Anger in the context of postnatal depression: An integrative review

Postpartum anger among low-income women with high rates of trauma exposure

Few studies have examined anger concerns among postpartum women despite their risk of mood dysregulation. This study examined the performance of the Dimensions of Anger Reactions-5 (DAR-5) scale, a brief screen for problematic anger, in a sample of 1,383 postpartum women in Wisconsin who received perinatal home visiting services. We aimed to analyze the discriminant validity and measurement invariance of the DAR-5, the occurrence of problematic anger symptoms and their co-occurrence with mental health concerns, and the association between elevated anger levels and exposure to potentially traumatic events in childhood and adulthood. Descriptive statistics for anger symptoms and their associations with depression, anxiety, and PTSD were calculated. Psychometric properties of the DAR-5 were assessed via confirmatory factor analyses, and associations between trauma exposure and anger were evaluated as bivariate and partial correlations. Approximately 21% of the sample exhibited problematic anger based on an established DAR-5 cutoff score (≥ 12). Anger symptoms co-occurred with posttraumatic stress disorder (PTSD), depressive, and anxiety symptoms, though the DAR-5 sufficiently distinguished anger from these correlated symptom profiles. The DAR-5 also demonstrated acceptable measurement invariance across levels of trauma exposure. Higher levels of trauma exposure in childhood and adulthood significantly increased the risk of problematic anger even after controlling for PTSD, anxiety, and depressive symptoms, partialγ ${{\bm \gamma }}$ pb range: .07-.16. The findings suggest the DAR-5 is a valid brief screen for anger in postpartum women. Increased attention should be paid to elevated anger and the co-occurrence of other mental health concerns following childbirth.

'Living in two worlds': A qualitative analysis of first-time mothers' experiences of maternal ambivalence

OBJECTIVE

The aim of this qualitative study was to examine experiences and meanings of maternal ambivalence in first-time mothers with young children.

BACKGROUND

In contrast with normative expectations surrounding contemporary motherhood, there is growing recognition that becoming and being a mother involves ambivalent feelings, and that these feelings are normal and have positive psychological consequences. Yet, little attention has been paid to women's subjective experiences of maternal ambivalence, and capacity to acknowledge and manage ambivalent feelings.

METHODS

Eleven semi-structured online interviews, with first-time mothers, were conducted and analysed using Interpretative Phenomenological Analysis (IPA) methodology.

RESULTS

Two group experiential themes were identified: Crossing boundaries of acceptable mothering feelings and Mothering from a place of 'enough'. Ambivalent mothering feelings challenged participants' expectations about motherhood and themselves as mothers, producing anxiety, self-doubt and feelings of failure. Distress accompanying maternal ambivalence was especially acute when participants perceived their feelings to be unacceptable. Viewing conflicting feelings with compassion, however, helped participants to cope with their diverse and fluctuating emotional mothering experiences, allowing them to mother with a greater sense of equanimity, agency and competence.

CONCLUSION

The study's findings indicate the potential benefits of providing information about the emotional turbulence of early motherhood as part of routine maternity care, as well as the potential value of offering parenting interventions that promote self-compassion to mothers struggling to manage feelings of ambivalence.

Fluctuations in Maternal Depressive Symptoms, Anxiety, and Anger and Children's Depression Risks in Middle Childhood

Research suggests a robust link between the severity of maternal depression and children's depression risks in middle childhood. Variations among depressed mothers in terms of affective dysregulation and frequent mood changes are also observed. However, the understanding of how fluctuations in maternal depressive symptoms and negative affect influence children is limited. Guided by life history theory, the current study tested whether the degree of fluctuations in maternal depressive symptoms, anxiety, and anger contributed to depression risks among school-aged children. The sample included 1,364 families where maternal depressive symptoms, anxiety, and anger were longitudinally assessed when children were in Grades 1, 3, 5, and 6. Children's anxious depression and withdrawn depression behaviors were rated in Grades 1, 3, 4, 5, and 6 by two caregivers. Parallel latent growth curve analyses revealed that, first, fluctuations in maternal anxiety from Grade 1 to 6 were related to an increase in children's withdrawn depression over the same period. Second, mean maternal anger over time was related to higher mean levels of child anxious and withdrawn depression, yet fluctuations in maternal anger were not linked to child outcomes. Findings support life history theory by highlighting the degree of fluctuations in maternal anxiety as a source of environmental unpredictability and reveal different effects of maternal anxiety and anger in the intergenerational transmission of depression, with important theoretical and clinical implications.

Emotional stimulation processing characteristics in depression: Meta-analysis of eye tracking findings

Objective

To systematically evaluate the attentional bias in patients with depression toward emotional stimuli and to explore eye movement indicators and potential regulatory variables that can distinguish such patients from healthy individuals.

Methods

Case-control studies regarding eye-tracking in major depressive disorder published in PubMed, Web of Science, ScienceDirect, The Cochrane Library, EBSCOhost, Embase, China National Knowledge Infrastructure, Wanfang, and VIP databases from database initiation until March 12, 2022 were included in the present meta-analysis. Two researchers independently screened the literature and performed data extraction. The quality of the literature was assessed using the Newcastle-Ottawa quality assessment scale.RevMan 5.4 software was used for Meta-analysis.

Results

Overall, 14 studies were included, including 1,167 participants (N _depression = 474; N _healthy = 693). We found that (1) fixation duration was significantly lower for positive emotional stimuli in the depression group than that in the healthy group; however, for negative stimuli, the fixation duration was significantly more in the depression group than in the healthy group. No significant difference was observed in terms of neutral emotional stimuli between groups. (2) Patients with depression exhibited a significantly lower fixation count for positive emotional stimuli than healthy individuals, whereas the fixation count for negative emotional stimuli was significantly higher in the depression group than in the healthy group. No significant difference was found for neutral emotional stimuli between groups. (3) No significant difference was detected in terms of the first fixation duration of the positive, negative, and neutral emotional stimuli between groups. (4) subgroup analysis indicated that age effected fixation duration for positive emotional stimuli. In addition, age and the type of negative emotional picture (sad, dysphoric, threat, anger) effected fixation duration for negative emotional stimuli.

Conclusion

Our research supports that patients with depression exhibit a negative attention bias toward emotional stimuli, and the fixation duration and fixation counts may be used as auxiliary objective indicators for depression screening.

Seeing Red: A Grounded Theory Study of Women's Anger after Childbirth

Persistent intense anger is indicative of postpartum distress, yet maternal anger has been little explored after childbirth. Using grounded theory, we explained how and why mothers develop intense anger after childbirth and the actions they take to manage their anger. Twenty mothers of healthy singleton infants described their experiences of anger during the first two postpartum years. Mothers indicated they became angry when they had violated expectations, compromised needs, and felt on edge (e.g., exhausted, stressed, and resentful), particularly around infants' sleep. Mothers described suppressing and/or expressing anger with outcomes such as conflict and recruiting support. Receiving support from partners, family, and others helped mothers manage their anger, with more positive outcomes. Women should be screened for intense anger, maternal-infant sleep problems, and adequacy of social supports after childbirth. Maternal anger can be reduced by changing expectations and helping mothers meet their needs through social and structural supports.

Expectant parents' emotions evoked by pregnancy: A longitudinal dyadic analysis of couples in the Swedish Pregnancy Panel

RATIONALE

Holistic antenatal care requires knowledge of individuals' emotional response to pregnancy. Little is known about how a pregnant woman and her partner influence each other emotionally during a pregnancy.

OBJECTIVE

This study examines six discrete emotions that expectant couples experience during pregnancy, how these emotions change mid-to late-pregnancy, and whether the partners' emotional responses influence each other.

METHODS

A longitudinal dyadic study where pregnant women and their partners (1432 couples) rated the extent to which the pregnancy evoked joy, strength, security, worry, shame, and anger at pregnancy week 12-19, 22-24, and 36. Latent curve models with structured residuals identify levels of and change in these emotions over time, while accounting for between- and within-couple variance.

RESULTS

Pregnancy evoked mainly joy, strength, security, and worry, and lower levels of anger and shame. Pregnant women and partners felt similar levels of joy, strength, and security, but pregnant women felt more worry, shame, and anger. There was little to no mean-level change in all six measured emotions evoked by pregnancy (between-couple change), and no reciprocal effects between the partners (within-couple change).

CONCLUSIONS

Emotions in mid-pregnancy were also felt in late pregnancy. Furthermore, the pregnant woman and her partner have individual emotional trajectories. The results can assist healthcare professionals and researchers target interventions to expectant mothers and partners, specifically by understanding emotional response to pregnancy as a stable confound and by not approaching the couple as one emotional unit.

Trajectories and Correlates of Anger During the Perinatal Period

OBJECTIVES

To investigate trajectories of anger during pregnancy and the early postpartum period; to identify baseline psychosocial predictors of anger trajectory group membership; and to examine correlates of anger trajectory group membership, including symptoms of depression, anxiety, insomnia, and social support, in the postpartum period.

DESIGN

Longitudinal descriptive design.

SETTING

We recruited participants from a maternity clinic in Calgary, Alberta, Canada.

PARTICIPANTS

The sample included a convenience sample of 143 pregnant women who had basic fluency in English, were older than 17 years of age, and were less than 19 weeks gestation with a single fetus at the time of recruitment.

METHODS

Participants completed online questionnaires at four time points: early, mid-, and late pregnancy and 2 months after birth. We used group-based semiparametric mixture modeling to estimate patterns of anger. We used multinomial logistic regression to explore associations between baseline predictors and trajectory membership.

RESULTS

We identified four distinct trajectories of anger during pregnancy through 2 months after birth: minimal-stable anger (52.4%), mild-stable anger (27.5%), moderate-stable anger (12.7%), and high-decreasing anger (7.4%). Membership in the moderate-stable group was associated with greater baseline symptoms of depression, anxiety, and insomnia severity scores compared to the minimal-stable anger group. Moderate-stable trajectory group membership was also associated with greater symptoms of anxiety, depression, and insomnia at 2 months after birth.

CONCLUSION

Higher levels of anger were associated with worse mental health in pregnancy and after childbirth in our participants. Women should be made aware of anger as a possible mood disturbance by clinicians, and researchers should investigate the consequences of anger during the perinatal period.

Objective and subjective sleep and caregiving feelings in mothers of infants: a longitudinal daily diary study

Study Objectives

This study explored the links between mothers’ objective and subjective sleep and their caregiving feelings toward their infant (i.e. patience for the infant, desire to be with the infant, and anger toward the infant), using a diary study design. We were particularly interested in examining whether nights of lower sleep quality within individual mothers predict more negative maternal caregiving feelings the following day.

Methods

The sample included 151 women, who were recruited during pregnancy. Data were collected at 4 and 8 months after delivery. Maternal sleep was monitored at home for seven nights using actigraphy and sleep diaries. Mothers rated their caregiving feelings each evening.

Results

Multilevel modeling (controlling for depressive symptoms, feeding method, and background variables) revealed that actigraphic and subjective sleep variables were associated with maternal caregiving feeling, both at the between- and within-person levels. For example, lower sleep percent predicted reduced levels of maternal patience for the infant at 4 and 8 months (between-person effect). Moreover, when a mother had a lower sleep percent on a given night (compared to her average), she reported lower levels of patience for her infant the following day (within-person prospective effect).

Conclusions

The findings demonstrate, for the first time, that maternal nightly variations in objective and subjective sleep quality predict daily changes in maternal feelings toward her infant at two different assessment points. Improving maternal sleep quality might be an important target for future interventions which may help mothers to feel more positively toward their infants.

Correlates of Canadian mothers' anger during the postpartum period: a cross-sectional survey

BACKGROUND

Although some women experience anger as a mood problem after childbirth, postpartum anger has been neglected by researchers. Mothers' and infants' poor sleep quality during the postpartum period has been associated with mothers' depressive symptoms; however, links between mothers' sleep quality and postpartum anger are unclear. This study aimed to determine proportions of women with intense anger, depressive symptoms, and comorbid intense anger and depressive symptoms, and to examine mothers' and infants' sleep quality as correlates of postpartum anger.

METHODS

This cross-sectional survey study was advertised as an examination of mothers' and babies' sleep. Women, with healthy infants between 6 and 12 months of age, were recruited using community venues. The survey contained validated measures of sleep quality for mothers and infants, and fatigue, social support, anger, depressive symptoms, and cognitions about infant sleep.

RESULTS

278 women participated in the study. Thirty-one percent of women (n = 85) reported intense anger (≥ 90th percentile on State Anger Scale) while 26% (n = 73) of mothers indicated probable depression (>12 on Edinburgh Postnatal Depression Scale). Over half of the participants rated their sleep as poor (n = 144, 51.8%). Using robust regression analysis, income (β = -0.11, p < 0.05), parity (β = 0.2, p < 0.01), depressive symptoms (β = 0.22, p < 0.01), and mothers' sleep quality (β = 0.10, p < 0.05), and anger about infant sleep (β = 0.25, p < 0.01) were significant predictors of mothers' anger.

CONCLUSIONS

Mothers' sleep quality and anger about infant sleep are associated with their state anger. Clinicians can educate families about sleep pattern changes during the perinatal time frame and assess women's mood and perceptions of their and their infants' sleep quality in the first postpartum year. They can also offer evidence-based strategies for improving parent-infant sleep. Such health promotion initiatives could reduce mothers' anger and support healthy sleep.

Prolactin-mediated restraint of maternal aggression in lactation

Heightened intruder-directed aggressive behavior in female mice is displayed during lactation to enable a mother to protect her offspring. Although recent work has identified that the ventromedial nucleus of the hypothalamus plays an important role in governing aggressive behavior, it is unknown how the changing hormones of pregnancy and lactation might regulate this behavior during specific reproductive states. Here, we show that prolactin-responsive neurons are activated during aggression and project to multiple brain regions with known roles in regulating behavior. Through neuron-specific and region-specific deletion of the prolactin receptor, our data reveal that prolactin is an important modulator of maternal aggression. By acting on glutamatergic neurons in the ventromedial nucleus, prolactin restrains maternal aggression, specifically in lactating female mice.

Aggressive behavior is rarely observed in virgin female mice but is specifically triggered in lactation where it facilitates protection of offspring. Recent studies demonstrated that the hypothalamic ventromedial nucleus (VMN) plays an important role in facilitating aggressive behavior in both sexes. Here, we demonstrate a role for the pituitary hormone, prolactin, acting through the prolactin receptor in the VMN to control the intensity of aggressive behavior exclusively during lactation. Prolactin receptor deletion from glutamatergic neurons or specifically from the VMN resulted in hyperaggressive lactating females, with a marked shift from intruder-directed investigative behavior to very high levels of aggressive behavior. Prolactin-sensitive neurons in the VMN project to a wide range of other hypothalamic and extrahypothalamic regions, including the medial preoptic area, paraventricular nucleus, and bed nucleus of the stria terminalis, all regions known to be part of a complex neuronal network controlling maternal behavior. Within this network, prolactin acts in the VMN to specifically restrain male-directed aggressive behavior in lactating females. This action in the VMN may complement the role of prolactin in other brain regions, by shifting the balance of maternal behaviors from defense-related activities to more pup-directed behaviors necessary for nurturing offspring.

Acceptance Mindfulness-Trait as a Protective Factor for Post-Natal Depression: A Preliminary Research

(1) Background: the prevalence of postnatal depression (PND) reaches up to 20%. PND could be based on the interaction between a psychological vulnerability and chronic stress that pregnancy would activate. Vulnerability factors reflect a psychological profile mirroring mindfulness-trait (MT). A high level of MT is associated with an efficient regulation of both physiological and psychological stress, especially negative moods. Interestingly, mindfulness level can be improved by program based on mindfulness meditation. We hypothesize that MT is a protective factor for PND. We also postulate that negative moods increase during the pregnancy for women who develop a PND after delivery (2) Methods: we conducted a multicentric prospective longitudinal study including 85 women during their first trimester of their pregnancy and 72 from the childbirth to the baby's first birthday". At the inclusion, presence and acceptance of MT and various variables of personality and of psychological functioning were assessed. Mood evolution was monitored each month during the pregnancy and a delivery trauma risk was evaluated after delivery. PND detection was carried out at 48 h, 2, 6 and 12 months after the delivery with the Edinburgh Postnatal Depression Scale with a screening cut-off >11. (3) Results: high-acceptance MT is a protective factor for PND (OR: 0.79). Women without PND displayed less negative mood during pregnancy (p < 0.05 for Anxiety, Confusion and Anger). (4) Conclusions: these results suggest the value of deploying programs to enhance the level of mindfulness, especially in its acceptance dimension, before, during and after pregnancy, to reduce the risk of PND.

The Prolactin Family of Hormones as Regulators of Maternal Mood and Behavior

Transition into motherhood involves profound physiological and behavioral adaptations that ensure the healthy development of offspring while maintaining maternal health. Dynamic fluctuations in key hormones during pregnancy and lactation induce these maternal adaptations by acting on neural circuits in the brain. Amongst these hormonal changes, lactogenic hormones (e.g., prolactin and its pregnancy-specific homolog, placental lactogen) are important regulators of these processes, and their receptors are located in key brain regions controlling emotional behaviors and maternal responses. With pregnancy and lactation also being associated with a marked elevation in the risk of developing mood disorders, it is important to understand how hormones are normally regulating mood and behavior during this time. It seems likely that pathological changes in mood could result from aberrant expression of these hormone-induced behavioral responses. Maternal mental health problems during pregnancy and the postpartum period represent a major barrier in developing healthy mother-infant interactions which are crucial for the child's development. In this review, we will examine the role lactogenic hormones play in driving a range of specific maternal behaviors, including motivation, protectiveness, and mother-pup interactions. Understanding how these hormones collectively act in a mother's brain to promote nurturing behaviors toward offspring will ultimately assist in treatment development and contribute to safeguarding a successful pregnancy.

Preconception depression and anxiety symptoms and maternal-infant bonding: a 20-year intergenerational cohort study

Early maternal-infant bonding problems are often forerunners of later emotional and behavioural difficulties. Interventions typically target the perinatal period but many risks may be established well before pregnancy. Here we examine the extent to which adolescent and young adult depression and anxiety symptoms predict perinatal maternal-infant bonding difficulties. The Victorian Intergenerational Health Cohort Study (VIHCS, est. 2006) is following offspring born to the Victorian Adolescent Health Cohort Study (VAHCS; est. 1992). VAHCS participants were assessed for depression and anxiety symptoms nine times during adolescence and young adulthood (age 14-29 years), and then contacted bi-annually (from age 29-35 years) to identify pregnancies. The Postpartum Bonding Questionnaire (PBQ) was administered to mothers at 2 and 12 months postpartum. A total of 395 women (606 infants) completed the 2-month and/or 12-month postpartum interviews. For most infants (64%), mothers had experienced depression and/or anxiety before pregnancy. Preconception depression and anxiety symptoms that persisted from adolescence into young adulthood predicted maternal-infant bonding problems at 2 months (β = 0.30, 95% CI 0.04, 0.55) and 12 months postpartum (β = 0.40, 95% CI 0.16, 0.63). Depression and anxiety symptoms occurring in young adulthood only, also predicted bonding problems at 12 months postpartum (β = 0.37, 95% CI 0.02, 0.71). Associations between preconception depression and anxiety symptoms and anxiety-related maternal-infant bonding problems at 12 months postpartum remained after adjustment for antenatal and concurrent postpartum depressive symptoms. This study puts forward a case for extending preconception health care beyond contraception and nutrition to a broader engagement in supporting the mental health of young women from adolescence.

Mediating effect of resilience during pregnancy on the association between maternal trait anger and postnatal depression

OBJECTIVE

The association between anger and postnatal depression has been reported in previous studies. However, whether this association is mediated by resilience is unknown. Resilience is a dynamic process of individuals' positive adaptation to stress and adversity. This study investigated the mediating effect of resilience during pregnancy on the association between trait anger during pregnancy and postnatal depression at one-month.

METHODS

A longitudinal study from the third trimester to one-month postnatal using online self-report questionnaires was conducted in two maternity clinics in Tokyo. Trait anger and resilience during pregnancy and postnatal depression at one-month were measured by the State-Trait Anger Expression Inventory, resilience test, and the Edinburgh Postnatal Depression Scale. To test the hypothesis, Structural Equation Modeling was used.

RESULTS

Data of 531 participants were analyzed. The final Structural Equation Modeling model demonstrated that resilience during pregnancy had a partial mediating effect on the association between trait anger during pregnancy and postnatal depression at one-month. Trait anger was significantly associated with resilience during pregnancy (β = -0.28) and postnatal depression (β = 0.24). Resilience during pregnancy was significantly associated with postnatal depression (β = -0.20).

CONCLUSIONS

This study demonstrated that resilience during pregnancy had a partial mediating effect on the association between trait anger during pregnancy and postnatal depression at one-month. The findings highlight the importance of identifying pregnant women with high trait anger and providing interventions to enhance their resilience to decrease the risk of postnatal depression.

Becoming a mother: Predicting early dissatisfaction with motherhood at three weeks postpartum

OBJECTIVE

The peripartum period can go along with increased insecurity, strain or frustration, potentially leading to a dissatisfying experience of motherhood, which itself is associated with poorer postnatal adjustment. Identifying prenatal influencing factors on the early postnatal dissatisfaction with motherhood is crucial to enable specific support for parents from pregnancy on. The aim of this study was to investigate the predictive relevance of prenatal levels of anxiety and hostility as manifestations of prenatal strain, and further maternal-fetal bonding, adult attachment style and recalled parenting by the own mother on the dissatisfaction with motherhood.

DESIGN

Data was assessed longitudinally.

SETTING

The study took place at the University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

PARTICIPANTS

N=100 pregnant women from the general population.

MEASUREMENTS AND FINDINGS

Pregnancy-related anxiety, hostility, maternal-fetal bonding and adult attachment style were assessed in the last trimester of pregnancy, and recalled parenting by the own mother and current dissatisfaction with motherhood at three weeks postpartum. Hierarchical regression analysis showed that lower recalled care by the own mother predicted higher dissatisfaction with overall motherhood, from the perspective as an adult and related to their child. Higher pregnancy-related anxiety predicted higher overall and child-related dissatisfaction. Higher hostility predicted higher child-related dissatisfaction.

KEY CONCLUSION

Prenatal negative emotional states and lower recalled care by the own mother can serve as indicators for maternal dissatisfaction.

IMPLICATION FOR PRACTICE

Shaping professional support around negative emotional states and addressing experiences of own upbringing already prenatally might prevent an early dissatisfaction with motherhood and negative consequences for mother and child.

Perinatal Mixed Affective State: Wherefore Art Thou?

Mixed states in patients with a perinatal mood episode is seldom encountered. Lack of appropriate assessment tools could be partly responsible for this observation. The authors conducted a selective review of studies dealing with the reporting of mixed symptoms in women during the perinatal period with the intention to quantify the phenomenon. In many instances of reported postpartum depression, either a first onset or an onset in the context of bipolar disorder, mixed states were identifiable. However, the strict application of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, mixed features specifier to these episodes risks misdiagnosis.