Evidence-Based Reviews

Posttraumatic stress disorder: How to meet women’s specific needs

Current Psychiatry. 2003 March;2(3):25-39

References

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Some human studies suggest gender differences in PTSD-related neurophysiologic changes. For example, activation of both the sympathetic and adrenocortical systems (epinephrine and cortisol) has been seen in women with PTSD from childhood sexual abuse, whereas activation of only the sympathetic system (epinephrine but not cortisol) has been seen in men with combat-related PTSD.¹³ Research with improved methodology is investigating whether sex hormones modulate human response to trauma.

Gender role differences. Because of cultural expectations, women may more easily acknowledge and report distress and feelings of being traumatized.¹⁴ This behavioral difference may contribute to higher PTSD prevalence rates in women than in men. Women also may develop more negative beliefs in response to some types of trauma, such as nonsexual assault by a stranger.³

Treating PTSD in women

Drug therapy. Antidepressants—including tricyclics, monoamine oxidase inhibitors, and selective serotonin reuptake inhibitors (SSRIs)—have shown efficacy in treating PTSD. Some studies have found that women respond more robustly to SSRI antidepressants than men.¹⁵

Cognitive-behavioral therapy. Trauma victims tend to avoid reminders of the trauma. Although this coping strategy can provide short-term relief, it can also constrict a person’s life and preclude opportunities to correct distorted information. For example, a person may attribute danger to benign stimuli that were coincidentally associated with the trauma, such as fearing all men with mustaches after being raped by a man with a mustache.³

Table 2

MALADAPTIVE REACTIONS DURING LABOR AND DELIVERY

Reaction type	Description
Fighting	Tenses muscles when told to relax Misdirects pushing energy to upper part of body
Regression	Assumes a fetal position Hides under the covers Speaks in a childlike voice
Dissociation	Disoriented to time and place Relives abuse
Over-control	Brings detailed lists of exactly how the labor and delivery should go Becomes enraged or panicky when something about the plan has to change

Cognitive-behavioral therapy (CBT) for PTSD aims to activate and correct information by prolonged exposure to traumatic stimuli and to restructure incorrect cognitions. CBT approaches to PTSD include exposure therapy, cognitive therapy, cognitive processing, stress inoculation training, assertiveness training, systematic desensitization, biofeedback, and relaxation training. Of these, exposure therapy has been studied the most systematically and found to work especially well for female rape victims.¹⁶ Exposure therapy consists of confronting feared stimuli—such as returning to the scene of a rape or recalling detailed memories of childhood sexual abuse—until anxiety diminishes.

Psychodynamic therapy aims to re-engage normal adaptive mechanisms by introducing the unconscious into consciousness in tolerable doses.¹⁷ Therapy serves as a means of processing traumatic events, such as childhood sexual abuse, and exploring the psychological meanings of traumas.¹⁸ Few well-controlled studies have examined psychodynamic therapy in PTSD, in part because of the difficulty in operationally defining and assessing mechanisms of change. However, at least one relatively controlled study found reduced avoidance symptoms with psychodynamic therapy, compared with wait list and active treatment groups.¹⁹

EMDR. During eye movement desensitization and reprocessing (EMDR), the patient focuses on a disturbing image, a negative cognition, and somatic sensations associated with the trauma while tracking the movement of the clinician’s finger within her visual field.²⁰ The procedure is repeated until the patient’s distress is reduced and she develops more adaptive thoughts about the trauma.

Most EMDR practitioners recommend its use primarily for single-event traumas, such as rape or traumatic labor and delivery. Meta-analyses have suggested that EMDR may be as effective as other exposure therapy,²¹ although methodologic problems in several studies limit our ability to determine EMDR’s efficacy in treating women with PTSD.²²

Treating and preventing perinatal PTSD

Historically, common outcomes of giving birth included death or chronic disability. Despite advances in obstetric care, labor and delivery remains painful, frightening, and potentially dangerous. Although childbirth is a normative experience for many women, an estimated 2.8 to 5.6% of new mothers develop labor-related PTSD.^23-25 Risk of PTSD is increased in women with:

high general anxiety levels prior to labor
a history of mental illness
unplanned pregnancy
absence of partner during labor and delivery
the perception that obstetric staff is unsupportive or ineffective
a need for obstetric interventions, including episiotomy, emergency cesarean section, or use of forceps
a perception of lack of control.

Table 3

LABOR INTERVENTIONS FOR VICTIMS OF CHILDHOOD SEXUAL ABUSE

Limit obstetric examinations; prepare the woman for necessary examinations Obtain explicit permission to touch the woman Ensure privacy Explain sensations; help the woman visualize what is happening to her body Involve the woman in decisions whenever feasible Keep the woman moving to minimize dissociation For flashbacks, reframe violent or frightening images into soothing ones

Limit obstetric examinations; prepare the woman for necessary examinations
Obtain explicit permission to touch the woman
Ensure privacy
Explain sensations; help the woman visualize what is happening to her body
Involve the woman in decisions whenever feasible
Keep the woman moving to minimize dissociation
For flashbacks, reframe violent or frightening images into soothing ones

Untreated PTSD may impair the woman’s functional ability and compromise her relationship with the infant: