Mickey Sperlich

Prevalence, Trauma History, and Risk for Posttraumatic Stress Disorder Among Nulliparous Women in Maternity Care

OBJECTIVE: To estimate prevalence and assess the association of types of trauma with posttraumatic stress disorder (PTSD) in a sociodemographically and racially mixed sample of women from both predominantly Medicaid and privately insured settings who are expecting their first infant. METHODS: Structured telephone diagnostic interview data were analyzed for prevalence of trauma exposure, PTSD, comorbidity, risk behaviors, and treatment-seeking among 1,581 diverse English-speaking nulliparous women. RESULTS: The overall rate of lifetime PTSD was 20.2%, 17% in the predominantly private-payer settings, and 24% in the predominantly public-payer settings. The overall rate of current PTSD was 7.9%, 2.7% in the predominantly private-payer settings and 13.9% in the predominantly public-payer settings. Those with current PTSD were more likely to be African American, pregnant as a teen, living in poverty, with high school education or less, and living in higher-crime areas. Adjusted odds of having current PTSD were highest among those whose worst trauma exposure was abuse (odds ratio 11.9, 95% confidence interval 3.6–39.9), followed by reproductive trauma (odds ratio 6.1, 95% confidence interval 1.5–24.4). Health risk behaviors and exposures were concentrated among those with PTSD. CONCLUSION: These findings affirm that PTSD affects pregnant women. Women with PTSD in pregnancy were more likely to have had exposures to childhood abuse and prior traumatic reproductive event, to have cumulative sociodemographic risk factors, comorbid depression and anxiety, and to have sought mental health treatment in the past. Obstetric risk behaviors occur more in women with PTSD. LEVEL OF EVIDENCE: II

Childhood Abuse History, Posttraumatic Stress Disorder, Postpartum Mental Health, and Bonding: A Prospective Cohort Study

INTRODUCTION Research is needed that prospectively characterizes the intergenerational pattern of effects of childhood maltreatment and lifetime posttraumatic stress disorder (PTSD) on womens mental health in pregnancy and on postpartum mental health and bonding outcomes. This prospective study included 566 nulliparous women in 3 cohorts: PTSD-positive, trauma-exposed resilient, and not exposed to trauma. METHODS Trauma history, PTSD diagnosis, and depression diagnosis were ascertained using standardized telephone interviews with women who were pregnant at less than 28 gestational weeks. A 6-week-postpartum interview reassessed interim trauma, labor experience, PTSD, depression, and bonding outcomes. RESULTS Regression modeling indicates that posttraumatic stress in pregnancy, alone, or comorbid with depression is associated with postpartum depression (R(2) = .204; P < .001). Postpartum depression alone or comorbid with posttraumatic stress was associated with impaired bonding (R(2) = .195; P < .001). In both models, higher quality of life ratings in pregnancy were associated with better outcomes, while reported dissociation in labor was a risk for worse outcomes. The effect of a history of childhood maltreatment on both postpartum mental health and bonding outcomes was mediated by preexisting mental health status. DISCUSSION Pregnancy represents an opportune time to interrupt the pattern of intergenerational transmission of abuse and psychiatric vulnerability. Further dyadic research is warranted beyond 6 weeks postpartum. Trauma-informed interventions for women who enter care with abuse-related PTSD or depression should be developed and tested.

Mental Health, Demographic, and Risk Behavior Profiles of Pregnant Survivors of Childhood and Adult Abuse

Our objective was to address the gap in knowledge about the extent to which perinatal mental health and risk behaviors are associated with childhood and adult experiences of abuse that arises because of barriers to screening and disclosure about past and current abuse. Survey data from an ongoing study of the effects of posttraumatic stress on childbearing were used to describe four groups of nulliparous women: those with no abuse history, adult abuse only, childhood abuse only, and abuse that occurred during both periods. The rates of abuse history disclosure were higher in the research context than in the clinical settings. Mental health morbidity and risk behaviors occurred in a dose-response pattern with cumulative abuse exposure. Rates of current posttraumatic stress disorder ranged from 4.1% among those never abused to 11.4% (adult only), 16.0% (childhood only), and 39.2% (both periods). Women abused during both periods also were more likely to be using tobacco (21.5%) and drugs (16.5%) during pregnancy. We conclude that mental health and behavioral risk sequelae affect a significant portion of both childhood and adult abuse survivors in prenatal care. The integration into the maternity setting of existing evidence-based interventions for the mental health and behavioral sequelae of abuse is needed.

Previous experience of spontaneous or elective abortion and risk for posttraumatic stress and depression during subsequent pregnancy

Background: Few studies have considered whether elective and/or spontaneous abortion (EAB/SAB) may be risk factors for mental health sequelae in subsequent pregnancy. This paper examines the impact of EAB/SAB on mental health during subsequent pregnancy in a sample of women involved in a larger prospective study of posttraumatic stress disorder (PTSD) across the childbearing year (n=1,581). Methods: Women expecting their first baby completed standardized telephone assessments including demographics, trauma history, PTSD, depression, and pregnancy wantedness, and religiosity. Results: Fourteen percent (n=221) experienced a prior elective abortion (EAB), 13.1% (n=206) experienced a prior spontaneous abortion (SAB), and 1.4% (n=22) experienced both. Of those women who experienced either an EAB or SAB, 13.9% (n=220) appraised the EAB or SAB experience as having been “a hard time” (i.e., potentially traumatic) and 32.6% (n=132) rated it as their index trauma (i.e., their worst or second worst lifetime exposure). Among the subset of 405 women with prior EAB or SAB, the rate of PTSD during the subsequent pregnancy was 12.6% (n−51), the rate of depression was 16.8% (n=68), and 5.4% (n−22) met criteria for both disorders. Conclusions: History of sexual trauma predicted appraising the experience of EAB or SAB as “a hard time.” Wanting to be pregnant sooner was predictive of appraising the experience of EAB or SAB as the worst or second worst (index) trauma. EAB or SAB was appraised as less traumatic than sexual or medical trauma exposures and conveyed relatively lower risk for PTSD. The patterns of predictors for depression were similar. Depression and Anxiety, 2010.© 2010 Wiley‐Liss, Inc.

Exploring dissociation and oxytocin as pathways between trauma exposure and trauma-related hyperemesis gravidarum: a test-of-concept pilot.

Posttraumatic stress disorder (PTSD) is associated with gastrointestinal and genitourinary comorbidities. These map onto the somatization disorder symptoms in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) and the dissociative (conversion) disorders symptoms in the International Classification of Diseases taxonomy (World Health Organization, 2007). Hyperemesis gravidarum (HG) is one of these symptoms and a gastrointestinal comorbidity of PTSD occurring in pregnancy. It is an idiopathic condition defined as severe vomiting with dehydration, metabolic imbalance, wasting, and hospital care seeking. HG is more severe than the normative phenomenon of nausea and vomiting of pregnancy. This test-of-concept pilot (N = 25) explored the hypothesis that there is a trauma-related subtype of HG characterized by (a) high levels of dissociative symptoms and (b) altered plasma concentrations of oxytocin. This hypothesis is informed by a theory of posttraumatic oxytocin dysregulation that posits altered oxytocin function as a mechanism of gut smooth muscle peristalsis dysfunction. A 4-group analysis compared controls with nausea and vomiting of pregnancy (NV only) and cases with HG only, NV and PTSD, or HG and PTSD. Oxytocin was correlated with the nausea and vomiting symptom severity score (r = .464, p = .019) and with the dissociation symptom score (r = .570, p = .003). Women in the group with both PTSD and HG (the trauma-related HG subtype) had the highest levels of dissociation and the highest levels of oxytocin. A linear regression model indicated that the independent association of the trauma-related HG subtype with oxytocin level was mediated by high levels of dissociative symptoms.

The Survivor Moms' Companion: Open Pilot of a Posttraumatic Stress Specific Psychoeducation Program for Pregnant Survivors of Childhood Maltreatment and Sexual Trauma

The Survivor Moms’ Companion (SMC) is a fully manualized, 10-module self-study psychoeducation program developed to address the pregnancy-specific needs of traumatic stress-affected abuse survivors. It aims to improve affect regulation, reduce interpersonal reactivity, and support posttraumatic stress disorder (PTSD) symptom management despite the presence of triggers. An open pilot enrolled “survivor moms” prior to 28 weeks gestation and they completed baseline diagnostic telephone interviews, fidelity measures, pretest and posttest, and self-report measures assessing the efficacy of the proposed mechanisms of intervention effect. Of 57 eligible women invited to participate, 32 took up the intervention, 9 completed at least the core 4 modules, and 18 completed all 10 modules. Participant scores showed improvements in anger expression, interpersonal reactivity, and PTSD symptom management, suggesting that participation in the SMC is beneficial. Results will inform the protocol for a cluster randomized trial of the SMC.

The Survivor Moms' Companion: Feasibility, Safety, and Acceptability of a Posttraumatic Stress Specific Psychoeducation Program for Pregnant Survivors of Childhood Maltreatment and Sexual Trauma

Pregnant women with history of abuse and posttraumatic stress disorder (PTSD) have increased risk of adverse mental health and childbearing outcomes. The Survivor Moms’ Companion (SMC) is a psychoeducation program designed to meet the needs of women abuse survivors affected by PTSD during the childbearing year. This article reports on the feasibility, safety, and acceptability findings of an open pilot. Participants completed 10 self-study modules and structured tutoring sessions, and completed self-report measures, including reports of tutor fidelity to the manual, repeated assessment of PTSD symptoms, Subjective Units of Disturbance (SUD) scores, and evaluation interviews. Results indicate that the intervention can be implemented within low-resource settings with high level of fidelity to the manual. Monitoring of PTSD symptom level and distress indicate that the intervention is safe. Participants report satisfaction with the format and content and appreciation for the tutoring component. The SMC appears to be feasible, safe, and acceptable.

Gestational and Postnatal Cortisol Profiles of Women With Posttraumatic Stress Disorder and the Dissociative Subtype

Objective: To test the hypothesis that women with posttraumatic stress disorder (PTSD) have greater salivary cortisol levels across the diurnal curve and throughout gestation, birth, and the postpartum period than women who do not have PTSD. Design: Prospective, longitudinal, biobehavioral cohort study. Setting: Prenatal clinics at academic health centers in the Midwest region of the United States. Participants: Women expecting their first infants who fit with one of four cohorts: a nonexposed control group, a trauma‐exposed control group, a group with PTSD, and a group with the dissociative subtype of PTSD. Methods: In the first half of pregnancy, 395 women provided three salivary cortisol specimens on a single day for diurnal data. A subsample of 111 women provided three salivary cortisol specimens per day, 12 times, from early pregnancy to 6 weeks postpartum for longitudinal data. Trauma history, PTSD, and dissociative symptoms were measured via standardized telephone diagnostic interviews with the use of validated epidemiologic measures. Generalized estimating equations were used to determine group differences. Results: Generalized estimating equations showed that women with the dissociative subtype of PTSD had the highest and flattest gestational cortisol level curves. The difference was greatest in early pregnancy, when participants in the dissociative subtype group had cortisol levels 8 times greater in the afternoon and 10 times greater at bedtime than those in the nonexposed control group. Conclusion: Women with the dissociative subtype of PTSD, a complex form associated with a history of childhood maltreatment, may have toxic levels of cortisol that contribute to intergenerational patterns of adverse health outcomes.

Post‐traumatic stress disorder and birthweight: methodological challenges

Sir, Sampling, trauma history assessment, and symptom reporting all play a role in determining the prevalence of post-traumatic stress disorder (PTSD). The prevalence of prenatal PTSD ranges from 3.5% in a sample with a 29% trauma rate to 16% in a sample with a 60% rate of abuse. We found an 8% prevalence overall, but defined a range from 2.9% in the private sector to 13.9% in the public sector. The highly sensitive trauma measure we used did not seem to inflate PTSD rates, as less severe trauma exposures were rarely antecedents to PTSD diagnosis (e.g. divorce was the ‘worst’ trauma in 1% of cases). Childhood maltreatment conveyed the greatest risk (OR 11.9, 95% CI 3.6–39.9) for PTSD in pregnancy. We chose the National Women’s Study PTSD module, a goldstandard structured diagnostic interview used in the largest study of PTSD in women from the USA, so that we could compare symptom profiles of our pregnant sample with 2000 women of childbearing age from the nationally representative sample. We concluded that pregnant women reported symptoms that were specific to traumatic stress. Dr Reed’s point that PTSD alone did not account for the entire 200 g decrement is well taken and warrants nuancing. A more precise wording of our finding would be that ‘the PTSD-affected cohort experienced a decrement of more than 200 g in birthweight’. Our PTSD cohort differed, as expected, in its levels of socio-economic disadvantage and risk behaviours. Disadvantage and substance use are both vulnerabilities for and outcomes of PTSD. To echo Dr Reed’s point empirically, we modelled just three variables: PTSD, socio-economic status (SES) and substance use, predicting birthweight. With the whole sample, the relationship of PTSD to birthweight was mediated by SES, and substance use was not independently associated. The group not maltreated followed this pattern. In the childhood maltreatment group, the associations of PTSD and SES were additive, and both were mediated by substance use in the final step. The combination of early developmental trauma and prenatal PTSD seems potent in human childbearing, as has been shown in animal models. We should not diminish the potential import of PTSD as a risk factor for adverse perinatal outcomes because it co-occurs with other intractable problems. Rather, we should consider how perceiving maltreatment and PTSD as potential root causes for some young women’s disadvantages and stress might provide opportunities for novel approaches to addressing these issues. Finally, we had provided correlations addressing a conceptual issue about the extent to which mechanisms for trauma or PTSD-associated adverse outcomes might differentially affect growth and parturition. Due to the post hoc and conceptual nature of this analysis, we had not provided tests of significance. The difference between the birthweight and gestational age correlation of the PTSD-affected (n = 255, r = 0.699) and non-trauma-exposed (n = 277, r = 0.765) cohorts was not significant (P = 0.102). The difference between birthweight and gestational age correlation in infants born to mothers maltreated in childhood (n = 174, r = 0.608) and those of infants born to non-maltreated mothers (n = 665, r = 0.760) was significant (P < 0.001). We hope this exchange facilitates the work of other research teams studying the impact of trauma and traumatic stress on women’s health and childbearing. j