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Evidence Based

Treatment for PTSD during Pregnancy:

What prenatal care providers need to know

Robin Lange, Ph.D.

(2)

Why bother?

 PTSD in pregnant mothers has been associated with:

 Shorter gestation

 Lower birth weight(Seng et al., 2011)

 Providers need to know:

 Signs and Symptoms

 Mental health treatment options

 Best practices for supporting mothers and

minimizing risk

(3)

Psychological Trauma 101

(4)

Trauma

Dictionary Definition

1. Pathology - a body wound or shock

produced by sudden physical injury, as from violence or accident.

2. Psychiatry. an experience that produces

psychological injury or pain.

DSM-V Definition

Criterion A: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows:

Direct exposure,

witnessing, in person;

indirectly, repeated or

extreme indirect exposure

to aversive details of the

event(s),

(5)

Response to stressors/trauma

1. Emotional (shock, anger, disbelief, terror, guilt, grief, irritability, helplessness, anhedonia,

regression to earlier developmental phase)

2. Cognitive (impaired concentration, confusion, distortion, self-blame, intrusive thoughts,

decreased self-esteem/efficacy)

3. Biological (fatigue, insomnia, nightmares, hyperarousal, somatic complaints, startle response)

4. Psychosocial (alienation, social withdrawal,

increased stress within relationships, substance

abuse, vocational impairment)

(6)

Types of post traumatic responses

 National comorbidity study (Kessler, 1995)

 50-60 percent of respondents reported having experienced a trauma in their lifetimes

 Only 5-10 percent of this sample went on to develop PTSD

PTSD is an atypical response to a trauma

PTSD is a disorder of impeded recovery

related to avoidance

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Symptom severity trajectory following a traumatic event

0 10 20 30 40 50 60 70 80

Month

1 Month

2 Month

3 Month

4 Month

5 Month 6

Typical response

Impeded recovery

Delayed onset

(8)

Posttraumatic Stress Disorder

D. Negative alterations in

cognition and mood

Avoidance C.

B. Intrusion symptoms E. Alterations

in arousal

reactivity and

(9)

PTSD and pregnancy

How is it different? How common is it? What are the

effects of PTSD on outcome?

(10)

Incidence and Prevalence in pregnancy

 Limited research on this important, under studied population

 Lifetime prevalence of PTSD in women:

 10 percent of women will receive a

diagnosis of PTSD in their lifetime (Breslau et al., 1998)

 Approximately 13 million women

 If untreated, many will experience

symptoms for years

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Types of pregnancy related PTSD

Preexisting PTSD

 PTSD caused by pre-pregnancy history of trauma

 Trauma that occurs during the

pregnancy

“Birthing Trauma”

 Postpartum PTSD

caused by traumatic labor and delivery experiences

 3% of women (Alcorn et al, 2010)

 1-2%(Stamrood et al., 2011)

Pregnancy onset

PTSD

(12)

Effects of PTSD on pregnancy outcome

 Reduction in mean birth weight (Seng et al., 2011)

 Shorter gestation (Seng et al., 2011)

 Negative effects on maternal self care and infant emotional and cognitive development (Murray, 1992)

 Maternal attachment difficulty

(13)

Course of PTSD in pregnancy

 Higher rates of suicidal thoughts and

psychiatric comorbidity in pregnant versus non pregnant women with PTSD (Smith et al., 2006)

 Of women who developed PTSD following

a stillbirth, “Symptoms generally resolved

naturally by 1 year postpartum,” (Turton et

al., 2001)

(14)

PTSD risk factors

What relevant history should I be aware of?

(15)

General risk factors for PTSD

Berwin et al, 2000 Meta-analysis

 Being female

 Experiencing intense or long-lasting trauma

 Having experienced multiple traumas

 Having other mental health problems, such as anxiety or depression

Lacking a good support system of family and friends

 Having first-degree relatives with mental health problems, including PTSD

 Having first-degree relatives with depression

 Having been abused or neglected as a child

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Pregnancy specific risk factors

 previous history of childhood trauma (Seng et al., 2011),

 sexual trauma, (Hamama, et al., 2010),

 previous history of spontaneous or elective abortion that was perceived as traumatic (Hamama, et al., 2010),

 the experience of a stillbirth during a previous pregnancy, (Turton, et al., 2001).

 Becoming pregnant within a year of a previous stillbirth (Turton, et al., 2001).

 Preeclampsia and preterm premature rupture of membranes (Stamrood et al., 2011).

 Depressive symptoms during pregnancy (Stamrood et al., 2011)

 Death of infant during the postpartum period

(Stamrood et al., 2011)

(17)

Prevalence of PTSD related to

childbirth (Stamrood et al., 2011)

(18)

Factors contributing to

“birthing trauma”

Creedy et al., 2000

(19)

PTSD Warning Signs

What should I look for in my patients?

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Warning Signs

 Dissociation

 Isolation

 Not engaging in basic self care

 Preexisting mental health conditions

 Part of a vulnerable group

 Lacking social support

20

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What your patient may report

Cognitive
“I don’t care about going to therapy anymore.” 
“Nothing is working out for me. I am never going to get better.” 
“No one cares about me or what I do. What’s the point of going on?” 
“I’m feeling a little down. This must mean that I am going to fall into a deep

depression again.” 


Emotional 
“Everyone is getting on my nerves lately.” 
“I just don’t feel happy, even when I am around people that I know I love.” 
“I am

beginning to feel really jumpy and on edge.” 
“My mood keeps changing rapidly. In minutes, I can go from feeling really happy to really down or terrified.” 


Behavioral
“I just don’t have the energy to take care of myself in the

morning. I haven’t showered for days.” 
“I don’t want to be around

people anymore. I’ve been isolating myself.” 
“I’ve been drinking

more, but just to take the edge off of my feelings a little.” 
“I’ve

noticed that I am less talkative than I used to be.”

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My patient has

experienced a trauma

What now?

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23

Trauma Event

Phase 1: Psychological First Aid

Phase 2: Intermediate Support

Phase 3: PTSD treatment options

Provide for Basic Needs

Evaluate & Assess

Anxiety Management using CBT

Refer for PTSD Assessment

Continuation of CBT and Anxiety Management

Initiate Exposure Based Treatments

T ime

0-3 days

3-30 days

30-90 days

(24)

Psychological First Aid Tasks

 Contact and engagement

 Safety and comfort

 Stabilization (if necessary)

 Information gathering: Current Needs and Concerns; Risk Factors

 Practical assistance—Shelter, Support, Med

 Connection with social supports

 Information on coping

 Linkage with collaborative services

(25)

Exposure Therapy

 PTSD as a disorder of avoidance

 Intervention based on helping people confront feared objects, situations,

memories, and images in the absence of feared consequences

 Promotes learning

 Decreases debilitating avoidance and emotion

 EBT’s for PTSD

 Prolonged Exposure

 Cognitive Processing Therapy

(26)

Prolonged Exposure

 9-12 weekly sessions

 Education about

common reactions to trauma

 Safe exposure to trauma triggers and memories

 In vivo exposure:

Confronting safe trauma- related situations

between sessions

 Imaginal exposure:

Revisiting trauma

memories in session and

listening to the audio

recorded revisiting

between sessions

(27)

Cognitive Processing Therapy

Manualized trauma focused cognitive

behavioral therapy for PTSD

Originally developed in 1988 to treat rape survivors

Protocol is 12 sessions

60 min sessions for individual therapy

90 minute group sessions

Can be done with (CPT) or without (CPT-C) a trauma account with similar effects at post treatment (Resick et al., 2008)

Goal: To gain and

understanding of and modify the meaning

attributed to the traumatic

experience

(28)

PE versus CPT (Resik et al.,

2007)

(29)

Exposure treatments during pregnancy

 Women with PTSD postpartum should be referred to psychotherapy, and be offered treatment during subsequent pregnancy (Turton et al. 2001)

 Case study research has indicated no adverse effects of Prolonged Exposure

treatment on pregnant women, developing fetus, or infant (Twohig & O’Donohue, 2007).

 Therapist required signed letter from OB/GYN to proceed with treatment (Twohig &

O’Donohue, 2007).

(30)

Best practices for PTSD in

pregnancy

(31)

For all patients

 Monitoring mood symptoms throughout the course of the pregnancy

 Staying aware of any changes in patient’s ability or motivation to care for herself

 Inquiring about relevant trauma history on

intake

(32)

Following still birth and pregnancy loss

 Encouraging mothers to see and hold their stillborn infant has been associated with

increased incidence of PTSD and depression in the mother following the birth (Hughes et al., 2002).

 Having a funeral and keeping mementos were not associated with averse outcome (Hughes et al., 2002).

 Helping women to engage their crisis support network was associated with increased

resilience following a pregnancy loss

(Englehard et al., 2003).

(33)

PTSD during pregnancy

 Provide referral for patients to obtain

counseling and or additional assessment if you suspect client may have PTSD

 There is no data showing averse effects of engaging in EBT for PTSD during pregnancy, and benefits likely outweigh any risks

 Collaboration between health care provider and psychotherapist is encouraged

 In situations requiring a high level of obstetric

intervention, encourage patient involvement

in decision making process and help patient

to engage social support network.

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Questions and Comments

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Selected References

Smith, M.V., Poschman, K., Cavaleri, M.A., Howell, H.B., Yonkers, K.A. (2006).

Symptoms of posttraumatic stress disorder in a community sample of low income pregnant women. American Journal of Psychiatry, 163, 881-884.

Breslau N, Kessler RC, Chilcoat HD, Schultz LR, Davis GC, Andreski P: Trauma and posttraumatic stress disorder in the community: the 1996 Detroit Area Survey of Trauma. Arch Gen Psychiatry 1998; 55:626–632

Engelhard, I. (2003). The Sense of Coherence in Early Pregnancy and Crisis Support and Posttraumatic Stress After Pregnancy Loss: A Prospective Study.

Behavioral Medicine, 29, 80 -84.

Hamama, L. (2010). Previous experience of spontaneous or elective abortion and risk for posttraumatic stress and depression during subsequent

pregnancy. Depression and anxiety, 27, 699 -707.

Alcorn, K L. (2010). A prospective longitudinal study of the prevalence of post- traumatic stress disorder resulting from childbirth events. Psychological

Medicine, 40, 1849 -1859.

Twohig, M P. (2007). Treatment of Posttraumatic Stress Disorder with Exposure Therapy During Late Term Pregnancy. Clinical case studies, 6, 525 -535.

Seng, J. (2011). Post-traumatic stress disorder, child abuse history, birthweight and gestational age: a prospective cohort study. BJOG: an international journal of obstetrics and gynecology, 118, 1329 -1339.

Rogal, S, (2007). Effects of posttraumatic stress disorder on pregnancy outcomes. Journal of affective disorders, 102, 137 -143.

Bell, S. (2013). Childhood Maltreatment History, Posttraumatic Relational Sequelae, and Prenatal Care Utilization. Journal of obstetric, gynecologic, and neonatal nursing, 42, 404 -415.

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My contact info

Robin Lange, Ph.D.

Clinical Psychologist and CEO

Utah Center for Evidence Based Treatment Robin.lange@ucebt.com

www.ucebt.com

801-419-0139

(37)

PTSD (DSM-V)

Criterion A: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows:

Direct exposure, witnessing, in person; indirectly, repeated or extreme indirect exposure to aversive details of the event(s),

Criterion B: intrusion symptoms: (1 required)

re-experiencing, Traumatic nightmares, Dissociative reactions, Intense/prolonged distress, Marked physiologic reactivity

Criterion C: avoidance: (1 required)

avoidance of stimuli, thoughts/feelings, external reminders

Criterion D: negative alterations in cognitions and mood: (2 required)

Inability to recall, negative beliefs/expectations about oneself, blame of self or others, negative trauma-related emotions, diminished interest in activities,

Feeling alienated from others, Constricted affect

Criterion E: alterations in arousal and reactivity: (2 required)

Irritable or aggressive behavior, Self-destructive or reckless behavior,

Hypervigilance, Exaggerated startle response, Problems in concentration, Sleep disturbance.

Criterion F: duration :

Persistence of symptoms (in Criteria B, C, D and E) for more than one month.

Criterion G: functional significance :

Significant symptom-related distress or functional impairment (e.g., social, occupational).

Criterion H: attribution :

Disturbance is not due to medication, substance use, or other illness.

References

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