Read Part One in this series . . .

Risk Factors for Perinatal Mental Illness (saaay what -so many??)

Etiology: Bio-psycho-social

Current research does not give us a crystal clear cause for perinatal mooddisorders. It seems that a convergence of biological, psychological and social (biopsychosocial) factors play a role in the intensification of anxiety and mood disorders during the childbearing year.

In other words, it is likely that a mixture of past mental health issues, hormonal changes and stressors from your current situation create a vulnerability to a mood disorders in the childbearing year (Kleiman & Wenzel, 2011; Kleiman, 2009; PSI, 2009; Puryear, 2007; Nonacs, 2006; Kendall-Tackett, 2005).

Listed below are some of the commonly acknowledged risk factors. I tried to group them into bio/psycho/social categories, but as you can see, there is much overlap.

Biological / Psychological

• A personal history of a mental illness in her lifetime, ie, depression anxiety, PTS/PTSD, OCD or bipolar disorder (may have been diagnosed & treated or was undiagnosed & untreated) (previous PPD history increases risk to 50 - 80 % risk of recurrent PPD, as compared to 10- 20% risk w/o a prior episode)
• A familial history of depression or anxiety disorders, etc (undiagnosed/diagnosed)
• Premenstrual syndrome/disorder. A woman with a heightened sensitivity to her hormonal cycle, may be more vulnerable to the hormonal changes of pregnancy & birth.
• A heightened sensitivity to hormonal fluctuations of pregnancy and childbirth.
• Going through a traumatic birth. Traumatic birth occurs on a continuum from disappointing care to painful natural birth to life rescue efforts during the birth (huge topic)
• Her infant is born premature (both the birth and the NICU experiences can be traumatic)
• A history of extensive infertility treatments, trauma from necessary medical procedures
• A history of previous miscarriages (can accompany infertility tx or not)
• Unresolved feelings about termination of an earlier pregnancy
• Her infant is born with a disability.
• Her infant is stillborn, or a history of previous stillbirth

Social / Psychological

• Poverty is a big risk factor for the development of perinatal mental illness.
• Lack of social support: geographical move, a non-supportive family structure (alcoholism, etc), or a major change in job (ie, from career to SAHM).
• Unhealthy current family dynamics: Occurs on a continuum from feelings of disconnect, poor communication & relationship skills, different parenting styles, bullying, to domestic violence
• Domestic Violence creates a complex history of trauma/PTS/PTSD
• Personal history of sexual abuse or sexual assault creates a complex history of trauma/PTS/PTSD.
• Past family dynamics: Unresolved issues from childhood regarding parenting and being parented interferes with the transition to parenthood (huge topic -can cause major anxiety and depression)
• Major life stressors, such as an accident or death in the family.

Differential Types of Perinatal Mental Illness

An accurate diagnosis?

I've gotten feedback (thank you Lara!) that I need to acknowledge not all sadness and stress in new mothers should be considered pathological, ie, needing diagnosis and treatment. So I'd like to publicly say that being a mom, caring for a newborn, can be overwhelming and that sleep deprivation can be a big factor in destabilizing a person emotionally, and some support for a new mom such a hard job can go a long way. Debra Flashenberg, CD(DONA), LCCE, wrote an article for Lamaze about her friend's personal experience with a perinatal mood disorder.

The thing about any mental illness is that it exists on a broad continuum from 'adjustment' behavior to varying degrees of 'abnormal' behavior, where the person becomes so disorganized in their daily living that it does warrant treatment, Where that line is, is not always obvious, and requires discernment and sensitivity to individual needs.

The clinical presentation of the diagnoses below often overlap and/or co-occur. Diagnosis is sometimes not simple, and may be confounded by a prior history of depression, anxiety, post-traumatic stress influenced by previous life experiences.

Simpler depression and anxiety can be diagnosed and treated in primary care. A psychiatric consult is necessary for more complex cases. Licensed mental health professionals can diagnose and treat a broad range of mental disorders. Optimal treatment is usually a combination of medication, therapy and social support, tailored to individual needs.

Not all of the following categories of perinatal mental illnesses are recognized by the Diagnostic and Statistical Manual of Mental Disorders (DSM). But, many practitioners in perinatal mental health, including authors of the references to this article, recognize these differential diagnoses in clinical practice.. There is currently an active discourse in creating these new diagnoses.

Rates of perinatal mood disorders occurrence:

• 85% suffer baby blues
• 15% suffer depression
• 10% suffer postpartum anxiety
• 3 - 5% postpartum OCD
• .1% postpartum psychosis
• 1 - 6 % postpartum (birth) trauma - PTSD

Alphabet soup: BB, PPD, PPA/PPOCD, PP, PTSD/CB

These categories may seem confusing, but, as a childbirth educator, you don't have the burden of diagnosis, this is for educational purposes.

BB - Baby Blues. Not a mental illness. The baby blues self-resolve and are normal. Occurs in the first two weeks or so after birth, goes away by itself. Not a mild form of postpartum depression.

PPD - Postpartum Depression.

Symptoms: If weepiness, sleeplessness, low self-esteem, change in appetite, feelings of being abandoned, alone, anger (rage), listlessness continue past two - three weeks, may be indicative of PPD. May have thoughts of self-harm or of harming the baby. In general, women who are depressed after birth who actually attempt and commit suicide are those who have histories of previous psychiatric events or previous suicide attempts. But, whenever harming behaviors are mentioned, please take it seriously. Some specialists believe PPD can overlap BB and can occur anytime in the first year. If the sad feelings are dragging on past the two-three week delimiter, it is best to seek help, rather than continue to suffer painful debilitating symptoms while also caring for an infant.

PPA/PPOCD - Postpartum Anxiety/OCD - PPA/PPOCD.

Some research suggests that some women who develop PPA/PPOCD have a heightened sensitivity to hormonal levels, in particular oxytocin, and this sensitivity may over-stimulate natural maternal behaviors, thus increasing maternal behaviors to over-protectiveness (Driscoll and Sichel, 1999). Other researchers believe the pre-existence of perfectionistic/rigid thinking styles may predispose a woman to PPA / PPOCD (Kleiman & Wenzel, 2011).

Symptoms: A pervasive anxiety that expresses itself as over-concern for the baby, over concern about germs, cleanliness, sleep arrangements, parenting skills and the normal attachment process. The mom becomes hyper-vigilant. She may bring baby to the hospital or doctor over and over again. She may develop checking behaviors such as checking to see if the blankets around the baby are folded properly, checking to see if the baby is breathing over and over again. She may engage in checking and counting rituals (counting the ceiling tiles, right angles, etc), which help her feel safe & soothed. She ay have scary thoughts about harming the baby or herself may occur. As in PPD, these must be taken seriously.

PP - Postpartum Psychosis. Separate disorder from PPD/ PPA/PPOCD

Most significant risk factor for PP is previously (un)diagnosed bipolar disorder, a previous psychotic episode or a family history of schizophrenia. Healthcare provider screening and prevention is extremely relevant to PP. Women are most susceptible in the first thirty days after childbirth.Postpartum psychosis is a psychiatric emergency. Get help immediately.

Symptoms:

Not sleeping for a few nights in a row, delusions, speaking about nonsensical beings, thoughts about evil beings, death, intense fear, mumblings, robotic movements, acting as if she can hear words coming from somewhere else (command language), staring, flat affect, deflated speech, one word answers, catatonia, staring, paranoia. You cannot talk a person out of their psychotic delusions. Best to nod your head, say, 'I understand' or 'Must be hard' and GET HELP IMMEDIATELY. The person is very ill and needs help, not ridicule or fear.

Post-traumatic Stress Disorder (PTSD) Secondary to Childbirth -PSTD/CB.

Walker Karraa has written many articles about trauma and childbirth for Science and Sensibility. Like all emotional experiences, trauma is experienced on a continuum. There are two recognized diagnoses: post-traumatic stress (PTS) and post-traumatic stress disorder (PTSD), with PTSD having more long-term symptoms.

Symptoms of PTS are considered normal reactions to a traumatic event. PTS symptoms are the same as PTSD, but present to a lesser extent: dissociation, avoidance, numbing, flashbacks, hypervigilance, anxiety, depression. Normal response to trauma is considered a normal survival response, our mindbody's way of integrating traumatizing events slowly, in small chunks. This way of ignoring things to get by, to a normal extent, is sometimes called 'coping ugly.' PTS symptoms are self-limiting, and most people recover from it.

Ayers (2004) reports 1/3 women in western world consider their birth to be traumatic and ten percent report severe symptom of traumatic stress. Dr Ayers (2004) says difficult birth experiences affects psychological health, but for majority it is self-resolved. 1% - 2% develop clinical post-traumatic stress symptoms which need treatment.

'Part Three' coming up is a guide to positive helping and suggested resources.

Do you believe you can be a positive influence regarding maternal mental health?

Do you believe it is important to be aware of perinatal mental illness?

Please share your views below. Love to hear from you!

References

Ayers, S. (2004). Delivery as a traumatic event: Prevalence, risk factors, and treatment for postnatal post-traumatic stress disorder. Clinical Obstetrics and Gynecology, 47(3), 552-567.

Driscoll, D. and Sichel, J. (1999). Women's moods: What every woman must know about hormones, the brain, and emotional health. New York: HarperCollins

Kendall-Tackett, K. (2005). Depression in new mothers. New York: Haworth Press.

Kleiman, K. (2009). Therapy and the postpartum woman. New York: Routledge Press.

Nonacs, R. (2006). A deeper shade of blue. New York: Simon and Schuster.

Postpartum Support International (2009). Components of care. Seattle: PSI

Puryear, L. J. (2007). Understanding your moods when you're expecting. New York: Houghton Mifflin Company.

Twomey, T.M. (2009). Understanding postpartum psychosis: A temporary madness. Westport, Ct.: Praeger Publishers.

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