Exploring Dissociation and Oxytocin as Pathways Between Trauma Exposure and Trauma-Related Hyperemesis Gravidarum: A Test-of-Concept Pilot

Abstract

Posttraumatic stress disorder (PTSD) is associated with gastrointestinal and genitourinary comorbidities. These map onto the somatization disorder symptoms in the Diagnostic and Statistical Manual of Mental Disorders (APA, 1994) and the dissociative [conversion] disorders symptoms in the International Classification of Diseases taxonomy (WHO, 2007). Hyperemesis gravidarum (HG) is one of these symptoms and a gastrointestinal comorbidity of PTSD occurring in pregnancy. It is an idiopathic condition defined as severe vomiting with dehydration, metabolic imbalance, wasting, and hospital care-seeking. HG is more severe than the normative phenomenon of nausea and vomiting of pregnancy (NV). This test-of-concept pilot (N=25) explored the hypothesis that there is a trauma-related subtype of HG characterized by (1) high levels of dissociative symptoms and (2) altered plasma concentrations of oxytocin. This hypothesis is informed by a theory of posttraumatic oxytocin dysregulation positing altered oxytocin function as a mechanism of gut smooth muscle peristalsis dysfunction. A four-group analysis compared controls with nausea and vomiting of pregnancy (NV only) and cases with HG only, NV and PTSD, or HG and PTSD. Oxytocin was correlated with nausea and vomiting symptom severity score (r = .464, p = .019) and with the dissociation symptom score (r = .570, p = .003). Women in the group with both PTSD and HG (the “trauma-related HG subtype”) had the highest levels of dissociation and the highest levels of oxytocin. A linear regression model indicated that the independent association of the trauma-related HG subtype with oxytocin level was mediated by high levels of dissociative symptoms.

In Search of an Adult Attachment Stress Provocation to Measure Effect on the Oxytocin System

“…Although we did not expect to find cases of severe psychopathology in the form of PTSD or dissociation, there were participants with distinct psychiatric symptom patterns, allowing us to consider them as a preliminary indication of what a clinical sample might show. Consistent with what we found in another study of oxytocin, the woman with high dissociative symptoms had the strongest response to the provocation (Seng et al, 2013). Since dissociation psychopathology is strongly associated with early relational trauma (van der Kolk, 2005), and since oxytocin has been theorized to be dysregulated in the face of early relational trauma (Schore, 2003; Seng, 2010; Teicher et al, 2002), the correlation of dissociation symptom level and oxytocin level found here, as well as the pattern seen in this sentinel case, warrant further consideration.…”

“…Depression, which is characterized by low mood and loss of pleasure, also is frequently comorbid with PTSD (American Psychiatric Association, 1994). A recent pilot study of oxytocin during pregnancy demonstrated, for example, that oxytocin levels among those with a history of trauma and associated PTSD were predicted by dissociation symptoms (Seng et al, 2013). This finding is consistent with the possible role that oxytocin dysregulation may have in relation to mental and physical health conditions in which insults to or deficits in interpersonal relations play a role, per the cascade theory (Teicher, Andersen, Polcari, Anderson, & Navalta, 2002) and the posttraumatic oxytocin dysregulation theory (Seng, 2010).…”

“…The combination of these related elements has demonstrated an association with dysregulated oxytocin levels. For example, high or pulsatile oxytocin levels have been associated with trauma history, including childhood abuse (Pierrehumbert et al, 2010); trauma history and insecure attachment style (Pierrehumbert, Torrisi, Ansermet, Borghini, & Halfon, 2012); early relational trauma and complex PTSD (Seng, 2010; Seng et al, 2013), and depression in women (Cyranowski et al, 2008). …”

The prevalence of posttraumatic stress disorder in pregnancy and after birth: A systematic review and meta-analysis

“…PTSD during pregnancy arose from different events including interpersonal violence (Mahenge et al, 2013), a history of sexual or physical abuse (Cook et al, 2004), and pregnancy-related events such as a diagnosis of fetal anomaly (Horsch et al, 2013) or pregnancy complications (Annagur et al, 2013;Forray et al, 2009;Seng et al, 2013a). The results suggested that the risk of PTSD varied substantially from study to study (Fig.…”

“…PTSD in pregnancy was highest in samples of women with nausea, vomiting or hyperemesis gravida with a prevalence of 40% (Seng et al, 2013a), followed by women diagnosed with fetal anomaly 35% (Horsch et al, 2013) or with a history of childhood maltreatment 34.4% (Rowe et al, 2014). The mean prevalence for all studies was 4.6% with 95% confidence intervals of 3.42% to 6.14%.…”