Cortico-limbic interactions and carotid atherosclerotic burden during chronic stress exposure.

BACKGROUND AND AIMS: Chronic stress associates with cardiovascular disease, but mechanisms remain incompletely defined. Advanced imaging was used to identify stress-related neural imaging phenotypes associated with atherosclerosis. METHODS: Twenty-seven individuals with post-traumatic stress disorder (PTSD), 45 trauma-exposed controls without PTSD, and 22 healthy controls underwent 18F-fluorodeoxyglucose positron emission tomography/magnetic resonance imaging (18F-FDG PET/MRI). Atherosclerotic inflammation and burden were assessed using 18F-FDG PET (as maximal target-to-background ratio, TBR max) and MRI, respectively. Inflammation was assessed using high-sensitivity C-reactive protein (hsCRP) and leucopoietic imaging (18F-FDG PET uptake in spleen and bone marrow). Stress-associated neural network activity (SNA) was assessed on 18F-FDG PET as amygdala relative to ventromedial prefrontal cortex (vmPFC) activity. MRI diffusion tensor imaging assessed the axonal integrity (AI) of the uncinate fasciculus (major white matter tract connecting vmPFC and amygdala). RESULTS: Median age was 37 years old and 54% of participants were female. There were no significant differences in atherosclerotic inflammation between participants with PTSD and controls; adjusted mean difference in TBR max (95% confidence interval) of the aorta 0.020 (-0.098, 0.138), and of the carotids 0.014 (-0.091, 0.119). Participants with PTSD had higher hsCRP, spleen activity, and aorta atherosclerotic burden (normalized wall index). Participants with PTSD also had higher SNA and lower AI. Across the cohort, carotid atherosclerotic burden (standard deviation of wall thickness) associated positively with SNA and negatively with AI independent of Framingham risk score. CONCLUSIONS: In this study of limited size, participants with PTSD did not have higher atherosclerotic inflammation than controls. Notably, impaired cortico-limbic interactions (higher amygdala relative to vmPFC activity or disruption of their intercommunication) associated with carotid atherosclerotic burden. Larger studies are needed to refine these findings.

Preventing posttraumatic stress disorder following childbirth: a systematic review and meta-analysis.

OBJECTIVE: Women can develop posttraumatic stress disorder in response to experienced or perceived traumatic, often medically complicated, childbirth; the prevalence of these events remains high in the United States. Currently, no recommended treatment exists in routine care to prevent or mitigate maternal childbirth-related posttraumatic stress disorder. We conducted a systematic review and meta-analysis of clinical trials that evaluated any therapy to prevent or treat childbirth-related posttraumatic stress disorder. DATA SOURCES: PsycInfo, PsycArticles, PubMed (MEDLINE), ClinicalTrials.gov, CINAHL, ProQuest, Sociological Abstracts, Google Scholar, Embase, Web of Science, ScienceDirect, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched for eligible trials published through September 2023. STUDY ELIGIBILITY CRITERIA: Trials were included if they were interventional, if they evaluated any therapy for childbirth-related posttraumatic stress disorder for the indication of symptoms or before posttraumatic stress disorder onset, and if they were written in English. METHODS: Independent coders extracted the sample characteristics and intervention information of the eligible studies and evaluated the trials using the Downs and Black's quality checklist and Cochrane's method for risk of bias evaluation. Meta-analysis was conducted to evaluate pooled effect sizes of secondary and tertiary prevention trials. RESULTS: A total of 41 studies (32 randomized controlled trials, 9 nonrandomized trials) were reviewed. They evaluated brief psychological therapies including debriefing, trauma-focused therapies (including cognitive behavioral therapy and expressive writing), memory consolidation and reconsolidation blockage, mother-infant-focused therapies, and educational interventions. The trials targeted secondary preventions aimed at buffering childbirth-related posttraumatic stress disorder usually after traumatic childbirth (n=24), tertiary preventions among women with probable childbirth-related posttraumatic stress disorder (n=14), and primary prevention during pregnancy (n=3). A meta-analysis of the combined randomized secondary preventions showed moderate effects in reducing childbirth-related posttraumatic stress disorder symptoms when compared with usual treatment (standardized mean difference, -0.67; 95% confidence interval, -0.92 to -0.42). Single-session therapy within 96 hours of birth was helpful (standardized mean difference, -0.55). Brief, structured, trauma-focused therapies and semi-structured, midwife-led, dialogue-based psychological counseling showed the largest effects (standardized mean difference, -0.95 and -0.91, respectively). Other treatment approaches (eg, the Tetris game, mindfulness, mother-infant-focused treatment) warrant more research. Tertiary preventions produced smaller effects than secondary prevention but are potentially clinically meaningful (standardized mean difference, -0.37; -0.60 to -0.14). Antepartum educational approaches may help, but insufficient empirical evidence exists. CONCLUSION: Brief trauma-focused and non-trauma-focused psychological therapies delivered early in the period following traumatic childbirth offer a critical and feasible opportunity to buffer the symptoms of childbirth-related posttraumatic stress disorder. Future research that integrates diagnostic and biological measures can inform treatment use and the mechanisms at work.

The association of delivery during a war with the risk for postpartum depression, anxiety and impaired maternal-infant bonding, a prospective cohort study.

OBJECTIVE: To examine the impact of war conditions on maternal mental health postpartum outcomes, specifically depression and anxiety, as well as on maternal-infant bonding (MIB). STUDY DESIGN: A prospective cohort study was performed on women who gave birth in a tertiary medical center during (October-November 2023) and before (March-May 2020) the Israel-Hamas War. All participants completed validated self-reported questionnaires: The Edinburgh Postnatal Depression Scale (EPDS ≥ 10), State-Trait Anxiety Inventory (STAI > 39) and the Postpartum Bonding Questionnaire (PBQ ≥ 26). RESULTS: A total of 502 women were included in the study, with 230 delivering during the war and 272 delivered before. The rates of postpartum depression (PPD) were higher in women delivering during the war (26.6% vs. 12.4%, p < 0.001), while multivariable regression revealing a two-fold higher risk (adjusted OR 2.35, 95% CI 1.16-4.74, p = 0.017). The rate of postpartum anxiety (PPA) risk was also higher (34.3% vs 17.0%, p < 0.001), reaching a trend towards significance when accounting for other risk factors (adjusted OR 2.06, 95% CI 0.97-4.36, p = 0.058). Additionally, delivery during the war was associated with specific factors of impaired maternal-infant bonding (MIB), although it did not increase the overall impaired MIB (PBQ ≥ 26) (10.2 ± 14.1 vs 8.3 ± 6.9, p = 0.075). CONCLUSION: The study revealed an increased risk of PPD, a marginally risk for PPA, and some aspects of impaired MIB among women delivering during the war. Maternal mental illness in the postpartum period has negative impacts on the entire family. Therefore, comprehensive screening and adequate resources should be provided for women delivering in war-conflict zones.

Establishing the validity of a diagnostic questionnaire for childbirth-related posttraumatic stress disorder.

BACKGROUND: Labor and delivery can entail complications and severe maternal morbidities that threaten a woman's life or cause her to believe that her life is in danger. Women with these experiences are at risk for developing posttraumatic stress disorder. Postpartum posttraumatic stress disorder, or childbirth-related posttraumatic stress disorder, can become an enduring and debilitating condition. At present, validated tools for a rapid and efficient screen for childbirth-related posttraumatic stress disorder are lacking. OBJECTIVE: We examined the diagnostic validity of the Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, for detecting posttraumatic stress disorder among women who have had a traumatic childbirth. This Checklist assesses the 20 Diagnostic and Statistical Manual of Mental Disorders, posttraumatic stress disorder symptoms and is a commonly used patient-administrated screening instrument. Its diagnostic accuracy for detecting childbirth-related posttraumatic stress disorder is unknown. STUDY DESIGN: The sample included 59 patients who reported a traumatic childbirth experience determined in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, posttraumatic stress disorder criterion A for exposure involving a threat or potential threat to the life of the mother or infant, experienced or perceived, or physical injury. The majority (66%) of the participants were less than 1 year postpartum (for full sample: median, 4.67 months; mean, 1.5 years) and were recruited via the Mass General Brigham's online platform, during the postpartum unit hospitalization or after discharge. Patients were instructed to complete the Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, concerning posttraumatic stress disorder symptoms related to childbirth. Other comorbid conditions (ie, depression and anxiety) were also assessed. They also underwent a clinician interview for posttraumatic stress disorder using the gold-standard Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. A second administration of the checklist was performed in a subgroup (n=43), altogether allowing an assessment of internal consistency, test-retest reliability, and convergent and diagnostic validity of the Checklist. The diagnostic accuracy of the Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, in reference to the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, was determined using the area under the receiver operating characteristic curve; an optimal cutoff score was identified using the Youden's J index. RESULTS: One-third of the sample (35.59%) met the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria for a posttraumatic stress disorder diagnosis stemming from childbirth. The Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, symptom severity score was strongly correlated with the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, total score (ρ=0.82; P<.001). The area under the receiver operating characteristic curve was 0.93 (95% confidence interval, 0.87-0.99), indicating excellent diagnostic performance of the Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. A cutoff value of 28 maximized the sensitivity (0.81) and specificity (0.90) and correctly diagnosed 86% of women. A higher value (32) identified individuals with more severe posttraumatic stress disorder symptoms (specificity, 0.95), but with lower sensitivity (0.62). Checklist scores were also stable over time (intraclass correlation coefficient, 0.73), indicating good test-retest reliability. Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, scores were moderately correlated with the depression and anxiety symptom scores (Edinburgh Postnatal Depression Scale: ρ=0.58; P<.001 and the Brief Symptom Inventory, anxiety subscale: ρ=0.51; P<.001). CONCLUSION: This study demonstrates the validity of the Posttraumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, as a screening tool for posttraumatic stress disorder among women who had a traumatic childbirth experience. The instrument may facilitate screening for childbirth-related posttraumatic stress disorder on a large scale and help identify women who might benefit from further diagnostics and services. Replication of the findings in larger, postpartum samples is needed.

Association of sexual assault history with traumatic childbirth and subsequent PTSD.

Although childbirth-related posttraumatic stress (CB-PTSD) has received recognition, how sexual assault (SA) history influences obstetrical and traumatic stress outcomes remains unclear. Six hundred eighty-three women provided information about their childbirth and mental health. Obstetric complications and unplanned cesareans were more prevalent among women with SA history. They also had higher rates of probable CB-PTSD and were two times more likely to have premature deliveries than women without SA history. Screening women for history of sexual trauma is warranted to optimize birth outcomes.

Maternal psychological growth following childbirth.

Although maternal postpartum mental health has been extensively studied, rather little is known regarding the factors that may facilitate psychological growth following childbirth. The present study set forth to examine various pre-birth, birth, and post-birth correlates of overall psychological growth and growth domains in postpartum women, assessed within the first months following childbirth. A sample of 428 women completed self-report measures pertaining to psychological growth, mental health, maternal attachment, and childbirth characteristics. We found that the majority of women reported psychological growth following childbirth, with those experiencing stressors in childbirth reporting the highest levels of appreciation for life. In regression analyses, postpartum factors were significantly associated with overall growth and growth domains, taking into account other factors. The more the childbirth was perceived as central to the mothers' identity and the better the maternal attachment was to the child, the higher levels of growth. Growth was also negatively related to endorsement of childbirth PTSD. Background factors, such as maternal age, education, and prior mental health, were associated with specific growth domains, although the association was small and there was no association with overall growth. Post-birth factors are important in ensuing psychological growth in the first months following birth. Attention to opportunities of growth following childbirth is warranted in clinical care, in particular following traumatic childbirth.

Peritraumatic dissociation in childbirth-evoked posttraumatic stress and postpartum mental health.

A significant minority of women can suffer from postpartum posttraumatic stress disorder (PP-PTSD) following childbirth, in particular if involving obstetrical complications. While peritraumatic dissociation has been repeatedly shown to play a significant role in coping in the aftermath of trauma, little is known about peritraumatic dissociation in relation to positive adaptation following childbirth or failure thereof. We studied a large sample of 846 women who were on average 3 months postpartum. Participants completed an anonymous survey with psychometric measures pertaining to peritraumatic dissociation, PP-PTSD, postpartum depression, and other psychiatric symptoms. Women who had assisted vaginal deliveries or unscheduled Cesareans reported higher peritraumatic dissociation levels than those who had regular vaginal deliveries or scheduled Cesareans. Peritraumatic dissociation predicted PP-PTSD above and beyond premorbid and other childbirth-related factors. In contrast, we found that when controlling for PP-PTSD symptoms, higher levels of peritraumatic dissociation were associated with lower depression and other psychiatric symptom severity. Childbirth can evoke a dissociative response for some women. Rather than the mere focus on the mode of delivery and premorbid health, our findings highlight the role of the women's immediate emotional response in PP-PTSD. Screening women for dissociative responses immediately following childbirth may offer a tool for identifying women at risk for PP-PTSD. The multifaceted role of peritraumatic dissociation in psychological adaptation as potentially adaptive on the one hand, and maladaptive on the other, warrants future scientific attention.

Beyond postpartum depression: posttraumatic stress-depressive response following childbirth.

Although depression following childbirth is well recognized, much less is known about comorbid postpartum psychiatric conditions. Some women can endorse posttraumatic stress related to the childbirth experience accompanied by symptoms of depression. The objective of our study was to examine the nature of the comorbidity of symptoms of childbirth-related posttraumatic stress disorder (PTSD) and postpartum depression. We studied a sample of 685 women who were on average 3 months following childbirth and collected data about their mental health pertaining to PTSD, depression, general distress, and childbirth experience. The vast majority of women with elevated childbirth-related PTSD symptoms also endorsed elevated postpartum depression symptoms. Factor analysis revealed that symptoms of childbirth-related PTSD and postpartum depression loaded onto one single factor rather than two factors. Stepwise multi-nominal regression analysis revealed that childbirth stressors, including obstetric complications and peritraumatic distress in birth, predicted the likelihood of developing comorbid childbirth-related PTSD and postpartum depression, but not depression alone. The findings suggest that beyond postpartum depression, postpartum women suffer from a posttraumatic stress-depressive response in the wake of a traumatic childbirth experience. Increasing awareness in routine postpartum care about traumatic childbirth and its associated emotional sequela is warranted.

Is childbirth-induced PTSD associated with low maternal attachment?

Few studies examined maternal attachment in childbirth-related postpartum posttraumatic stress disorder (PP-PTSD). We studied 685 postpartum women, assessing for PP-PTSD, non-childbirth PTSD, maternal attachment, pre-birth, birth, and post-birth factors. Attachment was lower in PP-PTSD than in non-childbirth PTSD and no PP-PTSD. Hierarchical regression showed that PP-PTSD predicted less maternal attachment above and beyond pre-birth psychiatric conditions, acute distress in birth, and lack of breastfeeding. Childbirth-induced posttraumatic stress may interfere with the formation of maternal attachment, warranting screening of at-risk women.

Delivery mode is associated with maternal mental health following childbirth.

Childbirth is a life-transforming event often followed by a time of heightened psychological vulnerability in the mother. There is a growing recognition of the importance of obstetrics aspects in maternal well-being with the way of labor potentially influencing psychological adjustment following parturition or failure thereof. Empirical scrutiny on the association between mode of delivery and postpartum well-being remains limited. We studied 685 women who were on average 3 months following childbirth and collected information concerning mode of delivery and pre- and postpartum mental health. Analysis of variance revealed that women who had cesarean section or vaginal instrumental delivery had higher somatization, obsessive compulsive, depression, and anxiety symptom levels than those who had natural or vaginal delivery as well as overall general distress, controlling for premorbid mental health, maternal age, education, primiparity, and medical complication in newborn. Women who underwent unplanned cesarean also had higher levels of childbirth-related PTSD symptoms excluding those with vaginal instrumental. The risk for endorsing psychiatric symptoms reflecting clinically relevant cases increased by twofold following unplanned cesarean and was threefold for probable childbirth-related PTSD. Maternal well-being following childbirth is associated with the experienced mode of delivery. Increasing awareness in routine care of the implications of operative delivery and obstetric interventions in delivery on a woman's mental health is needed. Screening at-risk women could improve the quality of care and prevent enduring symptoms. Research is warranted on the psychological and biological factors implicated in the mode of delivery and their role in postpartum adjustment.

Peripartum Depression, Traditional Culture, and Israeli Society.

Although it is known that culture affects psychopathology, the nature of the relationship between culture and peripartum depression (PPD) is not fully understood. Here we report on 2 cases of Israeli women who are affiliated with traditional cultural groups that emphasize reproduction but developed PPD after childbirth. The first woman is an ultra-Orthodox Israeli Jew and the second is an Israeli Arab. The 2 cases illustrate the effect of cultural beliefs and rituals on the conceptualization, treatment, and trajectory of PPD. The cases suggest a complex relationship between traditional cultures and PPD, including the possibility that cultural factors may have both adaptive and maladaptive consequences. Future qualitative and quantitative studies are needed to further clarify this relationship.

Persistence of collective memory of corporate bankruptcy events discussed on X (Twitter) is influenced by pre-bankruptcy public attention.

Collective attention and memory involving significant events can be quantitatively studied via social media data. Previous studies analyzed user attention to discrete events that do not change post-event, and assume universal public attention patterns. However, dynamic events with ongoing updates are common, yielding varied individual attention patterns. We explore memory of U.S. companies filing Chapter 11 bankruptcy and being mentioned on X (formerly Twitter). Unlike discrete events, Chapter 11 entails ongoing financial changes as the company typically remains operational, influencing post-event attention dynamics. We collected 248,936 X mentions for 74 companies before and after each bankruptcy. Attention surged after bankruptcy, with distinct Low and High persistence levels compared with pre-bankruptcy attention. The two tweeting patterns were modeled using biexponential models, successfully predicting (F1-score: 0.81) post-bankruptcy attention persistence. Studying bankruptcy events on social media reveals diverse attention patterns, demonstrates how pre-bankruptcy attention affects post-bankruptcy recollection, and provides insights into memory of dynamic events.

OpenAI's Narrative Embeddings Can Be Used for Detecting Post-Traumatic Stress Following Childbirth Via Birth Stories.

Free-text analysis using Machine Learning (ML)-based Natural Language Processing (NLP) shows promise for diagnosing psychiatric conditions. Chat Generative Pre-trained Transformer (ChatGPT) has demonstrated preliminary initial feasibility for this purpose; however, whether it can accurately assess mental illness remains to be determined. This study evaluates the effectiveness of ChatGPT and the text-embedding-ada-002 (ADA) model in detecting post-traumatic stress disorder following childbirth (CB-PTSD), a maternal postpartum mental illness affecting millions of women annually, with no standard screening protocol. Using a sample of 1,295 women who gave birth in the last six months and were 18+ years old, recruited through hospital announcements, social media, and professional organizations, we explore ChatGPT's and ADA's potential to screen for CB-PTSD by analyzing maternal childbirth narratives. The PTSD Checklist for DSM-5 (PCL-5; cutoff 31) was used to assess CB-PTSD. By developing an ML model that utilizes numerical vector representation of the ADA model, we identify CB-PTSD via narrative classification. Our model outperformed (F1 score: 0.82) ChatGPT and six previously published large language models (LLMs) trained on mental health or clinical domains data, suggesting that the ADA model can be harnessed to identify CB-PTSD. Our modeling approach could be generalized to assess other mental health disorders.

AI and narrative embeddings detect PTSD following childbirth via birth stories.

Free-text analysis using machine learning (ML)-based natural language processing (NLP) shows promise for diagnosing psychiatric conditions. Chat Generative Pre-trained Transformer (ChatGPT) has demonstrated preliminary initial feasibility for this purpose; however, whether it can accurately assess mental illness remains to be determined. This study evaluates the effectiveness of ChatGPT and the text-embedding-ada-002 (ADA) model in detecting post-traumatic stress disorder following childbirth (CB-PTSD), a maternal postpartum mental illness affecting millions of women annually, with no standard screening protocol. Using a sample of 1295 women who gave birth in the last six months and were 18+ years old, recruited through hospital announcements, social media, and professional organizations, we explore ChatGPT's and ADA's potential to screen for CB-PTSD by analyzing maternal childbirth narratives. The PTSD Checklist for DSM-5 (PCL-5; cutoff 31) was used to assess CB-PTSD. By developing an ML model that utilizes numerical vector representation of the ADA model, we identify CB-PTSD via narrative classification. Our model outperformed (F1 score: 0.81) ChatGPT and six previously published large text-embedding models trained on mental health or clinical domains data, suggesting that the ADA model can be harnessed to identify CB-PTSD. Our modeling approach could be generalized to assess other mental health disorders.

Screening for post-traumatic stress disorder following childbirth using the Peritraumatic Distress Inventory.

BACKGROUND: Post-traumatic stress disorder (PTSD) following traumatic childbirth may undermine maternal and infant health, but screening for maternal childbirth-related PTSD (CB-PTSD) remains lacking. Acute emotional distress in response to a traumatic experience strongly associates with PTSD. The Peritraumatic Distress Inventory (PDI) assesses acute distress in non-postpartum individuals, but its use to classify women likely to endorse CB-PTSD is unknown. METHODS: 3039 women provided information about their mental health and childbirth experience. They completed the PDI regarding their recent childbirth event, and a PTSD symptom screen to determine CB-PTSD. We employed Exploratory Graph Analysis and bootstrapping to reveal the PDI's factorial structure and optimal cutoff value for CB-PTSD classification. RESULTS: Factor analysis revealed two strongly correlated stable factors based on a modified version of the PDI: (1) negative emotions and (2) bodily arousal and threat appraisal. A score of 15+ on the modified PDI produced high sensitivity and specificity: 88 % with a positive CB-PTSD screen in the first postpartum months and 93 % with a negative screen. LIMITATIONS: In this cross-sectional study, the PDI was administered at different timepoints postpartum. Future work should examine the PDI's predictive utility for screening women as closely as possible to the time of childbirth, and establish clinical cutoffs in populations after complicated deliveries. CONCLUSIONS: Brief self-report screening concerning a woman's emotional reactions to childbirth using our modified PDI tool can detect those likely to endorse CB-PTSD in the early postpartum. This may serve as the initial step of managing symptoms to ultimately prevent chronic manifestations.

Is the Holocaust implicated in posttraumatic growth in second-generation Holocaust survivors? A prospective study.

With the growing interest in posttraumatic growth (PTG), and the ongoing debate on the implications of transgenerational transmission of trauma, this longitudinal study examined PTG among Holocaust survivor offspring following their own exposure to trauma. Using self-report questionnaires, we assessed PTG over time in middle aged (age: M = 53 years) Israeli male combat veterans of the 1973 Yom Kippur War whose parents were (n = 43) and were not (n = 156) second-generation survivors of the Nazi Holocaust at 2 time points: 30 and 35 years following the war (in 2003 and 2008). Posttraumatic stress disorder symptoms and trauma exposure were also assessed in 1991. We hypothesized that second-generation survivors would report more PTG than controls. However, repeated measures design revealed that the second-generation veterans reported less PTG than veterans who were not second generation, which was evident in the PTG domains of relations to others, personal strength, and appreciation of life. Our findings suggest that transmission of trauma from one generation to the next is possibly implicated in the offspring's propensity for growth following subsequent trauma. Future research is warranted to examine the link between transmission of trauma and positive outcomes following trauma.

Cortisol and PTSD symptoms among male and female high-exposure 9/11 survivors.

Only a few studies have examined cortisol response to trauma-related stressors in relation to posttraumatic stress disorder (PTSD). We followed a sample of high-exposure survivors of the attacks on September 11, 2001 (9/11; 32 men and 29 women) and examined their cortisol response after recalling the escape from the attack, 7 and 18 months post-9/11. PTSD symptoms and saliva cortisol levels were assessed before and after trauma recollection. Hierarchical regression analyses revealed that PTSD symptoms and male sex predicted increased cortisol response following recollections. For men, elevated cortisol was associated with greater severity of reexperiencing symptoms (p < .001) and lower severity of avoidance symptoms (p < .001). For women, recall-induced cortisol was minimal and unrelated to PTSD symptoms (p = .164 and p = .331, respectively). These findings suggest that augmented cortisol response to trauma-related stressors may be evident in men reporting symptoms of PTSD. Thus, as cortisol abnormalities related to PTSD symptoms appear sex-specific, future research on mechanisms of sex differences in response to trauma is warranted.

A Systematic Review of Interventions for Prevention and Treatment of Post-Traumatic Stress Disorder Following Childbirth.

Objective: Postpartum women can develop post-traumatic stress disorder (PTSD) in response to complicated, traumatic childbirth; prevalence of these events remains high in the U.S. Currently, there is no recommended treatment approach in routine peripartum care for preventing maternal childbirth-related PTSD (CB-PTSD) and lessening its severity. Here, we provide a systematic review of available clinical trials testing interventions for the prevention and indication of CB-PTSD. Data Sources: We conducted a systematic review of PsycInfo, PsycArticles, PubMed (MEDLINE), ClinicalTrials.gov, CINAHL, ProQuest, Sociological Abstracts, Google Scholar, Embase, Web of Science, ScienceDirect, and Scopus through December 2022 to identify clinical trials involving CB-PTSD prevention and treatment. Study Eligibility Criteria: Trials were included if they were interventional, evaluated CB-PTSD preventive strategies or treatments, and reported outcomes assessing CB-PTSD symptoms. Duplicate studies, case reports, protocols, active clinical trials, and studies of CB-PTSD following stillbirth were excluded. Study Appraisal and Synthesis Methods: Two independent coders evaluated trials using a modified Downs and Black methodological quality assessment checklist. Sample characteristics and related intervention information were extracted via an Excel-based form. Results: A total of 33 studies, including 25 randomized controlled trials (RCTs) and 8 non-RCTs, were included. Trial quality ranged from Poor to Excellent. Trials tested psychological therapies most often delivered as secondary prevention against CB-PTSD onset (n=21); some examined primary (n=3) and tertiary (n=9) therapies. Positive treatment effects were found for early interventions employing conventional trauma-focused therapies, psychological counseling, and mother-infant dyadic focused strategies. Therapies' utility to aid women with severe acute traumatic stress symptoms or reduce incidence of CB-PTSD diagnosis is unclear, as is whether they are effective as tertiary intervention. Educational birth plan-focused interventions during pregnancy may improve maternal health outcomes, but studies remain scarce. Conclusions: An array of early psychological therapies delivered in response to traumatic childbirth, rather than universally, in the first postpartum days and weeks, may potentially buffer CB-PTSD development. Rather than one treatment being suitable for all, effective therapy should consider individual-specific factors. As additional RCTs generate critical information and guide recommendations for first-line preventive treatments for CB-PTSD, the psychiatric consequences associated with traumatic childbirth could be lessened.