October – November 2018 Research Update

Grief and Post-traumatic Growth Following Miscarriage: The Role of Meaning Reconstruction and Partner Supportive Communication.

Death Stud. 2018 Nov 19:1-11. doi: 10.1080/07481187.2018.1539051. [Epub ahead of print]

Tian X1Solomon DH1.


This study used the meaning reconstruction model of bereavement and the theory of conversationally induced reappraisals to investigate factors that influence the association between grief following a miscarriage and post-traumatic growth. Participants included 298 women who had experienced a miscarriage within the previous year. As predicted, a moderate level of grief corresponded with the most post-traumatic growth among bereaved mothers and meaning reconstruction and partner supportive communication moderated this association. The results clarify how grief is integral to post-traumatic growth in the aftermath of a miscarriage and how intrapersonal and interpersonal coping resources can foster post-traumatic growth in the face of grief.


Childbirth Related Post-traumatic Stress Symptoms and Maternal Sleep Difficulties: Associations With Parenting Stress.

Front Psychol. 2018 Nov 2;9:2103. doi: 10.3389/fpsyg.2018.02103. eCollection 2018.

Di Blasio P1Camisasca E1,2Miragoli S1.


In the literature, increasing evidence is showing the importance of sleep difficulties in the development or maintenance of posttraumatic stress (PTS) symptoms as well as the association between childbirth-related PTS symptoms and early maternal emotions and perceptions of their children. However, little is known regarding the effects of maternal sleep difficulties on parenting or about the mediational role of childbirth-related PTS symptoms in this association. The present study (pregnancy: T0; 1 month postpartum: T1; 3 months postpartum: T2) had two aims. The first one was to explore whether maternal sleep difficulties could contribute to the maintenance of PTS symptoms and whether PTS symptoms could contribute to the maintenance of maternal sleep difficulties. The second purpose was to explore, at 3 months (T2), the associations among childbirth-related PTS symptoms, maternal sleep difficulties, and the three dimensions of parenting stress [parental distress (PD), parent-child dysfunctional interaction, and difficult child] by examining the mediational role of both maternal sleep difficulties and childbirth-related PTS symptoms. Self-report questionnaires were administered to 95 women at different times (T0, T1, and T2). Mediational results confirmed the bidirectional effects between maternal sleep difficulties and PTS symptoms and their reciprocal role of maintenance of symptoms. Moreover, at 3 months postpartum (T2), sleep difficulties mediated the association between PTS symptoms and the three dimensions of maternal parenting stress, while PTS symptoms mediated the associations among maternal sleep difficulties, PD, and difficult child dimensions of parenting stress. The study contributes to the understanding of the maintenance factors of childbirth-related PTS symptoms and of the relationships among PTS symptoms, maternal sleep difficulties, and parenting stress.


Exposure to traumatic events in childhood predicts cortisol production among high risk pregnant women.

Biol Psychol. 2018 Oct 22. pii: S0301-0511(18)30738-5. doi: 10.1016/j.biopsycho.2018.10.006. [Epub ahead of print]

Swales DA1Stout-Oswald SA2Glynn LM3Sandman C4Wing DA5Davis EP6.


Childhood exposure to traumatic events has a profound and disruptive impact on mental and physical health, including stress physiology. In the current study, we evaluate 90 pregnant women at risk for preterm delivery and assess the association between history of exposure to traumatic events and hair cortisol concentrations, an integrated measure of cortisol production. Exposure to more traumatic events in childhood and in adulthood independently predicted elevated hair cortisol concentrations in pregnancy. Notably, the impact of childhood exposure to traumatic events remained after accounting for more proximal traumatic events in adulthood. Further, there was a significant interaction between childhood and adult exposures. Traumatic experiences in adulthood were more strongly associated with hair cortisol concentrations among mothers with a history of greater childhood trauma. Findings suggest that not only do proximal adult exposures impact HPA-axis functioning during pregnancy, but that childhood traumatic experiences have persisting consequences for HPA-axis functioning during pregnancy. Maternal HPA-axis dysregulation in pregnancy has consequences for both maternal health and for fetal development. Therefore, we consider prenatal maternal HPA-axis functioning as a potential biological pathway underlying intergenerational consequences of childhood trauma.


Transgenerational inheritance of behavioral and metabolic effects of paternal exposure to traumatic stress in early postnatal life: evidence in the 4th generation.

Environ Epigenet. 2018 Oct 16;4(2):dvy023. doi: 10.1093/eep/dvy023. eCollection 2018 Apr.

van Steenwyk G1Roszkowski M1Manuella F1Franklin TB1,2Mansuy IM1.


In the past decades, evidence supporting the transmission of acquired traits across generations has reshaped the field of genetics and the understanding of disease susceptibility. In humans, pioneer studies showed that exposure to famine, endocrine disruptors or trauma can affect descendants, and has led to a paradigm shift in thinking about heredity. Studies in humans have however been limited by the low number of successive generations, the different conditions that can be examined, and the lack of mechanistic insight they can provide. Animal models have been instrumental to circumvent these limitations and allowed studies on the mechanisms of inheritance of environmentally induced traits across generations in controlled and reproducible settings. However, most models available today are only intergenerational and do not demonstrate transmission beyond the direct offspring of exposed individuals. Here, we report transgenerational transmission of behavioral and metabolic phenotypes up to the 4th generation in a mouse model of paternal postnatal trauma (MSUS). Based on large animal numbers (up to 124 per group) from several independent breedings conducted 10 years apart by different experimenters, we show that depressive-like behaviors are transmitted to the offspring until the third generation, and risk-taking and glucose dysregulation until the fourth generation via males. The symptoms are consistent and reproducible, and persist with similar severity across generations. These results provide strong evidence that adverse conditions in early postnatal life can have transgenerational effects, and highlight the validity of MSUS as a solid model of transgenerational epigenetic inheritance.


Trauma-informed care with women diagnosed with postpartum depression: a conceptual framework.

Soc Work Health Care. 2018 Oct 22:1-16. doi: 10.1080/00981389.2018.1535464. [Epub ahead of print]

Polmanteer RSR1Keefe RH2Brownstein-Evans C1.


Postpartum depression (PPD) is a mental health disorder that affects approximately 20% of all new mothers. PPD frequently co-occurs with and is exacerbated by trauma, particularly for women from vulnerable populations. Trauma-informed care (TIC) is a best practice that recognizes the importance of, and takes steps to promote recovery from, trauma while preventing retraumatization. Despite its potential utility, there is limited research published on TIC, including how TIC is operationalized across practice settings. Further, despite the prevalence and negative effects of untreated PPD, to date there have been limited articles published on TIC and PPD. The purpose of this article is to provide a TIC framework for service delivery for women diagnosed with PPD including explicit strategies for how TIC should be structured across roles, settings, and systems. Implications for health practice, policy, and future research are provided.


Relationship Between Mindfulness and Posttraumatic Stress in Women Who Experienced Stillbirth.

J Obstet Gynecol Neonatal Nurs. 2018 Nov;47(6):760-770. doi: 10.1016/j.jogn.2018.09.002. Epub 2018 Oct 5.

Huberty JGreen JCacciatore JBuman MPLeiferman J.


OBJECTIVE: To explore the potential factors that mediate the relationship between mindfulness and symptoms of posttraumatic stress (PTS) in women who experienced stillbirth.

DESIGN: A cross-sectional analysis of baseline data before women’s participation in an online mindfulness intervention (i.e., online yoga).

SETTING: This was a national study, and women participated in their own homes.

PARTICIPANTS: Women who experienced stillbirth (N = 74) within the past 2 years and resided in the United States.

METHODS: Women were recruited nationally, primarily through social media. Participants (N = 74) completed baseline assessments (self-report mental and physical health surveys) via a Web-based survey tool. We conducted an exploratory factor analysis of the COPE Inventory subscales to reduce the number of variables before entry into a mediation model. We then tested the mediation effects of sleep quality, self-esteem, resilience, and maladaptive coping on the relationship between mindfulness and PTS symptoms.

RESULTS: Through the exploratory factor analysis we identified a two-factor solution. The first factor included nine subscales that represented adaptive coping strategies, and the second factor included five subscales that represented maladaptive coping strategies. Results from multiple mediation analysis suggested that mindfulness had a significant inverse relationship to PTS symptoms mediated by sleep quality.

CONCLUSION: Mindfulness practices may have potential benefits for grieving women after stillbirth. Evidence-based approaches to improve sleep quality also may be important to reduce PTS symptoms in women after stillbirth.


A longitudinal, multi-centre, superiority, randomized controlled trial of internet-based cognitive behavioural therapy (iCBT) versus treatment-as-usual (TAU) for negative experiences and posttraumatic stress following childbirth: the JUNO study protocol.

BMC Pregnancy Childbirth. 2018 Oct 1;18(1):387. doi: 10.1186/s12884-018-1988-6.

Sjömark J1Parling T2,3Jonsson M2Larsson M2Skoog Svanberg A2.


BACKGROUND: About one-third of women report their childbirth as traumatic and up to 10% have severe traumatic stress responses to birth. The prevalence of Posttraumatic stress disorder following childbirth (PTSD FC) is estimated to 3%. Women with PTSD FC report the same symptoms as other patients with PTSD following other types of trauma. The effect of psychological treatment for women with PTSD FC has only been studied in a few trials. Similarly, studies on treatment needs for women not diagnosed as having PTSD FC but who nevertheless face psychological problems are lacking.

METHODS/DESIGN: Women who rate their overall birth experience as negative on a Likert scale, and/or had an immediate caesarean section and/or a major postpartum haemorrhage are randomized to either internet delivered cognitive behaviour therapy (iCBT) plus treatment as usual (TAU) or TAU. The iCBT is to be delivered in two steps. The first step consists of six weekly modules for both the woman and her partner (if they wish to participate) with minimal therapeutic support. Step 2 consists of eight weekly modules with extended therapeutic support and will be offered to participants whom after step 1 report PTSD FC. Assessments will be made at baseline, 6 weeks, 14 weeks, and at follow-ups at 1, 2, 3 and 4 years after baseline. The primary outcome measures are symptoms of posttraumatic stress and depression. Secondary outcomes are quality of life, parent-child bonding, marital satisfaction, coping strategies, experience regarding the quality of care received, health-related quality of life, number of re-visits to the clinic and number of appointments for counselling during the 4 years’ period after the negative childbirth experience, time until the woman gets pregnant again, and the type of birth in the subsequent pregnancy. A health economic evaluation in the form of a cost utility analysis will be conducted.

DISCUSSION: This study protocol describes a randomized controlled trial that will provide information about the effectiveness of iCBT in women with negative experiences, posttraumatic stress, and PTSDFC.


Fear of Childbirth, Postpartum Depression, and Birth-Related Variables as Predictors of Posttraumatic Stress Disorder After Childbirth.

Worldviews Evid Based Nurs. 2018 Oct 3. doi: 10.1111/wvn.12326. [Epub ahead of print]

Çapik A1Durmaz H2.


BACKGROUND: Childbirth may be a significant cause of postpartum posttraumatic stress disorder (PTSD) in women.

AIMS: The objective of this study is to examine the effect of fear of childbirth, postpartum depression, and certain birth-related variables on postpartum PTSD.

METHODS: This study is a cross-sectional study. The study was carried out in a maternity hospital nonstress unit between December 1, 2015, and February 29, 2016. Three hundred and one pregnant women who met the criteria for inclusion in the study made up the research sample.

RESULTS: Fear of childbirth and postpartum depression significantly and positively predicted the level of posttraumatic stress after childbirth (β = 0.17, p < .01; β = 0.68, p < .001). Fear of childbirth explains 3% of the total variance in posttraumatic stress (R2  = .03, adjusted R2  = .02, F = 7.141, p < .01), while postpartum depression explains 47% of it (R2  = .47, adjusted R2  = .46, F = 196.35, p < .001). Satisfaction with the attitudes of the medical staff during childbirth, defining the childbirth experience, and the state of experiencing postpartum problems by the mother are significant predictors of postpartum posttraumatic stress (β = -0.21, p < .01; β = -0.14, p < .05; β = 0.17, p < .01). When these three variables are addressed together, they explain 14% of the total variance (R2  = .14, adjusted R2 = .13, F = 9.33, p < .001).

LINKING EVIDENCE TO ACTION: Postpartum PTSD is a situation that must be carefully emphasized in terms of maternal, baby, and family health. For this reason, it is necessary to evaluate postpartum PTSDmore quickly and objectively, and healthcare providers have major duties in this respect.


Correlates of Perinatal Post-Traumatic Stress Among Culturally Diverse Women with Depressive Symptomatology.

Issues Ment Health Nurs. 2018 Oct 2:1-10. doi: 10.1080/01612840.2018.1488313. [Epub ahead of print]

Vignato J1Connelly CD2Bush RA2Georges JM2Semino-Asaro S2Calero P2Horwitz SM3.


Post-traumatic stress disorder (PTSD) is an important and often neglected comorbidity of pregnancy; left untreated, it can lead to serious health complications for the mother and developing fetus. Structured interviews were conducted to identify risk factors of PTSD among culturally diverse women with depressive symptomatology receiving perinatal services at community obstetric/gynecologic clinics. Women abused as adults, with two or more instances of trauma, greater trauma severity, insomnia, and low social support were more likely to present perinatal PTSD symptoms. Perinatal PTSD is prevalent and has the potential for chronicity. It is imperative healthcare providers recognize salient risk factors and integrate culturally sensitive screening, appropriate referral, and treatment services for perinatal PTSD.


Intergenerational transmission of trauma effects: putative role of epigenetic mechanisms.

World Psychiatry. 2018 Oct;17(3):243-257. doi: 10.1002/wps.20568.

Yehuda R1,2Lehrner A1,2.


This paper reviews the research evidence concerning the intergenerational transmission of traumaeffects and the possible role of epigenetic mechanisms in this transmission. Two broad categories of epigenetically mediated effects are highlighted. The first involves developmentally programmed effects. These can result from the influence of the offspring’s early environmental exposures, including postnatalmaternal care as well as in utero exposure reflecting maternal stress during pregnancy. The second includes epigenetic changes associated with a preconception trauma in parents that may affect the germline, and impact fetoplacental interactions. Several factors, such as sex-specific epigenetic effects following trauma exposure and parental developmental stage at the time of exposure, explain different effects of maternal and paternal trauma. The most compelling work to date has been done in animal models, where the opportunity for controlled designs enables clear interpretations of transmissible effects. Given the paucity of human studies and the methodological challenges in conducting such studies, it is not possible to attribute intergenerational effects in humans to a single set of biological or other determinants at this time. Elucidating the role of epigenetic mechanisms in intergenerational effects through prospective, multi-generational studies may ultimately yield a cogent understanding of how individual, cultural and societal experiences permeate our biology.


Depressive and trauma symptoms in expectant, risk-exposed, mothers and fathers: Is mindfulness a buffer?

J Affect Disord. 2018 Oct 1;238:179-186. doi: 10.1016/j.jad.2018.05.044. Epub 2018 May 31.

Hicks LM1Dayton CJ2Victor BG3.


BACKGROUND: Perinatal depression is reported in 15-20% of women (Marcus, 2009), 8-16% of men (Paulson and Bazemore, 2010) and low-SES, diverse populations are particularly at risk (Sareen, 2011). Trauma symptoms are commonly comorbid with depression, especially when individuals are exposed to risk factors such as community violence and poverty (Kastello et al., 2015; WenzGross et al., 2016). Parental mental illness places infants at risk for negative outcomes (Junge et al., 2016). Evidence supports that dispositional mindfulness is linked to mental health in many populations, however, a gap lies in the understanding of the relationship between mindfulness, trauma and depression in risk-exposed, pregnant populations, especially with fathers. We hypothesize that dispositional mindfulness is negatively associated with lower depression and trauma symptoms in pregnancy, in mothers and fathers.

METHODS: Dispositional mindfulness, depressive and trauma symptoms were examined in women and men, exposed to adversity who were expecting a baby (N = 102). Independent t-tests, and bivariate correlations examined the relationships between these variables. Hierarchical regression was utilized to understand how mindfulness and trauma symptoms may contribute to antenatal depression symptoms.

RESULTS: Significant differences were observed with mindfulness and depressive symptoms, with no differences reported across gender. Mindfulness, depressive and trauma symptoms were associated in the expected directions. Total mindfulness, specifically being non-reactive to one’s own thoughts and trauma symptoms predicted depressive symptoms.

LIMITATIONS: Limitations include small sample size, cross-sectional data and self-report measures.

CONCLUSION: Mindfulness and trauma symptoms were found to be significant predictors of depressive symptoms in parents-to-be. Those with lower mindfulness exhibited higher levels of depression. These findings may be helpful in disseminated mindfulness-based interventions aimed at treating antenatal depression in both expectant mothers and fathers who are exposed to adversity. Further research is necessary to understand the mechanisms of mindfulness in risk-exposed, expectant parents.


Memories of Infant Pain in the Neonatal Intensive Care Unit Influence Posttraumatic Stress Symptoms in Mothers of Infants Born Preterm.

Clin J Pain. 2018 Oct;34(10):936-943. doi: 10.1097/AJP.0000000000000620.

Vinall J1Noel M2,3Disher T4Caddell K4Campbell-Yeo M4,5,6.


OBJECTIVES: The birth of a preterm infant and witnessing ones’ infant in pain is remembered by parents as being one of the most stressful aspects of the neonatal intensive care unit (NICU). Elevated posttraumatic stress symptoms (PTSS) are highly prevalent among mothers of preterm infants, however, little is known about mothers’ memories of invasive procedures in the NICU and how these memories may contribute to the development of PTSS. We examined the relationships between number of invasive procedures, mothers’ memories of these procedures, and their PTSS at discharge from the NICU.

MATERIALS AND METHODS: Participants included 36 mothers of infants born below 37 weeks gestational age recruited from a tertiary-level NICU. Medical chart review was performed between birthand discharge from the NICU. At discharge, a research nurse conducted a structured memory interview with the mothers to assess their memories of their infants’ invasive procedures. Mothers also completed a self-report measure of PTSS (Posttraumatic Stress Disorder Checklist for the DSM-5).

RESULTS: Mothers of infants exposed to greater numbers of invasive procedures had more elevated PTSS at discharge (R=0.37). Moreover, mothers who recalled having greater anxiety about their infant’s invasive procedures had greater symptoms of reexperiencing (R=0.34) and avoidance (R=0.28) at discharge from the NICU.

DISCUSSION: Greater neonatal exposure to invasive procedures and mothers’ recall of these procedures were related to mothers’ posttraumatic stress symptomatology at discharge. Invasive procedures in the NICU represent an important target area for neonatal intervention to reduce maternal distress and improve outcomes.


Couples Facing the Birth of a Newborn with a Congenital Anomaly: PTSD Symptoms in the First Year.

Am J Perinatol. 2018 Oct;35(12):1168-1172. doi: 10.1055/s-0038-1641591. Epub 2018 Apr 18.

Bevilacqua F1Morini F2Zaccara A3De Marchis C2Braguglia A2Gentile S1Bagolan P2Aite L1.


OBJECTIVE: The objective of this study was to assess the presence of posttraumatic stress disorder (PTSD) symptoms in parental couples of newborn requiring early surgery at 6 and 12 months after birth.

STUDY DESIGN: A longitudinal study was set up from January 2014 to June 2015. As a measure of PTSD, we used the Italian version of the Impact of Event Scale-Revised (IES-R).

RESULTS: Thirty-four couples form the object of the study. At 6 months, half of mothers (52.9%) and fathers (44.1%) reported traumatic stress symptoms above the clinical cutoff. Percentages remained stable at 12 months. When parental gender and length of follow-up were compared with two-factor analysis of variance, none had an impact on IES-R score, nor an interaction between these factors was found. A significant correlation of IES-R total score was present within the couple both at 6 and 12 months (6 months-r: 0.6842, p < 0.0001 and 12 months-r: 0.4045, p = 0.0177).

CONCLUSION: Having a child with a repaired malformation represents a complex prolonged stressful situation with persistent burden for both parents who are at high risk of developing PTSD symptoms.


Postnatal post-traumatic stress: An integrative review.

Women Birth. 2018 Oct;31(5):367-379. doi: 10.1016/j.wombi.2017.12.003. Epub 2018 Jan 11.

Simpson M1Schmied V2Dickson C2Dahlen HG3.


PROBLEM:Post-traumatic stress disorder and post-traumatic stress symptoms following birth occur amongst a small proportion of women but can lead to poor maternal mental health, impairment in mother-infant bonding and relationship stress. This integrative review aims to examine the associated risk factors and women’s own experiences of postnatal post-traumatic stress in order to better understand this phenomenon.

METHOD: Fifty three articles were included and critically reviewed using the relevant Critical Appraisal Skills Program checklists or Strengthening the Reporting of Observational studies in Epidemiology assessment tool.

FINDINGS: Risk factors for postnatal post-traumatic stress symptoms and disorder include factors arising before pregnancy, during the antenatal period, in labour and birth and in the postnatal period. Potential protective factors against postnatal post-traumatic stress have been identified in a few studies. The development of postnatal post-traumatic stress can lead to negative outcomes for women, infants and families.

DISCUSSION: Risk factors for post-traumatic stress symptoms and disorder are potentially identifiable pre-pregnancy and during the antenatal, intrapartum and postnatal periods. Potential protective factors have been identified however they are presently under researched. Predictive models for postnatal post-traumatic stress disorder development have been proposed, however further investigation is required to test such models in a variety of settings.

CONCLUSIONS: Postnatal post-traumatic stress symptoms and disorder have been shown to negatively impact the lives of childbearing women. Further investigation into methods and models for identifying women at risk of developing postnatal post-traumatic stress following childbirth is required in order to improve outcomes for this population of women.


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