Cognitive Behavioral Therapy for Perinatal Distress

Amy Wenzel, Karen Kleiman

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781317668435
• Edition: 1
• Topic: Psychology
• Subtopic: Cognitive Psychology & Cognition
• Index: Psychology

Countless studies have established the efficacy of cognitive behavioral therapy (CBT) for many manifestations of depression and anxiety. In Cognitive Behavioral Therapy for Perinatal Distress, Wenzel and Kleiman discuss the benefits of CBT for pregnant and postpartum women who suffer from emotional distress. The myths of CBT as rigid and intrusive are shattered as the authors describe its flexible application for perinatal women. This text teaches practitioners how to successfully integrate CBT structure and strategy into a supportive approach in working with this population. The examples used in the book will be familiar to postpartum specialists, making this an easily comprehensive and useful resource.

1
Perinatal Distress

An Overview

It is increasingly being recognized that the transition to parenthood is difficult and is associated with significant stress that can put women at risk of mental health problems. Although a newborn can bring much joy and fulfillment to one’s life, there is no getting around the fact that, for many women, pregnancy is fraught with discomfort and excruciating uncertainty, and that the postpartum period brings overwhelming sleep deprivation, fatigue, and emotional ups and downs. Moreover, perhaps like no other event in one’s life, the process of becoming a mother makes one critically examine core values and beliefs and can change her sense of self. When the transition to parenthood is difficult, this shift can feel unwanted and scary. Common sentiments expressed by women who seek treatment for distress during the perinatal period are, “I don’t feel like myself” and “I can’t imagine ever feeling normal again.”

Although postpartum depression has received a great deal of attention for many years in research literature and in the media, more recently, it has been recognized that anxiety is a significant manifestation of postpartum distress in its own right (Wenzel, 2011). There is increasing awareness that clinically significant expressions of depression and anxiety are not limited to the postpartum period. Many women experience depression and anxiety during pregnancy, which has the potential to affect self-care and care of the developing fetus (e.g., attendance at prenatal visits, use of alcohol or drugs; Lobel, Dunkel-Schetter, & Scrimshaw, 1992). This recognition led the developers of the Diagnostic and Statistical Manual, 5th Edition (DSM-5) (American Psychiatric Association, 2013) to change the “with postpartum onset” specifier associated with the diagnosis of major depressive disorder to “with perinatal onset,” defined as the onset of depression during pregnancy or in the first four weeks following childbirth.

Although the DSM-5 recognizes the onset of postpartum depression only within the first four weeks following childbirth, many perinatal experts define postpartum depression as occurring at any time during the first year following childbirth (e.g., C. T. Beck & Driscoll, 2006). For example, women may experience an increase in distress when they return to work, which often occurs 8 to 12 weeks following childbirth. Moreover, some researchers have indicated that breastfeeding protects against some manifestations of emotional distress, as some hormones remain elevated in order to stimulate milk production (Klein, Skrobala, & Garfinkel, 1995). Because many women choose to nurse their infants for at least six months, according to the guidelines put forth by the World Health Organisation (WHO, 2003), it follows that some women may exhibit signs of emotional distress several months after the birth of their child when they discontinue breastfeeding. This is particularly true if they wean abruptly.

This book describes the application of a well-established psychotherapeutic approach to the treatment of perinatal distress, defined as the experience of depression and/or anxiety during pregnancy or within the first postpartum year. Depression is a fairly circumscribed construct; the symptoms that contribute to a diagnosis of major depressive disorder are: (a) depressed mood more of the time than not; (b) anhedonia, or the loss of interest in previously enjoyable activities; (c) appetite disturbance; (d) sleep disturbance; (e) psychomotor disturbance; (f) fatigue; (g) a sense of worthlessness or inappropriate guilt; (h) concentration difficulties or indecisiveness; and (i) suicidal ideation (APA, 2013). Diagnosing depression in perinatal women can be difficult, as many of the symptoms (e.g., sleep disturbance, fatigue) can also be attributable to being pregnant or to having a newborn. The key feature in establishing a diagnosis of major depressive disorder in a perinatal woman is that the symptoms must be in excess of that which are expected by her life circumstances (Wenzel, 2011).

In contrast, perinatal anxiety is more diffuse and can have many manifestations, defined as follows:

• Generalized anxiety: Generalized anxiety is excessive, uncontrollable worry associated with the following symptoms: (a) restlessness; (b) fatigue; (c) concentration difficulties; (d) irritability; (e) muscle tension; and (f) sleep disturbance. In order to meet the criteria for a diagnosis of generalized anxiety disorder (GAD), a person must report these symptoms more days than not for a period of at least six months (APA, 2013). Perinatal women who report a shorter duration of worry are diagnosed with adjustment disorder with anxious mood (Matthey, Barnett, Howie, & Kavanagh, 2003).
• Panic attacks: A panic attack is a sudden onset of intense fear or discomfort that peaks within several minutes. Characteristic symptoms of panic attacks include: (a) heart palpitations; (b) sweating; (c) trembling; (d) shortness of breath; (e) a sensation of choking; (f) chest pain or tightness; (g) gastrointestinal distress; (h) dizziness or lightheadedness; (i) chills or hot flashes; (j) tingling or numbness; (k) derealization or depersonalization; (l) a fear of losing control or going crazy; and (m) a fear of dying during the episode. A person is diagnosed with panic disorder when she has recurrent panic attacks accompanied by persistent worry about having the attacks or a change in behavior because of the attacks (e.g., avoiding circumstances that are perceived as prompting the attacks; APA, 2013).
• Social anxiety: Social anxiety is excessive fear of negative evaluation by others or embarrassment in front of others. A diagnosis of social anxiety disorder is made when the person goes to great lengths to avoid social or evaluative situations, or endures them with great distress, and when the social anxiety causes significant life interference or subjective distress (APA, 2013).
• Obsessions and compulsions: Obsessions are unwanted, intrusive thoughts, often of a disturbing nature. Compulsions are mental or behavioral rituals that a person performs, often to neutralize the anxiety associated with obsessions. In order to be diagnosed with obsessive compulsive disorder (OCD), the obsessions or compulsions must be time consuming (i.e., take up at least one hour per day), cause life interference, or cause clinically significant distress (APA, 2013).
• Posttraumatic stress: Posttraumatic stress is emotional distress resulting from exposure to actual or threatened death, serious injury, or sexual violence. Many women perceive childbirth to be traumatic, as they fear that they or their child will die during childbirth. A person is diagnosed with posttraumatic stress disorder when he or she has had exposure to a traumatic event, as defined above, and experiences symptoms in the realms of: (a) re-experiencing the trauma (e.g., through intrusive memories); (b) avoidance of memories or reminders of the trauma; (c) negative effects on mood or cognition (e.g., lack of interest in meaningful activities, detachment from others); and (d) increase in arousal and reactivity (e.g., irritability, hypervigi-lance) for at least one month (APA, 2013). If a person experiences these symptoms immediately after the trauma, but they have not yet persisted for one month, then he or she is diagnosed with acute stress disorder.

Many mental health practitioners question when to make a diagnosis of one of these mental health disorders. After all, the transition to parenthood is one of substantial adjustment, and surely most new mothers experience some emotional lability as their hormone levels drop to their pre-pregnancy levels. Research does, indeed, support this observation. The postpartum blues is a transient mood disturbance experienced by 40–80% of new mothers, characterized by a few days of tearfulness, mood swings, and insomnia (Buttner, O’Hara, & Watson, 2012). The key in this definition is the word “transient”; if these symptoms persist for at least two weeks out of a month then a diagnosis of major depressive disorder should be considered. In addition to the duration of symptoms, a diagnosis of a depressive, anxiety, obsessive compulsive-related, or trauma or stressor-related disorder should be considered if the woman is experiencing life interference or substantial emotional distress. The most salient example of life interference in perinatal women is difficulty caring for the newborn or for older children in the household. This does not mean that asking for help is diagnostic of perinatal distress, as cognitive behavioral therapists encourage perinatal women to seek assistance with child care in order to maintain optimal self-care during the transition to parenthood. However, when a woman is having trouble providing consistent care, avoiding providing child care, or letting essential duties slip, she meets the criteria for life interference associated with her emotional distress.

Features of Perinatal Distress

Women who experience perinatal distress are usually quite concerned about their emotional state. They want to know whether what they are experiencing is normal, whether they are going crazy, and whether their children would be better off being raised by somebody else. Although entire books can be written about the features of perinatal distress, this section describes some highlights from the empirical literature about the prevalence, risk factors for, and consequences and cost of perinatal emotional distress. The important message is that perinatal distress is common and understandable in light of many vulnerability factors that put women at risk of emotional distress in times of stress, such as the transition to parenthood (see also Chapter 2). It is a significant public health problem, as untreated emotional distress is associated with adverse effects in children and lost work days.

Prevalence

The majority of studies examining the prevalence of perinatal emotional distress have focused on postpartum depression. When postpartum depression is defined as major and minor depression, the prevalence has been estimated at 19.2%; when only cases of major depression are considered, then the prevalence has been estimated at 7.2% (Gavin et al., 2005). Even though the rates are high, there is only weak evidence that the perinatal period represents a time of increased risk for depression, relative to other times in women’s lives (O’Hara & McCabe, 2013), although a small body of literature suggests that there is a subset of women who are particularly vulnerable to develop postpartum depression, relative to depression at other times in their lives (e.g., Bloch et al., 2000; Forty et al., 2006).

Studies have also investigated the prevalence of various manifestations of perinatal anxiety. Those rates are as follows:

• GAD: Results from some studies suggest that the rates of GAD are elevated in pregnant (10.5%; Adewuya, Ola, Aloba, & Mapayi, 2006) and postpartum (8.2% at 8 weeks, 7.7% at 6 months, 7.0% at 12 months; Wenzel, Haugen, Jackson, & Brendle, 2005) women, relative to rates between 1% and 3% in women representative of the general population (Jacobi et al., 2004). However, it must be acknowledged that other studies have reported low rates of GAD in perinatal samples (e.g., 0.6%; Navarro et al., 2008).
• Panic disorder: Research shows that the prevalence of panic disorder during pregnancy is elevated (5.2%; Adewuya et al., 2006; 2.5%; Guler et al., 2008) relative to the rate of panic disorder in women representative of the general population (1.3%; Jacobi et al., 2004). In contrast, the rate of panic disorder in the postpartum period is similar (1.4%; Wenzel et al., 2005) to that observed in women representative of the general population (Jacobi et al., 2004).
• Social anxiety disorder: There is a paucity of research that has examined the prevalence of social anxiety disorder in perinatal women. In one exception, Adewuya et al. (2006) reported that 6.4% of women in their third trimester of pregnancy met criteria for social anxiety disorder, relative to 1.7% of non-pregnant women. Wenzel et al. (2005) found prevalence of 4.1%, not appreciably different from rates of up to 5.2% in women representative of the general population (Magee, Eaton, Wittchen, McGonagle, & Kessler, 1996). Although these results might suggest that social anxiety is not particularly problematic for perinatal women, particularly those who are postpartum, Wenzel (2011) noted cases of women who reported a postpartum onset of social anxiety that was associated with isolation from friends (especially friends without children) and marital dissatisfaction that was beyond the typical dissatisfaction that accompanies the transition to parenthood.
• OCD: A recent meta-analysis found that the risk for OCD during pregnancy (2.07%) and the postpartum period (2.43%) was elevated relative to the risk at other times in a woman’s life (1.08%; Russell, Fawcett, & Mazmanian, 2013). Moreover, research by Jonathan Abramowitz and his colleagues suggests that at least two-thirds of new mothers, if not more, experience upsetting intrusive thoughts about harm coming to their infants (e.g., Abramowitz, Schwartz, & Moore, 2003).
• PTSD: Approximately one-third of women report that they had a stressful childbirth experience (Creedy, Shochet, & Horsfall, 2000), and 10–15% of women describe having fear that they or their baby will die during delivery (Lyons, 1998). Studies using responses to PTSD checklists to diagnose PTSD have reported that between 3% (Czarnocka & Slade, 2000) and almost 6% (Creedy et al., 2000) report clinically significant symptoms of posttraumatic stress.

Taken together, the implications of these rates are staggering. We cannot simply add the rates to obtain an overall estimate of the prevalence of perinatal distress, as these manifestations of emotional distress often co-occur. Nevertheless, we can make a conservative estimate that 10–15% of perinatal women meet diagnostic criteria for one or more depressive, anxiety, obsessive compulsive-related, or trauma- or stressor-related disorder. Each year, there are approximately 4 million births in the United States (www.susps.org/overview/birthrates.html; M. Martin et al., 2009). This means that approximately 400,000 to 600,000 women meet diagnostic criteria for one of these disorders each year. This number does not account for the significant numbers of women who report sub- syndromal symptoms of these disorders, or symptoms that do not reach the threshold for a diagnosis, but are concerning to women and noticeable to their significant others (cf. Wenzel, 2011). It also does not account for emotional distress in women who experience pregnancy loss or infertility. Thus, there is a clear need for healthcare services that detect perinatal distress, can effectively treat it in women who experience it, and prevent it in women who are at risk of it. A foundation for treatment and prevention packages is described in this book.

Risk Factors

Investigation of the factors that put women at risk of perinatal anxiety are still in their infancy, but many studies have been conducted that identify factors that put women at risk of postpartum depression. Results from these studies have been aggregated into several meta-analyses (C. T. Beck, 2001; O’Hara & Swain, 1996; Robertson, Grace, Wallington, & Stewart, 2004). The most significant risk factors for postpartum depression that emerged from these meta-analyses include a history of depression, depression and anxiety during pregnancy, a neurotic personality style, low self-esteem, life stress, a poor partner relationship, and a low level of social support. A history of depression, an episode of emotional distress that is already in place, a neurotic personality style, and low self-esteem can function as vulnerabilities to emotional distress during major life transitions. Additional life stress, a poor partner relationship, and a low level of social support could exacerbate the stress associated with the transition to parenthood all the more. Other risk factors identified by these meta-analyses include low socioeconomic status (SES), which is often associated with financial difficulties and pressures, being single, having an unwanted pregnancy, obstetric complications, and a difficult infant temperament. It is not difficult to imagine how these factors would present challenges during the transition to parenthood.

One life stressor that has received increasing attention by researchers is the effect of intimate partner violence (IPV) on postpartum adjustment. IPV is defined as “physical violence, sexual violence, threats of physical/sexual violence, and psychological/emotional abuse perpetrated by a current or former spouse, common-law spouse, non-marital dating partners, or boyfriends/girlfriends of the same of opposite sex” (Chang et al., 2005). According to a systematic review by Beydoun, Beydoun, Kaufman, Lo, and Zonderman (2012), studies have found that between 4% and 44% of women have experienced physical, sexual, and/or emotional abuse in the past year. When they pooled results from 37 studies into a meta-analysis (see more about meta-analysis in Chapter 3), they determined that the risk of postpartum depression was 1.81 times greater in women who were exposed to IPV, compared to women who were not exposed to IPV. Clearly, IPV is a significant stressor that not only has the potential to disrupt the transition to parenthood, but also put the woman and fetus or infant at risk of harm. IPV is receiving an increasing amount of attention in both the research literature and in clinical practice, and we strongly encourage therapists to assess for its presence as they begin work with perinatal clients.

Consequences

Although emotional distress is associated with impaired functioning and personal suffering at any time in a person’s life, it is particularly concerning in the perinatal period, when women have an infant (and possibly other young children) for whom they care. Research shows that postpartum depression is associated with a host of negative infant and child outcomes, such as poor cognitive functioning, insecure attachment, and emotional and social maladjustment (see Murray & Cooper, 2003, for a comprehensive review). For example, studies have demonstrated that postpartum depression is associated with impaired ability in child care practices such as putting infants down to sleep, using car seats correctly, and attending well-child visits (Field, 2010; Zajicek- Farber, 2009), as well as diminished responsiveness to infants (e.g., Beebe et al., 2008; Stanley, Murray, & Stein, 2004). Postpartum depression has been linked with behavioral problems that span from early childhood through to adolescence (Avan, Richter, Ramchandani, Norris, & Stein, 2010; Murray et al., 2011), as well as cognitive impairment (e.g., poorer language and IQ development; Grace, Evindar, & Stewart, 2003). These findings would understandably be alarming to any new mother who is experiencing emotional distress. However, it is important to acknowledge that some scholars have concluded the chronicity of depression is more significant in explaining these results than the timing of depression (Sohr-Preston & Scaramella, 2006). Thus, early intervention for perinatal distress has the potential to shorten the length of the episode and reduce the likelihood of future episodes, thereby limiting the child’s exposure ...

Table of contents

• Cover
• Title
• Copyright
• CONTENTS
• List of Figures
• Foreword
• 1 Perinatal Distress: An Overview
• 2 A Cognitive Behavioral Conceptualization of Perinatal Distress
• 3 Efficacy of CBT for Perinatal Distress
• 4 The Therapeutic Relationship
• 5 Cognitive Behavioral Therapy for Perinatal Distress: An Overview
• 6 Evaluating Unhelpful Cognitions
• 7 Behavioral Interventions for Perinatal Depression
• 8 Behavioral Interventions for Perinatal Anxiety
• 9 Problem Solving Training
• 10 Communication Skills Training
• 11 Relapse Prevention and the Completion of Treatment
• 12 Special Considerations and Future Directions
• References
• Index