Julia Seng, PhD, CNM, FAAN Kristen Choi, RN, BSN University of Michigan Ann Arbor, Michigan, USA

1. PERITRAUMATIC DISSOCIATION IN LABOUR:
IS ITA SENTINEL SIGNAL OF MOTHERS AT RISK FOR
IMPAIRED PARENTING AND A NEW OPPORTUNITY FOR
PREVENTIVE INTERVENTION?
Julia Seng, PhD, CNM, FAAN
Kristen Choi, RN, BSN
University of Michigan,
Ann Arbor, Michigan, USA

2. A research question from clinical practice
• Nurse-midwife
• Working with very young and traumatized clients
• Women and girls would “go inside themselves” during the
most intense time of labour
• Some felt to me to be experiencing well-being (meditative)
• Others felt “absent” or “unreachable”
• This was in the 1990’s, when PTSD among women was
not yet well studied, dissociation was not broadly
recognized as an aspect of PTSD, and maternity care
providers did not have a way to “name” what we
observed.
• So…a program of research unfolded.

3. Dissociation is gaining attention
Defined as “…a disruption in the usually integrated
functions of consciousness, memory, identity, or perception
of the environment.”
DSM-5 Dissociative Subtype of PTSD includes
“substantial depersonalization or derealization.”
WHO epidemiology (n=25,000, 16 nations) indicates
approximately ~14% of PTSD cases fit the subtype.
Not broken down by nature or age of trauma.
(A not entirely satisfying nod to Complex PTSD, DESNOS, and
Developmental Trauma Disorder)

4. Dissociation and parenting concerns
• Manifestation of trauma to the attachment system
• Originally an “escape when there is no escape”
• Subsequently a dysregulation in response to triggers or
overwhelm (or no escape/feeling trapped?)
• Labour?
• Crying infant?
• Risk for maltreatment? (Loss of integration of cognition,
perception of the environment, judgment, emotion—at a
physiologic level)
• “Ghosts” in the nursery?
• Dissociation as a marker of maternal “unresolved trauma”?
• Is dissociation “invisible” to birth attendants?

5. Part of an intergenerational pattern?
• Associated with impaired parenting
• Risk factor for child maltreatment and sequelae
• disorganized infant attachment
• developmental deficits
• Daisy N, Hien D. The role of dissociation in the cycle of violence. J
Fam Violence, 2014;29(2):99-107.
• Hulette A, Kaehler L, Freyd J. Intergenerational Associations Between
Trauma and Dissociation. J Fam Violence, 2011;26(3):217-225.
• Liotti G. Trauma, dissociation, and disorganized attachment: Three
strands of a single braid. Psychotherapy: Theory, Research, Practice,
Training, 2004;41(4):472-486.

6. Body and mind dysregulated
3 pillars of adaptation to maltreatment (per Teicher)
• HPA axis, catecholamines, oxytocin
Afternoon cortisol across
gestation and postpartum

7. Qualitative data about labour
Sonya: “…kind of glazed over and drugged is the way it felt.”
Julie: “I was probably being ‘out of it’.”
Elizabeth: “…you know, you may not be dealing with
someone who's acting as an adult here. There is stuff getting
triggered…”
Terry: “…I can only remember [labour] up to a point, and then
it just all goes away…And I picked that up from, you know,
when my brother used to molest me…I would just close my
eyes real tight and just imagine my spirit being lifted up out of
my body and sitting on the bed until he was done. Then I
would come back into myself. [And in labour] what happened
was I just blocked myself out.
Seng, Kane Low, Sparbel & Killion, Journal of
Advanced Nursing, 2004

8. The STACY Project: Stress, Trauma,
Anxiety, and the Childbearing Year
 US NIH R01 NR-008767 “Psychobiology of PTSD & Adverse
Outcomes of Childbearing”—STACY Project
 Not a post-disaster study. Community sample, observing
usual care at three different settings to have adequate sample
size for complex models.
 Julia Seng, PhD, CNM (PI)
 Lisa Kane Low, PhD, CNM (Detroit sites, labor details)
 David Ronis, PhD (statistician)
 Israel Liberzon, MD, (neuroendocrinology)
 Mickey Sperlich, PhD, MSW, CPM (infant mental health, social work, midwifery)
 OB nurses in three sites
 Numerous RAs
 What are the effects of PTSD on childbearing outcomes?

9. Settings
UM, Ann Arbor:
90% European American
90% insured
Detroit Medical Center
(Hutzel Hospital):
90% African-American
10% insured
Henry Ford Health System
(New Center One):
30% African-American
30% insured
All are nulliparas
27 is mean age
71% partnered
Diverse in race/ethnicity
Range of education

10. Data Collection:
Screen & assign
to cohort
•Un-exposed controls
•Trauma+ controls
•PTSD+ cases
34% dismissed due to
not fitting a cohort
UNSELECTED
Survey 1
Initiating care
Diurnal
salivary
cortisol
by mail
50% return
Next
week
Survey 2
~35 wks
Survey 3
~6 wks pp
After EDD Later
Third
trimester
items,
including
interim
trauma
and PTSD
Medical
records
review:
•Usual
•OI-US
•ICD-9
Postpartum
outcomes:
•Labor appraisal
•Perception care
•Parenting Sense
of competence
•PDEQ
•pp PTSD
•pp Depression
•Bonding
DNA
for
SNPs
n=1,581 total,
n=1,049 followed
n=425n=576 n=645 n=981 n=564

11. Results:
PTSD prevalence 8%
3% in Ann Arbor
14% in Detroit
Biggest risk
factors:
Childhood
maltreatment
12-fold risk

12. Results:
Infants of PTSD-affected women
weigh 283 grams less than resilient
women’s infants.
The relationship of PTSD with
adverse outcomes is stronger for
women with PTSD subsequent
to maltreatment.
Now replicated by Yonkers et al, 2014
and Shaw et al, 2014.

13. Results:
STACY Project
statistical
models support
intergenerational
patterns of trauma
and psychiatric
vulnerability
intersecting in the
childbearing year.

14. Peritraumatic Dissociation Experiences
Questionnaire (PDEQ)
• In other trauma studies, peritraumatic dissociation is a
consistent predictor of PTSD onset (gunshot, stabbing,
accident)
• PDEQ is the most widely used measure (10 items)
• Has been used in 3 other studies of labour
• Would the PDEQ be a useful measure for predicting
vulnerability to parenting difficulties based on
dissociative response to the stress / overwhelm of
labour? (akin to a natural provocation experiment)

15. PDEQ
• 10 items
• Not at all true = 1
• Extremely true = 5
• 10-50
• Derealization = #4
• Depersonalization = #5
Wording
1….spaced out
2….auto-pilot
3….slow motion
4….seemed unreal*
5….outside of body*
6….body distorted
7….happening to others
8….not aware
9….confused
10….disoriented

16. PDEQ
Is some extent of
dissociation
normal in labor?
No.
Mean = 14 (sd 5)
Median = 12
Mode = 10 (not
even one
symptom)

17. Study Predictors of Dissociation in Labour
Zambaldi, Cantilino,
Farias, Moraes, &
Botelho Sougey (2011)
 Previous trauma
 Traumatic childbirth
 Unemployment, age
Lev-Wiesel & Daphna-
Tekoah (2010)
 CSA
 Prenatal PTSD symptoms
 Depression
 Dissociation (DES score)
Boudou, Sejourne, &
Chabrol (2007)
 Primiparity
 Prolonged labor
 Poor interaction with obstetric team
 Dysphoric emotion
Previous predictors of dissociation in
labour

18. Prospective model
Childhood
Maltreatment
History
Lifetime PTSD
Prenatal
Parenting
Sense of
Competence
Peritraumatic
Dissociation in
Labour
Postnatal
PTSD (and
depression)
Postnatal
Parenting
Sense of
Competence Impaired
Bonding

19. Does PDEQ predict impaired bonding?
Step 1: R2=1.5%
Childhood Maltreatment .123 .007
Step 2: R2=3.1%
Childhood Maltreatment .071 .142
Lifetime PTSD Diagnosis .138 .004
Step 3: R2=9.8%
Childhood Maltreatment .052 .270
Lifetime PTSD Diagnosis .119 .011
Prenatal Parenting Competence - .260 <.001
Step 4: R2=16.0% (c/s, nicu n.s.)
Childhood Maltreatment .035 .442
Lifetime PTSD Diagnosis .066 .150
Prenatal Parenting Competence -.245 <.001
PDEQ-Labour Dissociation Score .257 <.001

20. Model continued
Step 5: R2=19.6%
Childhood Maltreatment .019 .672
Lifetime PTSD Diagnosis .038 .407
Prenatal Parenting Competence -.225 <.001
PDEQ-Labour Dissociation Score .222 <.001
Postnatal PTSD Diagnosis .200 <.001
Step 6: R2=23.1%
Childhood Maltreatment .023 .594
Lifetime PTSD Diagnosis .010 .828
Prenatal Parenting Competence -.219 <.001
PDEQ-Labour Dissociation Score .163 <.001
Postnatal PTSD Diagnosis .123 .007
Postnatal Depression Diagnosis .222 <.001

21. Final model
Step 7: R2=38.1%
Childhood Maltreatment -.016 .691
Lifetime PTSD Diagnosis .014 .721
Prenatal Parenting Competence -.093 .015
PDEQ-Labour Dissociation Score .119 .003
Postnatal PTSD Diagnosis .089 .030
Postnatal Depression Diagnosis .157 <.001
Postnatal Parenting Competence -.430 <.001

22. Implications for research
• Replication of link of peritraumatic dissociation in labour with adverse
parenting outcomes.
• Clarifying overlap of dissociation, dissatisfaction with care, and
naming the birth as traumatic—which factor used depends on the
researchers’ agenda.
• Specific focus on at-risk and clinical samples—specialist midwives.
• Specific focus on dissociation in response to the triggers of infant
crying or young child’s challenging behavior.
• Intervention development and testing.
• NAMING it as a concern.
• Adapting existing programs to address it with education and skills.
• Trauma treatment to reduce response to trigger (i.e., PE, EMDR).
• Supportive care and attention for these mothers to prevent need for
dissociative coping: Self-care? Child care? Infant massage?
• Understanding of physiology of dissociation may add weight to our
awareness, especially across professions.

23. Implications for practice
• For women with CMT-PTSD, is labour a “stress test” for
parenting difficulties and continuity of vulnerability?
• Child welfare and mental health professionals can play a
key role here.
• Discuss dissociation as a sentinel signal for parenting difficulties.
• Case consults for midwives and obstetricians during learning curve.
• Give them the vocabulary to “see” dissociation in labour.
• Give them strategies to respond to dissociation in labour.
• Be available to visit women in the postnatal days to teach
• strategies to stay grounded,
• settling the infant, and
• getting help if crying is a trigger.

24. Thank you.
jseng@umich.edu