A Qualitative Study. Idun Røseth - PDF

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The Essential Meaning Structure of Postpartum Depression A Qualitative Study Idun Røseth Telemark Hospital, Department of Psychiatry Oslo University Hospital, Department of Neuropsychiatry and Psychosomatic

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The Essential Meaning Structure of Postpartum Depression A Qualitative Study Idun Røseth Telemark Hospital, Department of Psychiatry Oslo University Hospital, Department of Neuropsychiatry and Psychosomatic Medicine Norwegian Research Network on Mood Disorders (NORMOOD) - Helse Sør-Øst PhD thesis submitted to the Faculty of Medicine, University of Oslo, Norway Idun Røseth, 2013 Series of dissertations submitted to the Faculty of Medicine, University of Oslo No ISBN All rights reserved. No part of this publication may be reproduced or transmitted, in any form or by any means, without permission. Cover: Inger Sandved Anfinsen. Printed in Norway: AIT Oslo AS. Produced in co-operation with Akademika publishing. The thesis is produced by Akademika publishing merely in connection with the thesis defence. Kindly direct all inquiries regarding the thesis to the copyright holder or the unit which grants the doctorate. Acknowledgments First I would like to thank my supervisor, Professor Per-Einar Binder for your valuable support throughout my academic development and for generously sharing your extraordinarily broad knowledge of phenomenological methods and psychological theories. You represent the hermeneutic side of phenomenology, which has sharpened but also modified my statements from a descriptive phenomenological perspective. A big thank you to my co-supervisor, Professor Ulrik Fredrik Malt. You have been there all the steps of the way, aiding me in the process of developing the project right from the start. Supportive when needed and critical when called for, you helped me to bring the project to a higher level of academic achievement. I am also grateful to my former supervisor and friend Richard Alapack for sharing your invaluable knowledge on phenomenology and existentialism, which has been a great inspiration for me. A special thanks to my friend Amedeo Giorgi for teaching me your phenomenological method and so generously sharing your wisdom. Wanting to learn more about phenomenology and your method was a major motivation for my research. I also wish to thank the women who so generously shared their experiences with me. I extend my gratitude to my colleagues and fellow PhD students in the Norwegian network on mood disorder (NORMOOD); Siv G. Johansen, Asja Zivdsic, Dag V. Skjelstad, Anne-Marit Langår, Erlend Bøen, Johan Dahl and Ketil N. Jørgensen for our many professional discussions and enjoyable gatherings and conferences. Thanks to Tove H. Otterstad, the coordinator of NORMOOD, for all your support. I would also like to thank Telemark Hospital for financing and supporting the study. My thanks go to Jostein Todal, Irene Hvale Gustavsen and Ulrike Sagen from the Department of Psychiatry for their generous help and support and to Arnlaug Kaasin and Poul Jensen from the Department of Child and Adolescent Psychiatry for their much appreciated support in the final phase of writing up my dissertation. Last, but not least, thanks to my loving, caring family: Rob, Nora, Iris and Imre. Many thanks, Rob, for reading through my articles and for your invaluable comments and suggestions. But most of all, thank you for being there, loving and supporting me. iii Summary Postpartum depression (PPD) is a fairly common yet often unidentified disorder which not only affects the mother, but may also have an adverse effect on the cognitive, emotional and social development of her baby. The nature of PPD and whether it may be qualitatively different from non-postpartum depression (NPPD) is still disputed. The main aim of this thesis is to explore the phenomenon of PPD from the first person perspective. In order to deepen our understanding of PPD we compare it with the phenomenon of NPPD. The methodological approach towards this aim is descriptive phenomenology as outlined by Giorgi. The participants are 4 PPD and 3 NPPD women who were interviewed in-depth two to three times about their experience of depression. The findings of this thesis are presented in three separate papers. The first paper Two ways of living through postpartum depression presents two identified essential meaning structures of PPD: 1) The looming threatening world and 2) Loss of primordial my-ness. In the looming threatening world we describe how mothers after birth may experience themselves as anxiously thrown into an alienated and threatening world in which their inhibited body is perceived as an obstacle for their attunement to their baby. The baby becomes a catalyst for feelings of guilt and shame, and they tend to withdraw from others into loneliness. In loss of primordial my-ness we describe how a mother experiences a fundamental feeling of unreality and disconnection both in relation to self, the baby, and the social and material world. She experiences a basic loss of ownership of her own perceptions, feelings, thoughts and actions. In parallel, the world is perceived as unreal, colorless, strange, and robbed of its meaning. Unbearable anxiety accompanies this overwhelming feeling of depersonalization. The second paper Incest and postpartum depression intertwined is a case study which explores how incest experiences in the past constrain perceptions, thoughts, emotions and actions in the present. We describe how the birth of a baby girl may reactualize and throw a mother into a world of incest where she is overwhelmed by intruding fantasies of men who abuse her children. Constantly on guard, she actively seeks information about abuse of other children in the media, which in turn feeds her anxious vigilance and fantasies. v The third paper Engulfed by an alienated and threatening body: The essential meaning structure of depression in women describes the essential meaning structure of NPPD. We described how NPPD women initially feel entrapped in a personal mission that has gone awry. Experiencing her lack of personal resources to resolve the situation, the NPPD woman crumbles under the perceived disapproval of others. She doubts her own judgments and experiences others negative emotions almost as if they were her own. Excessive feelings of responsibility are coupled with strong feelings of shame and guilt, which lead her to overwork or over-involve herself. In the process she ignores her embodied emotions, which gradually become alienated and threatening and in which she is ultimately submerged. This qualitative study suggests that the most striking difference between PPD and NPPD is that PPD mothers felt in essence disconnected and alienated from the world and others (the baby), and in the case of one mother, also in relation to self, whereas in NPPD the problem was rather an experienced heightened sensitivity to others distress or negative judgments. Thus, there may be a difference in the development of PPD and NPPD which seems to be centered around two opposites; heightened sensitivity versus disconnection. We conceptualized the alienation in PPD as existential depression and anxiety, and the increased sensitivity in NPPD as a more relational type of depression and anxiety. vi List of papers Paper I Røseth, I., Binder, P-E., & Malt, U. F. (2011). Two ways of living through postpartum depression. Journal of Phenomenological Psychology, 42(2), Paper II Røseth, I., Bongaardt, R., & Binder, P-E. (2011). Postpartum depression and incest intertwined: A case study. International Journal of Health and Well-being, 6: Paper III Røseth, I., Binder, P-E., & Malt, U. F. (2013). Engulfed by an alienated and threatening emotional body. The essential structure of depression in women. Journal of Phenomenological Psychology, 44(2), forthcoming. vii Abbreviations APA CBT DSM-IV-TR text DST EPDS GHQ HPA ICD-10 MDD NPPD PPD WHO American Psychological Association Cognitive behavioral therapy Diagnostic and statistical manual of mental disorders 4 th edition, revision Dynamic systems theory Edinburgh postnatal depression scale General health questionnaire Hypothalamic-pituitary-adrenal International classification of diseases and related health problems, 10th revision Major depressive disorder Non-postpartum depression Postpartum depression World Health Organization viii Table of contents ACKNOWLEDGMENTS... III SUMMARY... V LIST OF PAPERS... VII ABBREVIATIONS... VIII INTRODUCTION... 1 POSTPARTUM DEPRESSION: THE MAGNITUDE OF THE PROBLEM... 2 WHAT IS POSTPARTUM DEPRESSION? PPD: A DISORDER? BIOLOGICAL PERSPECTIVE EVOLUTIONARY PERSPECTIVE Social evolutionary perspective PSYCHOLOGICAL PERSPECTIVE The psychoanalytic model The cognitive behavioral model The dynamic systems theory CRITICAL FEMINIST PERSPECTIVE ADDITIONAL COMMENTS WHAT DO WE KNOW? QUANTITATIVE STUDIES COMPARING PPD AND NPPD QUALITATIVE STUDIES ON PPD AND NPPD WHAT IS NEXT? THE DEPARTURE POINT FOR THIS STUDY THE PHENOMENOLOGICAL PERSPECTIVE AIMS METHOD PHENOMENOLOGICAL STUDY Interviews The phenomenological reduction Selection of subjects PPD participants NPPD participants Data analysis A PHENOMENOLOGICAL CASE STUDY ETHICS FINDINGS PAPER I: TWO WAYS OF LIVING THROUGH POSTPARTUM DEPRESSION The looming threatening world Loss of primordial my-ness PAPER II: POSTPARTUM DEPRESSION AND INCEST INTERTWINED: A CASE STUDY PAPER III: ENGULFED BY AN ALIENATED AND THREATENING EMOTIONAL BODY: THE ESSENTIAL STRUCTURE OF DEPRESSION IN WOMEN DISCUSSION OF METHODOLOGICAL ISSUES ix 7.1 TRUSTWORTHINESS IN PHENOMENOLOGY DESCRIPTIVE VERSUS INTERPRETIVE PHENOMENOLOGY Phenomenological reduction and reflexivity Essential meaning structures versus themes or idiographic descriptions Systematic procedures versus methodological eclecticism ADDITIONAL COMMENTS DISCUSSION OF RESULTS PAPER I: TWO WAYS OF LIVING THROUGH POSTPARTUM DEPRESSION The looming threatening world Loss of primordial my-ness PAPER II: A CASE STUDY OF A MOTHER S INTERTWINING EXPERIENCES WITH INCEST AND POSTPARTUM DEPRESSION PAPER III: ENGULFED BY AN ALIENATED AND THREATENING BODY: THE ESSENTIAL STRUCTURE OF DEPRESSION IN WOMEN COMPARING PPD AND NPPD Similarities How do they differ? How can we understand these differences? Differences: Theoretical perspectives The special quality of mood in Loss of my-ness A comparison of qualitative and quantitative findings ADDITIONAL COMMENTS IMPLICATIONS PSYCHOTHERAPEUTIC IMPLICATIONS RESEARCH IMPLICATIONS CONCLUSION REFERENCES PAPER I-III x I am not the outcome or meeting-point of numerous causal agencies which determine my bodily or psychological make-up. I cannot conceive myself as nothing but a bit of the world, a mere object of biological, psychological or sociological investigation. I cannot shut myself up within the realm of science. All my knowledge of the world, even my scientific knowledge, is gained from my own particular point of view, or from some experience of the world without which the symbols of science would be meaningless. (Merleau-Ponty, 1945/1962, p. viii) 1 Introduction Giving birth to a child represents a moment in life where the body and existence are most intimately intertwined. Pregnancy and birth in themselves represent an extreme and existential transformation of the mother s lived-subject-body-world; how she as subjectbody exists in her lived world and is able to adjust to a world which is abruptly transformed by the presence of the all-encompassing vulnerable and helpless infant. How can we understand what happens when this existential period in a woman s life, the postnatal period, coincides with the development of depression? From a phenomenological perspective the self, body and world are inseparable. To be ill, even with just a trivial illness, as much as with a mortal illness, means, above all, to experience things in a different way, to live in another, maybe hardly different, maybe completely different world (Van den Berg, 1972, pp. 45). Van den Berg describes how we in illness perceive the world around us in different ways and that the way we perceive the world reflects our mode of existence. Thus, the patient s perception of the world is a facet of his or her lived illness. Merleau-Ponty (1945/1962) states that the properties of consciousness and the world complement each other and are mutually dependent. The way we perceive the world depends on our consciousness. Not only are consciousness and the world inseparable, but our consciousness is also inseparable from our body, the body-subject (Merleau-Ponty, 1945/1962). Patients awareness of their embodied self is bound up with their awareness of the world. Hence, illness and disease are not something added on to a person who remains the same; rather they change everything; one s sense of self, body, and the world one lives in. 1 Our mood plays an important part in how we constitute phenomena, how we experience our self, our body, and the world (Heidegger, 1927/1996). We do not experience emotions in isolation; rather emotions are the atmosphere or tone of our perceived world. Our emotional body is the medium through which we gain access to the world, providing both the possibilities and the constraints of our existence in the world. Transitioning into motherhood can be said to represent an existential crisis that presents women with a number of challenges. Most mothers live through this transformational experience without succumbing to depression, but unfortunately for some mothers this is a time of despair. How can we best understand postpartum depression (PPD)? From a phenomenological viewpoint we first have to describe the phenomenon we seek to understand before we try to explain it. The fundamental presupposition is that we all share the same human existence and it follows that patients share certain essential characteristics that we can describe (Van den Berg, 1972, p. 52). Phenomenology does not offer definitions of psychiatric symptoms or an overview of syndromes; rather it offers insight into certain modes of being in this world. This dissertation is a phenomenological study of PPD which may add important dimensions to our understanding of the specifics of the existential crisis experienced by mothers who develop PPD. To be able to fully understand PPD, we compare it with depression in women in general. We have therefore conducted a separate phenomenological study on nonpostpartum depression (NPPD). This study of NPPD also provides valuable knowledge on depression in women that stands in its own right. However, in this dissertation it functions primarily as a tool to compare and sharpen our findings on PPD. A comparison of results was enabled by our use of the same phenomenological method for our studies of both PPD and NPPD. 1.1 Postpartum depression: The magnitude of the problem Prevalence rates of PPD may vary according to definitions of PPD (major and/or minor depression, or simply depressive symptoms) and different methods of collecting data (self-report or diagnostic interviews). In Norway the prevalence of PPD (defined as Edinburgh Postnatal Depression Scale (EPDS) score 10) is reported to be from 8.9% 2 (Eberhard-Gran, Eskild, Tambs, Samuelsen, & Opjordsmoen, 2002) to 10% (Berle, Aarre, Mykletun, Dahl, & Holsten, 2003). Using the 28-item version of the General Health Questionnaire (GHQ-28), Skari et al. (2002) found the prevalence of clinically important depression (GHQ-28: depression subscale case score 2) at 4 days after delivery to be 6%, and only 1% 6 weeks after birth when controlling for the impact of giving birth to infants with serious malformations. This is a somewhat lower prevalence rate than the meta-analysis of 59 studies by O Hara & Swain (1996), where the estimate was 13%. Here the method of assessment and period of time under assessment were found to affect prevalence rates. Also, studies using a wider window (e.g. the first eight weeks) usually reported higher prevalence rates than studies that used a narrower window (e.g. the first four weeks). An evidence report (a meta-analysis for the U.S. Department of Health and Human Services) showed a prevalence of major depression as defined by DSM-IV-TR (Diagnostic and statistical manual of mental disorders, 4th ed., text rev.; American Psychological Association, 1994) after delivery ranging from 1.0% to 5.9% at different times during the first postpartum year (Gavin et al., 2005). For both major and subthreshold (minor) depression the prevalence rate ranged from 6.5% to 12.9% at different times during the first year postpartum, indicating that approximately half of the affected women experience a major depressive episode and half a minor depressive episode at any given time. PPD should be distinguished from postpartum blues and postpartum psychosis. Postpartum blues is the most common puerperal mood disturbance with estimates of prevalence ranging from 30% to 75% (O'Hara, Neunaber, & Zekoski, 1984). Postpartum psychosis is a rare condition with rates of % of all deliveries (Kendell, Chalmers, & Platz, 1987). Some studies report that the prevalence of depression postpartum is no higher than at other times in a woman s life (Cox, Murray, & Chapman, 1993; Gotlib, Whiffen, Mount, Milne, & Cordy, 1989; O'Hara, Zekoski, Philipps, & Wright, 1990), suggesting no special link between childbirth and depression. Other studies, however, indicate an increased risk of depression in the postpartum period (Eberhard-Gran et al., 2002; Kumar & Robson, 1984; Vesga-Lopez et al., 2008; Watson, Elliott, Rugg, & Brough, 1984). One study suggests that primiparas have a three times higher risk of hospital admission for clinical depression (Munk-Olsen, Laursen, Pedersen, Mors, & Mortensen, 2006). Fatherhood was not associated with any increase. The study also indicates a natural dynamic process of selection into parenthood. These results are comparable to the results 3 of a study by Eberhard-Gran et al. (2002), who found that women choosing to be mothers tend to have good psychic health. In her study, postpartum women originally had a lower prevalence of depression compared to non-postpartum women. However, when controlling for known risk factors, postpartum women had a higher risk for clinical depression. In sum, there seems to be evidence that the postpartum period is a time with increased risk for depression in women. Unfortunately, many women suffering from PPD are not identified and do not seek professional help (Abrams, Dornig, & Curran, 2009; Sword, Busser, Ganann, McMillan, & Swinton, 2008). Clinically significant PPD raises unique questions concerning parental function, mother-child interaction and the potential harm the mother s depression causes to the infant. Studies show that the sadness, irritability and social withdrawal that characterize depressed people have a negative effect on the mother-child dyad, and consequently on the emotional, cognitive and social development of the child (Forbes, Cohn, Allen, & Lewinsohn, 2004; Murray & Cooper, 1997; Reck et al., 2004; Whiffen & Gotlib, 1989). A recent review by Kingston, Tough, & Whitfield (2012) suggests that prenatal and postnatal depression may have different adverse effects on child development; prenatal depression negatively affects the cognitive, behavioral, and psychomotor development whereas PPD contributes negatively to cognitive and socio-emotional development. Over the last two decades there has been an increasing focus on PPD, which has had a positive impact in a number of areas including the recognition of depression after birth and the fight for improved clinical services for women and their families (Cooper et al., 2007). Nevertheless, PPD is still presumed to be an under-diagnosed illness (Eberhard-Gran, Tambs, Opjordsmoen, Skrondal, & Eskild, 2003; Horowitz & Cousins, 2006; O'Hara & Swain, 1996). Despite an increasing amount of research on PPD, there is considerable confusion about the definition and even the existence of PPD as a unique disorder. Today, the prevailing view is that PPD is no different from depression occurring at other times in life, at least from a symptomatic point of view (Cooper et al., 2007; Murray
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