Evidence Based Treatment for PTSD during Pregnancy: What prenatal care providers need to know

Evidence
Based
Treatment for
PTSD during
Pregnancy:
What prenatal care
providers need to know
Robin Lange, Ph.D.

Why bother?
 PTSDin 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          DSM-V Definition
1.   Pathology - a body            Criterion A: death,
     wound or shock                 threatened death,
     produced by sudden             actual or threatened
     physical injury, as from       serious injury, or actual
     violence or accident.          or threatened sexual
                                    violence, as follows:
2.   Psychiatry. an                     Direct exposure,
     experience that                
                                        witnessing, in person;
     produces                           indirectly, repeated or
     psychological injury or            extreme indirect exposure
     pain.                              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
80
     following a traumatic event
70
60
50
40                                         Typical response
                                           Impeded recovery
30
                                           Delayed onset
20
10
 0
     Month Month Month Month Month Month
       1     2     3     4     5     6

Posttraumatic Stress Disorder

                         D. Negative
        E. Alterations   alterations in
          in arousal      cognition
             and          and mood
          reactivity

         B. Intrusion        C.
         symptoms        Avoidance

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         “Birthing Trauma”
 PTSD caused by          Postpartum PTSD
  pre-pregnancy            caused by traumatic
  history of trauma        labor and delivery
                           experiences
  Pregnancy onset         3% of women (Alcorn
  PTSD                     et al, 2010)
 Trauma that occurs      1-2%(Stamrood et al.,
 during the                2011)
 pregnancy

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?

20

Warning Signs
 Dissociation
 Isolation
 Not engaging in basic self care
 Preexisting mental health conditions
 Part of a vulnerable group
 Lacking social support

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?

23

           Trauma Event

0-3 days                                            Phase 1: Psychological First Aid

                          Provide for Basic Needs

                                                    Evaluate & Assess
 Time

3-30 days                                           Phase 2: Intermediate Support

                                                             Anxiety Management using CBT

                                                                                    Refer for PTSD Assessment

                                                    Phase 3: PTSD treatment options
30-90 days
                                                                                              Continuation of CBT and Anxiety Management

                                                                                              Initiate Exposure Based Treatments

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