Evidence Based Treatment for PTSD during Pregnancy:

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

80 Symptom severity trajectory following a traumatic event 70 60 50 40 30 20 Typical response Impeded recovery Delayed onset 10 0 Month 1 Month 2 Month 3 Month 4 Month 5 Month 6

Posttraumatic Stress Disorder E. Alterations in arousal and reactivity D. Negative alterations in cognition and mood B. Intrusion symptoms C. 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 PTSD caused by pre-pregnancy history of trauma Pregnancy onset PTSD 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)

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?

Time 23 Trauma Event 0-3 days Phase 1: Psychological First Aid Provide for Basic Needs Evaluate & Assess 3-30 days Phase 2: Intermediate Support Anxiety Management using CBT Refer for PTSD Assessment 30-90 days Phase 3: PTSD treatment options 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 traumarelated 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 posttraumatic 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.