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Download by: [Istanbul Universitesi Kutuphane ve Dok] Date: 17 January 2017, At: 10:20
Journal of Trauma & Dissociation
ISSN: 1529-9732 (Print) 1529-9740 (Online) Journal homepage: http://www.tandfonline.com/loi/wjtd20
Acute dissociative reaction to spontaneous
delivery in a case of total denial of pregnancy:
Diagnostic and forensic aspects
Vedat Şar MD, Nazan Aydın MD, Onno van der Hart PhD, A. Steven Frankel
JD, PhD, Meriç Şar LLB, LLM, & Oğuz Omay MD
To cite this article: Vedat Şar MD, Nazan Aydın MD, Onno van der Hart PhD, A. Steven
Frankel JD, PhD, Meriç Şar LLB, LLM, & Oğuz Omay MD (2016): Acute dissociative reaction to
spontaneous delivery in a case of total denial of pregnancy: Diagnostic and forensic aspects,
Journal of Trauma & Dissociation, DOI: 10.1080/15299732.2016.1267685
To link to this article: http://dx.doi.org/10.1080/15299732.2016.1267685
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Dec 2016.
Published online: 20 Dec 2016.
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Acute dissociative reaction to spontaneous delivery in a case
of total denial of pregnancy: Diagnostic and forensic aspects
Vedat Şar, MD
a
, Nazan Aydın, MD
b
, Onno van der Hart, PhD
c
, A. Steven Frankel,
JD, PhD
d,e,f
, Meriç Şar, LLB, LLM,
g,h
, and Oğuz Omay, MD
i
a
Department of Psychiatry, Koc University School of Medicine (KUSOM), Istanbul, Turkey;
b
Bakirkoy
Prof. Dr. Mazhar Osman Research and Training Hospital on Mental Disorders, Istanbul, Turkey;
c
Department of Psychology, Utrecht University, Utrecht, The Netherlands;
d
Department of Psychology,
University of Southern California, California, USA;
e
California Bar Association, California, USA;
f
District of
Columbia Bar Association, Washington, DC, USA;
g
New York Bar Association, New York, New York, USA;
h
Istanbul Bar Association, Istanbul, Turkey, USA;
i
Perinatal Psychiatry Unit, La Teppe Medical Center,
Tain l’Hermitage, France
ABSTRACT
This article presents the history of a 21-year-old female college
student with total denial of pregnancy who experienced an acute
dissociative reaction during the spontaneous delivery at home
without medical assistance where the newborn died immediately.
Psychiatric examination, self-report questionnaires, legal docu-
ments, and witness reports have been reviewed in evaluation of
the case. Evidence pointed to total denial of pregnancy, that is,
until delivery. The diagnoses of an acute dissociative reaction to
stress (remitted) and a subsequent PTSD were established in a
follow-up examination conducted 7 months after the delivery.
Notwithstanding the inherently dissociative nature of total denial
of pregnancy, no other evidence has been found about pre-
existing psychopathology. For causing the newborn’s death, the
patient faced charges for “aggravated murder,”which were later
on reduced into “involuntary manslaughter.”Given the physical
incapacity to perform voluntary acts due to the loss of control over
her actions during the delivery, and the presence of an acute
dissociative reaction to unexpected delivery, the legal case repre-
sents an intricate overlap between “insanity”and “incapacitation”
defenses. The rather broad severity spectrum of acute dissociative
conditions requires evaluation of the limits and conditions of
appropriate legal defenses by mental health experts and lawyers.
Denial of pregnancy as a source of potential stress has attracted
little interest in psychiatric literature although solid research exists
which documented that it is not infrequent. Arguments are pre-
sented to introduce this condition as a diagnostic category of
female reproductive psychiatry with a more neutral label: “unper-
ceived pregnancy.”
ARTICLE HISTORY
Received 10 August 2016
Accepted 11 November 2016
KEYWORDS
Denial; dissociation; forensic;
neonaticide; pregnancy
“Denial of pregnancy”is defined as not recognizing the condition until the
20th week after conception. In the case of total denial, the pregnancy is not
perceived till delivery neither by the woman, nor her partner, nor her
CONTACT Vedat Şar, MD vsar@ku.edu.tr Koc University School of Medicine, Rumelifeneri Yolu, 34450,
Sariyer, Istanbul, Turkey.
JOURNAL OF TRAUMA & DISSOCIATION
http://dx.doi.org/10.1080/15299732.2016.1267685
© 2017 Taylor & Francis
parents, in some cases not even by her doctors. Denial of pregnancy, when
total in particular, can lead to a traumatic delivery, loss of newborn, and
medical and psychiatric complications alongside forensic consequences.
Pregnancy denial has not attracted sufficient attention in the psychiatric
literature despite the existing solid epidemiological research concerning this
phenomenon. Partial denial of pregnancy occurs in approximately one of 500
pregnancies (Wessel & Büscher, 2002). In one of 2500, denial of pregnancy
continues until delivery (total denial). Aydin (2013) reported a series of seven
cases (including one total denial) between 18 and 38 years of age. For six of
them, it was the first pregnancy. In a recent epidemiological study in Turkey
(Yuce et al., 2015), partial denial was reported in 1/526 (0.19%) of all
pregnancies. Of the 30 identified cases (age range 18–46; 1–6th pregnancy),
none of them had a psychotic disorder.
Such dramatic but non-psychotic denial may be related to dissociation (see
MacFarlane, 1998), which involves a disruption of and/or discontinuity in
usually integrated mental functions such as consciousness, memory, identity,
emotion, perception, body representation, motor control, and behavior
(American Psychiatric Association, 2013). Dissociation is involved in a broad
spectrum of trauma-related disorders as a main component of psychopathol-
ogy (Şar, 2011). Such mental disruption can lead both to a chronic and acute
dissociative disorder. The latter can transiently lead to disorganized behavior
involving diminished awareness of oneself and the environment. In the present
article, a special emphasis is placed on the forensic aspects of the acute
dissociative reaction—a new diagnostic category in DSM-5 listed among
other specific dissociative disorders—to unexpected delivery, which ended
with the loss of the newborn. This study also aims raising awareness s about
denial of pregnancy—a little known phenomenon—as a potential source of
acute traumatic stress. Considering its potentially complex and multi-factorial
etiology, we suggest a more neutral name for this condition: “Unperceived
pregnancy.”
Case presentation
The patient/client has given informed written consent for the publication. Her
identity has been disguised by omission and alteration in non-crucial informa-
tion. The older one of three siblings, Maria (pseudonym) was a 21-year-old
female exchange student from Western Europe temporarily located in Istanbul.
Without being aware of her pregnancy, she gave birth to a child in the third
month of her stay in Turkey. The child died during the unexpected spontaneous
delivery at home with no medical assistance.
Maria was living in an apartment house shared by college students. She
was described by her friends as a cheerful, socializing girl with a warm
attitude and no behavioral problems. Her grandfather passed away 6 months
2V. ŞAR ET AL.
prior to her arrival in Istanbul, with whom she was in a close relationship.
She has had a boyfriend for 5 years, who was the father of the newborn
according to Maria’s report.
Unperceived pregnancy
Maria’s last menstruation occurred approximately 8–9 months prior to the
delivery. She additionally had two menstrual periods lasting shorter than
usual (only 2 days). She interpreted this irregularity as a side effect of the
contraceptives, which she stopped taking after coming to Turkey. She had
nausea a few times in early stages of the pregnancy, which she associated
with frequent alcohol consumption. Maria related her mild overweight to
eating and drinking in student parties she frequently attended. When
pictures of that period and those taken in the pregnancy period were
compared, she looked, paradoxically, more overweight in the former.
Neither she herself nor her friends and parents realized that she was
pregnant.
Delivery and acute dissociative reaction
Maria woke up due to abdominal pain during midnight. Taking this as a sign
of menstrual period, she got a shower. As she felt abdominal pressure, she
repeatedly visited the restroom afterwards and tried to defecate. Due to the
on-going bleeding and abdominal pain, she woke up her friends toward early
morning and asked for assistance. According to the witness’reports, she was
frantic in behavior and her facial expression reflected severe pain. Sitting on
the water closet, she examined her vulva with her hand. She said that she
“touched something hard inside”and screamed: “something is coming out of
my body.”While she stood up, a newborn in pallor and violet color fell into
the water closet. Being puzzled, Maria screamed and left the bathroom while
the umbilical cord, disrupted due to her hectic movements, was hanging
below. In order to stop bleeding, Maria’s friends assisted her in putting a
towel to her vulva. When Maria took the towel out shortly afterwards, her
placenta fell to the floor.
According to her friends, she was looking like “crazy”at that time and
started to scream again. She repeatedly said, “this cannot be true,”“some-
thing is wrong.”Presenting a dissociative state, she was “shocked,”confused,
and entered in a transient stupor; she did not respond to comments of her
friends. Her dissociative, disorganized behavior lasted approximately 1 hour,
that is, until arrival of an ambulance. She was transported to a hospital.
Police officers and ambulanciers found the fully developed dead newborn in
the water closet with its head inside of the water.
JOURNAL OF TRAUMA & DISSOCIATION 3
Follow-up and psychiatric examination
According to her friends, she was upset and crying continuously for days
after the event. She was asking, “why did I not recognize what occurred in
my body?’’ Temporarily demonstrating lack of realization, she could not give
any meaning to the milk coming out of her breasts. According to her lawyer’s
report, Maria repeatedly stated that she could not remember what happened
during and immediately after delivery. Moreover, she continued to have
micro-amnesias which interfered with her daily functioning (e.g., forgetting
her appointments).
A psychiatric evaluation was ordered by the state attorney upon request by
the defendant’s lawyer, which was carried out by two female psychiatrists
7 months after the delivery. One of the examiners (N.A.) was serving as the
chief physician of a general psychiatric clinic in the largest state mental
hospital in Istanbul (a professional training and research institution) and as
the head of the Women’s Mental Health Center affiliated with the same
hospital. The second expert was an attending psychiatrist of the latter center.
Maria was diagnosed as having had a total pregnancy denial, described by
Van der Hart, Faure, Van Gerven, and Goodwin (1991)as“non-realization,”
acute dissociative reaction (remitted), and post-traumatic stress disorder
(current). She still had partial dissociative amnesia to the delivery and to
her reaction. The Dissociative Experiences Scale (DES) (total = 4.3 with a
possible range of 0–100) and Somatoform Dissociation Questionnaire
(total = 30, with a possible range of 20–100) scores were below the cut-off
level for chronic complex dissociative disorders.
The trial: Insanity or incapacitation?
Under Turkish criminal law, defenses related to “mental capacity”are
recognized as affirmative defenses which can only be raised during trial.
Thus, the predominance of the psychiatric question in Maria’s case led the
state attorney initiate a file without the consideration of Maria’smental
status in the preliminary phase of the case. Maria was initially charged
with aggravated murder for “intentionally killing a child or a person who
is mentally or bodily incapable to defend himself,”and a travel ban was
pronounced by the court until further proceedings. During the investiga-
tion, the state attorney requested psychiatric examination of Maria by a
team of two psychiatrists, who were also given the task of answering four
medico-legal questions: (1) the medical possibility of pregnancy denial; (2)
whether the accused person’sstatusfitted this condition; (3) whether the
accused person demonstrated the behavior reasonably expected in such
condition; (4) whether and how the accused person’s status of “shock”
affected her consciousness (whether one may expect from her the capability
4V. ŞAR ET AL.
of undertaking any necessary assistance to the newborn). The psychiatric
examiners stated that denial of pregnancy was medically possible, and the
physical incapacitation arising from an acute dissociative reaction to the
unexpected delivery could have rendered Maria’sactsasinvoluntaryin
relation to the failed delivery.
In response to this opinion, the judge lifted the prohibition of leaving the
country during the preliminary hearings and revised the charge as “involun-
tary manslaughter.”The judge ordered a more holistic forensic medical
inquiry by the court’s medical referee (i.e., medical experts’panel of the
State Institution of Forensic Medicine) to determine Maria’s degree of
responsibility in the action causing the death of the newborn in consideration
of the entirety of relevant factors (i.e., including Maria’s mental conditions).
This request was rejected by the court’s medical referee as improperly for-
mulated. In the medical referee’s opinion, the court’s request was erroneous
and unusual as it demanded a graded estimation in relation to the defen-
dant’s mental capacity. It was common for the forensic authority to issue
such graded reports in relation to causality-related inquiries regarding mate-
rial events; however, such a graded opinion would be improper in determin-
ing mental incapacity or insanity.
Discussion
Legal aspects
The already traumatic delivery led to a judicial process that added further
distress to the affected person and a major challenge to forensic experts.
Namely, Maria’s non-realization prior to, and panic during delivery led to a
criminal prosecution for “murder”which was later reduced into “involuntary
manslaughter”based on an initial psychiatric review, which supported the
view that Maria was likely to be suffering from “pregnancy denial.”From a
legal standpoint, the loss of behavioral control during the delivery and the
related acute dissociation can be seen as allowing both insanity and incapa-
citation defenses due to her inability to conduct voluntary acts during the
delivery (MacFarlane, 1998). Indeed, an acute dissociative reaction may
involve disorganized behavior and may turn even to a brief psychosis (Sar
& Ozturk, 2008; Spiegel et al., 2011; Van der Hart &Witztum, 2008)as
mentioned in DSM-5 (p. 292) as well. However, in cases involving acute
dissociation, usually courts tend to be reluctant to acquit defendants under
the generally accepted standards of the insanity defense due to the transient
nature of the syndrome. A court would be more likely to accept the incapa-
city defense in a case involving severe physical incapacity and duress caused
by an objectively incapacitating event such as the delivery of a child.
JOURNAL OF TRAUMA & DISSOCIATION 5
Indeed, the case represents an interesting conundrum from a legal stand-
point. Assuming that the patient suffered from pregnancy denial (and thus
did not carry the requisite specific intent to cause the death of the newborn),
the difficulty in dissecting the applicable legal norms arises from the apparent
coexistence of both insanity (due to acute dissociation) and physical incapa-
citation (due to the mother’s physical incapacitation during birth). The
judge’s intuitive awareness of this tension seems to have led the court to
proceed with a more holistic inquiry on “causality”by downplaying the role
of acute dissociation and the related insanity defense. Another reason for the
court’s hesitation in framing the issue solely as a matter of “insanity”can be
the onerous conditions associated with the sentencing of individuals who
successfully plead an insanity defense and the likelihood of defendant’s
incarceration at a psychiatric facility regardless of being found not guilty
due to mental insanity. In the court’s mind, such hospitalization can be
avoided only by assignment of the psychiatric condition as a transient impact
factor in a situation of general incapacitation due to multiple coexisting
causes. The immediate reaction to the unexpected delivery was relatively
transparent in consideration of the presence of eyewitnesses; hence, simula-
tion or intended murder can be considered as ruled out for the presented
case.
It is well established in the USA law that insanity defense may be available
for defendants suffering from chronic dissociative disorders—such as disso-
ciative identity disorder. In U.S. experts who are familiar with dissociative
episodes, in cases where there is supporting evidence, would also argue that
the disruptions in functioning could meet criteria for both insanity and
incapacitation defenses (McFarlane, 1998). There is also at least one court
decision that recognizes the availability of both incapacitation defense an
acute dissociative episode of a military veteran suffering from PTSD (People
v. Lisnow, 88 Cal. App. 3d Supp. 21, 151 Cal. Rptr. 621 (App. Dep’t Super Ct.
1978)). This is due to the coexistence of both physical “loss of control”and
the diminishing mental capacity to “distinguish between right and wrong.”
However, if there are no sufficient witness reports, it would be a matter of
whether the defendant’s account is viewed as credible by the jury and it
would also depend on forensic examinations. Having a low DES score would
not be important if more comprehensive evaluations of dissociative disorders
were administered and were positive for the presence of dissociation. Even an
evaluation of hypnotic capacity could help, as shown by Dell (2016), who
states that hypnotic capacity is a “necessary diathesis for dissociation.”
The availability of insanity and involuntariness/incapacity defenses for
psychiatric conditions is not finely defined under Turkish criminal law
code contrary to the U.S. law that adopts a stricter separation between the
two. However, within the general framework that defines defenses available
for situations involving “diminished mental capacity,”the Turkish criminal
6V. ŞAR ET AL.
statute nevertheless contains language that may be interpreted in a way to
allow a defense that resembles the incapacity defense available under the
U.S. law. Under Turkish criminal code, the forensic/medical expert will have
to testify either that 1) at the time of the conduct the individual could not
comprehend the legal meaning and consequences of his or her act due to a
psychiatric condition (diminishing of mental capacity to differentiate right or
wrong), or 2) at the time of the conduct the capacity of the individual to
direct his or her acts in relation to the conduct was substantially impaired
(physical incapacitation). The second prong potentially provides an implied
involuntary movement defense that may be more deferential and flexible than
the first prong.
Clinical aspects
The connection between neonaticide and unperceived pregnancy is not clear
yet. In one study on 32 cases of neonaticide, only two women had unper-
ceived pregnancy (Vellut, Cook, &Tursz, 2012). In another study, pregnancy
was negated in 25 of 28 (89.3 %) cases, while two (7.1 %) women died
immediately after delivery, so there was a lack of information on their
motives (Amon et al., 2012). Spinelli (2001) reported with regard to 16
cases of neonaticide that nearly all of the women reported similar precipi-
tants and symptoms, including depersonalization, dissociative hallucinations,
and intermittent amnesia at delivery. Nine women reported a history of
childhood sexual trauma, and seven of those reports were corroborated by
independent sources. Six women reported a history of physical abuse. The
women’s scores on the DES (mean = 28.9 within a possible range of 0–100)
suggested a high level of chronic dissociative pathology. “Unawareness of
pregnancy”has been reported in dissociative identity disorder (Van der Hart
et al., 1991). Indeed, an acute dissociative reaction may be superposed on a
pre-existing chronic dissociative process (Tutkun, Yargic, & Sar, 1996).
However, in the present case, current evidence is not indicative of a pre-
existing chronic dissociative disorder.
The role of dissociation in Maria’s acute reaction to the unexpected
delivery needs some clarification. Acute dissociative reactions are seen in
psychologically traumatized populations (Spiegel et al., 2011). Recently, acute
dissociative reaction to stressful events has been introduced as a new category
among DSM-5’s Other Specified Dissociative Disorders (OSDD). Symptoms
such as amnesia, transient stupor, constriction of consciousness, and disor-
ganized behavior are sufficient to warrant this diagnosis (American
Psychiatric Association, 2013, p. 291). Experiencing the delivery as trauma-
tizing and subsequently developing PTSD are rather prevalent (Haagen,
Moerbeek, Olde, Van der Hart, & Kleber, 2015). However, dissociative
symptoms may also play a dominant role in any “partus stress reaction”
JOURNAL OF TRAUMA & DISSOCIATION 7
(Moleman, Van der Hart, &Van der Kolk, 1992), in particular during an
unexpected delivery. This is an old label for acute dissociative reaction—not a
normative phenomenon—specifically and during and/or right after the deliv-
ery. Moleman et al. (1992) described three cases of women for whom the
delivery was a traumatic experience which manifested in dissociative and, in
subsequent post-traumatic stress symptoms. These three women all had
histories of infertility and complicated pregnancies. They all had feared that
they would lose their babies and during the delivery had become panic-
stricken in anticipation of what they thought would be an inevitably disas-
trous outcome. Panic ceased when they dissociated from both their subjective
physical experience and from contact with their surroundings. Two of the
three patients had amnesia for their delivery.
Orientation to reality during an acute dissociative reaction to unexpected
delivery may be of vital importance for long-term psychiatric outcome.
Another medico-legal case followed up by one of the authors (O.O.), one
woman committed three neonaticides during acute dissociative reactions in
the aftermath of her all three consecutive pregnancies. The babies’corpses
found several years later. This observation suggested that a dissociation with
regard to such events may last many years: the acute dissociative reactions
led to persistent focal amnesia in these cases (Omay, 2016). In the presented
case, the presence of Maria’s friends during delivery and the acute dissocia-
tive reaction allowed some degree of reality orientation. Apart from the
subsequent PTSD, this may have prevented a worse outcome in terms of
chronification.
Denial of pregnancy still constitutes an enigma for psychiatry as it is a
scarcely studied subject. There is no established evidence about increased
prevalence of childhood trauma (e.g., sexual abuse) in cases of unperceived
pregnancy. Given that sexual intercourse in non-married relationships is so
widespread and accepted, at least in western countries where Maria is from,
such an origin cannot be claimed as a main causal factor either. Explanations
such as denial of fertility (Struye, Zdanowicz, Ibrahim, & Reynaert, 2013)or
an unconscious evolutionary wish of transmitting genes without being a
mother (Sandoz, 2016) have been proposed. Denial of pregnancy is the
somatic inverse of false pregnancy (pseudocyesis) which has a firm basis as
a psychosomatic disorder (Kenner & Nicholson, 2015). According to a recent
review of related studies (Kenner &Nicolson, 2015), abdominal muscle tone,
persistent corpus luteum function, and reduced availability of biogenic
amines contribute to false pregnancy while posture, fetal position, and corpus
luteum insufficiency play a role in denial of pregnancy. For each condition,
there are multiple reports in which the body reveals her true pregnancy status
as soon as the woman is convinced of her diagnosis.
As no homogenous and scientifically proven cause has yet been estab-
lished, we suggest another name for this condition, because “denial”
8V. ŞAR ET AL.
suggests a motivational cause. Hence, using the term “denial”may add to the
suffering of women and families concerned. “Unperceived pregnancy,”the
translation of “die nicht wahrgenommene Schwangerschaft”used by Wessel
(1998) in his initial thesis in German, which is in line with Van der Hart
et al.’s(1991)“unawareness of pregnancy”as well as with their construct of
“non-realization,”seems to be the best way to describe this condition in a
rather neutral fashion. Beside its inherently dissociative nature (i.e., enduring
disruption of bodily and cognitive perception), as a psychosomatic disorder
of potential source for traumatic stress, unperceived pregnancy deserves to be
a diagnostic category in female reproductive psychiatry in its own right
(Beier, Wille, & Wessel, 2006).
Last but not least, we would like to add an excerpt from Maria’s recent
testament to the authors (published by her permission) about her extraor-
dinary experience here which reflects a tragedy made possible by the human
nature: “It is really hard for me to describe how I feel about the denial of
pregnancy. I know that, in the weeks following the birth, I asked myself a lot
of questions about it. I felt betrayed by my body. I felt like my body was a
part of me that I can’t control. I thought that if my body did this to me, and
hid all these things from me, I could not be certain about anything that I felt,
or anything that I thought about me. The main feeling that I had, was to not
trust myself anymore.”
Acknowledgments
The authors are grateful to Maria (pseudonym) for her permission in studying and publishing
on her tragic personal and medico-legal story. Her sincere expressions have been most helpful
in developing the main line of the present article.
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