Anxiety obsessional and stressrelated neuroses

Post-traumatic stress disorder

After excessively painful labours, some women suffer insomnia, nightmares, and repetitive daytime intrusion of images and memories, similar to those that occur after the harrowing experiences of war and natural disaster. (53> If they become pregnant, the symptoms may return, especially in the last trimester. They may develop a secondary tocophobia.

This disorder can be treated by ventilation and cognitive-behavioural psychotherapy. Tocophobia is an indication for elective Caesarean section. Querulant reactions

Another reaction to a severe labour experience is pathological complaining ( Querulantenwahn). These women complain bitterly about mistakes, or sometimes the 'dehumanization' of modern obstetrics, and their humiliation by procedures involving the most intimate parts of their bodies. Some confine themselves to vengeful fantasies and verbal or written criticism, but others proceed to litigation. Careful assessment is needed to distinguish these reactions from normal reasonable complaining.

This disorder can be treated by a psychotherapeutic approach, which distracts the mother from her grievances and reinforces productive child-centred activity. Puerperal panic

Some mothers are overwhelmed by the fear that they will not be able to cope with the care of the newborn.(54) The panic and agitation seen in extreme examples is an exaggeration of the anxiety that many women experience when they first confront their awesome responsibility. The disorder is not limited to first-time mothers; it can occur after the second pregnancy when the grandmother has supervised the first baby, or after a long gap between pregnancies. If no help is available, a mother's anxiety can get out of hand, and there is a risk that she will lose her baby.

This disorder can often be handled by the family, without invoking professional help. All difficulties are avoided if the mother's own mother or the extended family are at hand. In an isolated 'nuclear' family, the husband may need to take compassionate leave. The mother needs sedation, especially at night. During waking hours, she should remain with the baby, but must be fully supported at all times. The baby is cared for by the supporter, with the participation of the mother. Gradually she takes over, at her own pace, undertaking the easiest tasks first, and becoming involved in all decisions. Thus she becomes desensitized to her fear. In severe cases, conjoint admission may be the only way of rescuing the situation. With correct diagnosis and management the prognosis is excellent.

Fear of cot death

Another postpartum anxiety is the fear of sudden infant death.(55> These mothers suffer severe insomnia, because they lie awake listening to the baby's breathing; they may sleep with their hand on the infant's chest, check the infant many times each night, or even wake the baby to ensure that he or she is still alive. This results in excruciating tension and exhaustion.

A mother may be helped by ventilating these fears, and explanations about the rarity of SIDS, and the infant's resistance to asphyxia. Devices to monitor the infant's breathing should be installed. The vicious cycle of insomnia and hypervigilance can be interrupted periodically by involving relatives or friends, so that the mother can sleep under sedation. However, these are only palliatives, because the underlying cause is an event, which, albeit uncommon, remains possible during a period of several months. Anxiety management and cognitive therapies may help.

Generalized anxiety

Even without the specific components of puerperal panic and fear of sudden infant death, the care of an infant involves ceaseless vigilance. In women prone to anxiety and excessive worrying, motherhood can lead to persistent overarousal, with excessive solicitude about banal tasks that put the baby at risk (e.g. bathing) and sensitivity to the slightest indication of illness. These symptoms are prominent in mothers who have suffered years of infertility or recurrent miscarriage.

These mothers require an anxiety management programme, teaching an effective relaxation technique. A day-hospital programme, with relaxation therapy and group support is appropriate.

In postpartum anxiety disorders, benzodiazepines should be used with caution if the mother is breast feeding. They are well absorbed from the gut, and more slowly metabolized in the neonatal liver, but occasionally causing lethargy and weight loss in breast-fed infants.

Phobic avoidance of the infant

A mother suffering from anxiety or obsessions may develop a phobia for her infant and be unable to approach her child at all. (56) In these mothers, the main therapy is behavioural, gradually desensitizing her to her fear of the infant.

Obsessions of child harm

Obsessive-compulsive disorder may present with thoughts, images, or impulses of child harm, (57) including infanticide by savage means such as stabbing, decapitation, or strangulation. These mothers fear being left alone with their children and may take extraordinary precautions. The obsessional content may be of child sexual abuse, for instance masturbating or castrating their sons.

Ventilation and explanation are part of the treatment, but are rarely sufficient. These mothers require psychotropic medication, either in the form of antidepressant agents or neuroleptics. It is important to discourage avoidance of the child, and encourage cuddling and play, thus strengthening positive maternal feelings. Cognitive-behavioural treatment can help her to achieve mastery over irrational impulses. (For the treatment of obsessive-compulsive disorder see Chapter.4.8.)

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