SDR 23-24 Psychiatry of the mother

Question 0

What is the stage 1 task?

Answer 0

Acceptance

Question 1

What are the characteristics of Psychological Stage 1 of Pregnancy?

Answer 1

Lasts from first learning of pregnancy to the first ultrasound (performed at 6-8 weeks). Characterized by memory impairments, ambivalence, fear of miscarriage.

Question 2

What are the characteristics of Psychological Stage 2 of Pregnancy?

Answer 2

Lasts from the first ultrasound to the point of viability. Involves sharing the news and realization that life exists within. It is a time of relative peace and fulfillment.

Question 3

What is the stage 2 task?

Answer 3

Recognition of fetus as separate from self

Question 4

What are the characteristics of Psychological Stage 3 of Pregnancy?

Answer 4

Lasts from point of viability (week 24-26) to birth. It is characterized by nesting behavior and fear about the birth process & baby’s health.

Question 5

What is the stage 3 task?

Answer 5

Attachment

Question 6

What are the four general situations that a patient might be referred to mental health services?

Answer 6

1. New psychiatric illness while pregnant (e.g. onset of panic attacks), 2. discovery of pregnancy while taking psychotropic meds (e.g. depressed women that are taking Zoloft to manage it), 3. history of psychiatric illness with plans to become pregnant - this is the ideal scenario (e.g. women with bipolar disorder that has been on lifelong meds would visit to weigh the risks and benefits of staying medication versus untreated bipolar disorder) 4. history of psychiatric illness (e.g. a woman who has had three episodes of depression that all occured around major events)

Question 7

When do psychiatric disorders most often arise?

Answer 7

Between ages of 18-45, which roughly corresponds to the reproductive years.

Question 8

What poor birth outcomes have been linked to psychiatric disorders in pregnancy?

Answer 8

Pre-eclampsia, low birth weight, preterm labor, fetal distress

Question 9

What percent of women exhibit clinically significant symptoms of depression during pregnancy? Major depressive disorders?

Answer 9

20% exhibit clinically significant symptoms; 10-15% experience major depressive disorder.

Question 10

Why is it difficult to diagnose depression during pregnancy?

Answer 10

Many symptoms of depression can be considered normal effects of pregnancy, e.g. insomnia, low energy, lack of concentration, appetite changes, moodiness

Question 11

What is the biggest risk factor for depression during pregnancy?

Answer 11

A prior history of depression

Question 12

What is the strongest risk factor for postpartum depression?

Answer 12

Antenatal depression (3x risk)

Question 13

What are risk factors for depression during pregnancy?

Answer 13

A prior history of depression, young age, marital conflict, low spousal/social support, more previous children, termination of previous pregnancy, early parental bereavement, excessive ambivalence about pregnancy

Question 14

What behavior during pregnancy is characteristic of untreated depression?

Answer 14

Poor self-care, substance abuse, suicide, non-compliance with prenatal care

Question 15

What might be the long-term outcomes for child from untreated depression?

Answer 15

Elevated cortisol levels, poor adaption to stress, increased risk for anxiety/depression/behavioral disorders increased risk for medical problems

Question 16

Bipolar diorder

Answer 16

Mood disorder in which the person experiences depression, followed by mania, hypomania, and/or mixed states. Left untreated, it is severely disabling.
Though to be based on biological conditions in the brain which may cause the chemical imbalance in serotonin and norepinephrine levels.

Question 17

What percent of women with a history of bipolar disorder have postpartum relapse?

Answer 17

70% - very high risk of relapse

Question 18

True of false: modest levels of anxiety are common during pregnancy

Answer 18

True. High levels of anxiety during pregnancy, however, are a strong predictor of high levels of anxiety after delivery.

Question 19

What physiological changes that are normal during pregnancy may contribute to increased anxiety/panic?

Answer 19

During pregnancy, heart rate, blood volume, ventilation rate, GFR all increase.

Question 20

What might occur in women with eating disorders during pregnancy/delivery?

Answer 20

Fetal complicaitons, C-section, postpartum depression

Question 21

What percent of women have a depressive relapse after discontinuing medications during pregnancy? With continued medication use?

Answer 21

68% after discontinuing medication; 28% relapsed with continued medication use - may be due to underdosing, as drugs are metabolized more rapidly during pregnancy.

Question 22

True of false: physicians often use antidepressants, some benzodiazepines, and sleep aids in pregnancy

Answer 22

True

Question 23

What is the Gerber Myth?

Answer 23

The unrealistic and idealistic image of motherhood that may contribute to a mother’s disappointment

Question 24

What is the biggest predictor of PPD?

Answer 24

Major depressive disorder (MDD)

Question 25

True or false: no women with PPD experiences initial stages of motherhood as she had fantasized

Answer 25

True

Question 26

What factors contribute to PPD?

Answer 26

Unrealistic expectations, hormonal changes, sleep deprivation, single biggest identity transition for women, possible difficulties in pregnancy or birth, possible predisposition for depression (MDD)

Question 27

What are the postpartum blues

Answer 27

Common, benign transitory mild symptoms occurring in the first 10 days. More pronounced than normal daily mood fluctuations. Most recover within two weeks. No pharmacologic or psychosocial interventions needed unless it continues past two weeks or escalates to a more severe level.

Question 28

What are symptoms of postpartum blues?

Answer 28

Weeping, emotional lability, sad mood, irritability, lack of affection, hostility towards husband, feelings of unreality.

Question 29

True or False: baby blues are a psychological disorder.

Answer 29

False - Baby blues are NOT a psychological disorder; it is completely separate from PPD. May begin day 3 or 4 (when baby first comes home) and peaks around day 4 or 5 (when mother is alone with baby at home)

Question 30

When does PPD usually begin?

Answer 30

1-6 months after delivery.

Question 31

What may bring on diagnosis of PPD?

Answer 31

There is no DSM criteria for PPD - a woman may be diagnosed with PPD after a major depressive episode within 4 weeks postpartum

Question 32

What is prevalence of PPD?

Answer 32

12-14% or 1/9 women

Question 33

What are symptoms of PPD?

Answer 33

tearfulness, despondency, emotional lability, excessive guilt, excessive worry about the baby’s well-being & sees self as bad/inadequate mother, poor concentration & memory, ego dystonic thoughts

Question 34

What are ego dystonic thoughts?

Answer 34

Distress associated with the thought of harming the baby, occurs in the context of loving the child and keeping him/her safe. The mother is very anxious that she may lose control over herself and do something she does not want to do. This is an extreme form of anxiety. Ex: drowning the baby while giving him/her a bath

Question 35

What are the risk factors for PPD?

Answer 35

history of mood disturbances/depression; low family income/occupational status; poor marital relationship/social support; co-existence of excessive life stress

Question 36

What are treatment options for PPD?

Answer 36

SSRIs and psychosocial interventions.

Question 37

True or false: breastfeeding is safe while on SSRIs

Answer 37

True

Question 38

What is the prevalence of postpartum psychosis?

Answer 38

2/1000 new moms

Question 39

What is the highest period of risk for PPP?

Answer 39

First month. Note: new moms are usually asymptomatic for the first 2-3 days postpartum, and since follow up appointment is usually 6 weeks after birth, many women suffering from PPP are left untreated.

Question 40

What is the most common presentation of PPP?

Answer 40

Affective disorder

Question 41

What is the hallmark red flag of PPP?

Answer 41

Sleeplessness

Question 42

What are the symptoms of PPP?

Answer 42

sleeplessness, impairment in reality testing, delusions, hallucinations, tearfulness, psychomotor retardation, excessive guilt/worthlessness, appetite disturbances,

Question 43

What is major difference between PPD mom and PPP mom?

Answer 43

In contrast to the PPD mother, thoughts of hurting the baby do NOT create distress for the PPP mother

Question 44

What is the risk of a woman with bipolar disorder developing PPP?

Answer 44

50%. Note - first degree relative with bipolar disorder also increases the risk

Question 45

What percent of women with schizophrenia develop PPP?

Answer 45

24%

Question 46

How do you treat PPP?

Answer 46

PPP is a psychiatric emergency. The patient MUST be admitted. Pharmacological treatment comes first: antidepressants, mood stabilizers, and antipsychotic agents. Psychosocial interventions once psychotic symptoms remit. 95% of adequately treated women improve within 2-3 months

Question 47

What are non-pharmacological treatment interventions?

Answer 47

Involve ways to manage anxiety. Elimination of caffeine, nicotine and alcohol to allow new mom to get adequate sleep. Support groups, light therapy, or marital therapy to reduce stress. Myth debunking in therapy.

Question 48

What is IPT?

Answer 48

Interpersonal Psychotherapy - short term and supportive, focusing on interactions between people and development of psychiatric symptoms. Process of recovery from PPD involves healing from unrealized fantasies and developing a strong support network and close bond with the baby.

Question 49

What is cognitive behavioral therapy?

Answer 49

Short term, structured treatment that involves collaborative relationships. Uses a series of interventions that focus on educating patients on the importance of self-care. Negative thoughts are viewed as “hypotheses” that can be questioned and then proved inaccurate. These hypotheses are replaced with more balanced thoughts.

Question 50

What is engrossment?

Answer 50

New father’s total absorption with the presence of the newborn in his life. It is the transformation of a man’s identity into a father. Validation of masculinity.