Postpartum PTSD: Beyond Postpartum Depression in Maternal Mental Health

Introduction to Postpartum Post-traumatic Stress Disorder (PTSD)

Most people consider maternal mental health to be synonymous with postpartum depression. However, there are many other similar disorders, collectively described as perinatal mood and anxiety disorders (PMADs). One such disorder is postpartum post-traumatic stress disorder. While PTSD as a whole used to be characterized as an anxiety disorder in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), it is now in a new chapter in DSM-V titled “Trauma- and Stress-Related Disorders.” 

In general, PTSD affects approximately 10% of women during their lifetimes.¹ There is a significant increase in the prevalence of PTSD surrounding childbirth, specifically in the postpartum period. One study that analyzed 212 primiparous mothers found the prevalence of PTSD symptoms to be 12.7% immediately after childbirth and 13.6% up to 6 months later.² As Ami Baxi, MD, director of inpatient psychiatric services at Lenox Hill Hospital in New York City, New York, observed, “these numbers are equivalent to the prevalence data for postpartum depression and anxiety.” Unfortunately, there is a scarcity of literature on postpartum PTSD, resulting in limited physician knowledge. Dr. Baxi notes that “postpartum PTSD is underdiagnosed and undertreated.”

Symptoms of Postpartum PTSD

Postpartum PTSD is not a specific diagnosis in the DSM-V; it is a subset of the diagnosis of PTSD itself. In a postpartum woman, the trauma in question could be a negative perception of the birthing process, but previous traumas, such as a history of sexual abuse, can also qualify for the diagnosis of postpartum PTSD. The diagnosis requires the presence of 4 categories of symptoms. The first is persistent re-experiencing of the trauma, which can play out as dreams, thoughts, or flashbacks. Second is avoidance of stimuli associated with the trauma. For example, a patient may avoid the hospital where she gave birth to avoid the feelings she had during the delivery. 

Third, the patient should display negative changes in mood and cognition, such as the inability to remember details of the event, a depressed state of mind, feelings of detachment from others, and exaggerated negative views of the world. Patients often present with depressed mood and, as Dr. Baxi explains, “they are often misdiagnosed to have postpartum depression.” However, the treatment is different and, thus, it is important to understand the nuances of the two diseases. 

The final category is an increase in arousal and reactivity. Patients often describe sleep changes and an inability to concentrate. Some women present with irritability and self-destructive behavior. To fulfill the criteria for PTSD, a patient must have symptoms that are clinically distressing for more than one month.¹

Risk factors

There are a number of risk factors for postpartum PTSD. Contrary to common belief, neither a history of PTSD nor a complicated delivery is necessary for this diagnosis. However, a personal history of antenatal depression or anxiety, as well as previous trauma, are possible risk factors. A study by Montmasson, et al showed that social isolation, a history of abortion, infertility, and obstetrical factors are additional risk factors. A woman’s perspectives on how long her labor lasted and obstetrical complications are significant risk factors.² Therefore, women can develop postpartum PTSD even if the birthing process appears to have gone well.

Emily Cook, PhD, LCMFT, owner at Emily Cook Therapy, LLC in Bethesda, Maryland, describes a woman who “had a fast and early labor during which the father was unavailable to participate emotionally or supportively. The symptoms of postpartum PTSD are deeply distressing on their own, and yet they are often compounded by a sense of shame or blame that the mother has failed herself or the baby by her trauma response.” We know, however, that actual birth trauma increases the risk of postpartum PTSD 10-fold.²

Another study by Zaers and colleagues looked at postpartum women and the predisposing factors for postpartum PTSD. The study found that the strongest predictor of PTSD was anxiety occurring late in pregnancy.³ Depression was found to be significantly comorbid, with almost one-quarter of the women expressing symptoms of depression. Finally, having a baby in the neonatal intensive care unit (NICU) showed an increased rate of postpartum PTSD.³ Dr. Baxi explains, “these symptoms are not temporary; they can last for many months.” This is an important population that would benefit from focused screening measures for postpartum PTSD.⁴

It is important that providers play a preventative role for patients. Self-care for women, including appropriate sleep, nutrition, and exercise, can help reduce the symptoms of PTSD. Also, discussions regarding the realities of the birthing process and what to expect can set a woman up for a healthier perception of the birthing process, which could avoid the development of postpartum PTSD.⁵

A word about early pregnancy loss

Early pregnancy loss (EPL) affects about a quarter of women. Farren, et al did a prospective study of the emotional symptoms experienced by women who experienced an EPL, and found that the rates increased from 28% to 38% over the first 3 months. These women are generally not seen in follow-up, but given this data, this is a vulnerable population that needs to be further assessed for emotional difficulties.

Brief overview of treatment options

Postpartum PTSD is treatable. Medication management and therapy can both be effective treatments. The first line of medications often tried in these patients is selective serotonin receptor inhibitors (SSRIs). The therapy for postpartum PTSD is different from that of postpartum depression. As in patients who have PTSD, re-processing and re-framing are essential to treatment, and it is important for the work to revolve around the trauma.⁵ 

Dr. Cook notes that “therapy definitely provides relief and healing. Involving the father in treatment through couples therapy is a powerful part of the work. We tell and retell the birth story, going back in memory by honoring the intensity of experience and reframing positive elements and going forward to the present by paying attention to all the ways the trauma is impacting their bodies, minds, emotions, expectations, and interactions.”

Consequences

Patients struggling with postpartum PTSD experience a significant burden. In the short term, mothers are less likely to seek out medical care for themselves or their babies.⁵ They are also less likely to breastfeed. Imagine a woman trying to bond with her child after a traumatic birth; there is much difficulty with both attachment and bonding. In the long-term, patients are less likely to have another child, or to try to control the process via an epidural or a C-section, even when not medically indicated. These patients also endure challenges in their relationships, both emotionally and physically.⁵

A recent study showed a decline in psychomotor speed and attention, learning, and working memory and a significant overall cognitive decline in women with PTSD. The consequences were worsened with the presence of comorbid depression.⁷  Dr. Baxi emphasizes, “there needs to be further education about postpartum PTSD and screening needs to be in place. Mothers are suffering and they need to be heard and validated.”

References

1. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. Arlington: American Psychiatric Association, 2013. 
2. Montmasson H, Bertrand P, Perrotin F, El-Hage W. Predictors of postpartum post-traumatic stress disorder in primiparous mothers [published online May 21, 2012].  J Gynecol Obstet Biol Reprod.  doi:10.1016/j.jgyn.2012.04.010.
3. Zaers S, Waschke M, Ehlert U.  Depressive symptoms and symptoms of post-traumatic stress disorder in women after childbirth.  J Psychosom Obstet Gynaecol. 2008;29:61-71. doi:10.1080/01674820701804324.
4. Kim WJ, Lee E, Kim KR, et al.  Progress of PTSD symptoms following birth: a prospective study in mothers of high-risk infants [published online April 19, 2015].  J Perinatol. doi:10.1038/jp.2015.9.
5. Postpartum PTSD risk factors symptoms. Postpartum Progress. www.postpartumprogress.com/postpartum-ptsd-risk-factors-symptoms. Updated 2011.  Accessed April 15, 2017.
6. Farren J, Jalmbrant M, Ameye L, et al.  Post-traumatic stress, anxiety and depression following miscarriage or ectopic pregnancy: a prospective cohort study.  BMJ Open. 2016;6(11):10.  
7. PTSD in women linked to cognitive impairment. ADAA. www.medscape.com/viewarticle/878399?nli d=114049_4401&src=wnl_dne_170411_mscpedit&uac=38562DX&impID=1326457&faf=1#vp_1. Updated 2017.  Accessed April 12, 2017.