PERITRAUMATIC DISSOCIATION IN LABOUR: IS IT A SENTINEL SIGNAL OF MOTHERS AT RISK FOR IMPAIRED PARENTING AND A NEW OPPORTUNITY FOR PREVENTIVE INTERVENTION?

Julia Seng, PhD, CNM, FAAN

Kristen Choi, RN, BSN

University of Michigan,

Ann Arbor, Michigan, USA

A research question from clinical practice

• Nurse-midwife• Working with very young and traumatized clients• Women and girls would “go inside themselves” during the

most intense time of labour• Some felt to me to be experiencing well-being (meditative)• Others felt “absent” or “unreachable”

• This was in the 1990’s, when PTSD among women was not yet well studied, dissociation was not broadly recognized as an aspect of PTSD, and maternity care providers did not have a way to “name” what we observed.

• So…a program of research unfolded.

Dissociation is gaining attention

Defined as “…a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment.”

DSM-5 Dissociative Subtype of PTSD includes “substantial depersonalization or derealization.”

WHO epidemiology (n=25,000, 16 nations) indicates approximately ~14% of PTSD cases fit the subtype.

Not broken down by nature or age of trauma.

(A not entirely satisfying nod to Complex PTSD, DESNOS, and Developmental Trauma Disorder)

Dissociation and parenting concerns • Manifestation of trauma to the attachment system• Originally an “escape when there is no escape”• Subsequently a dysregulation in response to triggers or

overwhelm (or no escape/feeling trapped?)• Labour?• Crying infant?

• Risk for maltreatment? (Loss of integration of cognition, perception of the environment, judgment, emotion—at a physiologic level)

• “Ghosts” in the nursery? • Dissociation as a marker of maternal “unresolved trauma”?• Is dissociation “invisible” to birth attendants?

Part of an intergenerational pattern?• Associated with impaired parenting• Risk factor for child maltreatment and sequelae

• disorganized infant attachment • developmental deficits

• Daisy N, Hien D. The role of dissociation in the cycle of violence. J Fam Violence, 2014;29(2):99-107.

• Hulette A, Kaehler L, Freyd J. Intergenerational Associations Between Trauma and Dissociation. J Fam Violence, 2011;26(3):217-225. 

• Liotti G. Trauma, dissociation, and disorganized attachment: Three strands of a single braid. Psychotherapy: Theory, Research, Practice, Training, 2004;41(4):472-486.

Body and mind dysregulated3 pillars of adaptation to maltreatment (per Teicher)

• HPA axis, catecholamines, oxytocin

Afternoon cortisol across gestation and postpartum

Qualitative data about labour

Sonya: “…kind of glazed over and drugged is the way it felt.”

Julie: “I was probably being ‘out of it’.”

Elizabeth: “…you know, you may not be dealing with someone who's acting as an adult here. There is stuff getting triggered…” 

Terry: “…I can only remember [labour] up to a point, and then it just all goes away…And I picked that up from, you know, when my brother used to molest me…I would just close my eyes real tight and just imagine my spirit being lifted up out of my body and sitting on the bed until he was done. Then I would come back into myself. [And in labour] what happened was I just blocked myself out.

Seng, Kane Low, Sparbel & Killion, Journal of Advanced Nursing, 2004

The STACY Project: Stress, Trauma, Anxiety, and the Childbearing Year

US NIH R01 NR-008767 “Psychobiology of PTSD & Adverse Outcomes of Childbearing”—STACY Project

Not a post-disaster study. Community sample, observing usual care at three different settings to have adequate sample size for complex models. Julia Seng, PhD, CNM (PI) Lisa Kane Low, PhD, CNM (Detroit sites, labor details) David Ronis, PhD (statistician) Israel Liberzon, MD, (neuroendocrinology) Mickey Sperlich, PhD, MSW, CPM (infant mental health, social work, midwifery) OB nurses in three sites Numerous RAs

What are the effects of PTSD on childbearing outcomes?

Settings

UM, Ann Arbor: 90% European American90% insured

Detroit Medical Center (Hutzel Hospital): 90% African-American10% insured

Henry Ford Health System (New Center One): 30% African-American30% insured

All are nulliparas27 is mean age 71% partnered Diverse in race/ethnicityRange of education

Data Collection:

Screen & assign to cohort•Un-exposed controls•Trauma+ controls•PTSD+ cases

34% dismissed due to not fitting a cohort

UNSELECTED

Survey 1Initiating care

Diurnal salivary cortisol by mail

50% return

Next week

Survey 2~35 wks

Survey 3~6 wks pp

After EDD Later

Third trimester items, including interim trauma and PTSD

Medical records review:•Usual•OI-US•ICD-9

Postpartum outcomes:•Labor appraisal•Perception care•Parenting Sense of competence•PDEQ•pp PTSD•pp Depression•Bonding

DNA for SNPs

n=1,581 total,n=1,049 followed

n=425n=576 n=645 n=981 n=564

Results:

PTSD prevalence 8%

3% in Ann Arbor

14% in Detroit

Biggest risk factors:

Childhood maltreatment 12-fold risk

Results:Infants of PTSD-affected women weigh 283 grams less than resilient women’s infants.

The relationship of PTSD with adverse outcomes is stronger for women with PTSD subsequent to maltreatment.

Now replicated by Yonkers et al, 2014 and Shaw et al, 2014.

Results:

STACY Projectstatistical models supportintergenerationalpatterns of trauma and psychiatricvulnerability intersecting in thechildbearing year.

Peritraumatic Dissociation Experiences Questionnaire (PDEQ)

• In other trauma studies, peritraumatic dissociation is a consistent predictor of PTSD onset (gunshot, stabbing, accident)

• PDEQ is the most widely used measure (10 items)• Has been used in 3 other studies of labour• Would the PDEQ be a useful measure for predicting

vulnerability to parenting difficulties based on dissociative response to the stress / overwhelm of labour? (akin to a natural provocation experiment)

PDEQ

• 10 items • Not at all true = 1• Extremely true = 5• 10-50

• Derealization = #4• Depersonalization = #5

Wording

1….spaced out

2….auto-pilot

3….slow motion

4….seemed unreal*

5….outside of body*

6….body distorted

7….happening to others

8….not aware

9….confused

10….disoriented

PDEQ

Is some extent of dissociation normal in labor?

No.

Mean = 14 (sd 5)Median = 12Mode = 10 (not even one symptom)

Study Predictors of Dissociation in Labour

Zambaldi, Cantilino, Farias, Moraes, & Botelho Sougey (2011)

Previous trauma Traumatic childbirth Unemployment, age

Lev-Wiesel & Daphna-Tekoah (2010) 

CSA Prenatal PTSD symptoms Depression Dissociation (DES score)

Boudou, Sejourne, & Chabrol (2007) 

Primiparity Prolonged labor Poor interaction with obstetric team Dysphoric emotion

Previous predictors of dissociation in labour

Prospective modelChildhood

Maltreatment History

Lifetime PTSD

Prenatal Parenting Sense of

CompetencePeritraumatic

Dissociation in Labour

Postnatal PTSD (and depression)

Postnatal Parenting Sense of

Competence Impaired Bonding

Does PDEQ predict impaired bonding?Step 1: R2=1.5%    

Childhood Maltreatment .123 .007Step 2: R2=3.1%    

Childhood Maltreatment .071 .142Lifetime PTSD Diagnosis .138 .004

Step 3: R2=9.8%    Childhood Maltreatment .052 .270Lifetime PTSD Diagnosis .119 .011Prenatal Parenting Competence - .260 <.001

Step 4: R2=16.0% (c/s, nicu n.s.)    Childhood Maltreatment .035 .442Lifetime PTSD Diagnosis .066 .150Prenatal Parenting Competence -.245 <.001PDEQ-Labour Dissociation Score .257 <.001

Model continuedStep 5: R2=19.6%    

Childhood Maltreatment .019 .672

Lifetime PTSD Diagnosis .038 .407

Prenatal Parenting Competence -.225 <.001

PDEQ-Labour Dissociation Score .222 <.001

Postnatal PTSD Diagnosis .200 <.001

Step 6: R2=23.1%    

Childhood Maltreatment .023 .594

Lifetime PTSD Diagnosis .010 .828

Prenatal Parenting Competence -.219 <.001

PDEQ-Labour Dissociation Score .163 <.001

Postnatal PTSD Diagnosis .123 .007

Postnatal Depression Diagnosis .222 <.001

Final modelStep 7: R2=38.1%    

Childhood Maltreatment -.016 .691

Lifetime PTSD Diagnosis .014 .721

Prenatal Parenting Competence -.093 .015

PDEQ-Labour Dissociation Score .119 .003

Postnatal PTSD Diagnosis .089 .030

Postnatal Depression Diagnosis .157 <.001

Postnatal Parenting Competence -.430 <.001

Implications for research• Replication of link of peritraumatic dissociation in labour with adverse

parenting outcomes.• Clarifying overlap of dissociation, dissatisfaction with care, and naming

the birth as traumatic—which factor used depends on the researchers’ agenda.

• Specific focus on at-risk and clinical samples—specialist midwives.• Specific focus on dissociation in response to the triggers of infant crying

or young child’s challenging behavior.• Intervention development and testing.

• NAMING it as a concern.• Adapting existing programs to address it with education and skills.• Trauma treatment to reduce response to trigger (i.e., PE, EMDR).• Supportive care and attention for these mothers to prevent need for dissociative

coping: Self-care? Child care? Infant massage?

• Understanding of physiology of dissociation may add weight to our awareness, especially across professions.

Implications for practice• For women with CMT-PTSD, is labour a “stress test” for

parenting difficulties and continuity of vulnerability?• Child welfare and mental health professionals can play a

key role here.• Discuss dissociation as a sentinel signal for parenting difficulties.• Case consults for midwives and obstetricians during learning curve.• Give them the vocabulary to “see” dissociation in labour.• Give them strategies to respond to dissociation in labour.• Be available to visit women in the postnatal days to teach

• strategies to stay grounded, • settling the infant, and • getting help if crying is a trigger.

Thank you.jseng@umich.edu