Panic Disorder in Pregnancy, Postpartum, and Family Risk

In "Panic Disorder during Pregnancy and Postpartum Period" (Bandelow, Sojka, et al., 2006), researchers interviewed 128 Caucasian women about panic disorder. The participants were blind to the intent of the study, but the interviewers were not. Pregnant women were asked 16 additional questions. Researchers defined panic disorder according to DSM-IV/ICD-10 criteria. They asked the women to describe the first onset of panic symptoms and to rank them — as well as subsequent exacerbations — from mild to very severe. The researchers calculated a PMQ (panic manifestation quotient), defined as the appearance of symptoms that were at least moderate in severity. The PMQ was divided by the observation time: 266 days of pregnancy and 180 days postpartum. Age was also factored in.

Researchers asked the participants about breastfeeding and symptoms of postpartum depression. The women assessed their psychosocial stress during pregnancy and afterward on a scale ranging from no stress to very severe stress, and described the kinds of stress they encountered as well. Women who had miscarriages or abortions were compared to women who delivered normally. Some of the women were being treated with drugs or psychological therapy and were asked to rate their improvement on a scale ranging from very effective to getting worse.

Results showed that manifestations of panic disorder were significantly lower during pregnancy but increased significantly during the postpartum period: "…a 132-fold increase compared with the non-post-partum period" (p. 497). Women who had never been pregnant had higher PMQs than those who had been. Breastfeeding had no effect on panic disorder, nor did occurrences of miscarriage or abortion.

However, the occurrence of postpartum depression was higher than expected among women who reported panic attacks. Risk of panic attacks also increased in women who reported high stress. Women receiving drug therapy for panic disorders reported less improvement than women in psychological therapy, who rated improvement higher. The researchers concluded that pregnancy somewhat protects women from panic manifestations, but the postpartum period appears to increase their risk. They cite some psychosocial reasons but argue that biochemical changes — mainly drops in hormone levels after birth — are a more likely explanation. They offer no explanation for the increased risk of panic disorder in women who have never been pregnant.

In "Maternal Panic Disorder: Infant Prematurity and Low Birth Weight" (Warren, Racu, Gregg, & Simmens, 2006), researchers wanted to determine whether women with panic disorders give birth prematurely more often or have babies with lower birth weights. Knowing that some women experience panic attacks during pregnancy, they sought to find out whether those attacks affected fetal outcomes. They reviewed the medical records of 25 Caucasian, middle-to-upper-class mothers with panic disorders and compared them to the records of 33 mothers with similar demographics and no lifetime history of anxiety disorders or other major psychopathology.

The women also completed questionnaires covering demographic information and life stresses. Women who reported alcohol or drug abuse — or used these substances during pregnancy — were excluded from the study, as were women whose children had experienced a major medical problem, trauma, or abuse, and women with maternal diabetes. The Family Inventory of Life Events was used to measure stress. Gestational age in weeks was calculated from the mother's last menstrual period; when an LMP date was unavailable, ultrasonography was used. If neither was available, gestational age was taken from the delivery record.

Results indicate that mothers with panic disorder continued to experience panic attacks throughout their pregnancies. Only 8% also had symptoms of depression during pregnancy. No significant differences were found between the two groups in maternal age, race, socioeconomic status, primiparous status, smoking during pregnancy, or psychotropic medications taken during pregnancy. Panic disorder mothers had higher blood pressures and were more likely to report eating disorders, but no significant differences were found in gestational ages between the two groups. However, infants born to mothers with panic disorder had significantly lower birth weights — though while statistically significant, these weights were not below normal clinical thresholds.

Statistical analysis allowed the researchers to conclude that other variables, such as smoking and high stress, were not responsible for the finding of lower birth weight in panic disorder mothers. They noted that if panic disorder risk were combined with other risk factors, this could present greater problems for the child. The researchers acknowledged that the causes of low birth weight may not have been fully determined and that some analytic methods could have affected their findings. The use of Caucasian, middle-to-upper-class women meant the sample was not representative of the broader population.

In "Effects of Prenatal Anxiety Disorders in Children at High Risk for Panic Disorder: A Controlled Study" (Biederman, Petty, et al., 2006), the researchers wanted to test the hypothesis that anxiety disorders "breed true in offspring" (p. 191). They assessed participants using structured diagnostic interviews. Although anxiety disorder and panic disorder are distinct diagnoses, they frequently co-occur, and children of parents with panic disorder are at higher risk for anxiety disorders, including agoraphobia, generalized anxiety disorder, obsessive-compulsive disorder, social phobia, and separation anxiety disorder. The purpose of the study was to examine the association between anxiety disorders in parents and children at risk for panic disorder, with the hope that a better understanding of how these disorders are transmitted could eventually support prevention and early intervention.

The researchers selected children at high risk for panic disorder from a previous longitudinal study. Parents with panic disorder and depression were recruited, and only patients with a positive lifetime diagnosis of panic disorder or major depression were included. Parents in the control group were free of both anxiety disorders and mood disorders. A committee of mental health specialists, blind to each participant's history, had to reach a consensus to establish a positive diagnosis.

Researchers then conducted a statistical analysis of the data. For each disorder found to be elevated in the offspring, the researchers attempted to determine whether it could be accounted for by the presence in the parent of panic disorder, an identical disorder, or parental major depression. Social phobia and separation anxiety in the offspring were accounted for by the same disorders in the parent. Parental panic disorder, on the other hand, conferred a risk of agoraphobia and obsessive-compulsive disorder in their children. These findings imply that risk factors differ across disorders.

The authors argue that separation anxiety disorder is limited to a subgroup of children with familial separation anxiety disorder, though they could not determine whether these children are at higher risk for panic disorder. They found that social phobia in children is more clearly associated with social phobia in the parent than with panic disorder or major depression — social phobia breeds true in offspring. Panic disorder in a parent also increases the risk of OCD in children. The researchers concluded: "These findings shed light on the nature of transmission of anxiety disorders between parents and their high-risk offspring and suggest that differing risk factors underlie the expression of individual anxiety disorders" (p. 196). As with the other studies reviewed, a disproportionate number of participants were Caucasian and of higher socioeconomic status, limiting the generalizability of the results.