Stillbirth as a Major Traumatic Event: PTSD, Depression, and Marital Adjustment



thank you very much for a very comprehensive and raising few questions that we would be able to discuss about the effects on families I would like to invite dr. Danny Horesh senior lecturer and the head of the trauma and stress research lab at bar-ilan University Department of Psychology is also the head of the head of the child clinical psychology truck program at bar-ilan University dr. harsh as we said before completed his PhD under the supervision of professors I have a solemn own focusing on delayed onset of PTSD among Israeli War veterans following his doctoral studies he received a Rhodes Scholarship and did his postdoctoral training at NYU Department of Psychiatry under the supervision of Professor Charlie Mama dairy study trauma among both military and civilian populations including residents of urban low income areas in the United State dr. Hodge still holds an adjunct faculty Pahlavi position at the NYU where he has several research collaborations currently dr. Hodge and his team are conducting multiple research project in the area of trauma and stress this includes studies of child births related PTSD that we will hear about it today a large study of PTSD and trauma perception among individuals with autism very interesting and several project examining secondary dramatization and trauma narratives his team also conduct randomized clinical trials of mindfulness based intervention for variety strike related conditions so we welcome [Applause] good morning everyone first of all it's a great honor to be here today honoring Sahaba and remembering all those years in the lab these very precious years Ahava has been you have been a great mentor to me you know that and yesterday mean Gaddy were talking in the hall and we were thinking that not only did we learn so much about science and research and life here in the lab but we actually got married during our years not being gaudy but each one of us separately we got married during these years and we had children and we established our families and I think for many of us this was a second home and I think it's no coincidence that people who come to be your students and I still see them here today stay for very very long years it's it really isn't the coincidence it's due to your inviting and generous and warm characters so thank you for these formative years so I will be talking about still birth and pregnancy loss and PTSD today I have to say as a disclaimer this is a secondary geometers Asian symposium my study this study is not a classic secondary to matters Asian study but I think it has a lot of implications for secondary to analyzation as I will try to point out and especially for family coping with charms of the contextual nature of the study I hope will be very apparent so what I was described is a collaboration it's a collaborative study that's been going on for several years between my lab at bar-ilan and Hadassah women's department in Jerusalem and I think since we're going to enter a quite difficult topic an emotionally difficult topic I will try to give you a few examples or a few testimonies from people who have gone through this experience this is a very beautiful book poetry book by an israeli poet named around Bereal it's called the soul of growing pumpkins the entire book is a metaphor about trying to raise this vegetable garden as a metaphor for trying to raise a child or getting birth to a child I think you can see the very direct pain of the father this time not the mother which will connect to my talk so I will not go into every single definition of pregnancy loss and stillbirth I will try to say something maybe a bit more general that will kind of serve as a gateway into my talk mostly referring to the this I think disputed categorization between early pregnancy losses and late pregnancy losses we can use a gestational week or pregnancy week 22 as kind of a benchmark which many medical institutions tend to hang on to divide between early pregnancy losses to late pregnancy losses in stillbirth stole birth is mostly refers to pregnancy loss from week 22 of pregnancy and onwards the definition slightly changed from country to country that would be the average it entails the birth of a dead well either fetus or baby or anyone can choose their own personal subjective ideology the present study will discuss late pregnancy losses and stillbirth as potentially traumatic events and we are dealing with traumas and traumatic events so the details are important and the circumstances of losses can be highly varied they can the loss can be caused from either fetal death or medical termination or numerous other medical complications this means that it may entail a decision by both partners to end the pregnancy or it can occur naturally so the circumstances are multiple it's not it's not a very rare occasion and I think I will try to say something about how rare a trauma is and how and how rare are the studies actually examining it so I said that it's not a secondary to meditation study but I think that if we're going to refer back to sahabas metaphor of the stone and the water then the circles or the cycles of adversity are very very clear in this specific events so these are just some of the cycles but I think it's quite obvious that starting from the individual we have a woman who gave birth in a very very traumatic way usually but not always she may have a spouse there of course affected and as gravity show they think no direction is unidirectional we have bi-directional associations they still live together and their distress may affect one another we obviously have well usually at least in Israel there may be current children or future children so pre or post child birth how are they affected by the distress and the most neglected population in terms of secondary to meditation is the medical staff if you try to look how many studies of midwives have been conducted in this specific circumstance you will find very few and of course if you look at doctors you will find a bit more and you know the hierarchy of trauma which was something that I learned a lot from Sahaba the politics of trauma research so a few shortcomings or I think yeah you can say shortcomings of previous pregnancy loss and stillbirth research almost exclusively were they done in developed in Western english-speaking countries I think the UK is has turned into an empire in childbirth related PTSD and it's kind of paved the way for a lot of us but when you look at developing countries and non-western countries you will find very very few in terms of outcome measures a lot of the studies most of the studies have focused on depression and complicated brief there I think there's something very intuitive about looking into grief and depression and dysphoric disorders in this in this context PTSD has came to the to the forefront I think only in recent years in this respect but really not enough studies especially in the area of dsm-5 and what God has talked about and not surprisingly the vast majority of studies have focused on the mother and even and just asking about the dyad or couples of relationship in in the context of pregnancy loss has been very scarce and again looking at Israel you know unfortunately I think we were such a trauma Empire and an unnatural stress lab but we we certainly know a lot about military the military context of trauma what about the civilian daily day to day traumas I think we know much less about them and then because of all these reasons about five years ago my team and I decided to conduct what is the the first large-scale quantitative Israeli study of psychopathology following pregnancy loss and when I was saying the emphasis is on quantitative because there are great qualitative studies in Israel the samples are naturally smaller the methodologies are different and we wanted to do something that is quantitative and is based on a larger sample so the very general aims first to assess the prevalence of psychopathology using validated measures of PTSD and depression among women who have experienced residency loss and to examine various predictors of psychopathology the ones that have interested us the most were dyadic measures that's why I think I'm in this symposium what happens to the diet that is in the shadow this is not an individual trauma it's mostly a spousal and familial trauma but do we know about that what measures predict psychopathology resilience and vulnerability and also background variables not only socio-demographic but pregnancy related variables the circumstances of the loss the circumstances of the pregnancy when did it occur how did it occur because we believe that in terms of prevention that would be very important so the dear woman here is Malka nucleon she was my partner for this study a very special woman I think you can say she's a true champion for advocates of the pregnancy loss issue in Israel she's been leading support groups in Hadassah for many years she's also a midwife and she kind of got the informal role of taking care of women who have gone through pregnancy loss at Hadassah Hospital which is a huge Hospital in Jerusalem with a highly varied population and she was responsible for this amazing recruitment with also almost no refusals on part of the women it's a very very vulnerable population approaching them and getting them to actually participate could be very very difficult if you don't have someone who really is from the inside and knows the emotional experience so 103 interesting women who experienced pregnancy loss after the first trimester I'm going to say something about that the vast majority of women in this study have gone through very late pregnancy losses it's a very high-risk population there were a few maybe six to eight women who experienced losses at week 17 18 19 we decided to include them post-talk we did some analyses and we saw that actually in terms of outcomes and psychopathology there were no different from women who experienced them very late so it's a late pregnancy loss study but we do have a few women there I'm just saying this method logically I'm used to answering the viewers about this question it's an important question they were recruited through Hadassah and Karin hospitals women's Department so the mean week of pregnancy where they lost the baby was almost 28 but actually when you look at the the sample 42% were week 30 and above about 35 percent were actually weeks 35 to 41 so it's a very a priori very high-risk population highly educated sample since it was Jerusalem it allowed us for a nice distribution of religiosity which turned to be very important for us most of them in a relationship vast majority with children we had a quite a big spectrum of the meantime since the loss we thought real hard about whether we want to restrict or have very very strict exclusion and inclusion criteria and disregard and then we decided that no we want as a first study we want to do something exploratory and actually kind of opened the space for a wide variety of recency effects but still almost half the sample was 6 months or less so pretty fresh dramas for a large proportion of our sample almost 90% experience still birth and deaths of course highly correlated with the fact that they were the vast majority experienced late pregnancy losses and I think an interesting finding for us which we haven't really touched yet or the number of previous losses so the average woman in our sample has already this was already her third loss and this has medical reasons but you know talking about transmission or looking at this a systemic approach to trauma maybe there are also emotional or stress-related reasons the at least the gynecologist we we consulted had no clear reason for this other than the medical reason so this was a self-report measure cross-sectional design we have more measures than are presented here but these are the ones that I will discuss today we administered the pcl5 for PTSD Beck Depression Inventory for depression that they addict adjustment scale which is a scale that I kind of fell in love with working with Ahava in many context the self disclosure index and the post-traumatic growth inventory okay so if I had to say only one thing and then leave I would say something about the next slide because I think that's the most important one at least for me and that's just the rates of psychopathology for once taking validated tools and looking at the breadth of this phenomena of PTSD in pregnancy loss in Israel so here they are we used several cut-offs of the PCL the PCL is the most commonly used self-report measures of PTSD today there is a debate about the adequate cutoff these days when we started I think we also had these conversations we adopted the most conservative cutoff for civilian population which was then 38 and adopting this cutoff we found that one-third of our sample had full-blown PTSD and I think it's kind of interesting to come after Gaddy who showed us the the rates of people coming back from combat or from torture and I think it's not that different if you that so these are very very alarming rates of a very very daily civilian trauma ever since since then is DSS and and the National Center for PTSD have recommended actually using lower cut-offs for civilian populations right now the formal recommendation of the National Center for PTSD is 33 so we tried that and then we into 42 percents of PTSD so this I think should be very very alarming to us where are we not looking and why and I'm sure I won't do that but I should that if I ask anyone in here if he or she knows anyone who have gone through late pregnancy loss or stillbirth there would be a hundred percent yeah everyone who raised their hands and and we're talking about personal acquaintances again when we we play with the criteria according to full dsm-5 criteria which are very very harsh the rates came came down not that they're not alarming but they are still lower and a very large portion of women who had subclinical PTSD the vast majority of them 33 percent but out of them about eighty and ninety percent were actually very very very close to the cutoff so the true rate of distress of PTSD related distress are much higher in this sample going to major depression should come as no surprise so about the same thirty percent of our sample had at least at least moderate depression so moderate to severe major depression and I think Maria you spoke yesterday about comorbidity and I think it's it for me it has always been a major issue in a major point of interest but here I found it again very very alarming so the comorbidity is very high around 50 percent as you presented but then we have this one group one subgroup the women who had severe 100% of them had also full-blown PTSD so that's so we have here we have a group we have we have an identified group of very vulnerable group which we don't feel they know enough about who are these women can we identify them already at the women's Department how can we prevent how can we screen because this would be a very important group to identifying treats to get a feeling of that this is something that one of our participants had said some of them had were kind enough to talk to us and also to express themselves more freely so a lot of guilt a lot of shame a lot of confusion obviously and when we think about PTSD in regards to pregnancy loss we should think or we all know in this room that PTSD feeds off of sensory experiences its feeds off the graphical of the very unique characters of the event kept basics of the event and we should think about pregnancy loss late pregnancy loss and stillbirths as is giving birth there are so many smells and sights and touch and medical staff is all around you and there is a lot to remember the senses have a lot to feed off from sometimes in a very very aching way so looking at the predictors of psychopathology following pregnancy loss we did we were in a few regressions separately for PTSD and for major depression and of the regression we see that younger women who were if we looking for a profile so wing women who were younger at the time of the loss the younger mothers were the most vulnerable the secular mothers as opposed to the ultra-orthodox mothers and again in Jerusalem had the entire spectrum and we know a lot about the associations of the complex association there's been the jia city and PTSD and obviously time since the last and the week of loss okay so the more recent the loss and the more advanced the week of pregnancy the more vulnerable the woman was so here we have somewhat of a profile of a vulnerable woman i have circled whether or not the woman currently has children to show you that it was in no way predicting PTSD or lack of PTSD but it will pop up again somewhere in this study and it will be interesting to see why then and not now and when looking at depression we have well less predictors but similar ones mostly the time since the pregnancy loss in the week of pregnancy loss and a marginally significant effect for religiosity previous pregnancy losses no and of course this is only the final model of the regression we had so many background predictors related to the circumstances of the loss what happened in the room how did the pregnancy go we did not find effects there okay and interestingly and as opposed to some of the other studies so this is what i just said the circumstances of loss played no role the week was again we talked we spoke within ourselves and when we published about the fact that there is something very unique again another thing I learned is that Ava's lab was to treat the time is a very complex entity and I think pregnancy kind of allows us to look at each passing week as something that has a lot of psychological correlates what happens to the woman's expectations what what happens to the expectations when pregnancy reaches when pregnancy reaches week thirty or thirty five or forty one and obviously we don't know that because we haven't asked about that but we have very good reasons to believe that this is what time brought about a lot of expectations something very tangible about the emerging motherhood that is about to happen and then when it's shattered then psychopathology kicks in so not secondary to meditation but where is the potential what do we know about the couple about the father in the shadows or the couples in the shadows so this is another thing another quote from one of our participants talking about the highly different ways of coping that she and her husband adopted after the the loss he felt relieved he didn't understand the grief I was feeling but then you'll also find fathers saying something else feeling that well you know pregnancy loss is a feminine trauma it's an individual feminine trauma that's how the the the medical institution sees it and then what about me did I get any care do I deserve any care there's any one o'clock acknowledge the fact that it it also happened to me or to us there's me and us here so did the Attic adjustment scale has several sub scales very interesting in themselves consensus cohesion satisfaction affectional expression and then here you can find a variety of psychopathology we'll all the PTSD clusters and major depression and what we saw that maybe people had good reason to study the dysphoric aspects of pregnancy loss in previous years there is something that there is a very fuzzy line between PTSD and traumatic grief in this in this experience and maybe that's why the larger correlations and most of the correlations were between major depression and the dyadic aspects so the data the better dyadic adjustment in various sub scales or that protective in the face of major depression and the depressive or dysphoric cluster of PTSD which is negative operations and mood and cognition okay there is an always a depressive undercurrent in this population and this undercurrent is the one that reacts to the predictors we looked at you can also see that when you just look at groups this is the depressed depression groups and what was very interesting to see I don't know for me I used the the Attic adjustment scale in a few of our my studies and I always felt that one sub scale wasn't that interesting that was the consensus one it has a lot of so the scale has a lot of very emotional subscales like expressiveness and cotton and items referring to conflict but I always felt like agreements between couples well it's important but it's something very technical and in every analysis we did and we did a lot more than those we found that the most important aspect the most protected aspect for couples after pregnancy loss was consensus whether or not they can agree on things solve problems seeing eye-to-eye and making shared decisions without arguing and then we kind of thought why are we seeing consensus everywhere this is also the PTSD differences in consensus why are we seeing consensus everywhere and when we talk to some of the women they said you know at least looking for a couples perspective but what hurts the most is the fact that you have to make a lot of decision immediately after the loss and even before the loss so there's a lot of shared decision-making and if that's a problem then it really hurts so much decision-making about medical termination of pregnancy just imagine what happens if it hurts so much and you don't agree there is no support about seeing the dead born child there are a lot of I don't want to be too graphical but there are a lot of micro decisions very very traumatic micro decisions do we look at it the child no you have seen the baby but I haven't what does that mean are we together in that because you have the image and I don't then decisions about burial and Oriol which today are very very it's a hot debate has reached new media do we want to attend the burial or no or not are we going to memorials are we trying to forget together or maybe we've seen couples that one is going and the other is not how do you come home from that going to therapy obviously having another child and how and more generally coping styles and I can I can also tell you from my clinic I sometimes treat women after pregnancy loss that I see this as a major issue the consensus lack of consensus or high consensus and again going back to the issue of comorbidity so I myself and I think that a lot of people in this room have begun to think chance diagnostically in recent years this is the era of our Doc's etc etc and I think that comorbidity is not just one disorder and then the other I think that today we're looking at different psychopathological entities and different ways symptoms can cluster together Thalia can attest to that and others in this room and what was very interesting to see so that if you combine depression PTSD together and then you look at the data current you see that something very different happens for people who have PTSD which are those in green and people who do not have PTSD which are those in blue we try to understand what happens to those who have PTSD and severe depression and why can we see that they addict adjustment or support is high we had various explanation for that some were positive for example saying that when you have a lot of distress it mobilizes couples support or spousal support but another one was more pessimistic saying that we know that emotional support in PTSD is kind of tricky and we know that for some people who are really suffering being over suffocated or being too supported or they sometimes need their space and we also looked at various measures of self-disclosure gada you talked about talking or not talking and is that good or bad so at least in our sample I guess their recommendation would be if you go through the loss and you have feelings of shame and guilt and even positive feelings just just talk talk to your partner we don't know what happens to the partner obviously from being exposed to that but at least some part of the woman talking we assess both disclosure about specifically about the pregnancy loss and general self disclosure about a lot of feelings positive and negative but they all were positively correlated negatively correlated with psychopathology and of course among themselves okay I see I have like two or three minutes so I'll try to wrap it up but but why is talking important Belov course we know the immense feelings of shame and guilt and loneliness that can be alleviated by talking to the partner we also looked at post-traumatic growth I'm not going to say a lot about that because I see I have very little time maybe the next lecture but we did identify post-traumatic growth I will tell one anecdote about that so basically the main measure of growth with life appreciation and it was mostly correlated with PTSD hyper arousal and I think sahaba is you found distress does not exclude growth quite the contrary and they go together for various reasons some of them are kind of provocative as a yeah lab is sitting here she wrote about that but I think that one important that I want to say is that one of the predictors of growth may be the strongest beautiful growth was how many children do you have have you had since the loss so remember the number of children that did not play a role it did roll here but not in PTSD and then we were interviewed to the media and we talked about this finding which we found very optimistic and we got it's the same day we got like 20 phone calls from women in our sample but very very angry raging saying how could you say that having another child is a factor for me for these women having another child was this constant testimony a constant reminder for the loss this was the factor for reactivation had already gone through therapy I came home I thought this was in the past and then I gave birth to a live child a healthy child but this was and it was kind of humbling to see that nothing works on averages okay we know that okay very general discussions pregnancy loss and syllabus are major traumatic events are we doing enough there's a howl that you have taught us to always ask are we doing enough and the answer was always no and I think that that's one of the important things of being supervised by you we're not doing enough we're ignoring a lot both in terms of just trying I get like five males a week asking me about specific protocols for treating pregnancy loss related PTSD don't even try to find nothing validated only very good people trying to suggest things but it's it's it's kind of weird can we intervene and screen early already at the women's Department much more attention to this topic is warranted and again the politics of trauma why are Nina are we not looking it's an unheroic trauma it's a feminine trauma women are expected to go on with their lives and in the Israeli context we have these sayings right pregnancy is not a disease children are a joy which they are Hinault's I always do this how much you are we giving to this discourse in our Naturals just lath trauma empire I don't think we were giving it enough and even less validated intervention in terms of couples couples therapy really treating the dyad looking at it from a contextual perspective very very little what is encouraging is for me at least that ever since this study was first published we've been getting exposure and a lot of very very good and sensitive men and women throughout Israel who have been contacting us offering their help in research in advocacy in funding and it just shows the immense hunger and thirst there is for this issue so many people who are untreated men and women throughout Israel we've been in the Knesset three times already in discussions of legislation I think there's a very big interest and also champions real champions like ELISA Davi was a parliament member in Israel who actually changed in in a very short period of time changed the laws concerning the rights of women not men yet but women after pregnancy loss and a month ago we actually established candles of Hope which is an interdisciplinary foundation for pregnancy loss research treatment and advocacy and hopefully we'll be able to continue our research and clinical work in this field so thank you and thank you sir hava Thank You question the research Danny's been doing please we looked at data from 9/11 among parents of lost children in 9/11 and traumatic grief wolf kind of came out what as as a different entity above and beyond PTSD and depression and and I think this opportunity he was really able to understand a little bit more about the difference between trauma and loss and obviously and losing pregnancy or a child is really more about paying painful loss rather than fear for your life and and and and physical integrity and and and and the question is really what what is the underlying you know basis of the two phenomena in how much they interact so the question that I have is really about whether you looked specifically and for the role of a kind of intrusive symptoms are experiencing versus avoidance it's predicting and depression and and pit using this sample first of all I agree with you I think that again the what's interesting about this population is that the lines that look like kind of blurred lines between all the entities you just said what is what is the painful component in their experience is it the the loss and grief component or something more intrusive and fearful I think both exists from from what I see we I can tell you that the intrusion symptoms were the most dominant in this population but we did not and it's a good idea to kind of see whether or not they're the most predictive for example of depression and and an other distress met and distress measures we can do that that's that's a good idea but they were very present they were very present I think that's because the event itself and that that's maybe one of the decay my plays the the the place I came from looking at PTSD trying to say beyond the loss in its meaning there is also an event the event has very sensory graphical characteristics something should manifest these characteristics themselves and I think that's intrusion but yeah that's that's a good idea thank and they were not collected in that fashion but I totally agree with you I can tell you that this was done in between 2014 and 16 and the studies have been conducting in other contexts since then have always included a qualitative aspect a really like a built-in qualitative aspect even if even if small because I'm not a qualitative researcher per se but I totally agree with you I think that you know Chama is so multi-layered and talking about averages and how they can mislead and I think and I think also you've asked question about grief and PTSD can be enlightened by qualitative work trying to understand that not only by looking at clusters and tried to categorize sub-sites which is very important but how do they talk about the things what kind of words do they use where is the emotional pain located I totally agree with you no argument thank you

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