Reflections on postpartum post-traumatic stress disorder: from theory to clinical practice

This is the fifth week of our Maternal Mental Health series, which is dedicated to postnatal post-traumatic stress disorder (PTSD). We are publishing two blogs: one by Becky Fisher, sharing her personal experience with postnatal PTSD, and another one by Professor Colin Martin focusing on describing the clinical and scientific perspective of postnatal PTSD.

Becky’s account of her experience of postpartum post-traumatic stress disorder (PP-PTSD) is shared and conveyed with sincerity, honesty, bravery and with a fundamental insight that many, even seasoned, practitioners find challenging to grasp.

This should not though, be a surprise, neither is it a criticism. The presentation of mental health issues in the postnatal period and indeed, over the perinatal period more generally, raises important theoretical and clinical questions about the cause, identification and treatment of mental health problems during a period and context (childbirth) almost universally perceived to be associated with excitement and optimism.

However, the reality, as elegantly expressed within Becky’s account, may be altogether different to the widely believed ideal. Certainly, many of the symptoms of PTSD will cause considerable distress and within the context of the postnatal period, additional burden above and beyond that of caring for a new baby.

Symptoms of PTSD classically include re-experiencing the traumatic event, through for example ‘flashbacks’ or nightmares, and using strategies to avoid things or circumstances that may remind of the traumatic event. In addition, hyperarousal is frequent, typically exemplified by high anxiety and difficulty in relaxing, and by sleep problems. There are a variety of other symptoms too associated with PTSD. The very positive news is that PTSD is very effectively treated by cognitive behavioural therapy (CBT), a ‘talking’ therapy, as detailed by Becky.

Having the opportunity to do this blog allows me the rare chance to express some views and indeed, even express an opinion, on issues within the perinatal mental health area which are both vexing and sometimes uncomfortable, simply because they sound straightforward to understand and explain but in reality, they are perplexing.

Perinatal mental health problems are not uncommon and indeed vary widely both in terms of presentation (for example, anxiety, depression) and severity. Mental health problems specific to the period following birth have long been accepted as both a potential issue of concern and moreover, imbued with characteristics of the presentation making them unique in cause, symptom profile and course, compared to similar conditions occurring outside the postnatal period.

The most well-established in the clinical literature is postnatal depression (PND), occurring in 12–15% of women postpartum. More recently recognised mental health conditions identified within the perinatal period include tokophobia (fear of childbirth) and PP-PTSD. Interestingly, though more recently recognised, PP-PTSD shares several commonalities in terms of accurately and conceptually defining what the phenomenon is. This has implications for the provision of evidence-based treatment interventions, since these should be based on a coherent model of aetiology (causation).

Let me explain. PND remains, despite broad clinical awareness, an enigmatic presentation. There is still no agreed consensus on whether PND is ‘normal’ depression occurring postnatally or a special type of depression specific to the perinatal period. This is not a subtle distinction since the implications in favour of either perspective may influence thinking regarding the most appropriate interventions.

One of the most inconvenient questions a clinical researcher may be asked if giving a talk on PND is, why are the rates of PND similar to general population rates of depression? Common sense might dictate that they might be higher if specific to the postpartum period and moreover, if we only screen postnatally, could we actually simply be identifying, in some instances at least, pre-existing depression? It has further been observed that screen positive depression rates during pregnancy are similar to those observed postnatally in some studies.

Interestingly, this conundrum also appears salient to PP-PTSD. Irrespective of attitudes, opinions and beliefs about the cause, course and outcome following the onset of PP-PTSD, it has also been observed that PP-PTSD rates are not hugely dissimilar to those observed in the general population.

Thus, it is not conclusively known whether PP-PTSD is a specific form of PTSD unique to the postnatal period or whether, in some instances, the individual may have pre-existing PTSD, which is identified through opportunistic screening postpartum.

The symptoms described by Becky are undoubtedly those of PTSD and within the narrative clearly related to the causal event/s occurring during and immediately after childbirth. However, consider the case of a woman with previously undiagnosed but pre-existing PTSD screening positive postpartum. In that event, might the assertion be to associate the diagnosis with the most obvious event (childbirth), contextualised within the screening protocol (screening for PP-PTSD)?

Moreover, what of the situation where there may be pre-existing PTSD and then PP-PTSD, could this lead to additive effects?

The path of evidence-based and effective interventions in relation to the occurrence of perinatal mental health problems is firstly accurate identification. However, we can see, that in relation to PP-PTSD this is by no means a simple undertaking, particularly in terms of differentiating which type of PTSD it may be (childbirth-specific or not).

Though it may seem fundamental, many studies examining PP-PTSD do not differentiate in terms of screening methodology used between childbirth-specific PTSD and PTSD related to other factors. A large study by Harrison and colleagues (2021) with 16,000 postpartum women recruited in England recently published striking findings related to this issue looking at post-traumatic stress (PTS) using a questionnaire-based PTSD screening tool.

Harrison et al. (2021) found a fundamentally different profile of predictors of childbirth-related PTS compared to PTS related to non-childbirth-related factors. They found that those who reported childbirth-related PTS were significantly more likely to report re-experiencing symptoms of PTSD than those who reported PTS related to other factors. Indeed, the ‘smoking gun’ highlighted within the Harrison et al. (2021) study was the observation that PTS occurring during the postpartum period was not only common but often not related to childbirth but to other factors. Importantly, the small number of factors found to be associated with both were anxiety during pregnancy, health problems specifically related to pregnancy, and lower birth satisfaction.

Taking this final point and under this rubric, addressing issues of antenatal anxiety, health problems during pregnancy and improving the birth experience and thus birth satisfaction may be highly beneficial in mitigating against the occurrence and severity of PP-PTSD symptoms. In fact, two of these factors precede the birth by a considerable period and strategies to improve the birth experience may be considered in many respects prior to birth also.

Within the clinical research field, we clearly, need to understand PP-PTSD to a significantly greater degree than we do to date, through a process of systematic research, with the goal of improving the experience of women following birth, through the prevention (where possible), identification, treatment and enhancing recovery.

Work continues apace, for example, the global International Survey of Childbirth-related Trauma (INTERSECT) study, however more can, could and should be done to improve outcomes for women at risk or, or experiencing PP-PTSD.