate postabortion period. In 3 women the neurotic depressions were still present at follow-up (2 at 4 years and 1 at 2 years postabortion). In the other 3 women, the depression lasted several months postabortion but was not in evidence at follow-up, 5, 7, and 9 years postabortion. In 20 women there was no evidence of new psychiatric symptoms relating to the spontaneous abortion after the immediate postabortion period. Immediate response fo the spontaneous abortion Thirteen women reported they experienced depressed feelings at the time of the spontaneous abortion. In most of these cases, these feelings began prior to the completion of the abortion, when the patients were told by their obstetricians that the abortion was inevitable. Another 9 women reported feelings of disappointment, but did not report feeling appreciably depressed at the time of the abortion. Six women had open and outright feelings of relief and were glad the abortion had occurred. Two women reported mixed feelings of disappointment and relief. The responses of two other women could not be categorized. Eight of the 13 women who were depressed at the time of the spontaneous
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abortion had diagnosable psychiatric illness at follow-up. Only 1 of the 9 women who were disappointed had a psychiatric diagnosis at follow-up. Depression at the time of abortion was also more common in those women who had planned pregnancies (6 of 13) and less common in those who did not (3 of 9). Guilt
following
spontaneous
abortion
Twenty-five (78 per cent) of the 32 women included in this study reported either very little or no feelings of guilt related to the spontaneous abortion. Seven (22 1x1 cent) of the women did report feelings of guilt that were quite conscious and concerned them for periods up to many months follolving the abortion. In the spontaneous abortion group only one of the 12 women who did not have a psychiatric diagnosis made at the titncs of the evaluation reported conscious feelings of the 20 women with of guilt. However, psychiatric diagnoses, 6 (30 per cent) rrported moderate to marked conscious guilt feelings (Table IV). There appears to hp a relationship between the presence of psychiatric illness and the appearance of moderate to marked conscious guilt following :I spontaneous abortion. It should be added that in all of these cases in which guilt feelings of signific.ant intensity were reported, the women had not made attempts to induce an abortion. Seven of the 26 women with living children reported conscious guilt, while none of the 6 women without living childrrn reported guilt feelings. The women who did experience conscious guilt tverr, as ;I
Table IV. Psychiatric and conscious abortion
guilt
diagnoses at follow-ul) after spontaneous
Moderate to marked conscious guilt
group, slightly older than those who did not (an average of 30.0 years versus an average of 28.3 years). Psychological
dOC!S.
For one woman (3 per cent) the ‘1‘ score on the D scale was over 70. This compares \vith I.? won~en (28 per cent) in the therapeutic abortion group who had T scores above 70. PD arid MF sca1c.r. The PD scale measures trends toward psychopathy and acting out behavior. The average raw score for the 32
Table V. MMPI with -~-
raw scores for women spontaneous and therapeutic abortioll .~-~...~-~-Hatha- .-.-- ---..-- .-__ __
D scale
Average Raw score Range S. D. PD
6
14
20
1
11 --___.
12
Total
7
25
32
\ way and / Briggs
19.3
Spontaneous
Therapeutic
20.7
24.6 t 5-37 5.70
1 I-3.5 5.18
4.20 (N.S.)
(P-
O.OOlj
and 0.4K
S.D.
Psychiatric diagnoses No psychiatric diagnosis
data
D .scale. The D scale on the MMPl is a measure of depressive mood. The average raw score on the D scale for the 31 women Ivho completed the MMPI was 20.7. These scores can bc compared with the data obtained in the group of women studied previously who had therapeutic abortion and also with Hathaway and Briggs”” results from a study of a large normal population of woman (Table V) . The spontaneous ahortion group does not differ significantly from Hathabvay and Briggs’ normal population of women? but the therapeutic abortion group
Range
Total
test
MMPI.
Average Raw score Little 01 no conscious guilt
July 15, 1969 J. Obst. & Gynrc.
18.4 4.40
21.5 13-29 4.35 rP=O.oolj
24.3 14-34. (P=O.o01i
38.5 30-46 4.76 (Pm-0.05)
38.7 29-49 5.15 (P-0.01)
5.18
MF .4verage Raw score
36.5
Range S.D.
4.83
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women with spontaneous abortions was 21.7 for the PD scale. Both the spontaneous and therapeutic abortion groups differ significantly from Hathaway and Briggs’ normal women (Table V) . When the raw scores are converted to the T scores, only 2 women (6 per cent) of the group had scores of 70 or greater. In the therapeutic abortion group 17 women (37 per cent) had T scores greater than 70. The MF scale is related to concerns about sexual role. High raw scores (or low T scores when the data are converted) indicate trends toward resolving conflicts about sexuality by exaggeration of “typical feminine attitudes.” The raw score on the MF scale for the spontaneous abortion group was 38.5. Both the spontaneous abortion group and the therapeutic abortion group differ from Hathaway and Briggs’ normal No woman in the spontaneous women. abortion group had a T score lower than 30, but 8 (25 per cent) had T scores between 30 and 39. Only 12 women (38 per cent) had T scores above 50 on the MF scale. In the therapeutic abortion group 5 women (11 per cent) had T scores below 30, 6 women (13 per cent) between 30 and 39 and 16 (35 per cent) over 50. The combination of low MF scores and high PD scores is consistent with sadomasochistic conflicts in character structure. Four women (13 per cent) in the spontaneous abortion group had a combination of low MF (T score less than 39) and high PD (T score over 60). An additional 2 women (6 per cent) had differences of greater than 20 between their MF and PD scores. In the therapeutic abortion group 20 women (43 per cent) had this type of MF/ PD configuration. Table VI relates scores on the PD and MF scales to the number of abortions. Women with three or more abortions have scores on the MF scale higher than the group as a whole and have scores on the PD scale lower than the group average. Attitude toward feminine biologic role. Thirty-one women completed the Loevinger Family Problems Test. The Feminine Biolog-
Psychological
factors
Table VI. MMPI raw of spontaneous abortions
in abortion
scores
No. I
of
I
and
803
number
abortions 2
I
2:
PD + 0.4K
Average raw score Range
21.3
23.2
20.6
13-27
17-29
17-26
38.7 30-46
37.0 32-45
39.6 31-43
MF
Average raw score Range
Table VII. Attitude toward feminine biologic role in 31 women with spontaneous and 40 women with therapeutic abortion Spontaneous f%)
Therapeutic (%)
Rejection of feminine biologic role
32
40
Normal range, feminine biologic role
68
50
High positive feminine biologic role Total
100
10 100
ical Role scale in this test measures attitudes toward feminine functions such as nurturing, childbearing, etc. Ten women (32 per cent) had scores on this scale which indicated rejection of feminine biologic role. The remaining 68 per cent scored within normal range (Table VII). Of the 10 women who had scores which indicated significant rejection of feminine biologic role, 6 had psychiatric diagnoses made at the time of interview (5 neurotic reactions and one personality trait disturbance). Comment We embarked upon this study of women who had spontaneous abortions in order to compare them with women who had undergone therapeutic abortion. The group of spontaneous aborters studied appears to be a representative group of middle class, white,
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married, American women. In the spontaneous abortion group, 62.5 per cent had diagnosable psychiatric illness at the time they were interviewed. This compares with 70 percent of the therapeutic abortion group who had diagnosable psychiatric illness at the time of follow-up. While the numerical difference is not statistically significant, qualitatively there was a marked difference. In the spontaneous abortion group, the psychiatric illness was strikingly less severe. There were no psychotic reactions diagnosed in the spontaneous abortion group, while there were 7 (15 per cent) schizophrenic reactions in the therapeutic abortion group. Since one third of the therapeutic abortion group was aborted for psychiatric indications the differences in severity and extent of psychiatric illness are not surprising. Yet this is not the whole story for there was more extensive and serious psychopatholo
July 15, 1969 Am. J. Obst. Sr Gynec.
abortion group on these two scales, some important qualitative and quantitative differences must be noted. There were many high scores on the PD scale, but not as many of these women peaked at T scores over 70 as did the therapeutic abortion group. Only two women in the spontaneous abortion group had T scores on the PD scale over 70, while 17 of the therapeutic abortion group had T scores over 70. Similarly, the strikingly low MF scores seen in the therapeutic abortion group were not present. The therapeutic abortion group included 5 women with T scores on the MF scale of less than thirty. Thirty was the lowest score in the spontaneous abortion group and leas present only in one case. While there were 6 women with MF/PD differences of greater than 20, there were fewer of the very dramatic differences which were seen in the therapeutic abortion group, which had 5 women with differences of over 40 between the MF and PD scales and another 15 women with differences of greater than 20 points in the T scores on these scales. ‘l’his information, coupled with the data from the clinical interviews, which reveals much less evidence of acting out sociopathic behavior, leads to the conclusion, that while these trends are present in the spontaneous group, qualitatively, they are not so intense, are dealt with in different ways, and cause less apparent difficulty in the lives of the women studied. Twenty-two per cent of the spontaneous abortion group had feelings of conscious guilt that appear to be important to them and lasted for some time. This compares with 35 per cent in the therapeutic abortion group who experienced moderate to marked conscious guilt following the abortion. A not unexpected finding for the spontaneous abortion group is that those women with no psychiatric diagnoses had little guilt about the abortion and seemed to deal with the loss of the fetus in adaptive ways. Characteristically, there was transient grief, and a sense of loss and unhappiness which usually lifted in a few days. The women with positive psychiatric diagnoses experienced the most
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conscious guilt about the spontaneous abortion, In addition, the women with psychiatric diagnoses were the most equivocal about being pregnant or, once pregnant, had not accepted the idea of being pregnant. Fairly short periods of disappointment were most characteristic for those women who did not have diagnosable psychiatric illness. The women with psychiatric diagnoses tended to be depressed immediately following the spontaneous abortion. There were 29 cases in which enough time had elapsed SO the process could be understood. In 22 women there were no persistent psychiatric symptoms directly related to the spontaneous abortion itself. In 6 cases the feeling of depression continued for an appreciable period following the spontaneous abortion. Our data would indicate a marked difference in the amount of psychiatric illness following abortion in the spontaneous abortion group as compared to the therapeutic abortion group. In the therapeutic abortion group, 6 women had psychiatric hospitalization subsequent to their abortions; 4 developed depressive reactions and 2 developed duodenal ulcers. The amount of psychopathology seen following spontaneous abortion over the same 10 year follow-up period is minor when compared to the therapeutic abortion group. However, the data indicate a rather surprising difference. In the therapeutic abortion very little of the subsequent psygroup, chiatric illness appeared related to the therapeutic abortion. It was, instead, seen as part of chronic psychopathology that existed prior to the therapeutic abortion and appeared in time sequences that were, in most cases, unrelated to the abortion. This was true in 9 of 12 cases of psychiatric illness after therapeutic abortion. In the spontaneous abortion group, while the amount and extent of the psychopathology were much less, that which does appear seems to be much more closely related to the abortion. In 6 women neurotic reactions (predominantly depressive) developed at the time of the spontaneous abortion and persisted for periods ranging from several months to 4 years.
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Our data tend to confirm some of the findings from our first study. The women who come to therapeutic abortion appear to be a selected group in terms of their psychodynamics and psychopathology and there is a strong suggestion of a similar selection in spontaneous abortion. That is to say, our data would indicate that pre-existing conflicts appear to be a very important determinant, no matter whether the abortion is spontaneous or induced, even though flagrant sadomasochistic behavior, so characteristic of the therapeutic abortion group, was not present. The MMPI and Loevinger Family Problems Scale indicate that conflicts around acting out, psychopathic behavior, exaggerated feminine attitudes, sadomasochism, and feminine biologic role are of considerable importance in the dynamics of the spontaneous abortion group. However, the data we have available indicate that the pregnancy itself appears to be one focus for the acting out of sadomasochistic conflicts. Women whom we found to have greater conflicts around sadomasochism were also those who had more unplanned pregnancies and pregnancies which were not accepted once they occurred and also appeared to experience greater relief at the time of the abortion and had less depression following the abortion. Finding sadomasochistic conflicts and rejection of feminine biologic role present in a significant number of the spontaneous aborters underlines the rather obvious fact that there may be more than one way to skin a cat. That is, previous work2mg has indicated that psychological conflicts can play a very important part in spontaneous abortion. The spontaneous abortion itself may represent an alternative way of dealing with and acting out sadomasochistic impulses and conflicts around feminine biologic role. Our data have led us to speculate about two issues. The first speculation grows out of the findings that the total abortion rate for both spontaneous and therapeutic abortions was identical. We feel data should be gathered on a much larger sample to see if this can be replicated. From our experi-
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ence we would predict that larger samples will show similar findings. Our material suggests that there are women who wish either consciously or unconsciously to get rid of the pregnancy, and they seemto accomplish this in one way or another. The cycle of pregnancy and abortion (whether spontaneous os induced) seemsto us an important avenue of discharge for pressingunconsciouspsycholo,gical conflicts. Our second speculation grows out of our finding of significantly more guilt in women with living chiIdren than in women without children. We believe that the unconscious meaning, i.e.. the transference meaning, of the
REFERENCES
1. Simon, M., Senturia, A., and Rothman. D.: Am. J. Psychiat. 124: 59, 1967. 2. Grimm, E. R.: Psychnsom. Med. 24: 369, 1962. 3. James, W. H.: A~I. J. ORST. & GYNEC. 85: 38, 1963. ‘1. Javert, C. T.: Spontaneous and Habitual Abortion, New York, 1957, McGraw-Hill Book Company, Inc. 5. Mann, E. C.: S. Clin. North America 37: 447, 1957.
Discussion DK. JOHN I’. HARROL), Chicago, Illinois. ‘I‘hc authors have presented a very timely and intert:sting article which scientifically confirms what some have proposed for years, that there is a relationship between women who have therapeutic absortions and those who abort spontaneously. I dislike the restricting of the term “therapeutic absortion” to those done in the hospital as I believe some illegal absortions are also therapeutic. Therese Benedek has stated that therapeutic abortions are motivated not only by social, ethical, and economic factors but also by unconscious fears in women, which in those of lesser fertility may cause sterility or spontaneous absorti0n.l The authors have interviewed each patient for one to 2 hours and have been able to probe their unconscious levels. I wonder if some of this might be conjecture, since the gynecologist may require four or five visits before the conscious reason for the first visit is discerned.
fetus to the mother is critical in determining this response.Two possibilitiessuggestthemselves; the first is that undischarged or poorly neutralized hostility to the living children could be involved. The pregnancy could mobilize resentment and anger and malit> consciously experienced guilt an important mechanism in dealing with the abortion which may have been unconsciously desired. Another possibility would involve identitication of the fetus with siblings in the mother’5 family of origin. Again unconsciousjealous) :tnd resentment stimulated by the transferrnce meaninp of the fetus could produc’tu more conscious guilt.
6. Rothman, D., Kaplan, A. H., and Nettles. E.: AM. J. OBST. & GYNEC. 83: 383, 1962. 7. Mann, E. C.: Obst. & Gynec. 7: 589, 1956. 8. Tupper, C., and Weil, R. H.: AM. J. OHSI-. & GYNEC. 83: 421. 1962. 9. Rothman, D., and Kaplan, A. H.: .4m. CIIII. Obst. & Gynec. 25: 457, 1965. 10. Hathaway, S., and Briggs, P. F.: J. Clin. Psychol. 13: 364, 1957. 216 South Kingshighwq St. Lmks, Missouri 631 IO
Was there a reason for selecting December for obtaining the cases? I would think, that with holidays in December basically devoted to children, this would favor the occurrence of mild psychiatric disturbances. Fifteen out of the 32 spontaneous aborters had neurotic reactions and 5 had personality trait disturbances. Doesn’t everyone have a personality trait disturbance? Thirteen of the spontaneous aborters expcrienced moderate depression and another 9 disappointment. I wonder how one differentiates the two, especially since interviews were conducted 3 months to 10 years after the absortion occurred. Could this not be retrospective falsification on the part of the patient in that society expects these emotions of them. All of us, I believe, experience disappointment daily. In my own practice I frequently see disappointment after spontaneous absortion but seldom what I call true depression. Were the investigators looking for depression?
Vchne 104 Number 6
The Christian influence that has so strongly affected our morals and emotions for the past 100 years has taught actively or passively that life entered the fetus at conception and any interruption was murder, hence, I’m surprised that only 22 per cent had guilt feelings. Society must bear the blame for all psychiatric residuals after any type of abortion. In Switzerland, where the influence of John Calvin still thrives, over 50 per cent had psychiatric disturbances after abortion.2 In Norway, where sexual matters and morals are much more logical, Bard Brekke in a study of 400 abortions found only 2 cases of mild psychiatric disturbance. This certainly indicates the psychological disturbances are not intrinsic3 Concerning the psychological data (MMPT and Leovinger Family Problems Test) I would like to ask the authors if they found a correlation between the findings on the test pertaining to psychopathy and the rejection of the feminine biologic role and the clinical findings of the same. My understanding is that no correlation exists. REFERENCES
Benedek, T.: In Arieti, S.: American Handbook of Psychiatry, New York, 1967, Basic Books, vol. I. Chap. 37, p. 727. Simon, N. M., and Senturia, A. G.: Arch. Gen. Psychiat. 15: 378, 1966. Brekke. B.: In Calderone. M. S.: Abortion in the United States, New York, 1958, Hoeber Medical Division, Harper & Row, p. 134. DR. GEORGE J. L. WULFF, St. Louis, Missouri. The authors have made a psychiatric study of a group of women who had spontaneous abortions and have compared the findings with those in women who had had therapeutic abortions. Aside from confirming their own statement that their conclusions have been drawn from a very small group of patients, my comments about this paper will relate to the problem of trying to compare apples and oranges. The authors attempt to compare two very dissimilar groups of pregnant patients, pointing out, in one instance, that 65 per cent of the therapeutic aborters had psychiatric illness antedating their abortion, but that none of the spontaneous aborters showed such earlier illness. I would like to call your attention to other areas of dissimilarity. In almost all cases of therapeutic abortion the conceptus must be considered normal, and the termination of such pregnancy, therefore, involves the destruction of
Psychological
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807
a potentially normal human being. We are all aware of the emotional conflicts arising in these women as they struggle to make this decision. Having taken the step, many patients, therefore, will develop guilt feelings and/or psychiatric illness undoubtedly related to this destruction of a normal conceptus. Spontaneous aborters on the other hand have an entirely different pregnancy. It is usually a desired one, and its termination usually does not involve a normal embryo. Unfortunately, the authors do not mention either of these facts. Neither do they evaluate the role of the attending physician in his management of the spontaneous aborter. These patients frequently exhibit warning symptoms for days or weeks; vaginal spotting or bleeding and failure of the uterus to enlarge properly. These symptoms afford the physician and his patient time to suspect and prepare emotionally for a possible unfavorable outcome. These patients can be oriented as to the inevitable outcome and its actual desirability. They can be reassured that the pregnancy was probably an improperly developing one, and that its rejection was a normal physiologic process. Obstetric literature is filled with evidence to support this thesis, and there is ample evidence that a high percentage of these spontaneous aborters have abnormal pregnancies. Nayak showed that of 417 cases of spontaneous abortions, 65 per cent were doomed because of faulty conceptus or faulty placental development and implantation. In their cases of spontaneous abortion, Dr. Simon and his co-workers have noted that 63 per cent developed a diagnosable psychiatric illness during the follow-up and infer that these are related. I cannot believe these same figures would have been obtained if the nature of the abortion itself had been determined prior to the study, and if the orientation by the patient’s physician had been properly evaluated. If they had, I believe that little or no relationship would be found between spontaneous abortions and subsequent psychiatric illness. Finally, it seems illogical to me to compare patients having spontaneous abortions with those having therapeutic abortions-they are as dissimilar as apples and oranges. REFERENCE
1. Nayak, S. K.: Obst. & Gynec. 32: 316, 1968. DR. SIMON (Closing). I would like to turn first to Dr. WulfT’s comments because they touch
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on what was for us the most surprising and critical issue, i.e., Dr. Wulff’s comments about the apples and oranges. We originally embarked on this study when, as part of our study of therapeutic abortion, we thought we would get a control group, and we entertained the apple and oranges hypothesis, too. We thought if we compared our therapeutic aborters with women who aborted spontaneously that would be holding the element of pregnancy itself constant, that is, two groups-both of whom became pregnant, both of whom lost the fetus, but in quite different ways. Now I would say that the dissimilarities are perhaps more superficial than real and more apparent than real. We were quite surprised by our findings. We had no idea that when we examined the spontaneous aborters closely that they would turn out on several parameters to resemble the therapeutic aborters. Those parameters were conflicts about feminine role and sadomasochism. In these respects, we think these two groups are very much alike, although there is some difference in degree. We don’t quibble about that. There is a difference in degree, but we think that in terms of basic conflicts they arc very much alike and much more like each other than groups of normal women who have been studied in this same way. So, I must differ with Dr. Wulff’s comment about the dissimilarities between women who have had spontaneous and therapeutic abortions. I think the important thing is from a psychological standpoint, that what looks so dissimilar can be quite similar inside somebody’s head, and sometimes the most important thing for the woman is not actually how the pregnancy MGIS lost but the fact that the pregnancy was lost, and what the meaning of the pregnancy was to her in the first place. I agree with Dr. Wulff on one point completely. Our sample is a very small one. We are in the process of studying a much larger group of women to see if we can replicate our own findings. In reference to Dr. Wulff’s comments about
July 15, 1969 Am. J. Obst. & Gym.
psychiatric illness after abortion, either we have not made this point clearly or have been misread. For one thing, we do not say at any point in our paper that the appearance of the neurotic illness in either group of women is always related to the abortion in a causal way. We do not say that there is a one-to-one relationship generally. Only in those cases that WC can really establish a hard and fast relationship do we say that. As a matter of fact, for the therapeutic abortion group, we found, for example, that out of 6 women who are hospital&d after thcrapcutic abortion, in only one of those women did we think the therapeutic abortion had anything 10 do with her hospitalization. In the group we stltdied for spontaneous abortion, there was one lvornan hospitalized. She was hospitalized following the birth of a child 5 years after the spontnncous abortion. i\ftcr my evaluation of the &(a on that woman, I thought that it ~vas not the spontaneous abortion that was really critical IO her illness. As a matter of fact, it has been established fairly clearly that there is a higher rate of psychiatric illness growing out of the postpartum prriod than there is out of thr postabortion period, and that having a living child may be more psychologically stressful than abortirl,q for some wompn. I also differ with Dr. Wulff about his feelin? aboul normal conceptions and abnormal cone-cptions and how women arc able to handle them. In our csxpcricncc that did not scrm to bc so (.ritic.al. The question is not that you can rcassure the ~von~an that it ~YIS an nhormal pt-rgnanny and would have been lost anyhow. bllt what that pregnancy meant to her. I would say that WC recognize very well that w-omen begin to mourn the loss of a fetus clue-ing the period of time before the spoutaneous abortion goes to completion. That is a vc~y unclcrstandable thin,q, and we know that. Mourning hegins ahead of time just like mourning begins for a spouse or parent who is dying, but not yrt dead. ‘These women begin the same way, and so the depression begins before the pregnancy is actually terminated.