EMOTIONAL CHALLENGES OF THE REPRODUCTIVE YEARS PART II:  PREGNANCY AND POSTPARTUM SPECTRUM DISORDERS 

Gina Hassan, Ph.d., Donna Rothert, Ph.D., & Lee Safran, MFT
of Perinatal Psychotherapy Services - A collective of psychotherapists who specialize in issues facing women during the reproductive years.

Denise became pregnant with her first child at age 37. While she had a difficult first trimester with severe morning sickness, increasing anxiety, and sleeplessness, she was thrilled to be expecting a child. Her son was born 4 weeks premature following an emergency c-section.  Six weeks postpartum, Denise was proud of how well things were going, despite a great deal of sleep deprivation and slow physical recovery. However, Denise began to have difficulty sleeping even when her baby was resting. She worried about not getting enough sleep and often felt preoccupied.  She started checking on her baby frequently when he was asleep “to make sure he was still breathing.”  She was horrified by images of him being attacked by dogs and felt frightened and overwhelmed at the thought of taking him out in his stroller. The other new moms she knew appeared at ease, or even elated with their babies, but Denise felt frightened by her morbid thoughts and feelings and too ashamed to share them with family and friends. She felt increasingly isolated and depressed and was worried that she had made a terrible mistake and was not fit to be a mother. 

This vignette illustrates some of the confusing and overwhelming experiences that can be a part of a woman’s pregnancy and postpartum world. Given cultural expectations that having a baby is the happiest time in a woman’s life, it is often hard for a woman to recognize perinatal mental health issues and to seek needed support and information. Although mothers and pregnant women who are experiencing distressing symptoms during or  after pregnancy often feel alone in their  experience, women are more at risk of  experiencing  emotional  difficulties  following the birth of a baby than at any  other  time  in  their  lives.  Furthermore, these difficulties often begin during pregnancy. (Moses-Kolko, & Roth, 2004)

Pregnancy
Pregnancy can be a time of profound physical and emotional transformation, and a time rich with symbolic meaning. It is a time that may be filled with hope and expectation, fears and conflicts, growth and regression. For many women attachment begins instantly, for others fear and anxiety are predominant.

In our culture, pregnancy is most often perceived of as a time of bliss and happiness. Women who suffer from anxiety  and  depression  may  feel  very  isolated  and may even be told by their physicians  that  this  is  normal.  Differentiating the physiological symptoms of pregnancy from those of depression may be difficult as the symptoms overlap. The difference, however, seems to be in the degree of impairment. Suicidal ideation and anhedonia, for example, are not normal symptoms of pregnancy, but fatigue and mood instability are.

In addition to a growing belly and breasts, there are massive hormonal changes that may affect a woman’s mood during pregnancy. The rise in estrogen and progesterone during pregnancy, as well as the effects of prolactin and cortisol, will influence a woman’s emotional stability.  Some women are more sensitive to these changes then others. For many women, the first trimester is a time of emotional upheaval, followed by a period of relative calm, even euphoria. For others, however, the hormonal changes can wreak havoc and set off a course of biochemical changes that alone or in conjunction with psychological factors may lead to serious depression or anxiety. 

Untreated clinical depression or anxiety during pregnancy is very serious since the condition usually worsens over time.  Women with untreated mental illness during pregnancy are two and a half times more likely to suffer from postpartum mood disorders then the normal population. Furthermore, it has been linked to increased risk of low birth rate, neonatal intensive care admissions, and increased rates of still births, retarded fetal growth, and poor maternal-fetal attachment. (Chung  et. al. 2001)

Postpartum Spectrum Disorders 
As in pregnancy, many women anticipate great joy after giving birth and are unaware of the range of emotional reactions they are likely to experience. Dramatic physical and hormonal changes, chronic sleep deprivation, new responsibilities and a new identity can provide a woman with one of the most stressful and anxiety producing life transitions she will ever experience. Other factors that  are believed to contribute to postpartum  emotional distress include; a history of  depression or anxiety (either personally  or in a blood-relative); a difficult or traumatic birth experience; a colicky, hardto-care-for baby; nursing difficulties or  weaning; a predisposition to perfectionism and self-criticism; lack of social supports;  and  a  poor  partner  relationship.  Many women do not experience postpartum reactions right away, but may be surprised to feel the onset a number of months after delivery.

Up to 80% of women experience some emotional stress after the birth (or adoption) of a new child - “the baby blues.”  For many these responses are brief and resolve themselves on their own. Up to  20% of new mothers experience stronger reactions which include: postpartum  depression, postpartum anxiety or panic  disorder,  postpartum  obsessive  compulsive disorder (OCD) and postpartum  psychosis (Bennett and Indman, 33). The  overarching  term  “postpartum  depression” is often used to describe all of these  responses,  which  can  be  confusing  to  women who do not identify with the typical symptoms of depression.  The more inclusive term, Postpartum Spectrum Disorders, will be used here. 

Symptoms of postpartum spectrum disorders include: extreme irritability and  restlessness, feelings of depression/hopelessness, intense anxiety (with or without  panic  symptoms),  intrusive  repetitive  thoughts  or  images,  difficulty  sleeping  (even when the baby is asleep), feelings  of  guilt,  inadequacy  or  worthlessness,  uncontrollable crying, and fear of harming the baby or oneself. While many people confuse the symptoms of postpartum OCD, as illustrated in the vignette, with postpartum psychosis, understanding the differences between these two disorders is crucial.  Postpartum psychosis is an extremely rare and dangerous disorder that can lead to suicide or infanticide, while postpartum OCD is generally less dangerous and much more common. This confusion, however, may leave women with postpartum OCD reluctant to report their symptoms to family or professionals, for fear that their infant will be removed from their care.

Treatment of Perinatal Spectrum Disorders 
There is clear evidence that early intervention better protects women and their babies from negative outcomes (Bennett and Indman, 42). Professional treatment  of perinatal spectrum disorders includes  medical  evaluation  (including  postpartum thyroid tests), psychotherapy, support  group  participation  and,  at  times,  medication (depending on the symptom  severity.) Most women feel that it is a combination of these supports that helps them recover and begin to feel like themselves again.

Educating women about what is happening and normalizing their experience is often an important component of working with women who are suffering from perinatal emotional dysregulation.  Furthermore,  individual  therapy  and  support group participation can reduce stress  through  normalizing  and  validating  a  woman’s experience, acting to support  self care and combating isolation.

For many women, a medication evaluation is necessary. It is helpful to frame this evaluation as a vehicle to weigh the risks of medication versus the impact of untreated maternal stress on the fetus or infant.

Depression and anxiety during pregnancy and the postpartum period may be tragic if not treated properly. Fortunately, there is clear evidence that early treatment of perinatal spectrum disorders alleviates more chronic problems and leads to better outcomes for women and their families. 

References:

Bennett, Shoshana, & Indman, Pec.  Beyond the Blues - A Guide to Understanding and Treating Prenatal and Postpartum  Depression,  Mood  Swings  Press,  San Jose, CA, 2003.

Chung T, Lau T, Chio H, Lee D. Antepartum Depression Symptomatology Is  Associated With Adverse Obstetric and  Neonatal  Outcomes.  Psychosomatic  Medicine. 2001; 63: 830-834.

Moses_Kolko E & Roth E. Antepartum  and  Postpartum  Depression:  Healthy  Mom,  Healthy  Baby.  Journal  of  the  American  Medical  Women’s  Association. 2004; 181-191.

Misri, Shaila. Pregnancy Blues: What  Every  Woman  Needs  to  Know  About  Depression During Pregnancy, Bantam  Dell, New York, 2005.

Sichel,  Deborah,  &  Driscoll,  Jeanne.  Women’s  Moods:  What  Every  Woman  Must Know About Hormones, The Brain,  and Emotional Health, HarperCollins,  New York, 2000. Ψ.