Abstract and Introduction

Abstract

Posttraumatic stress disorder (PTSD) is a psychiatric disorder that may develop following exposure to threatened or actual injury or death. While commonly associated with war or natural disaster, symptoms of PTSD have been described in patients who are undergoing or who have completed infertility treatment or high-risk pregnancies. Three case studies of patients who developed PTSD following such pregnancies are discussed, demonstrating the variety of symptoms and presentations of these patients. The clinician must be vigilant in monitoring infertility patients with PTSD. These women, as the result of infertility, may be at increased risk of developing PTSD, one of the recognized postpartum psychiatric disorders. It is important to distinguish PTSD from postpartum depression, because treatment guidelines vary.

Introduction

Posttraumatic stress disorder (PTSD) is diagnosed in patients with persistent psychiatric distress resulting from events involving actual or threatened death or injury.[1] Subsequent to the trauma, victims experience feelings of intense fear, helplessness, or horror. The precipitating trauma sets in motion a series of physical and emotional reactions that can have major and long-lasting effects. The characteristic triad of PTSD symptoms include (1) persistent re-experiencing of the event, (2) avoidance of reminders and numbing of responsiveness, and (3) increased arousal. Significant distress and functional impairment may result. Psychologically, PTSD is characterized by a classic triad of intrusive, avoidant, and hyperarousal symptoms.

Although PTSD commonly occurs in situations such as war or natural disaster, other life-threatening situations like sexual or physical assault, being kidnapped or taken hostage, or being diagnosed with a life-threatening illness[2] have been cited as precipitants. Presently, there are no published studies linking PTSD to infertility, yet anecdotal reports have linked the stress of trying to overcome infertility and trying to manage a high-risk pregnancy with triggering stress responses associated with PTSD symptoms. The 3 cases presented here typify the stress some women experience battling infertility. For women such as these, the problems associated with pregnancy and childbirth are sufficiently devastating to cause a stress response syndrome.

The inability to conceive can catapult some patients into a state of shock, disbelief, and helplessness.[3] Infertile couples must grieve 2 losses simultaneously: the loss of their ability to procreate as well as the loss of the hope for children. Women who have difficulty conceiving may react to these dual realizations as simply loss, or alternatively as psychological trauma. Those who experience a loss may subsequently develop major affective or adjustment disorders, but those who experience this loss as a trauma may instead develop PTSD. We have observed the development of PTSD in women who have experienced a variety of reproductive problems, including infertility, miscarriage, complicated pregnancy or delivery, and multiple births.

When PTSD develops in response to infertility or other adverse reproductive events, patients exhibit the classic triad of symptoms described above. They may re-experience the trauma as nightmares, flashbacks, and intrusive thoughts about distressing procedures or pregnancy loss.[1] Symptoms may manifest as extreme distress under seemingly innocuous circumstances, such as seeing a pregnant woman, menstruating, or visiting the doctor's office; these types of occurrences may trigger a recollection of the infertility battle or mark an anniversary of events in the struggle to conceive and/or to complete a difficult pregnancy.

Avoidant symptoms include hesitance to discuss the trauma or to engage in any activities, thoughts, and feelings connected with infertility, pregnancy, or childbirth. The woman may be reluctant to discuss the experience with even her most intimate contacts. Avoidance may result in failure to bond, or a delay in bonding, with a newborn. Some PTSD-afflicted women even experience an aversion to the baby and become anxious just holding the infant. Other symptoms include amnesia regarding certain aspects of the trauma, apathy toward previously cherished pleasures or toward other children at home, hopelessness, feelings of isolation, and a general dulling of emotional responsivity.

Hyperarousal symptoms can be severe and manifest as the persistent inability to "let down one's guard," even after the danger has passed. Insomnia can be extreme and the resulting fatigue exacerbates all other symptoms. Hypervigilance regarding pregnancy and the health of the newborn can be dramatic. Excessive irritability is often directed toward the spouse or parents if they are perceived as unsupportive. Outbursts of anger, severe concentration difficulties, and an exaggerated startle response are seen in addition to physical manifestations of anxiety.

The clinician who sees any patient during the course of an infertility work-up or a high-risk pregnancy, or during the postpartum period following such a pregnancy or delivery, should be vigilant regarding any symptoms suggestive of PTSD or any other postpartum psychiatric illness. Patients who become symptomatic should be referred to a psychiatrist for further evaluation and treatment. The following cases demonstrate the range of presentations of PTSD following adverse reproductive events.