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Postpartum Depression: Diagnosis and Treatment
Postpartum Depression: Diagnosis and Treatment

Section 16
The Reality of Anger in the Postpartum Period

CEU Question 16 | CEU Test | Table of Contents | Depression
Social Worker CEUs, Counselor CEUs, Psychologist CEs, MFT CEUs

Other than postpartum depression, little is known about women's emotional responses to childbirth and subsequent stressors. Anger was explored on the basis of theory and evidence that it is a likely emotional response in this context. During their third trimester of pregnancy and approximately six weeks after delivery, 163 participants completed the Beck Depression Inventory and the anger subset of the Affect Balance Scale. A number of childbirth-relevant variables were examined as predictors of postpartum emotional response, controlling for prepartum levels and for the association between anger and depressed mood. As expected, a substantial group of women reported high levels of anger irrespective of depressed mood. Although the majority of variables predicted depressed mood, childcare stress, age, and religious self-identification were independently predictive of postpartum anger (all p values < .05). Implications for research and clinical intervention are discussed.

The typical woman presented in psychological literature has a restricted range of responses to negative experiences: She is often presented as inwardly focused, depressed, and ineffectual. Particularly striking is the inattention to emotional responses other than depression. In comparison, the emotion of anger has been remarkably understudied (Kassinove & Sukhodolsky, 1995; Thomas, 1995), which may be due in part to lingering stereotypes about women's emotional responses to negative experience. Anger in women is often seen as both unusual and inappropriate (Kopper & Epperson, 1991; Miller, 1991). Moreover, the majority of studies of anger employ clinically depressed or anxious participants (Thomas, 1995), limiting understanding of the causes and implications of anger itself (Eckhardt & Deffenbacher, 1995).

The focus on depression to the exclusion of other emotional responses such as anger is particularly striking in research on pregnant and postpartum populations. Although a few studies exist on postpartum reactions such as disappointment, satisfaction, and frustration (e.g., DiMatteo et al., 1996; Green, Coupland, & Kitzinger, 1990; Hyde, Klein, Essex, & Clark, 1995; Mackey, 1995), the vast majority of studies of emotional responses to childbirth focus on depressed mood (DiMatteo, Kahn, & Berry, 1993; Nicolson, 1999). It seems likely that there are even stronger social restrictions against anger in postpartum women, for there is a general perception that the process of becoming a mother should be and is a solely happy event (Nicolson, 1999) and that mothers are particularly selfless and nurturing (Thomas, 1991). Whereas depressed mood is typically seen (often erroneously) as either hormonally inevitable or representative of pathology on the part of the mother (Nicolson, 1999), anger in particular implies that there is something to be angry about, which starkly challenges the stereotype of new mothers. Despite such stereotypes, pregnancy and childbirth present a unique opportunity to study women's anger. First, events during pregnancy, delivery, and the surrounding time period comprise a relatively finite set of stressors experienced by many healthy women (Lobel, 1998; O'Hara, 1995). In addition, there are sound theoretical reasons to expect that such stressors would cause anger. According to cognitive models of emotion (e.g., Weiner, 1985), anger typically results from attributions of controllability and accountability for negative or aversive events (Averill, 1983; Lazarus, 1991, chap. 6). Childbirth is associated with significant changes and disruptions in one's familial, work, and other roles (Neter, Collins, Lobel, & Dunkel-Schetter, 1995; Nicolson, 1999; Wells, Hobfoll, & Lavin, 1999), many of which may reasonably be attributed to others, including one's spouse or partner, family members, employers, or health care providers. Such changes are often frustrating, threatening, and anger-provoking for postpartum women (Hyde et al., 1995). In addition, anger is sometimes an automatic reaction to aversive situations (Berkowitz, 1990), which may occur in response to the pain, exhaustion, and discomfort common to delivery and the postpartum period.

There are a number of reasons why it is crucial to study anger in the postpartum period. Unless it represents a chronic, debilitating pattern, experiencing anger in and of itself is not pathological but rather a normal response to a negative occurrence (Lazarus, 1991). It is likely that postpartum anger is adaptive to the extent that it is expressed constructively and helps with goal achievement (Lazarus, 1991). Thus, one motivation for identifying women's anger during the postpartum period is to increase awareness and acceptance of anger as a normal experience during what can be a difficult as well as joyous time. In addition, since anger is often the result of a particular stressor (Averill, 1983), understanding anger can provide information about what types of experiences contribute to it, suggesting relevant interventions to reduce the aversiveness of childbirth and the postpartum period. Finally theory and research in general populations suggest that there may be profound negative repercussions of habitual or unresolved state anger for both a woman and her infant. Trait anger, which is a tendency to experience frequent and intense state anger (Deffenbacher et al., 1996), and patterns of negative anger expression have been linked conclusively to elevated blood pressure and coronary heart disease (Miller, Smith, Turner, Guijarro, & Hallet, 1996; Spielberger, 1999). Preliminary research also suggests that very high levels of state anger may be associated with rejecting or aggressive behavior towards infants (Colin, 1996; Dix, 1991), with implications for infant attachment and health. Anger in pregnancy may also affect the health of the mother or fetus, perhaps via avoidant coping behavior, which is high in angry women (Rusting & Nolen-Hoeksema, 1998) and predictive of greater maternal distress (Lobel, Yali, Zhu, DeVincent, & Meyer, 2002). Like other negative emotional responses to prenatal maternal stress, anger may also elicit unhealthful behaviors such as smoking and poor eating habits, which adversely affect fetal health (Dunkel-Schetter, Gurung, Lobel, & Wadhwa, 2001). Clearly, more information is needed about women's anger during the critical time surrounding pregnancy and childbirth.

Prevalence of Anger and Depressed Mood
The current study focuses on state anger rather than hostility or related constructs. Although sometimes used interchangeably with anger, hostility is a more stable cognitive tendency towards negative beliefs and attitudes, particularly cynicism and mistrust (Miller et al., 1996). Anger is more relevant to the current study as it is instead a reactionary state, consisting of feelings such as irritation, annoyance, and fury (Spielberger, Jacobs, Russell, & Crane, 1983). Anger can be particularly adaptive when it is expressed constructively. However, as the primary goal of this study was not to document the consequences of postpartum anger but to establish that it exists, we focus on state anger rather than on expressed, suppressed, or other behavioral manifestations of anger. Furthermore, we use the term postpartum anger throughout this article to refer to the time period in which anger occurs and to contrast this emotion with postpartum depressed mood. We are not suggesting that postpartum anger is a syndrome or pathological condition or that anger experienced in the postpartum period is qualitatively different from that which occurs at other times in a woman's life.

A large number of scales used to measure anger and related constructs make it difficult to judge the prevalence with which people experience angry emotions (Miller et al., 1996). Adding to such difficulties, most studies of angry emotions have been conducted with male-only samples (Thomas, 1995; Miller et al., 1996). Recent studies, however, are beginning to provide information about the prevalence of anger in women. In one of the very few methodologically sound studies incorporating a measure of postpartum anger (Wells et al., 1999), for example, participants scored on average approximately half a standard deviation above means for their age group (Spielberger et al., 1983). This study found that women who perceived a loss of resources following childbirth experienced an increase of anger from the prepartum to postpartum period (Wells et al., 1999). Postpartum women have also been shown to have elevated anger in response to inadequacy of parental leave from paid employment (Hyde et al., 1995).

In contrast to the limited research on state anger, there is an immense body of research on the prevalence of depression (Kassinove & Sukhodolsky, 1995), including a substantial amount on postpartum depression. Depression during pregnancy is one of the strongest predictors of clinically defined postpartum depression (O'Hara & Swain, 1996), which is characterized by two or more weeks of symptoms including anxiety irritability dysphoria, fatigue, poor appetite, and insomnia, and which affects approximately 10% of childbearing women (O'Hara, 1995) at 2 to 11 weeks postpartum. An additional 20–25% (Hopkins, Marcus, & Campbell, 1984) of women experience mild to moderate levels of depressed mood within this same period. Such moderate levels of depressed mood are distinct from a phenomenon known as the postpartum blues, which is characterized by mood swings, anxiety tearfulness, and irritability affects between 50–80% of all women in the first 10 days after childbirth (Hopkins et al., 1984), and which is thought to be caused by extreme fatigue, sleep disruption, and recovery from delivery (Levy, 1987).

Association Between Depressed Mood and Anger
It is necessary to examine whether anger exists independently of depressed mood in order to determine whether those who experience the former may compose a neglected group of individuals in distress. Most studies of the relationship between depressed and angry emotions reveal a moderate to high correlation, although the majority have focused on hostility rather than state anger (Riley, Treiber, & Woods, 1989). While some researchers have argued for a broader construct such as neuroticism or negative affect that subsumes constructs such as anxiety, depression, and anger (McCrae, 1991; Watson & Clark, 1984), the majority of research supports the conceptualization of anger and depression as distinct constructs. For example, depression and anxiety have been found to be more highly associated with each other than with anger (Bridewell & Chang, 1997). That the correlation between anger and depression is less than perfect has also been taken as evidence that "anger and depressed mood represent distinguishable constructs" (Wells et al., 1999, p. 1176). In addition, the degree and even existence of the association between angry emotions and depression seems to be inconsistent across different studies, perhaps due to differences in the way anger is measured or what type of anger experience or expression is examined (Riley et al., 1989).
- Graham, J.E., Lobel, M., Deluca, R.S.; Anger After Childbirth: An Overlooked Reaction to Postpartum Stressors; Psychology of Women Quarterly; Fall 2002; Vol. 26, Issue 3.

Maternal Depression and Childhood Aggression: Literature Review

- Hendricks, K., & Liu, J. (2012). Childbearing depression and childhood aggression: literature review. MCN. The American journal of maternal child nursing, 37(4), 253–261. doi:10.1097/NMC.0b013e3182482c5e.

Postpartum Training Module

- Health Communications Division. Postpartum Nutrition Module. TEXAS DEPARTMENT OF HEALTH • BUREAU OF NUTRITION SERVICES, Rev. 7/1/03.

Personal Reflection Exercise #2
The preceding section contained information regarding anger during the postpartum period.  Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Dellagiulia, A., Lionetti, F., Pastore, M., Linnea, K., Hasse, K., & Huizink, A. C. (2020). The Pregnancy Anxiety Questionnaire Revised-2: A contribution to its validation. European Journal of Psychological Assessment, 36(5), 787–795.

Gilkes, M., Perich, T., & Meade, T. (2019). Predictors of self-stigma in bipolar disorder: Depression, mania, and perceived cognitive function. Stigma and Health, 4(3), 330–336.

Handelzalts, J. E., Hairston, I. S., Muzik, M., Matatyahu Tahar, A., & Levy, S. (2019). A paradoxical role of childbirth-related posttraumatic stress disorder (PTSD) symptoms in the association between personality factors and mother–infant bonding: A cross-sectional study. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication.

Online Continuing Education QUESTION 16
What phenomena, separate from postpartum depression, is characterized by mood swings, anxiety tearfulness, and irritability, affecting between 50–80% of all women in the first 10 days after childbirth? Record the letter of the correct answer the CEU Test.

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