Cognitive Behavioral Therapy for Anxiety and Depression During Pregnancy and Beyond

How to Manage Symptoms and Maximize Well-Being

Sheryl M. Green, Benicio N. Frey, Eleanor Donegan, Randi E. McCabe

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781315452470
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychopathologie

This book is a hands-on guide for facilitating treatment of anxiety and depression during pregnancy and the postpartum period. Readers will learn about why anxiety and related difficulties can increase during pregnancy and the postpartum period, the critical roles that thoughts and behaviors play in maintaining symptoms, and how to apply practical cognitive and behavioral strategies to reduce distress and increase coping skills. Chapters are integrated with the latest research, and clinicians and individuals alike are presented with customizable cognitive behavioral therapy-based handouts, exercises, and worksheets proven to meet the unique needs of the perinatal population.

Part I

Anxiety and Depression During Pregnancy and Beyond

Understanding Symptoms and the CBT Approach

Chapter 1

Understanding Anxiety During Pregnancy and the Postpartum Period

A Vulnerable Time

What is Anxiety?

Why am I Having an Increase in Anxiety During Pregnancy and the Postpartum?

When Should I Seek Treatment for my Anxiety?

People who have difficulties with anxiety are often surprised to learn that it is a normal, natural, emotional, and physical reaction that all people experience – often on a daily basis. You might be even more surprised to learn that it serves an important role in our daily lives by alerting us to danger and generating a fear response that can save our lives in day-to-day occurrences. For instance, consider the following scenarios. You decide to cross the street after determining that the coast is clear. You begin to proceed but notice in the corner of your eye a car darting out on to the road headed straight for your path. At that point, you do not have time to think ‘wow, that car is really going fast, I should probably get out of the way’ – you just do it! That is an example of anxiety and the fear response saving your life! Or perhaps you have an interview scheduled for your dream job the following day. Do you stay up late or possibly try to get a good night’s sleep by going to bed at a reasonable time? Do you say you will ‘wing it’ or perhaps spend some time preparing with responses to anticipated questions? Do you show up in your pajamas or do you choose your outfit the night before? Anxiety plays a role in all of these circumstances and decisions by alerting you to the possibility of danger and motivating you to prepare to cope with a high-stakes situation. In many situations, the danger isn’t a physical one as it is in the scenario of being hit by a car, it is in the form of a performance situation where you could lose out if you do not do well, such as reducing your chances of getting the dream job that you have an interview for.

When we are anxious, it is not just an emotional experience – there are physical and thought components as well. Physically, we feel it in our bodies with common symptoms such as a racing heart, hotness or sweating, chest pain or pressure, shortness of breath, dizziness or lightheadedness, and tingling or numbness in your arms and legs to name a few. These physical symptoms can be very uncomfortable, or even scary, to experience. So why does this happen? Read on to get some insight into our amazing physiology and understand how our nervous system works.

The Physical Component of Anxiety (Our ‘Fight or Flight’ System)

The autonomic nervous system, more commonly known as our ‘fight or flight’ system, is a part of the nervous system that controls and regulates our internal organs. Interestingly, this does not require any effort on our part and in fact, we are not even aware that this is happening – our body just does it automatically! The autonomic nervous system is made up of two subsystems: (1) the sympathetic nervous system and (2) the parasympathetic nervous system. These two systems work closely together to control our energy levels and to help our bodies prepare for action when we are in danger.

How Does It Work?

When we perceive danger (or even when we simply anticipate danger) our brain starts by activating the sympathetic nervous system. When this system is activated, there is a release of hormones (e.g., epinephrine (adrenaline) and norepinephrine (noradrenaline)) that brings about changes in the body very quickly to help us prepare to fight or flee. These changes may affect cardiovascular function (e.g., increased heart rate, changes in blood flow), respiration (e.g., increased rate of breathing), and temperature regulation (e.g., increased sweating). Importantly, the sympathetic nervous system operates on an ‘all-or-none’ principle. That is, once it is activated, all or most of the systems that could help you fight the danger that you are faced with or flee/run away from the danger become activated regardless of the situation. This explains why we often experience more than one physical symptom when we are anxious. For further reading about the fight-or-flight response, Barlow and Craske (2007) provide a summary. Have a look at Figure 1.1 to understand some of the other bodily changes that take place and the functions they serve when the sympathetic nervous system is activated during a fight or flight response.

Figure 1.1 Impact of Autonomic Nervous System

Although the bodily sensations associated with our fight or flight response can be very uncomfortable (and they should be – otherwise we wouldn’t act to protect ourselves!) we want to emphasize here that these symptoms are not dangerous and are part of the body’s powerful and adaptive system to protect you from harm. It is also very important to note that these changes are transient. Over time, the parasympathetic nervous system is activated. This system is also automatic and reverses the bodily changes produced by the sympathetic nervous system (e.g., returning breathing rate to normal, slowing heart rate, re-starting digestion). This is important because many of the people we treat for anxiety difficulties express concerns that their anxiety will simply continue to increase forever or will increase to harmful levels. In fact, with the parasympathetic nervous system, we have a built-in recovery system that is specifically designed to calm us down over time. However, this system tends to be cautious and it may take longer for symptoms associated with anxiety to decrease than it took for the sympathetic nervous system to produce them (Figure 1.2).

Figure 1.2 Anxiety by Time

The Thought Component of Anxiety

The thought component of anxiety is often experienced in the form of worry. Worries tend to focus on the future and the bad things that might happen or be out of your control. Based on our two examples above, worries might sound something like, ‘What if I say something stupid or wrong during the job interview tomorrow’ or ‘This is a dangerous intersection, I am going to get hit by a car.’ Anxious thoughts are typically focused on danger or threat in a situation and tend not to accurately capture all the information in a situation in a balanced way. They also tend to ignore your strengths or ability to cope. They may happen automatically, across a variety of situations. For example, ‘My baby is sleeping so soundly, there must be something wrong with him’ or ‘People are judging me because I am bottle feeding my baby. They must think I am a bad mother.’

There are definitely times in life when anxiety very naturally tends to increase. For instance, certain life transitions such as moving out on your own, starting a new school program or job, or life situations such as preparing for an exam, or dealing with ongoing conflict with a neighbor or boss, can all increase anxiety. Anxiety can be adaptive in these types of situations if we are able to respond in a functional way (e.g., by arranging a moving truck for the move, completing all the administrative paperwork before arriving on the first day of school, preparing in advance for the exam). As you can see through these examples, anxiety is actually helping us by motivating us to prepare and act. Although we can all agree that anxiety does not feel very comfortable when we experience it, it plays a crucial role in our daily lives.

However, problems with anxiety may emerge when you experience (1) too much anxiety and (2) anxiety at the wrong time. When you experience too much anxiety, even at appropriate times, it can be interfering and distressing in your life. In these times, your anxiety may exceed your ability to cope and manage in an effective way. It is also at this time that anxiety is no longer helpful. When anxiety comes about at the wrong time or at a time when you believe there is danger when there really is none (e.g., believing you missed a spot when you washed the baby bottles after having washed them twice already), it is not helpful and in fact can reduce your ability to function on a daily basis and/or affect your quality of life.

Why Am I Experiencing so Much Anxiety during Pregnancy or the Postpartum Period?

A Biological Perspective

During pregnancy and the postpartum period women experience greater variation in their hormonal levels than in any other period of life. To put this into perspective, there are no medications or treatments that can increase the levels of hormones (e.g., estrogen and progesterone) to the same extent that a woman experiences naturally during her third trimester of pregnancy! Moreover, shortly after the baby is born a woman’s hormone levels decrease almost 1,000-fold. Researchers believe that this extreme fluctuation of hormone levels likely increases the biological risks for anxiety and depression symptoms during pregnancy and the postpartum period, in addition to each woman’s unique personal risk associated with her genetic makeup (Steiner et al., 2003). Other risk factors exist and will be discussed in the next section. For more information on the biological contributions to anxiety and depression symptoms, please see Chapter 11.

In Addition to the Biological Perspective …

In addition to the biological factors that can increase anxiety during pregnancy and the postpartum period, a number of other factors can also contribute to anxiety during this time. Read the vignette below and engage in the following exercise to understand why pregnancy and the postpartum period can increase a woman’s vulnerability to experience higher levels of anxiety, in addition to the biological changes that occur.

Meet Dahlia

Dahlia is a physically and mentally healthy 28-year-old woman who lives in Toronto with her husband of three years. She works as a high school teacher. Both her parents and in-laws live and work about an hour away, in the suburbs. She recently moved into a two-bedroom starter home, one bedroom of which is used as a storage room. She has a few close friends from high school whom she regularly sees to go shopping or out for dinner. Although some of her friends are also married, none have children. Dahlia is very active, playing soccer or running once a week. Further, she and her husband enjoy planning a bi-weekly ‘date night’ and drive to visit their families o...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Figures, Tables, and Forms
• Acknowledgements
• Introduction
• Part I: Anxiety and Depression During Pregnancy and Beyond: Understanding Symptoms and the CBT Approach
• Part II: CBT for Anxiety and Depression: A Step-By-Step Approach to Treatment
• Part III: Other Approaches to Enhance Well-Being: Medication and Support
• Index