Sunday, February 14, 2010

Non-Drug Treatments for Trauma Symptoms and PTSD

Traumatic events are relatively common in the lives of women. According to the U.S. National Center for PTSD, 51% of American women have been exposed to at least one trauma-producing event in their lifetimes, and 6% have been exposed to four or more. Fortunately, exposure to traumatic events does not automatically lead to a diagnosis of PTSD (American Psychiatric Association, 2004).


But women are twice as likely as men to meet full diagnostic criteria (10.4% of women vs. 5% of men). And even when they don’t, up to one third can have symptoms of trauma that impair their physical and mental health (Kendall-Tackett, 2005).

The National Center for PTSD lists the most common traumatic experiences for women as rape, sexual molestation, physical attack, being threatened with a weapon, and childhood physical abuse (www.ncptsd.va.gov). Trauma in the perinatal period can also be caused by previous pregnancy loss, preterm birth, neonatal death, or a frightening or life-threatening birth experience (Kendall-Tackett, 2005; 2010).

Diagnostic Criteria for PTSD

Screening questions can indicate whether patients have experienced traumatic events. However, a formal diagnosis of PTSD is more exacting. According to Diagnostic and Statistical Manual IV TR Criteria (American Psychiatric Association, 2000), and the American Psychiatric Association’s Practice Guidelines for PTSD (2004), a diagnosis of PTSD requires a discernible traumatic event, one that victims perceive as life-threatening for themselves or a loved one. The victim must have responded with fear, helplessness or horror. In addition, there must be symptoms in each of three clusters: 1) Re-experiencing, 2) Avoidance/numbing, and 3) Hyperarousal.

Re-experiencing includes frequent intrusive thoughts of the event via nightmares or repetitive daytime thoughts. Avoidance includes numbing, avoiding situations that remind them of the traumatic event, and even amnesia about all or part of the event. Hyperarousal includes persistent jumpiness, sleep disturbances, poor concentration, and chronic activation of the sympathetic nervous system. Depression, another manifestation of chronic hyperarousal, is a common co-occurring symptom that must be addressed as well.

Non-Drug Treatments for PTSD and Trauma Symptoms

Comprehensive trauma treatment involves a wide range of activities including patient education, peer support, and trauma-focused psychotherapy. There are also medications that can be added to the treatment regimen. While medications are useful adjuncts, they are not the primary treatments for PTSD and will be described in a future post.

Psychoeducation and Peer Counseling

The role of both psychoeducation and peer counseling is to help clients understand their experiences and their reactions in the wake of traumatic events. Clients are given information on how to avoid secondary exposure to the event, how to reduce stress responses, and where to go if they need ongoing support. By understanding that their reactions are predictable after traumatic events, clients are less likely to blame themselves and are more likely to comply with treatment.

Trauma-focused Psychotherapy

The two most effective therapies for PTSD and trauma symptoms are cognitive behavioral therapy and EMDR. As non-drug treatments, they are both safe for pregnancy and breastfeeding.

Cognitive-Behavioral Therapy. The focus of cognitive therapy, in general, is to help clients identify faulty ways of thinking that increase the risk of depression, and challenging those beliefs with more accurate cognitions. In trauma treatment, this same approach targets distortions in clients’ threat appraisal processes, and helps to desensitize them to trauma-related triggers (i.e., events that remind them of the traumatic event; American Psychiatric Association, 2004). CBT is a highly effective approach and variants to this approach include exposure therapy and stress-inoculation training (Friedman, 2001; Kendall-Tackett, 2003).

Eye Movement Desensitization and Reprocessing (EMDR). In EMDR the client is instructed to focus on the image, negative thought, and body sensations while simultaneously moving his/her eyes back and forth following the therapist's fingers as they briefly move across his/her field of vision. Eye movements are the most commonly used external stimulus. But therapists often use auditory tones, tapping, or other types of tactile stimulation. Clients can simply think about their traumatic experiences, rather than having to verbalize them. This technique has proven highly effective in reducing symptoms after a few sessions, and has been approved by the American Psychiatric Association and the U.S. Veterans Administration for treating PTSD. Certified practitioners of EMDR are available in many parts of the world. An international list of practitioners can be found at the EMDR Institute (www.emdr.com) or the EMDR International Association (www.emdria.com).

Summary

Trauma symptoms and PTSD are quite treatable. There are  a wide array of treatment options available. Non-drug modalities are frontline treatments for PTSD, and these are both safe and effective. For more information, go to http://www.apatraumadivision.org/.
References

American Psychiatric Association. (2000) Diagnostic and statistical manual of mental disorders, 4th Ed., Text Revision. Washington DC: Author.

American Psychiatric Association. (2004). Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Washington, DC: Author.
Friedman, M.J. (2001). Posttraumatic stress disorder: The latest assessment and treatment strategies. Kansas City, MO: Compact Clinicals.
Kendall-Tackett, K.A. (2003). Treating the lifetime health effects of childhood victimization. Kingston, NJ: Civic Research Institute.
Kendall-Tackett, K.A. (2005). Handbook of women, stress and trauma. New York: Taylor & Francis.
Kendall-Tackett, K.A. (2010). Depression in new mothers: Causes, consequences and treatment options, 2nd Edition. London: Routledge.
National Institute for Clinical Excellence. (2005). Posttraumatic stress disorder: The management of PTSD in adults and children in primary and secondary care. London: Author (available at www.nice.org.uk).

Friday, February 5, 2010

Depression in New Mothers at OneTrueMedia.com

I created this short video to provide information about the causes and treatments for depression in new mothers. Please let me know what you think.

Thursday, February 4, 2010

Women Speak Out about Trauma Caused by their Births

I posted this powerful slide show on my Facebook page and received an outpouring of response. If your birth experience was frightening, disappointing, or caused you to experience any lingering psychological distress, you may find this validating and healing.

Birth Trauma

Wednesday, February 3, 2010

Why Breastfeeding Lowers Women's Cardiovascular Risk


Heart disease is the number one killer of women in the world. But you may be surprised to learn what women can do to lower their risk.

An intriguing new study will be published this month in Diabetes. It was a study of 704 women who were enrolled during their first pregnancy and followed for 20 years. At the end of the study period, they noted that women who had breastfed for at least nine months had a 56% reduction in developing metabolic syndrome during the study period. Metabolic syndrome is the precursor syndrome to Type 2 diabetes and includes a cluster of symptoms such as insulin resistance, high LDL and VLDL cholesterol, high triglycerides, high BMI, and visceral obesity.

Along these same lines, a paper published last year in Obstetrics & Gynecology found that post-menopausal women (average age of 60) who had breastfed had significantly lower rates of heart disease, hyperlipidemia, high LDL cholesterol, and a host of other cardiovascular risk factors. Since cardiovascular disease is the number killer of women worldwide, these studies are of interest. But why would breastfeeding lower women's risk of heart disease?
To a health psychologist, these findings make perfect sense. And it all has to do with understanding the human stress response. Allow me to illustrate by describing what happens when this stress response is chronically activated.

In the Dunedin Multidisciplinary Health and Development, a birth cohort from Dunedin, New Zealand of 1,037 participants was followed for 32 years. During the first 10 years of the study, the children were assessed for three types of adverse childhood experiences: socioeconomic disadvantage, maltreatment and social isolation. These experiences, particularly if chronic, can permanently upregulate the stress response, increasing the risk for disease. As predicted, when study participants were 32 years old, researchers found that those who experienced adverse childhood experiences had higher rates of major depression, high levels of systemic inflammation, and higher rates of having at least 3 metabolic risk markers (Archives of Pediatric & Adolescent Medicine). Each of these factors increases the risk for both cardiovascular disease and diabetes.

So back to our original question: How does breastfeeding lower women’s risk metabolic and cardiovascular disease? The Dunedin study demonstrates that an upregulated stress response increases the risk for CV and metabolic disease. But what does breastfeeding do? Several studies conducted with mothers of infants have shown that breastfeeding downregulates stress in both mothers and babies. In fact, after breastfeeding, women are less stress-responsive in laboratory settings, meaning that when researchers try to stress them in the half hour or so after having their babies at the breast, the mothers show less of a stress response. That’s the short-term effect of breastfeeding.

The results of the recent studies on cardiovascular disease and metabolic syndrome suggest that breastfeeding has a far longer-term stress-lowering effect than anyone suspected. And this is a great news indeed.











Kathleen Kendall-Tackett, Ph.D., IBCLC is a health psychologist, board-certified lactation consultant, and clinical associate professor of pediatrics at Texas Tech University School of Medicine. Her Web site is UppityScienceChick.com.

Sunday, January 31, 2010

Deconstructing Gerber: Why Industry Should Not be Giving Health Advice

I was recently interviewed by a reporter from WebMD. She was knowledgeable and pleasant to talk with, and wrote a nice article about a new research study on how the SSRI-class of antidepressants influenced a breastfeeding woman’s milk supply. Since only 8 women in the study were actually taking the medication, the findings were not something that particularly worried me. And the resulting article was well-written and reflected that.

Imagine my surprise when I actually received the link to the article and found a slide-show imbedded right in the middle. It was entitled “Breastfeeding Hints and Hurdles.” I thought “what a good idea. I’ll take a look.” What I found was an attractive slide show, with some accurate information. The problem was that there was enough inaccurate information to cause breastfeeding failure. And on the very last page, just in case failure occurred, there was an ad for formula. Did I mention that the slide was funded by Gerber? (I posted the entire slide show on my previous post.)

In recent years, there has been a move throughout the health care industry to free health care from relationships with commercial companies. It is an idea I have always supported. But it is sometimes challenging for health care centers to implement having become accustomed to everything from free pens to continuing education to hospital equipment. But the Gerber slideshow is a great example of why these policies must be implemented. It does not make sense for a company to provide health information, in this case breastfeeding advice, when it is in their economic interest for breastfeeding to fail. It’s a bit like cigarette companies funding anti-smoking campaigns.


Let me show you what I mean. The photographs are copyrighted, so I can’t show them here. But I will do my best to describe them. Because of limited space, I can only share a couple. But you can read the analysis of all of the slides on my Web site.

Soothing Sore Nipples
(Picture of a rolled white terrycloth towel)
To soothe sore nipples, use warm moist compresses, rub a bit of fresh breast milk on your nipples and then let it dry, or dab on a bit of lanolin made for breastfeeding. A little pain and tenderness is normal at first. Pain usually goes away once you find a good breastfeeding position and baby latches on comfortably. Be sure to see your doctor if soreness increases or lasts several weeks.

Here's My Take
Warm compresses for sore nipples? Really? Lanolin is OK, as long as there's not an infection and the reason for soreness is addressed. But here’s where it gets bad. First, nipple pain as normal. At least they only said “a little.” But “be sure to see you doctor if soreness increases or lasts several weeks.[emphasis added] How many mothers would still be breastfeeding?

Ready for another one?

How Often Do Babies Nurse?
Photo of a jaundiced breastfeeding baby


Newborns should nurse every two to three hours, according to the American Academy of Pediatrics. That’s eight to 12 times in 24 hours.
Baby may feed from both breasts during one nursing session. And you can switch from side to side to avoid exhaustion. Baby is full when sucking has slowed or he turns away. After the first month, feedings may start decreasing to seven to nine times a day.

Here's My Take
OK, they’ve got the 8-12 times/day right. But every 2-3 hours? What about when babies cluster feed, such as in the evening?

Switch from side to side to “avoid exhaustion”? Whose exhaustion and how does that help avoid it?
“Baby is full when sucking has slowed”? Is that true for the jaundiced baby in the photo or is he simply falling asleep because he is jaundiced?
And decreasing feedings to 7-9 times a day after the first month? Says who? What if a mother has a small storage capacity and her baby needs to be fed more often? Unfortunately, mothers who follow this advice wonder why their supply has suddenly dropped. Good thing there is a coupon for formula!

At the end of this slide show purportedly about breastfeeding is an ad with coupons for Gerber infant formula, information on bottle-feeding, and link so readers can forward this “health information” to others. To me, the tactics of the formula companies are nothing new. Lactation consultants encounter them all the time.

But I’ll tell what I did find concerning: finding this slide show on WebMD. Consumers come to this site expecting to see evidence-based, impartial information--and this is anything but. True, they did clearly post that this was slide show was funded by Gerber. But new parents, the very ones most susceptible to this campaign of misinformation, may not realize the significance of that, and may take as gospel the advice that may very well derail their efforts to breastfeed their babies. And that, to me, is the real shame.

Saturday, January 30, 2010

Breastfeeding Hints

Breastfeeding Hints

Sunday, January 24, 2010

Why Would Breastfed Children Be Less Depressed?

I had an interesting call this week from a reporter. A new study is being released showing that children who were breastfed for 6 months or longer were significantly less likely be depressed several years later. Did I have any ideas about why they might have found that?

Actually, I did. It all comes back to the human stress response.

We know from a number of different studies that women who breastfeed past six months are doing a lot of things differently than women who stop in the first few weeks. For example, women who are still breastfeeding at six months are more likely to sleep near their babies, increasing the ease of nighttime breastfeeding while also sustaining their milk supply. These mothers are more likely to practice babywearing, or carrying their babies on their bodies rather than in a carseat or stroller. Finally, they are more likely to breastfeed their babies on cue rather than according to a schedule.

It's this total constellation of behaviors that sustains breastfeeding past the first few days and weeks, and I believe it accounts for the lower rates of depression among breastfed children. This pattern of behavior increases mothers' responsiveness to their babies, which lowers babies' stress levels. That is the key to understanding their lower risk.

When babies are ignored, or left to cry it out, their stress levels rise. If this only happens from time to time, babies adapt. But when this pattern becomes the norm, it has a fundamental effect on babies' developing brains. When their brains are bathed in stress hormones on a regular basis, they become more vulnerable to stress. Further, their bodies become hyper-responsive to stressful stimuli. That increases their vulnerability to depression not only in childhood, but throughout their lives.

By breastfeeding, and parenting in a responsive way, mothers are ensuring that their babies are not chronically stressed--and that shows up years later as decreased rates of depression and myriad other health problems.

Can a non-breastfeeding mother get the same effect? Yes, of course. But she will consciously need to be responsive to her baby's cues. From a practical standpoint, the beauty of breastfeeding is that this responsiveness is built into the system.

I think the takeaway message from this study is that responsive parenting does make a difference in how children fare throughout their lives. So it's something important for parents to consider next time someone advises them to let their babies cry it out.

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