Insights and Understandings about Parental Anxiety · Insights and Understandings about Parental...

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?