"Nobody could prepare me for the nightmare that I’d live in the months following this day"
Psychological Trauma: Practice Points for health professionals
Post-traumatic Stress Disorder (PTSD)? Anxiety? Depression? All of the above?
PTSD is one of a group of ailments referred to as Trauma and Stressor-Related Disorders (DSM-5). It is often considered to be something that only war veterans, police officers, paramedics and similar groups experience, but trauma-related disorders and difficulties are widespread in the community and are more common in women than men. Trauma disorder can occur after one or multiple events that included actual or threatened serious injury, death or sexual violence to ourselves or others.
Not all trauma symptoms meet criteria for a formal diagnosis of PTSD. Although some women and partners may be relieved to hear there is a diagnostic label, such as PTSD, for their suffering, not everyone wants or requires a psychiatric diagnosis. In addition, co-morbidity is considerable, as it would hardly be surprising if the symptoms did not include or result in anxiety, depression, relationship problems, and many ineffective strategies for self-treatment. When the symptoms interfere with the person’s life, professional help is essential.
Not everyone is traumatised by infertility, a complicated pregnancy, miscarriage, physically damaging delivery process or other pregnancy-related phenomena such as postpartum haemorrhage, just as some women and their partners will be traumatised in the short- or longer- term by what seems to health professionals to be “an uneventful pregnancy and delivery”. What matters is the experienced or subjective severity of the occurrence (although some events would traumatize anyone), the prior vulnerability of the person in question (previous unresolved adverse life experiences such as loss or abuse), and the responses of other people, especially close family and health professionals at the time and subsequently.
Invariably, by the time we are contemplating a diagnosis of PTSD or other trauma disorder, the situation will be complex. Detailed consultation is essential, and some practitioners may wish to include relevant quantitative scales.Some responders will minimize their suffering while others will emphasise or deny it, so using scales does not negate the necessity for in-depth discussion of the person’s past and present context.
Scales to offer before or during the consultation
Edinburgh Postnatal Depression Scale (Cox et al, 1987). A simple 10-item scale that the woman has undoubtedly already met during the pregnancy. It covers depressive and anxiety symptoms, including thoughts of self-harm. It does not diagnose depression but indicates degree of distress and complexity.
The EPDS may also be offered to men postpartum but the threshold for concern needs to be lower. (Scale available from beyondblue, Black Dog websites)
If the consultation is not within the first postpartum year, another scale may be preferable. The DASS-21 is widely used, measuring depression, anxiety and stress (e.g. Cunningham et al, 2013).
PTSD scales (e.g. PC-PTSD-5; Prins et al, 2015) tend to be aimed at war veterans and may need to be amended for use in this population.
Just ask the question
Alternatively, if trauma seems likely, appropriate questions may simply be asked within the consultation. Questions usually include items such as:
Since the delivery, have you:
- Had nightmares about it, or found it coming into your mind when you didn’t want to think about it?
- Tried hard not to think about it and avoided situations that reminded you of it?
- Noticed that you were hypervigilant, on guard, jumpy, easily startled, irritable?
- Felt numb, detached from your surroundings, activities or other people?
Scales should never be used without accompanying professional consultation; full details are needed regarding the circumstances of the pregnancy, delivery, outcome and subsequent events. Research indicates that women are reluctant to complain to or about their obstetrician, midwife or other professional, and this must be kept in mind. The tendency for many women is to seek approval and avoid open criticism.
Thus, for example, the postnatal six-week check needs to include the EPDS (take a quick look at this at the beginning of the interview and then discuss it towards the end if appropriate), discussion of the baby, whether breast feeding is occurring and proceeding smoothly, relationship with the partner, who is providing practical and emotional support, is she getting any sleep etc. The couple’s thoughts and feelings regarding further pregnancies and contraception can be very revealing. The consultation should include pelvic examination.
In a GP practice, a longer consultation and follow-up appointments need to be scheduled, and appropriate referral(s) should be made, e.g. to the obstetrician/gynaecologist; specialist physiotherapist, and/or psychiatrist.
The woman’s story must be heard and details acquired from the clinic where the pregnancy and delivery care occurred. If possible, the partner should be involved in at least part of the consultation process. As time passes over that first postpartum year, appointments to discuss contraception, the sexual relationship and any related difficulties can be discussed, but advantage should be taken of other practice visits, eg. for immunization, baby health problems etc, to inquire about the mother’s recovery and any ongoing physical difficulties, such as incontinence, dyspareunia.
Cox JL, Holden JM, Sagovsky R. (1987) Detection of postnatal depression: Development of the 10-item Edinburgh postnatal depression scale. Brit J Psychiatry 150: 782-786
Cunningham, N.K., Brown, P.M., Brooks J. & Page, A.C. (2013). The structure of emotional symptoms in the postpartum period: Is it unique? Journal of Affective Disorders, 151, 686-694.
Lovibond, S.H. & Lovibond, P.F. (1995). Manual for the Depression Anxiety Stress Scales. (2nd. Ed.) Sydney: Psychology Foundation.
Prins, A., Bovin, M. J., Kimerling, R., Kaloupek, D. G., Marx, B. P., Pless Kaiser, A., & Schnurr, P. P. (2015). The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5).
The primary care PTSD screen (PC-PTSD)
In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you…
- Have had nightmares about it or thought about it when you did not want to? (Yes/No)
- Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? (Yes/No)
- Were constantly on guard, watchful, or easily startled? (Yes/No)
- Felt numb or detached from others, activities, or your surroundings? (Yes/No)
You may find these websites useful:
Please refer to physical trauma resources for more information.