Evidence Based
Treatment for PTSD during Pregnancy:
What prenatal care providers need to know
Robin Lange, Ph.D.
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
Psychological Trauma 101
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),
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)
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
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
Posttraumatic Stress Disorder
D. Negative alterations in
cognition and mood
Avoidance C.
B. Intrusion symptoms E. Alterations
in arousal
reactivity and
PTSD and pregnancy
How is it different? How common is it? What are the
effects of PTSD on outcome?
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
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
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
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)
PTSD risk factors
What relevant history should I be aware of?
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
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)
Prevalence of PTSD related to
childbirth (Stamrood et al., 2011)
Factors contributing to
“birthing trauma”
Creedy et al., 2000
PTSD Warning Signs
What should I look for in my patients?
Warning Signs
Dissociation
Isolation
Not engaging in basic self care
Preexisting mental health conditions
Part of a vulnerable group
Lacking social support
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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.”
My patient has
experienced a trauma
What now?
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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
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
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
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
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
PE versus CPT (Resik et al.,
2007)
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).
Best practices for PTSD in
pregnancy
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
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).
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.
Questions and Comments
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.
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
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 :