Class 6: Perinatal Mood and Anxiety Disorders, Substance Use, Infant Loss

• Class 6 of Doula Training & Mentorship covers:
  • Perinatal Mood and Anxiety Disorders
  • Substance Use
  • Infant Loss

About PMADS

• Pregnancy can be a risk factor for developing certain mood conditions.
• Fluctuations are normal in pregnancy, longer term symptoms should be noted.
• PMADs can occur during pregnancy or in the 12 months after.
• Perinatal refers to the pregnancy period and up to 12 months after birth.

Types of PMADS

• Perinatal depression
• Perinatal anxiety
• Perinatal panic
• Perinatal OCD
• Perinatal PTSD
• Perinatal bipolar disorder
• Perinatal psychosis

PMAD Risk Factors

• Having a chronic mood or anxiety disorder.
• A prior PMAD in a previous pregnancy.
• Family history of mood or anxiety disorders.
• A traumatic birth experience.
• Clinical complications during pregnancy or postpartum.
• Hormonal imbalance.
• Low social support.

Pregnancy vs Depression

• Pregnancy can be a labile, teary mood with unchanged self-esteem

• Sleep is uninterrupted except when bladder is full or experiencing heartburn, and there is no suicidal ideation/intent

• Pleasure includes joy and anticipation with an increased appetite

• Depression can be a gloomy, irritable, agitated, enraged mood with low self-esteem and guilt

• Sleep is difficult to initiate or sustain and may be accompanied with suicidal thoughts, plans, or intentions

• Loss of interest in things that were once exciting with a dysregulated appetite

Baby Blues

• Affects 60-80% of new mothers universally.
• They are due to hormonal fluctuation and acute sleep deprivation.
• Lasts between two days and two weeks post-delivery and peaks 3-5 days after delivery.
• Baby Blues includes Symptoms
• Tearfulness, lability, reactivity, exhaustion
• Predominantly happy, self-esteem remains unchanged
• Unrelated to stress or psychiatric history
• Baby blues is not considered a perinatal mood or anxiety disorder
• If symptoms persist after two weeks postpartum, it is not the baby blues and should be further evaluated Consider:
  • Severity/intensity
  • Timing/onset
  • Duration/chronicity

Major Unipolar Depression

• Five or more symptoms must be present during the same two-week period:
  • Depressed mood most of the day, nearly everyday
  • Loss of interest, joy, pleasure
  • Significant weight change or appetite disturbance
  • Sleep disturbances (insomnia or hypersomnia)
  • Psychomotor agitation or retardation
  • Fatigue or loss of energy
  • Poor concentration, focus, indecisiveness
  • Feelings of worthlessness
  • Excessive or inappropriate guilt
  • Recurrent thoughts of death or suicide

Presentation of Perinatal Depression

• Overwhelmed with feelings like "I can't cope."
• Lack of feelings or connection toward the baby.
• Inability to take care of oneself or one's family.
• Frequently co-morbid with anxiety.
• Isolation and social withdrawal.
• Agitation, irritability with feelings like "This doesn't feel like me."
• Increased somatic symptoms (headaches, back pain, GI distress, etc.).

Perinatal Anxiety

• Prevalence is about 16%.
• Must have three or more symptoms:
  • Excessive anxiety and worry (often about one's health or one's baby)
  • Difficulty controlling one's worry
  • Agitation, irritability, can escalate to rage (then spiral to guilt/shame)
  • Usually a trigger to the thought spiral or symptom onset
  • Restlessness, inability to sit still, feeling on edge
  • Poor concentration or mind going blank
  • Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)
  • Increased somatic symptoms (muscle tension, palpitations, racing heartbeat, shortness of breath, Gl distress)

PMADs and Partners

• For new dads and anxiety
  • 4% - 16% occurs during the prenatal period
  • 2% - 18% occurs during the postnatal period
• Partners are 50% more likely to experience PMAD if the birthing person experiences one.

Perinatal Panic Disorder

• Prevalence is about 16%.
• Must have four or more symptoms:
  • Episodes of intense fear or discomfort reaching a peak within minutes
  • Shortness of breath, chest pain, sensations of choking or smothering, dizziness
  • Hot or cold flashes, trembling, rapid heart rate, numbness or tingling sensations
  • Restlessness, agitation, irritability
  • Excessive worry or fear
  • Persistent fear of dying, going crazy or losing control
  • Often no identifiable trigger to the thought spiral or symptom

Perinatal Obsessive-Compulsive Disorder

• Prevalence is about 32%; 65% have co-morbid depression

Obsessions

• Defined by:
  • Recurrent and persistent thoughts, urges, or impulses that are intrusive and unwanted and cause marked anxiety or distress
  • Individual attempts to ignore or suppress thoughts, urges, or images to neutralize them with some other thought or action

Compulsions

• Defined by:
  • Repetitive behaviors that the individual feels driven to perform in response to obsession
  • Behaviors or mental acts are aimed at preventing or reducing anxiety or distress

Perinatal OCD Presentation

• Intrusive, repetitive thoughts – usually of harm coming to baby

• Caught in a spiral of "what if" thinking

• Tremendous guilt and shame

• Horrified by these thoughts

• Hypervigilance Mothers engage in behaviors to avoid harm or minimize triggers

• Common fears:

  • Deliberate harm
  • Contamination
  • Accidental harm
  • Ordering/arranging
  • Religious
  • Checking

Perinatal Post-Traumatic Stress Disorder

• Prevalence: 16% in high risk samples (Medicaid population)
• Symptoms follow a traumatic event that last for more than one month after the event

Birth Trauma

• An event occurring after labor and birth can involve actual or threatened serious injury/death to the mother/infant or stripping the woman of her dignity
• The birthing individual may experience intense fear, helplessness, loss of control, and horror.
• Potentially Traumatic Perinatal Events
  • Emergency cesarean delivery
  • Postpartum hemorrhage
  • Prematurity or stillbirth
  • Unexpected NICU admission
  • Forceps/vacuum extraction
  • Severe preeclampsia
  • Third or fourth degree tear
  • Hyperemesis gravidarum
  • Traumatic vaginal birth
  • Fetal anomaly diagnosis in pregnancy
  • Witnessing partner's birth experience
  • Shoulder dystocia
  • Long labor process
  • Failed pain medication or poor response to anesthesia

Bipolar Disorder Presentation

• Often misdiagnosed as postpartum depression 50% of the time!
• At least one lifetime episode of mania Elevated mood symptoms
  • Euphoria or agitation
  • Decreased need for sleep
  • Racing thoughts
  • Increased productivity
  • Noticed by others
  • Pressured speech
  • Increased energy

Hypomania episodes

• up to 4 days in length and often improves functioning

Mania episodes

• severe symptoms where Functioning is impaired
• At least 7 days in length that requires hospitalization or psychotic symptoms, like hallucinations, paranoia, or disorganized thinking

Psychosis Risk Factors

• First baby
• Discontinuation of mood stabilizer
• Obstetric complications
• Perinatal or neonatal loss
• Previous bipolar episodes, psychosis or postpartum psychosis
• Family history of bipolar disorder or postpartum psychosis
• Sleep deprivation

Psychosis Prevalence

• 1-2 in 1,000 postpartum women develop it
• Of those affected:
  • 5% die by suicide, 5% commit infanticide, and 50% of first-time mothers who experience psychosis had no previous psychiatric hospitalization
  • Onset usually within the first two weeks after birth
  • Clinical Features Postpartum Psychosis Symptoms

Postpartum Psychosis Presentation

• Onset is within 2 weeks postpartum
• Cognitive is defined by poor concentration, impaired sensorium, disorientation
• Behavioral is defined by agitated, hyperactive, emotionally distant, aloor, lack of self-care
• Mood is defined by Elated, labile, dysphoric or less often depressed
• Speech is rambling
• Thought Content includes thought broadcasting, ideas of reference, persecutory, jealousy, paranoia of being controlled, delusion of grandiosity
• Thought Process is disorganized thinking, flight of ideas
• Perceptions are hallucinations
  • Acute dysfunction of the brain

Substance Use Disorder

• Includes drug and/or alcohol usage during pregnancy and postpartum
• It requires ongoing clinical and behavioral management
• You should not manage this on your own as a doula

Infant Loss

• Can be due to a known genetic condition or anomaly
• Can occur due to stillbirth (born deceased) or immediately postpartum (complications that were not treatable or curable) or due to accidental death like SIDS
• Bereavement doula services are common

Study Points

• How might screening for PMADs help improve outcomes?
• Research the statistics in black vs. white prevalence of PMADs