Peritraumatic dissociation in childbirth-evoked posttraumatic stress and postpartum mental health

A diagnostic questionnaire for childbirth related posttraumatic stress disorder: a validation study

BACKGROUND

Labor and delivery can entail complications and severe maternal morbidities that threaten a woman's life or cause her to believe that her life is in danger. Women with these experiences are at risk for developing posttraumatic stress disorder. Postpartum posttraumatic stress disorder, or childbirth-related posttraumatic stress disorder, can become an enduring and debilitating condition. At present, validated tools for a rapid and efficient screen for childbirth-related posttraumatic stress disorder are lacking.

OBJECTIVE

We examined the diagnostic validity of the Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, for detecting posttraumatic stress disorder among women who have had a traumatic childbirth. This Checklist assesses the 20 Diagnostic and Statistical Manual of Mental Disorders, posttraumatic stress disorder symptoms and is a commonly used patient-administrated screening instrument. Its diagnostic accuracy for detecting childbirth-related posttraumatic stress disorder is unknown.

STUDY DESIGN

The sample included 59 patients who reported a traumatic childbirth experience determined in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, posttraumatic stress disorder criterion A for exposure involving a threat or potential threat to the life of the mother or infant, experienced or perceived, or physical injury. The majority (66%) of the participants were less than 1 year postpartum (for full sample: median, 4.67 months; mean, 1.5 years) and were recruited via the Mass General Brigham's online platform, during the postpartum unit hospitalization or after discharge. Patients were instructed to complete the Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, concerning posttraumatic stress disorder symptoms related to childbirth. Other comorbid conditions (ie, depression and anxiety) were also assessed. They also underwent a clinician interview for posttraumatic stress disorder using the gold-standard Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. A second administration of the Checklist was performed in a subgroup (n=43), altogether allowing an assessment of internal consistency, test-retest reliability, and convergent and diagnostic validity of the Checklist. The diagnostic accuracy of the Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, in reference to the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, was determined using the area under the receiver operating characteristic curve; an optimal cutoff score was identified using the Youden's J index.

RESULTS

One-third of the sample (35.59%) met the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria for a posttraumatic stress disorder diagnosis stemming from childbirth. The Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, symptom severity score was strongly correlated with the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, total score (ρ=0.82; P<.001). The area under the receiver operating characteristic curve was 0.93 (95% confidence interval, 0.87-0.99), indicating excellent diagnostic performance of the Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. A cutoff value of 28 optimized the sensitivity (0.81) and specificity (0.90) and correctly diagnosed 86% of women. A higher value (32) identified individuals with more severe posttraumatic stress disorder symptoms (specificity, 0.95), but with lower sensitivity (0.62). Checklist scores were also stable over time (intraclass correlation coefficient, 0.73), indicating good test-retest reliability. Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, scores were moderately correlated with the depression and anxiety symptom scores (Edinburgh Postnatal Depression Scale: ρ=0.58; P<.001 and the Brief Symptom Inventory, anxiety subscale: ρ=0.51; P<.001).

CONCLUSION

This study demonstrates the validity of the Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, as a screening tool for posttraumatic stress disorder among women who had a traumatic childbirth experience. The instrument may facilitate screening for childbirth-related posttraumatic stress disorder on a large scale and help identify women who might benefit from further diagnostics and services. Replication of the findings in larger, postpartum samples is needed.

Preventing posttraumatic stress disorder following childbirth: a systematic review and meta-analysis

OBJECTIVE

Women can develop posttraumatic stress disorder in response to experienced or perceived traumatic, often medically complicated, childbirth; the prevalence of these events remains high in the United States. Currently, no recommended treatment exists in routine care to prevent or mitigate maternal childbirth-related posttraumatic stress disorder. We conducted a systematic review and meta-analysis of clinical trials that evaluated any therapy to prevent or treat childbirth-related posttraumatic stress disorder.

DATA SOURCES

PsycInfo, PsycArticles, PubMed (MEDLINE), ClinicalTrials.gov, CINAHL, ProQuest, Sociological Abstracts, Google Scholar, Embase, Web of Science, ScienceDirect, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched for eligible trials published through September 2023.

STUDY ELIGIBILITY CRITERIA

Trials were included if they were interventional, if they evaluated any therapy for childbirth-related posttraumatic stress disorder for the indication of symptoms or before posttraumatic stress disorder onset, and if they were written in English.

METHODS

Independent coders extracted the sample characteristics and intervention information of the eligible studies and evaluated the trials using the Downs and Black's quality checklist and Cochrane's method for risk of bias evaluation. Meta-analysis was conducted to evaluate pooled effect sizes of secondary and tertiary prevention trials.

RESULTS

A total of 41 studies (32 randomized controlled trials, 9 nonrandomized trials) were reviewed. They evaluated brief psychological therapies including debriefing, trauma-focused therapies (including cognitive behavioral therapy and expressive writing), memory consolidation and reconsolidation blockage, mother-infant-focused therapies, and educational interventions. The trials targeted secondary preventions aimed at buffering childbirth-related posttraumatic stress disorder usually after traumatic childbirth (n=24), tertiary preventions among women with probable childbirth-related posttraumatic stress disorder (n=14), and primary prevention during pregnancy (n=3). A meta-analysis of the combined randomized secondary preventions showed moderate effects in reducing childbirth-related posttraumatic stress disorder symptoms when compared with usual treatment (standardized mean difference, -0.67; 95% confidence interval, -0.92 to -0.42). Single-session therapy within 96 hours of birth was helpful (standardized mean difference, -0.55). Brief, structured, trauma-focused therapies and semi-structured, midwife-led, dialogue-based psychological counseling showed the largest effects (standardized mean difference, -0.95 and -0.91, respectively). Other treatment approaches (eg, the Tetris game, mindfulness, mother-infant-focused treatment) warrant more research. Tertiary preventions produced smaller effects than secondary prevention but are potentially clinically meaningful (standardized mean difference, -0.37; -0.60 to -0.14). Antepartum educational approaches may help, but insufficient empirical evidence exists.

CONCLUSION

Brief trauma-focused and non-trauma-focused psychological therapies delivered early in the period following traumatic childbirth offer a critical and feasible opportunity to buffer the symptoms of childbirth-related posttraumatic stress disorder. Future research that integrates diagnostic and biological measures can inform treatment use and the mechanisms at work.

The Maternal Psychic Impact of Infection by SARS-CoV-2 during Pregnancy: Results from a Preliminary Prospective Study

Due to a higher risk of maternal complications during pregnancy, as well as pregnancy complications such as stillbirth, SARS-CoV-2 contamination during pregnancy is a putative stress factor that could increase the risk of perinatal maternal mental health issues. We included women older than 18 years, who delivered a living baby at the Geneva University Hospitals' maternity wards after 29 weeks of amenorrhea (w.a.) and excluded women who did not read or speak fluent French. We compared women who declared having had COVID-19, confirmed by a positive PCR test for SARS-CoV-2, during pregnancy with women who did not, both at delivery and at one month postpartum. We collected clinical data by auto-questionnaires between time of childbirth and the third day postpartum regarding the occurrence of perinatal depression, peritraumatic dissociation, and peritraumatic distress during childbirth, measured, respectively, by the EPDS (depression is score > 11), PDI (peritraumatic distress is score > 15), and PDEQ (scales). At one month postpartum, we compared the proportion of women with a diagnosis of postpartum depression (PPD) and birth-related posttraumatic stress disorder (CB-PTSD), using PCL-5 for CB-PTSD and using diagnosis criteria according DSM-5 for both PPD and CB-PTSD, in the context of a semi-structured interview, conducted by a clinician psychologist. Off the 257 women included, who delivered at the University Hospitals of Geneva between 25 January 2021 and 10 March 2022, 41 (16.1%) declared they had a positive PCR test for SARS-CoV-2 during their pregnancy. Regarding mental outcomes, except birth-related PTSD, all scores provided higher mean values in the group of women who declared having been infected by SARS-CoV-2, at delivery and at one month postpartum, without reaching any statistical significance: respectively, 7.8 (±5.2, 8:4-10.5) versus 6.5 (±4.7, 6:3-9), p = 0.139 ***, for continuous EPDS scores; 10 (25.0) versus 45 (21.1), p = 0.586 *, for dichotomous EPDS scores (≥11); 118 (55.7) versus 26 (63.4), p = 0.359 *, for continuous PDI scores; 18.3 (±6.8, 16:14-21) versus 21.1 (±10.7, 17:15-22), 0.231 ***, for dichotomous PDI scores (≥15); 14.7 (±5.9, 13:10-16) versus 15.7 (±7.1, 14:10-18), p = 0.636 ***, for continuous PDEQ scores; 64 (30.0) versus 17 (41.5), p = 0.151 *, for dichotomous PDEQ scores (≥15); and 2 (8.0) versus 5 (3.6), p = 0.289 *, for postpartum depression diagnosis, according DSM-5. We performed Chi-squared or Fisher's exact tests, depending on applicability for the comparison of categorical variables and Mann-Whitney nonparametric tests for continuous variables; p < 0.05 was considered as statistically significant. Surprisingly, we did not find more birth-related PTSD as noted by the PCL-5 score at one month postpartum in women who declared a positive PCR test for SARS-CoV-2:15 (10.6) versus no case of birth related PTSD in women who were infected during pregnancy (p = 0.131 *). Our study showed that mental outcomes were differently distributed between women who declared having been infected by SARS-CoV-2 compared to women who were not infected. However, our study was underpowered to explore all the factors associated with psychiatric issues during pregnancy, postpartum, depending on the exposure to SARS-CoV-2 infection during pregnancy. Future longitudinal studies on bigger samples and more diverse populations over a longer period are needed to explore the long-term psychic impact on women who had COVID-19 during pregnancy.

AI and narrative embeddings detect PTSD following childbirth via birth stories

Free-text analysis using machine learning (ML)-based natural language processing (NLP) shows promise for diagnosing psychiatric conditions. Chat Generative Pre-trained Transformer (ChatGPT) has demonstrated preliminary initial feasibility for this purpose; however, whether it can accurately assess mental illness remains to be determined. This study evaluates the effectiveness of ChatGPT and the text-embedding-ada-002 (ADA) model in detecting post-traumatic stress disorder following childbirth (CB-PTSD), a maternal postpartum mental illness affecting millions of women annually, with no standard screening protocol. Using a sample of 1295 women who gave birth in the last six months and were 18+ years old, recruited through hospital announcements, social media, and professional organizations, we explore ChatGPT's and ADA's potential to screen for CB-PTSD by analyzing maternal childbirth narratives. The PTSD Checklist for DSM-5 (PCL-5; cutoff 31) was used to assess CB-PTSD. By developing an ML model that utilizes numerical vector representation of the ADA model, we identify CB-PTSD via narrative classification. Our model outperformed (F1 score: 0.81) ChatGPT and six previously published large text-embedding models trained on mental health or clinical domains data, suggesting that the ADA model can be harnessed to identify CB-PTSD. Our modeling approach could be generalized to assess other mental health disorders.

Screening for post-traumatic stress disorder following childbirth using the Peritraumatic Distress Inventory

BACKGROUND

Post-traumatic stress disorder (PTSD) following traumatic childbirth may undermine maternal and infant health, but screening for maternal childbirth-related PTSD (CB-PTSD) remains lacking. Acute emotional distress in response to a traumatic experience strongly associates with PTSD. The Peritraumatic Distress Inventory (PDI) assesses acute distress in non-postpartum individuals, but its use to classify women likely to endorse CB-PTSD is unknown.

METHODS

3039 women provided information about their mental health and childbirth experience. They completed the PDI regarding their recent childbirth event, and a PTSD symptom screen to determine CB-PTSD. We employed Exploratory Graph Analysis and bootstrapping to reveal the PDI's factorial structure and optimal cutoff value for CB-PTSD classification.

RESULTS

Factor analysis revealed two strongly correlated stable factors based on a modified version of the PDI: (1) negative emotions and (2) bodily arousal and threat appraisal. A score of 15+ on the modified PDI produced high sensitivity and specificity: 88 % with a positive CB-PTSD screen in the first postpartum months and 93 % with a negative screen.

LIMITATIONS

In this cross-sectional study, the PDI was administered at different timepoints postpartum. Future work should examine the PDI's predictive utility for screening women as closely as possible to the time of childbirth, and establish clinical cutoffs in populations after complicated deliveries.

CONCLUSIONS

Brief self-report screening concerning a woman's emotional reactions to childbirth using our modified PDI tool can detect those likely to endorse CB-PTSD in the early postpartum. This may serve as the initial step of managing symptoms to ultimately prevent chronic manifestations.

OpenAI's Narrative Embeddings Can Be Used for Detecting Post-Traumatic Stress Following Childbirth Via Birth Stories

Free-text analysis using Machine Learning (ML)-based Natural Language Processing (NLP) shows promise for diagnosing psychiatric conditions. Chat Generative Pre-trained Transformer (ChatGPT) has demonstrated preliminary initial feasibility for this purpose; however, whether it can accurately assess mental illness remains to be determined. This study evaluates the effectiveness of ChatGPT and the text-embedding-ada-002 (ADA) model in detecting post-traumatic stress disorder following childbirth (CB-PTSD), a maternal postpartum mental illness affecting millions of women annually, with no standard screening protocol. Using a sample of 1,295 women who gave birth in the last six months and were 18+ years old, recruited through hospital announcements, social media, and professional organizations, we explore ChatGPT's and ADA's potential to screen for CB-PTSD by analyzing maternal childbirth narratives. The PTSD Checklist for DSM-5 (PCL-5; cutoff 31) was used to assess CB-PTSD. By developing an ML model that utilizes numerical vector representation of the ADA model, we identify CB-PTSD via narrative classification. Our model outperformed (F1 score: 0.82) ChatGPT and six previously published large language models (LLMs) trained on mental health or clinical domains data, suggesting that the ADA model can be harnessed to identify CB-PTSD. Our modeling approach could be generalized to assess other mental health disorders.

Peripartum dissociation, sense of control, postpartum posttraumatic stress disorder and emotional adjustment to motherhood in adult survivors of childhood maltreatment

Survivors of childhood maltreatment (CM) may experience difficulties in the peripartum period and in adjustment to motherhood. In this study we examined a model wherein CM is associated with maternal self-efficacy and maternal bonding three months postpartum, through mediation of peripartum dissociation and reduced sense of control during childbirth and postpartum-posttraumatic-stress disorder (P-PTSD). Women were recruited in a maternity ward within 48 h of childbirth (T1, N = 440), and contacted three-months postpartum (T2, N = 295). Participants completed self-report questionnaires: peripartum dissociation, sense of control (T1), and CM, P-PTSD, postpartum-depression, maternal self-efficacy and bonding (T2). Obstetrical data were collected from medical files. Structural equation modeling was conducted to test the hypothesized model, controlling for mode of delivery and postpartum-depression. Reported CM included child emotional neglect (CEN; 23.5%), child emotional abuse (CEA; 16.3%), child sexual abuse (CSA; 12.9%) and child physical abuse (CPA; 7.1%). CM was positively associated with peripartum dissociation and P-PTSD (p < .001). Peripartum dissociation was positively associated with P-PTSD (p < .001). P-PTSD was negatively associated with maternal self-efficacy (p < .001) and maternal bonding (p < .001). Association between CM and maternal self-efficacy and bonding was serially mediated by peripartum dissociation and P-PTSD, but not by sense of control. Findings remained significant after controlling for mode of delivery and postpartum-depression. CM is a risk factor for adjustment to motherhood, owing to its effects on peripartum dissociation and P-PTSD. Implementation of a trauma-informed approach in obstetric care and recognition of peripartum dissociative reactions are warranted.

A Systematic Review of Interventions for Prevention and Treatment of Post-Traumatic Stress Disorder Following Childbirth

Objective

Postpartum women can develop post-traumatic stress disorder (PTSD) in response to complicated, traumatic childbirth; prevalence of these events remains high in the U.S. Currently, there is no recommended treatment approach in routine peripartum care for preventing maternal childbirth-related PTSD (CB-PTSD) and lessening its severity. Here, we provide a systematic review of available clinical trials testing interventions for the prevention and indication of CB-PTSD.

Data Sources

We conducted a systematic review of PsycInfo, PsycArticles, PubMed (MEDLINE), ClinicalTrials.gov, CINAHL, ProQuest, Sociological Abstracts, Google Scholar, Embase, Web of Science, ScienceDirect, and Scopus through December 2022 to identify clinical trials involving CB-PTSD prevention and treatment.

Study Eligibility Criteria

Trials were included if they were interventional, evaluated CB-PTSD preventive strategies or treatments, and reported outcomes assessing CB-PTSD symptoms. Duplicate studies, case reports, protocols, active clinical trials, and studies of CB-PTSD following stillbirth were excluded.

Study Appraisal and Synthesis Methods

Two independent coders evaluated trials using a modified Downs and Black methodological quality assessment checklist. Sample characteristics and related intervention information were extracted via an Excel-based form.

Results

A total of 33 studies, including 25 randomized controlled trials (RCTs) and 8 non-RCTs, were included. Trial quality ranged from Poor to Excellent. Trials tested psychological therapies most often delivered as secondary prevention against CB-PTSD onset (n=21); some examined primary (n=3) and tertiary (n=9) therapies. Positive treatment effects were found for early interventions employing conventional trauma-focused therapies, psychological counseling, and mother-infant dyadic focused strategies. Therapies' utility to aid women with severe acute traumatic stress symptoms or reduce incidence of CB-PTSD diagnosis is unclear, as is whether they are effective as tertiary intervention. Educational birth plan-focused interventions during pregnancy may improve maternal health outcomes, but studies remain scarce.

Conclusions

An array of early psychological therapies delivered in response to traumatic childbirth, rather than universally, in the first postpartum days and weeks, may potentially buffer CB-PTSD development. Rather than one treatment being suitable for all, effective therapy should consider individual-specific factors. As additional RCTs generate critical information and guide recommendations for first-line preventive treatments for CB-PTSD, the psychiatric consequences associated with traumatic childbirth could be lessened.

Disrespect during childbirth and postpartum mental health: a French cohort study

BACKGROUND

While the World Health Organisation (WHO) warned about mistreatment, disrespect and/or abuse during childbirth as early as 2014. This same year a social media movement with #payetonuterus brought to light the problematic of obstetrical violence in French speaking countries, and more specifically on issues of disrespect. The experience of care is an integral part of the quality of care, and perception on inadequate support during labour and loss of control in labour are some of the most frequently reported risk factors for childbirth-related post-traumatic stress disorder (CB-PTSD). Therefore, it seems crucial to study the associations between disrespect during childbirth and the mental well-being of mothers.

METHODS

We performed a multicentered cohort study using auto-questionnaires within a French perinatal network. The main outcome was women's report of disrespect during childbirth measured by the Behavior of the Mother's Caregivers - Satisfaction Questionnaire (BMC-SQ) 3 days and 2 months after childbirth. CB-PTSD and Postpartum Depression (PPD) were assessed 2 months after childbirth using respectively the Post-Traumatic Checklist Scale (PCLS) and the Edinburgh Postnatal Depression Scale (EPDS).

RESULTS

This study followed 123 mothers from childbirth to 2 months postpartum. Among them, 8.13% (n = 10/123) reported disrespect during childbirth at 3 days after childbirth. With retrospect, 10.56% (n = 13/123) reported disrespect during childbirth at 2 months postpartum, i.e. an increase of 31%. Some 10.56% (n = 13/123) of mothers suffered from postpartum depression, and 4.06% (n = 5/123) were considered to have CB-PTSD at 2 months after childbirth. Reported disrespect during childbirth 3 days after birth was significantly associated with higher CB-PTSD 2 months after birth (R² = 0.11, F(1,117) = 15.14, p < 0.001 and β = 9.11, p = 0.006), PPD at 2 months after childbirth was positively associated to reported disrespect in the birth room, 3 days after birth (R² = 0.04, F(1, 117) = 6.28, p = 0.01 and β = 3.36, p = 0.096). Meanwhile, PPD and CB-PTSD were significantly associated 2 months after childbirth (R² = 0.41, F=(1,117) = 82.39, p < 0.01 and β = 11.41, p < 0.001).

CONCLUSIONS

Disrespect during childbirth was associated with poorer mental health during the postpartum period. Given the high prevalence of mental health problems and the increased susceptibility to depression during the postpartum period, these correlational results highlight the importance of gaining a deeper awareness of healthcare professionals about behaviours or attitudes which might be experienced as disrespectful during childbirth.

The Maternal Disintegrative Responses Scale (MDRS): Development and initial validation

OBJECTIVE

This study aimed to design and examine the validity of the Maternal Disintegrative Responses Scale (MDRS) to assess intrusive thoughts and dissociative experiences in the postpartum period.

METHOD

A convenience sample of 455 mothers whose babies were up to 12 months old completed the MDRS and a series of questionnaires assessing postnatal depression (Edinburgh Postnatal Depression Scale [EPDS]), childbirth-related post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), and general symptoms of dissociation.

RESULTS

The final scale consists of eight items tapping two dimensions, intrusive thoughts and dissociative experiences, and displays good psychometric properties. Both factors were found to be related to EPDS, PTSD OCD, and general symptoms of dissociation. Primiparous women scored higher than multiparous women on both dimensions, and mothers of infants up to 3 months old scored higher on dissociative experiences than those whose infants were aged 4-12 months.

CONCLUSIONS

The MDRS can contribute to the theoretical and practical conceptualization and assessment of these phenomena.

Traumatic Childbirth and Birth-Related Post-Traumatic Stress Disorder in the Time of the COVID-19 Pandemic: A Prospective Cohort Study

BACKGROUND

Birth-related post-traumatic stress disorder occurs in 4.7% of mothers. No previous study focusing precisely on the stress factors related to the COVID-19 pandemic regarding this important public mental health issue has been conducted. However, the stress load brought about by the COVID-19 pandemic could have influenced this risk.

METHODS

We aimed to estimate the prevalence of traumatic childbirth and birth-related PTSD and to analyze the risk and protective factors involved, including the risk factors related to the COVID-19 pandemic. We conducted a prospective cohort study of women who delivered at the University Hospitals of Geneva between 25 January 2021 and 10 March 2022 with an assessment within 3 days of delivery and a clinical interview at one month post-partum.

RESULTS

Among the 254 participants included, 35 (21.1%, 95% CI: 15.1-28.1%) experienced a traumatic childbirth and 15 (9.1%, 95% CI: 5.2-14.6%) developed a birth-related PTSD at one month post-partum according to DSM-5. Known risk factors of birth-related PTSD such as antenatal depression, previous traumatic events, neonatal complications, peritraumatic distress and peritraumatic dissociation were confirmed. Among the factors related to COVID-19, only limited access to prenatal care increased the risk of birth-related PTSD.

CONCLUSIONS

This study highlights the challenges of early mental health screening during the maternity stay when seeking to provide an early intervention and reduce the risk of developing birth-related PTSD. We found a modest influence of stress factors directly related to the COVID-19 pandemic on this risk.

It's About Time: The Circadian Network as Time-Keeper for Cognitive Functioning, Locomotor Activity and Mental Health

A variety of organisms including mammals have evolved a 24h, self-sustained timekeeping machinery known as the circadian clock (biological clock), which enables to anticipate, respond, and adapt to environmental influences such as the daily light and dark cycles. Proper functioning of the clock plays a pivotal role in the temporal regulation of a wide range of cellular, physiological, and behavioural processes. The disruption of circadian rhythms was found to be associated with the onset and progression of several pathologies including sleep and mental disorders, cancer, and neurodegeneration. Thus, the role of the circadian clock in health and disease, and its clinical applications, have gained increasing attention, but the exact mechanisms underlying temporal regulation require further work and the integration of evidence from different research fields. In this review, we address the current knowledge regarding the functioning of molecular circuits as generators of circadian rhythms and the essential role of circadian synchrony in a healthy organism. In particular, we discuss the role of circadian regulation in the context of behaviour and cognitive functioning, delineating how the loss of this tight interplay is linked to pathological development with a focus on mental disorders and neurodegeneration. We further describe emerging new aspects on the link between the circadian clock and physical exercise-induced cognitive functioning, and its current usage as circadian activator with a positive impact in delaying the progression of certain pathologies including neurodegeneration and brain-related disorders. Finally, we discuss recent epidemiological evidence pointing to an important role of the circadian clock in mental health.

[Association of postpartum depression with postpartum posttraumatic stress disorder in Korean mothers: a longitudinal survey]

PURPOSE

This study aimed to determine the level of postpartum posttraumatic stress disorder (PTSD) and postpartum depression (PPD) in Korean mothers with healthy babies and to explore the factors related to postpartum PTSD.

METHODS

This study used a longitudinal survey design to explore the levels and association of PPD and PTSD. Two hundred women were recruited during pregnancy and the data were collected via online survey from 166 mothers (84% retained) who gave birth to healthy babies, at two postpartum periods: Fear of childbirth was assessed at the 1st week; and spousal support, PPD, and postpartum PTSD were surveyed at the 4th week postpartum. Descriptive statistics, t-test, one-way analysis of variance, Chi square test, and multiple regression were done.

RESULTS

The mean age of mothers was 33.12 (±3.97) years old. Postpartum PTSD was low (8.95±6.49) with 1.8% (n=3) at risk (≥19). PPD was also low (6.68±5.28) and 30.1% (n=50) were identified at risk (≥10). The comorbid rate of PPD with PTSD was 6%. Mothers who did not have a planned pregnancy had higher scores of PPD (t=-2.78, p=.008), whereas spousal support and PPD had negative relationship (r=-.21, p=.006). The overall explanatory power for postpartum PTSD was 55.2%, of which PPD was the only significant variable (β=.76, t=13.76, p<.001).

CONCLUSION

While only 1.8% was at risk of postpartum PTSD at 4 weeks postpartum, PPD prevalence was 30.1% and PPD was the only influential factor of postpartum PTSD. Assessment and counseling of PPD are required as well as screening for postpartum PTSD. More research is also needed on postpartum PTSD in Korean women.

[A longitudinal study about post-traumatic stress disorder after delivery in Tunisian primiparous]

OBJECTIVES

The aims of this study were to estimate the incidence of the post-partum post-traumatic stress disorder (PP-PTSD) in primiparous women, and to determine the profile of women at risk of developing this disorder.

METHODS

We conducted a descriptive, prospective and longitudinal study carried out at the maternity department of the Hedi Chaker Hospital, Sfax-Tunisia over a period of 15 months. At the first stage of the study, the Saint-Antoine pain questionnaire, the peri-traumatic dissociative experiences questionnaire and the peri-traumatic distress inventory were used respectively to assess the pain of delivery, the peri-traumatic dissociation and distress. At the second stage of the study, the questionnaires, perinatal post-traumatic stress disorder (PPQ), hospital anxiety and depression scale and the Edinburgh postnatal depression scale were used respectively for the PP-PTSD screening and the assessment of the post-partum anxious and depressive symptomatology.

RESULTS

The study population consisted of 183 parturients at the first stage of the study and 150 parturients at the second stage of the study. The incidence of the PP-PTSD was 9.3 %. In the multivariate study, some factors studied were significantly associated with the development of PTSD-PP, including a history of therapeutic termination of pregnancy, a history of miscarriage, exposure to a stressful event during pregnancy, prenatal hospitalization of the mother, instrumental delivery, pain intensity especially in the affective component, peri-traumatic dissociation and avoidance of sexual intercourse for fear of a new pregnancy. However the skin to skin contact with the new-born immediately after delivery was a significant protective factor.

CONCLUSION

The psychological consequences associated with the first birth, particularly the PP-PTSD, are common. The Identification of women at risk and a systematic screening of postpartum post-traumatic stress symptoms are desirable.

Maternal postpartum depression: risk factors, impacts, and interventions for the NICU and beyond

PURPOSE OF REVIEW

Postpartum depression (PPD) negatively impacts caregivers, infants, siblings, and entire families. Mothers with infants admitted to the neonatal intensive care unit (NICU) face additional risk for PPD, coupled with risk factors extending beyond a NICU admision. The novelty of this review is the focus on maternal PPD for mothers with infants admitted to the NICU. Interventions aimed at limiting and preventing PPD in this population include: prenatal and postpartum depression screening, PPD symptom awareness and monitoring, and trauma-informed care.

RECENT FINDINGS

PPD, the most frequent complication of childbirth, affects approximately 10-15% of mothers worldwide. Prevalence rates increase to 40% for mothers whose infant is admitted to the NICU. PPD can affect maternal and child health across the life course and predispose future generations to a myriad of developmental, psychosocial, and physical challenges. Prevalence rates are higher for racial and ethnic minorities, immigrant and refugee populations, and mothers in rural locations. Trauma-informed care is suggested at individual and organizational levels, leading to better care for those with and without previous trauma exposure.

SUMMARY

Increasing PPD symptom awareness, screening for PPD, and connections with resources should begin during prenatal visits. Care teams should discuss barriers to resources for mothers, children, and families to improve access and support.

The birthing brain: A lacuna in neuroscience

During pregnancy, maternal brain neuroplasticity indicates vast neurofunctional and neuroanatomical changes. Recent findings documented a similarly massive readjustment after pregnancy. Currently, these brain changes are interpreted as preparation for and adjustment of the maternal brain to motherhood. Yet, this perspective leaves many questions unsolved. Neuroscientific studies have not yet been conducted to determine the brain areas that function during natural childbirth even though physiological birth is the natural process of women who have reproduced successfully throughout two million years of evolution of the genus Homo. It is rational to believe that the female brain is an active and crucial actor during birth and that birth, itself, is a process that requires brain neuroplasticity. Lack of studies of the birthing brain and brain preparation for birth is a significant lacuna in neuroscience research. I demonstrate theoretically that a new hypothesis for complementary interpretation of maternal brain neuroplasticity is reasonable: Certain maternal brain changes during pregnancy can be interpreted asbrain preparation for birth and certain maternal brain changes after birth can be interpreted asbrain recovery after the tremendous event of birth. This essay can be a starting point for new directions in neuroscience studies.

Traumatic memories of childbirth relate to maternal postpartum posttraumatic stress disorder

The trauma memory is a crucial feature of PTSD etiology and maintenance. Nonetheless, the nature of memories associated with childbirth-related posttraumatic stress disorder (CB-PTSD) requires explication. The present study, as part of a larger project on psychological outcomes of childbirth, utilized a multi-method approach to characterize childbirth memories in relation to CB-PTSD symptoms. We here assessed 413 women who completed self-report measures pertaining to CB-PTSD, postpartum depression, and childbirth memories. Additionally, a subset of 209 women provided written childbirth narratives, analyzed using Linguistic Inquiry and Word Count software. Women endorsing CB-PTSD symptoms on the PTSD-Checklist (PCL)-5 reported more incoherent childbirth memories with more emotional and sensory details, and more frequent involuntary recall and reliving of the memory. They also indicated the childbirth experience was more central to their identity. Written narratives in those with probable CB-PTSD were characterized by less (positive) affective processes, and more cognitive processes. We infer that childbirth memories in women who endorse symptoms of CB-PTSD in the early postpartum period resemble those described in the general PTSD literature. This suggests that childbirth may be experienced as traumatic and evoke a traumatic memory, implicated in symptom endorsement. Opportunities for therapeutic interventions modifying traumatic memories of childbirth in women at risk for CB-PTSD need to be investigated. Future research examining characteristics of traumatic childbirth memories is needed to advance our understanding of this overlooked postpartum condition.

Birthing Consciousness as a Case of Adaptive Altered State of Consciousness Associated With Transient Hypofrontality

In this article, I present the concept of “birthing consciousness,” a psychophysical altered state of women that can occur during natural and undisturbed birth. I demonstrate that this altered state of consciousness (ASC) has phenomenological and cognitive features of hypofrontality; thus, birthing consciousness probably shares a similar brain mechanism to that postulated by the transient-hypofrontality theory (THT). I argue that until recently (with the advent of modern medical intervention), in evolutionary terms, women lacking the proclivity for this specific brain mechanism had a lower chance of reproducing successfully. Hence, I suggest a general and preliminary hypothesis concerning THT: Birthing consciousness is one example of an adaptive pain-induced ASC associated with transient hypofrontality.