Elsevier

Infant Behavior and Development

Volume 44, August 2016, Pages 148-158
Infant Behavior and Development

Full length article
Postpartum depression and infant-mother attachment security at one year: The impact of co-morbid maternal personality disorders

https://doi.org/10.1016/j.infbeh.2016.06.002Get rights and content

Highlights

  • The first study to examine the role of comorbid personality disorder in the association between postpartum depression and infant attachment.

  • Postpartum depression was associated with attachment insecurity only if the mother also had a co-morbid personality disorder.

  • In terms of intervention, a focus is needed not only on the depressive symptoms; also underlying psychological factors should be addressed.

Abstract

Previous studies on effects of postpartum depression (PPD) on infant-mother attachment have been divergent. This may be due to not taking into account the effects of stable difficulties not specific for depression, such as maternal personality disorder (PD).

Mothers (N = 80) were recruited for a longitudinal study either during pregnancy (comparison group) or eight weeks postpartum (clinical group). Infants of mothers with depressive symptoms only or in combination with a PD diagnosis were compared with infants of mothers with no psychopathology. Depression and PD were assessed using self-report and clinical interviews. Infant-mother attachment was assessed when infants were 13 months using Strange Situation Procedure (SSP). Attachment (in)security was calculated as a continuous score based on the four interactive behavioral scales of the SSP, and the conventional scale for attachment disorganization was used.

PPD was associated with attachment insecurity only if the mother also had a PD diagnosis. Infants of PPD mothers without co-morbid PD did not differ from infants of mothers with no psychopathology. These results suggest that co-existing PD may be crucial in understanding how PPD impacts on parenting and infant social-emotional development. Stable underlying factors may magnify or buffer effects of PPD on parenting and child outcomes.

Introduction

Infant-mother attachment as measured by the Strange Situation Procedure (SSP: Ainsworth, Blehar, Waters, & Wall, 1978; Main & Solomon, 1990), is one of the most well-established, reliable and valid measures (in the 2nd year of life) of how well or poorly toddlers are functioning in their primary attachment relationship (to mother) with long-term consequences for childreńs social and emotional adaptation throughout childhood and adolescence (for a review, see Thompson, 2008). The quality of the early attachment relationship has been found to be related to later externalizing, internalizing, and peer-related problems in diverse studies. In particular, attachment disorganization has been documented to be a major risk factor for the development of socio-emotional problems as well as for developing symptoms of psychiatric illness later in childhood (for three recent meta-analyses, see Fearon, Bakermans-Kranenburg, van IJzendoorn, Lapsley, & Roisman, 2010; Groh et al., 2014; Groh, Roisman, van IJzendoorn, Bakermans-Kranenburg, & Fearon, 2012).

Maternal postpartum depression (PPD) has traditionally been considered as one of the most important risk factors for infant-mother attachment insecurity and disorganization within the field of perinatal and infant mental health (see for example, Goodman & Brand, 2009). However, recently, a discussion has begun to emerge regarding the effects of maternal postpartum depression (PPD) on infant-mother attachment and subsequent social-emotional problems in children: Whereas some previous studies have found long-term effects of PPD on infant-mother attachment insecurity independently of whether the mother still presented with depressive symptoms when infant-mother attachment quality was measured (Murray et al., 1996; Righetti-Veltema, Bousquet, & Manzano, 2003), such effects have not consistently been found. For example, two prominent large-scale studies (comprising in total 1704 mother-infant dyads) failed to find associations between PPD and attachment quality at one year (Tharner et al., 2012a) and at 36 months (Campbell et al., 2004). In the latter study, only children of mothers with late, intermittent, or chronic depressive symptoms who were also low in sensitivity had a heightened risk of insecure attachment.

Such inconsistencies between studies raise the question whether PPD per se puts at risk the developing mother-infant attachment relationship or whether it is rather a combination of risk-factors that often co-exist with PPD that explain the associations found in some studies. Indeed, the most consistent associations between depression and infant-mother attachment have been found in populations where the depressive symptoms occurred in combination with other severe psycho-social risk factors such as poverty (Lyons-Ruth, Lyubchik, Wolfe, & Bronfman, 2002, for a review, see Belsky & Fearon, 2008). However, in such samples it is difficult to disentangle the effects of depressive symptoms from other environmental risk factors (Goodman & Gotlib, 1999). Furthermore, it has been suggested that mothers with PPD are a very heterogeneous group with a substantial number of PPD-mothers presenting co-existent persistent psychological difficulties such as personality disorder or insecure attachment representations (Akman, Uguz, & Kaya, 2007; Apter, Devouche, Gratier, Valente, & Le Nestour, 2012; McMahon, Barnett, Kowalenko, & Tennant, 2006; Smith-Nielsen et al., 2015). For these mothers, it might be much more difficult to establish a secure attachment relationship with their child than for PPD-mothers who do not have such co-occurring difficulties.

Support for the idea that PPD mothers may be a far more heterogeneous population than has traditionally been assumed also comes from Lovejoy, Graczyk, O’Hare, & Neuman (2000)’s meta-analytic review on the effects of maternal depression on parenting. They suggest that the critical, intrusive, and coercive behaviors displayed by some depressed mothers may not be specific to depression, but are instead a consequence of other psychiatric conditions, such as chronic interpersonal problems or high levels of stress or anxiety, even in the absence of depressive symptoms. Along the same lines, it has recently been argued that maternal depression is too frequently considered as a unitary construct, ignoring the likely diversity among mothers with depression, in terms of their psychological disturbances (Goodman, 2014).

One important source of such diversity might be the presence of comorbid personality disorders (PD) that often, but not always, co-occur with depression in adults (Vilaplana, McKenney, Riesco, Autonell, & Cervilla, 2010; Viinamaki et al., 2006). For example, Gunderson et al. (2008) showed that having a comorbid PD confers very high risk for major depression, stressing the fact that depression is not a diagnosis that jusitfiably pushes the question of PD away. The importance of examining effects of PD on child outcomes was also underlined in a study showing that children of mothers suffering from Borderline PD exibihited significantly more emotional and behavioral problems than children of mothers with depression only, children of mothers with no psychiatric condition, or children of mothers with cluster C PDs (Barnow, Spitzer, Grabe, Kessler, & Freyberger, 2006). This means that when addressing the question of personality disorder in the context of PPD, we are both focusing on prevention of adverse child outcomes and on selecting groups for whom intervention might be more necessary than others.

DSM-IV and DSM-5 delineate 10 different PDs (American Psychiatric Association, 2000; American Psychiatric Association, 2013) grouped into three Clusters that are based on similarities among the specific PD diagnoses. Cluster A, includes paranoid, schizoid, and schizotypal PD, and individuals who qualify for a Cluster A diagnosis often appear odd, eccentric, or very socially withdrawn. Cluster B includes antisocial, borderline, histrionic, and narcissistic PD, and individuals who have a Cluster B disorder often appear dramatic, emotional, or erratic. Cluster C includes avoidant, dependent, and obsessive PD. Individuals with a Cluster C diagnosis often appear anxious, fearful or ‘neurotic’. Moreover, DSM-IV/5 allows the diagnosis of “other personality disorder”, which includes PDs that are not among the officially recognized diagnostic categories, e.g. depressive PD and passive-aggressive PD, as well as personality disorder not otherwise specified (PDNOS). PDNOS is among the most prevalent PD diagnoses in patient samples, with a relative prevalence in the range of 21–49%, dependent of the criteria used for diagnosing PDNOS and/or method of assessment (Verheul & Widiger, 2004; Verheul, Bartak, & Widiger, 2007).

Although individuals with PD thus appear differently across the three Clusters and specific PDs, essential commonalities also exist. Regardless of the specific diagnosis, PD (in definition) is characterized by having persistent and pervasive distorted perceptions of self and others, perspective-taking deficits, and importantly, a core feature of any PD is having persistent and pervasive interpersonal difficulties, particularly in close relationships (American Psychiatric Association, 2000; American Psychiatric Association, 2013). For example, while those with dependent PD are compliant and over-reliant in their relationships (Bornstein, 1992) individuals with schizoid PD lack interest in others (Sperry & Mosak, 1996). Moreover, those with borderline PD typically have relationships that are highly unstable and intense (Millon & Davis, 1996) whereas those with narcissistic PD typically are exploitative and do not regard for other people (Lyddon and Sherry, 2001, Sperry and Mosak, 1996). Support for the notion that commonalities with respect to relationship difficulties exist across the three PD clusters also comes from Sherry, Lyddon, and Hendson (2007) who found that insecure adult attachment style in close relationships was associated with 7 of the 10 PDs.

Strikingly few studies have examined effects of PD on parenting and the infant-parent relationship and subsequent social-emotional development in the child. Indeed, the authors of a recent systematic review on links between (any) PD and parenting remarked that research on associations between psychopathology and parenting has mainly focused on the DSM-IV notion of Axis-I disorders (American Psychiatric Association, 2000), and only to a small degree examined the impact of the more persistent Axis II personality disorders (Laulik, Chou, Browne, & Allam, 2013). Nine out of the identified 11 studies in this review suggested that PD among mothers elevates the risk for impaired parenting behaviors, e.g., insensitive, intrusive, poorly attuned and disrupted parent-infant interactions; all features of parenting behavior assumed to be associated with an increased risk for insecure attachment and/or disorganization.

Informed by this research the current paper aims at studying the effects of PPD on parenting and infant-mother attachment, taking into account maternal PD. To the best of our knowledge, to date there has been only one prior study specifically focusing on the effects of PD on infant-mother attachment. In this study, comprising 10 mother-infant dyads, where the mothers were diagnosed with the Cluster B diagnosis borderline personality disorder (BPD), and 20 mothers with no psychopathology, it was found that infants of mothers with BPD had a higher risk for attachment insecurity and disorganization at one year compared with infants of mothers with no psychopathology (Hobson, Patrick, Crandell, Garcia-Perez, & Lee, 2005). Considering the severe and often very dramatic disturbances in close interpersonal relationships that characterizes Cluster B disorders, the Hobson et al. finding may not seem surprising. Whether this finding holds for PD more generally, has remained unknown and is now addressed in the present study. That is, we address whether persistent relationship oriented difficulties, which characterizes any PD, though not necessarily as dramatic as in the case of BPD, co-occurring with maternal PPD may increase the risk of attachment insecurity in the infant as compared with infants of mothers without co-occurring PD and mothers with no psychopathology.

Research is also very limited with respect to examining the cumulative effect of PPD and co-morbid PD on parenting and infant outcomes. Only two studies have specifically done this, both originating from the same research group. Conroy and colleagues compared early parenting behaviors and infant development at 18 months of age in dyads with mothers either meeting criteria for depression at two months postpartum, PD, both conditions, or neither condition (Conroy, Marks, Schacht, Davies, & Moran, 2010; Conroy et al., 2012). They found that sensitivity, engagement, and being aware of infant care practices two months postpartum were all negatively affected in depressed mothers only when they also had PD. Correspondingly, infant behavior was only dysregulated at 18 months if the mother had both PPD and PD.

Drawing on these previous findings, the current study examines the role of PD in the association between maternal PPD and infant-mother attachment. We examined this in an otherwise low-risk sample, thereby limiting the impact of confounding variables that are often present in high-risk samples, such as poverty, single parenthood, and low maternal educational level. We hypothesized that infants of mothers with both PPD and PD would be at greater risk for attachment insecurity and disorganization than infants of mothers with depression only or infants of non-clinical mothers. Based on previous findings from PPD samples similar to the current one with few risk factors besides the depressive symptoms (Campbell et al., 2004, McMahon et al., 2006, Tharner et al., 2012a), we expected that infants of mothers only presenting depressive symptoms would not differ from infants of non-clinical mothers with respect to infant-mother attachment quality.

Section snippets

Participants and procedures

Sampling strategy, drop outs, flow of participants, and procedures for inclusion are described in detail in recently published work (Smith-Nielsen et al., 2015). In short, first-time mothers with postpartum depressive symptoms (PPD group) were referred to the research unit by public health nurses based on routine screenings for postpartum depressive symptoms during home-visits eight weeks postpartum.1

Descriptives

The majority of infants were securely attached, i.e. 63% of the infants of PPD mothers and 66% of the infants of non-clinical mothers. Table 1 shows that the two groups did not differ with respect to the conventional ABCD-classifications. Of the PPD mothers, 93% (n = 27) fulfilled the criteria for clinical depression according to DSM-IV, and the remaining presented subclinical levels of depression.

As reported previously (Smith-Nielsen et al., 2015), the two groups differed with respect to

Discussion

To the best of our knowledge, this study has been the first to examine the role of co-morbid personality disorder in the association between maternal postpartum depression and infant-mother attachment. We found that in an otherwise low-risk sample, depression was associated with attachment insecurity only if the mother also had a PD diagnosis.

It has been suggested previously that a maternal PD can interact with depressive symptoms in affecting parenting behavior and child developmental outcomes

Conclusion

When studying the effects of PPD on infant developmental outcomes, other concurrent persistent psychological difficulties should be taken into account, as PPD-mothers may be a very heterogeneous group in this regard. Underlying personality pathology may be highly important in determining how PPD impacts on parenting and infant developmental outcomes. Considering that patients with co-morbid PD and unipolar depression have a heightened risk for poor treatment outcome in comparison with patients

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