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Loss & the Biopsychosocial Model of Perinatal Mental Health

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Loss & the Biopsychosocial Model of Perinatal Mental Health Perinatal loss: What therapists need to know MODULE 4 Loss & the biopsychosocial model of perinatal mental health © The Perinatal Loss Centre theperinatallosscentre.com.au facebook.com/theperinatallosscentre Loss & the biopsychosocial model of perinatal mental health Lesson 1 When clients present: From pre-conception to the postpartum. Lesson 2 The Biopsychosocial model of perinatal mental health. Lesson 3 Loss in the context of perinatal mental health. Lesson 4 Diagnostic considerations. © The Perinatal Loss Centre Losses from conception to the postpartum Psychiatric history Personality Past experiences REPRODUCTIVE STORIES & ATTACHMENT Previous losses Preconception Pregnancy Birth Postpartum Recurrent miscarriage Miscarriage Complications of birth Baby in NICU Trying to conceive after loss Anticipating childbirth after loss Loss of fallopian tube Baby died Starting IVF Pregnant after loss Unexpected hysterectomy Parenting subsequent baby Ongoing IVF Fetal diagnosis Traumatic birth after loss Donor conception Termination Premature birth …………………………………… Infertility - childlessness Late term loss Stillbirth Death of baby or toddler © The Perinatal Loss Centre © The Perinatal Loss Centre Module 4 1 When a baby dies Life stress “The moment we were told there was no heartbeat was surreal. We’ll never forget it”. “My heart was racing” “I was in shock”. “Our world was shattered”. “I felt broken”. “I felt like I’d been stabbed in the heart”. I sobbed to my partner, “I won’t survive this”. © The Perinatal Loss Centre Why Loss is a stressful life event • Decisions a couple makes, big or small, include the newest member of the family. • This baby’s life has begun for the couple, their families. • The narrative of the greater family incorporates this new member. • This little person has been mentalized. • Hearts have opened up. • The baby might have a name or a nickname. • The couple and family may be following pictures of developing fetus online. • A bond has been formed. • Conception may not have been an easy road. • A woman’s age may be an added stressor. • Feeling left behind in peer group. • The reproductive story is shattered. • TRAUMA. © The Perinatal Loss Centre © The Perinatal Loss Centre Module 4 2 When supporters are not supportive Friends and family can respond in ways that reduce or deny the importance of the event, leaving the grieving woman feeling alone, with little sense of support. “Because nobody wants to talk about it. Unsure of what to say, friends, relatives, and coworkers often feel uncomfortable around bereaved parents. They aren’t sure how to respond to emotional expression, often avoid asking parents about it, and may ultimately avoid the parents as well. Such attitudes merely compound the parents’ grief and isolation”. (Davis, 2016. p. 2) Suffering can be intensified when other people don’t recognize parents’ bond with their child. Ø Friends and families may fail to recognize the bereaved parent’s need for support. Ø Bereaved parents may reject the potential support of others by not expressing their needs. © The Perinatal Loss Centre Biopsychosocial model: Cultural/spiritual factors Genetic / Cultural biological Spiritual vulnerability Complicated Grief Sensitivity to Depression hormonal change Life stress Anxiety PTSD Psychological vulnerability Social support Adapted from Milgrom, Martin, & Negri (1999) and Wenzel (2011). © The Perinatal Loss Centre © The Perinatal Loss Centre Module 4 3 Loss in the context of perinatal mental health After the initial shock and distress, the majority of individuals or couples who experience perinatal loss, adjust well, and regain a sense of purpose. (Leon, 2001) © The Perinatal Loss Centre Loss in the context of perinatal mental health • Post-loss mental health complications include chronic or complicated grief, depression, anxiety, and PTSD. (Bennett et al., 2008; Hutti, et al., 2017) • 15 – 30% of women who experience perinatal loss have enduring adjustment problems. (Bennet et al., 2008; Hughes et al., 2002; Hutti et al., 2017; Klier, et al., 2000; Swanson, 1999) • Relationship breakdown is common after miscarriage and stillbirth as compared to live births. (see Hutti, et al., 2017) • 25% of women who suffered stillbirth, developed clinically significant symptoms of depression, anxiety or PTSD. (Scheidt et al., 2007) • Early pregnancy loss increases risk for developing anxiety, depression and PTSD. Particularly when: Ø psychiatric history, low support, multiple miscarriages, subfertility. (Farren, et al., 2018) © The Perinatal Loss Centre © The Perinatal Loss Centre Module 4 4 Loss in the context of perinatal mental health • Depressive symptoms have been found in women who failed to achieve a subsequent pregnancy within one year post-miscarriage. (Swanson, 2000) • Women who miscarried reported more depressive symptoms, more anxiety symptoms and lower satisfaction than women with no fertility difficulties. (in McGee et al., 2018). • Recurrent miscarriage increases the risk for experiencing depression and stress. (Kolte, et al., 2015, cited in Rich, 2018) • One third of women attending recurrent miscarriage clinics were clinically depressed and had high levels of anxiety. (Rai, Rega, & Backos, 2011, cited in Rich, 2018) • High risk of complicated grief after termination of pregnancy due to fetal anomalies. (Kersting & Wagner, 2012) © The Perinatal Loss Centre Risk factors for poor mental health outcomes • Previous history of depression and anxiety is the strongest predictor of psychological functioning after loss (and in a subsequent pregnancy). • Loss is a risk factor in and of itself (without psychiatric history). • Not enough time spent with the baby after birth. • Longer than 6 months to fall pregnant again. • Advanced gestational age. • History of previous trauma. • Loss irrespective of gestation, increases risk of anxiety, depression and stress in subsequent pregnancies. Rich (2018) © The Perinatal Loss Centre © The Perinatal Loss Centre Module 4 5 Cumulative sources of stress • Recurrent miscarriages • Other reproductive losses • Infertility • Antenatal depression or anxiety Life stress • Traumatic birth • Relationship problems / domestic violence • Family problems • Ill health • Housing issues • Financial pressures • Other stressful life events / losses © The Perinatal Loss Centre Other losses in perinatal mental health • Loss of old self (pre-loss) • Loss of naivety around having babies • Loss of relationships • Loss of trust in the world • Loss of faith or belief in God • Loss of trust in body • Loss of control (body, life) • Loss of positive body image • Loss of work identity • Loss of a loved one • Other losses in the life of the client © The Perinatal Loss Centre © The Perinatal Loss Centre Module 4 6 Loss histories • Earlier life losses. • ‘Motherless mothers’. • Trauma histories. • Estranged family relationships. • Intergenerational losses. • Insecure attachment style © The Perinatal Loss Centre Protective factors • Resilience • Hardiness • Coping skills • Relationship support • Social support • Secure attachment style • Support groups © The Perinatal Loss Centre © The Perinatal Loss Centre Module 4 7 Diagnostic issues DSM-5 Historically • DSM-1V-TR (2000) included a ‘bereavement exclusion’ to diagnoses of Major Depressive Disorder • If met criteria for MDD with bereavement in the past 2 months, could not be diagnosed as MDD Current • The bereavement exclusion removed. • Commentators are concerned that the removal of this exclusion criterion could lead to pathologizing normal grief, over-diagnosing depression, and inappropriate use of medications. © The Perinatal Loss Centre Why bereavement criterion was removed 1. Normal adjustment to bereavement can last for years therefore little data to support a 2 month exclusion. 2. There is now greater knowledge on how to distinguish normal bereavement from depression. 3. Bereavement is a recognized stressor for precipitating a depressive episode. 4. When major depression occurs in the context of bereavement, it represents Ø additional risk for suffering Ø feelings of worthlessness Ø poorer functioning Ø increased suicidality Ø a more prolonged and complicated trajectory 5. Bereavement-related major depression most likely to occur with psychiatric history or family history of depression. Hall (2014) © The Perinatal Loss Centre © The Perinatal Loss Centre Module 4 8 Distinguishing between bereavement & depression • Sad mood, anhedonia, disturbed sleep, guilt and suicidal ideation can be present in both. • Overlap in symptomatology between bereavement and depression can make it challenging to clinically disentangle grief from MDD. • Bereavement can occur without depression. • Bereavement and depression can co-occur. • Clients with complicated bereavement are not necessarily depressed. Hall (2014) © The Perinatal Loss Centre Bereavement Depression Ø Sadness in waves Ø Sadness more pervasive Ø Capacity to identify positive Ø Meaninglessness emotions (e.g. love for the baby) and Ø Loss of pleasure (anhedonia) global and memories (e.g. how it felt being pregnant) more pervasive Ø Loss of pleasure (anhedonia) associated Ø “My life is worthless” with yearning for the baby Ø “I must have done something wrong. I Ø “My life has changed forever always ruin things, I don’t deserve to have a Ø “What did I do wrong? If only I had…” baby” Ø Suicidal thoughts about being with the Ø Suicidal thoughts associated with baby worthlessness Ø Preserved self esteem Ø Self-loathing Ø Sense of purpose Ø Lack of purpose Adapted from Hall
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