4/4/2019 Perinatal Mood & Anxiety Disorders: From Recognition to Recovery HILARY WALLER, MS, LPC Director of Programming [email protected] The Postpartum Stress Center • postpartumstress.com ©The Postpartum Stress Center, LLC Who are you? What do you bring to this work? Why is training important? Trigger Disclaimer & We’re only scratching the surface ©The Postpartum Stress Center, LLC 2 Learning Objectives Recognize & describe how and why mood disorders in the perinatal period are unique. Differentiate between “normal” perinatal experiences and clinically relevant symptoms. Identify best practices for screening, evidence-based therapeutic interventions, self help/ social supports, and interview strategies that optimally position patient for recovery. Discuss impact of special circumstances on therapeutic process and treatment planning. ©The Postpartum Stress Center, LLC 3 1 4/4/2019 “SOUNDS LIKE IT’S TIME FOR SOME FORMULA” ©The Postpartum Stress Center, LLC 4 What was missed? • Psychoeducation • Medical Evaluation • Psychosocial Consequences for a healthy mother: Termination of psychotherapy ©The Postpartum Stress Center, LLC Consequences of missed DX • Pregnancy: Poor prenatal self care, Increased risk for Postpartum mood and anxiety disorders • Long-term effects on child development. (Peindl, Wisner, & Hanusa, 2004; Weissman, Wickramaratne, Nomura, Warner, Pilowsky, Verdeli, 2006) • Chronicity • Increased risk for recurrence of PMAD • Impaired maternal attachment • Marital and social distress 6 ©The Postpartum Stress Center, LLC 2 4/4/2019 MASQUERADE Women with postpartum depression who told everyone they were “fine” while struggling with thoughts of self- harm ©The Postpartum Stress Center, LLC 7 1 in 7 women are suffering from a PMAD in the postpartum period ©The Postpartum Stress Center, LLC 8 If you do not ask every single pregnant and postpartum woman if she is having thoughts of hurting herself, you have no idea whether she is suicidal or not. 9 ©The Postpartum Stress Center, LLC 3 4/4/2019 Women who died by suicide during a postpartum depressive episode ©The Postpartum Stress Center, LLC 10 NUANCED PERINATAL PERIOD And this is why we need perinatal specialists BIOLOGICAL/ PSYCHOLOGICAL MEDICAL SOCIAL ©The Postpartum Stress Center, LLC 11 Why? It’s Not Just Hormones some examples… PHYSICAL: EMOTIONAL: Bodily Changes Self Esteem Discomfort, pain Loss of Self Sleep Deprivation Fatigue Recovery from Birth Isolation Delivery/Pregnancy Unexpected Outcomes Nutritional Needs No Time For Myself Lactation Failure ©The Postpartum Stress Center, LLC 12 4 4/4/2019 Signs & Symptoms PHYSICAL EMOTIONAL Headaches Feelings of inadequacy Overwhelming sadness Difficulty breathing Guilt/ Shame Palpitations Isolation Fatigue Anger/ Overwhelm Stomach ache or nausea Depletion Extreme agitation Lack of confidence or self esteem Insomnia/ Excessive sleeping Overall irritability or over sensitivity Helplessness, hopelessness, worthlessness Shakiness Scary fantasies Loss of appetite/ Overeating Thoughts of suicide or self harm Poor concentration Thoughts of infanticide or harm to baby ©The PostpartumNightmares Stress Center, LLC 13 Risk Factors BIOLOGICAL PSYCHOLOGICAL SOCIAL Baby Blues Prenatal anxiety S.E.S. Severe PMS/ PMDD Prenatal mood/anxiety disorders Child care stress Prenatal complications/ bedrest History of mood/anxiety disorders Work stress/ new job History of thyroid dysfunction Family history of mood/anxiety Poor social support Bereavement Poor marital relationship History of loss Poor family of origin relationships (pregnancy/infant/child) Difficult infant temperament Bipolar Disorder Single parent Unplanned pregnancy * Plus Unexpected Outcomes History of violence/ abuse ©The Postpartum Stress Center, LLC 14 Perinatal definition Medically: Pregnant or within 12 months of delivery Clinically: Pregnant or within two years of delivery Consider overlapping perinatal periods as well. Mothers outside these periods can still struggle. ©The Postpartum Stress Center, LLC 15 5 4/4/2019 Spectrum of PPD mod mild severe . | | || | | BB AD PPD PPP Transient Serious Disability Medical Emergency non pathological Kleiman, K. 2006. Postpartum mood disorders: Identification and screening ©The Postpartum Stress Center, LLC Baby Blues- Typical Experience • Occur within 2 weeks of baby’s birth and resolves in a few days • Weepiness, fatigue, anxiety, difficulty sleeping, “hormonal feeling” • Requires good self care, does not require professional intervention ©The Postpartum Stress Center, LLC If a woman complains of symptoms that bear a resemblance to Baby Blues and she is BEYOND the 2-3 week post-delivery time-frame It is NOT the BLUES. ©The Postpartum Stress Center, LLC 6 4/4/2019 Postpartum Psychosis- Rare Experience • Occurs in 0.1% of women • Onset within first 2 postpartum weeks • Risk Factors: family history, previous bipolar dx • Symptoms: Confusion, disorientation, delusions, mood swings, hallucinations, paranoia, ego syntonic thoughts of harm to baby ©The Postpartum Stress Center, LLC Postpartum Depression- A Clinical Depression •Serious, sometimes life-threatening •Onset often within first 3 mos pp, may occur anytime during the first year •During the first month after delivery, childbearing women have 3x greater risk for depression compared to non-childbearing women. •An agitated depression ©The Postpartum Stress Center, LLC Postpartum Anxiety- Common! •Often co-morbid with PPD, dx according to dominant symptoms •Marked by excessive worry, somatic symptoms of panic Postpartum Panic Postpartum OCD ©The Postpartum Stress Center, LLC 7 4/4/2019 PPOCD • Distressing, UNWANTED, intrusive, ego dystonic thoughts • Thoughts/ images often relate to harm coming to baby, sometimes involving mother bringing harm to baby • Compulsive rituals often include checking and cleaning. • Compulsive behaviors are often AVOIDANT, aiming to prevent harm. ©The Postpartum Stress Center, LLC PPOCD/ Scary Thoughts • To date, there is NO evidence that women who report unwanted, intrusive thoughts of intentional infant-related harm are more likely to report increased aggression toward their infant. - Fairbrother, 2018 • http://postpartumstress.com/get-help-2/are-you-having-scary- thoughts/10060-2/ ©The Postpartum Stress Center, LLC When mom and baby need space… 24 8 4/4/2019 Can YOU Relate/ How do clients differ from you? Tolerance levels vary Suffering is subjective frequency+duration+intensity = Distress level Degree of interference ©The Postpartum Stress Center, LLC SCREENING TREATMENT RECOVERY 26 SCREENING with the EPDS • http://postpartumstress.com/wp-content/uploads/2012/02/EPDS.pdf 27 9 4/4/2019 What’s the problem? 28 ©The Postpartum Stress Center, LLC Recommended screening for pregnancy and postpartum period • 1st prenatal visit 26-28 wks Birth 2 wks pp 6 wks pp Administer EPDS Administer EPDS for high-risk patients ©The Postpartum Stress Center, LLC 29 Adapted from MCPAP Massachusetts Child Psychiatry Access Project TREATMENT • Medical Underlying: Thyroid, Vitamin, Anemia • Alternative Treatments: Exercise, Acupuncture, Hypnosis, Essential Oils, Relaxation, EMDR • Pharmacology: Referral to MD • Non-pharmacologic: Social Support, Self Care • Therapy Nearly 60% of women with depressive symptoms do not receive appropriate clinical diagnosis, and 50% of women with a diagnosis ©The Postpartum Stress Center, LLC do not receive any treatment 30 10 4/4/2019 Barriers to Treatment • Practitioner resources are lacking • Stigma • Unsupportive/ Fear of unsupportive spouse • Desire for quick fix • Social/family pressure and expectations • Cost • Geographic isolation ©The Postpartum Stress Center, LLC 15 31 • Failure to recognize symptoms/ symptoms resembling normal postpartum changes • Difficult to discern abnormal degrees of normal perinatal experience • Typical symptoms of depression interfere with help-seeking behavior • Lack of prenatal education for both partners • Lack of focus on self-care or mental health issues during this stage Worst of all: • Fear being labeled a “bad mother” • Worry that her baby will be taken away ©The Postpartum Stress Center, LLC 32 How is PMAD different? When symptoms onset with motherhood, she misinterprets symptoms as motherhood’s fault: Motherhood ruined me… I am a terrible mother… A terrible mother is a terrible person ©The Postpartum Stress Center, LLC 11 4/4/2019 SOCIAL SUPPORT • Support Groups • Social Media Interactions • www.postpartum.net • www.postpartumstress.com • Find Opportunities • Create Opportunities ©The Postpartum Stress Center, LLC 34 SELF CARE • Messaging at postpartum follow up appointment • Consider expectations for a mother’s self care • Assess perception of gains & losses r/t self care • Psycho-educate & adjust expectations to fit “new normal” • Exercise • Nutrition • Sleep • Social/ Intimate ©The Postpartum Stress Center, LLC 35 THERAPY https://postpartumstress.com/for-professionals/assessments/ • PMAD Interview Questions • How are you feeding your baby? • Are you sleeping at night when the baby sleeps? • When did your symptoms start? During pregnancy? Before? • Are you having thoughts that are scaring you? • Do you ever have thoughts about hurting yourself? • Is there anything you are afraid to tell me but you think I should know? • Evidence Based: CBT, IPT ©The Postpartum Stress Center, LLC 36 12 4/4/2019 THERAPY •Evidence Based Treatment •Interpersonal Psychotherapy •Cognitive Behavioral Therapy • Supportive Psychotherapy ©The Postpartum Stress Center, LLC 37 ACCESSING AUTHENTIC SUFFERING A place