Anxious for Two: Assessing and Treating Antenatal Anxiety Disorders

                                                      Part I- Screening and Diagnosis

She just paged you again. It is “urgent”, just like the last 5 times. You sigh deeply: no matter how many times you tell her that her labs are normal, explain that some shortness of breath is expected in the last trimester, or reassure her that her heartburn is not a first sign of a heart attack (yes, you checked) – it simply won’t stick.

She tells you that she knows better but can’t help it, or that this time something really is wrong with her baby - she just knows it. The fact that her last ultrasound, (merely 2 days ago), was completely normal is irrelevant. She is consumed with worry, can’t sleep at night and feels “totally exhausted.” You can share the sentiment.

How common are anxiety disorders during pregnancy?

Quite. About 10% of pregnant women suffer form Generalized Anxiety Disorder (GAD), up to 5 %  suffer from a panic disorder, a similar percentage meets criteria for Obsessive Compulsive Disorder and about 3% of expecting mothers exhibit signs and symptoms of Post Traumatic Stress Disorder. ^(1,2)  Overall, the prevalence of these disorders is equal or higher in pregnant women than the prevalence among the general population. Since one third of women will suffer from an anxiety disorder at some point in their lives, chances are you are no stranger to these challenging, yet highly treatable disorders:

GAD: “the worrier”: This patient tends to worry excessively and uncontrollably about a variety of everyday issues (health, relationships, money etc.) leading to intense anxiety, insomnia, muscle tension and other physical symptoms. This disorder is chronic, lasting at least 6 months and often as long as the patient remembers. DSM-IV TR diagnostic criteria

Panic Disorder: Recurrent episodes of intense anxiety that develop unpredictably and almost instantaneously, subside within 30 minutes or so, and include at least 4 of 13 physical symptoms (e.g. shortness of breath, palpitations, perspiration). These episodes lead to anticipatory anxiety for at least a month, and avoidance of feared triggers. In its most severe form, patients avoid all triggers by staying at home, leaving only when absolutely necessary and with a companion (=agoraphobia). The diagnosis of a panic disorder is made only after relevant medical and drug induced conditions have been ruled out.  DSM-IV TR diagnostic features

OCD: A combination of intrusive, irrational, anxiety provoking thoughts and images (=obsessions) that are counteracted by repetitive behaviors (compulsions) that may become very time consuming. Unlike psychotic disorders, patients with OCD are fully aware of their “crazy” thoughts and “silly” rituals and are embarrassed by them but feel compelled to carry them on, in order to reduce their anxiety.  DSM-IV TR diagnostic criteria

PTSD:  chronic re-experiencing (via visual flashbacks and/and dreams), hyper vigilance and avoidance of triggers that remind a patient of a highly distressing event in her past. The trauma involves a perceived threat to the psychological or physical well being of the patient herself or to someone else.  DSM-IV TR diagnostic criteria

Unlike milder worries and concerns, antenatal anxiety disorders involve intense, very distressing symptoms, and carry risks of preterm labor ⁽³⁾, low birth weight ⁽⁴⁾, lower Apgar scores ⁽⁵⁾, enduring emotional and cognitive changes ⁽⁶⁾, indirect risks associated with maternal behavior (substances used for self treatment, missing appointments, avoiding important tests or undergoing risky, unnecessary ones, etc.) and post partum depression⁽⁷⁾. Correct diagnosis and appropriate treatment can minimize these risks. However, most ob/gyns are more accurate in identifying depression than anxiety, and only one-fifth routinely screen pregnant patients for anxiety ⁽⁸⁾.

Specific tools (e.g. GAD-7, ⁽⁹⁾) identify specific anxiety disorder. However, a good first step toward screening is using a more general tool like The anxiety subscale of the Edinburgh Postnatal Depression Scale (EPDS ,⁽¹⁰⁾), that has been validated for anxiety symptoms in pregnancy.

Part II – Presentation of Anxiety Disorders in Pregnancy

References:

1.  Sutter-Dallay AL, Giaconne-Marcesche V, Glatigney-Dallay E, Verdoux H.  Women with anxiety disorders during pregnancy are at increased risk of intensie postnatal depressive symptoms: A prospective study of the MATQUID cohort.  European Psychiatry, 2004; 19:459-463.
2.  Adewuya AO, Ola BA, Aloba OO, Mapayi BM.  Anxiety disorders among Nigerian women in late pregnancy: A controlled study. Arch Womens Ment Health. 2006; 9: 325-328
3.  Dayan J, Creveuil C, Herlicoviez M, et al. Role of anxiety and depression in the onset of spontaneous preterm labor. Am J Epidemiol. 2002;155(4):293-301.
4.  Warren SL, Racu C, Gregg V, Simmens SJ. Maternal panic disorder: Infant prematurity and low birth weight. J Anxiety Disord. 2006;20(3):342-352.
5.  Berle JØ, Mykletun A, Daltveit AK, et al. Neonatal outcomes in offspring of women with anxiety and depression during pregnancy. A linkage study from The Nord-Trøndelag Health Study (HUNT) and Medical Birth Registry of Norway. Arch Womens Ment Health 2005;8(3):181-189.
6.  Van den Bergh BR, Mulder EJ, Mennes M, Glover V. Antenatal maternal anxiety and stress and the neurobehavioural development of the fetus and child: links and possible mechanisms. A review.  Neuroscience & Biobehavioral Reviews. 2005;29(2):237-258.
7.  Coelho HF, Murray L, Royal-Lawson M, Cooper PJ. Antenatal anxiety disorder as a predictor of postnatal depression: a longitudinal study. J Affect Disord. 2011;129(1-3):348-53.
8.  Leddy MA, Lawrence H, Schulkin J. Obstetrician-Gynecologists and Women's Mental Health: Findings of the Collaborative Ambulatory Research Network 2005-2009. Obstet Gynecol Surv. 2011 May;66(5):316-23.
9.  Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7.Arch Intern Med. 2006;22;166(10):1092-1097.
10.  Swalm D, Brooks J, Doherty D, et al. Using the Edinburgh postnatal depression scale to screen for perinatal anxiety.  Arch Womens Ment Health 2010;13(6):515-522.