Understanding Perinatal Anxiety – By Dr Sofia Rallis

What is Perinatal Anxiety?

Perinatal Anxiety is a general term used to refer to anxiety experienced during pregnancy and/or the first year post-birth. For many years, depression and in particular postnatal depression, was often the sole point of focus when considering one’s mental health during the perinatal period. In turn, postnatal depression has received the most attention to date in both research and clinical settings. In more recent years however, it has become evident that anxiety can be just as common as depression, if not more so, pre and post birth. It also very common for individuals to experience both anxiety and depression at the same time (referred to as comorbid or co-occurring anxiety and depression).

While it is fairly typical for parents to experience a certain level of stress, worry or feelings of uncertainty, clinical anxiety differs in that it involves symptoms such as persistent and excessive worry on most days, which significantly impact on one’s life and daily functioning. If this level of anxiety continues for at least a two week period, speaking to a partner, friend, or trusted family member and/or seeking professional support is strongly encouraged.

Symptoms of Perinatal Anxiety

Anxiety disorders are the most common type of mental health problem experienced by individuals of all ages. The symptoms of anxiety during the perinatal period are the same as those at any other time of life. A range of symptoms may be experienced with some individuals experiencing more somatic symptoms (e.g., muscle tension, heart racing, tightness in the chest), while others may experience more cognitive symptoms (e.g., recurring thoughts that something is wrong with the baby, persistent worry, difficulty concentrating). Often a combination of both types of symptoms are experienced. The symptoms of anxiety usually have a notable impact on one’s behaviour; for example it is common for individuals who are experiencing anxiety to withdraw and/or avoid situations that make them feel uncomfortable, or are perceived to be stressful. Other behaviours, such as repeated checking or seeking reassurance from others can also be common. For some individuals symptoms of anxiety develop gradually over time, while for others they develop suddenly and intensely, at times catching individuals ‘off guard’ as to what has brought this on so suddenly.

Types of Anxiety Conditions

There are a number of different types of anxiety conditions, with each one having a different presentation. The most common anxiety disorders include:

  • Generalised Anxiety Disorder (GAD): GAD is characterised by feelings of anxiety and excessive worry about a variety of issues on most days over an extended period of time (e.g., a minimum of six months). A minimum of three of the following characteristic symptoms must also be present:

• restlessness or feeling keyed up or ‘on edge’ • being easily fatigued • difficulty concentrating or mind going blank • irritability • muscle tension • and sleep disturbance.

The anxiety and worry, along with the additional symptoms are difficult to control and have a significant impact on the individual.

  • Panic Disorder (PD): PD is characterised by frequent and recurring attacks of intense feelings of anxiety that seem like they cannot be controlled. Physiological changes such as accelerated heart rate, sweating, dizziness, trembling, and chest pain are also prominent. It is common for individuals with PD to actively avoid certain situations (e.g., leaving the house and going into crowded places), due to fear of having a ‘panic attack’ and being unable to control it.
  • Social Anxiety Disorder (SAD): SAD (which until recently was referred to as Social Phobia) involves an intense fear of being criticised, embarrassed, rejected and/or humiliated, even in fairly typical ‘everyday’ situations (e.g., making small talk in a store, eating in public). SAD often co-occurs with depression, other anxiety disorders and substance use disorders.
  • Specific Phobia (SP): SP involves an intense fear of a particular object, animal or situation (e.g., fear of flying on a plane, being near a dog), resulting in active avoidance of situations where there may be exposure to the feared stimulus. The fear/anxiety response occurs every time the individual is exposed to the stimulus and may include symptoms of panic attack. The fear and anxiety experienced is considerably stronger and disproportionate to the actual threat posed by the object or situation (e.g., the realistic likelihood of a plane malfunctioning or crashing, or potential danger posed by a dog).
  • Obsessive-Compulsive Disorder (OCD): Individuals with OCD experience persistent and unwanted intrusive thoughts (obsessions) and fears that cause anxiety, often accompanied by an intense urge to conduct certain actions or ‘rituals’ in an effort to reduce the anxiety (compulsions). Interestingly, and somewhat controversially, in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) OCD now falls under its own unique category known as Obsessive-Compulsive and Related Disorders due to its distinctive presentation.
  • Post-traumatic stress disorder (PTSD): PTSD involves intense bursts of anxiety following the experience of a traumatic event (e.g., physical or sexual assault, exposure to a natural disaster, experiencing a traumatic delivery), which continue to occur one month or more after the traumatic event was experienced. Unwanted and intrusive symptoms are experienced (e.g., ‘flashbacks’ or nightmares), along with persistent avoidance of stimuli that remind the individuals of the trauma. In recent years, it has become increasingly recognised that women may experience their labour as a traumatic event (e.g., if complications arose, or if their/their baby’s wellbeing was threatened), which can in turn result in the development of PTSD. Interestingly, once again in the most recent edition of the DSM-5, PTSD is now recognised as a Trauma Related Disorder which entails anxiety symptoms, rather than a direct Anxiety Disorder, due to the fact that exposure to a traumatic event is the catalyst for its onset.

As indicated from the brief summary above, the symptoms of anxiety do not always present in the same manner or at the same time, which can make it difficult to identify. Furthermore, accurate identification and diagnosis can also be complicated by the presence of other comorbid conditions, such as other mental health disorders, or other physical conditions. With this in mind, careful assessment is needed to differentiate between these experiences. It is strongly encouraged that individuals speak with an appropriate health professional if such symptoms are present and impacting on their life.

Risk factors for Perinatal Anxiety

In a similar manner to depression, there is no one single definitive cause of anxiety. Once again, it is often a combination of various factors that tend to increase the likelihood of perinatal anxiety developing. While less research has focused specifically on predictors of perinatal anxiety, available evidence indicates that the risk factors are similar to those of depression. These include:

  • a past history of anxiety and/or depression
  • a family history of anxiety and/or other mental health difficulties
  • lack of practical, financial, social and/or emotional support
  • lack of support from partner or the presence of marital/relationship problems
  • the presence of significant life events and stressors, particularly in the preceding 12 months (e.g., death of a loved one, unemployment, moving house, major illness)
  • Having unrealistic/unmet expectations about parenthood
  • Previous miscarriage/stillbirth
  • Complications in labour and/or delivery
  • Problems with the baby’s health

It is once again important to remember that experiencing one or more of the above mentioned risk factors it does not mean that experiencing perinatal anxiety is ‘inevitable’. Instead, if you can relate to some of the above experiences/events, it is likely that some additional support or assistance will be helpful in managing the complex demands and uncertainty often associated with parenthood.

Treatment and Support Options

Pregnancy and the postnatal period are both characterised by a significant number of physical, emotional, and psychosocial changes. When one considers all the changes that occur during this time, it is not surprising that a considerable number of individuals find this period challenging. In some instances, prioritising some time for one’s own self-care, and drawing on support from partners, family and friends (where available), may be all the support that’s needed. In other cases, formal assistance from a health professional may be required. Fortunately, anxiety (like depression), is very responsive to treatment. With a range of different treatments options available, the decision on which one to undertake should be done in consultation with an appropriately trained health professional (e.g., GP, child and family health nurse, psychologist, psychiatrist). This will allow an informed decision to be made based on each individual’s unique set of circumstances. Some of the most effective treatment options include:

Psychological treatments:

·         Cognitive behaviour therapy (CBT) for anxiety, including mindfulness based cognitive therapy (MBCT), acceptance and commitment therapy (ACT), and schema therapy.

  • Interpersonal psychotherapy (IPT) for anxiety,
  • Psychodynamic therapy,
  • Exposure therapy,
  • Debriefing and trauma focused therapy.

Pharmacological treatments:

·         Medication: Various medications can be beneficial in helping individuals manage their anxiety and mood. During the perinatal period, it is particularly important that medication is only prescribed after careful consideration and discussion with each woman and how it may affect her pregnancy, infant, or desire to breastfeed. Most women tend to prefer psychotherapy to medication during pregnancy because of such concerns; however medication may need to be considered either as a stand-alone treatment, or in combination with psychotherapy, in cases where symptoms of anxiety are severe, or where other comorbid issues are present. In such instances, involving a psychiatrist is recommended.

Summary:

Anxiety can present in many different ways, at various times across the perinatal period. In more recent years we have come to recognise that widening the scope of focus beyond depression and keeping an eye out for anxiety during pregnancy and after giving birth is essential, given how prevalent it is. Clinical anxiety goes beyond the ‘usual worry’ and stress associated with parenthood, and makes it difficult for individuals to function and look after themselves and their family. Given the negative impact that perinatal anxiety can have on parents, their families, and their social and occupational functioning, increased awareness of these experiences along with accurate identification and treatment is needed. If you or someone you care about is struggling, don’t hesitate to reach out for support. You’ll probably be surprised to find that there are many other mums and dads out there going through some similar struggles and perhaps more importantly that support is available!

References and sources for additional information:

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders(5th ed.). Washington, DC: Author.
  • Austin M-P., Highet N., and the Expert Working Group (2017). Mental Health Care in the Perinatal Period: Australian Clinical Practice Guideline. Melbourne: Centre of Perinatal Excellence.
  • (2011). Clinical practice guidelines for depression and related disorders – anxiety, bipolar disorder and puerperal psychosis – in the perinatal period. A guideline for primary care health professionals. Melbourne: beyondblue: The national depression initiative.
  • Beyondblue (2012).Managing mental health conditions during pregnancy and early parenthood: A guide for women and their families

Disclaimer:
Please note that the information provided in this article, and any associated references, is general and is not intended to be therapeutic in nature. If you feel that you would benefit from additional support and/or require urgent assistance please contact your GP, or one of the following services in your state.

Crisis and Support Services

National Services:
Lifeline
13 11 14 (24 hours a day, 7 days a week)
www.lifeline.org.au

Perinatal Anxiety and Depression Australia (PANDA)
1300 726 306 (Monday-Friday 9am – 7.30pm (AEST / ADST)
www.panda.org.au

Pregnancy, Birth and Baby Helpline
1800 882 436
https://www.pregnancybirthbaby.org.au

MensLine
1300 78 99 78
www.mensline.org.au

Suicide Call Back Service
1300 659 467 (24 hours a day, 7 days a week)
www.suicidecallbackservice.org.au

Additional State Based Services:
Victoria:
Maternal and Child Health Line 24 hours a day, 7 days a week 13 22 29
Parentline VIC 8am to 12am Monday to Friday, 10am to 10pm weekends 13 22 89

NEW SOUTH WALES:
Karitane Careline 24 hours a day, 7 days a week 1300 227 464
Parentline NSW 24 hours a day, 7 days a week 1300 130 052

ACT:
healthdirect Australia 24 hours a day, 7 days a week 1800 022 222
Parentline ACT 9am – 9om Monday to Friday (except public holidays) (02) 6287 3833

QUEENSLAND:
Child Health Line 24 hours a day, 7 days a week 13 43 25 84
Parentline QLD & NT 8am to 10pm, seven days a week 1300 30 1300

SOUTH AUSTRALIA:
Child and Youth Health Service 9am – 4.30pm Monday to Friday 1300 733 606
Parent Helpline SA 24 hours a day, seven days a week 1300 364 100

WESTERN AUSTRALIA:
healthdirect Australia 24 hours a day, 7 days a week 1800 022 222
Parent Help Centre WA 24 hours a day, 7 days a week 1800 654 432

NORTHERN TERRITORY:
healthdirect Australia 24 hours a day, 7 days a week 1800 022 222
Parentline QLD & NT 8am to 10pm, seven days a week 1300 30 1300

TASMANIA:
Parenting Line TAS 24 hours a day, 7 days a week 1300 808 178

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