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Post-Traumatic Stress Disorder
Perinatal Psychiatry, Birth Trauma & Perinatal PTSD, Part 3
An Interview with Dr. Rebecca Moore
Posted September 14, 2016
Last week, I shared Part 2 of my interview with Dr. Rebecca Moore, lead psychiatrist for the Tower Hamlets Perinatal Mental Health service based in London, U.K. Her clinical interests include PTSD and birth trauma, premenstrual dysphoric disorder (PMDD), the treatment of anxiety and depression in the perinatal period, and supporting the parent infant bond. Dr. Moore is passionate about improving services for women traumatized by birth and hosts an annual forum on Birth Trauma in London in December each year. Her goal is to form networks with those working with families with Birth Trauma around the world to share knowledge and innovative practices.
I recently spoke with her to understand more about Birth Trauma and PTSD. Here is Part 3 of our interview.
Dr. Jain: What psychological interventions work for Postpartum PTSD? What about preventative measures (e.g. identifying high risk women or screening programs) or debriefing interventions?
Dr. Moore: There isn’t a standardized screening program as of yet in the UK. We screen women in our service but they only represent a minority of women. One also wonders how a woman may feel about being identified as “high risk” for developing perinatal trauma, and care would need to be taken to fully explain this risk in a nonthreatening or frightening way.
Psychological interventions that work in the postnatal period include the usual trauma focused psychotherapies, like cognitive behavioral therapy (CBT) and eye movement desensitization and reprocessing (EMDR), and Compassion Focused therapy approaches are also frequently used.
Debriefing can be used and can help some women but not all—it very much depends on who is doing the debriefing and how it is done. Studies into the efficacy of debriefing have not identified any clear link with it leading to reduced maternal morbidity, and formal debriefing is not recommended. In 2011, Professor Ayers from City University, a leading expert in this area, found that 46 women with PTSD who had formal debriefing had reduced PTSD over time and a greater reduction in symptoms overall than women who had not been debriefed. Debriefing also led to reduction in negative appraisals but did not affect symptoms of depression. Therefore, results suggest that providing debriefing as a treatment to women who request or are referred to it may help to reduce symptoms of PTSD.
In my service we have a specialized pathway of care for women with a prior traumatic birth or those at risk, which includes regular review and having these long detailed discussions about birth. We have a specialist team of midwives who co-work cases with us to give extra support and an obstetric lead who reviews women prior to birth.
We offer informal debriefing postnatally and really take time and care to listen to women’s birth stories, and this is crucial. If needed we can then also add in specialist timely therapeutic interventions—we offer CBT, Compassion Focused Work, Yoga Therapy, Art Therapy, and Music Therapy in my service.
Dr. Jain: Finally, are there any biological or physiological factors associated with the act of giving birth itself (e.g. hormonal shifts, changes in adrenaline, cortisol, serotonin, or dopamine) that may be implicated in increasing vulnerability for developing PTSD during that particular life event?
Dr. Moore: That’s a very complex question that we don’t yet fully understand the answer to. There is as of yet little research on the specific area of perinatal PTSD, and we have to try to piece together what we know about the etiology of PTSD along with the large evidence base for depression after birth related to hormonal shifts.
Of course I am sure your readers will know the existing literature purely relating to PTSD that suggests that lower baseline cortisol at the time of a psychological trauma may facilitate over-activation of the central CRH-NE cascade, resulting in enhanced and prolonged stress responses which could then be accentuated by poor regulation of GABA, serotonin, and NPY. Altered norepinephrine and stress hormone activity may be involved in learning and extinction. This mixture of elevated noradrenergic activity and relative hypocortisolism may lead to the enhanced encoding of traumatic memories and the lack of inhibition of memory retrieval, both of which then trigger the re-experiencing phenomena in PTSD.
My own interest lies more in the role of the HPA axis in pregnancy and after birth. Much of the literature relates to depression, but there are studies now focusing on PTSD. It is likely that prenatal hormones are both markers of risk and causal factors in the development of postpartum depression.
During pregnancy the maternal hypothalamic-pituitary-adrenal axis undergoes dramatic alterations, due in large part to the introduction of the placenta, a transient endocrine organ of fetal origin.
Models are suggested, such as those by Professor Vivette Glover, where the positive feedback loop involving the systems regulating the products of the HPA axis results in higher prenatal levels of cortisol and placental corticotrophin-releasing hormone. Greater elevations in placental corticotrophin-releasing hormone are related to a disturbance in the sensitivity of the anterior pituitary to cortisol and perhaps to decreased central corticotrophin-releasing hormone secretion. Secondary adrenal insufficiencies of a more extreme nature may predict an extended postpartum hypothalamic-pituitary-adrenal refractory period, which in turn would represent a risk factor for the development of postpartum depression
During pregnancy we see a rapid rise in plasma estrogen and progesterone, coupled with a very large increase in plasma corticotrophin-releasing hormone (CRH), and an increase in cortisol. Levels of all these hormones drop rapidly at birth, as do serotonin levels. We can also assume that for most women, adrenaline levels will be raised for some of their birth experience.
We also need to add into this discussion the literature on the role of estrogen, and its role in fear conditioning and fear extinction. Estrogen calms the fear response in healthy women and, as illustrated by the work of Kelimer Lebron-Milad, the same is true for women suffering from PTSD. The higher the estrogen was in their blood when they trained on a fear-extinction task, the less likely women were to startle.
Progesterone is also known to have antiglucocorticoid properties and thus interfere with the HPA axis reactivity to stress. Studies have demonstrated a higher neuroendocrine response to stress (i.e., higher cortisol levels after ACTH administration) in women during the luteal phase of the menstrual cycle, indicating that the negative feedback of the HPA axis may be somewhat affected.
Further research is needed to understand the impact that changes in sex hormone levels may have on subjects' behavioral and neuroendocrine ability to respond to stress. It could be plausible that abrupt changes in hormone levels (such as that observed in the immediate postpartum period) would alter not only the HPA axis response to a stressful event, but also the negative feedback necessary to avoid potential damages induced by prolonged exposure to “stress hormones.”
How all these strands connect is not yet fully understood, but to my mind women entering labor are subject to momentous physiological and psychological changes over a rapid time frame, which to some can lead to the development of their perinatal PTSD.
Copyright: Shaili Jain, MD. For more information, please see PLOS Blogs.
