Handbook of Perinatal Clinical Psychology

From Theory to Practice

Rosa Maria Quatraro, Pietro Grussu, Rosa Quatraro, Pietro Grussu, Rosa Maria Quatraro

• Publisher: Routledge
• Year: 2020
• eBook ISBN: 9781000027914
• Edition: 1
• Topic: Medicine
• Subtopic: Nursing

The book examines the major issues in perinatal clinical psychology with the presence of theoretical information and operational indications, through a biopsychosocial approach.

The multiplicity of scientific information reported makes this book both a comprehensive overview on the major perinatal mental health disorders and illnesses, and a clinical guide. It covers perinatal clinical psychology through a journey of 15 chapters, putting the arguments on a solid theoretical basis and reporting multiple operational indications of great utility for daily clinical practice. It has well documented new evidence bases in the field of clinical psychology that have underpinned the conspicuous current global and national developments in perinatal mental health.

As such, it is an excellent resource for researchers, policy makers, and practitioners – in fact, anyone and everyone who wishes to understand and rediscover, in a single opera, the current scientific and application scenario related to psychological health during pregnancy and after childbirth.

Part I
Stress

1 Overview of Perinatal Maternal Stress

Dawn Kingston and Muhammad Kashif Mughal

Faculty of Nursing, University of Calgary, Calgary, Canada

2 Fetal Exposure to Mother’s Distress: New Frontiers in Research and Useful Knowledge for Daily Clinical Practice

Catherine Monk, Sophie Foss, and Preeya Desai

Columbia University, New York, USA

Vivette Glover

Imperial College London, London, UK

1

Overview of Perinatal Maternal Stress

Dawn Kingston and Muhammad Kashif Mughal

The Concept of Perinatal Maternal Stress

The “definition” of stress has been hotly debated for decades – a reflection of its conceptual, behavioral, and physiological complexity. At the heart of the stress process is the body’s adaptive response to a threatening environmental stress by instigating the sympathetic nervous system and the hypothalamic-pituitary-adrenal (HPA) axis. The resultant release of glucocorticoids – the endpoint of the stress response – leads to a cascade of events in the brain that contributes to epigenetic changes, remodeling of neurons and synapses, neurogenesis, neuroinflammation, and circuitry remapping (McEwen, Bowles, et al., 2015; Sapolsky, 2015). While intended as an acute, adaptive response to promote safety and survival in a threatening situation, the persistent activation of the stress response that characterizes modern social stress can lead to physiological (e.g., over-activation of the HPA axis, over-secretion of glucocorticoids) and experiential (e.g., physical and emotional exhaustion, a feeling of not being in control, low self-esteem) overload over months and years (McEwen et al., 2015).

Some of the key aspects of stress that have emerged with the resurgence of stress research over the past few decades are:

• The stress response can be activated solely by psychological states and thoughts, especially those of loss of control and unpredictability, the experience of low social support (Sapolsky, 2015), and the perception of whether stress is a negative (i.e., damaging) or positive (i.e., growth-producing) force (Crum, Akinola, Martin, & Fath, 2017; Crum, Salovey, & Achor, 2013).
• The experience of stress and its outcomes vary dramatically across individuals (Sapolsky, 2015). Indeed, Sapolsky argues that the stressor itself is of less consequence than the individual’s perception as they manage life’s challenges (Sapolsky, 2015).
• Prenatal stress can have deleterious physical and emotional effects not only for the immediate offspring, but also across generations through epigenetic mechanisms (Babenko, Kovalchuk, & Metz, 2015; Metz, Ng, Kovalchuk, & Olson, 2015).
• Most physiologic endpoints, structural outcomes (e.g., synaptic plasticity in the hippocampus), and behavior show an inverted-U pattern in response to a stressor and the concomitant stress response. In other words, at ranges of very low and high stress, an individual’s outcomes are worse than at a level of mild to moderate stress, which acts to optimize outcomes (Sapolsky, 2015).
• The notion that early life stress can result in adverse neurobiological outcomes that can persist across the life course needs to be balanced by the advantage of neuroplasticity, a process that is also active through adulthood (Sapolsky, 2015).

Prenatal maternal stress is of particular concern, given its dual impact on the mother-child dyad. Much research has focused on the life-long influence of prenatal stress on the offspring’s physical, psychological, behavioral, and developmental outcomes – a body of evidence collectively brought under the “fetal programming” paradigm of the developmental origins of disease (Lewis, Austin, Knapp, Vaiano, & Galbally, 2015; Moisiadis & Matthews, 2014).

However, at times this research shows inconsistent results that are likely the reflection of the lack of a distinct conceptualization of stress in general (Peters, McEwen, & Friston, 2017), and in particular prenatal maternal stress. Several primary studies and reviews of “prenatal stress” operationalize stress as stress, depression, and/or anxiety, which only serves to cloud our ability to understand the unique contribution of prenatal stress. However, the correlations between stress, depression, and anxiety are low to moderate at best (Liou, Wang, & Cheng, 2014). In addition, recent research demonstrates that the relationships between stress, depression, and anxiety and child outcomes differ, as do the associations between various operationalizations of stress (e.g., as objective or subjective stress) and child outcomes. Different factors also predict subjective and objective stress (Kingston, Heaman, Fell, Dzakpasu, & Chalmers, 2012). Taken together, these findings suggest that stress is a form of distress that is distinct from depression and anxiety. Future research would benefit from distinguishing stress from depression and anxiety when studying the influence of maternal psychological distress on child outcomes, and when exploring the patterns (severity, duration) of maternal stress and its role in the risk, comorbidity, and treatment of depression and anxiety.

In addition, it is important to highlight recent studies’ results of the clear, differential relationship between various forms of objective and subjective stress (e.g., objective life event stress, cognitive appraisal of a stressor, perceived impact of life events) and child outcomes when simultaneously assessed within the same study (see discussion in Stress Effects On Child Development). While life event assessments (the most common approach to measuring stress) represent objective measures of stress, they cannot account for the contribution of individual variability that occurs through stress perception – the individual appraisal of whether a stressor is threatening, controllable, predictable – and therefore manageable – or threatening and unpredictable – with the concomitant cascade of stress hormones. Indeed, stress expert, Robert Sapolsky, has highlighted the need to understand the modulating effect of perception on stress-related outcomes as critical in the future of stress research:

Individual differences in stress biology were once mostly an experimental irritant: oh no, because of variability we need a bigger sample size. However, individual variability as to whether something is perceived as stressful, and in resilience and vulnerability to stress-related disease, should be viewed as the most important topic in the field … To best appreciate the importance of individual differences in stress responsiveness, it is worth focusing on the single most important concept in the field.

(Sapolsky, 2015) (p.1346)

Perinatal Stress and Women’s Psychological Health

Prevalence Rates

Rates of subjective psychological stress in the perinatal period are not well reported. In a Canadian population-based study of 6,421 new mothers, 12% reported high levels of perceived stress in the 12 months preceding the infant’s birth, with 17.1% reporting three or more stressful life events during the same period (Kingston, Heaman, et al., 2012). In a second Canadian study (N = 441), a similar prevalence of perceived stress was found with 12.3% of pregnant women reporting the past year as extremely or very stressful and 31.8% as moderately stressful (Kingston, Sword, Krueger, Hanna, & Markle-Reid, 2012). Using data from a Canadian pregnancy cohort to conduct latent class analysis, Mughal et al. reported three trajectories of stress generated from measures of perceived stress at five time points from the second trimester of pregnancy to three years postpartum: low stress symptoms (n = 762, 38.4%), moderate stress symptoms (the second and largest trajectory of n = 969, 48.9%), and persistent high stress symptoms (n = 251, 12.7%) (Mughal et al., 2017, under review).

The majority of studies of stress in the perinatal period conceptualize stress as objective life event stress and thus prevalence rates of life event stress are more common than those of perceived stress. Giallo et al. (2014) reported that 36% of women with minimum depression symptoms experienced “some to many” stressful life events, whereas this prevalence was almost double in women with persistently high depression symptoms (70.6%) (Giallo, Cooklin, & Nicholson, 2014). Using data from the US Pregnancy Risk Assessment Monitoring System (N = 115,704), Mukherjee et al. reported that 35% of pregnant women experienced multiple stressors or illness-/death-related stressors, with 70% of participants reporting at least one stressful life event in the year prior to delivery (Mukherjee, Coxe, Fennie, Madhivanan, & Trepka, 2017b). This is consistent with research by Whitehead et al. (Whitehead, Hill, Brogan, & Blackmore-Prince, 2002), who have also identified that 65–70% of pregnant women report having one stressful life event in the year before birth. Mukherjee also reported the most common stressful life events during pregnancy as moving to a new address (33.1%), arguing with the partner more than usual (24.0%), and having a sick close family member (22.5%) (Mukherjee et al., 2017b).

Predictors of Stress

Studies demonstrate that different psychological, demographic, behavioral, and health variables are associated with different forms of stress. For instance, using data from the population-based Canadian Maternity Experiences Survey, Kingston et al. reported that demographic factors were associated only with life stress, while psychological factors contributed to both life event and perceived stress (Kingston, Heaman, et al., 2012). The factor most strongly associated with perceived stress was having three or more stressful life events in the year prior to delivery (AOR 3.18, 95% CI 2.65–3.82). Other significant factors included being unhappy or ambivalent about being pregnant – having a diagnosis of depression or been prescribed antidepressants before becoming pregnant; having none, little, or some support available during pregnancy; having a previous miscarriage; having a medical condition before or during pregnancy, not attending prenatal classes; and having three or more ultrasounds (a proxy for pregnancy-related complications). Having three or more stressful life events was most strongly associated with demographic factors (single marital status, AOR 3.14, 95% CI 2.48–3.98; income below the low-income cut-off level, AOR 2.32, 95% CI 1.95–2.77) and having a diagnosis of depression or being prescribed antidepressants pre-pregnancy (AOR 2.19, 95% CI 1.81–2.65). Other significant risk factors included demographic variables such as young age and being Aboriginal (recent immigrant status was protective), and psychological/health factors such as being unhappy or ambivalent about the pregnancy, wanting to become pregnant later or not at all, having no, little, or some social support during pregnancy, having a previous miscarriage or abortion, and developing a new medical condition during pregnancy (Kingston, Heaman, et al., 2012). Another Canadian study of pregnant women (N = 441) used structural equation modeling to demonstrate that prenatal stress is an interplay of perceived and life stress in childhood and adult stressors and perceived stress, with retrospectively reported childhood stress (combined life event and perceived stress) having a significant impact on prenatal stress (Std ß = .54, p <.001) after controlling for adult factors, including perceived stress, family cohesion, social support, and socioeconomic position (Kingston, Sword, et al., 2012).

Stress as a Predictor of Depression and Anxiety

Parker et al. have reported that psychological stress is a preceding factor in 85% of cases of depression (Parker, Schatzberg, & Lyons, 2003). Other studies have shown causal commonalities between stress and depression, in that ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Authors’ and Contributors’ Biographies
• Acknowledgments
• Foreword
• Introduction
• Part I Stress
• Part II Procreation, Pregnancy, and Delivery
• Part III Postnatal Period
• Part IV Risk of Psychopathology and Prevention
• Afterword
• Index