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

Section 8
Anxiety During Pregnancy: Panic Disorder

CEU Question 8 | CEU Test | Table of Contents | Depression
Psychology CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs

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In the last section, we discussed undiagnosed depression and when depression leads to addiction.

In this section, we will discuss panic and depression.  This will include panic disorder; panic attacks and pregnancy; and panic vs. depression, which comes first?  If you are already familiar with these disorders, you might use this section as a review.

As you may know, pregnancy is a period of heightened anxiety in a woman’s life.  No matter how confident they may be, many women are anxious about embarking upon motherhood.  Some women may be fearful that their baby could be born with some kind of physical problem or deformity, or they may simply fear the pain of labor and delivery. 

Many women, in fact, prepare for their pregnancy by giving up coffee or cigarettes, trying to eat more nutritiously, and generally becoming more fit.  Both the anxiety and the preparation are normal reactions to pregnancy.  Let’s look at differentiating a diagnosis of anxiety, a panic disorder and depression.  Here’s a review.

♦ Panic Disorder
First, panic disorder, which afflicts approximately 5% of women, is characterized by episodes of a truly terrifying cluster of psychological as well as physical symptoms that seem to appear out of the blue and that can last anywhere from a few minutes to a few hours. 

Panic attacks are characterized by the abrupt, intense onset of at least four of the following thirteen symptoms, as identified in the DSM.  These include palpitations; shortness of breath; sweating; trembling or shaking; chest pain; feelings of choking; nausea or abdominal distress; feeling dizzy, light-headed or faint; feelings of being detached from one’s body; fear of losing control or becoming crazy; fear of death; unusual numbness or tingling in various parts of the body and chills or hot flashes.

To complicate matters, these attacks can occur with or without agoraphobia, the fear and avoidance of places where escape or assistance might be difficult or embarrassing.  People can actually fear and avoid many spaces, open or not, from bridges and tunnels to airplanes and movie theaters.  For those who are agoraphobic, a panic attack might be triggered either by being in the place or situation that is feared or by the anticipation of having to be in such a place or situation.

Without agoraphobia, a panic attack may come on without any obvious stimulus at all.  This lack of obvious stimulus can be even more frightening, as it was for Jada, who had never experienced one until she was 28 years old and twelve weeks pregnant.  Jada’s husband, Rob, was in Europe on business when she awakened in the middle of the night drenched in sweat with severe heart palpitations, acute shortness of breath, and the feeling that her chest was being crushed. 

Terrified, Jada called 911 and was rushed to the nearest emergency room, where she was immediately put on a heart monitor and an extensive cardiac workup was begun.  When Rob arrived the next day, having caught the first available flight, all the tests had proved negative and Jada was sent home with a clean bill of health.

Three weeks later, while Jada was at work preparing a difficult cost analysis for a client and feeling overwhelmed by all the figures in front of her, her vision suddenly blurred, she became dizzy, and she thought she was about to faint.  Jada had to leave work and return home, a safe place where no one would see how anxious she was.  This time, Jada knew she wasn’t having a heart attack.  Subsequently, she came to see me, and I treated her with cognitive behavior therapy to help her cope with what she now realized were panic attacks.

♦ Panic Attacks During Pregnancy
Now that we have looked at panic attacks in general, let’s discuss panic attacks specific to pregnancy.  Like Jada, most pregnant women who experience panic attacks make several trips to the emergency room and are often investigated for heart attacks before being diagnosed with panic disorder.  I have found that the attacks generally occur just before bedtime, in the middle of the night, or upon awakening, and they are always all-consuming and totally petrifying.

Unlike depression, symptoms of panic do not creep up silently.  Rather, they arrive like a bolt from the blue and cannot be overlooked or ignored.  Rob described one of Jada’s panic attacks this way, "Jada was in the kitchen peeling vegetables.  One minute she was happy as a lark, humming to herself, and the next minute she was shaking all over.  Her face turned red and her pupils dilated until they were huge.  She was bending over, holding her chest, and I just thought, ‘Oh my God, it’s another panic attack.’"

I have found that many women do not experience relief from panic attacks during pregnancy.  If anything, some remain the same while others grow worse, but only a very few of them become better.  It is generally accepted that those who experience panic attacks during pregnancy are at increased risk for postpartum symptoms.

♦ Panic vs. Depression, Which Comes First?
Third, in addition to, panic disorder and panic attacks during pregnancy, let’s discuss which comes first, panic or depression?  Many women who experience repeated panic attacks subsequently become depressed, while others may first become depressed and then see their depression complicated by the onset of panic disorder.  In either situation, the management and treatment of these women becomes even more challenging than the treatment of either condition alone, especially when the woman is pregnant.

Celeste, a Native American, was admitted to the hospital because of uncontrollable high blood pressure during her pregnancy.  Celeste was in the hospital for more than a week without ever disclosing to any of her caregivers that she’d been having eight to ten panic attacks a day.  In fact, Celeste hid her symptoms very well until a nurse went to check on her one night and found Celeste sitting up in bed meditating. 

When the nurse asked her what was wrong, Celeste finally broke down and confessed that she was constantly experiencing breathlessness, tingling, and numbness in various parts of her body and that she was afraid she was dying.

When I saw Celeste the following day, I started her on a low dose of antidepressant medication in addition to the blood pressure medications she was already taking and to which she had not responded.  Celeste remained in the hospital for another three weeks, after which she was discharged with her panic attacks substantially diminished.

In Celeste’s case, the high blood pressure and panic attacks occurred as two separate problems, and the connection between the two still remains unclear.  In my practice, however, I very frequently see them occur in conjunction with one another, and once the panic attacks are treated, the blood pressure often returns to normal.  Celeste has stopped drinking coffee, exercises regularly, and continues to take her medication.

Do you have a Jada or a Celeste?  Might she benefit from hearing this section in your next session? 

In this section, we have discussed panic and depression.  This has included panic disorder; panic attacks and pregnancy; and panic vs. depression, which comes first?

In the next section, we will continue our discussion of anxiety.  This will include untreated anxiety, when a child is truly at risk, and ghosts in the nursery.

Peer-Reviewed Journal Article References:
Conway, C. C., Rutter, L. A., & Brown, T. A. (2016). Chronic environmental stress and the temporal course of depression and panic disorder: A trait-state-occasion modeling approach. Journal of Abnormal Psychology, 125(1), 53–63.

Dellagiulia, A., Lionetti, F., Pastore, M., Linnea, K., Hasse, K., & Huizink, A. C. (2019). The Pregnancy Anxiety Questionnaire Revised-2: A contribution to its validation. European Journal of Psychological Assessment. Advance online publication.

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.

Mogg, K., Wilson, K. A., Hayward, C., Cunning, D., & Bradley, B. P. (2012). Attentional biases for threat in at-risk daughters and mothers with lifetime panic disorder. Journal of Abnormal Psychology, 121(4), 852–862. 

Whisman, M. A., Davila, J., & Goodman, S. H. (2011). Relationship adjustment, depression, and anxiety during pregnancy and the postpartum period. Journal of Family Psychology, 25(3), 375–383. 

Online Continuing Education QUESTION 8
What are some symptoms of a panic attack? To select and enter your answer go to CEU Test.

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