PSIKIATRI IBU DAN ANAK

Perinatal Psychiatry

Eri Achmad, PSIKIATER

RSUD Arjawinangun
RS Mitra Plumbon
RS Sumber Waras
Education, knowledge and
understanding
Guardian 29.9.08

2
 Contoh Kasus
Ny. A 37 th, G4 P2 A1 kehamilan 28-30 minggu,
datang dengan keluhan teriak-teriak, marah-
marah, dan perilaku tidak wajar. Kejadian
tersebut sudah berlangsung 2 minggu terakhir
yang semakin hari semakin berat. Stresor
masalah marital konflik dan sosioekonomi.
 Tujuan Pembelajaran
• Menjelaskan hubungan psikologis ibu dan
anak
• Menjelaskan gangguan jiwa yang dapat timbul
pada ibu & anak pasca melahirkan
Hubungan
Psikologis
Ibu dan Anak
Hubungan Psikologis Ibu dan Anak
• Fisiologis
– Pola asuh / correct
parenting
• Patologis
– Postnatal mental
illness
• Early pregnancy
• Denial or conceal pregnancy
• During – Antenatal (partial – total)
• Postnatal • Komorbiditas
• Komplikasi
Sigmund Freud: The Psyche
The Psyche
Freud: Psychosexual Stages
Fixated Stages
 Mother and Child Attachment
• An enduring emotional tie to a special person,
characterized by a tendency to seek and
maintain closeness, especially during times of
stress
 Other risk factors – postnatally in terms of environment,
relationship and attachment – thanks to Robin Balbernie

PET scan of 2 year old Romanian baby

PET scan of healthy 2 year old institutionalised shortly after birth
 Importance of Attachment
• Implications for infant's sense of security
• Freud, Erikson, Bowlby, behaviorists described its
impact on development
• The quality of the attachment predicts subsequent
development
– Longitudinal study found that securely attached infants
were more competent at age-appropriate tasks
throughout adolescence (Sroufe, Egeland, Carlson, &
Collins, 2005)
• An infant’s attachment style to a caregiver predicts:
– Effective social functioning during childhood and
adolescence
– Sociability through early, middle, and late adulthood
– Self-esteem
– School grades
– Teenage sexual activity
– Quality of attachment to their own children
– Attitudes toward their own children
 Attachment Styles
1. Securely Attached: Belief that the caregiver
will protect and provide for them
– Explores the environment with the parent
– Might protest separation from parent but smiles
more often when the parent is present
– Shows pleasure at reunion with parent
– 65% of middle-class American infants
2. Insecure-Avoidant: Belief that the caregiver
will not protect or provide. The caregiver is
not a safe haven in stressful circumstances
– Does not protest at parent’s departure
– Responds the same to the stranger and the
parent, or more positively to the stranger
– Avoid parent upon return
– 20% of middle-class American infants
3. Insecure-Resistant: Uncertainty about
whether the parent will protect or provide
safety in stressful circumstances
– Remain close to parent. Refuse to explore the new
environment
– Distressed at separation of parent
– Mixture of approach and avoidance when
reunited
– 10% of middle-class American infants
4. Disorganized or Disoriented: No consistent way
of dealing with the stress
– Exhibits contradictory behavior at the strange situation
– Typical attachment style when the infant is abused or
neglected
– Less than 5% of middle-class American infants
• The same four types of attachments have been
found in various cultures, but the proportion of
children in each category differ by culture
 Factors which Affect Attachment
1. Opportunity for attachment
2. Quality of caregiving
• respond promptly and consistently
• interactional synchrony – the sensitively tuned
“emotional dance”
3. Caregiver’s sensitivity to the infant’s needs
• Children are less likely to develop a secure attachment if
they are raised in an orphanage
• Parents living in poverty tend to provide less sensitive
environments
• Sensitivity to infants can be taught to mothers, that then
leads to a higher probability of secure attachment (Van
den Boom, 1994)
4. Infant characteristics
• infant's temperament, special needs, prematurity, or
illnesses
5. Family circumstances
• Stress can undermine attachment
• Infants exposed to verbally aggressive fighting among their
parents form more insecure attachments
6. Parents’ internal working models
• Parental psychopathology
• Depressed mothers tend to have lower quality interactions
with their infants
• Parents’ own attachment experiences
• Parents’ ability to accept their past
 Implications of Attachment Theory
• Parents need to be sensitive to their infants’
needs.
• Parents need to provide a stable home
environment for their children
• If children are not functioning well in school, the
first problem to investigate is their home life.
• Any caring, stable adult can provide a secure
attachment for a needy child
 Gg. Mental Perilaku Onset Masa Kanak
• 0 to 3
• Gangguan Perilaku dan Emosional dengan Onset biasanya pada
masa Kanak dan Remaja
– Gg. Hiperkinetik
– Gg. Tingkah laku
• Gg. Tingkah laku berkelompok
• Gg. Sikap menentang (membangkan)
– Gg. Campuran Tingkah Laku dan Emosi
• Gg. Tingkah laku depresif
– Gg. Emosional dengan onset khas pada masa kanak
• Gg. Anxietas perpisahan masa kanak
– Gg. Fungsi Sosial dengan Onset Khas pada Masa Kanak dan Remaja
– Gg. Tic
– Gg. Perilaku dan Emosional lainya
• Enuresis non organik
• Pika masa bayi dan kanak
• Gagap
 Gg. Jiwa Perinatal
(Perinatal Psychiatry)
• Gg. Jiwa pada Ibu
• Gg. Jiwa pada anak (0-3th)
– Klasifikasi DSM 0 to 3 (Psikiater Anak-Remaja)
Pre & Postpartum Prevalence of Psychiatric
Admissions among Women
 Types of Perinatal Psychiatry
• Classic triad
– “baby blues”
– Postnatal depression
– Puerperal psychosis
• Pre-existing active psychiatric disorder; schizophrenia,
bipolar, depression, anxiety, etc
• New disorder during pregnancy ; antenatal depression
• Substance abuse, personality disorder
• Disorder associated with the relationship with the baby -
attachment disorder
 Diagnosis Multiaksial Psikiatri
I. Diagnosis Klinis / Primer
Diagnosis Sekunder
Perhatian Klinis
II. Gg. Kepribadian atau Retardasi Mental
III. Penyakit Medik
IV. Masalah Psikososial
V. GAF
 Contoh Diagnosis Multiaksis
I. Episode Depresi Berat dengan gejala psikotik
II. None
III. G4 P2 A1 Kehamilan 28-30 minggu
IV. Masalah Psikososial
– Masalah primary support (marital konflik)
– Masalah ekonomi (banyak hutang)
V. GAF Buruk (ADL buruk, merawat diri buruk)
 Perinatal Psychiatry
• “Baby blues” 50-80%
• Postpartum depression 10-15%
• Postpartum psychosis 0.1-0.2%
• Antenatal depression 10-15%
• Pre-existing disorder 1-2%
• Disorders of mother-infant attachment 18%
• Non-puerperal anxiety/depression 9.8%
 PPDGJ III
• Sindrom Perilaku yang Berhubungan dengan
Gangguan Fisiologis dan Faktor Fisik (F50-F59)
– Gangguan Mental dan Perilaku yang Berhubungan
dengan Masa Nifas YTK (F53)
• Gangguan mental dan perilaku ringan yang berhubungan
dengan masa nifas YTK (F53.0)
• Gangguan mental dan perilaku berat yang berhubungan
dengan masa nifas YTK (F53.1)
• Gangguan mental dan perilaku lainnya yang berhubungan
dengan masa nifas YTK (F53.8)
• Gangguan jiwa masa nifas YTT (F53.9)
 Penatalaksanaan Kasus
• Identifikasi pasien
• Identifikasi permasalahan
– Medik (gejala, keluhan, riwayat terapi, RPD, RPK)
• Psikiatrik
• Non psikiatrik
– Non medik
• Psiko-sosio-ekonomi-spiritual
• Pemeriksaan penunjang jika diperlukan
• Diagnosis kerja dan diagnosis banding
• Rencana penatalaksanaan
– Medik
– Non medik
 Facts in Perinatal Psychiatry
• Research has shown women experience anxiety and
depression during pregnancy at the same rate as
postpartum 10-15% (Heron et al.,2004)
• Prenatal maternal depression is significantly
associated with low birth weight, premature labor and
delivery, and pre-eclampsia & infant temperament
• Pregnant women with high levels of mood disturbance
and/or stress have double the risk of preterm birth or
fetal growth restriction compared to those women
reporting low levels of stress
• Three-fold risk of having non-psychotic depressive
disorder in first month postpartum (Cox et al.,1993)
• 22-fold increased risk of affective psychosis following
childbirth (Kendell at al.,1987)
• The chance of psychiatric admission during the first
four weeks postpartum is 18 times greater than
during pregnancy (Paffenbarger,1982)
 “Baby Blues”
• Most common perinatal mood disturbance
• Adjustment reaction with depressed mood
• Exhibits depressed mood with physiologic abrupt
withdrawal of hormones, estrogen, progesterone,
and cortisol
• Onset day 3 or 4
• Mild, transient lasting hours to days
• Resolve within 2 weeks
• No treatment necessary
 Baby Blues: signs and symptoms

• Crying
• Loneliness
• Anxiety
• Exhaustion
• Insomnia
• Restlessness
• Irritability
• Difficulty concentrating
 Risk Factors for Baby Blues
• Hormonal fluctuations- Decreased estrogen, progesterone, and
thyroid. Increased prolactin.
• Sudden loss of circulating volume, weight, internal organ
rearrangement.
• Stress, isolation, lack of social support.
• Sleep disruption.
• Low self esteem, preterm birth, problems with newborn, hx of
infertility.
• Feelings of loss – identity, freedom, control.
• Concurrent losses – family death, job loss, relocation.
 Postpartum Depression
• Most common complication of childbirth
• Onset after 2 weeks, usually up to 6-12 months
• Duration: weeks to months
• Treatment necessary
– Psychological interventions or
– Medication
• Clinically no different from depression occurring at other
times
• High risk of further episodes following childbirth is 40-60%
• Estimated risk of depression unrelated to childbirth is 25%
 Post-Partum Depression
Causes
• Exact cause not known. Levels of estrogen,
progesterone, cortisol, and thyroid hormones
drop sharply after birth.
 Diagnostic Problems
• Differentiating between clinical symptoms of
depression and normal sequelae of childbirth
• Symptoms include
– Emotional
– Behavioral
– Physical
• Caused disability / disorder
• Women can be reluctance to disclose symptoms or
to recognize them as pathological
 Post-Partum Depression
Emotional Symptoms
• Increased Crying
• Irritability
• Hopelessness
• Loneliness
• Sadness
• Uncontrollable mood swings
• Feeling overwhelmed
• Guilt
• Fear of hurting self or baby
 Post-Partum Depression
Behavioral Symptoms
• Lack of, or too much, interest in the baby
• Poor self-care
• Loss of interest in otherwise normally
stimulating activities
• Social withdrawal and isolation
• Poor concentration, confusion
 Post-Partum Depression
Physical Symptoms
• Exhaustion, fatigue
• Sluggishness
• Sleeping problems (not related to screaming baby)
• Appetite changes
• Headaches
• Chest pain
• Heart Palpitations
• Hyperventilation
 Risk Factors:
Postpartum Depression
• Undesired/ unplanned pregnancy
• Hx of depression or previous PPD
• Lack of social support
• Recent major life change: family death,
financial stress, job loss, relocation, marital
discord, homelessness.
 Treatment
• Medication and non medication
• 70-80% of women recover with treatment
– Antidepressants (issues relating to breastfeeding)
– Psychotherapy – CBT
– Supportive counseling, peer support groups
– ECT
• For mild to moderate symptoms, focus less on
pharmacological treatment and more on
counseling and group therapy.
 Post-Partum Depression
Treatment
• In addition to counseling or talk-therapy (individual or group
therapy), other steps can be taken by the mother to fight the
depressive symptoms:
– Exercise
– Eat healthy
– Use an outlet, such as a diary, a family member, or a
friend.
– Try not to isolate one’s self
– Promote sleep
– Take breaks, and make time to do the things you enjoy
 “Baby Blues” vs. Post-Partum Depression
Onset

Baby Blues Postpartum

Depression
Onset at 3rd or 4th day Onset can be anytime
post-delivery and can one year after delivery
last from a few days to a
few weeks
 “Baby Blues” vs. Post-Partum Depression
Prevalence

Baby Blues Postpartum

Depression
70-80% of women will 10% experience some
experience depressive degree of postpartum
symptoms that depression which can
disappear within a few last a year.
weeks.
 Postpartum Psychosis
• Most rare and severe form of postpartum mood
disorder
• Onset: rapid, within 72 hours of birth, 95% of cases
within 2 weeks
• Treatment: psychiatric emergency
• Depressed or elated mood which can fluctuate
rapidly
• Disorganized behavior
• Mood lability
• Confusion
• Hallucinations and delusions (religious, visual,
misidentification)
• Most cases are manic or mixed presentations
• Most cases of PP meet criteria for mania,
schizoaffective disorders or depression with
psychotic features
• Hospitalization nearly always required
• Although rare, risk of suicide and infanticide – suicide
is leading cause of maternal death in the UK (Oates,
2003)
• Infanticide – delusions or neglect
Sekian....