Post Traumatic Stress DisorderWith the advances in nutrition and fluid replacements, most women survive hyperemesis gravidarum with fewer life-threatening complications. However, being treated and surviving hyperemesis can cause psychological problems for some people.
Survivors of hyperemesis may have problems with self-esteem, intimacy, guilt, and conditioned food aversions. Women may experience anxiety and depression related to receiving inadequate treatment for hyperemesis, fear of the hyperemesis recurring in future pregnancies, and having to face the fear of harm or death to herself and/or her unborn child when pregnant. Some survivors of hyperemesis experience trauma-related symptoms, such as avoiding situations, continuously thinking about problems, and being over-excited. These symptoms are similar to symptoms experienced by people who have survived highly stressful situations, such as combat, natural disasters, rape, or other life-threatening events. This group of symptoms is called post traumatic stress disorder (PTSD) or post traumatic stress syndrome (PTSS). It is more common in women than in men.
People with histories of hyperemesis are at risk for PTSD. The physical and mental stress of having a potentially life-threatening disease (threatening them or their unborn child), not being believed by health professionals, receiving treatment for hyperemesis, and living with unexpected and possibly uncontrolled threats to one's body and life (and one's unborn child) during pregnancy are traumatic experiences for many hyperemetic women.
Hyperemetic women experience pain, distress, extreme fatigue, muscle weakness, incessant nausea and/or vomiting. The sensation of suffocation that accompanies forceful, unrelenting retching or vomiting can be quite traumatic. In fact, inducing that sensation is a torture technique that is documented to cause psychological trauma.
Hyperemetic women also may undergo painful and invasive procedures, as well as be faced with possible guilt as they decide whether they can continue the pregnancy when they are so sick. Relationships are strained and she may feel misunderstood and alone. They may be in the hospital for a few days or weeks, leading to feelings of frustration, isolation and loss of control. They may be unable to care for themselves or their family for weeks or months. These experiences may lead to feelings of helplessness, especially for women who have certain risk factors, such as having little social support, experiencing a trauma, being victimized in the past, or having a history of mental disorder.
Applying PTSD to Hyperemesis Gravidarum
One problem health professionals have in determining if a hyperemetic woman has PTSD is figuring out what exactly is the cause of trauma. Because the hyperemesis experience involves so many upsetting events, it is much more difficult to single out one event as a cause of stress than it is for other traumas, such as natural disasters or rape. For hyperemesis women, the stressful incident may be related to frequent episodes of vomiting, many relapses with a worsening of symptoms, painful or stressful procedures, fear of death, loss of unborn child, complications such as severe infection or convulsions, scary scenes such as vomiting blood, treatment delays or insufficient treatment, and not being taken seriously. Some women may also experience abandonment and abuse, causing further trauma.
PTSD is defined as the development of certain symptoms following a mentally stressful event that involved actual death or the threat of death, serious injury, or a threat to oneself or others. These events may include being diagnosed with a potentially life-threatening illness. In the case of hyperemesis, the illness threatens the baby and mother if left untreated or inadequately treated. Many hyperemetic women fear death, especially those with more severe symptoms that do not respond to prescribed treatment.
These events may cause responses of extreme fear, helplessness, or horror and may trigger PTSD symptoms. These symptoms include re-experiencing the trauma (nightmares, flashbacks, and interfering thoughts), continuously avoiding reminders of the trauma (avoiding situations, responding less to people, and showing less emotion), and being continuously excited (for example, having sleeping problems or being overly defensive, watchful, or irritable). Other common emotional responses include unhappiness, guilt over actions taken or not taken, and overwhelming loss. It is common for some women with hyperemesis to experience this for months or years after pregnancy.
In hyperemesis, as in other stressful major life events, over-excitability, avoiding certain thoughts and reminders, and having intrusive thoughts may occur during or after pregnancy. The number of women with these symptoms is unclear and has not been studied to date. It has been estimated that approximately 10% of women with hyperemesis have severe symptoms. Thus, the number with PTSD may be close to that number, or perhaps greater. It is not uncommon for women to seek information on hyperemesis for many years postpartum, trying to get answers to their questions. They may even become quite emotional discussing or thinking about their experience for years afterwards.
Childbirth is also a known risk factor for PTSD. If the childbirth experience is perceived as traumatic due to complications or difficulties, the risk of PTSD is likely greater in women with hyperemesis. Future pregnancies may bring about significant anxiety and panic attacks, symptoms of PTSD. PTSD is often overlooked or undiagnosed in women with a history of hyperemesis. Instead, they may be diagnosed with depression and anxiety that may be chronic.
In studies of cancer patients, some have these symptoms even 6 years after their last treatments. It is unknown how long women with hyperemesis will experience symptoms. Some hyperemesis survivors may have higher levels of general mental distress. People with a history of PTSD may be at risk for developing ongoing emotional problems.
Symptoms typical of PTSD may be seen in family members of hyperemesis survivors. These symptoms may be due to family members having to face the woman or baby's possible death, as well as witnessing painful treatments and relentless vomiting. It is not uncommon for children to have anxiety and fear the death of their mother. Behavioral changes may result especially if the child is not reassured and their world is greatly altered by the mother's illness. These symptoms may lessen over time, however, assistance may be needed from health professionals.
Causes and Risk Factors
As many as one-third of people who experience traumatic events may develop PTSD. It is caused by an extremely upsetting event; however, this one event alone does not explain why some people get PTSD. Not everyone who experiences these upsetting events develops PTSD. For some people, mental, physical, or social factors may make them more likely to experience it. PTSD symptoms develop due to both adapting and learning.
Adapting explains the fear responses caused by certain triggers that were first associated with the upsetting event. Triggers (such as, smells, sounds, and sights) that occurred at the same time as symptoms (for example, bathroom cleaners smelled while vomiting) may cause anxiety, upset, and fear when occurring alone, even after the trauma has ended. Once established, PTSD symptoms are continued through learning. That is, avoiding certain triggers continues because this avoidance prevents unpleasant feelings and thoughts.
The most critical factors in determining which women develop PTSD due to hyperemesis seem to be the severity and duration of the symptoms. The suddenness of the onset and the level of threat to her or her unborn child's life and health are also important.
While the type of event is the main factor in how a person responds to a traumatic event, other individual and social factors may also play a role. Previous psychological problems, history of trauma, high levels of mental distress, and ineffective coping skills have been linked to a risk of PTSD. Genetic and other biologic factors (for example, hormone changes) may also make some people more at risk for PTSD. The amount of social support available has also been shown to affect the risk of PTSD, and may influence severity of hyperemesis as well.
Factors That May Increase The Risk Of PTSD After Hyperemesis Gravidarum
- Medical Complications
- History of mental illness
- Prolonged symptoms
- Severe symptoms
- Sudden onset
- Delay in diagnosis/care
- Inadequate treatment
- First HG pregnancy
- Genetic/biological factors
- Hormone levels
- Stress level
- Social support
- Coping skills
- Painful procedures
- History of trauma
- Loss of unborn child
- Perceived threat to self
- Disbelief by others of severity
- Inability to care for self/family
Women with hyperemesis should be assessed for signs of anxiety and depression during pregnancy and after delivery. At the same time, she should be evaluated for signs of PTSD. This is especially true in women with a history of hyperemesis and/or other traumas. Future pregnancies may trigger a return of PTSD symptoms. While these women may have problems adjusting to a recurrence of hyperemesis and its treatment, their PTSD symptoms may vary, and be greatest at the beginning of pregnancy or possibly postpartum. She may avoid intimacy for fear of pregnancy. This further strains her relationships. Postpartum depression may also be more prevalent among these women and screening should be done at intervals after delivery.
Family members should also be educated on signs to watch for to ensure these women get the help they need. Symptoms of PTSD usually begin within the first 3 months after delivery, but sometimes they may not appear for months or even years afterwards. Therefore, hyperemesis survivors and their families should be involved in long-term monitoring.
Some people who have experienced an upsetting event may show early symptoms without meeting the full diagnosis of PTSD. However, these early symptoms predict that PTSD may develop later. Early symptoms also indicate the need for repeated and long-term follow-up of hyperemesis survivors and their families.
Diagnosing PTSD can be difficult since many of the symptoms are similar to other psychiatric problems. For example, irritability, poor concentration, increased defensiveness, excessive fear, and disturbed sleep are symptoms of both PTSD and anxiety disorder. Other symptoms are common to PTSD, phobias, and panic disorder. Some symptoms, such as loss of interest, a sense of hopelessness, avoidance of other people, and sleep problems may indicate the woman has PTSD or postpartum depression. Even without PTSD or other problems, normal reactions to unrelenting vomiting/retching and treatment of a potentially life-threatening disease can include interfering thoughts, separating from people and the world, sleep problems, and irritability.
The chronic and sometimes disabling effects of PTSD mean the disorder needs to be identified and treated quickly. However, the avoidant symptoms that appear with PTSD often keep the woman from seeking help. Further, signs of postpartum depression may make an accurate diagnosis challenging. Health professionals may be too quick to treat the depression since she has recently been pregnant, and fail to assess further and accurately diagnose PTSD. Therapies used are those used for other trauma victims and involve more than one type of therapy.
The crisis intervention method tries to lessen the symptoms and return women to their normal or pre-pregnancy level of functioning. The therapist focuses on solving problems, teaching coping skills, and providing a supportive setting for the woman.
Thinking-behavior methods may be helpful. Some of these methods include helping the woman understand symptoms, teaching coping and stress management skills (such as relaxation training), reforming one's thinking, and trying to make the woman less sensitive to conditioned aversions.
Support groups may also help people who experience post-traumatic stress symptoms. It may be impossible to find a group of women who have experienced hyperemesis. However, there are several online support groups that may be supportive. Some mental health professionals specialize in women's health and may be most experienced in working with women suffering from complications of pregnancy.
For women with severe symptoms, medications may be used. These include antidepressants, antianxiety medications, and when necessary, antipsychotic medications.
Posttraumatic stress disorder and pregnancy complications.
Seng JS, Oakley DJ, Sampselle CM, Killion C, Graham-Bermann S, Liberzon I.
School of Nursing, The University of Michigan, Ann Arbor, Michigan, USA. (e-mail: firstname.lastname@example.org)
Obstetrics & Gynecology 2001 Jan;97(1):17-22
Pregnant women with posttraumatic stress disorder might be at higher risk for certain conditions, and assessment and treatment for undiagnosed posttraumatic stress might be warranted for women with those obstetric complications.
Women and trauma: a contemporary psychodynamic approach to traumatization for patients in the OB/GYN psychological consultation clinic.
New York Hospital-Cornell University Medical College, New York, New York, USA.
Bulletin of the Menninger Clinic 1996 Winter;60(1):22-38
Many patients referred to an OB/GYN psychological consultation clinic were found to be suffering from the emotional effects of early traumatization. Obstetrical and gynecological conditions possess a unique power to reactivate psychological damage originally engendered by traumaÉ Two clinical cases-a pregnant teenager and a woman with hyperemesis gravidarum (excessive and persistent vomiting in pregnancy)-illustrate the frequent emergence of transference-countertransference dynamics centered around "blaming the victim" in work with these patients. Suggestions for therapeutic interventions in short-term consultation with these patients are articulated.
Experiences of fears associated with pregnancy and childbirth: a study of 329 pregnant women.
Centre for Extension Studies, University of Turku, Finland.
Birth 2002 Jun;29(2):101-11
Women may experience a variety of fears in association with pregnancy and childbirthÉ Of the 329 respondents, 78 percent expressed fears relating to pregnancy, to childbirth, or to both. Specific fears concerned childbirth, the child's and mother's well-being, health care staff, family life, and cesarean section. Causes of fears were negative mood, negative stories told by others, alarming information, diseases and child-related problems, and, in multiparas, negative experiences of previous pregnancy, childbirth, and baby's health and care; causes were significantly related to occupation. Fears were manifested as symptoms of stress, effects on everyday life, and a wish to have a cesarean section or to avoid pregnancy and childbirth; employment situation and elective cesarean section were the most important factors related to manifestation of fears. Parity and antenatal training were the most important variables related to objects of fears.
Updated on: Apr. 18, 2013