Post-traumatic stress disorder after childbirth
After childbirth, post-traumatic stress disorder (PTSD, a lasting stress illness that can follow a frightening event) is recognised above all by unwanted memories that replay the birth.
Remember
Memories and nightmares that keep replaying the traumatic birth, and that persist, are what separate PTSD from a transient stress reaction.
Memory aid
PTSD is the past replaying in the present
Use it to recall that the memories of the traumatic birth keep replaying as if they were happening now.
PTSD can follow a frightening or life-threatening event, and a difficult birth is a recognised trigger.
Doctors sort the symptoms into three linked groups, or four when negative changes in mood and thinking are included. Intrusions, also called re-experiencing, are unwanted memories, flashbacks and nightmares that replay the event. A flashback is the feeling that the event is happening again. Avoidance means keeping away from reminders, such as talking about the delivery. Negative changes in mood and thinking form another group. The last is heightened arousal: being constantly on guard, irritable or sleeping badly.
Time matters. PTSD needs symptoms lasting at least a month, while symptoms between three days and one month after the trauma fit acute stress disorder (a short-lived stress reaction). The baby blues, the very common tearfulness after birth, usually settle within about 14 days.
Postnatal depression, which is common after birth, is mainly low mood. Puerperal psychosis, a rare psychiatric emergency that develops within about four weeks of birth, can involve mania (elevated mood) and delusions (fixed false beliefs). Panic attacks are sudden surges of fear with a racing heartbeat. Re-experiencing ties the symptoms to the traumatic birth, which distinguishes PTSD from depression, psychosis and panic attacks.
A leading explanation is fear conditioning, which is learning by association. During the birth, intense fear became tied to cues such as the sights, sounds and sensations of the delivery. Meeting those cues again in safety normally makes the fear fade, a process called fear extinction. Extinction is learning that the cue no longer predicts danger. In PTSD, extinction is thought to be deficient, so reminders keep triggering the fear response. Laboratory evidence for this extinction deficit is mixed.
Key facts
- Trigger
- a difficult or frightening birth can be the traumatic event.
- Symptom groups
- intrusions, avoidance and heightened arousal, plus negative changes in mood and thinking when four groups are counted.
- Timing
- symptoms may begin straight after the birth or months later, and they persist, unlike the baby blues.
- Baby blues
- mild tearfulness that usually clears within about 2 weeks.
- Mechanism
- a leading model is a fear response learned during the trauma (conditioning) that fails to fade (impaired extinction), although laboratory findings on extinction in PTSD are mixed.
Exam traps
- Fears of harming a baby that are relieved by repeated checking rituals suggest obsessive-compulsive disorder rather than PTSD, because they are fears of future harm, not memories that re-enact a traumatic delivery.
- Unexpected attacks of intense fear followed by worry about further attacks suggest panic disorder, not PTSD, because they do not establish re-experiencing of the traumatic birth.
- Low mood and loss of enjoyment that build over months, with no trauma reminders, describe postnatal depression, not PTSD. PTSD can include low mood, but the intrusive re-experiencing of the traumatic birth is what points to PTSD rather than depression.
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