Guilt

Thomas W. Strahan Memorial Library
Index
Standard of Care for Abortion
Abortion Decision-Making
Psychological Effects of Abortion
Social Effects and Implications
Physical Effects of Abortion
Abortion and Maternal Mortality
Adolescents and Abortion
Definition of Terms
Women's Health After Abortion
Material Yet to be Cataloged
Strahan Summary Articles

Sub-Index
Psychological Effects
Validity of Studies
Reviews
Risk Factors
PTSD
Grief and Loss
Guilt
Ambivalence or Inner Conflict
Anxiety
Intrusion / Avoidance / Nightmares
Denial
Dissociation
Narcissism
Self-Image
Self Punishment
Depression
Psychiatric Treatment
Self-Destructive Behavior
Substance Abuse
Long-Terms Effects of Abortion
Replacement Pregnancies
Sterilization
Impact of Abortion On Others
Violence
Rape, Incest, Sexual Assault
After Late Term Abortion

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Guilt

Background Studies

Guilt is much understood in contemporary society. Some believe that guilt is only relative to the culture, while others believe that results from violation of some basic value intrinsic in human nature.

"The Psychophysiology of Confession: Linking Inhibitory and Psychosomatic Processes," J.W. Pennebaker et al, J. Personality and Social Psychology 52(4): 781, 1987.

Failure to confide traumatic events was found to be stressful and associated with long- term health problems.

"Sin, The Lesser of Two Evils," O. Hobart Mowrer, American Psychologist, May, 1960, pp. 301-304.

Comments by the author:

For several decades we psychologists looked upon the whole matter of sin and moral accountability as a great incubus and acclaimed our liberation from it as epochmaking.... In reconsidering the possibility that sin must, after all, be taken seriously, many psychologists seem perplexed as to what attitude one should take toward the sinner. Non- judgmental, nondirective, warm accepting, ethically neutral are words generally used.... We have reasoned the way to get the neurotic to accept and love himself is for us to love and accept him, an inference which flows equally from the Freudian assumption that the patient is not really guilty or sinful but only fancies himself so and from the view of Rogers that we are all inherently good and are corrupted by our experiences with the external, everyday world.

But what is here generally overlooked, it seems, is that recovery (constructive change, redemption) is most assuredly attained, not by helping a person reject and rise above his sins, but by helping him accept them. This is the paradox which we have not at all understood and which is the very crux of the problem. Just so long as a person lives under the shadow of real, unacknowledged, and unexcited guilt, he cannot (if he has any character at all) "accept himself"; and all our efforts to reassure him and accept him will avail nothing. He will continue to hate himself and to suffer the inevitable consequences of self-hatred. But the moment he (with or without "assistance") begins to accept his guilt and his sinfulness, the possibility of radical reformation opens up; and with this, the individual may, legitimately, though not without pain and effort, pass from deep, pervasive self-rejection and self-torture to a new freedom of self-respect and peace.

"The Myth of Mental illness," Thomas Szasz, American Psychologist 15:113-118 (1960).

"The notion of mental illness has outlived whatever usefulness it might have had and..- now functions merely as a convenient myth...mental illness is a myth whose function is to disguise and thus render more palatable the bitter pill of moral conflicts in human relations."

"The Theology of Therapy: The Breach of the First Amendment through the Medicalization of Morals," Thomas Szasz, N.Y.U. Review of Law and Social Change (1975); also. "The Control of Conduct: The Ethics of Helping People," Szasz, Crim. Law Bulletin II, pp. 617-622, September-October 1975.

"In the Therapeutic State many medical acts are considered scientific when, in fact, they are moral, and many psychiatric acts are considered medical, when, in fact, they are religious."

Szasz observes a close parallel between church and state relations 200 years ago and between medicine and state relations today. He notes that "in each case (church or medicine) we are faced with a social institution to which men and women turn to for protection when they feel most endangered. Hence, they want their protector to be as powerful as possible. [But] protection from injuries and diseases requires knowledge and skills, not power; protection from guilt and shame requires honesty and courage, not power; power is necessary to oppose the external enemies of freedom but not the internal enemies of freedom."

"Guilt and Guilt Feelings," Martin Buber, Proceedings of the International Conference on Medical Psychotherapy, Vol. Ill, International Conference of Mental Health, London, 1948. (New York: Columbia University Press, 1948).

Comments by the author:

As a result of the teachings of Freud, who presented the naturalism of the enlightenment with a scientific system.. .guilt was simply not allowed to acquire an ontic character; it had to be derived from the transgression against ancient and modern taboos, against parental and social tribunals. The feeling of guilt was now to be understood as essentially only the consequence of dread of punishment and censure by this tribunal. (p. 115)

Guilt does not exist because a taboo exists to which one fails to give obedience, but rather that taboo and the placing of taboo have been made possible only through the fact that the leaders of early communities knew and made use of a primal fact of man as man- the fact that man can become guilty and know it. (pp-116-117)

The psychotherapist is no pastor of souls and no substitute for one. It is never his task to mediate a salvation; his task is only to further a healing, (p. 119)

The therapist in order to do this must recognize one thing steadfastly and recognize it ever again: There exists real guilt, fundamentally different from all the anxiety induced bugbears that are generated in the cavern of the unconscious. Personal guilt, whose reality some schools of psychoanalysis contest and others ignore, does not permit itself to be reduced to the trespass against a powerful taboo, (pp. 119-120)

Each man stands in an objective relationship to others; the totality of this relationship constitutes his life as one that factually participates in the being of the world. It is this relationship, in fact, that first makes it at all possible for him to expand his environment into a world. It is his share in the human order of being, the share for which he bears responsibility.

Injuring a relationship means that at this place the human order of being is injured. No one other than he who inflicted the wound can heal it. He who knows the fact of this guilt and is a helper can help him try to heal the wound (p. 120).

The doctor is not concerned with whether or not the demand of the society is right or not. This does not concern the doctor as doctor; he is incompetent here.. .nor can faith be his affair. Here the action commences within the relation between the guilty man and his God and remains therein. The therapist may lead up to conscience but no farther. Conscience means to us the capacity and tendency of man radically to distinguish between those of his past and future actions which should be approved and those which should be disapproved. Conscience only rarely fully coincides with a standard received from the society or community. Self-illumination, perseverance and reconciliation is required. (pp. 120-121)

Toward a Psychology of Being, Abraham Maslow (Princeton: F. Van Nostrand Co.,1962)

"Intrinsic conscience" is the necessity of being true to one's inner self, and not denying it our of weakness or for special advantage.

Conscience and Guilt, Tames A. Knight, (New York: Appleton-Century-Crofts, 1969).

The bond between the principle and the act is conscience. There is something wrong with psychology's emphasis on "adjustment", rather than "goodness." Real guilt follows in the wake of wrongdoing, seen and accepted as such by the doer, who seeks expiation and makes restitution.

Abortion-Related Guilt/Regret/Violation of Conscience or Belief

By adopting a pragmatic approach to abortion-decision making, higher ethical, moral or religious standards are frequently violated as the following studies demonstrate.

Associations of Pregnancy Loss and Psychological State. Serapinas D. Health Sciences 25(2):4-8, 2015. doi:10.5200/sm-hs.2015.021

Summary: Miscarriage and induced abortion are life events that can potentially cause mental distress. The objective of this study was literature review and to perform case study to determine whether there are any differences in the patterns of psychological symptoms after these two events and to point the importance of informed consent. In our study 20 women who experienced miscarriages and 20 women who underwent induced abortions were interviewed in Vilnius out patients clinics. We found that women who had pregnancy termination had more mental distress than women who experienced a miscarriage (guilty, anxiety, anger, episodes of crying etc). Women under going abortion had significantly more conflicts in their partnerships. Separation occurred in about one-quarter of all couples. In conclusion women who had undergone an abortion exhibited higher frequency of psychological symptoms than after miscarriage. Although an answer to the causal question is not readily discerned based on the data available, as more prospective studies with numerous controls are being published, indirect evidence for a causal connection is beginning to emerge. So we may consider that it is necessary still before induced abortion procedure to inform the couples about an increasing possibility of mental distress.

Key Findings: "The main finding of our study is, that women who had pregnancy termination had more mental distress than women who experienced a miscarriage. (guilty 16 vs 10; anxiety 17 vs 8 , suicidal minds 7 vs 3, episodes of crying 15 vs 10, anger 13 vs 2, community avoidance 12 vs 4, p < 0.05)." "After termination of pregnancy, 4 couples of 20 separated. The majority of women (n = 18) did not report changes in their sexual behaviour after miscarriage. On the other hand, 13 of women after abortion presented a decrease in sexual desire. Changes in eating (mostly lack of appetite) habits mentioned 10 women in abortion group and 5 women in miscarriage group (p < 0.05). In abortion group 16 women mentioned that after event their sleep become more disturbed (insomnia, nightmires), while in control group 12 had such problems (p>0.05). The start of use of anxiolitics [to treat anxiety] mentioned 11 women in analyzed group and 9 women in miscarriage group (p>0.05). "

"Many in Survey Who Had Abortion Cite Guilt Feelings," George Skelton, Los Angeles Times, March 19, 1989 p.28

In a national U.S. telephone survey by the Los Angeles Times in March, 1989, 56% of women who admitted to at least one abortion expressed a sense of guilt and 26% said they now mostly regretted their abortion.

"Abortion Counselling. A New Component of Medical Care," Uta Landy, Clinics in Obstetrics and Gynecology 13(1):33, 1986

An article by the former executive director of the National Abortion Federation based on observations of its members stated that women obtaining abortions will make the decision by a "spontaneous" response without much thought, engage in denial or procrastination, be overly rational, or allow others to make the decision for them thus making it more likely that the women will have later regrets.

"Testing a Model of the Psychological Consequences of Abortion," WB Miller et al in The New Civil War. The Psychology, Culture, and Politics of Abortion, Ed. LJ Beckman and SM Harvey, (Washington, D.C.:American Psychological Association, 1998) 235

Women about to undergo abortion with Mifepristone exhibited acute stress and appeared to be trying to control their response to the unwanted pregnancy/abortion situation by not thinking about it The researchers concluded that there is a broad, multidimensional affective response.At two weeks postabortion 29.7% of the women expressed some guilt. At 6-8 months 35.9% of postabortion women expressed some guilt. The authors concluded that long term studies should be undertaken to ascertain the psychological effects of abortion.

"Physical and Psychological Injury in Women Following Abortion:Akron Pregnancy Services Study," L Gsellman, Association for Interdisciplinary Research in Values and Social Change Newsletter 5(4):1-8, 1993

In a questionnaire survey of postabortion women receiving a variety of services at a pregnancy services center, 66% expressed guilt and 54% expressed remorse or regret approximately 6 years postabortion.

"Induced Abortion as a Violation of Conscience of the Woman," Thomas Strahan, Life and Learning VI.. Proceedings of the Sixth University Faculty for Life Conference. (June, 1996, ed. Joseph W. Koterski

A majority of U.S. women appear to violate their conscience by obtaining an induced abortion. Among the reasons are a belief that if it is legal it must be all right; encouragement of her male partner or others, including abortion facility workers to obtain an abortion, lack of respect for the moral or religious beliefs of the woman, and a frequent crisis situation where the woman may be easily influenced by others or use primitive coping methods.

"Objective Versus Subjective Responses to Abortion," James M Robbins, Journal of Counsulting and Clinical Psychology 47(5): 994-995, 1979

In a study of medically indigent unmarried black women who had abortions, deep regret was reported by 14.6%, some regret by 34.1%, a little regret by 19.5%, and no regret by 31.7% one year postabortion.

"Obsessive-Compulsive Neurosis After Viewing the Fetus During Therapeutic Abortion," S Lipper and W Feigenbaum, Am J Psychotherapy 30:666-674, 1976

Following her abortion, a woman was preoccupied with thoughts of being " dirty" and washed her hands 30-40 times a day.

"Unsafe Abortions: Methods Used and Characteristics of Patients Attending Hospitals in Nairobi, Lima, and Manila," A Ankomah et al, Health Care for Women Int'l 18:43, 1997

The beliefs of women regarding when abortion is justified conflicted with their actions in a study of postabortion women in Kenya, Peru and the Philippines. The authors concluded, " it can be seen that abortion is not an acceptable option even for those who resort to it , and that it is employed as the final option."

Ambivalence or Inner Conflict

Ambivalence is common both pre and postabortion. It appears to be acceptable at one level of consciousness, but unacceptable at a different level.

"The Ambivalence of Abortion," Linda Bird Francke (1978).

Interviews with various people involved in abortion. Demonstrates ambivalence as well as many other emotions and considerable confused thought. For an extensive discussion of this book see Rachael Weeping, James T. Burtchaell (1982,1984)

"Abortion: Subjective Attitudes and Feelings," Ellen Freeman, Family Planning Perspectives 10:150-155, 1978.

This article concludes that feelings of ambivalence, both before and after the abortion, are common..

"The Psychological Reaction of Patients to Legalized Abortion," J Osofsky and H Osofsky, American Journal Orthopsychiatry 42(1): 48-60, January, 1972.

A leading early study on the effects of abortion, often cited. Psychological evaluation of 250 postaborted women reported 24% experiencing guilt (much or moderate); 47% reported the decision was either considerably difficult (28%) or mildly difficult (19.5%). Some 32.5% expressed the desire for the child as the reason for difficulty. 45%-48% expressed happiness or much relief following abortion.

"Pregnancy Decision Making as A Significant Life Event: A Commitment Approach," J Lydon et al, Journal of Personality and Social Psychology 71(1): 141-151, 1996.

Initial commitment to the pregnancy predicted subsequent depression, guilt and hostility among those who had abortions. Women who previously had at least one prior abortion reported more commitment to the pregnancy than women with no prior abortion history.

Fragmentation of the Personality Associated with Post-Abortion Trauma , Joel O Brende, Association for Interdisciplinary Research in Values and Social Change Newsletter 8(3): 1-8. July/Aug 1995.

People enduring extreme stress often suffer profound rupture in the very fabric of the self. Factors which are likely to produce dissociation, memory lapses, and evidence of self- fragmentation, include (1) the severity of the violation, (2) lack of support from others, (3) subsequent self-blame and shame, (4) loss of idealism and purpose. Fragmentation predisposes to unstable and destructive relationships.

"Post-Abortion Syndrome as a Variant of Post Traumatic Stress Syndrome," Robert C Erikson, Association for Interdisciplinary Research in Values and Social Change Newsletter 3(4):5-6, Winter, 1991.

Conflict between incompatible goals of attachment and destruction leads to the experience of stress.

“ Voluntary interruption of pregnancy: comparative study between 1982 and 1996 in the main center of Cote d’Or. Study of women having repeat voluntary interruption of pregnancy”, S Douvier et al, Gycecol Obstet Fertil 29(3): 200, Mar 2001

A French study of women who had repeated abortion in 1996 found that this group had been characterized by unstable couples and ambivalence with a wish of pregnancy but no wish of children.

Anxiety

Previous pregnancy outcomes and subsequent pregnancy anxiety in a Quebec prospective cohort. Shapiro GD, Séguin JR, Muckle G, Monnier P, Fraser WD. J Psychosom Obstet Gynaecol. 2017 Jun;38(2):121-132. doi: 10.1080/0167482X.2016.1271979. Epub 2017 Jan 12.

INTRODUCTION: Pregnancy anxiety is an important psychosocial risk factor that may be more strongly associated with adverse birth outcomes than other measures of stress. Better understanding of the upstream predictors and causes of pregnancy anxiety could help to identify high-risk women for adverse maternal and infant outcomes. The objective of the present study was to measure the associations between five past pregnancy outcomes (live preterm birth (PTB), live term birth, miscarriage at <20 weeks, stillbirth at ≥20 weeks, and elective abortion) and pregnancy anxiety at three trimesters in a subsequent pregnancy.

METHODS: Analyses were conducted using data from the 3D Cohort Study, a Canadian birth cohort. Data on maternal demographic characteristics and pregnancy history for each known previous pregnancy were collected via interviewer-administered questionnaires at study entry. Pregnancy anxiety for the index study pregnancy was measured prospectively by self-administered questionnaire following three prenatal study visits.

RESULTS: Of 2366 participants in the 3D Study, 1505 had at least one previous pregnancy. In linear regression analyses with adjustment for confounding variables, prior live term birth was associated with lower pregnancy anxiety in all three trimesters, whereas prior miscarriage was significantly associated with higher pregnancy anxiety in the first trimester. Prior stillbirth was associated with greater pregnancy anxiety in the third trimester. Prior elective abortion was significantly associated with higher pregnancy anxiety scores in the first and second trimesters, with an association of similar magnitude observed in the third trimester.

DISCUSSION: Our findings suggest that the outcomes of previous pregnancies should be incorporated, along with demographic and psychosocial characteristics, into conceptual models framing pregnancy anxiety.

Anxiety and quality of life after first-trimester termination of pregnancy: a prospective study. Toffol E, Pohjoranta E, Suhonen S, Hurskainen R, Partonen T, Mentula M, Heikinheimo O. Acta Obstet Gynecol Scand. 2016 Oct;95(10):1171-80. doi: 10.1111/aogs.12959.

INTRODUCTION: Possible effects of termination of pregnancy (TOP) on mental health are a matter of debate.

MATERIAL AND METHODS: We assessed anxiety and quality of life during a one-year follow up after first-trimester TOP using the State-Trait Anxiety Inventory (STAI) Scale and EuroQoL Quality of Life Questionnaire (EQ-5D, EQ-VAS) in 742 women participating in a randomized controlled trial on early provision of intrauterine contraception. The measurements were performed before TOP, at 3 months and 1 year after TOP. Inclusion criteria were age ≥18 years, residence in Helsinki, duration of gestation <12 weeks, non-medical indication for TOP, and approval of intrauterine contraception. The trial was registered with Clinical Trials.

RESULTS: When compared with baseline, the overall anxiety level was significantly lower and quality of life higher at 3 months and at 1 year. Reduction of anxiety and improvement of quality of life was especially evident (p < 0.001) in the 58% of women reporting clinically relevant anxiety at baseline. High levels of anxiety at baseline, history of psychiatric morbidity and smoking predicted significantly greater risk of poorer quality of life and elevated level of anxiety during the follow up.

CONCLUSIONS: TOP is associated with a significant overall reduction of anxiety and an improvement of quality of life among women undergoing it for non-medical indications. High baseline anxiety, history of psychiatric morbidity and smoking are risk factors of persistently high levels of anxiety and poor quality of life after an induced abortion. These data are important when designing and providing post-abortion care.

Editor Notes:

• It appears the researchers are burying data. This is the only explanation for why did they excluded analysis of the trait anxiety subscale. Also, since the original objective was to "assess the mental well being of women during the first year after TOP," surely they must have also included scales for depression, PTSD, and more. Indeed, they later admit that they had more mental health variables, but they don't report any test of these others as outcome variables. Clearly, they are reporting on the anxiety state subscale and very similar quality of life index only because the produced baseline scores that allowed them to spin the results in a way that advance their agenda.

• The baseline scores for both anxiety and the quality of life indexes are clearly depressed by the fact that they are accessed on a day of high stress--the day these women are undergoing an abortion. Obviously, the proper baseline would be an assessment a week or month before these women became pregnant. Only then could see if they "bounced back" from their abortions to their pre-pregnancy state. Otherwise, the baseline measure may simply be a measure of a "worst day" in these women's lives and the subsequent "bounce back" is simply evidence that time heals . . . or at least moderates anxiety.

• In the methods section, the researchers reveal that that alcohol use, drug use, smoking, and psychiatric morbidity varied across the three time frames measured. But they don't use any of these as outcome variables to show us how they varied over time. Instead, they inappropriately employ them control variables. The use as control variables is inappropriate since they are not "independent factors" but may also be affected by exposure to abortion and other pregnancy losses. They also reveal that they have data on prior history of abortion and miscarriage. Their analyses should include measures of how multiple pregnancy losses may impact these findings...especially at baseline. If women with a prior pregnancy loss have higher anxiety levels at baseline, that would be a meaningful finding.

• High attrition rate. Control group loss 52% at 3 months and 57% at one year. The intervention group was modestly better since an inserted IUD gave them more motivation to participate at 3 months. Complete data was available for only 45% of the women. The claim that approximately 70% are represented in the results is based on the inflating qualifier "baseline plus at least partial follow-up data were available for approximately 70% of the original sample."

• Notably, women who had surgical abortion did not experience any improvement in anxiety or quality of life scores. The "benefit" were exclusive to women who had medical abortions. (p1175 col 1) The "benefits" were also associated with only the NLG-IUS IUD but not the Cu-IUD.

Abortion, substance abuse and mental health in early adulthood: Thirteen-year longitudinal evidence from the United States. Sullins DP. SAGE Open Medicine 2016 vol: 4 (0) pp: 2050312116665997

Objective: To examine the links between pregnancy outcomes (birth, abortion, or involuntary pregnancy loss) and mental health outcomes for US women during the transition into adulthood to determine the extent of increased risk, if any, associated with exposure to induced abortion.

Method: Panel data on pregnancy history and mental health history for a nationally representative cohort of 8005 women at (average) ages 15, 22, and 28 years from the National Longitudinal Study of Adolescent to Adult Health were examined for risk of depression, anxiety, suicidal ideation, alcohol abuse, drug abuse, cannabis abuse, and nicotine dependence by pregnancy outcome (birth, abortion, and involuntary pregnancy loss). Risk ratios were estimated for time-dynamic outcomes from population-averaged longitudinal logistic and Poisson regression models.

Results: After extensive adjustment for confounding, other pregnancy outcomes, and sociodemographic differences, abortion was consistently associated with increased risk of mental health disorder. Overall risk was elevated 45% (risk ratio, 1.45; 95% confidence interval, 1.30–1.62; p < 0.0001). Risk of mental health disorder with pregnancy loss was mixed, but also elevated 24% (risk ratio, 1.24; 95% confidence interval, 1.13–1.37; p < 0.0001) overall. Birth was weakly associated with reduced mental disorders. One-eleventh (8.7%; 95% confidence interval, 6.0–11.3) of the prevalence of mental disorders examined over the period were attributable to abortion.

Conclusion: Evidence from the United States confirms previous findings from Norway and New Zealand that, unlike other pregnancy outcomes, abortion is consistently associated with a moderate increase in risk of mental health disorders during late adolescence and early adulthood.

NOTE:Table 1: Anxiety, adjusted OR 1.23 (95% CI 0.97-1.55); Number of mental health problems OR=1.54 (95% CI 1.42-1.68) ( "Exposure to induced abortion was consistently associated with increased rate of most mental disorders, with ORs ranging from 1.02 to 2.83. This trend is summarized in the fact that women exposed to abortion from ages 15 to 29 (on average) experienced overall rates of mental health problems 1.34 (95% confidence interval (CI), 1.22–1.47) times higher than those not exposed to abortion (p < 0.001)."

Anxiety and depression in patients with advanced ovarian cancer: a prospective study. Mielcarek P, Nowicka-Sauer K, Kozaka J. J Psychosom Obstet Gynaecol. 2016 Mar 3:1-11.

INTRODUCTION: Women with advanced ovarian cancer with long-term survival are at persistent risk of anxiety and reactive depression due to poor prognosis and risk of burdensome symptoms. The aim of the study was to assess changes in anxiety and depression during multimodality ovarian cancer treatment and to identify correlates of anxiety and depression.

METHOD: The study included 106 consecutive patients with advanced ovarian cancer. Mean age of the study group was 53.9 years (SD  =  10.8, range: 23-79). The participants completed Hospital Anxiety and Depression Scale and State-Trait Anxiety Inventory four times: prior to and one week after surgery, and before the second and the fourth course of adjuvant chemotherapy. Multivariate analysis was performed to identify the independent determinants of distress at various stages of treatment.

RESULTS: The level of anxiety and the prevalence of pathological anxiety (74%) were the highest prior to surgery and gradually decreased thereafter. Irrespective of the treatment stage, the level of anxiety was higher than the corresponding level of depression. History of abortion, presence of intestinal stoma, poor general status, residual disease and time from the initial diagnosis were the main determinants of distress in ovarian cancer patients.

CONCLUSIONS: Significant changes in the level of anxiety and slight fluctuations in the depression level experienced during ovarian cancer treatment are mostly determined by clinical variables. Identification of individuals with psychological comorbidities is a vital component of patient-oriented multidisciplinary care.

The Impact of Prior Abortion on Anxiety and Depression Symptoms During a Subsequent Pregnancy: Data From a Population-Based Cohort Study in China Huang Z, et al. Bulletin of Clinical Psychopharmacology 2012;22(1):51-8

Objective: The aim of the study was to assess anxiety and depression in women with history of spontaneous abortion or induced abortion during a subsequent pregnancy.

Methods: The data were consecutively obtained from seven maternal and child health (MCH) Centers in the Anhui Province of China. The sociodemographic characteristics of the women, the number of previous pregnancies, number of living children, and gestational age of the current pregnancy were ascertained at the time of the interview.

Results: The pregnant women who were in the first trimester of their pregnancy reported significantly higher scores than those in the second trimester both on SAS (Zung’s Self-Rating Anxiety Scale) and CES-D (The Center for Epidemiologic Studies-Depression Scale) (SAS score means: 32.11 vs 31.68, P=0.000; CES-D score means: 4.59 vs 4.06, P=0.012). The women with a history of induced abortions were significantly more likely to report more “cases” of depression (OR = 1.543, 95% CI = 1.055- 254) and more “cases” of anxiety (OR = 2.142, 95% CI = 1.294-3.561) during the first trimester than those with no history of abortion. Controlling for confounding variables yielded similar results. However, “cases” of depression and “cases” of anxiety were equally common in women with history of spontaneous abortions and in those with no abortion history.

Conclusions: These results suggest women who have experienced a previous induced abortion have omnipresent anxiety and depression symptoms during a subsequent pregnancy, specially during the first trimester.

Psychological sequelae of medical and surgical abortion at 10-13 weeks gestation. Ashok PW, Hamoda H, Flett GM, Kidd A, Fitzmaurice A, Templeton A. Acta Obstet Gynecol Scand. 2005 Aug;84(8):761-6.

METHODS: Partially randomized patient preference trial in a Scottish Teaching Hospital was conducted. The hospital anxiety and depression scales were used to assess emotional distress. Anxiety levels were also assessed using visual analog scales while semantic differential rating scales were used to measure self-esteem. A total of 368 women were randomized, while 77 entered the preference cohort.

RESULTS: There were no significant differences in hospital anxiety and depression scales scores for anxiety or depression between the two groups of women having medical or surgical abortion. Visual analog scales showed higher anxiety levels in women randomized to surgery prior to abortion (P < 0.0001), while women randomized to surgical treatment were less anxious after abortion (P < 0.0001). Semantic differential rating scores showed a fall in self-esteem in the randomized medical group compared to those undergoing surgery (P = 0.02).

Associations Between Abortion, Mental Disorders, and Suicidal Behaviour in a Nationally Representative Sample. Mota NP, Burnett M, Sareen J. The Canadian Journal of Psychiatry, Vol 55, No 4, April 2010

Methods: Data came from the National Comorbidity Survey Replication (n = 3310 women, aged 18 years and older). The World Health Organization–Composite International Diagnostic Interview was used to assess mental disorders based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria and lifetime abortion in women. Multiple logistic regression analyses were employed to examine associations between abortion and lifetime mood, anxiety, substance use, eating, and disruptive behaviour disorders, as well as suicidal ideation and suicide attempts. We calculated the percentage of respondents whose mental disorder came after the first abortion. The role of violence was also explored. Population attributable fractions were calculated for significant associations between abortion and mental

disorders.

Results: After adjusting for sociodemographics, abortion was associated with an increased likelihood of several mental disorders—mood disorders (adjusted odds ratio [AOR] ranging from 1.75 to 1.91), anxiety disorders (AOR ranging from 1.87 to 1.91), substance use disorders (AOR ranging from 3.14 to 4.99), as well as suicidal ideation and suicide attempts (AOR ranging from 1.97 to 2.18). Adjusting for violence weakened some of these associations. For all disorders examined, less than one-half of women reported that their mental disorder had begun after the first abortion. Population attributable fractions ranged from 5.8% (suicidal ideation) to 24.7% (drug abuse).

Conclusions: Our study confirms a strong association between abortion and mental disorders. Possible mechanisms of this relation are discussed.

The Long Term Psychological Effects of Abortion, Catherine A Barnard. (Portsmouth, NH: Institute for Pregnancy Loss, 1990).

47.5% of women exhibited an elevated level of anxiety on the Millon Clinical-Multi-Axial Inventory 3-5 years postabortion.

"Emotional Distress Patterns Among Women Having First or Repeat Abortions," EW Freeman, Obstetrics and Gynecology 55(5):630, 1980.

Phobic anxiety was identified as a postabortion reaction and was higher among women repeating abortion compared to women with one abortion.

"Incidence of complicated grief and post-traumatic stress in a post-abortion population," LM Butterfield, Dissertation Abstracts Int'l 49(8): 3431-B, 1988.

Postabortion women consistently showed death anxiety on the Grief Experience Inventory.

"Psychological Responses Following Medical Abortion (using Mifepristone and Gemepost) and Surgical Vacuum Aspiration," R Henshaw et al, Acta Obstet Gynecol Scand 73:812, 1994.

A Scottish study found that postabortion anxiety correlated with cigarette smoking with the most anxious women having the heaviest smoking habits.

The effects of induced abortion on emotional experiences and relationships: a critical review of the literature. Bradshaw Z, Slade P. Clin Psychol Rev. 2003 Dec; 23(7): 929-58.

This paper reviews post-1990 literature concerning psychological experiences and sexual relationships prior to and following induced abortion. It assesses whether conclusions drawn from earlier reviews are still supported and evaluates the extent to which previous methodological problems have been addressed. Following discovery of pregnancy and prior to abortion, 40-45% of women experience significant levels of anxiety and around 20% experience significant levels of depressive symptoms. Distress reduces following abortion, but up to around 30% of women are still experiencing emotional problems after a month. Women due to have an abortion are more anxious and distressed than other pregnant women or women whose pregnancy is threatened by miscarriage, but in the long term they do no worse psychologically than women who give birth. Self-esteem appears unaffected by the process. Less research has considered impact on the quality of relationships and sexual functioning, but negative effects were reported by up to 20% of women. Conclusions were generally concordant with previous reviews. However, anxiety symptoms are now clearly identified as the most common adverse response. There has been increasing understanding of abortion as a potential trauma, and studies less commonly explore guilt. The quality of studies has improved, although there are still some methodological weaknesses.

Assessing traumatic reactions of abortion with the emotional stroop.]Toledano, Levana. Dissertation Abstracts International: Section B: The Sciences & Engineering, Vol 64(9-B), 2004. pp. 4639. Hofstra U., US

The primary purpose of this study was to investigate whether PTSD and its related symptoms are present in a sample of women following abortion. Two groups of women were included in this study: 59 women who had undergone an abortion and a control group of 28 women who had comparable surgical procedures. The mean age of the participants was 29.82, with ages ranging from 18 to 50 years. Symptoms of PTSD were assessed using the Posttraumatic Diagnostic Scale (PDS), the Impact of Event Scale (IES), and the Emotional Stroop paradigm. The Emotional Stroop procedure utilized was a color-naming task comprised of abortion-relevant words (i.e., sex, pregnant, fetus), positive words, neutral words, and obsessive-compulsive disorder (OCD) words. Levels of depression and anxiety were assessed with the Beck Depression Inventory-II (BDI-II), and the State-Trait Anxiety Inventory (STAI). The role of social support at the time of abortion was measured via the Multidimensional Scale of Perceived Social Support (MSPSS). Background variables such as religiosity, the presence or absence of coercion, marital status, gestational length, number of children, and age were also explored as possible risk factors mediating responses to abortion. Multivariate tests indicated the presence of PTSD in both groups of women, but to a greater extent in the post-abortion group. The two groups reported similarly elevated scores for anxiety. Post-abortion women exhibited significantly longer response latencies on the Stroop for abortion/trauma-relevant stimuli as compared to the control group. There were no significant differences found between groups on measures of depression. Significant risk factors included low levels of perceived social support, younger age, and the presence of coercion. Implications for community and clinical psychology are outlined. (PsycINFO Database Record (c) 2004 APA, all rights reserved)

Generalized anxiety following unintended pregnancies resolved through childbirth and abortion: a cohort study of the 1995 National Survey of Family Growth. Cougle JR, Reardon DC, Coleman PK. J Anxiety Disord. 2005;19(1):137-42.

Women with a history of abortion are significantly more likely to subsequently have elevated rates of general anxiety disorder.

Abortion in young women and subsequent mental health. Fergusson DM, John Horwood L, Ridder EM. J Child Psychol Psychiatry. 2006 Jan;47(1):16-24.

Methods: Data were gathered as part of the Christchurch Health and Development Study, a 25-year longitudinal study of a birth cohort of New Zealand children. Information was obtained on: a) the history of pregnancy/abortion for female participants over the interval from 15-25 years; b) measures of DSM-IV mental disorders and suicidal behaviour over the intervals 15-18, 18-21 and 21-25 years; and c) childhood, family and related confounding factors.

Results: Forty-one percent of women had become pregnant on at least one occasion prior to age 25, with 14.6% having an abortion. Those having an abortion had elevated rates of subsequent mental health problems including depression, anxiety, suicidal behaviours and substance use disorders. This association persisted after adjustment for confounding factors.

Conclusions: The findings suggest that abortion in young women may be associated with increased risks of mental health problems.

The course of mental health after miscarriage and induced abortion: a five-year follow-up study. Broen AN, Moum T, Bødtker AS, Ekeberg O. BMC Medicine 2005, 3:18 (12 December 2005)

Broen et al.'s results show that women who had a miscarriage suffer more mental distress up until six months after the event than women who had an abortion. Women who had an abortion, however, experienced more mental distress long after the event - two and five years afterwards - than women who had a miscarriage. Women who experienced induced abortion had significantly greater IES scores for avoidance and for the feelings of guilt, shame and relief than the miscarriage group at two and five years after the pregnancy termination (IES avoidance means: 3.2 vs 9.3 at T3, respectively, p < 0.001; 1.5 vs 8.3 at T4, respectively, p < 0.001). Compared with the general population, women who had undergone induced abortion had significantly higher HADS anxiety scores at all four interviews (p < 0.01 to p < 0.001), while women who had had a miscarriage had significantly higher anxiety scores only at T1 (p < 0.01).

Sleep Disorders

See Sleep Disorders

Intrusion/Avoidance/Dreams/Nightmares

This section demonstrates that it is easier to physically remove the aborted child from the body of the mother than remove the image from the mind of the mother.

Introduction to Psychodynamics: A New Synthesis, MJ Horowitz (New York: Basic Books, 1988) 48

Four stages of grief are identified (1) outcry, (2) denial, (3) intrusion, and (4) working through. When the intrusion phase is prolonged, the bereaved person may be troubled by recurring thoughts or images including nightmares and flashback experiences which may interfere with sleep and daytimes activities for months and years beyond the time expected for normal grieving.

"Postabortion Syndrome: An Emerging Public Health Concern," AC Speckhard and VM Rue, Journal of Social Issues 48(3):95, 1992.

Intrusive nightmares of postabortion women fall into three general categories: horrors about how the fetal child dies, fearful symbols of judgment and penalty, and searching for something precious that cannot be found.

The Negative Impact of Abortion on Women and Families, E Joanne Angelo in Post-Abortion Aftermath, ed. Michael T Mannion (Kansas City, MO: Sheed&Ward, 1994) 50.

Clinical psychiatrist E Joanne Angelo has observed: " the woman has often formed a mental image of her child which haunts her day and night- an image of an infant being torn to pieces, sucked down a tube, crying out in pain, or reaching out to her for help. She may have named her baby and have regularly occurring conversations with him or her in mind begging forgiveness for what she has done."

Experiencing Abortion, Eve Kushner (New York: Harrington Park Press, 1997) 166.

One 22 year old woman, the night after her abortion said, " I felt my baby's spirit come to visit me." She adds that the spirit "found its body gone. Then it disappeared. I was positive that's what happened and I cried like I never had before, sobbing and sobbing. The world seemed so empty, with nothing left to live for."

Abortion. Loss and Renewal in the Search for Identity, Eva Pattis Zoja (English Trans. Henry Martin (New York: Routladge, 1997) 91-94

This book describes a woman's dream 5 days before her abortion: " We've only got five more days. Then you will have to go. It's going to be horrible and I'm the one who has made that decision. For now, we're still together, we've still got a little time, I'll be with you, up until the end." The night before the abortion, this same woman had this dream: " It was the morning of the abortion. I knew I had to go to the hospital. My partner and two little boys had given me gifts; it seemed like my birthday. My younger sister was also there; there was a family atmosphere. Everybody was ready to accompany me. It made it easy to enter the hospital."

Seven months later, at precisely the time when the baby was due, this same woman had the following dream: " I was in the bathroom at the home of my parents. I was sitting on the toilet, and I thought that I was having my period. I realized that a tiny baby had fallen out into the water, where it was moving about like a sea horse. I saw that it was alive, but the front of its head seemed squashed, as though it had no brain. It was a spontaneous miscarriage. I felt very sorry for it. I knew that the child couldn't survive; it would die as soon as I lifted it out of the water. I took it out of the water and held it in my hand. I didn't want it to die alone. There were people around me, and I found that very disturbing. I looked for a place in which to be alone, and found the room I had had as a little girl. Then Maria entered, an aunt of whom I was very fond. Finally alone and quiet, I saw that the child had died in the palm of my hand. I knew that I was supposed to burn the body. Now it looked like a sheet of paper, and I set fire to one of its corners. It burned and burned, but didn't turn to ashes; it took on a series of very bright colors, like the colors of a figure in enamel. It had turned into a Christ child, and was alive and smiling."

The Long Term Psychological Effects of Abortion, Catherine A Barnard, (Portsmouth NH: Institute for Pregnancy Loss, 1990.)

In a study of women 3-5 years postabortion, 23% had recurrent and distressing dreams of the event, 45% had a sense of reliving the experience, 29% had recurrent and intrusive recollections of the event, 45% had hypervigilance, 35% made efforts to avoid feelings associated with the event, and 11% made efforts to avoid activities associated with the event.

"Abortion in Adolescence," NB Campbell et al, Adolescence Vol XXIII No.92: 813, 1988

Women in a postabortion support group who had abortions as teenagers were more likely to have nightmares after abortion (80%) compared to women who had abortions as adults (43%)

"Therapeutic Abortion During Adolescence: Psychiatric Observations," P Barglow and S Weinstein, Journal of Youth and Adolescence 2(4): 331, 1973

This article describes numerous dreams and nightmares of adolescents, both pre and postabortion. The authors stated," almost all adolescent subjects experienced the abortion procedure as frightening, dangerous, and punitive, and often as temporarily overwhelming." Dreams represented the fetus as a baby, child, or animal such as a worm, frog, parakeet, cat or even a dinosaur. The abortion procedure, hospital, or doctor appeared without disguise in 95% of the dreams." Examples of the content of these dreams include a 16 year old girl with a Black Muslim mother. The girl wept and screamed in terror during the abortion procedure. Her preabortion dream: " I dreamed the devil performed the abortion. He just reached up his black hand, pulled it out, and then danced around me with it in his hands while laughing and yelling";Another who had a conflict with her mother dreamt following her abortion " My mother and four men chased me into a white garage. The men held me and my mother made a cut in my vagina while I screamed"; A 16 year old who underwent a second abortion who was evaluated for severe depression and suicidal preoccupation after her abortion had the following dream before her abortion. "I had a nightmare that there was an atomic war and that I alone was left in the world."

"Prolonged Grieving After Abortion: A Descriptive Study," D Brown et al, The Journal of Clinical Ethics 4(2):118, 1993

Postabortion women frequently fantasized about the aborted fetus and had other intrusive thoughts when reminded of pregnancy or childbirth.

"A consideration of ketamine dreams," P Hejja, S Galloon, Can Anaesth Soc J 22(1): 100-105, Jan, 1975

This study used ketamine anesthesia to attempt to reduce the incidence of unpleasant dreams at the time of abortion.

"Induced Elective Abortion and Perinatal Grief," GB Williams, Dissertation Abstracts Int'l 53(3): 1296-B, 1992.

Inability to control overt emotional responses had the highest scores in a Grief Experience Inventory 11 years postabortion.

“ Memories Unleashed” in Forbidden Grief. The Unspoken Pain of Abortion, Theresa Burke and David Reardon (Springfield, Il: Acorn Books, 2002) 121- 132

Describes flashbacks, dreams and nightmares, hallucinations, trauma and memory of postabortion women.