Exploring the role of OXTR gene methylation in attachment development: A longitudinal study.

The current study explored longitudinally whether oxytocin receptor gene methylation (OXTRm) changes moderated the association between parental sensitivity changes and children's attachment changes over three waves. Six hundred six Flemish children (10-12 years, 42.8%-44.8% boys) completed attachment measures and provided salivary OXTRm data on seven CpG sites. Their parents reported their sensitive parenting. Results suggest that OXTRm changes hardly link to attachment (in)security changes after the age of 10. Some support was found for interaction effects between parental sensitivity changes and OXTRm changes on attachment changes over time. Effects suggest that for children with increased OXTRm in the promotor region and decreased methylation in the inhibitor region over time, increased parental sensitivity was associated with increased secure attachment and decreased insecure attachment over time.

Screening for post-traumatic stress disorder following childbirth using the Peritraumatic Distress Inventory.

BACKGROUND: Post-traumatic stress disorder (PTSD) following traumatic childbirth may undermine maternal and infant health, but screening for maternal childbirth-related PTSD (CB-PTSD) remains lacking. Acute emotional distress in response to a traumatic experience strongly associates with PTSD. The Peritraumatic Distress Inventory (PDI) assesses acute distress in non-postpartum individuals, but its use to classify women likely to endorse CB-PTSD is unknown. METHODS: 3039 women provided information about their mental health and childbirth experience. They completed the PDI regarding their recent childbirth event, and a PTSD symptom screen to determine CB-PTSD. We employed Exploratory Graph Analysis and bootstrapping to reveal the PDI's factorial structure and optimal cutoff value for CB-PTSD classification. RESULTS: Factor analysis revealed two strongly correlated stable factors based on a modified version of the PDI: (1) negative emotions and (2) bodily arousal and threat appraisal. A score of 15+ on the modified PDI produced high sensitivity and specificity: 88 % with a positive CB-PTSD screen in the first postpartum months and 93 % with a negative screen. LIMITATIONS: In this cross-sectional study, the PDI was administered at different timepoints postpartum. Future work should examine the PDI's predictive utility for screening women as closely as possible to the time of childbirth, and establish clinical cutoffs in populations after complicated deliveries. CONCLUSIONS: Brief self-report screening concerning a woman's emotional reactions to childbirth using our modified PDI tool can detect those likely to endorse CB-PTSD in the early postpartum. This may serve as the initial step of managing symptoms to ultimately prevent chronic manifestations.

Screening for Post-Traumatic Stress Disorder following Childbirth using the Peritraumatic Distress Inventory.

Background: Maternal psychiatric morbidities include a range of psychopathologies; one condition is post-traumatic stress disorder (PTSD) that develops following a traumatic childbirth experience and may undermine maternal and infant health. Although assessment for maternal mental health problems is integrated in routine perinatal care, screening for maternal childbirth-related PTSD (CB-PTSD) remains lacking. Acute emotional distress in response to a traumatic event strongly associates with PTSD. The brief 13-item Peritraumatic Distress Inventory (PDI) is a common tool to assess acute distress in non-postpartum individuals. How well the PDI specified to childbirth can classify women likely to endorse CB-PTSD is unknown. Objectives: We sought to determine the utility of the PDI to detect CB-PTSD in the early postpartum period. This involved examining the psychometric properties of the PDI specified to childbirth, pertaining to its factorial structure, and establishing an optimal cutoff point for the classification of women with high vs. low likelihood of endorsing CB-PTSD. Study Design: A sample of 3,039 eligible women who had recently given birth provided information about their mental health and childbirth experience. They completed the PDI regarding their recent childbirth event, and a PTSD symptom screen to determine CB-PTSD. We employed Exploratory Graph Analysis (EGA) and bootstrapping analysis to reveal the factorial structure of the PDI and the optimal PDI cutoff value for CB-PTSD classification. Results: Factor analysis of the PDI shows two strongly correlated stable factors based on a modified 12-item version of the PDI consisting of (1) negative emotions and (2) bodily arousal and threat appraisal in regard to recent childbirth. This structure largely accords with prior studies of individuals who experienced acute distress resulting from other forms of trauma. We report that a score of 15 or higher on the modified PDI produces strong sensitivity and specificity. 88% of women with a positive CB-PTSD screen in the first postpartum months and 93% with a negative screen are identified as such using the established cutoff. Conclusions: Our work reveals that a brief self-report screening concerning a woman's immediate emotional reactions to childbirth that uses our modified PDI tool can detect women likely to endorse CB-PTSD in the early postpartum period. This form of maternal mental health assessment may serve as the initial step of managing symptoms to ultimately prevent chronic symptom manifestation. Future research is needed to examine the utility of employing the PDI as an assessment performed during maternity hospitalization stay in women following complicated deliveries to further guide recommendations to implement maternal mental health screening for women at high risk for developing CB-PTSD.

A unified model of the biology of peripartum depression.

Peripartum depression (PPD) is a prevalent and debilitating disorder that adversely affects the development of mothers and infants. Recently, there has been a plea for increased mental health screening during the peripartum period; however, currently, there is no accurate screening tool to identify women at risk of PPD. In addition, some women do not respond to current treatment schemes and develop treatment-resistant depression. The current perspective aims to propose a unified understanding of the biological underpinnings of PPD (UmPPD) that considers the heterogeneity in the onset, symptoms cluster, and severity of PPD. Such a model could promote basic and applied research on PPD and suggest new treatment avenues. The central hub of the model is the kynurenine pathway (KP) and the KP-serotonin ratio. The forces and specific processes at play that cause an imbalance within the KP and between KP and serotonin are inflammation, stress, reproductive hormones (especially estradiol and progesterone), and oxytocin. UmPPD predicts that the most severe PPD would comprise prolonged inflammation, ongoing or multiple stressors, excessive estrogen, progesterone resistance, and avoidance of breastfeeding, skin-to-skin contact, and social proximity. These factors would be associated with a higher likelihood of developing PPD, early onset, and more significant symptom severity. In addition, subtypes of PPD would consist of different compositions and expressions of these components, with one central common factor. UmPPD could aid in directing future research and possibly detecting critical processes that could help discover, develop, and utilize novel treatments for PPD.

Traumatic childbirth during COVID-19 triggers maternal psychological growth and in turn better mother-infant bonding.

BACKGROUND: Although posttraumatic psychological growth (PTG) occurs following stressful events, knowledge of maternal psychological growth as a result of giving birth during the novel coronavirus (COVID-19) pandemic is lacking. METHODS: We assessed PTG associated with recent childbirth (Posttraumatic Growth Inventory) in a sample of 2205 women who gave birth during the pandemic and 540 who gave birth before. They also provided information about birth-related traumatic stress (Peritraumatic Distress Inventory; PTSD Checklist), mother-infant bonding (Maternal Attachment Inventory), and breastfeeding. RESULTS: Close to two thirds (60.45 %) of participants reported childbirth-related PTG with greater appreciation of life endorsed most frequently. No group differences in PTG prevalence were noted between deliveries during or before COVID-19 (χ2 = 0.35, p = 0.84). A multigroup mediation model revealed that in deliveries during the pandemic, childbirth-related acute stress was linked with elevated PTG (ß = 0.07, p < 0.01); in turn, PTG was associated with lower posttraumatic stress symptoms (ß = -0.06, p < 0.05) and better mother-infant bonding (ß = 0.22, p < 0.001). These indirect paths via PTG were not significant in deliveries before the pandemic. LIMITATIONS: Reliance on a convenient sample, self-reports, and cross-sectional design may introduce bias. CONCLUSIONS: Perceived positive maternal psychological changes as a result of childbirth are endorsed by a significant portion of women during the pandemic and can ensue in response to traumatic childbirth. Maternal growth is further implicated in successful postpartum adjustment and positive mother-infant interactions during an important period. Hence, directing clinical attention to opportunities of maternal psychological growth may have benefits especially for women at risk for the adverse outcomes of exposure to traumatic experiences of childbirth.

COVID-19 positivity associated with traumatic stress response to childbirth and no visitors and infant separation in the hospital.

As the novel coronavirus (COVID-19) has spread globally, a significant portion of pregnant and delivering women were infected with COVID-19. While emerging studies examined birth outcomes in COVID-19 positive women, knowledge of the psychological experience of childbirth and maternal wellness remains lacking. This matched-control survey-based study included a sample of women recruited during the first wave of the pandemic in the US who gave birth in the previous six months. Women reporting confirmed/suspected COVID-19 (n = 68) during pregnancy or childbirth were matched on background factors with women reporting COVID-19 negativity (n = 2,276). We found nearly 50% of COVID positive women endorsed acute traumatic stress symptoms at a clinical level in response to childbirth. This group was more than twice as likely to endorse acute stress and to have no visitors during maternity hospitalization than COVID negative women; they were also less likely to room-in with newborns. The COVID positive group reported higher levels of pain in delivery, lower newborn weights, and more infant admission to neonatal intensive care units. Our findings suggest COVID-19 affected populations are at increased risk for traumatic childbirth and associated risk for psychiatric morbidity. Attention to delivering women's wellbeing is warranted during the pandemic.

Patients' individual differences in implicit and explicit expectations from the therapist as a function of attachment orientation.

Patients' attachment orientation was found to be an important predictor of the process and outcome of psychotherapy. The present study is the first to examine whether patients' attachment orientation toward significant others predicts their implicit and explicit expectations from the therapist, and whether this effect is moderated by the extent to which the therapist has become an attachment figure. In two studies (N = 308), we developed measures of implicit (lexical decision task) and explicit expectations from therapist, and tested the presence of individual differences in expectations as a function of the patients' attachment orientation, early and late in treatment. Whereas individuals higher on attachment anxiety did not report having fewer positive expectations from therapist early in treatment, they showed lower accessibility of positive expectations when measured implicitly. As treatment progressed, the extent to which the therapist has become an attachment figure may mitigate the adverse effects of pretreatment attachment anxiety. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

COVID-19 is associated with traumatic childbirth and subsequent mother-infant bonding problems.

BACKGROUND: Knowledge of women's experience of childbirth in the outbreak of the coronavirus (COVID-19) pandemic and associated maternal health outcomes is scarce. METHODS: A sample of primarily American women who gave birth around the height of COVID-19 (n = 1,611) and matched controls, i.e., women who gave birth before COVID-19 (n = 640), completed an anonymous Internet survey about recent childbirth, birth-related traumatic stress (peritraumatic distress inventory; PTSD-checklist), maternal bonding (maternal attachment inventory; mother-to-infant bonding scale) and breastfeeding status. Groups (n = 637 in each) were matched on demographics, prior mental health/trauma and childbirth factors to determine the unique contribution of COVID-19 to the psychological experience of childbirth. RESULTS: Mothers in COVID-19-exposed communities endorsed more clinically acute stress response to childbirth than matched controls (Z = 2.65, p = .008, OR= 1.38). A path mediation model revealed that acute stress mediated the relationship between study group and postpartum outcomes. Specifically, higher acute stress response in birth was associated with more childbirth-related posttraumatic stress disorder symptoms (ß = .42, p < .001) and less bonding with the infant (ß = .26, p < .001), including breastfeeding problems (ß = .10, p < .01). LIMITATIONS: Use of a convenient internet sample introduces bias towards more educated women and reliance on retrospective self-report assessments may entail recall bias. CONCLUSIONS: COVID-19 is a major stressor for delivering women. It can heighten traumatic childbirth experiences and interfere with successful postpartum adjustment. Clinical attention to traumatic stress in childbirth and problems with caring for the young during this pandemic is important.

Giving birth under hospital visitor restrictions: Heightened acute stress in childbirth in COVID-19 positive women.

As the novel coronavirus (COVID-19) has spread globally, a significant portion of women have undergone childbirth while possibly infected with the virus and also under social isolation due to hospital visitor restrictions. Emerging studies examined birth outcomes in COVID-19 positive women, but knowledge of the psychological experience of childbirth remains lacking. This study survey concerning childbirth and mental health launched during the first wave of the pandemic in the US. Women reporting confirmed/suspected COVID-19 during childbirth were matched on various background factors with women reporting COVID-19 negative. We found higher prevalence of clinically significant acute stress in birth in COVID-19 positive women. This group was 11 times as likely to have no visitors than matched controls and reported higher levels of pain in delivery, lower newborn weights, and more infant admission to neonatal intensive care units. Visitor restrictions were associated with these birth outcomes. COVID-19 positive women with no visitors were 6 times as likely to report clinical acute stress in birth than COVID-19 positive women with visitors. The findings underscore increased risk for childbirth-induced psychological morbidity in COVID-19-affected populations. As hospitals continue to revise policies concerning visitor restrictions, attention to the wellbeing of new mothers is warranted.

Giving birth under hospital visitor restrictions: Heightened acute stress in childbirth in COVID-19 positive women.

As the novel coronavirus (COVID-19) has spread globally, a significant portion of women have undergone childbirth while possibly infected with the virus and also under social isolation due to hospital visitor restrictions. Emerging studies examined birth outcomes in COVID-19 positive women, but knowledge of the psychological experience of childbirth remains lacking. This study survey concerning childbirth and mental health launched during the first wave of the pandemic in the US. Women reporting confirmed/suspected COVID-19 during childbirth were matched on various background factors with women reporting COVID-19 negative. We found higher prevalence of clinically significant acute stress in birth in COVID-19 positive women. This group was 11 times as likely to have no visitors than matched controls and reported higher levels of pain in delivery, lower newborn weights, and more infant admission to neonatal intensive care units. Visitor restrictions were associated with these birth outcomes. COVID-19 positive women with no visitors were 6 times as likely to report clinical acute stress in birth than COVID-19 positive women with visitors. The findings underscore increased risk for childbirth-induced psychological morbidity in COVID-19-affected populations. As hospitals continue to revise policies concerning visitor restrictions, attention to the wellbeing of new mothers is warranted.

Risk factors for developing posttraumatic stress disorder following childbirth.

Women can develop childbirth-related posttraumatic stress disorder (CB-PTSD) in at-term delivery with healthy baby outcome as well as following pre-term delivery and neonatal complications, a potential added stressor. No study compares risk factors of CB-PTSD associated with different infant outcomes. We investigated CB-PTSD risk factors by comparing women with or without neonatal complications. Analysis reveals the importance of antepartum and birth-related risk factors in CB-PTSD above and beyond child outcomes, suggesting childbirth is an independent stressor capable of evoking CB-PTSD.

A functional neuro-anatomical model of human attachment (NAMA): Insights from first- and second-person social neuroscience.

Attachment theory, developed by Mary Ainsworth and John Bowlby about seventy years ago, has become one of the most influential and comprehensive contemporary psychology theories. It predicts that early social interactions with significant others shape the emergence of distinct self- and other-representations, the latter affecting how we initiate and maintain social relationships across the lifespan. A person's attachment history will therefore associate with inter-individual differences in emotional and cognitive mechanisms sustaining representations, modeling, and understanding of others on the biological and brain level. This review aims at summarizing the currently available social neuroscience data in healthy participants on how inter-individual differences in attachment associate with brain anatomy and activity across the lifespan, and to integrate these data into an extended and refined functional neuro-anatomical model of human attachment (NAMA). We first propose a new prototypical initial attachment pathway and its derivatives as a function of attachment security, avoidance, and anxiety. Based on these pathways, we suggest a neural attachment system composed of two emotional mentalization modules (aversion and approach) and two cognitive mentalization modules (emotion regulation and mental state representation) and provide evidence on their functionality depending on inter-individual differences in attachment. We subsequently expand this first-person social neuroscience account by also considering a second-person social neuroscience perspective comprising the concepts of bio-behavioral synchrony and particularly inter-brain coherence. We hope that such extended and refined NAMA can inform attachment theory and ultimately help devising new prevention and intervention strategies for individuals and families at risk for attachment-related psychopathology.

The link between attachment orientations and cellular aging among former prisoners of war.

Objective: Ex-prisoners of war (ex-POWs) experience prolonged distress that in some cases may influence their cellular aging (telomere length). The current research examines whether attachment orientations of ex-POWs and their spouses can explain individual differences in telomere length 40 years after the experience of captivity.Methods: Eighty-eight Israeli ex-POWs were assessed at four time points since captivity, whereas their spouses at three time points. Attachment orientations (anxiety, avoidance) were assessed in three time points and telomere length was measured at time four.Results: Findings indicated that ex-POWs' attachment avoidance was associated with shorter telomere length. In addition, spouses' attachment anxiety was associated with shorter telomere length among ex-POWs, whereas spouses' attachment avoidance was unexpectedly related to longer telomere length among ex-POWs.Conclusions: Results suggest that the effects of trauma on cellular aging are not uniform and that intrapersonal and interpersonal variables may moderate responses to trauma at the cellular level.

Beyond postpartum depression: posttraumatic stress-depressive response following childbirth.

Although depression following childbirth is well recognized, much less is known about comorbid postpartum psychiatric conditions. Some women can endorse posttraumatic stress related to the childbirth experience accompanied by symptoms of depression. The objective of our study was to examine the nature of the comorbidity of symptoms of childbirth-related posttraumatic stress disorder (PTSD) and postpartum depression. We studied a sample of 685 women who were on average 3 months following childbirth and collected data about their mental health pertaining to PTSD, depression, general distress, and childbirth experience. The vast majority of women with elevated childbirth-related PTSD symptoms also endorsed elevated postpartum depression symptoms. Factor analysis revealed that symptoms of childbirth-related PTSD and postpartum depression loaded onto one single factor rather than two factors. Stepwise multi-nominal regression analysis revealed that childbirth stressors, including obstetric complications and peritraumatic distress in birth, predicted the likelihood of developing comorbid childbirth-related PTSD and postpartum depression, but not depression alone. The findings suggest that beyond postpartum depression, postpartum women suffer from a posttraumatic stress-depressive response in the wake of a traumatic childbirth experience. Increasing awareness in routine postpartum care about traumatic childbirth and its associated emotional sequela is warranted.

Delivery mode is associated with maternal mental health following childbirth.

Childbirth is a life-transforming event often followed by a time of heightened psychological vulnerability in the mother. There is a growing recognition of the importance of obstetrics aspects in maternal well-being with the way of labor potentially influencing psychological adjustment following parturition or failure thereof. Empirical scrutiny on the association between mode of delivery and postpartum well-being remains limited. We studied 685 women who were on average 3 months following childbirth and collected information concerning mode of delivery and pre- and postpartum mental health. Analysis of variance revealed that women who had cesarean section or vaginal instrumental delivery had higher somatization, obsessive compulsive, depression, and anxiety symptom levels than those who had natural or vaginal delivery as well as overall general distress, controlling for premorbid mental health, maternal age, education, primiparity, and medical complication in newborn. Women who underwent unplanned cesarean also had higher levels of childbirth-related PTSD symptoms excluding those with vaginal instrumental. The risk for endorsing psychiatric symptoms reflecting clinically relevant cases increased by twofold following unplanned cesarean and was threefold for probable childbirth-related PTSD. Maternal well-being following childbirth is associated with the experienced mode of delivery. Increasing awareness in routine care of the implications of operative delivery and obstetric interventions in delivery on a woman's mental health is needed. Screening at-risk women could improve the quality of care and prevent enduring symptoms. Research is warranted on the psychological and biological factors implicated in the mode of delivery and their role in postpartum adjustment.

Early Environments Shape Neuropeptide Function: The Case of Oxytocin and Vasopressin.

Oxytocin (OT) and vasopressin (AVP) are neuropeptides that govern the social-emotional functioning of humans. We contend that to fully understand their function, research should consider how they are flexibly fitted to maximize survival and reproduction given the variety of human experience. In a series of two studies, we show that early life stress is associated with change in the core function of OT and AVP in evolutionary predictable ways: Under high early life stress, AVP promotes threat-detection capabilities, whereas OT motivates non-selective proximity seeking to others. Conversely, under low early life stress these neuropeptides have an opposite, yet adaptive response: AVP promotes low vigilance and preservation of energy, whereas OT increases detection of interpersonal flaws. Our results demonstrate the plasticity of neuropeptide functioning that mirrors the variance in human social-emotional functioning.

The dynamic course of peripartum depression across pregnancy and childbirth.

OBJECTIVE: Peripartum depression (PPD) pertaining to depression in pregnancy and postpartum is one of the most common complications around childbirth with enduring adverse effects on mother and child health. Although psychiatric symptoms may improve or worsen over time, relatively little is known about the course of PPD symptoms and possible fluctuations. METHODS: We applied a person-centered approach to examine PPD symptom patterns across pregnancy and childbirth. 824 women were assessed at three time points: first trimester (T1), third trimester (T2), and again at eight weeks (T3) postpartum. We assessed PPD symptoms, maternal mental health history, and childbirth variables. RESULTS: Growth mixture modeling (GMM) analysis revealed four discrete PPD symptom trajectory classes including chronic PPD (1.1%), delayed (10.2%), recovered (7.2%), and resilient (81.5%). Delivery complications were associated with chronic PPD but also with the recovered PPD trajectory class. History of mental health disorders was associated with chronic PPD and the delayed PPD class. CONCLUSION: The findings underscore that significant changes in a woman's depression level can occur across pregnancy and childbirth. While a minority of women experience chronic PDD, for others depression symptoms appear to significantly alleviate over time, suggesting a form of recovery. Our findings support a personalized medicine approach based on the woman's symptom trajectory. Future research is warranted to identify the mechanisms underlying modifications in PPD symptoms severity and those implicated in recovery.

To die for a cause but not for a companion: Attachment-related variations in the terror management function of self-sacrifice.

In 8 studies, we examined the terror management function of self-sacrifice and the moderating role of attachment orientations. Studies 1-5 focused on readiness to self-sacrifice for a cause, whereas Studies 6-8 focused on self-sacrifice to save a relationship partner's life. In Studies 1-3 and 6, we examined whether mortality salience increases readiness to self-sacrifice. In Studies 4-5 and 7-8, we examined the defensive nature and anxiety-buffering role of self-sacrifice-that is, whether providing another terror management defense reduces the readiness to self-sacrifice following mortality salience and whether thoughts about self-sacrifice mitigate death-thought accessibility. Findings indicated that self-sacrifice for a cause served a terror management function mainly among attachment-anxious participants, whereas self-sacrifice for a relationship partner served this defensive function mainly among participants scoring low on avoidant attachment. Attachment-avoidant participants reacted to mortality salience with reluctance to self-sacrifice for another person. Discussion focuses on attachment orientation as a basis for using self-sacrifice as an existential defense. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Examining Symptom Clusters of Childbirth-Related Posttraumatic Stress Disorder.

OBJECTIVE: Recent studies document posttraumatic stress disorder (PTSD) symptoms in women following at-term deliveries with health baby outcomes. However, the notion that childbirth can trigger PTSD remains controversial, and the symptom clusters are mostly unknown. The objective of this study was to examine the clustering of childbirth-induced postpartum PTSD (PP-PTSD) symptoms in comparison to DSM-5 clusters. METHODS: We examined the symptom presentation of childbirth-related postpartum PTSD (PP-PTSD) in a sample of 685 women. The majority of these women delivered at term. Peritraumatic stress reactions to childbirth and PP-PTSD symptoms were assessed approximately 3 months after delivery. A hierarchical cluster analysis was used to detect grouping of the PP-PTSD symptoms. RESULTS: Childbirth-related peritraumatic stress was strongly and positively associated with PP-PTSD symptom severity. Cluster modeling revealed 4 distinguished symptom groups: reliving (some reexperiencing symptoms), namely nightmares and flashbacks; avoidance coupled with unwanted memories (other reexperiencing symptoms); negative cognitions and mood; and hyperarousal reactivity. CONCLUSIONS: Our findings show that the representation of symptoms of PTSD that develops following a stressogenic childbirth experience appears, for the most part, to resemble DSM-5 symptom clusters. More research integrating descriptive symptom assessment with biological measures is warranted to better characterize the symptom presentation of this neglected posttraumatic stress syndrome.