Psychiatric–Medical ComorbidityNeuroticism and low educational level predict the risk of posttraumatic stress disorder in women after miscarriage or stillbirth☆
Introduction
Almost one in five pregnancies end in pregnancy loss. This is the most common complication in pregnancy [1]. There are 47,500 such incidences in the Netherlands every year (http://statline.cbs.nl), and 80% occurs within the first 20 weeks. Even during the early stages of pregnancy, many women find this a stressful experience, resulting in sadness, anger, tension, a sense of guilt and search for meaning [2], [3], [4]. These reactions generally decrease with time. However, a minority of women suffer from depression and anxiety disorders or problems recorded in the DSM-IV [5] as posttraumatic stress disorder (PTSD). PTSD is typified by three symptom clusters: “reexperiencing the traumatic event” (e.g., upsetting intrusive recollections, nightmares, flashbacks, being upset by reminders), “avoidance of its reminders and emotional numbing” (e.g., avoidance of thoughts, places and activities, restricted affect, diminished interest, detachment from others) and “increased arousal” (e.g., sleeping problems, irritability, hypervigilance, difficulty concentrating). The DSM-IV requires the occurrence of at least one reexperiencing symptom, three avoidance symptoms and two symptoms of increased arousal for at least 1 month that cause significant distress or impairment in functioning to diagnose PTSD. Although PTSD was initially associated with war, violence and disasters, it has been shown that a similar disorder can follow threatening medical experiences [6]. This may involve a miscarriage, particularly if it is experienced as the death of a baby, if parental bonding has taken place and if the patient is exposed to potentially unpleasant images of blood and tissue [2], [3], [7], [8].
Although the prevalence of PTSD is only 1.7% after a normal pregnancy [9], it seems to be around 25% about 1 month after pregnancy loss, with a symptom severity comparable to that of clinical PTSD patients [10]. This percentage decreases to 10% after around 4 months, 5% after 6 months and 4% after 12 months. Depressive symptoms are more severe for women with PTSD after 1 month and appear to extend beyond 4 months [10], [11]. The onset of such disorders can lead to problems in a subsequent pregnancy, including the reactivation of PTSD. This occurs in 20% of cases [12] and can have unfavorable obstetric and postnatal consequences [13]. PTSD can also lead to fear of subsequent pregnancy, avoidance of sexual intercourse, avoidance of medical care, and so forth [4], [7]. Such avoidance symptoms increase in time. The symptoms described above and the avoidance behavior suggest that early intervention is important.
Psychological intervention in all patients who have experienced a potentially traumatic event is not effective and can have more disastrous effects than no intervention [14]. Interventions must be aimed at individuals at higher risk [14]. Who are they? First of all, it has been found that PTSD is predicted by indicators of the severity of the stressor, such as the gestational age [10]. In the case of longer gestation, parental bonding increases. However, this is not always a good predictor [6]. Much research has been conducted into premorbid risk and protective factors but almost always retrospectively. This is a problem because variables can be distorted by PTSD symptoms. Some extensive prospective trauma studies found that lower cognitive ability (intelligence and education) and higher neuroticism (the stable tendency to interpret experiences in a negative way) are among the best pretrauma predictors of PTSD (e.g., Ref. [15]). Note also that in countries with a very accessible and differentiated secondary education system, there is a high correlation between educational level and intelligence. The predictive value of education and neuroticism corresponds with an influential theory [16], which suggests that PTSD does not originate directly from the traumatic event but from negative interpretations of the (effects of a) traumatic experience and from the lack of integration of traumatic memories in autobiographical memory.
The goals of this study were to document the predictive value of these factors in the onset of PTSD after pregnancy loss and to develop a risk table for practical usage. Gestational age was taken into account. Participants enrolled in the study in early pregnancy. This way, PTSD predictors could be assessed before pregnancy loss (see Refs. [10], [17], [18]).
Section snippets
Participants
In advertisements in Dutch national newspapers (from June to November 1999), women in the early stages of pregnancy (less than 12 weeks) were requested to take part in a study regarding the experience of pregnancy. Immediately after enrolment, they received the Eysenck Personality Questionnaire and other questionnaires, including one involving educational level (see Section 2.2). Every other month during the pregnancy and 1 month after the expected birth date, they received short questionnaires
Results
The average neuroticism score was 7.3 (S.D.=4.6), and the average PTSD Symptom Scale score was 18.1 (S.D.=9.1). Based on the PSS-SR, 31 women (26%) met the PTSD symptom criteria and 86 women did not. The average PSS-SR score was 28.2 (S.D.=7.0) for the group with PTSD and 14.7 (S.D.=6.7) for the group without PTSD. Table 1 shows age, gestational age, education and neuroticism for women who met the PTSD criteria and those who did not. The groups differed only on the latter three variables.
Table 2
Discussion
Based on the PTSD Symptom Scale, 31 of the 117 women fulfilled the DSM-IV criteria for PTSD. It was possible to predict whether they would or would not develop symptoms on the basis of a combination of two elementary factors: neuroticism and education. For patients with a high education and low neuroticism, the risk of PTSD is negligible; for patients with a low education and high neuroticism, the estimated risk is around 70%. Elsewhere and previously, the predictive ability of
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This article has been published before as Engelhard IM, van den Hout MA, Schouten E. Vroege identificatie van vrouwen met verhoogd risico op post-traumatische stress stoornis na miskraam of doodgeboorte. Ned Tijdschr Geneeskd 2004;148:2540–44.