Post-Abortion Syndrome (PAS) is a suggested variant of Post Traumatic Stress Disorder (PTSD) and abortion was one of the traumatic events listed in DSM-111R,60 the diagnostic manual used in the U.S. for the diagnosis of mental disorder.
The Fourth Edition of DSM dropped abortion from its list of possible precipitants, but this is far more likely to have been a political decision than one based on clinical evidence. Since then, even more evidence has accumulated indicating that abortion can form the substrate for psychiatric disorder. Post Traumatic Stress Disorder is the result of having suffered an event so traumatic that the person is unable to process the event in a "normal" manner.
There are several theories behind the pathogenesis of PTSD, but thus far they remain theoretical. Sufferers of PTSD are unable to simply resume their lives where they left off before the traumatic event. Instead, they experience a variety of severe psychological symptoms that do not go away merely with the passage of time.
The risk that an experience will be traumatic is increased when the traumatising event includes threats of physical injury, sexual violation, or the witnessing and/or participation in a violent event.
Women experience abortion as a traumatic event for a variety of reasons. Some may be forced into an unwanted abortion by boyfriends, parents, doctors, counsellors or others.
Certainly, some women, no matter how sure they were about wanting the abortion, may still perceive the termination of their pregnancy as the killing of their own child. The fear, anxiety and guilt associated with the procedure often become overwhelming.
The abortion researcher David C Reardon records in his book, Aborted Women: Silent No More, that some women reported that the pain of abortion inflicted by a masked stranger in surgical garb feels identical to rape. Indeed, researchers have found that women with a history of sexual assault may experience greater distress during and after an abortion because of the association between the two experiences. (61)
The overwhelming similarities between the defined Post Traumatic Stress Disorder and the purported Post-Abortion Syndrome leave little room for doubt that PAS is a variant of PTSD. As with PTSD, the symptoms and signs are varied and may not appear for some time after the trauma.
They are, nonetheless, real, and should be dealt with accordingly. Each of the symptoms of PAS/PTSD may appear independently and not every woman is necessarily going to experience the entire syndrome. Some symptoms may occur immediately after the abortion, while others may take months or even years to surface.
The primary features of Post-Abortion Syndrome are as follows:
Hyper-arousal is the characteristic of inappropriately and chronically aroused "fight or flight" defence mechanisms. The person is seemingly on permanent alert for any threat of danger.
2. Intrusions / Flash-backs:
The re-experience of the traumatic event at unwanted and unexpected times. This includes recurrent and intrusive thoughts about the abortion or aborted child, flashbacks in which the woman relives the abortion momentarily, intense grief at certain times such as the anniversary of the abortion, etc. (62)
A person who has experienced a highly painful loss will sometimes develop an instinct to avoid future situations that may remind them of the previous traumatic event. In post-abortion trauma cases, avoidance behaviour may include an unwillingness to recall the abortion experience, efforts to avoid situations which may arouse recollections of the abortion, withdrawal from relationships, avoidance of children, etc.
Depression is one of the most frequently encountered adverse abortion consequences. Shame, secrecy, suppressed thoughts and emotions regarding an abortion, are all associated with greater post-abortion depression, anxiety and hostility. Frederick Burkle writes in The Practitioner that if the loss is valued depression will occur. He concludes that to resolve this depression a process of mourning will have to occur. (63)
Depression may be associated with impacted or pathological grief (loss of the baby, loss of a role as mother, loss of a dream). It may also derive from unexpressed anger, changes in primary relationships or personal circumstances. Parry et al, (64) also confirm the association between abortion and subsequent depression in their report. They conclude that "women are vulnerable to depressions associated with abortion."
Feelings of guilt are among the most common immediate, as well as delayed, reactions to abortion. Guilt is a normal reaction that usually surfaces after the woman fully comes to terms with the consequences of the abortion. One particular study, (65) which interviewed a number of post-abortion women who were receiving a variety of services at a pregnancy services centre, found that 66% of them experienced guilt and 54% expressed remorse or regret after the abortion. Feelings of guilt are, of course, more common in cultures in which there is obvious hostility to abortion. The guilt is often expressed through anger at herself and others involved in the abortion decision, such as her parents, doctor, social worker, counsellor etc.
Anxiety is essentially an unpleasant emotional and physical state of apprehension. Catherine Barnard did a study on post-abortive women for the Institute of Pregnancy Loss (65a) and found that 47.5% of the women exhibited an elevated level of anxiety after the abortion. Post-abortive women with anxiety may experience any of the following; tension (inability to relax, irritability), physical responses (pounding heart, headaches), worry about the future, disturbed sleep.
60. DSM IV, American Psychiatric Association 2000
61. Zakus G, Wilday S, "Adolescent Abortion Options," Social Work in Healthcare, 12(4):77, Summer 1987
62. Speckhard A C, Rue V M, "Post-abortion Syndrome, An Emerging Public Health Concern," Journal of Social Issues, Vol 48(3): 95-119, 1992
63. Burkle F M, "A Developmental Approach to Post-Abortion Depression", The Practitioner 218:217, February 1977
64. Parry B L, "Reproductive Factors Affecting the Course of Affective Illness in Women," Psychiatric Clinics of North America 12(1): 207, March 1989
65. Gsellman L, "Physical and Psychological Injury in Women Following Abortion: Akron Pregnancy Services Study," Assoc. for Interdisciplinary Research in Values and Social Change Newsletter 5(4): 1-8, 1993
65a. Barnard C, "The Long Term Psychological Effects of Abortion," Portsmouth: Institute for Pregnancy Loss, 1990
Melbourne psychiatrist Dr. Eric Seal, who defined PAS as "a delayed or slow developing, prolonged and sometimes chronic grief syndrome..." stated: "The post-abortion syndrome is not like a more severe form of postnatal blues. It is far more serious, more delayed in onset, more lasting and more fundamentally involved in subsequent personality development..."
He also said that "If the syndrome persists and is not treated adequately, personality changes will gradually emerge and affect one's family life, one's working capacity, and one's social and recreational potentials to say the least."
However, research on post abortion trauma has been inadequate, and numerous unscientific opinion papers have only served to confuse.
Health professionals are not being trained in the skills of diagnosis and treatment of PAS, and are generally reluctant to investigate when problems arise subsequent to an abortion, offering at best, symptomatic treatment. Therapists who are concerned about abortion trauma, not unreasonably fear being professionally attacked or isolated (particularly from those with a "personal investment" in the safety of abortion) if they speak publicly or professionally of their concerns.
It needs to be stated, although it would seem obvious, that for many women abortion, like miscarriage and stillbirth, is a death experience.The aborted woman may develop PAS, not simply because of the death of the foetus but because the reality of her responsibility, or part responsibility for that death has not allowed her to process that death as one would normally process a death loss.
This unprocessed grief is complicated by the fact that abortion is not a socially recognised loss. The aborted woman has no social support in which to gradually process the pain she has experienced. No matter what the stage of foetal gestation, the PAS-prone woman believes that what was destroyed in the abortion was an unborn baby. However, rather than make a decision that was consistent with her real feelings and convictions, in her fear and panic, she went into "denial."
In this she was usually assisted by those significant others to whom she turned for help.
The cardinal features of PAS are denial and suppression. Typically the abortion is followed (but not always) by years of unrecognised negative reactions, the woman not consciously associating the symptoms with the abortion.
The onset of delayed symptoms is often precipitated by a triggering event such as an anniversary date, the birth or loss of another child, or some other event associated with children or reproduction. As Professor Ney advises, "...they are usually able to keep up a façade, but easily decompensate with serious physical or psychiatric illnesses in times of crisis."
The severity and incidence of PAS is often related to how well "affirmed" a woman is, eg: women from an emotionally unstable or dysfunctional background are more likely to suffer severe psychological and emotional trauma. Research has been identifying "high risk" women since the early 1980's.
These include the young, the traumatised, those isolated or dispossessed, those whose coping mechanisms have already been compromised, the sexually abused, those with developmental or psychological limitations, the mentally ill and those who abort for health reasons. Rather than screening these vulnerable women out of the abortion solution, or even warning them, their pre-existing emotional state or impaired decision-making ability when in crisis is being used to explain their poor abortion outcome.
Dr. Vincent Rue calls this a new type of victim blaming.
Henry David's record link of 1.1 million Danish women, one of the best methodologically designed studies complete to date, found women who aborted were 53% more likely than delivering women to be admitted to a psychiatric hospital.
But women who aborted, and who were separated, divorced or widowed were nearly four times as likely as those (in the same category) who delivered, to be admitted to a psychiatric hospital.
Unfortunately, David limited his study to only three months post event, and did not identify how many of those delivering women admitted to a psychiatric hospital had abortion histories. (A later delivery is one of the common triggering events for the onset of PAS).
(David's findings were opposite to the much publicised, much quoted but inherently flawed Brewer study which found abortion psychologically safer than childbirth.)
In 1992, the British Journal of Psychiatry published a review by Zolese and Blacker, which found that psychological or psychiatric disturbances occur in association with abortion and seem marked, severe or persistent in approximately 10% of cases.
Given the serious limitations of many of the studies to date and their frequent interpreter bias coupled with the tendency of PAS to be labelled by its presenting symptoms, 10% probably underestimates the true picture.
In 1994, a private UK commission of Inquiry chaired by Lord Rawlinson into the effects of abortion on women found 87% of women it surveyed experienced long-term emotional consequences with 15% actually requesting counselling.
Dr. Patricia Casey, Professor of Psychiatry, Dublin, advises those working in this area to use models of treatment used in treating other forms of bereavement and major trauma.
Dr. Joanne Angelo, Assistant Clinical Professor of Psychiatry Boston, advises that the overwhelming needs of the PAS sufferer may be more than one discipline can or should try to meet, and suggests a multifaceted team approach. However, a great deal more work urgently needs to be done in this area.
[It is important to note that abortion referral agencies and institutions, because of their role in facilitating denial, are inappropriate venues for such therapy.]