Post-Abortion Syndrome

The paper develops the controversial topic of artificial termination of pregnancy in connection with its possible impact on the woman’s mental health in the form of the not infrequently appearing post-abortion syndrome. Post-abortion syndrome is a set of symptoms which in some women appear after an artificially induced abortion. It does not have its own diagnostic category and is considered to be a specific form of post-traumatic stress disorder. It manifests itself by general symptoms, which we can find in a post-traumatic stress disorder, but also by specific symptoms, on which the text of the paper focuses and which it analyses with reference to the literature. The paper further points out the risk factors identified by the American Psychological Association as those initiating or aggravating the course of post-abortion syndrome. The theoretical text is concluded by two case studies of women in whom post-abortion syndrome, or a form of post-traumatic stress disorder in direct connection with undergone artificial termination of pregnancy, was diagnosed.


Introduction
One of the foremost places among controversial topics is continually occupied by the issue of abortion, i.e., artificial termination of pregnancy. The topic ensures live debates. But the most zealous philosophico-ethical discussions of the topic are overrun by the intensive internal battle faced by women confronted with an unplanned pregnancy and possibility of abortion. It is a conflict of values, beliefs, desire, insecurities and fears. Every academic argument for or against abortion has been weighed by thousands of women wrestling with the same questions. There undoubtedly are women for whom deciding for artificial termination of pregnancy does not present any psychological load. Others believe, under the pressure of circumstances, that they in fact do not have a choice and make fast and apparently unambiguous decisions. These, however, can have serious impact on the physical, emotional, social and spiritual life of the woman.
However, we can also encounter opinions ranging from the harmfulness of the diagnosis of post-abortion syndrome, through denying its existence, up to views pointing to the positive effect of abortion on the psyche of women. Against proper diagnostics and empirical inquiry into further symptoms there stands the reasoning of abortion supporters, siding with the "prochoice" movement, who consider it to be a manipulative strategy whose aim is to discourage women from deciding freely on their pregnancy. Another setback of diagnosing post-abortion syndrome is according to them the fact that the etiquette of this diagnosis victimizes women by negating their ability to make independent decisions and bear their consequences and forces them into a position of dependence on others (most commonly partners or parents) who had forced them to undergo abortion. 1 According to the organization of Parenthood Federation of America post-abortion trauma is a myth, since allegedly up to 95% of questioned women do not regret the abortion and the organization presents instructions of medical character how to take care of oneself after abortion. 2 Members of this organization go as far as to accentuate the positive gain of an abortion experience. Abortion comprises deciding and successful coping with a personal crisis situation. 3 They present studies showing that abortion does not increase the risk of depression, drug abuse or any other psychological disorder in women any more than an unwanted pregnancy and/or childbirth. To support this attitude they refer to the result of the inquiry conducted by a special board of experts appointed by the American Psychological Association (APA), which had influenced the decision of APA to publish in 2005 an official statement refuting the connection between abortions and subsequent psychological trauma. 4 The psychologist David Fergusson reacted to this statement with his team of investigators. During his longitudinal study he monitored women over the period of 25 years and found that in women who had terminated their pregnancy there occurred suicidal behaviour, depression, drug abuse, anxiety and other psychological disorders, at significant levels.

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The problems were impossible to explain by another factor. This study is interesting in that Fergusson is an open supporter of pro-choice and staunch atheist, who cannot be accused of being biased to publish results that refuted his research presuppositions of the non-existence of post-abortion syndrome. Based on his research Fergusson got in touch with APA, disputed its 2005 statement that abortion presents no risk to the woman's psyche and APA removed its statement with the remark that it is necessary to carry out further investigation. 5 Today post-abortion syndrome is considered to be a specific form of post-traumatic stress disorder. Considering the possibility of abortion up to taking the final decision is in most cases a very strong emotional process accompanied by the feeling of pain, grief, regret. Abortion is an intervention into the bodily and psychic integrity of the woman and as such can be a traumatizing experience. As with other traumas from other causes the individuals often try to forget about the "trial" they had undergone, denying or ignoring the pain which can result from it. Many afflicted women do not consciously link the feelings of emotional discomfort they experience with the abortion, but suppression cannot be considered to be an effective way of coping with the experienced loss.

Risk factors
Researchers have identified a great number of statistically significant factors determining which factors can initiate the development or aggravate the course of post-abortion syndrome. APA in its report for 2008 6 presents an overview of risk factors with respect to the person of the woman and taking into account her personal, social and medical anamnesis: terminating a pregnancy the woman wanted or viewed as meaningful felt pressure of environment to terminate the pregnancy perceived disagreement of partner, family and/or friends with the abortion lack of social support from others personality traits, esp. low self-esteem, pessimistic attitudes, subjectively perceived low control over own life psychological problems in anamnesis before pregnancy feelings of stigmatization need to conceal the abortion from environment exposition to anti-abortion initiatives absence or inability to use coping strategies feelings of obligation to the pregnancy ambivalence concerning the decision for abortion subjectively perceived inability to cope with the abortion prior abortion in anamnesis term of abortion in a later phase of pregnancy low age (adolescence) impossibility of choice (enforced abortion) Here it is necessary to recall that risk factors are not a synonym of a sine qua non cause, just like the presence of one or more risk factors of the above list will not necessarily lead to the de-

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velopment of post-abortion syndrome. Similarly it is necessary to remark that symptoms of post-abortion syndrome need not temporarily directly follow the abortion, and not all of the described symptoms need to appear in a particular case. Some of the symptoms can appear immediately after the abortion, others after several months, others not at all. Whether a woman will develop post-abortion syndrome is determined to a great extent by her personality and circumstances.
For diagnosing post-abortion syndrome two of the symptoms listed below are sufficient. 7 1) Guilt. An individual feels guilt when she breaks her own moral code. For a woman who realizes -whether before the abortion or after it -that she agreed to killing her unborn child the load of guilt is unbearable. It is difficult to comfort a woman who suppressed one of the strongest instincts (i.e., the maternal one). Many women suffering of post-abortion syndrome believe that the unpleasant feelings they experience are inevitable, because they have deserved punishment for betraying their own moral conviction.
2) Anxiety. Anxiety is an unpleasant emotional and physical state manifesting itself among others by muscular pressure, dizziness, tachycardia, nausea, headache. Anxiety is accompanied by problems with concentration, sleep disorders, obtrusive thoughts linked with worries about the future. The conflict between moral norms and decision to undergo abortion can trigger massive anxiety. It frequently happens that the woman does not attribute the anxiety symptoms to the abortion she had undergone, but nevertheless will unconsciously try to avoid everything that has to do with children (and therefore nourishes her anxiety). Anxiety can take the form of tension (inability to relax, irritation, etc.) accompanied by physical symptoms (dizziness, increased heartbeat, nausea, headache, etc.), worries concerning the future, concentration problems and sleep disorders.
From the point of view of psychology the trigger of anxiety is conflict, in this case a conflict of moral, religious or social norms, which the woman had interiorized and which contradict her decision to undergo abortion. Although anxiety as part of the post-abortion syndrome manifests itself by general symptoms, it is frequently possible to trace an (unconscious) effort to avoid everything having to do with children.
3) Emotional inhibition. After abortion many women promise themselves never again to allow anybody to get them into a similarly hurtful position. The result is that they -often extra-consciously -begin to e.g. work hard in order to suppress negative emotions and memories of the event, which serves to protect them from psychological pain, but at the same time weakens their ability to establish and maintain close relations. Cutting themselves off from their own emotions they ascribe the unpleasant experience to another person, they feel as if it was not their own, whereby they eliminate the incongruence caused by the abortion.

4)
Depression and suicidal thoughts. A grave form of depression occurs in the anamnesis of women who have undergone abortion more than twice as often as with the rest of the population. 8 They often manifest decreased mood ranging from feelings of melancholy to overall despair, abrupt uncontrollable episodes of crying for apparently unknown (or ununderstandable) reasons, impaired self-esteem, insomnia, decreased appetite for food and/or sex, decreased motivation to performing everyday tasks, loss of interest in earlier favoured activities, impaired relationships (especially to those who had participated in the decision for abortion). Suicidal thoughts occur in approximately 60% of women with post-abortion syndrome, 28% have attempted suicide, half of them repeatedly. 9 5) Anniversary. 54% of affected women report symptom aggravation in periods around the anniversary of abortion and/or expected birth date. 10 6) Re-experiencing the abortion. A very frequent experience reported by women with post-abortion syndrome are abrupt, anxiety-causing, repeated flashbacks associated with the abortion, especially in situations which remind of abortion in some characteristics, as e.g. a normal gynaecological examination or even the sound of a vacuum cleaner. Flashbacks also appear in the form of repeated nightmares concerning children in general or own lost child. In these dreams the topics of lost, torn or crying children appear.

7)
Desire to become pregnant again. An important percentage of women willingly become pregnant within a year of artificial termination of pregnancy and many of them admit the wish to get pregnant as soon as possible. The newly conceived child should either redress the guilt, or it can manifest an unconscious desire to replace the child whose life had been terminated by abortion. 11 8) Worries concerning fertility and unproblematic pregnancy. Women suffering of post-abortion syndrome share the fear that they will not be able to get pregnant again or that they will not successfully bear the child. Some expect the birth of a disabled child, because by the abortion they "disqualified themselves from the role of good mother", many refer to divine punishment. 9) Termination of creating emotional bond with present offspring (if there is one in the family) and/or impairment of bond creation with future child. Fear of further damaging loss can make it harder or even impossible for the woman after abortion to create a real emotional bond with other children. Another common reaction to abortion is redressing one's guilt by the effort to be a perfect mother to present or future children. The woman who already is a mother at the time of the abortion may find that after the abortion she sees her children in different light: on the one hand she can unconsciously punish them for being allowed to live, or she will begin to protect them too much. Besides diminishing the emotional bond with own child abortion is associated with increased depressivity, violent behaviour, abuse of alcohol and drugs -a combination of these factors can result in child abuse. Clinical studies confirm the correlation of post-abortion trauma and subsequent syndrome CAN. 12 10) Guilt of the survivor. Most women do not decide for abortion for trivial reasons. They mostly interpret their situation as highly onerous and believe that if they decide to bear 5 2015 the child they will have to sacrifice much. Through this lens their decision ultimately shrinks to the sorrowful choice between themselves and the child, in which they choose themselves. While the abortion frees the woman from the current trauma, it often leaves behind an undiminishing feeling of guilt for preferring own leisure at the price of the child's life. 11) Sexual dysfunction. 30-50% of women who have difficulty coping with an abortion suffer of some form of sexual dysfunction, both short-term and long-term, beginning immediately after the abortion was carried out. These problems may comprise one or more of the following symptoms: loss of pleasure from sexual intercourse, painfulness of coitus, aversion to sex and/or men in general, development of promiscuous lifestyle. 13 12) Development of food intake disorders. Some women develop mental anorexia or mental bulimia after abortion. Even though this phenomenon has been little researched so far, there are several psychologically explainable factors for developing food intake disorders. For one thing, marked increase or decrease of body mass physiologically decreases the probability of becoming pregnant, which for some women affected by post-abortion syndrome need not be desirable. Further obesity or extreme thinness are considered unattractive in contemporary society and as such become greater or lesser obstacle to finding a suitable partner, with whom the woman could get pregnant. Unattractivity may also be a form of self-punishment and helps the woman maintain the belief that she is not worthy of someone's attention. Further strict control over eating habits is a sphere of consolation for women who feel that they cannot control their life in any other way.
13) Abuse of alcohol and drugs. Alcohol or drugs often serve affected women as a means of self-therapy, a pathological strategy how to deal with pain and memories of abortion. It is painful that a woman who resorts to alcohol and/or drugs eventually ends up with more (and more serious) problems and at the same time with fewer means of solving them, since abusing alcohol or drugs aggravates the negative symptoms the woman has in the acute phase of post-abortion syndrome.
14) Further auto-punitive and self-destructive behaviour. Besides food intake disorders and abuse of addictive substances a woman with post-abortion syndrome may throw herself into unpromising and complicated relationships, she can become promiscuous, may hurt herself physically and emotionally at conscious and unconscious level.
15) Acute transitory psychotic symptoms. In rare cases the woman after abortion may experience a psychotic episode lasting at most two weeks. The process of the attack and subsequent remission is very fast and in most cases the woman's personality becomes fully integrated without residues. Even though psychotic symptomatic in reaction to an undergone abortion appears rarely, it is worth mentioning, since the person in whom a short-term psychotic reaction to a stressful event occurs need not be necessarily labelled psychotic. During this episode there occur perception and thought disorders, which is why these individuals should receive professional psychiatric and psychological care.
The following case studies describe the psychological disorders of two women who had undergone artificial termination of pregnancy. The form their subsequent problems took is determined by their personality traits, early experiences, contexts of their lives, but bears a number of symptoms common to post-abortion states described in the literature and from the context evidently relating to the termination of pregnancy.

Case study I
The woman had been married three times and could not get pregnant with any of her husbands. She unexpectedly got pregnant with a former classmate. Although she had longed for a child before she decided to terminate the pregnancy. She describes the decision from the temporal point of view as abrupt, but she did not experience any intensive emotions, whether before or on leaving the hospital. She felt as if she had a dog put to sleep and assigned no importance to grief, and therefore did not allow any space for it.
In the sphere of sex she had no subsequent problems. Psychological problems appeared after several months. She lost interest in life, found no pleasure in work. When she had changed her job the situation did not change. She began taking painstaking care of herself, the focus of interest became external appearance, clothes, cosmetics, massages, healthy food. Care of the body did not help, however, at that time sleep disorders, anxiety in closed spaces and symptoms of mental anorexia began to appear. The client left work, registered for unemployment benefit and became so enclosed in herself that she practically stopped leaving the house. She got psychopharmaceutic treatment from her general practitioner, but refused the hospital stay her psychiatrist offered. Twice a week she went to psychotherapy, in the remaining time she lay at home aboulic, incapable of doing anything. She planned suicide several times. In the course of psychotherapy, when recapitulating her life, events from her childhood came up, from a period when her aunt, her mother's sister, died at childbirth and both her parents (the client's grand-parents) in an attack of grief killed themselves and died of strangulation. Since the death of her sister her mother could not bear to hear speak of childbirth. In such situation she ran away from the room crying. When in the course of therapy the topic of the client's abortion came up she spoke of it as "that" ("when that happened") and pressed her abdomen as if feeling pain. She denied pain but spoke of an empty black hole in herself, which she compared to a picture with a cut-out middle. She devoted the last part of her several month long psychotherapy to balancing and reflections on what she deserves in life and what she does not. She still sometimes stood in front of shop-windows with children's clothes, she detested prams with children pushed by mothers and had a long-lasting aversion to pregnant women. Her psychological state improved so much that she started a business, she spoke lovingly of her clients in the sense that she takes care of them as of babies. She passed over the question whether she is sure they like it without comment.

Case study II
A young woman living in a long-term relationship with a partner got pregnant without having planned it. Neither of them felt ready to assume the role of parent. The partner left space for the decision about the future fate to the woman. The woman felt weak without the partner's support and decided to terminate her pregnancy. It was at a time when she had already prepared little clothes for her child. The child was not born, they never spoke about it again with the partner and their relationship broke up. Twice they tried to renew it, but never succeeded. The woman went to work abroad for some time. Eight years after the abortion, back home, states of anxious depression appeared. In therapy the topic of abortion came up. She found hardest that her former partner was living with another woman and had a child by her. It was possible to reduce the depressive states over time, but anhedonia remained. The client lived in sorrow, lacking spontaneity and ease, even when she began a new relationship and gave the layette she had kept in the wardrobe for 8 years away.

Conclusion
The question to what extent abortion is linked to mental health has been raised many times in several ways. With respect to the legal aspects of the problem the question whether abortion negatively affects the mental health of women is raised most often. Not only scientific, but also ethical aspects decrease our ability to answer the question unambiguously. Briefly, the psychological reaction to an abortion is not and of its essence cannot be uniform. It changes depending on personality characteristics, events preceding the pregnancy or leading up to it, it reflects the circumstances of the woman's life and relationships at the time when she was deciding to terminate her pregnancy. These and many other variables must be considered when investigating this phenomenon. The existence of post-abortion syndrome in women who have undergone artificial termination of pregnancy has been proved by clinical research, which has shown that its development depends on a number of factors. These are conditions (personal, socio-cultural, and others) in the woman's life that can be crucial for mental health in general, regardless of a possible unwanted pregnancy and manner of coping with it, but also re-evaluation of attitude to pregnancy, to abortion, or the woman's ability to choose and accept one option. It also reflects the availability and application of suitable coping strategies, work with own emotions.