Post Traumatic Stress Disorder in Post-Partum Women. and its Link with Unresolved Childhood Sexual Abuse. A Literature Review.

Transcription

1 Running head: POSTPARTUM PTSD 1 Post Traumatic Stress Disorder in Post-Partum Women and its Link with Unresolved Childhood Sexual Abuse A Literature Review Presented to The Faculty of the Adler Graduate School In Partial Fulfillment of the Requirements for The Degree of Master of Arts in Adlerian Counseling and Psychotherapy By: Lynelle G. Thorpe Chair: Richard Close Reader: Louise Ferry February 2017

2 POST-PARTUM PTSD 2 Abstract This literature review examines published articles and other supporting literature on postpartum posttraumatic stress disorder (PTSD) and how unresolved childhood sexual abuse is linked to this diagnosis. This paper intends to provide a definition of PTSD, a review of the literature on women and childhood sexual abuse, as well as discuss the complexities of diagnosis due to the overlap in the symptomology between PTSD and Postpartum Depression (PPD). This paper will be completed by means of literature review so the distinction between PTSD and PPD in this population can be better understood and diagnosed, resulting in more effective and appropriate treatment interventions.

3 POST-PARTUM PTSD 3 Acknowledgements I want to express my gratitude to my husband Skip and my daughters, Lydia, and Angela, for the encouragement, time, love, and support given to complete this project is priceless. I want to thank my best friend Connie for the countless hours I have spent at her house writing many papers and for our friendship. I want to thank all of my professors and the support staff at Adler Graduate School for their dedication to their students, the excellent instruction, and most of all the encouragement, as Adler would say. I am truly grateful for the opportunity I have had to further my education. Last but not least, I have overwhelming gratitude towards my late father-in-law for providing me with the financial means to complete my Master s Degree. Although you are not here to see me graduate this spring, I know you would be proud of me. Blessing to all of you from the bottom of my heart.

4 POST-PARTUM PTSD 4 Table of Contents Abstract... 2 Acknowledgements... 3 Introduction... 5 Postpartum PTSD... 5 Definition... 5 Symptomology... 7 Research... 8 Past... 8 Current... 9 Risk Factors Postpartum Depression (PPD) Definition Comorbidity Childhood Sexual Abuse Definition Prevalence CSA-PTSD Link PTSD Management Recommendations EMDR Prevention A Survivor Story Conclusion References... 21

5 POST-PARTUM PTSD 5 Post Traumatic Stress Disorder in Postpartum Women and Its Link with Unresolved Early Childhood Sexual Abuse Introduction The transition to motherhood can be difficult, even under the best of circumstances. For some mothers, the birthing experience is exhilarating. For others, it can be frightening, with additional psychological symptoms and distress. Postpartum women may or may not meet the diagnostic criteria for postpartum depression (PPD). However, there is a sub group of women who additionally experience flashbacks, severe insomnia, nightmares, panic attacks, or feelings of detachment. These women are suffering from a disorder called posttraumatic stress disorder (PTSD). Evidence suggests that research into PTSD during this crucial time is increasing due to the need for effective screening tools as well as effective treatment approaches. Without these interventions, women often do not recover, leaving them at a high risk for reoccurrence after subsequent births unless the underlying trauma is addressed. Postpartum PTSD Definition The Diagnostic and Statistical Manual of Psychiatric Disorders (5 th ed.; DSM-5; American Psychiatric Association, 2013) lists Posttraumatic stress disorder (F43.10) under the Trauma-and Stressor-Related Disorders. The diagnostic features of PTSD fall in to 5 main categories and only apply to those who are above the age of 6. These are as follows, A. Exposure to actual or threatened death, serious injury, or sexual violence by directly experiencing the trauma, witnessing violence towards others, learning of a traumatic event that happened to a family member or friend, experiencing repeated exposure to the disturbing details

6 POST-PARTUM PTSD 6 of the trauma, (excluding exposure via pictures, television, movies, and electronic media unless work related; American Psychiatric Association, 2013, p. 271). B. Experiencing intrusive symptoms following the trauma in the form of memories, dreams, flashbacks (reliving the trauma in the present that may result in a dissociative state (loss of awareness of surroundings), and intense psychological distress and physiological reactions when exposed to reminders of the trauma. C. Avoidance of thoughts, memories, and feelings, as well as people, places, or objects. D. Negative alterations in cognition and mood, which could begin or worsen following the trauma. E. Alterations in arousal and activity, of which two or more of the following must be present, angry outbursts, irritability, self-destructive behavior, recklessness, hypervigilence, exaggerated startle response, poor concentration, or sleep disturbance, that begin or worsen following the trauma. F. The criteria in A, B, C, D, and E) is longer than 1 month. G. The symptoms cause clinically significant distress or impairment in social or occupational functioning, and other activities of daily living. H. The symptoms are not attributable to effects of substances such as medication, alcohol, or medical conditions. In addition to a diagnosis of PTSD, specifications need to be noted if the individual experiences 1 or both of the following dissociative symptoms. Experiencing depersonalization (a feeling of detachment from one s own body), or recurrent derealization (persistent or recurrent experiences of unreality of surroundings). These dissociative symptoms must not be attributable to the effects of medication, alcohol, or a medical condition. Another specification the DSM V notes is that an individual may not meet the full diagnostic criteria until at least 6 months following the trauma, even though the onset and expression of symptoms may be immediate. (American Psychiatric Association, 2013, p. 272).

7 POST-PARTUM PTSD 7 Symptomology Abuse memories are often spotty. Some women do not remember the abuse that happened too them (Spindler, (1992). Internal and external triggers may recall those memories, and they can return in many ways. Many survivors somaticize their symptoms. Pregnancy and childbirth can trigger those memories because of the locus of abuse, and its musculature are directly involved in the birthing process (Courtis, & Riley, 1992). Another symptom of Postpartum PTSD is sleep disturbance. Since sleep disruption is considered a normal part of new motherhood, difficulty sleeping while the infant sleeps can signal depression and anxiety. One study that looked at the relationship between sleep, childhood trauma, and PTSD in a sample of newly postpartum women. The study was conducted on 173 women who were 4 months postpartum (Swanson, Hamilton, & Muzik, 2014), found that 109 women with reported abuse histories had the most difficulty with sleeping. The results showed that 35 out of 173 women with reported histories of sexual abuse represented the highest percentage of sleep disturbances at 20.2% out of the total sample. (Swanson, et al., 2014). Some women report intense fear or even panic during labor. Eberhard-Gran, Slinning, and Eskild (2008) studied the occurrence of extreme fear during labor and its association with previous sexual abuse in adult life. The sample size consisted of 414 women in Norway, with an average age of 30, were given a questionnaire to rate their labor pain into 3 categories. The results of the questionnaire by Eberhard-Gran et al. (2008), showed that 3% of the women had extreme fear, 13% had some fear, and 84% had no fear at all. The other method used to collect data was the Abuse Assessment Screed (ASS). The results showed 12% of the women revealed they had been sexually abused as an adult. Among the 3% of women who reported extreme fear during labor, 1/3 rd had a history of sexual abuse in adult life. Eberhard-Gran et al. (2008)

8 POST-PARTUM PTSD 8 concluded that women with a history of sexual abuse in adult life have an increased risk of extreme fear during labor. The findings suggest that labor may reactivate past sexual abuse experiences and negatively affect labor. More research is needed to develop policies that identify and support pregnant women with a history of sexual abuse, symptoms of anxiety, and depression, or both. These women may also need extra care in the postnatal period in order to prevent the symptoms of PTSD (Eberhard-Gran et al., 2008). Research Past If we go back roughly 25 years to the 1990 s, little research existed on posttraumatic stress disorder after childbirth. PTSD was not even recognized as a disorder until 1980 when it was added to the DSM-III (American Psychiatric Association, 1980) as cited by (Olde, Kleber, Onno, van-der Hart, & Pop, 2006). PTSD during the postpartum period (time following childbirth up to 6 weeks) only began to be researched by doctors around 2006 (Strauss, 2015). However, research studies in the last decade provide evidence that suggests women can feel the effects of PTSD up 9.5 months following the birth of a child (Leeds & Hargraves, 2008). A research study by Reynolds (1997) examined what little research was available at the time, in order to get a clear understanding of the mystery of PTSD after childbirth. The intended purpose for the study was to shed light on the small percentage and little-recognized group of women who have experienced a traumatic birth. As reported by Reynolds (1997) only 5 studies and 1 personal account of PTSD experiences were found. Two out of those 5 case studies contained with the strongest research evidence of Postpartum PTSD. The first case series Reynolds examined was in England. A sample of 4 women with PTSD was analyzed during the postpartum period. All 4 women reported long or complicated

9 POST-PARTUM PTSD 9 labor, feeling loss of control over pain, and reliving their labor experiences through flashbacks, and dreams. One woman denied struggling with uncontrolled pain. However, all 4 women met the diagnostic criteria for PTSD (Reynolds, 1997). Reynolds reported there was suggestive evidence from two important case studies conducted in Sweden on women who had elective cesarean sections. The results concluded that 0.2% of the women demanding C-sections reported choosing this for 2 major personal reasons. The first reason given was the fear of experiencing another painful labor and not getting help, and the second reason was the fear of losing the baby. Out of this small sample of women, 2 out of the 5 women reported prior sexual abuse and despite being treated with short-term psychotherapy, they chose C-sections. Astonishingly, the results showed 58% of the women who planned C-sections for personal reasons followed through with their request (Reynolds, 1997). Current In an editorial written by Ayers, Mckenzie-Mcharg, & Slade (2015) PTSD is examined. It provides an up-to-date summary that shows that research is expanding rapidly in to postnatal PTSD. According to the United Nations Data on birth rates in 2011, as cited by Ayers, McKenzie-McHarg and Slade (2015), 3.17% (4.3 million) women have the potential to develop postnatal PTSD. The information for this editorial came from a workshop that was presented to key researchers and clinicians working in the field of postnatal PTSD. The purpose of the workshop was to provide an expert overview of what is known about postnatal PTSD, what gaps remain in their knowledge and the key issues that need to be addressed. The five areas identified and presented were, (1) Prevention and early intervention, (2) Importance of maternity staff and care pathways, (3) Impact on families and infants, (4) Positive outcomes such as post-traumatic

10 POST-PARTUM PTSD 10 growth, and (5) High-risk populations such as women with preterm or stillborn births (Ayers et al., 2015). In a longitudinal study in 2013, (the first one of its kind), 119 women in Oahu Hawaii were assessed for changes in PTSD, depression, anxiety, general stress and mental health during their first, second, and third trimesters as well as postpartum (Onoye et al., 2013). The methods used for collecting data are as follows 1.Traumatic Life Events Questionnaire (TLEQ) 2.The PTSD Checklist-Civilian version (PCL-C) based on the criteria in the Diagnostic & Statistical Manual of Mental Disorders (DSM-IV) to determine PTSD status 3.The Center for Epidemiologic Studies Depression Scale (CES-D). It was found that PTSD symptoms were significantly higher in the late third trimester just prior to delivery and beyond 6 weeks postpartum. There was a declining trend in PTSD symptoms prior to the end of the third trimester and the first 6 weeks postpartum. For the other mental health symptoms, there was also a declining trend in depression and general stress while anxiety symptoms remained stable throughout pregnancy. They also examined the effects of new trauma exposure from the second trimester to the end of the pregnancy to look for any rise or fall in the symptomology. The results showed a statistically significant effect of new trauma exposure for PTSD and depression but not for anxiety or general stress (Onoye et al., 2013). Risk Factors Women experience many different types of trauma that present risk factors for the development of PTSD. Some of those factors shown to be associated with developing PTSD after childbirth include invasive procedures (cesarean and manual), perception of loss of control during labor, and fear of the losing the baby (Polachek, Harari, Baum, & Strous, 2012). Other

11 POST-PARTUM PTSD 11 risk factors include a history of sexual or physical abuse, trait anxiety, low tolerance for pain preexisting mental illness, or a negative perception of childbirth (Zaunderer, 2014). In a study that evaluated the proportion of women who develop post-traumatic stress disorder as a result of childbirth, 83% of the 56 women participating in their study had a reported history of at least 1 traumatic experience (Schwab, Marth, & Bergant, 2012). At 6 weeks postpartum, 21.5% of the sample met full diagnostic criteria for PTSD. According to Schwab, et al., (2012) research shows that nearly 1/3 of all women experience childbirth as traumatic, however, only 10% present with severe stress reactions in the first weeks following delivery (Schwab et al., 2012). The expectations that women have during pregnancy and childbirth have also been shown to be a risk factor for postpartum PTSD and can leave everlasting psychological scars (Strauss, 2015). In a two-wave longitudinal study by Maggioni, Margola, and Filipi (2006) the incidence of chronic PTSD after childbirth in relation to the expectations women had during pregnancy and childbirth was examined. Expectations preceding events can influence perceptions, reactions, and overall satisfaction following childbirth (Maggioni et al., 2006). There were 93 pregnant women recruited from a University Hospital in Milan Italy, who were assessed in two phases. PTSD subscales, depression, and anxiety levels were measured. The women were given the Beck Depression Inventory (BDI), Post-traumatic Stress Disorder Questionnaire (PTSD-Q) between 38 and 42 weeks gestation and then again at 3-6 weeks after delivery. The State Trait Anxiety Inventory (STAI) was given only at the 3-6 week time period (Maggioni et al., 2006). The results showed that in terms of expectations, 31.42% of the participants hoped for quick and manageable (or pain free) labor, while 25.71% wanted a natural delivery, relying on loved ones for support through labor % of subjects also expected natural labor with the

12 POST-PARTUM PTSD 12 ability to maintain control anonymously over their labor and delivery process without the help of loved ones. The final 22.85% of the subjects wished for the quickest labor only. The results of the questionnaires showed 2.4 % of women had met the diagnostic criteria for PTSD, 3-6 months postpartum, 32.1% had one or two positive subscales of symptoms, 2.4% had complete PTSD, 15.5% positive intrusion scale, 25.0% had positive arousal subscale and 3.6% had a positive avoidance subscale (Maggioni et al., 2006). Postpartum Depression (PPD) Definition In the Diagnostic and Statistical Manual of Psychiatric Disorders of Psychiatric Disorders (4 th ed.; DSM-4; American Psychiatric Association, 1994) as cited by (Zaers, Waschke & Ehlert, 2008) depression after childbirth is diagnosed as a major depressive disorder beginning within the first 4 weeks postpartum, and lasting for at least 2 weeks. The criteria for the DSM-IV diagnosis are depressed mood, diminished interest or pleasure, weight loss or weight gain, appetite disturbance, insomnia for hypersomnia, fatigue, agitation, or retardation, worthlessness or guilt, problems concentrating and thoughts of death. However, the Diagnostic and Statistical Manual of Psychiatric Disorders (5 th ed.; DSM- 5; American Psychiatric Association, 2013) lists PPD as an Unspecified Depressive Disorder (F32.9) and referred to as an atypical depression with specified symptoms that appear during pregnancy, or in the four weeks following delivery. The major change in the definition of PDD from the DSM-IV to the DSM-V was the change from PPD as being a Major Depressive Disorder (MDD) to an Atypical Depression with specified symptoms.

13 POST-PARTUM PTSD 13 Comorbidity Postpartum depression (PPD) is a disorder that is often comorbid with postpartum PTSD, with the depressive symptoms the most frequent psychiatric disorders after childbirth. There are also women who suffer from some of the symptoms of PPD in addition to postpartum PTSD. The Women with PTSD were 5 times more likely to have current major depression than their counterparts without PTSD (Ammerman, Putnam, Stevens, Chard, & van Ginkel, 2012). Women with major depressive episodes often have severe anxiety and even panic attacks. It is estimated that between 3% and 6% of women will experience the onset of a major depressive episode during pregnancy or the weeks and the month following delivery (American Psychiatric Association, 2013, p. 186). As reported by Zaers, Waschke and Ehlert (2008), much attention had been given to PPD at that time, and very little on PTSD after childbirth. The range of studies on PPD differed between 6% and 22 % depending on postpartum depression. As part of a larger longitudinal study in 2009, PTSD and postpartum health were analyzed. Among a sample of 54 women of Caucasian, Asian, or Pacific Islander descent, Onoye et al. (2009) found that women with PTSD and subclinical PTSD were 73% more likely to experience stress, 64% experience anxiety, and 73 % experienced depression during the postpartum period, as compared to those without PTSD. When left untreated, PTSD and PDD symptoms can have an adverse effect on the relationship between the mother and child such as difficulty bonding with the child (Muzik, et al., 2013). Childhood Sexual Abuse Definition The Diagnostic and Statistical Manual of Mental Disorders (5 th ed.; DSM-5; American Psychiatric Association, 2013) defines childhood sexual abuse (CSA) as any sexual act involving

14 POST-PARTUM PTSD 14 a child that is intended to provide sexual gratification to a parent, caregiver, or another individual who has responsibility for the child. The DSM-5 describes sexual abuse as fondling a child s genitals, penetration, incest, rape, sodomy, and indecent exposure. Sexual abuse also includes non-contact exploitation of a child by a parent or caregiver who engages in forcing, tricking, enticing, threatening, or pressuring a child to perform acts for the sexual gratification of others that a form of covert sexual abuse that does not involve direct physical contact between the abuser and the child (American Psychiatric Association, 2013). Prevalence In 2016, 1 in 5 girls and 1 in 20 boys were victims of childhood sexual abuse. According to the National Center for victims of Crime, self-report studies show that 20% of adult females and 5-10% of adult males recall a childhood sexual assault or sexual abuse incident, with an estimate of as many as 20,000 cases going unreported every year, as cited by (Bryant, 2016). Several studies have concluded that there is a link between early CSA and the development of Postpartum PTSD. In a review article written by Wosu, Gelaye, and Williams (2015), current knowledge was evaluated on the association between CSA and PTSD in pregnant and postpartum women. The research information was accessed through 4 different databases with the search yielding 5 quantitative studies. Wosu et al. (2015) found 2 out of the 5 studies to be statistically significant. CSA-PTSD Link In the first study, data was analyzed data from a cohort 1,259 pregnant women in the United States who were part of the cohort for the Stress, Trauma, Anxiety, and the Childbearing Year (STACY) study. The Life Stressor Checklist was used with CSA being defined as sexual abuse occurring before the age of 16. Using the National Women s PTSD module, the authors

15 POST-PARTUM PTSD 15 observed a PTSD prevalence of 8.7% in the entire sample. There were 4.1% of women who reported no history of physical or sexual abuse, 11.4% in women with adult physical or sexual abuse history, 16% in women with childhood physical or sexual abuse histories, and 39% in women exposed to both childhood and adult physical or sexual abuse, as cited by (Seng et al., 2013). In a subsequent analysis of 1581 women from the same cohort, pregnant women with PTSD had over 5-fold odds of having a history of childhood rape compared to their counterparts without PTSD as cited by (Wosu, et al., 2015). As part of the same study, Lev-Wiesal analyzed data from a cohort of 1,586 pregnant Israeli women aged 18 years or older. For the purpose of this study, CSA was defined as any acts of sexual abuse occurring prior to the age of 14 years. The PTSD symptom scale was used to measure the DSM-IV criteria for PTSD during pregnancy (for the two-week preceding data collection) and was used to assess postpartum childbirth related PTSD symptoms. Similarly, the results from this study also showed a higher rate of PTSD symptoms among women with CSA compared to women who experienced non-csa trauma and women who had no trauma history, as cited by (Wosu, Geyale, & Williams, 2015). The goal of this review was to provide suggestions and highlight the need more longitudinal studies on the incidence and progression of PTSD among women with histories of CSA. Lev-Wiesal, Daphna-Tekoah, and Hallak (2009) investigated childhood sexual abuse to see the extent to which childbirth may function as a re-traumatization of childhood sexual abuse, and may exacerbate postpartum symptoms. Data was collected on a sample of 837 women who were an average of 35.5 years in age, in the middle of their 2 nd trimester and again at 2 and 6 months postpartum. This sample consisted of women who experienced CSA, women survivors of trauma other than CSA, and women who reported no trauma experiences. The results showed

16 POST-PARTUM PTSD 16 that CSA participants scored higher than the non-trauma group for PTSD, avoidance, disassociation, as well as intrusion (Lev-Wiesal et al., 2009). Among the types of childhood abuse, A study by Edwards, Munch, Massop, Devries, and Hagen (2014) investigated predictors of maternal PTSD as a result of labor and delivery (L & D), and compared the known risk factor of abuse vs. coercion during labor on subsequent PTSD symptoms. Out of 1,125 women who had given birth, 476 (42%) of women reported one or more types of childhood abuse. 34% of women reported symptoms of PTSD at the cutoff or above as a result of L& D. The methods used consisted of the PTSD symptom scale, a demographic questionnaire including childhood abuse such as emotional, verbal, physical, or sexual abuse or witnessing domestic violence, and questions about coercion during labor and the extent to which they felt informed and respected. A second study identified predictors of postpartum PTSD. Goutaudier, Séjourné, Rousset, Lami, and Chabrol (2012) examined predictors of postpartum PTSD such as negative emotion, childbirth pain, perinatal disassociation, and self-efficacy. This particular study recruited women from two different hospitals in the south of France. The sample consisted of women over the age of 18 who had given birth to a healthy infant. Pain was assessed using the French version (QDSA) of the McGill Pain Questionnaire. Feelings of self-efficacy during delivery were also assessed using the Childbirth Self-Efficacy Inventory (CBSEI). PTSD was assessed using the French version of the Impact of Even Scale-Revised (IES) at the 6-week post-partum mark. The potential cases of PTSD at this point were found to be 6.1%. Negative emotions and pain during childbirth were identified as direct predictors of PTSD, which could serve as a potential warning for the subsequent development of PTSD symptoms. The results suggest the need for developing

17 POST-PARTUM PTSD 17 better support and screening tools to prevent psychopathological disorders from developing (Goutaudier et al., 2012). PTSD Management Recommendations Literature concerning the prevalence and risk factors in the development of PTSD had been thoroughly defined up until However, treatment and the management of PTSD had just started to be investigated. (Lapp, Agbokou, Peretti, & Ferreri, 2010). Lapp et al. (2010) examined the overall effects of interventions on PTSD after childbirth. Their goal was to report on the results from 9 studies. The treatment interventions that were examined were debriefing or counseling, cognitive behavioral therapy (CBT), and Eye-Movement Desensitization and Reprocessing (EMDR). Lapp et al. (2010) found that the results of their study lined up with the findings from non-childbirth related literature. Debriefing and counseling were found to be inconclusive. However, CBT & EMDR did show some symptomatic improvement of PTSD. Due to the lack of research into postpartum PTSD at that time Lapp et al. (2010), suggested developing rigorous screening tools that would specifically target psychiatric histories, expectations about pregnancy and delivery, as well as the use of pain medications during labor. The need for educating the medical staff about what type of crises could occur, and teaching them intervention techniques, could ease the anxiety and fear present during the event. For example, in the case of disassociation during labor, medical staff could implement calming and grounding techniques. Lapp et al. (2010) also stressed the importance of looking at a larger more integrative system of care that included medical staff and families in order for women to receive the services they need when coping with the consequences of PTSD after childbirth.

18 POST-PARTUM PTSD 18 EMDR Eye Movement Desensitization and Reprocessing (EMDR) was developed by Francis Shapiro in EMDR is a treatment method that desensitizes patients to anxiety and integrates the processing of information into positive emotions and cognitive schema that improve PTSD symptoms (Chen, et. al. 2014). In sessions with a trained professional, individuals work through specific traumatic memories while using an external stimulus, such as eye movement or tapping, to facilitate the processing the traumatic memories (Griebnow, 2006). The movement of the eyes helps to unblock the information-processing centers in the brain to create new connections between stored information on previous events and adverse outcomes, and the response to the current stimulus. Aroused relaxation responses or physiological responses reconnect to the stored memories of adverse experiences and new information is reintegrated (Chen, et al., 2014). Prevention In support of prevention, evidence indicating that a woman s history of trauma could be a risk factor for pregnancy might help professionals in identifying pregnant women at risk prior to and during the initial phase of pregnancy (Lev-Wiesal, Chen, Dpahna-Tekoah, & Hod, 2009). Preventing sexual abuse from happening to children will reduce the prevalence of PTSD during the perinatal and postpartum stages. Health professionals need to know the signs and symptoms that point to a trauma history, how to provide support, and offer appropriate treatment interventions. Preventative and sustainable public health measures must be taken so children will not have to experience serious trauma, and the risk for women in developing PTSD before or after childbirth reduces (Sigurdardottir, Halldorsdottir, & Bender, 2013).

19 POST-PARTUM PTSD 19 A Survivor Story Women s childbirth experiences are all different. Too many times women give birth without a support system and at one of their most vulnerable times, they are poked and prodded in sometimes depersonalizing or violent ways (Griebnow, 2006). The authors of this article provide a story of a survivor of postpartum PTSD. This woman offers encouragement by admitting that even though the experience was horrifying for her, she has been able to look back and see the powerful gifts she had been given, and how those gifts keep on giving throughout her life s journey (Griebnow, 2006). In the book Survivor Moms by Sperlich and Seng (2008) women tell their labor stories, and the challenges they faced with mothering and healing after sexual abuse. One of the women in this book talks about her terrifying experience with her Caesarian section (C-section) and how it triggered her childhood sexual abuse. As a result of this unresolved trauma, she struggled with feeling attached to her son. She was crying all the time while she was alone, suffering from insomnia, and fantasizing about ways she could harm herself so she would be admitted to the hospital where she could finally sleep. When she sought counseling, as suggested, the first thing she was asked was if she had ever been sexually abused. She had a hard time connecting her memories of sexual abuse to how she was reacting in the present. Through 2 years of psychotherapy she was able to connect the C-section to her memories of being raped at 15, and molested by an uncle when she was a young child. She allowed the pain and other overwhelming emotions to surface and was able to forgive her abusers (Sperlich & Seng, 2008). Conclusion This literature review has shown that childhood sexual abuse is one of the largest contributors in the development of PTSD after childbirth. Postpartum PTSD, although often

20 POST-PARTUM PTSD 20 comorbid with postpartum depression, is distinctly different and does not resolve on it s own. If left untreated, the symptoms will return and often with a vengeance. Perhaps, more importantly, a woman with unresolved childhood sexual abuse must seek help in order to heal and reduce the risk of the symptoms returning. Current Research clearly shows what has been effective in treating this disorder and also highlights the great need for more effective screening tools that can aid in the development of an integrated care-plan that will support a woman s childbirth experience.

21 POST-PARTUM PTSD 21 References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5 th ed.). Washington, DC: Author American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. Ammerman, R.T., Putnam, F.W., Stevens, J., Chard, K.M., & van-ginkel, J.B. (2012). PTSD in depressed mothers in home visitation. (2011). Journal of Psychological Trauma Research, Practice, and Policy, 4(2), doi: /a Ayers, S., McKenzie-McHarg, K., & Slade, P. (2015). Post-traumatic stress disorder after birth. Journal of Reproductive and Infant Psychology, 33(3), doi: / Bryant, L. (2016, July 29). Sexual abuse and Childbirth: What s the connection? [Web log post]. Retrieved from Chen,Y. R., Hung, K. W., Tsai J. C., Chu H., Chung M. H., Chen, S. R., Liao, Y. M., Ou, K.., Chang, Y. C., & Chou, K. (2014). Efficacy of eye-movement desensitization and Randomized Controlled Trials. PLoS ONE, 9(8), 1-17e doi: /journal.pone Courtois C.A., & Riley C. (1992). Pregnancy and childbirth as triggers for abuse memories: Implications for care. Journal of Birth Issues in Perinatal Care, 19(4), doi/ /j x.1992.tb00408.x Eberhard-Gran, M., Slinning, K., & Esklid, A. (2008). Fear during labor: the impact of sexual abuse in adult life. Journal of Psychosomatic Obstetrics and Gynecology, 29(4),

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