CATHERINE LaROCHE, M.D. NANCY FULLER, M.S.W.

MARTINE LALINEC-MICHAUD, M.D. MARIAN COPP, B.N.

FRANK ENGELSMANN, Ph.D. KAREN VASILEVSKY, P.S.W.

Grief reactions to perinatal

death: An exploratory study
ABSTRACT: Mothers who lose a baby may show inappropriate be pregnant, (2) they had previ-
grief reaction (lG R) at varying times following the event. The ously lost a baby, and (3) there was
authors describe an interdisciplinary crisis-intervention team a failure of communication be-
aimed at assessing and reducing pathologic grief in such mothers, tween the woman and her husband.
and report their preliminary findings. Among the factors found They found that the type of
associated with increased risk of IG R are the mother's desire for mourning reaction did not differ
with the length of time the baby
a baby, history of previous psychiatric problems, premature
had lived.
birth, failure to see the baby, and poor communication between In 1972, Cullberg1 reported that
the parents. 19 of 56 women who had lost babies
suffered pathologic grief and a va-
For some time now, the staffs of help prevent pathologic grief reac- riety of psychiatric problems one to
medical and surgical services have tions. Based on our experience with two years after the perinatal loss.
been sensitized to the pathologic a multidisciplinary research and Those women who had initially
consequences of poorly resolved treatment team, we drew up a pro- suppressed their feelings were par-
grief reactions associated with tocol for management of grief reac- ticularly prone to prolonged mental
chronic illness and death in the tions to perinatal death and under- symptoms.
family. This increased awareness- took an exploratory study, which Wolff and associates3.4 followed
and the therapeutic interventions we report below. up 40 women one to three years
that have developed from it-have after perinatal loss. They found
been slower to reach obstetric and Previous studies that all the mothers experienced an
neonatal units. Published reports In 1970, Kennel and associates,' as initial grief reaction but that signif-
suggest that improved communica- part of a larger study on maternal- icant psychiatric difficulties oc-
tion between the medical staff and infant separation, found that there curred in only two women, both of
mothers who have suffered peri- was more intense mourning among whom had been treated for pre-
natal loss, as well as between these mothers who had lost their babies vious mental or emotional distur-
mothers and their husbands, may when (I) they had been pleased to bances. The authors noted, how-
ever, that the small incidence of
From the Child and Adolescent Service and the Women's Pavilion, Allan Memorial pathologic findings in their sample
Institute and Royal Victoria Hospital, Montreal. Reprint requests to Dr. LaRoche, may have been related to the inad-
Royal Victoria Ho.~pital, 687 Pine Ave W, Montreal, Quebec. H3A JA J, Canada. vertent therapeutic effect of peri-

510 PSYCHOSOMATICS
odic comprehensive interviews, the
main goal ofwhich was to gain and
collect research data.
A surprising finding was the
number of mothers (eight) who
were adamant about not having
another baby. Four of these eight
resorted to sterilization. Twenty
women who did have subsequent
pregnancies sought other obstetri-
cians.
In the 1978 study of Rowe and'
associates,S six of 26 mothers expe-
rienced grief reactions that lasted
12 to 20 months. The most vulnera-
ble women were those who had a
surviving twin or who became
pregnant again less than five
months after the perinatal death.
The investigators also found a cor-
relation between the degree of dis-
satisfaction with the medical care
received and the mother's extreme
grief reaction.
Interdisciplinary approach
Effective liaison between psychia-
try and other medical services often
develops most naturally through
interdisciplinary teams that form in
response to crises. Our treatment
and research team, which consists
of representatives from the depart-
ments of social service, nursing,
psychiatry, psychology, obstetrics,
and neonatology, grew out of a
number of shared experiences.
For more than a year, a group of
nurses, a social worker, and a psy-
chiatrist had met regularly to try to
deal with perinatal death in terms
of its painful impact on both fami-
lies and staff. At the same time, the
nursing department had become
aware, from responses to question-
naires, of considerable dissatisfac-
tion that some parents felt with
hospital procedures related to a
stillbirth or loss of a newborn. Re-
view of our hospital practices and
MAY 1982· VOL 23 • NO 5
comparison with other models de-
scribed in the literature l revealed
that perinatal deaths were being
dealt with in individualistic ways,
largely dependent on the intuition
of the physician and other profes-
sional staff who were involved.
Following several interdisciplin-
ary conferences, aimed at raising
the level of staff awareness and
promoting staff support systems, a
protocol for management of peri-
The investigators found a
correlation between the
degree ofdissatisfaction with
the medical care received
and the mother's extreme
griefreaction.
natal death was drawn up and im-
plemented by the obstetrics and
neonatology departments. An im-
portant component of the new pro-
tocol is the crisis intervention that is
offered to parents in an attempt to
facilitate their grief process. Video-
tapes of several crisis-intervention
interviews have been used effec-
tively for in-service training. In ad-
dition, a booklet for parents that
describes available services is being
prepared, and efforts are under way
to organize in the community a
self-help group for parents
bereaved of a newborn.
We also undertook an explor-
atory study with two aims: (I) to
examine the relationships between
appropriate and inappropriate
grief reactions and a number of
sociodemographic and clinical
variables, and (2) to evaluate the
effects of crisis intervention on
mothers at the time of the immedi-
ate loss of their baby and at follow-
up contacts.
Sample and procedure
Our sample consisted of 31 mothers
from the obstetric department of
the Women's Pavilion at Royal
Victoria Hospital who had lost
babies before birth or during the
first month oflife in 1979. Maternal
age ranged from 18 to 34 years,
with an average of 26 years.
All of the women but two were
married; one was single and the
other had separated from her hus-
band. More than half (16) of the
sample were of North American
origin. Six were born in the Carib-
bean region, one was born in Asia,
and eight in Europe. Fifteen
mothers indicated that they spoke
English at home; II were French-
speaking. The majority of mothers
(65%) were Catholic; 26% were
Protestant.
The mothers were interviewed
for approximately one hour. one to
two days after the loss of their child.
Whenever possible, fathers were
also included in the interview. The
plirpose was to assess and facilitate
the grief process, to clarify misun-
derstandings and confusion, and to
encourage communication be-
tween husband and wife and be-
tween parents and mc:dical staff.
On the basis of the interview, a
structured form was completed that
included clinical and sociodemo-
graphic variables such as educa-
tion, social class, occupation, living
space, and support system. Tele-
phone and direct contact were
made by the same interviewer two
to three weeks later and again after
approximately three months.
Assessments of grief reaction
were based on these interviews,
using the criteria of Parkesb and
Lindemann.' These criteria include
somatic distress, intense subjective
distress, preoccupation with an
image of the deceased. feelings of
(continued)
511
Brief Summary of Prescribing Information
Adaplne
(dOxepin HCI) Capsules
Indication. Relief of symptoms of anxiety
and depression.
Contraindication. Glaucoma. tendency
toward urinary retentiOn or hypersenSitivity to
doxepin.
WIlrnlng. Adapin has not been evaluated for
safety in pregnancy. No evidence of harm to
the animal fetus has been shown in reproduc-
tive studies. There are no data concerning
secretiOn in human milk. nor on efleet in nurs-
ing infants.
Usage in children under 12 years of age is
not recommended. MAO inhibitors should be
discontinued at least two weeks prior to the
cautious initiation of therapy with this drug. as
serious Side-efleets and death have been re-
ported with the concomitant use of certain
drugs and MAO inhibitors.
In patients who may use alcohol exces-
Sively. potentiation may increase the danger
inherent in any suicide attempt or overdosage.
Precaution. Drowsiness may occur and
patients should be cautioned against driving
a motor vehicle or operating hazardous ma-
chinery. Since suicide is an inherent risk in
depressed patients. they should be closely
supervised while receiving treatment. Al-
though Adapin has shown efleetive tranquiliZ-
ing activity. the posSibility of activating or
unmasking latent psychotic symptoms should
be kept in mind.
This product contains FD&C Yellow NO.5
(tartrazine) which may cause allergic-type re-
actions (including bronchial asthma) in certain
susceptible individuals. Although the overall
incidence of FD&C Yellow NO.5 (tartrazine)
senSitivity in the general populatiOn is low. it is
frequently seen in patients who also have
aspirin hypersensitivity.
Adv. . . RNCtiona Dry mouth. blurred
viSion and constipatiOn have been reported.
Drowsiness has also been observed.
Adverse efleets occurring infrequently
include extrapyramidal symptoms. gastro-
intestinal reactiOns. secretory efleets such as
sweating. tachycardia and hypotenSion.
Weakness. dizziness. fatigue. weight gain.
edema. parestheSias. flushing. chills. tinnitus.
photophobia. decreased libido. rash and pruri-
tus may also occur.
DoMge and Admlnl.tnltlon In mild to
moderate anxiety andlor depression: 25 mg
t.i.d. Increase or decrease the dosage accord-
ing to individual response. Daily dosage. up to
150 mg may be taken at bedtime without loss
of eflectiveness. Usual optimum daily dos-
age is 75 mg to 1SO mg per day not to exceed
300 mg per day.
Antianxiety efleet usually precedes the
antidepressant efleet by two or three weeks.
How Supplied Each capsule contains doxe-
pin as the hydrochloride. 10. 25. SO. 75 and
100 mg capsules in bottles of 100 and 1000.
For complete prescribing information.
please see package insert or PDA.
R~
1. Data on file. Medical Department.
Pennwalt Pharmaceutical DiviSion.
2. Barranco SF. Thrash ML. Hackett E.
et a1: Early onset of response to doxepin treat-
mentJ Clin Psychiatry 40:265·269.1979.-
·Sinequane brand of doxepin HCI was the
drug used in this study.
Perinatal death
guilt due to negligence, feelings of Inappropriate grief reaction. At
hostility toward others, and a the three-month follow-up, one
breakdown of normal patterns of mother was still crying daily, had
conduct. frequent nightmares about her
Clinical observation and evalua- baby, experienced somatic com-
tion of these items were the basis plaints, and could not concentrate.
for a clinical impression of the Another mother, who initially and
mother's grieving behavior, which at the first follow-up exhibited little
we classified as either "appropriate sadness or preoccupation with the
grief reaction" (AOR) or "inappro- loss of the baby, at three months
priate grief reaction" (lOR). An complained of nervousness to the
lOR was overly intense or shallow point of having difficulty leaving
compared to an AO R, or was ab- her home. She claimed she had not
sent. The following examples illus- had this problem before the still-
trate the two categories. birth.
Appropriate grief reaction. The
mother cried several times a day for Data analysis
a few weeks. She had trouble sleep- Data were analyzed by means of
ing and sometimes dreamed of the computers applying the Statistical
baby. She questioned whether the Package for Social Sciences (Nie
premature labor was her fault and and associates8). The significance of
expressed some anger at the physi- differences was determined by chi-
cian, who she felt had avoided her square techniques applied to the
after the stillbirth. Three months contingency tables using Yates's
later, the mother still felt sad and correction for small frequencies.
cried occasionally, but she had
started to resume her normal pat- Findings
Eleven of the 31 mothers displayed
tern of living and planned to return
to work soon. an inappropriate grief reaction
(continued)
of ... M_ma' Grief
or Perlnata' De"'"
Flnt Second
follow-up Iollow-up
(2-3_) (3mo)
1 X X
2 X X
3 X
4 X
5 X
8 X
7 X
X X X
X
X X
X X
SI4 PSYCHOSOMATICS
..... ~otPre....... In..........
................ UuIr. Management of anxlety disorders Ot short-term rellel of symptoms of
anxiety or anxiety associaled with depreaive symPletnS. Anxiety Ot tension assoclaled with
stress 01 everyday me usually does not require trealment with an anxiolyliC.
Effectiveness in long-term use. i.e.. more than 4 months. has not been assessed by system- Perinatal death
atic clinical studies. Reassess periodically usefulness of the drug lOt the Individual patient.
COO........-........: Known sensrtMly 10 benzodiazep;nes Ot acute narrow-angle glaucoma.
WerIIInlIa: Not recommended in primaty depressive disOtders Ot psychoses. 1.$ with all CNS-
acting drugs. warn palienlS not to operate machinety Ot motor llehicles. and of dimini8hed Iol-
erance for alcohol and other CNS depressants.
Physical and Psychological Dependence: Wrthdrawal symptoms like lhose noled with barbi- (IGR) at the initial evaluation or
Iurales and alcohol have occurred tollowing abrupt diaCOnIinuance of benzo<liazepines
(including convulsions. Iremor. abdominal and muscle cramps. vomiting and -'ing). Addic- follow-up assessments. There was
tion-prone individuals. e.g. drug addicts and alcoholics. ahould be under careful surveillance
when on benzo<liazep;nes because of their prediaposilion to habilualion and dependence. considerable variation in the IGR
Withdrawal symptoms have also been reported following abrupt disconlinuance ot benzo<li-
azep;nes taken continuously atlherapeutic levels for several morrlha.
occurrence over the period of ob-
PNoautIona: In depression accompanying anxiety. consider possibility fOt suicide. servation. Table I indicates that
For ekIerty or debilrtaled patients. initial daily dosage ahould nol exceed 2mg 10 avoid over·
sedation. Terminale dosage gradually since abrupt withdrawal of eny antianxiety egent may
there was a core group of mothers
resun in symplOms like Ihose being Ireated: anxiety. agrtation. irritability. tension. inSOmnia and with IGR; five of those showing
occasional convulsions. Observe usual precautions with impaired renal Ot hepatic function.
Where gastrOinlestinal or cardiovascular disorders coexist with anxiety. note that Iorazepam this reaction at the first follow-up
has not been shown of significant benelil in treating gastroinlestinal or cardiovasculer com!»'
nant. Esophageal dilatiOn occurred in rats treated Wrth Iorazepam for more than 1 year at
were still showing it at the second
6mg/kg/day. No elI8CI dosa was 1.25mg/kg/day (about 6 times maximum human therapeutic assessment. The one mother with
dose of1Omg/day). Effect was reve<sible only when treatment was withdrawn wrthin 2 months
01 first observatiOn. Clinical significance is unknown; but use 01 Ionazepam tor prolonged IGR at the initial assessment and
periods and in gerialrics requires caution and frequent monrtoring for symptoms of upper G.!.
disease. Safety and elIecliveness in children under 12 years have not been establi8hed. both follow-up contacts suffered a
ESSENTIAL LABORATORY TESTS: Some patients have developed leukoPenia: some have had
elevations 01 LDH. 1.$ with _ benZo<liazep;nes. periodic bIoocl counts and liver function tests
are recommended during long-term therapy.
CLINICALLY SIGNIFICANT DRUG INTERACTIONS: Benzo<liazepines pro<luce CNS depressant Eleven ofthe 31 mothers
eIlects when administered Wrth such medicatiOns as barbiturates Ot alcohol.
CARCINOGENESIS AND MUTAGENESIS: No evidence 01 carcinogenic potential emerged in
displayed an inappropriate
rats during an 18-month study. No studies regarding mutagenesis have been performed.
PREGNANCY: Repro<Iuclive studies were performed in mice. rats. and 2 strains of rabbits.
griefreaction (lGR) at the
Occasional anomalies (reductiOn 01 tarsals. tibia. metatarsals. malrotated limbs. gastroschisis.
manormed skull and microphthalmia) were seen in drug-treated rabbits wrthoul relationship to
initial evaluation or
dosage. Although all these anomalies were not present in the concurrent control group. they
have been reported 10 occur randomly in hiSforicat controls. AI40mg/kg and higher. there was
foHow-up assessments.
evidence 01 telal resorption and increased fetal loss in rabbits which was not seen at lower
doses. Clinical significance 01 these findings is not known. ..-sr. increased riSk of congeni-
lal manOtmations asociated with use Of minOt tranquilizers (chlordiazepoxide. diazepam and
meprobamate) during first trimester 01 pregnancy has been suggested in _ a l studies.
clear manic-depressive illness after
Because use 01 these drugs is rarely a maner 01 urgency. use of Iorazepam during thiS period the stillbirth.
ahould almost always be avoided. Possibility that a woman of child-be8rlng potential may be
pregnant at instrtution 01 therapy ahould be considered. AdvIse palienlS Wthey become preg- The commonest causes of still-
nant to communicate with their physician abOUI desirability 01 discontinul"9 the drug. In
humans. bloo<lleve/S from umbilical cord bIoo<I indicate placental transfer oflorazepam end rtI
birth among women demonstrating
glucuronide. IGR were prematurity, eclampsia,
NURSING MOTHERS: n is not known II oral Iorazepam is excreted in human milk like other
benzodiazepinee. As a general rule. nursing ahould not be undertaken while on a drug since and placental problems. Among
many drugs are excreted in mHk. women with AG R, malformation
~ ........... Wthay occur. ere usually observed at beginning 01 therapy and generally
disappear on continued medicatiOn or on decreasing dose. In a sample of abOUI3.500 anxious was the commonest cause; no mal-
palienlS. most frequent actvwse reection is sedation (15.~). followed by dizziness (6.~).
weak_ (4.2'llo) and unateadiness (3.4%). Less frequent are diSorientation. depression. nau-
formation was reported among
sea. change in appetite. headache. sleep disturbance. agrtatiOn. dermatological sympletnS. eye babies of mothers showing IG R.
function disturbance. variOUS gastrointestinal symptetn5 and autonomic manileslations. Inci-
dence of sedatiOn and unsteadiness incnsesed with age. Small decr_ in bIoocl pressure IGR was not related to age nor in
have been noted bul are not clinically significanl. probably being related to relief of anxiety.
0-.1.", In manegemenl of overdosage with any drug. bear in mind mulliple agents may
any conclusive way to gravidity,
have been taken. ManifestatiOns 01 overdosage include somnolence. confusion and coma. parity, or previous abortions. More
Induce vomrting and/or undertake gastric lavage lollowed by general supportive care. monrtOt-
ing vrtal Signs and cJo8e obIetvatiOn. Hypotension. though unlikely. usually may be controlled than half of the women with IG R
wrth Levarterenol Bitartrate InjectiOn U.S.P. Useful_ of dialysis has not been determined.
(six of I I) reported no previous
obstetric or gynecologic problems;
five reported such problems as in-
fertility, difficult pregnancy, and
premature birth. There were no
significant relationships between
IGR and labor complications or
DoNge: Individualize for maximum beneftclal effeds. Increase dolIe hospitalization during the preg-
gradually when needed, giving higher evening dolIe before increasing
d8yIime dolIes. AnxIety, uala11y 2-3mg/day given b.l.d. or Ll.d.; douge nancy. Nor did the sex of the baby
m., VIIIJ from 1 to 1lJmg/day In divided doNs. For elderly or debilI- seem related to the type of grief
tated, Inlllally 1·2mg/day; insomnia due to anxiety or ....lIIenI 1Itu. reaction.
tlonal ........ 2.-mg h.••
There was no association be-
How ...".,,: 0.5, 1.0 and 2.lJmg tabIeIs. tween IG R and touching or not
touching the baby, and there
seemed to be none between the

516 PSYCHOSOMATICS
Wyeth LabOIatories ~~
I~
Philadelphia. PA 19101
type of grief reaction and whether
the hospital or family disposed of
the dead baby. There appeared to
be no association between 10 Rand
preceding crises or recent death in
the family.
Table 2 shows the positive rela-
tions we found: between lOR and
unexpected stillbirth, gestation
length, and failure to see the baby.
Those women who had not ex-
pected a stillbirth, those who had
had premature deliveries, and
those who did not have the oppor-
tunity to see their babies experi-
enced more lOR (these were all
trends not reaching statistical sig-
nificance). Additionally, there was
a trend between planned preg-
nancy and lOR; those mothers who
had planned their pregnancies had
more lOR (eight of 21, or 38%)
compared with those who did not
(two of eight, or 25%).
Discussion
Some investigators9 claim it is im-
possible to predict which mothers
who lose a baby are at highest risk
for pathologic grief reactions. The
main difficulty in evaluating find-
Tllble 2-Varlable Affecting Inappropriate
Maternal Grief Reactions
StIllbirth
Expected
Unexpected
BIrth .....
Premature
Normal
Postmature
SeeIng b8bJ
No
Ves
MAY t982, VOL 23· NO 5
There were no significant
relationships between IGR
and labor complications or
hospitalization during the
pregnancy.
ings from most studies is the small
sample size, due to the improved
neonatal care that is increasing
chances of infant survival. Another
difficulty in comparing studies
arises from the variations in time
between perinatal death and fol-
low-up assessments.I.IO
In spite of the limited sample
size, our study demonstrates that
the mourning process is a dynamic
one, with individual differences in
reaction over time. To gain a
clearer understanding of the evolu-
tion of the mourning process, ex-
tended follow-up assessments will
be needed. At this point we cannot
predict which unexpected grief re-
actions may resolve normally and
which may become more severe or
last beyond (jur three-month eval-
uation. Indeed, Davidson 9 con-
N lOR
9 2(22%)
22 9(41%)
19 8(42%)
11 3(27%)
1 o
7 4(57%)
24 7(29%)
c1udes from his clinical studies that
the mourning process of women
losing a desired baby may take
from 18 to 24 months to resolve.
Lewisii further notes that the
pathologic effects of unresolved
grief reactions may only manifest
themselves in bonding problems
with a subsequent child.
Taking into account these time-
related methodologic problems, we
can identify a number of specific
factors associated with the in-
creased risk of unusual grief reac-
tions: a mother's desire for a baby,
previous psychiatric problems, fail-
ure to see the infant, and commu-
nication problems between the
parents. The study by Rowe and
associates 5 showed an association
between prolonged maternal griev-
ing and a surviving twin or sub-
sequent pregnancy within five
months of the death. Our own
study has shown a higher incidence
of lOR among mothers who gave
birth prematurely and unexpec-
tedly.
Future directions
Evaluating the relationship be-
tween crisis-intervention and
pathologic grief is a complex task.
Isolating the specific impact of
crisis intervention from the overall
input of the multidisciplinary team
approach that influences the atti-
tude and behavior of all staff
toward patients is difficult but nec-
essary. The active and useful ele-
ments within the crisis intervention
model must be elucidated. Facilita-
tion of grief by focusing on feelings
of distress about the loss. outlining
possible future manifestations of
grief, and promoting greater com-
munication and support between
family members may need to be
supplemented by recognition of in-
dividual differences in coping, both
SI7
Perinatal death

in the individual's style and time.
Control and comparison groups
are needed. but from an ethical
viewpoint it seems untenable to
withhold-for the sake of establish-
ing control groups-interventions
that have been shown to have posi-
tive therapeutic effects. Perhaps the
usefulness ofspecific strategies such
as crisis intervention and the inter-
disciplinary team approach could
be tested by carefully thought-out
and conducted comparison with
studies involving other approaches
to perinatal death. 0

REFERENCES
1 Kennel JH. Slyter H. Klaus M: The mourning
response of parents to the death of a new-
born Infant NEngIJMed283344-349. 1970
2 Cullberg J Mental reactions of women to
perinatal deafh. in Morns N (ed) Psychoso·
matlc Medicine In Obstetncs and Gynecol-
ogy. 3rd Int Congress. London. Karger. 1972,
pp 326-329
3 Wolft JR. Nielson PE, Schiller P The emo-
tional reactIon 10 a stillbirth. Am J Obslet
Gyneco/l0873-77. 1970
4 Wolft JR: The emotoonal reaction to stillbirth.
In Morris N (ed): Psychosomatic Medicine In
Obstetrics and Gynecology, 3rd Int Con-
gress. London, Karger, 1972. pp 330-332.
5 Rowe J, Clyman R, Green C, et al Follow-up
of families who experience a perinatal death.
Pediatrics 62: 166-170. 1978.
6. Parkes CM: Bereavement and mental illness,
pt 1: A clinocal study of the gnet of bereaved
psychiatric patients. Br J Med PsychoI38:1-
12,1965
7. Lindemann E: Symptomatology and manage-
ment of acute grief. Am J Psychiatry
101.141-148.1944
8. Nie H, Hull CH, Jenkins JG, et al: Sta/ls/lcal
Package for the Social SCiences. New York,
McGraw Hill, 1975.
9. Davidson GW: Underslanding Death of the
Wished· for Child. Springfield, III. OGR Ser-
vice Corp, 1979.
10 Peppers LG, Knapp R: Maternal reactions to
Involuntary tetal/lnfant death. Psychiatry
43155-159,1980
11 Lewis E, Page A Failure to mourn a stillbirth:
An overlooked catastrophe. Br J Med Psychol
51 :237-241. 1978

MEMBERSHIP
in the Academy of Psychosomatic Medicine
The philosophy of the Academy of Psychosomatic cine. psychology. neurology. and dentistry. but
Medicine stresses the growth of its members- other professionals who work in medical set-
through clinical practice. study. and research-as tings are also invited to apply.
advocates of the psychosomatic approach to the
Now in its 29th year. the Academy continues to
prevention. diagnosis. and treatment of iUness.
work for the goal set forth by its founders:
Membership The integration of medical treatment for ill-
ness-organic and psychologic-with the prac-
· .. provides opportunities to meet and ex-
tice of psychiatry to ensure the best compre-
change information while earning AMA and
hensive care for all patients in need of
AAFP Continuing Medical Education credit
therapy-emotional or physical.
through workshops. seminars. lectures. sympo-
sia. and demonstrations at the prestigious an- For further information about membership in the
nual meeting and other meetings held through- Academy. clip and send the coupon below.
out the year.
· .. enables you to participate. after three years. Mr. Tom Nelson. Executive Director
in the Distinguished Fellowship Program. cul- Academy of Psychosomatic Medicine
minating in certification as a Fellow of the 70 West Hubbard Street Suite 202. Chicago. IL 60610
Academy of Psychosomatic Medicine.
Please send me further information regarding mem-
· .. entitles you to receive Psychosomatics bership.
throughout the year.
Namee. _
· .. is open to physicians and other IndMduals
with postgraduate professional degrees who Address _
work as health care providers. Many members
represent the fields of psychiatry. family medi- City _ State Zip _

518 PSYCHOSOMATICS