Reprinted from "Women's" issue of Visions Journal, 2004, 2 (4), p. 18-19
Despite a vast literature on postpartum depression, very little systematic research has been conducted on anxiety disorders during pregnancy and the postpartum period. The small amount of research that has been done suggests that pregnancy and the early postpartum period may be a time in a woman’s life when she is more vulnerable to feeling anxious and even to developing an anxiety disorder.
Several theories have been proposed to account for this increased vulnerability. They include:
hormonal changes known to occur during pregnancy, birth and lactation
the stressful nature of pregnancy and the birth of a child
the feelings of loss of control and of being overwhelmed that often accompany new parenthood
negative interpretations of normal changes occurring during pregnancy and following birth (e.g., interpreting normal breathlessness of late pregnancy to mean that one’s baby is not receiving sufficient oxygen), leading to anxious feelings.
Studies have looked at a number of different anxiety disorders during pregnancy and the postpartum period, including panic disorder, generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and fear of childbirth (tokophobia).
Panic disorder is characterized by the presence of recurrent, unexpected, sudden feelings of panic. Although the evidence is limited, it appears that during pregnancy, some women with this disorder improve, others stay the same and some get worse. There is somewhat stronger evidence that panic disorder tends to worsen during the postpartum period. Further, there are a sufficient number of documented cases of panic disorder beginning in pregnancy and after the birth of a child to suggest that pregnancy and the postpartum period are a time of increased vulnerability for the development of this psychological problem.
Generalized anxiety disorder
GAD involves excessive and persistent anxiety and worry about a number of different areas of one’s life. In the only systematic evaluation of postpartum GAD, 4.4% of the women assessed (i.e., three women) met diagnostic criteria in the first eight weeks postpartum. One of these women (1.5%) developed the disorder during the eight-week postpartum period. The other two developed it prior to becoming pregnant.
The kinds of concerns expressed by these women (as well as a number of other participants with subclinical1 GAD) included worries about money, physical appearance, household chores, cleanliness, parenting ability, employment or schooling, child care, free time, harm occurring to the infant, the baby’s appearance, and relationships with others (friends, family and spouse).
OCD is characterized by obsessions (i.e., recurrent, unwanted and distressing thoughts, images or impulses) and/or compulsions (i.e., repetitive mental or behavioural acts intended to decrease the distress associated with the obsessions). People with OCD also often avoid situations related to their obsessions.
Approximately 2% to 3% of the general population will suffer from OCD at some point in their lifetime. Several studies of OCD sufferers have identified a subset of patients whose OCD either began or became worse during the pregnancy or shortly following the birth of a child. Taken together, these studies suggest an increased vulnerability to OCD during pregnancy and postpartum periods.
The small body of research in this area suggests that OCD beginning during pregnancy is often characterized by fears that the unborn baby will become contaminated or harmed by toxic substances. In these cases, compulsions involved repetitive cleaning and washing behaviours.
Postpartum-onset OCD typically involves obsessive thoughts related to harm coming to the infant. These may be thoughts of accidental harm coming to the infant (e.g., a car accident), or thoughts of actually harming the infant (e.g., pushing the baby under the water in the bath). Obviously, these kinds of thoughts can be highly distressing for the mothers who experience them and can lead to avoiding the infant.
Currently, BC-based investigators are beginning a study on postpartum thoughts of harm towards the infant. They hope to develop evidence-based guidelines for health professionals working with postpartum women who disclose thoughts of harm related to their baby.
Post-traumatic stress disorder
PTSD is characterized by re-experiencing a traumatic event, avoidance of situations and people who remind one of the event, and symptoms of hyperarousal (i.e., agitation and a heightened awareness of the environment). For many, if not most women and their infants today, childbirth is safe and uneventful. However, in rare instances, childbirth may result in injury or a threat to the bodily integrity of the mother, and/or injury to, or even the death of, the infant.
Following a traumatic birth, a woman may develop symptoms of post-traumatic stress disorder. Several studies have found evidence of post-traumatic disorder occurring following miscarriage, stillbirth and other forms of traumatic pregnancy and birth experiences. It appears that anywhere from 2% to 6% of women may meet diagnostic criteria for childbirth-related post-traumatic stress disorder. Even if a woman does not develop PTSD following a traumatic birth, she may be more vulnerable to developing PTSD subsequent to later childbirth experiences.
The empirical literature suggests that postnatal depression and PTSD often co-occur. Some distinctive features of postpartum-onset post-traumatic stress disorder include avoidance of sexual activity due to a fear of becoming pregnant again or from fear of triggering flashbacks of the traumatic birth, as well as fear of childbirth, and parenting difficulties such as mother– infant attachment.
Fear of childbirth (tokophobia)
Tokophobia can occur following a traumatic childbirth, and can be of sufficient intensity to motivate a request for an elective Caesarean delivery or even to terminate the pregnancy. In one study of first-time mothers, all of the women who requested a Caesarean delivery for a subsequent pregnancy reported traumatic memories of their first childbirth experience. The fear of childbirth may be related to a lack of trust of medical staff, fear of dying, fear of one’s infant dying, or a fear of pain.
Research in each of these areas suggests that pregnancy/postpartum is a time in a woman’s life when she is more vulnerable to developing an anxiety disorder. Unfortunately, for most of these disorders, large scale studies to properly assess the prevalence of pregnancy/postpartum-onset anxiety in the general population are lacking. At this time, postpartum depression is the only pregnancy/postpartum-related disorder that is routinely screened for.
In light of the evidence presented above, it seems likely that some women who are about to give birth, or who have recently given birth, may be suffering from an undetected and untreated anxiety disorder.
About the Author
Nichole is Postdoctoral Fellow with the Interdisciplinary Women’s Reproductive Health Research Training Program, through the BC Research Institute for Children’s and Women’s Health and the Department of Health Care and Epidemiology at UBC
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