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Specific fear of vomiting (SPOV) in early parenthood: Assessment and treatment considerations with two illustrative cases
Specific phobia of vomiting (SPOV) can be a severe and debilitating anxiety disorder and affects women in the childbearing years. The perinatal period and early parenthood is a time of increased risk for the onset or exacerbation of anxiety problems, which can have an impact on both the woman and the developing child. There are particular issues pertinent to the physical experience of pregnancy and tasks of early caregiving that women with SPOV may find difficult or distressing to confront, but these are not well documented. Cognitive behavioural therapy (CBT) focused on exposure to vomit cues and processing distressing early memories of vomiting is an effective treatment for SPOV. This paper describes the successful CBT treatment of two young mothers with SPOV, outlining the challenges faced by parents at this time and the need to take this into account in treatment, using illustrative case material. Key learning aims (1) To understand how specific phobia of vomiting (SPOV) affects women in early parenthood. (2) To know how to target and update traumatic early memories of vomiting with imagery rescripting. (3) To know how to design and carry out effective behavioural experiments for perinatal SPOV. (4) To understand how to take mother, baby, and the mother-infant relationship into account in SPOV treatment.
Exposure Therapy with Patients Who Are Pregnant
Approximately 15% of pregnant women are known to have an anxiety disorder. In addition to causing distress to women, studies have highlighted the longstanding impact of untreated maternal anxiety on infant and child outcomes. Whilst many studies have demonstrated that cognitive behavioural approaches using exposure are effective for anxiety disorders, scant evidence exists of their use with pregnant women. Furthermore, women are sometimes denied treatment due to assumptions about the risks involved. This chapter reviews evidence and techniques for the use of exposure-based treatments in pregnancy, presenting case material on the treatment of obsessive-compulsive disorder and post-traumatic stress disorder.
Knowledge and competency standards for specialized cognitive behavior therapy for adult obsessive-compulsive disorder.
Obsessive-Compulsive Disorder (OCD) is a leading cause of disability world-wide (World Health Organization, 2008). Treatment of OCD is a specialized field whose aim is recovery from illness for as many patients as possible. The evidence-based psychotherapeutic treatment for OCD is specialized cognitive behavior therapy (CBT, NICE, 2005, Koran and Simpson, 2013). However, these treatments are not accessible to many sufferers around the world. Currently available guidelines for care are deemed to be essential but insufficient because of highly variable clinician knowledge and competencies specific to OCD. The phase two mandate of the 14 nation International OCD Accreditation Task Force (ATF) created by the Canadian Institute for Obsessive Compulsive Disorders is development of knowledge and competency standards for specialized treatments for OCD through the lifespan deemed by experts to be foundational to transformative change in this field. This paper presents knowledge and competency standards for specialized CBT for adult OCD developed to inform, advance, and offer a model for clinical practice and training for OCD. During upcoming ATF phases three and four criteria and processes for training in specialized treatments for OCD through the lifespan for certification (individuals) and accreditation (sites) will be developed based on the ATF standards.
Fear of childbirth during pregnancy: associations with observed mother-infant interactions and perceived bonding.
Fear of childbirth (FOC) is a common phenomenon that can impair functioning in pregnancy but potential longer term implications for the mother-infant relationship are little understood. This study was aimed at investigating postpartum implications of FOC on the mother-infant relationship. A UK sample of 341 women in a community setting provided data on anxiety, mood and FOC in mid-pregnancy and subsequently completed self-report measures of postnatal bonding in a longitudinal cohort study. Postnatal observations of mother-infant interactions were collected and rated for a subset of 141 women. FOC was associated with maternal perception of impaired bonding, even after controlling for sociodemographic factors, concurrent depression and the presence of anxiety disorders (Coef = 0.10, 95% CI 0.07-0.14, p
Optimising psychological treatment for Anxiety DisordErs in Pregnancy (ADEPT): study protocol for a feasibility trial of time-intensive CBT versus weekly CBT.
BACKGROUND: Moderate to severe anxiety disorders such as obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), social phobia and panic disorder are common, and affect approximately 11-16% of women in pregnancy. Psychological treatments for anxiety disorders, primarily cognitive behaviour therapy (CBT), have a substantial evidence base and recently time-intensive versions have been found as effective as weekly treatments. However, this has not been trialled in women who are pregnant, where a shorter intervention may be desirable. METHODS: The ADEPT study is a feasibility randomised controlled trial with two parallel intervention groups. Time-intensive one-to-one CBT and standard weekly one-to-one CBT delivered during pregnancy will be compared. Feasibility outcomes including participation and follow-up rates will be assessed, alongside the acceptability of the interventions using qualitative methods. DISCUSSION: The study will provide preliminary data to inform the design of a full-scale randomised controlled trial of a time-intensive intervention for anxiety during pregnancy. This will include information on the acceptability of time-intensive interventions for pregnant women with anxiety disorders. TRIAL REGISTRATION: https://doi.org/10.1186/ISRCTN81203286 prospectively registered 27/6/2019.
High Prevalence and Incidence of Obsessive-Compulsive Disorder Among Women Across Pregnancy and the Postpartum.
Objective: During the perinatal period, women are at an increased risk for the onset/exacerbation of obsessive-compulsive disorder (OCD) and may experience perinatal-specific obsessions and/or compulsions. Past research has provided preliminary findings regarding the prevalence of OCD in the perinatal period but has often reported limited metrics and ignored perinatal specific symptoms. This research aimed to assess the prevalence and incidence of maternal OCD between the third trimester in pregnancy and 6 months postpartum. Methods: An unselected sample of 763 English-speaking pregnant women and new mothers participated in a longitudinal, province-wide study between their third trimester in pregnancy and 9 months postpartum. They completed 3 online questionnaires and interviews (data collected between February 9, 2014, and February 14, 2017) and were administered a diagnostic interview to determine OCD status based on DSM-5 diagnostic criteria. Results: A weighted prenatal period prevalence of 7.8% and a postpartum period prevalence of 16.9% were found. The average, prenatal, point prevalence estimate was 2.9%, and the average, postpartum, point prevalence estimate was 7.0%. Point prevalence gradually increased over the course of pregnancy and the early postpartum, attaining a peak of close to 9% at approximately 8 weeks postpartum, with a gradual decline thereafter. The cumulative incidence of new OCD diagnoses was estimated at 9% by 6 months postpartum. Conclusions: Our study suggests that when women are encouraged to report their perinatal-specific symptoms, and current diagnostic criteria are applied, estimates for perinatal OCD may be higher than previously believed.
OCD and COVID-19: a new frontier.
UNLABELLED: People with obsessive compulsive disorder (OCD) are likely to be more susceptible to the mental health impact of COVID-19. This paper shares the perspectives of expert clinicians working with OCD considering how to identify OCD in the context of COVID-19, changes in the presentation, and importantly what to consider when undertaking cognitive behaviour therapy (CBT) for OCD in the current climate. The expert consensus is that although the presentation of OCD and treatment may have become more difficult, CBT should still continue remotely unless there are specific reasons for it not to, e.g. increase in risk, no access to computer, or exposure tasks or behavioural experiments cannot be undertaken. The authors highlight some of the considerations to take in CBT in light of our current understanding of COVID-19, including therapists and clients taking calculated risks when developing behavioural experiments and exposure tasks, considering viral loading and vulnerability factors. Special considerations for young people and perinatal women are discussed, as well as foreseeing what life may be like for those with OCD after the pandemic is over. KEY LEARNING AIMS: (1)To learn how to identify OCD in the context of COVID-19 and consider the differences between following government guidelines and OCD.(2)To consider the presentation of OCD in context of COVID-19, with regard to cognitive and behavioural processes.(3)Review factors to be considered when embarking on CBT for OCD during the pandemic.(4)Considerations in CBT for OCD, including weighing up costs and benefits of behavioural experiments or exposure tasks in light of our current understanding of the risks associated with COVID-19.
Developing an intervention for paternal perinatal depression: An international Delphi study
Background: Around 10% of fathers suffer from depression during the perinatal period. There is a need to develop interventions which address the specific needs of fathers in order to reduce the burden on men and their families. This study aimed to achieve expert consensus about the components of a CBT-based intervention for paternal perinatal depression using the Delphi method. Methods: Ten international experts, recruited through purposive sampling, completed an online survey. This included an initial round of open-ended questions about the potential components and targets of an intervention, followed by a second round of scale questions to identify components with the greatest agreement across experts. Results: Free-text responses from round 1 covered a range of social, psychological and behavioural factors which could be targeted in an intervention for paternal depression. These were analysed using thematic analysis, and the resulting 82 codes were presented to respondents in round 2 as summary statements. 42 (52%) items reached consensus to include in an intervention. Limitations: Only two rounds were used, reducing opportunities to revise responses; one question produced very divergent types of responses which could not easily be summarised; some have argued there may be issues with representativeness of small samples of experts. Conclusions: Experts highlighted the importance of a strengths-based approach, with content framed around learning about fatherhood rather than overcoming symptoms of depression, including a focus on the partner relationship, understanding infant development, and social connections. These findings will contribute to the development of an intervention for paternal perinatal depression.
The characteristics and prevalence of phobias in pregnancy.
OBJECTIVE: The primary objective was to estimate the population prevalence of specific phobias (including pregnancy related specific phobias) and associated mental disorders. The secondary objective was to investigate the effectiveness of routinely collected screening tools (depression and anxiety screens, Whooley and GAD-2 respectively) in identifying specific phobias. Specific phobias are the most common anxiety disorder to occur during pregnancy, but studies on prevalence and clinical correlates of specific phobias, including pregnancy related specific phobias are lacking. DESIGN: Cross-sectional survey using a two-phase sampling design stratified according to being positive or negative on the Whooley questions routinely asked by midwives. Approaching all whooley positive women and drawing a random sample of Whooley negative women. Sampling weights were used to account for the bias induced by the stratified sampling. PARTICIPANTS: 545 pregnant women attending their first antenatal appointment. Language interpreters were used where required. SETTING: Inner-city maternity service, London, UK. MEASUREMENTS: The Structured Clinical Interview for DSM-IV Axis I Mental Disorders were administered to assess mental disorders and 544 women responded to the anxiety module on specific phobias. RESULTS: The maternity population prevalence estimate for specific phobias was 8.4% (95%CI: 5.8-12.1%) and for pregnancy related phobias was 1.5% (95%CI: 0.6-3.7%), most of which were needle phobias. The prevalence estimate of tokophobia was 0.032% (95%CI: 0.0044-0.23%). Over half (52.4%) the women with specific phobias had comorbid mental disorders. Routinely administered screening tools (Whooley and GAD-2) were not helpful in identifying phobias. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Phobias in pregnancy are common but pregnancy related phobias are rare, particularly tokophobia. As routinely administered screening tools were not helpful in identifying phobias, other indicators could be considered, such as avoidance of blood tests and requests for caesarean sections.
The association between prenatal maternal anxiety disorders and postpartum perceived and observed mother-infant relationship quality.
INTRODUCTION: Prenatal maternal anxiety disorders have been associated with adverse outcomes in offspring including emotional, behavioral and cognitive problems. There is limited understanding of the mechanisms underpinning these associations, although one possible candidate is an impaired mother-infant relationship. The authors investigated whether prenatal anxiety disorders were associated with poorer postpartum mother-infant relationship quality, measured by maternal self-reported bonding and observed mother-infant interactions. METHODS: A cohort of 454 pregnant women recruited from an inner-city maternity service in London (UK) were assessed for mental disorders using the Structured Clinical Interview for DSM-IV and followed up at mid-pregnancy and 3-months postpartum. Depressive symptoms were assessed at baseline and mid-pregnancy (using the Edinburgh Postnatal Depression Scale). At three months postpartum, women were assessed for self-reported bonding difficulties (using the Postpartum Bonding Questionnaire) and a subsample (n = 204) participated in video-recorded mother-infant interaction, coded using the Child-Adult Relationship Experimental Index by an independent rater. RESULTS: Prenatal anxiety disorders were associated with higher perceived bonding impairment, but not associated with observed poor mother-infant interaction quality. Higher levels of depressive symptoms were associated with lower maternal sensitivity. CONCLUSIONS: Interventions for anxiety disorders in the perinatal period could be tailored to address anxieties about mother-infant relationship and co-morbid depressive symptoms.
Correlates and Predictors of New Mothers' Responses to Postpartum Thoughts of Accidental and Intentional Harm and Obsessive Compulsive Symptoms.
BACKGROUND: Unwanted, intrusive thoughts of infant-related harm are a normal, albeit distressing experience for most new mothers. The occurrence of these thoughts can represent a risk factor for the development of obsessive compulsive disorder (OCD). As the early postpartum period represents a time of increased risk for OCD development, the transition to parenthood provides a unique opportunity to better understand OCD development. AIMS: The purpose of this study was to assess components of cognitive behavioural conceptualizations of postpartum OCD in relation to new mothers' thoughts of infant-related harm. METHOD: English-speaking pregnant women (n = 100) participated. Questionnaires were completed at approximately 36 weeks of gestation, and at 4 and 12 weeks postpartum. An interview to assess postpartum harm thoughts was administered at 4 and 12 weeks postpartum. Questionnaires assessed OC symptoms, OC-related beliefs, fatigue, sleep difficulties and negative mood. RESULTS: Prenatal OC-related beliefs predicted postpartum OC symptoms, as well as harm thought characteristics and behavioural responses to harm thoughts. The severity of behavioural responses to early postpartum harm thoughts did not predict later postpartum OC symptoms, but did predict frequency and time occupation of accidental harm thoughts, and interference in parenting by intentional harm thoughts. Strong relationships between OC symptoms and harm thought characteristics, and concurrent sleep difficulties, negative mood and fatigue were also found. CONCLUSIONS: Findings provide support for cognitive behavioural conceptualizations of postpartum OCD and emphasize the importance of maternal sleep, fatigue and negative mood in the relationship between OC-related beliefs and maternal cognitive and behavioural responses to postpartum harm thoughts.
Cognitive behaviour therapy for olfactory reference disorder (ORD): A case study
Olfactory Reference Disorder (ORD) is preoccupation with the belief that one is emitting a foul odour. It can be a distressing and substantially impairing problem. However, very little is known about its successful treatment. This study describes the treatment of a 38-year-old female with longstanding ORD using Cognitive Behavioural Therapy (CBT). Case conceptualisation focused on identifying unhelpful beliefs and maintaining factors including safety-seeking behaviours, self-focus and avoidance. These were then targeted using a variety of techniques including discussion and behavioural experiments to facilitate belief and behaviour change. Following a 12-week treatment, measures of anxiety and depression reduced to below clinical thresholds. In addition, there were reductions on a specific measure of symptoms of ORD. Issues regarding the use of CBT to treat this particular disorder are considered.
Context is Everything: An Investigation of Responsibility Beliefs and Interpretations and the Relationship with Obsessive-Compulsive Symptomatology across the Perinatal Period.
BACKGROUND: The cognitive-behavioural model of perinatal OCD suggests the role of increased sense of responsibility during the perinatal period in the development and maintenance of obsessive-compulsive symptoms. However, the idiosyncratic nature of responsibility attitudes and interpretations of intrusions is not fully understood. AIMS: To investigate how responsibility interpretations regarding intrusions vary across the perinatal period and how this relates to obsessive-compulsive symptomatology. METHOD: 94 women (26 antenatal, 35 postpartum and 33 non-childbearing controls) completed measures of responsibility attitudes and interpretations regarding specific intrusions (either general or baby-related), as well as obsessive-compulsive symptomatology, anxiety and depression. RESULTS: Postpartum ratings of responsibility interpretations regarding baby-related intrusions were significantly higher than: i) postpartum ratings of responsibility interpretations regarding non-baby intrusions; and ii) control group responsibility interpretations. The groups were not significantly different regarding general responsibility ratings. Ratings of baby-related responsibility interpretations predicted variance in obsessive-compulsive symptomatology. CONCLUSION: The postpartum group showed significant differences in responsibility interpretations regarding baby-related intrusions. These responsibility interpretations were shown to predict obsessive-compulsive symptomatology.
Treating disturbances in the relationship between mothers with bulimic eating disorders and their infants: a randomized, controlled trial of video feedback.
OBJECTIVE: Maternal eating disorders interfere with parenting, adversely affecting mother-infant interaction and infant outcome. This trial tested whether video-feedback treatment specifically targeting mother-child interaction would be superior to counseling in improving mother-child interaction, especially mealtime conflict, and infant weight and autonomy. METHOD: The participants were 80 mothers with bulimia nervosa or similar eating disorder who were attending routine baby clinics and whose infants were 4-6 months old. They were randomly assigned to video-feedback interactional treatment or supportive counseling. Both groups also received guided cognitive behavior self-help for their eating disorder. Each group received 13 sessions. The primary outcome measure was mealtime conflict; secondary outcome measures were infant weight, aspects of mother-infant interaction, and infant autonomy. RESULTS: Seventy-seven mothers were followed up when their infants were 13 months old. The video-feedback group exhibited significantly less mealtime conflict than the control subjects. Nine of 38 (23.7%) in the video-feedback group showed episodes of marked or severe conflict, compared with 21 of 39 (53.8%) control subjects (odds ratio=0.27, 95% confidence interval=0.10 to 0.73). Video feedback produced significant improvements in several other interaction measures and greater infant autonomy. Both groups maintained good infant weight, with no differences between groups. Maternal eating psychopathology was reduced across both groups. CONCLUSIONS: Video-feedback treatment focusing on mother-infant interaction produced improvements in interaction and infant autonomy, and both groups maintained adequate infant weight. To the authors' knowledge, this is the first controlled trial to show key improvements in interaction between mothers with postnatal psychiatric disorders and their infants.