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InsightsandUnderstandingsaboutParentalAnxiety
Dr PamCookeConsultantPsychiatrist
Overview
1. Whatisanxietyandhowcommonisitintheperinatalperiodandbeyond?
2. Whatimpactdoesmaternalanxietyhaveonthefetus?
3. Whatimpactdoesanxietyhaveonattachmentbehaviours?
4. Pullingitalltogether
1.Whatisanxietyandhowcommonisitintheperinatalperiod?
DefinitionofAnxiety
CambridgeDictionary
“anuncomfortablefeelingofnervousnessorworryaboutsomethingthatishappeningormighthappeninthefuture”
“somethingthatcausesafeelingoffearandworry”
AnxietyDisorders
• DSM5
• “anxietydisordersdifferfromdevelopmentallynormativefearoranxietybybeingexcessiveorpersistingbeyonddevelopmentallyappropriateperiods.”
Perinatalanxiety
Riskofananxietydisorderintheperinatalperiodis10%(Stuart2005)
Outofthis• 1.3-2.0%- PanicDisorder• 4.4-8.2%– GeneralizedAnxietyDisorder• 2.7-3.9%– OCD• 0-6.9%- PTSD
2.Whatimpactdoesmaternalanxietyhaveonthefetus?
Whyisitsoimportanttoidentify?
Shortandlongtermconsequencesforthepregnancy,foetus,childandsubsequently,theadult
Pregnancyoutcomesassociatedwithprenatalstress
• Increaseincongenitalmalformationsassociatedwithseverestressinfirsttrimestere.g.deathofolderchild(HansenDetal2000)
• Lowerbirthweight(Wadhwa PDetal1993)• Prematurity• Alteredsexratio– fewermalesbeingbornthaninanunstressedpopulation(Peterka Metal2004)
FetalOutcomes- FetalProgramming
Definition“whentheenvironmentinuteroduringspecificcriticalperiodsfordifferentoutcomes,canaffectthedevelopmentofthefetusandthechildinthelong-term”e.g.– especiallystudiedinrelationtofetalgrowthandlatervulnerabilitytocardiovasculardisease.
Newbornsandinfants
Adversebehavioural outcomesobservablefrombeginning• more“difficult”temperament• Sleepproblems• lowercognitiveperformance• Increasedfearfulness
Ages3-16yrs
• Increasedriskforchildemotionalproblemsespeciallyanxietyanddepression
• SymptomsofADHD• Conductdisorder(stressinlaterpregnancy)• Reductionincognitiveperfomance• Increasedriskofautisminsomestudies,withexposureinmid-lategestation(LiJetall–2009)
• Increasedriskforschizophreniawithseverestress(e.g.invasionoftheNetherlandsin1940)(vanOs Jetal– Prenatalexposuretostressandsubsequentschizophrenia.TheMay1940invasionoftheNetherlands.BrJPsychiatry1998
• Firsttrimesterexposureappearstobethesensitiveperiod.
Alsoarangeofalteredphysicalandphysiologicaloutcomes• Alteredfingerprintpattern(KingSetal2009)• Mixedhandedness(Obel Candothers2003)• Specificregionalreductionsinbraingrey-matterdensitylikelyresponsibleforfortheneurodevelopmental,psychiatric,cognitiveandintellectualimpairment
• AlteredfunctioningoftheHPAaxis- altereddiurnalrhythm
• Reducedlifespan(reducedtelomerelength-linkedtoprematureaging)
• Asthmaage7years
Ingeneral,prenatalstressincreasesanxietyanddepressivebehaviours toagreaterextentinfemaleoffspring,andimpairslearningandcognitionmoreinmaleoffsrping – whichisinkeepingwithahigherprevalenceofanxietydisordersand“neuroticism”foundinwomencomparedtomen
PotentialUnderlyingBiologicalMechanismsforFetalProgramming
• ?Increasedexposureoffetustocortisol.Certainamountneededbutoverexposurecanpredisposetoillhealthinlaterlife
• Stressmayaffectthetransportofmaternalcortisolthroughtheplacenta,andincreasethecortisollevelinthefetus.
3.Whatimpactdoesanxietyhaveonattachmentbehaviours?
Anxietyandattachment
Whatmakesanemotionallyhealthyperson?
Emotionallyhealthyhumans.
• Stemsbacktoearlyattachmenttoprimarycaregiver.Maternalanxietymayaffectthissignificantly
• AttachmentTheory- Bowlby andAinsworth-WHO1951– MaternalCareandMentalHealth“theinfantandyoungchildshouldexperienceawarm,intimate,andcontinuousrelationshipwith(his)mother(orpermanentmothersubstitute)inwhichbothfindsatisfactionandenjoyment”
AttachmentPatterns
• Classificationbetween12-18months
SecureAttachment
55-60%ofnon-clinicalpopulation
• good attunement between mother and baby • baby seeks out mother as secure base and
mother able to provide appropriate comfort • mother encourages appropriate exploration
InsecureAvoidant
20-25%ofpopulation
• parent may be dismissive of child’s need for comfort, or may not notice child’s needs
• Encourages independence in child
InsecureAmbivalent(Anxious)
10-15%ofpopulation
• child’s independence and exploration is minimised by parent
• child will seek out parent for comfort in times of distress, but will often be difficult to settle
InsecureDisorganised
15-20%ofpopulation
• Childexperiencescaregiversaseitherfrighteningorfrightened
• Characterizedby lackofacoherent‘organized’behavioural strategyfordealingwiththestresses
Assessment of Mother–Infant Relationship
Unsettledinsleepand/orfeedingDifficulttosettleIrritable/constantlycryingReflux/gastricdistressHyper-vigilanceDifficultyseparatingfromparent
Withdrawal/passivityFreezingGazeavoidantFailuretoThriveFlataffect/lackofcrying/limitedvocalisingEmotionallyunder-responsive
InteractiveResponsiveEngagingHoldseyegazeSmilingMirrorsparentalfacialexpressionCryingwhendistressedSettleswhencomfortedExplorestheworld
HEALTHYINFANTBEHAVIOURS BEHAVIOURSOFCONCERN
Avoidantattachmentbehaviours
Anxiousattachmentbehaviours
IndiscriminantAttachmentbehavioursInteractseasilywithstrangersAvoidsparents
WHATARETHECONSEQUENCESOFTHESEATTACHMENTPATTERNSFORCHILDRENANDSUBSEQUENTLY, FORADULTS?
AvoidantAttachment
Behaviours aschildren-externalizingbehaviours• Aggression• Hostility• Conductdisorders
Behaviours asadults• Denyfeelings• Hidefeelings• Denypainfulemotions• Dismisspainfulmemoriesorevents
AmbivalentAttachment
Behaviours aschildren• Anxietydisorders• Emotional
Behaviours asadults• Anxietydisorders• Overlyemotional• Limitedassertiveness
Disorganised AttachmentBehaviours aschildren• Aggressive• Pooremotional
regulation• Morelikelytodissociate• Lowerreflectivefunction• Lowerselfesteem• Academicproblems• Morelikelytoberejected
bypeers
Behaviours asadults• Depression• Anxiety• Substanceabuse• Excessivefocusonnew
romanticpartners“BorderlinePersonalityDisorder”
Roleoffearinattachment
• Securechildrenfeardanger• Avoidantchildrenfearcloseness• Ambivalentchildrenfearseparation• Disorganizedchildrenfeartheircaregiver
4.Pullingitalltogether.
Howdoesknowingallthisinfluencemypractice?
• Some anxiety is normal in pregnancy or the post natal period, however anxiety that is persisting, significantly distressing or has associated with it a decline in functioning may be symptomatic of an anxiety disorder
2subgroups.
- Peoplewithapre-existingcondition– eitherdiagnosedorundiagnosed
- Peopleinasituationalcrisis/adjustmentreaction/disorder
Question
Howdoyoudecideifapregnantwomanorparentismoreanxiousthanthe“norm”?
My“clinicalfilter”– totallyintuitiveandnon-evidencebased!
• Alotofreferencestofeelinganxiousareactuallymanifestationsofdepression- manypeopledon’tidentifywithhavingalowmood,butdoidentifywithfeelinganxious,andmoreoftenthannot,aclinicalsignificantlevelofanxietyhasacomponentofdepression
• Ifaparentcan’tgetbacktosleepafterthebaby/youngchildhasresettled,likelytobemoreclinicallysignificant.
• Howdotheyfeeliftheyhavesometimetothemselves,e.g.abreakfromthebaby/youngchild,todosomethingthattheyusuallywouldenjoydoinge.g.goingforacoffeewithoutthechild/childrenforacoupleofhours?
• Haveotherpeoplecommentedontheirpresentationoronanychangeintheirchild?
Issuesintreatment
• Howtoengage/educateawomanwhoispregnantandanxious,abouttheadverseoutcomesofbeinganxiousinpregnancyversusrisksfrompharmacotherapy?
• Enlistingthesupportofpartnerandfamilyifappropriate
• Knowingtheresourcesavailabletoyou–importanceoftheGPasthecoordinatorofcare
Multifacetedapproach
• Psychoeducation aboutthecondition• Elicitingbarrierstoeffectivetreatment• Behavioural modification- especiallydietandexercise
• Psychologicaltherapies• Medicationoptions• Selfhelp/supportgroups• ParentInfantResearchInstitute
CaseHistories
1. “Rob”– 19yr oldmaleinadultinpatientunit2. “Mary”27/40pregnantwithsevereOCD.
Cameoffsertralineat4weekspregnant,whenshediscoveredshewaspregnant.Severerelapse
3. “Anne”presentedat12monthspostpartum,withseverehealthanxietyandanxietyregardingherdeath.Hadtraumaticlabouranddelivery.
Takehomemessages1. Anxietyiscommon.Likelythat1:10antenatal
patientswillhaveananxietydisorder2. “Pathological”maternalanxietycanresultin
adverseconsequencesforthepregnancyandchildduetofetalprogramming
3. Disturbedmaternal-infantattachmentasaresultofmaternalanxietycanexacerbatebehavioural andmentalhealthissuesinoffspring.
4. Ifindoubt,refertoGPforfurthertriageorrefertohospitalpsychiatricservices.
Questions?
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