Development of Post-Traumatic Stress Disorder (PTSD) after Childbirth
The Role of Attachment in the Development of Post-Traumatic Stress Disorder (PTSD) after Childbirth: A comparison of women in Saudi and the UK.
This paper presents a proposal for a study on the role of attachment in the development of PTSD after childbirth. The research will be conducted on Saudi and UK women during the first two weeks of postnatal period. The paper will explore the impact of six main attachment sub-factors, namely, attachment style, religiosity, culture, support, shuttered assumptions and parent-infant bonding. As it will be noted, significant research has been conducted on the role of attachment in the development of PTSD after childbirth in the UK. However, no prior studies have been conducted on the issue in the context of Saudi Arabia. This research aims to bridge that gap and will utilize quantitative data that will be collected using questionnaire. Data collected will be analyzed using descriptive statistics (means, variances, and correlations). A work plan for the research project is also presented in the paper.
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The birth of a child is understood as a normative event in the society. However, giving birth is a time that involves substantial psychological and neural-hormonal changes which may present numerous challenges to a woman’s life. As Ayers & Ford (2009) explains, the birth of baby involves unique psychological and physiological demands and requires substantial adjustment. Majority of women have positive experiences after giving birth. However, a proportion of women encounter difficulties or even traumatic experiences after giving birth. In most cases, parents who are unable to effectively adjust to traumatic experiences develop PTSD. Unlike many other life experiences, giving birth is particularly important since it has wide-ranging impact on a woman’s emotions. Depression in women after giving birth has also been associated with poor cognitive development in children and depression in their partners (Ayers & Ford, 2009).
Attachment has been shown to influence the ability for people to cope with and manage stress and to retain psychological resilience after child birth (Gormley & McNiel, 2010). Attachment theory founded by John Bowlby might provide a theoretical explanation for the issue. Bowlby (1969/1982, 1973) conceptualized attachment as the innate motivation that drives an infant to seek proximity to the mother during stressful periods (Mikulincer et al, 2006). Bowlby further suggested that when a child contently interacts with a sensitive and supportive caregiver, he or she develops a cognitive schema of general support availability for minimizing or coping with stress during potentially threatening situations. In other words, humans are born with a unique psychological system that motivates them to seek proximity and support from attachment figures or significant others in times of need.
According to Bowlby, the relationships with significant others are presented in the mind in terms of stable working models (Gormley & McNiel, 2010). People form expectations in their minds that the attachment figures or significant others are going to provide support in times of need. When the attachment figures are unsupportive or unavailable, felt security is undermined and the individual may develop stress, emotional problems and health problems. On the other hand, an individual may follow insecure attachment, which can be conceptualized in terms of two major dimensions; anxiety and avoidance. Attachment-related anxiety refers to an individual’s degree of worries that attachment figures will not be available or will not be supportive in times of need. Avoidance is the extent to which an individual may distrust partner’s goodwill for support and subsequent withdrawal and maintenance of emotional distance and behavioral independence (Gormley & McNiel, 2010).
Attachment system functioning has been shown to be quit relevant to an individual’s mental health and adjustment to stressful situations. The sense of being supported and being loved by attachment figures results naturally in a stable sense of self-esteem and positive representation of others, and enhances ability to cope with and manage stress (Mikulincer et al 2006). On the other hand, attachment insecurities are perceived as risk factors that foster affectivity, reduces resilience in times of stress, and contributes to emotional difficulties, maladjustment, and psychopathology. As mentioned earlier, giving birth is a situation that demands unique psychological, physical and emotional needs. Adequate support from partner and other attachment figures has been associated with improved mental health and quick adjustment and recovery among women after childbirth (Gormley & McNiel, 2010). Women with more positive perceptions of the world and self are more likely to seek or to attract support from attachment figures. Attachment to a particular culture and religion may also influence accessibility to physical, psychological and emotional support after childbirth. Studies have also found association between a woman’s attachment to her child and development of stress and depression during postnatal period.
The role of attachment in the development of PTSD after childbirth is particularly relevant in this study given that approximately 0.6 million women give birth in both UK and Saudi Arabia every year, according to Central Intelligence Agency (2013) statistics. At the same time, research evidence shows that between 1% and 9% of women develop PTSD after giving birth, depending on the target population of study (Ayers & Ford, 2009). It is likely that cultural differences between UK and Saudi may lead to differences in PTSD prevalence rates after childbirth in the two countries.
The main purpose of this study is to determine the role of attachment in the development of PTSD after childbirth. Studies have shown that attachment factors such as attachment style, religiosity, culture, held world assumptions and social support may influence the development of PTSD after childbirth. However, studies are rare that explore the overall impact of all the aforementioned attachment factors. The purpose of this study is to explore the overall impact of the all the above factors in order to gain a more comprehensive understanding of the role of attachment in the development of PTSD after childbirth. Secondly, numerous studies have been conducted to determine the role of culture in development of PTSD in western and non-western countries. However, no prior studies have paid attention to the role of Islamic culture and religion in the development of PTSD after childbirth in Saudi Arabia. Therefore, this study aims to bridge that gap by comparing the impact of culture and religion in the development of PTSD after childbirth among UK and Saudi women.
The present study will contribute to the society in various ways. To start with, it will provide evidence of existence as well as prevalence rate of PTSD in Saudi Arabia. Clinicians in Saudi Arabia will find the information useful as reference for establishment of better and more effective treatment strategies for PTSD symptoms among women after childbirth. Secondly, the study will provide opportunity for making comparison between the impacts of Saudi’s Islamic culture and UK’s western culture in the development of PTSD after childbirth. This is vital given that the role of Saudi’s Islamic culture in the development of PTSD after childbirth has not been explored before. In addition, the study will provide an opportunity to determine the combined impact of different attachment sub-factors in the development of PTSD after childbirth. Finally, the study will be useful to clinicians, mothers and the society at large since it will provide them with vital knowledge on how attachment can help to mitigate effects of traumatic experiences after childbirth.
Numerous studies, mainly influenced by Bowlby’s attachment theory, have explored the role of attachment in the development of PTSD after childbirth. As mentioned earlier, the main attachment factors that may influence development of PTSD are attachment style, parent-infant bonding, shuttered assumptions model, religiosity, support, and culture. Therefore, a comprehensive understanding of the role of attachment in the development of PTSD after childbirth can be achieved by exploring the role played by each of the aforementioned factors.
There are just few studies that have paid attention to the relationship between attachment styles and development of PTSD. O’Connor and Elklit (2008) investigated the impact of attachment styles in development of PTSD among young adults. The study utilized a sample of 328 Danish students with an average age of 29.2 years. The results of this study found that attachment styles have a strong association with PTSD symptoms, emotional coping, social support, negative affectivity and attributions. In addition, the study found the distributions of attachment styles in relation to the symptoms of PTSD to be uni-directional.
Mikulincer and Shaver (2007) reviewed cross-sectional, prospective and longitudinal studies that included clinical samples and found that attachment insecurity was prevalent among individuals with variety of PTSD. Similar results have been reported in other studies. For instance, attachment insecurities has been found to be associated with depression (Catanzaro & Wei, 2010), PTSD (Ein-Dor et al, 2010), and suicidal tendencies (Gormley & McNiel, 2010). Meyer and Pilkonis (2005) found that the association between attachment insecurity and PTSD is dependent on prior experience of psychological, sexual or physical abuse. Studies involving large community samples usually give contradicting results. For instance, Mikulincer and Shaver (2007) found that studies involving large community samples showed no association between attachment style and PTSD symptoms. The present study will augment existing literature and will provide additional knowledge on the impact of attachment styles in the development of PTSD symptoms.
There are numerous studies that have focused on the association between parent-baby bonding and PTSD symptoms. However, majority of the prior studies have focused on the impact of PTSD symptoms on parent-baby bond rather than the effect of parent-infant bond in the development of PTSD symptoms. Despite that, the studies express the significance of parent-baby bond in the development of PTSD symptoms after child birth. Parfitt and Ayers (2009) sought to examine the effects of PTSD symptoms on the relationship between couples as well as on parent-baby bond. The study utilized information gathered using internet-based questionnaires from 150 parents (26 men and 126 women) on PTSAD symptoms, quality of couple’s relationship, depression and parent baby bond. The results of this study showed a strong correlation between parent-baby bond and symptoms of PTSD and depression. Forcada-Guex et al (2011) administered Perinatal Posttraumatic Stress Disorder Questionnaire on 47 mothers of pre-term infants and 25 mothers of full-term infants. The study found that mothers of full-term infants had relatively less PTSD symptoms, showed stronger parent-infant bond, demonstrated balanced representations of the infants and were likely to follow “cooperative dyadic pattern of interaction with the infant (Forcada-Guex et al, 2011). On the other hand, pre-term mothers portrayed more PTSD symptoms, had more distorted representations of their infants and were more likely to follow a controlling dyadic pattern of interaction (Forcada-Guex et al (2011). Generally, the findings of the study indicated a strong correlation between the parent-infant relationship and PTSD symptoms.
However, Ayers, Wright and Wells (2007) found little association between parent-baby bond and PTSD symptoms. The authors collected information from 64 couples about symptoms of PTSD, birth, parent-baby bond and the couple’s relationships. The study found 5 percent of the respondents to have severe symptoms of PTSD after birth. Further, women portrayed stronger parent-child bond compared to men. However, no significant difference was found between the magnitude of PTSD symptoms portrayed by men and women. In other words, the study did not find strong association between parent-baby bond and PTSD symptoms. Lack of strong association may be attributed to methodology that was used in conducting the research. Although the current study will focus on women, it will provide a more clear understanding of the effect of parent-infant bond in the development of PTSD after childbirth.
The theory of shattered assumptions developed by Ronnie Janoff-Bulman (1983;1992) (as cited in Lilly, Valdez & Graham-Bermann, 2011) can also be used to explain the role of attachment in the development of PTSD. The theory contends that people carry with them three key assumptions: the world is meaningful, the world is benevolent and the self is worthy. According to Janoff-Bulman the three assumptions enable human beings to make sense of the world and the events happening around them. They are integrated in the belief system of a human being and they assist people in overcoming unsafe and chaotic aspects of the world. However, the theory of shattered assumptions contends that the basic assumptions can be shattered by trauma, disintegrating a person’s belief system. When this happens, an individual may suffer from distress until the basic assumptions are restored (Lilly et al, 2011).
When testing theory among young adults, Lilly et al (2011) hypothesized that the basic assumptions aid in the creation, restoration and maintenance of sense of attachment security within an individual. Positive assumptions lead to an increase in meaningful interactions which impart a sense of safety, provide psychological resources for dealing with adversities and problems, and triggers positive emotions (such as love, gratitude, satisfaction and relief). In a study that recruited women who have survived from intimate partner violence, Lilly et al (2011) concluded that persons who hold onto the basic assumptions are less perturbed and recover quickly from associated distress. On the other hand, Lilly et al (2011) found that shattered assumptions lead individuals to feel insecure and to make less meaningful interactions. Janoff-Bulman’s argument has also been supported by other studies that have linked more negative world assumptions to more symptoms of PTSD (Nygaard & Heir, 2012; Zukerman & Korn, 2013). This study will augment prior research by focusing on the role of world assumptions in the development of PTSD.
Numerous studies have shown religiosity to have a moderating effect on the negative effects of posttraumatic stress. However, studies focusing on association between religiosity and PTSD after child birth are rare. A recent study by Zukerman and Korn (2013) 777 Israeli undergraduate students found a significant relationship between religious coping and world assumptions held by the respondents. Respondents who coped well with religion had more positive world assumptions while individuals who portrayed negative religious coping had more negative world assumptions. In addition, negative world assumptions were associated with more symptoms of attachment insecurity and PTSD. Zukerman and Korn (2013) concluded that religiosity affects world assumptions directly by shielding negative effects of negative experiences.
Another study carried out among veterans by Rosmarin et al (2009) showed that Jews with weak religious faith were relatively more hopeless and stressed. Gerber, Boals and Schuettler (2011) found similar results in a study that utilized a sample of 1,016 participants. The study found strong association between positive religious coping and post-traumatic growth and a strong association between negative religious coping and development of PTSD symptoms. On the other hand, research among veterans carried out by Resick, Monson and Chard (2008) found no significant association between religiosity coping and PTSD. However, Resick et al (2008) used the rate at which respondents sought counseling services as a proxy for measuring PTSD rather than focusing on the symptoms of PTSD. Although relevant, the results derived from the study are not convincing enough to overturn the findings of the other studies. The present study will explore the role of religiosity in order to gain better understand its impact on development of PTSD.
Earlier studies have found support to be strongly associated with the development of PTSD after childbirth. One of the most relevant studies was conducted by Iles et al (2011) on a sample of 372 couples who were on their first seven days of postpartum. The study sought to determine the role of partner attachment and perception of partner support on the development of PTSD symptoms after childbirth. The study found significant association between symptoms of PTSD within couples. Men’s acute trauma symptoms predicted the presence PTSD symptoms among their partners. Essentially, the findings showed that PTSD symptoms were more prevalent among women who were less satisfied with partner support (Iles et al, 2011). The study carried out by Iles et al (2011) confirmed the findings of an earlier research by Moller, Hwang and Wickberg (2006) which found partner attachment and support to be essential during marriage transition to adulthood as well as during early postpartum. Moller et al (2006) also found that individuals following secure attachment style were more inclined to seek support from their partners while insecure attachment may lead an individual to withdraw, reducing access to support. Generally Moller et al (2006) showed that attachment and support available to a woman from her partner may affect her psychological adjustment after childbirth. Despite, Iles et al (2011) suggested that attachment may have a direct association with PTSD irrespective of perceptions of support. For instance, an insecure attachment base may lead to an increase in PTSD symptoms directly without operating via social support (Iles et al, 2011).
According to Iles et al (2011), it is not yet clear whether a partner’s avoidance character has an impact on the other partner’s psychological adjustment or in suppressing depression and post-traumatic stress after childbirth. It is possible that a man who has insecure attachment to her partner may not provide the necessary support during times of difficulty, impacting on the psychological wellbeing of the partner. Ditzen et al (2008) also found insecure attachment and dissatisfaction with partner support to have significant association with higher PTSD symptoms. Tsai et al (2012) found PTSD symptoms to be more prevalent among individuals with less social support, less cohesion in their families, greater difficulties in their relationships with partners, and lower life satisfaction. Lemola, Stadlmayr, and Grob (2007) found that women who were more satisfied with partner support were less likely to develop PTSD symptoms. The authors found that women who perceived their partners as providing adequate emotional support discussed with them their concerns and worries without fear of criticism. Various studies have also shown the significance of social support from fiends and relatives (Mikulincer et al, 2006), and wider community (Mikulincer & Shaver, 2007) in the development of PTSD symptoms.
However, some studies have derived contradicting results. Stapleton et al (2012) and Elsenbruch et al (2006) found that lower perceptions of support among women during pregnancy were associated with more PTSD symptoms after child birth. However, Elsenbruch et al (2006) did not assess the relationship within couples; rather they focused on perceived support across a wider network. The present study therefore aims to explore the role of perceived partner support from in order to understand the effect of this factor on development of PTSD symptoms after childbirth.
Culture has been found to be a central factor in influencing PTSD symptoms. Available studies have largely sought to determine the role of culture in the development of PTSD across western and non-western countries. Researchers have hypothesized that there are certain elements that are present in non-western cultures that make them distinct and that protect against the development of PTSD among women after childbirth. These elements include mandated rest, assistance in doing household tasks from relatives and friends, social recognition through gifts, rituals and other means, social seclusion, protective measures to prevent harm on the new mother, and cultural partnering during a specific post-partum period (Hanlon et al, 2008). Those elements are absent in western cultures mainly due to modern rise in obstetric practices. As such, women in western cultures are alienated from accessing such support, rendering them susceptible to PTSD (Hanlon et al, 2008).
Despite the presence of various cultural elements that are tailored to give support to mothers after childbirth in Sub-Saharan Africa, studies conducted in the region have shown prevalence estimates of PTSD which are comparable to those from western nations (Adewuya et al, 2005; Nakku, Nakasi & Mirembe, 2006; Ayers & Smith, 2010). In fact, Adewuya et al (2006) found the rate of PTSD after childbirth among Nigerians to be higher than in western, high income nations. However, these studies largely used data collected from urban areas. It is possible that modernity has eroded social-cultural perinatal practices in urban areas in various parts of Africa leading to a rise in PTSD. The high prevalence can also be accounted for by difficulties in measuring PTSD across different sub-cultures.
Numerous studies have been conducted focusing on PTSD after childbirth in the UK (e.g Ayers, 2007; Ayers et al 2007; Iles et al, 2011; Davis & Stewart, 2008; Catanzaro & Wei 2010). However, there are no studies focusing PTSD after childbirth in the context of Saudi Arabia. The UK’s western culture is far much different from Saudi Arabia’s Islamic culture. It is not yet clear whether the cultural differences between the two countries have any effect on the development of PTSD after childbirth. Therefore, the present study will bridge this gap by exploring the impacts of the two cultures in the development PTSD after childbirth. In addition, earlier studies on the role of attachment on PTSD after child birth have focused on either one or just a few of the sub-factors identified. None has paid attention to the role of all the sub-factors at the same time. By including all the identified sub-factors, the present study will provide a more comprehensive understanding of the role of attachment in the development of PTSD after childbirth.
In this study, the researcher has adopted a descriptive research design. According to Creswell (2003), descriptive research design is concerned with finding out the how, what and where of a phenomena. It is applied in exploratory studies that are concerned with discovering what is happening, looking for new insight, asking questions, and assessing an observable fact in a new way. The choice of this design is based on the fact that cases of PTSD after childbirth have been present in the society. This study will give a new insight on the role of attachment in the development of PTSD symptoms after childbirth.
This study aims to recruit women from public hospitals and community antenatal clinics in UK and Saudi Arabia. Women will be eligible if they have given birth in the past two weeks. Women under 18 years of age will be excluded. In UK, women with a level of English that is insufficient to understand questionnaire will be excluded. In Saudi Arabia, women who do not sufficiently understand Arabic language will not be eligible. Women will also be excluded where permission will not be granted by caregivers and where they do not wish to participate. The researcher estimates that a sample of 200 women (100 from UK and another 100 from Saudi Arabia) will be sufficient for the study.
This research project will be conducted in two phases; conceptualisation and empirical phases. Conceptualisation phase involves review of prior literature related to the role of attachment in the development of PTSD symptoms after birth. During the empirical phase, data will be collected from the targeted subjects and analysed as per the set objectives of the research.
The study will utilize primary data which will be collected using survey questionnaire containing different scales testing the impacts of different attachment sub-factors. Questionnaires that will be distributed to women in UK will be written in English. The same questionnaires will be translated in Arabic and administered to women in Saudi Arabia. The researcher will be assisted by four individuals in each country to distribute and to collect the questionnaires. The women will be allowed to fill the questionnaires overnight and then submit the following day. Issues of confidentiality and ethics will be observed. Permission will be sought from relevant authorities before conducting the study.
To ensure high level of content validity, the researcher conducted extensive research on the subject matter and ensured that the instruments will accurately measure the intended factors as per the objectives of the study. The researcher also engaged peers and incorporated the opinions of supervisor in order to ensure that high level of validity of the instruments is attained.
Reliability of a data collection instrument reflects its consistency and stability within a given context (Plessis, 2004). The test-retest coefficient method was used to test the reliability of data collection instruments used in this study.
Symptoms of PTSD will be measured using the Modified Symptom Scale Self-Support (MPSS-SR). MPSS-SR is a 17-item measure that assesses PTSD symptoms in the past two weeks (Falsetti et al, 1993). The researcher will modify items of the questionnaire to address childbirth as the event to be assessed. An item will be considered as present if the corresponding symptom is present at least once in a week (is it scores 1 or greater). MPSS-SR in a clinical population has been found to be consistent (Cronbach’s alpha = .92 and .97, respectively). This scale has also been found to be highly reliable for this study as 0.92 (Falsetti et al, 1993). The scale has been widely used in the measurement of PTSD symptoms after childbirth and thus, it will allow for the researcher to make comparisons with earlier studies (Tanya, 2008).
The feeling of anxiety will be measured using the State-Trait Anxiety Inventory (STAI). STAI measures how individuals feel presently (state anxiety) and how they feel generally (trait anxiety) (Verreault et al, 2012). 20 statements are used for each form of anxiety. STAI-state will be administered at data collection points while STAI-trait will be completed at the entry of the study. Internal consistency for STAI-state has been found to be 0.81and 0.92 for AI-trait.
This study will focus on perceived partner’s practical and emotional support. The respondents will rate partners’ support using the Significant Other Scale (Iles et al, 2011) Practical support scores will be added to emotional support scores to give ‘total support’ scores. Each question included in the scale will be divided into ‘ideal levels of support’ and ‘perceived actual support.’ Dissatisfaction with partner support will be determined by summing ‘perceived actual support’ scores and subtracting the total from the sum of ‘ideal levels of support’ scores. Reliability for the scale in thus study has been found to be approximately 0.79
Parent-infant bond will be measured using original Postpartum Maternal Attachment Scale. The scale consists of 8 items addressing ‘anxiety regarding children’ and 11 items addressing ‘core maternal attachment.’ The scale has been found to be reliable at approximately 0.80.
The impact of held world assumptions will be measured using the World Assumptions Scale (WAS). This scale contains 31 items that assess the extent to which a respondent agrees with statements about meaningful of self, benevolence of the world and the worthiness of self (Janoff-Bulman, 1989). Participants rate statements using likert-type scales (e.g likert-type scale between 1= strongly disagree to 6 = strongly agree). Reliability for the scale in this study was 0.85
Rligiosity will be rated using The Multidimensional Measure of Religious Involvement scale. The scale contains 12 items measuring indicators of attachment to a particular religion (Levin et al., 2002). Participants are asked to rate statements using likert-type scale. In some cases, they are asked to mark ‘Yes’ or ‘No.’ The scale has been found to be reliable at 0.83
The impact of culture will be measured using the Multi-group Ethnic Identity Measure (Phinney, 2005). It contains various items that assess cultural identity achievement, affirmation/belonging and overall cultural identity. Participants are asked to rate statements using a likert-type scale between 1= strongly disagree to 4 = strongly agree. The scale will be modified to fit the context of the study. Reliability for the scale was found to be 0.84
Attachment will be assessed on the six key sub-factors (attachment style, support, parent-infant bond, culture, religiosity and shuttered assumptions) using revised Experiences in Close Relationships Scale (Iles et al, 2011). The respondents will rate the factors using a 6-point Likert-Type scale (between 0 = ‘strongly disagree’ and 6 = ‘strongly agree’ for each question. This scale has been shown to have good levels reliable and validity (Iles et al, 2011).
For the purpose of this study, the researcher has examined the applicability of both quantitative and qualitative approaches to data analysis. As Creswell (2003) explains, qualitative analysis is based on content analysis and the results are presented in non-numerical format. On the other hand, quantitative analysis involves collecting and analyzing numerical or statistical data rather than views and perceptions. This study will use numerical data and hence, it will be analysed using quantitative technique. The researcher will use descriptive statistics, namely, means, variances and correlations to analyse the data.
The research will be conducted on during the month of October 2013. Sampling the responses, analyzing the data and writing a report of the findings will be done between November 2013 and March 2014. This is shown in the schedule below:
|September 2013||October 2013||November/December 2013||January/February 2014||March 2014|
|Sourcing permission, preparing|
|Sample selection and administration of questionnaires|
Adewuya, A. O., Fatoye, F. O., Ola, B. A., Ijaodola, O. R., & Ibigbami, S. M. (2005).
Sociodemographic and obstetric risk factors for postpartum depressive symptoms in Nigerian women. Journal of Psychiatric Practice, 11(5), 353–358.
Adewuya, A. O., Ologun, Y. A. & Ibigbami, O. S. (2006). Post-traumatic stress disorder
after childbirth in Nigerian women: prevalence and risk factors. BJOG, 113(3), 284-8
Ayers, S. (2007). Thoughts and emotions during childbirth: a qualitative study. Birth,
Ayers, S. & Ford, E. (2009). Birth trauma: Widening our knowledge of postnatal mental
health. European Health Psychologist, 11, 16-19
Ayers, S., Wright, D. B., & Wells, N. (2007). Post-traumatic stress in couples after
birth: Association with the couple’s relationship and parent-baby bond. Journal of
Reproductive & Infant Psychology, 25(1), 40-50.
Ayers, S. & Smith, H. (2010). Pre- and postnatal psychological wellbeing in Africa: A
systematic review. Journal of Affective Disorders, 123, 7–29
Bowlby, J. (1988). A secure base. New York, NY: Basic Books
Butterworth, P., & Rodgers, B. (2006). Concordance in the mental health of spouses:
analysis of a large national household panel survey. Psychological Medicine, 36(5), 685–697
Catanzaro, A. & Wei, M. (2010). Adult attachment, dependence, self-criticism, and
depressive symptoms: a test of a meditational model. J Pers., 78(11), 35–1162
Central Intelligence Agency (2013). CIA World Factbook. Retrieved 1 September, 2013
Creswell, J. W. (2003). Research Design: Qualitative, Quantitative, and Mixed
Methods Approaches. London: Sage Publications
Adult attachment and social support interact to reduce psychological but no cortisol responses to stress. Journal of Psychosomatic Research, 64, 479–486.
Davis, J. & Stewart, P. (2008). Posttraumatic stress symptoms following childbirth and
mothers’ perceptions of their infants. Infant Mental Health Journal, 29(6), 537–554
Ein-Dor, T., Doron, G., Solomon, Z., Mikulincer, M. & Shaver, P. R. J. (2010).Together
in pain: attachment-related dyadic processes and posttraumatic stress disorder. Couns Psychol. 57(3), 317-27
Elsenbruch, S., Benson, S., Rücke, M., Rose, M., Dudenhausen, J., Pincus-Knackstedt,
- K., Klapp, B. F. & Arck, P. C. (2006). Social support during pregnancy: effects on maternal depressive symptoms, smoking and pregnancy outcome. Human Reproduction, 22(3), 869-877
Falsetti. S. A., Resnick, H. S. Resick P. A. & Kilpatrick, D. G. (1993). The modified PTSD symptom scale: a brief self-report measure of posttraumatic stress disorder.
The Behavioral Therapy 16, 161-2.
Fasel, R., & Spini, D. (2010). Effects of victimization on the belief in a just world in four
ex-Yugsoslavian countries. Social Justice Research, 23, 17–36
Forcada-Guex, M., Borghini, A., Pierrehumbert, B., Ansermet, F. & Muller-Nix, C.
(2011). Prematurity, maternal posttraumatic stress and consequences on the mother-infant relationship. Early human development, 87(1), 21 – 26
Gerber, M. M., Boals, A. & Schuettler, D. (2011). The unique contributions of positive
and negative religious coping to posttraumatic growth and PTSD. Psychology of Religion and Spirituality, 3(4) 298-307
Gormley, B., & McNiel, D. E. (2010). Adult attachment orientations, depressive
symptoms, anger, and self-directed aggression by psychiatric patients. Cognition Theory, 34, 272–281
Hanlon, C., Whitley, R., Wondimagegn, D., Alem, A. & Prince, M. (2009). Postnatal
mental distress in relation to the sociocultural practices of childbirth: An exploratory qualitative study from Ethiopia. Social Science & Medicine, 69, 1211–1219
Iles, J., Slade, P. &Spiby, H. (2011). Posttraumatic stress symptoms and postpartum
depression in couples after childbirth: The role of partner support and attachment. Journal of Anxiety Disorders, 25, 520–530
Illing. V., Tasca. G. A., Balfour, L., (2010). Attachment insecurity predicts eating
disorder symptoms and treatment outcomes in a clinical sample of women. J Nerv Ment Dis, 198, 653–659
Lemola, S., Stadlmayr, W., & Grob, A. (2007). Maternal adjustment five months after
birth: the impact of the subjective experience of childbirth and emotional support from the partner. Journal of Reproductive and Infant Psychology, 25(3), 190–202.
Levin, J. S., Taylor, R. J., & Chatters, L. M. (2002). A multidimensional measure of
religious involvement for African Americans. The Sociological Quarterly, 36, 157-173.
Lilly, M. M., Valdez, C. E., & Graham-Bermann, S. A. (2011). The mediating effect of
world assumptions on the relationship between trauma exposure and depression. Journal of Interpersonal Violence, 26, 2499–2516
Meyer B, Pilkonis PA. (2005). An attachment model of personality disorders. New York:
Mikulincer, M. & Shaver, P. R. (2007). Attachment theory and intergroup bias: evidence
that priming the secure base schema attenuates negative reactions to out-groups. J Pers Soc Psychol, 81, 97–115.
Mikulincer, M. & Shaver, P. R. (2012). An attachment perspective on psychopathology.
World Psychiatry, 11(1), 11–15.
Mikulincer, M., Shaver, P. R., Horesh, N. & Snyder, D. K. (2006). Attachment bases of
emotion regulation and posttraumatic adjustment. Washington DC: American Psychological Association
Möller, K., Hwang, P. & Wickberg, B. (2006). Romantic attachment, parenthood and
marital satisfaction. Journal of Reproductive and Infant Psychology, 25, 520-530
Nakku, J. E. M., Nakasi, G., & Mirembe, F. (2006). Postpartum major depression at six
weeks in primary health care: prevalence and associated factors. African Health Sciences, 6(4), 207–214.
Nygaard, E & Heir, T. (2012). World assumptions, posttraumatic stress and quality of life
after a natural disaster: A longitudinal study. Health Qual Life Outcomes, June 28, 2012 Online Publication, 10: 76
O’Connor, M. & Elklit, A. (2008). Attachment styles, traumatic events, and PTSD: a
cross-sectional investigation of adult attachment and trauma. Attach Hum Dev. 2008 10(1): 59-71
Parfitt, Y. M & Ayers, S. (2009). The effect of post-natal symptoms of post-traumatic
stress and depression on the couple’s relationship and parent-baby bond. Journal of Reproductive and Infant Psychology, 27(2), 127 – 142
Phinney, J. S. (2005). The multigroup ethnic identity measure: A new scale for use with
diverse groups. Journal of Adolescent Research, 7, 156-176.
Resick, P. A., Monson, C. M., & Chard, K. M. (2008). Cognitive processing therapy:
Veteran/military version. Washington, DC: Department of Veterans’ Affairs.
Rosmarin, D. H., Pargament, K. I., Krumeri, E., & Flannely, K. J. (2009). Religious
coping among jews: Development and initial validation of the JCOPE. Journal of Clinical Psychology, 65(7), 670–683
Stapleton, L. R., Schetter, C. D., Westling, E., Rini, C., Glynn, L. M., Hobel, C. J. &
Sandman, C. A. (2012). Perceived partner support in pregnancy predicts lower maternal and infant distress. J Fam Psychol, 26(3), 453-63.
Tsai, J., Harpaz-Rotem, I., Pietrzak, R. H., Southwick, S. M. (2012). The role of coping,
resilience, and social support in mediating the relation between PTSD and social functioning in veterans returning from Iraq and Afghanistan. Psychiatry, 75(2), 135-49
Verreault, N., Da Costa, D., Marchand, A., Ireland, K., Banack, H., Dritsa, M. & Khalifé,
- (2012). PTSD following childbirth: A prospective study of incidence and risk factors in Canadian women. Journal of Psychosomatic Research, 73, 257–263
Zukerman, G. & Korn, L. (2013). Post-Traumatic Stress and World Assumptions: The
Effects of Religious Coping. J Relig Health, 45(1), 10-61