Research paperLongitudinal effects of dysfunctional perfectionism and avoidant personality style on postpartum mental disorders: Pathways through antepartum depression and anxiety
Introduction
Postpartum depression (PPD) is the most common mental illness in the perinatal period. It is characterized by typical symptoms of major depression, and in addition, by ambiguous feelings towards the child, sometimes culminating in infanticidal thoughts, doubts about functioning as a mother, and is often combined with anxiety. The high international prevalence of between 13% and 19% (O’Hara and Swain, 1996, O’Hara and McCabe, 2013), with a peak in the first three months (Hübner-Liebermann et al., 2012, Gavin et al., 2005) and its negative consequences for the child and the mother–infant relationship (Goodman et al. (2011), see O’Hara and McCabe (2013)) may explain the increase in research on PPD risk factors during the last decade. Although some risk factors have been detected so far, there is a lot to learn until we can predict PPD in its complexity, with a sufficient explanatory model (O’Hara and McCabe, 2013). In particular, it is not clear whether risk factors influence PPD directly or indirectly (e.g. in combination with pre-existing mood disorders).
Well-known risk factors for PPD are depression and anxiety during pregnancy, as well as a previous history of mood disorders, mainly depression, and lack of social support (Beck, 2001, Martini et al., 2015, Milgrom et al., 2008, O’Hara and Swain, 1996, Robertson et al., 2004). The prevalence of 20% for antepartum depression (APD) appears to be higher than that of PPD (Giardinelli et al., 2011, Hübner-Liebermann et al., 2012, Milgrom et al., 2008).
The prevalence of antepartum anxiety disorders varies considerably between different studies (see Goodman et al. (2014) for a review) from 12% to 25% (Bennett et al., 2004, Ross and McLean, 2006) to 50%–60% (Faisal-Cury and Menezes, 2007, Lee et al., 2007). Yet, there is little data on postpartum anxiety (PPA) prevalence. In Germany, a prevalence of 11.1% has been reported (Reck et al., 2008). Interestingly, anxiety disorders before or during pregnancy have proven to be a stronger predictor of PPD (and for PPA) than depression (Della Vedova et al., 2011, Lee et al., 2007; Matthey et al., 2003). Ross et al. (2003) reported that nearly 50% of all depressed women in the peripartum period suffered from co-morbid anxiety. Women with an anxiety disorder during pregnancy (antepartum anxiety, APA), especially those with high anxiety scores, have a threefold risk of intense PPD symptoms (Austin et al., 2007, Sutter-Dallay et al., 2004). Coelho et al. (2011) found that an antepartum generalized anxiety disorder strongly predicted PPD at different time points. Nevertheless, peripartum anxiety is understood less than depression, because up to now, most screenings focus on depressive symptoms (Goodman et al., 2014, Matthey et al., 2003).
In recent years, personality characteristics have been included in the research on risk factors for PPD. Some evidence exists that certain personality characteristics increase the vulnerability to PPD. Higher levels of neuroticism have been found to be a stable predictor for PPD (Dudek et al., 2014, Jones et al., 2010, Podolska et al., 2010), but neuroticism is generally a well-known risk factor for depression in other life periods, so that it might not predict PPD specifically. Some data also report harm-avoidance and self-directedness, traits from Cloninger's Temperament and Character Inventory (Josefsson et al., 2007), as correlated with PPD. Moreover, perfectionism has proven to be a predictor of different mood disorders and especially of major depression. Recently, it has been the subject of controversy in the context of PPD (Gelabert et al., 2012, Macedo et al., 2009, Vliegen et al., 2006). Perfectionism is a personality disposition defined as the setting of excessively high performance standards and overly critical evaluations of one's own behavior (cf. Frost et al. (1990)). Perfectionism contains both negative (maladaptive or unhealthy) and positive (adaptive or sound) facets (Hawkins et al., 2006, Stumpf and Parker, 2000, Terry-Short et al., 1995) and can be divided into functional perfectionism (personal standards, organization) and dysfunctional perfectionism (concern over mistakes, doubts about actions, parental expectations and parental criticism). Two studies reported associations between high (maladaptive/dysfunctional) perfectionism, mainly excessive concern over mistakes, and PPD (Gelabert et al., 2012, Mazzeo et al., 2006). In contrast, two other studies did not find a higher risk for PPD in perfectionist women (Maia et al., 2012, Sweeney and Fingerhut, 2013). Cloninger et al. (2012) showed that highly persistent (i.e., perfectionistic) people generally have a higher risk of suffering from anxiety disorders, but to the best of our knowledge, there has been no study analyzing the effect of perfectionism on PPA. The only personality characteristics that have recently been described as enhanced in peripartum anxiety disorders are low self-esteem and low self-efficacy (Martini et al., 2015).
Going beyond the discussion on the role of personality characteristics as predictors of PPD, personality disorders (PDs) have been analyzed increasingly in the context of PPD. There is preliminary evidence of some PDs being correlated with PPD, particularly Cluster C PDs: dependent, avoidant, and obsessive–compulsive (Aceti et al., 2012, Akman et al., 2007, Enfoux et al., 2013). There is little data on the causal relationship between PPD and Cluster C PDs. Akman et al. (2007) found that avoidant, dependent, and obsessive–compulsive PDs independently predict PPD. Especially high levels of avoidant PD symptoms seem to be a significant predictor of poor treatment outcome. Joyce et al. (2007) found that the major determinant of psychotherapy outcome was avoidant symptoms. Whether an avoidant PD not only predicts PPD, but also PPA, has not yet been investigated. Besides Cluster C PDs, there is also some evidence that Cluster B PDs, mainly borderline PD, is predominant in PPD mothers or often combined with avoidant/dependent PDs (Aceti et al., 2012, Apter et al., 2012, Enfoux et al., 2013). Since personality styles – in the sense of not fully pronounced PDs – are risk factors of mental illnesses (Caspi et al., 1996, Skodol et al., 2005) our aim was to analyze the effect of personality styles on PPD, PPA, and BI. The avoidant PD seems to be the most influential PD for PPD, based on the few existing studies and will be examined further in the present study, also in the context of PPA.
A recent study observed a relationship between PDs as risk factors of PPD and impaired maternal bonding (Schwarze et al., 2014). Impaired bonding is a disturbance of the mother's emotional relationship towards the infant, associated with a lack of maternal feeling, unresponsiveness, feelings of rejection, and sometimes aggressive impulses. In contrast, impaired attachment refers to a disturbed relationship of the infant with its caregiver (see Klaus et al. (1995) for the concept of bonding, and Ainsworth et al. (1978) and Bowlby (1997) for attachment theory). Mothers suffering from PPD often display an impaired relationship with the child (Dubber et al., 2015; Edhborgh et al., 2003; Moehler et al., 2006; Reck et al., 2004). According to Brockington et al. (2001), approximately 30% of mothers with PPD have a bonding impairment. In a German study, up to 75% of PPD mothers were found to be afflicted with impaired bonding (Hornstein et al., 2009). Yet, subclinical depressive symptoms also influence a mother's bonding (Moehler et al., 2006, Tietz et al., 2014). The effect of anxiety on bonding is less clear so far. There are only a few studies dealing with bonding impairment and anxiety (Dubber et al., 2015, Edborgh et al., 2011, Tietz et al., 2014) and the results are heterogeneous. It seems that BI correlates with PPA, but is influenced mainly by PPD (Dubber et al., 2015, Tietz et al., 2014).
The objective of our study was to investigate the relationships between personality characteristics, peripartum anxiety and depression, as well as BI, in a longitudinal study of women from the third trimester of pregnancy until twelve weeks postpartum. The present prospective study combines, for the first time, the analysis of distinct personality characteristics – perfectionism and avoidant personality style – as risk factors for PPD and PPA, as well as their relationships with BI. We integrated the well-known risk factors APD and APA in our model and tested the extent to which dysfunctional perfectionism and avoidant personality style directly influence both PPD and PPA, or whether there is an indirect pathway through antepartum illness (APA and/or APD). We assumed that there might be differential effects of the two personality characteristics on the two postpartum disorder entities and that the direct effects may be controlled by antepartum mental health. Because of the scarcity of data on the effect of personality styles on BI, we followed an explorative approach to examine the relationships between personality styles, peripartum disorders, and BI. Given that some studies reported correlations between PPD and BI (Brockington et al., 2001, Dubber et al., 2015; Edhborgh et al., 2003; Hornstein et al., 2009; Moehler et al., 2006; Reck et al., 2004; Tietz et al., 2014), we hypothesized that the effects of the personality characteristics on BI are mediated mainly by PPD.
Section snippets
Study sample
Pregnant women were recruited at the Buergerhospital and the University Hospital of Frankfurt (Germany) as part of a research project on personality and PPD (cf. Hain et al. (2015)). Two measurement time points were selected from the research project for this study: the first in the third trimester of pregnancy (N=297; mean gestation week: M=30.15; SD=7.11) and the second twelve weeks postpartum (N=266). Fig. 1 shows the number of primarily recruited subjects and those finally enrolled in the
Descriptive statistics
From the 266 women, 10% (N=31) showed antepartum depression (BDI– V cut-off ≥35) with a mean of M=45.32 (SD=9.02). The mean of all participants was M=20.08 (SD=11.77). The prevalence of PPD (EPDS≥10) was 10% (M=15.12; SD=4.20). The EPDS mean of the whole study group was M=4.92 (SD=4.37).
In 12 of the 31 women with APD, depression persisted after birth, 15 recovered and 16 newly developed a PPD.
Moreover, 12% of the 266 women showed an impaired bonding (PBQ scale 1≥12; M=17.77, SD=6.58). The mean
Discussion
To the best of our knowledge, the present prospective-longitudinal study, investigated for the first time the effect of perfectionism and avoidant personality characteristics on the three most important postpartum mental health issues: postpartum depression, anxiety and bonding impairment. Until now, the two personality aspects have been analyzed separately and only in the context of PPD.
An additional strength of our study for the research on risk factors of postpartum mental disorders is the
Limitations
Although our data provided new insights into the field of risk factors on PPD, PPA, and BI, the study has some limitations. First, path analysis is based on manifest (observed) variables, which include measurement errors. Furthermore, using only one indicator to measure a construct, has an impact on the construct validity. Therefore, using structural equation modeling would be preferable, as this method takes the measurement errors into account and allows multiple indicators per construct in
Conclusion
This longitudinal study supports the inclusion of dysfunctional perfectionism and avoidant personality style as significant risk factors for PPD, PPA, and BI. Dysfunctional perfectionism and avoidant personality styles explained a high proportion of variance of PPD, but also a substantial proportion of PPA. Therefore, these two personality characteristics should be integrated in future antepartum screening in order to evaluate the risk of postpartum disorders and adopt preventive intervention.
Contributor's statement
S. Oddo conceptualized and designed the study, designed the data collection instruments, carried out the interpretation of the data, drafted the initial manuscript and approved the final manuscript as submitted.
S. Hain designed the data collection instruments, collected data for the study, carried out the statistical analysis, drafted the initial method and results part of the manuscript, critically reviewed the manuscript and approved the final manuscript as submitted.
F. Louwen was involved in
Author agreement
All authors have seen and approved the manuscript being submitted. The article is the authors’ original work, has not received prior publication and is not under consideration for publication elsewhere.
Role of funding source
This work had no funding.
Financial disclosure
All authors declare that they have no financial relationships to disclose.
Acknowledgments
The authors are grateful to Dr. Brian Bloch for his comprehensive editing of the manuscript.
References (78)
- et al.
Obsessive–compulsive symptoms in pregnancy and the puerperium: a review of the literature
J. Anxiety Disord.
(2003) - et al.
Maternal attachment patterns and personality in post partum depression
Riv. Psichiatr.
(2012) - et al.
Patterns of attachment. A psychological study of the strange situation
(1978) - et al.
Postpartum-onset major depression is associated with personality disorders
Compr. Psychiatry.
(2007) - et al.
Testgüte einer deutschsprachigen Version der mehrdimensionalen Perfektionsmusskala von Frost, Marten, Lahart und Rosenblate (MPS-F)
Diagnostica
(2006) - et al.
What lies behind postnatal depression: is it only a mood disorder?
J. Pers. Disord.
(2012) - et al.
Examinig the relationship between antenatal anxiety and postnatal depression
J. Affect. Disord.
(2007) Predictors of postpartum depression – an update
Nurs. Res.
(2001)- et al.
An inventory for measuring depression
Arch. Gen. Psychiatry.
(1961) - et al.
Prevalence of depression during pregnancy: systematic review
Obstet. Gynecol.
(2004)
Deutschsprachige Fassung und Validierung der »Edinburgh postpartum depression scale« [German version and validation of the Edinburgh depression scale (EPDS)]
Dtsch. Med. Wochenschr.
Attachment and Loss
A screening questionnaire for mother–infant bonding disorders
Arch. Women's Ment. Health
Behavioral observations at age 3 years predict adult psychiatric disorders: longitudinal evidence from a birth cohort
Arch. Gen. Psychiatry.
Inhibitory control as a mediator of bidirectional effects between early oppositional behavior and maternal depression
Dev. Psychopath.
The psychological costs and benefits of being highly persistent: personality profiles distinguish mood disorders from anxiety disorders
J. Affect. Disord.
Antenatal anxiety disorder as a predictor of postnatal depression: a longitudinal study
J. Affect. Disord.
Detection of postpartum depression. Development of the 10-item Edinburgh Postpartum Depression Scale
Br. J. Psychiatry
Maternal bonding and risk of depression in late pregnancy: a survey of Italian nulliparous women
J. Reprod. Infant Psychol.
Postpartum bonding: the role of perinatal depression, anxiety and maternal-fetal bonding during pregnancy
Arch. Women's Ment. Health
Postpartum depression: identifying associations with bipolarity and personality traits. Preliminary results from a cross-sectional study in Poland
Psychiatry Res.
Impact of postpartum depressive and anxiety symptoms on mothers emotional tie to their infants 2–3 months postpartum: a population-based study from rural Bangladesh
Arch. Women's Ment. Health
The parent–child relationship in the context of maternal depressive mood
Arch. Women's Ment. Health
Comorbidity between personality disorders and depressive symptomatology in women: a cross-sectional study of three different transitional life stages
Pers. Ment. Health
Prevalence of anxiety and depression during pregnancy in a private setting sample
Arch. Women's Ment. Health
The dimensions of perfectionism
Cogn. Ther. Res.
Perinatal depression: a systematic review of prevalence and incidence
Obstet. Gynecol.
Perfectionism dimensions in major postpartum depression
J. Affect. Disord.
Depression and anxiety in perinatal period: prevalence and risk factors in an Italian sample
Arch. Women's Ment. Health
Anxiety disorders during pregnancy: a systematic review
J. Clin. Psychiatry
Maternal depression and child psychopathology: a meta-analytic review
Clin. Child Fam. Psychol. Rev.
Development of a short form of the personality styles and disorder inventory (PSDI-6): initial validation in a sample of pregnant women
Eur. J. Psychol. Assess.
Psychometric properties of the Frost multidimensional perfectionism scale with Australian adolescent girls: clarification of multidimensionality and perfectionist typology
Educ. Psychol. Meas.
Perfectionism in the self and social contexts: conceptualization, assessment and association with psychopathology
J. Pers. Soc. Psychol.
Die postpartale Bindungsstörung: Eine Risikokonstellation für den Infantizid?
Forens. Psychiatr. Psychol. Kriminol.
Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives
Struct. Equ. Model.
Recognizing and treating peripartum depression
Dtsch. Arztebl Int.
Cognitive style, personality and vulnerability to postnatal depression
Br. J. Psychiatry.
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2020, Journal of Research in PersonalityMaladaptive personality styles in a clinical sample of women with postpartum depression
2020, Journal of Affective DisordersCitation Excerpt :Neuroticism and introversion have been shown to be important, independent and stable determinants of postpartum depression (Dudek et al., 2014; Iliadis et al., 2015; Jones et al., 2010; Martin-Santos et al., 2012; Podolska et al., 2010; Verkerk et al., 2005; Vliegen et al., 2010). High-perfectionism – especially high-concern over mistakes – might be an independent factor associated with postpartum depression (Gelabert et al., 2012; Mazzeo et al., 2006; Oddo-Sommerfeld et al., 2016) despite there being academic findings to the contrary (Maia et al., 2012; Sweeney and Fingerhut, 2013). Furthermore, women with a history of postpartum depression reported lower self-esteem and higher levels of dysfunctional attitudes compared with healthy controls (Jones et al., 2010).