توسعه و ارزیابی مقدماتی از مداخله شناختی- رفتاری برای پریناتال سوگ و داغداری

Abstract Perinatal loss, typically defined as fetal death beyond 20 weeks gestation through infant death 1-month postpartum, is a potentially traumatizing experience for parents occurring in approximately 1% of births in the United States. Although many women recover, 15% to 25% have enduring grief-related symptomatology and functional impairment. Perinatal grief is a unique bereavement experience, but clinical resources for detecting and treating severe perinatal grief are rare and interventions are largely without empirical support. We developed and pilot tested a cognitive-behavioral intervention targeting the psychological and behavioral sequelae of perinatal bereavement. To initially evaluate the feasibility and efficacy of the intervention, 5 women who suffered a perinatal loss were randomized to a 2-week, 4-week, or 6-week baseline period in a multiple-baseline single-case experimental design. In most cases, after the respective baseline periods, there was a steady decline in reported grief symptoms. These gains were largely maintained at a 6-week follow-up assessment. This study provides initial evidence in support of future research and clinical efforts tailoring cognitive behavioral interventions to meet the specific needs of women who experience perinatal loss.

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Results Participant 1 (P1) On the PGS (see Fig. 1), P1's score increased during her 2-week baseline period, reflecting a moderate worsening of grief symptoms in the absence of intervention. Immediately following the baseline-to-intervention phase change, a downward level shift of moderate magnitude was observed. Following some variability during the early weeks of intervention, P1's scores trended steadily downward to the postintervention assessment. However, her PGS score increased at the 6-week follow-up assessment and never fell below the cutoff score of 91. The RCI for the waitlist period was − 1.61 (see Table 4), which represents a trend toward significantly worsening symptoms. From pretreatment to posttreatment the RCI was 1.61, which is nonsignificant but represents a trend toward significant improvement in symptomatology. P1's scores on the Escape/Avoidance scale (EAS, see Table 4) showed a notable change. Her scores remained constant during the baseline period (RCI = 0), then decreased following the intervention and postintervention periods (RCI = 0.45). The intervention RCI was not significant; however, it appears the intervention may be related to a decrease in P1's use of some avoidant emotion-regulation coping strategies. This participant did not meet diagnostic criteria for an Axis I disorder at any time point. P1 completed the End-of-Session questionnaire after six of the eight sessions. Her mean and modal session satisfaction score was a 4 out of 5 (5 = extremely helpful and 1 = not at all helpful). She reported one session to be a 3 out of 5. Weekly Perinatal Grief Scale (PGS) scores across baseline (2-, 4-, or 6-weeks), ... Figure 1. Weekly Perinatal Grief Scale (PGS) scores across baseline (2-, 4-, or 6-weeks), intervention, and postintervention phases to 6-week follow-up for all participants. Figure options Table 4. Participant Scores for Outcome Measures across Study Phases. Measure Treatment Phase Participant (baseline) P1 P2 P3 P4 P5 (2 wk) (2 wk) (4 wk) (4 wk) (6 wk) PGS Intake 92 103 117 95 96 Post-baseline 99 92 117 103 88 RCI -1.61 2.52* 0 -1.83 1.83 Post-intervention 92 82 97 66 72 RCI 1.61 2.29* 4.59* 8.49* 3.67* 6-week follow-up 97 78 97 66 78 WOC-EA Intake 5 15 12 6 9 Post-baseline 5 15 12 9 7 RCI 0 0 0 -1.35 0.90 Post-intervention 4 12 6 1 6 RCI 0.45 1.35 2.70* 3.60* 0.45 6-week follow-up 3 7 7 3 7 Note. P = participant; PGS = Perinatal Grief Scale; WOC-EA = Ways of Coping, Escape/Avoidance Scale; wk = week; RCI = reliable change index; *p < 0.5. Table options Participant 2 (P2) P2's scores on the PGS (see Fig. 1) decreased significantly during her 2-week baseline phase (RCI = 2.52, see Table 4) and continued to trend downward, with some variability, during the intervention phase until Session 7. Her scores increased slightly toward the end of the intervention phase, but remained well below the clinical cutoff of 91 for this measure and decreased again at the 6-week follow-up assessment. From pretreatment to posttreatment, the RCI was also significant (RCI = 2.29); however, the impact of the intervention on P2's grief scores was inconclusive because the downward slope during the baseline phase precludes the possibility of determining improvements related to the intervention beyond the impact of time. The impact of the intervention appears to be noteworthy for her scores on the Escape/Avoidance scale of the WOC (EAS, see Table 4), which remained constant during the baseline phase (RCI = 0), and decreased following the intervention phase (RCI = 1.35), a change that approached statistical significance and was maintained at the postintervention assessment. This observation suggests that participation in the CBT intervention coincided with reported decreases in avoidant coping relative to no reported change during the baseline phase. P2 reported no current DSM-IV diagnoses on the ADIS-IV at the intake assessment (see Table 3). However, at the postbaseline/pretreatment assessment, she reported that she had three episodes of bingeing and purging behavior during the previous week. She agreed to monitor the frequency of the binge/purge behavior on a weekly basis during the course of the intervention, and found that the frequency of this behavior decreased steadily throughout the intervention period as she acquired more adaptive skills for regulating her emotions. At her postintervention assessment, the independent evaluator assigned a diagnosis of bulimia nervosa at a clinical severity rating of four out of eight. This clinical severity rating remained unchanged at the 6-week follow-up assessment, although P2 reported no disordered eating behavior at this assessment and reportedly had not engaged in binging or purging at all over the prior 2 weeks. P2 completed the End of Session questionnaire after six of the eight intervention sessions. Her mean and modal rating of the helpfulness of the intervention was a 5 out of 5, where 5 equals extremely helpful. She rated one session as a 4 out of 5. Participant 3 (P3) P3's scores on the PGS (see Fig. 1) showed relative consistency throughout the baseline phase (RCI = 0, see Table 4) and then increased during the first 2 weeks of the intervention. Her reported grief showed a significant drop at Week 3 of the intervention phase, concurrent with the acquisition and practice of cognitive reappraisal skills. Her PGS score increased at Weeks 4 and 5 at the start of exposure practice, and then decreased linearly, steadily, and significantly for the remainder of the intervention phase. Her overall RCI from pretreatment to posttreatment equaled 4.59 (see Table 4), which represents a significant change in reported symptomatology. However, P3's score on the PGS never fell below the clinical cutoff during the baseline, intervention, and postintervention phases. P3's score on the Escape/Avoidant scale (EAS, see Table 5) remained high and consistent during the baseline phase (RCI = 0), and then decreased significantly during the intervention phase (RCI = 2.70). Her score was observed to increase just slightly at the 6-week follow-up. This suggests that participation in the CBT intervention is related to a significant decrease in avoidant coping as compared to the waitlist condition. P3 met criteria for generalized anxiety disorder (GAD) at a clinical severity rating (CSR) of four out of eight, at the intake and postbaseline/preintervention assessment points (see Table 3). She also reported a significant level of depression symptoms, the onset of which coincided with the death of her babies, thus these symptoms were subsumed under her grief and a diagnosis of major depression was not assigned at that time. At her postintervention assessment, she no longer met criteria for GAD at a clinical level, but her depression symptoms persisted and then met criteria for a diagnosis of major depression of mild severity. At the 6-week follow-up, however, the depression symptoms had improved and thus the independent evaluator indicated that P3 no longer met full criteria for this diagnosis. P3 completed the End-of-Session questionnaire after five of eight intervention sessions. Her mean and modal rating of the sessions was a 3 out of 5. Participant 4 (P4) P4's scores on the PGS (see Fig. 1) increased during the waitlist period (RCI = − 1.83), a change that approached significance and was maintained across the phase change to Session 3. A significant decrease in reported symptoms then occurred between intervention Weeks 3 and 4, after learning and practicing cognitive reappraisal skills, which brought her score below the clinical cutoff score of 91 for this measure. Her scores dropped again between Weeks 5 and 6, increased at Week 7, and then decreased substantially at Week 8. The intervention phase RCI for P4 equaled 8. 49, which represents a significant change in symptomatology above and beyond the effects of time and/or measurement variance. Her score decreased slightly again at the posttreatment assessment time point and this change was maintained at the 6-week follow-up assessment point. P4's score on the Escape/Avoidance scale (EAS, see Table 4) increased during the baseline period (RCI = − 1.35), and then decreased significantly during the intervention phase (RCI = 3.60), supporting the conclusion that changes on this dependent measure were related to the manipulation on the IV (introduction of the CBT intervention). This participant did not meet diagnostic criteria for an Axis I disorder at any time point. P4 completed the End-of-Session Questionnaire following seven of the eight intervention sessions. Her mean and modal rating of the session helpfulness was 4 out of 5. Participant 5 (P5) P5's scores on the PGS (see Fig. 1) showed some variability during her 6-week baseline phase, becoming more consistent during the second half of the baseline phase and across the phase shift. Her RCI during the waitlist period was − 1.83, representing an increase in symptomatology that approached statistical significance. During the intervention phase, a substantial score increase was observed between intervention Week 4 to Week 5, followed by a steep drop from Week 6 to 7, at which point her score dropped below the clinical cutoff. This increase coincided with the onset of emotionally challenging exposures practices. P5's RCI during the intervention phase was 3.67, representing a significant decrease in reported symptomatology above and beyond the passage of time or measurement variance. Her score showed a slight decrease at the postintervention assessment point and this score was maintained at the 6-week follow-up assessment. P5s score on the EAS subscale of the WOC decreases during both the waitlist (RCI = 0.9) and intervention periods (RCI = 0.45), thus it cannot be determined form this measure that a decrease in avoidant coping was related to her participation in the intervention. At the intake and postbaseline assessments, P5 met criteria for a specific phobia of driving. She had been avoiding highway driving since she became pregnant, following an episode of panic symptoms she experienced while driving, for fear that she could get in a car accident and hurt her babies. During the intervention, P5's avoidance decreased a great deal as she participated in behavioral exposure practices targeting her phobic behavior, and at the postintervention assessment the independent evaluator indicated that P5 no longer met criteria for this diagnosis. Thus, it can be concluded that her change in diagnostic status was related to her participation in the intervention. P5 completed the End-of-Session questionnaire following four of the eight intervention sessions. Her mean and modal rating of session helpfulness was 5 out of 5.