Between two and four per cent of pregnant women experience Generalized Anxiety or have a Panic Disorder. A large number of these women would have experienced the onset of Generalized Anxiety or Panic Disorder prior to the pregnancy (approximately 40 per cent).
Between four and six per cent of women experience Panic Disorder with an onset in the postpartum period.

What is a Panic Disorder?

Women with symptoms of anxiety may experience agoraphobia and some of them may progress to have full blown panic attacks. A panic attack is a "discreet episode of intense fear reaching its peak in intensity within 10 minutes from onset. It is often associated with or accompanied by feelings of impending doom." It is associated with physical symptoms including racing heart, palpitations, and shortness of breath, trembling, hot and cold flashes and stomach upset.

Between panic attacks, women may have varying degrees of nervousness and apprehension which is characterized by tense, agitated, vigilant and scanning behavior.

The course of Panic Disorder during pregnancy varies from woman to woman. Some women experience a reduction in their symptoms. They may be able to tolerate medication reduction or discontinuation.

Other women who experience Panic Disorders during pregnancy may have an increase in their symptoms and require an increase in their anti-panic medication. There is some evidence that biological changes in pregnancy may increase symptoms in some women.

In late pregnancy and in the postpartum period an increased level of activity in the noradrenergic and serotenergic systems innervating the brain may cause increased neurotransmitter activity. This could act as an integral trigger for the onset of a panic attack.

Themes of Panic Disorders

Cheryl Tatano Beck (1998) described six themes from interviewing 10 women with postpartum onset of Panic Disorders:

1. The terrifying physical and emotional components of panic paralyzed women, leaving them feeling totally out of control. As panic worsened and women lost all sense of control in their lives, some had suicidal thoughts.

2. During panic attacks, women’s cognitive functioning abruptly diminished while between these attacks women experience a more insidious decrease in their cognitive functioning. During the panic attack women felt like they were going to loose their minds, and they had a sense of impending doom. Between panic attacks, women were not able to trust their minds or judgments because they were so consumed with worry of panic.

3. During the panic attacks, women feverishly struggled to maintain their composure, leading to exhaustion.

4. Because of the terrifying nature of panic, preventing further panic attacks was paramount in the lives of the women. Women sought to discover the triggers to their panic attacks, such as, certain times of day, confined rooms, over stressed etc.

5. As a result of recurring panic attacks, negative changes in women’s lifestyles ensued - lowering of their self-esteem and leaving them to bear the burden of disappointing not only themselves but also their families. Fear of having panic attacks would leave women unable to leave their homes.

6. Mothers were haunted by the prospect that their panic could have residual effects on themselves and their families. Women who were recovering from their panic attacks perceived that the panic attacks were never completely gone. Other women felt that their attacks had traumatized their children.

What are the risks for a Panic Disorder?

Women are at greater risk of experiencing a Panic Disorder if they have a previous history of Panic Disorder, for example:

a woman with a previous history prior to pregnancy is at higher risk of developing symptoms during pregnancy,
a woman with a history during pregnancy is at greater risk of developing symptoms during the postpartum period.
a woman with a history during previous pregnancies may/or may not be at greater risk of developing symptoms during subsequent pregnancies.

What are the signs and symptoms of a Panic Attack?

You may experience four of the following 14 symptoms during a panic attack:

shortness of breath
choking or smothering sensation
palpitations or accelerated heart rate
tingling sensation (parasthesia)
chest pain or discomfort
sweating
hot flashes or chills
faintness
trembling or shaking
dizziness, light headedness or unsteady feelings
nausea or abdominal distress
depersonalization (feeling disoriented or that the world has become unreal)
fear of going crazy or doing something uncontrolled
fear of dying

Why should women with Panic Disorders seek treatment in pregnancy or postpartum?

The incidence of Panic Disorders rises in the postpartum period.
Untreated Panic Disorders in pregnancy may predispose women to greater illness and increased symptoms postpartum.
Instituting approaches to treatment of Panic Disorder in pregnancy may increase coping skills of women in the postpartum period.
Use of anti-panic medication in the postpartum period has been shown to decrease symptoms.
Untreated Major Anxiety/Panic Disorders may affect the mother-child relationship and the woman’s ability to cope in the postpartum period

What are the treatments options for women with Panic Disorders?

Psycho education - Involve the significant other, friends and family supports. Teach coping strategies and how to build social networks and supports.

Supportive Psychotherapy - offers support, reassurance and education for women with postpartum depression.

Cognitive Behaviour Therapy (CBT) - is based on the fact that, the way we think affects the way we behave. Depressed women may experience a lot of negative thoughts. Cognitive Behavior Therapy helps women identify these thoughts, teaches them to challenge them and replace them with positive thoughts. The resulting thought patterns changes from their earlier ones. In cognitive therapy, the therapist helps the woman: identify her distorted thinking patterns, patterns, challenge these distortions and replace the thoughts with more realistic thoughts.

Some examples of Cognitive Disorders:

All-or-nothing thinking: You look at things in absolute, black-and-white categories.
Overgeneralization: You view a negative event as a never-ending pattern of defeat.
Mental filter: You dwell on the negatives and ignore the positives.
Discounting the positives: You insist that you accomplishments or positive qualities "don’t count".
Jumping to conclusions: Mind reading – you assume that people are reacting negatively to you when there’s no definite evidence for this.
Fortune-telling - you arbitrarily predict that things will turn out badly.
Magnification or minimizing: You blow things way up out of proportion or you shrink their importance inappropriately.
Emotional reasoning: You reason from how you feel: "I feel like an idiot, so I really must be one". Or "I don’t feel like doing this, so I’ll put it off"."
Should statements": "You criticize yourself or other people with "shoulds" or "shouldn’ts". "Musts", "oughts" and "have tos" are similar offenders.
Labeling: You identify with your shortcomings. Instead of saying "I made a mistake", you tell yourself, "I’m a jerk", or "a loser".
Personalization and blame: You blame yourself for something you weren’t entirely responsible for, or you blame other people and overload ways that your own attitudes and behaviour might contribute to a problem.

Adapted from David D. Burns, MD, “Feeling Good: The New Mood Therapy” (New York: William Morrow & Company, 1980.

Group Therapy - Public Health Nurses in conjunction with other community service providers may co-facilitate postpartum support groups Peer support groups are offered by several non-profit organizations across B.C., such as the Pacific Postpartum Support Society Mental Health Teams may offer general depression support groups. For more information , refer to your health suthority’s website link to Partners & Affiliations The Reproductive Mental Health Program offers group psychotherapy for those postpartum women attending the program.

Family & Relationship Counseling - assists women and their significant others to develop strategies to cope with this stressful time.

Pharmacotherapy (i.e., Antianxiety Medication)

How do Anti-anxiety medications work?

Anti-anxiety or benzodiazepines produce their effect within the central nervous system by interacting with neurotransmitters and brain receptors.

Possible side effects of benzodiazepines are sedation, problems with coordination, development of tolerance and physical dependency, and withdrawal symptoms when rapidly withdrawn. The minimum dose which gives therapeutic effect should be used. Benzodiazepines should be used in conjunction with other therapies such as Cognitive Behaviour Therapy or Supportive Therapy.

Anti-anxiety medication during pregnancy?

The goal of treatment is to minimize risk of fetal exposure to anti-anxiety medications while limiting the risks of untreated Anxiety/Panic Disorder. Ideally the woman should be on the lowest possible dose to treat her symptoms.

Shorter acting benzodiazepines, such as lorazepam, may have a less long lasting effect on the fetus. This may be the preferred treatment for episodic panic attacks. However, longer acting benzodiazepines may be preferred to obtain a longer lasting effect in a woman who is constantly anxious.

Anti-anxiety medication or benzodiazepines do cross the placenta and can affect the fetus. Any fetus exposed to benzodiazepines during pregnancy or delivery should be monitored for signs of apnea or central nervous system depression, such as lethargy or hypoventilation. Benzodiazepine concentrations will be higher and persist for a longer period in premature infants.

Anti-anxiety medication postpartum

Effects of antianxiety medication on breast milk:

Anti-anxiety medication or benzodiazepines cross into the breast-milk in small quantities, and are found in the newborn’s blood serum. Significantly more anti-anxiety mediation is found in the woman’s serum than in the breast milk or the newborn serum. The highest dose of benzodiazepines was found four hours after the woman took her medication.

If central nervous symptoms occur in the newborn, such as apnea, lethargy and weight loss, the maternal dose of anxiolytic medication should be reviewed and possibly reduced.

Effects of sedative hypnotic medication on breast milk:

Several studies found that women who took sedative hypnotic medications, such as clonazepam, temazepam, and zolpidem, had a low level of these medications in their breast milk. Zolpidem has a rapid onset, a short half-life, and rapid absorption, most of which is excreted in the breast milk within three hours of the mother receiving her dose.

Possible side effect of benzodiazepines is sedation.