Psychological Trauma Resources
Table of Contents
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 the 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 a 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 disorders, the situation will be complex. A 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 an in-depth discussion of the person’s past and present context.
Scale to offer before or during the consultation
Edinburgh Postnatal Depression Scale.1
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 the degree of distress and complexity.
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:
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 professionals, 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 breastfeeding 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 a 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.