Cogn Ther Res
DOI 10.1007/s10608-016-9823-8
ORIGINAL ARTICLE
Repetitive Negative Thinking and Impaired Mother–Infant
Bonding: A Longitudinal Study
Dana Schmidt1 • Sabine Seehagen1,5 • Gerrit Hirschfeld2 • Silja Vocks3
Silvia Schneider1 • Tobias Teismann4
•
Ó Springer Science+Business Media New York 2016
Abstract Recent theoretical models suggest that repetitive
negative thinking might be a key mechanism explaining the
negative effects of maternal psychopathology on mother–
infant relations. While an emerging body of research largely supports this idea, the relative importance of differences in the trajectory of repetitive negative thinking
during and after pregnancy for mother–infant bonding as
well as maternal depressive symptoms is currently
unknown. Therefore, we investigated associations between
the course of maternal repetitive negative thinking during
pregnancy and after birth and mother–infant-bonding and
maternal depressive symptoms in a longitudinal study. The
overall level of repetitive negative thinking was a significant predictor of mother–infant bonding, maternal anxiety
and rejection in dealing with her infant four months after
birth. Furthermore, differences in the trajectory of repetitive negative thinking predicted bonding, but not anxiety or
rejection. The overall levels of repetitive negative thinking
as well as the differences in the trajectory of repetitive
negative thinking were significant predictors of maternal
depressive symptoms. These findings indicate that changes
& Dana Schmidt
[email protected]
1
Department of Clinical Child and Adolescent Psychology,
Ruhr-Universität Bochum, Bochum, Germany
2
Department of Economics and Social Sciences, Hochschule
Osnabrück, Osnabrück, Germany
3
Department of Clinical Psychology and Psychotherapy,
Universität Osnabrück, Osnabrück, Germany
4
Department of Clinical Psychology and Psychotherapy,
Ruhr-Universität Bochum, Bochum, Germany
5
Present Address: The University of Waikato, Hamilton,
New Zealand
of repetitive negative thinking during and after pregnancy
can increase the risk of postpartum depressive symptoms.
Keywords Mother–infant bonding Repetitive negative
thinking Pregnancy Maternal well-being Birth
Introduction
Repetitive negative thinking is defined as a perseverative
cognitive activity that is negative in valence and experienced as difficult to control (Ehring and Watkins 2008). It
has been identified as a vulnerability factor for the onset
and maintenance of depressive disorders (Nolen-Hoeksema
et al. 2008). The role of repetitive negative thinking in
prolonging and intensifying dysphoria and depression has
been empirically shown in various experimental, crosssectional and longitudinal studies—using clinical and nonclinical samples of adults, adolescents and children (NolenHoeksema et al. 2008). Moreover, experimental studies
have provided evidence that repetitive negative thinking
negatively biases thinking in general, impairs motivation
and interferes with problem-solving (Lyubomirsky and
Tkach 2004). Furthermore, repetitive negative thinking has
been shown to be associated with more difficulties in
interpersonal relationships (e.g., Lam et al. 2003) and
diminished relationship satisfaction (Pearson et al. 2010).
Tse and Bond (2004) hypothesized that repetitive negative thinking fuels social functioning difficulties by
occupying cognitive resources necessary for social perception and interpersonal problem solving as well as by
negatively biasing how people interpret and respond to
social stimuli. With regard to the early mother–infant
relationship, Stein et al. (2009) suggested that repetitive
negative thinking, which they refer to as preoccupation,
123
Cogn Ther Res
interferes with maternal communication by altering the
attentional focus and reducing a mother’s responsiveness to
her environment. As a consequence, a mother’s ability to
respond sensitively to her infant’s cues and needs is
thought to decrease (see also DeJong et al. 2016). Mother–
infant bonding and maternal responsiveness within the
mother–infant interaction are known to be of crucial
importance for child development (e.g., Muzik et al. 2013;
Tester-Jones et al. 2015). Therefore, Stein et al. (2009)
emphasized the importance of maternal repetitive negative
thinking as a risk factor for the intergenerational transmission of psychiatric disturbances and unfavorable child
development.
Empirical support for these ideas stems from a study by
Stein et al. (2012) who tested whether an experimental
manipulation of maternal repetitive negative thinking
affected interactions between mothers and their 10-monthold infants. One group of participating mothers were
healthy, the second group suffered from Generalized
Anxiety Disorder (GAD), and the third group from Major
Depressive Disorder (MDD). Mothers were randomly
assigned to either receive a worry/rumination prime or a
neutral prime. Their sensitivity was assessed before and
after priming. Mothers suffering from GAD who were
induced to engage in repetitive negative thinking showed
reduced maternal responsiveness to vocalizations of their
10-month-old infants. The priming had a smaller effect on
mothers suffering from MDD and a reversed effect on the
behavior of healthy mothers. Thus, in mothers suffering
from GAD at least, repetitive negative thinking can lead to
changes in the way mothers react to their infants’ signals.
However, in a recent study with dysphoric and non-dysphoric mothers, Tester-Jones et al. (2016) demonstrated
that a rumination induction resulted in significant changes
in mother–infant interactions compared with a control
condition. Importantly, the effect of rumination on maternal sensitivity was not moderated by dysphoria. Rather, all
mothers, regardless of levels of depressive symptoms, who
were induced to ruminate demonstrated reduced maternal
sensitivity to their infant. In a further experimental study,
O’Mahen et al. (2015) found that repetitive negative
thinking can compromise parenting skills: Depressive
mothers of infants aged up to 12 months who were induced
to engage in repetitive negative thinking exhibited poorer
parental problem-solving effectiveness and poorer problem-solving confidence compared to depressed mothers
who were induced to distract from troubled thoughts.
Tester-Jones et al. (2015) found repetitive negative thinking to moderate the association between postpartum
depressive symptoms and maternal self-reported responsiveness—in mothers with infants low in negative temperament. For mothers of infants high in negative
temperament, postpartum depressive symptoms were
123
directly related to poorer self-reported responsiveness. In a
small-scale longitudinal study, Müller et al. (2013) could
show that repetitive negative thinking towards the end of
pregnancy was associated with a reduction in self-reported
mother–infant bonding 5 weeks postpartum. Women who
scored high on repetitive negative thinking during the
second to third trimester of their pregnancy felt more distant from their infant and were more discontent with having
a child. Furthermore, they reported more anxious feelings
and uncertainties in dealing with their child. Taken together, an emerging body of research supports the assumption
that repetitive negative thinking interferes with parenting
skills and may thus hamper the development of mother–
infant bonding (DeJong et al. 2016; Stein et al. 2009).
Potentially, this process already begins during pregnancy
(Dubber et al. 2014). The emergence of mother–foetal
bonding is the result of active cognitive and emotional
engagement with the pregnancy in an expectant mother
(Gloger-Tippelt 1988). In line with this reasoning, Schmidt
et al. (2016) found that repetitive negative thinking in the
first trimester of pregnancy predicted negative mother–
foetus attachment in the third trimester. Disturbed antenatal
attachment could, in turn, reduce the quality of mother–
infant interactions after birth (Shin et al. 2006; Siddiqui
and Hägglöf 2000).
However, further longitudinal studies are needed to
clarify whether the overall level of repetitive negative
thinking as well as differences in the trajectory of repetitive
negative thinking during pregnancy predict later mother–
infant bonding. Repetitive negative thinking is a tendency
that has been shown to be relatively constant over time
(e.g., Bagby et al. 2004). However, the transition to
motherhood is a challenging time involving many psychological and physical changes. It may thus well be that
the intensity of repetitive negative thinking changes during
pregnancy and after birth, resulting in differences in the
trajectory of repetitive negative thinking between women.
It has not yet been empirically examined whether the
intensity of repetitive negative thinking during and after
pregnancy might increase or decrease and, if the course
varies between women, whether any differences in the
trajectory are predictive of difficulties in the emerging
mother–infant bond.
In addition to clarifying the predictive value of repetitive
negative thinking for mother–infant bonding, a second unresolved issue is to determine the significance of repetitive negative thinking as a predictor for the development of postpartum
depressive symptoms. It has been repeatedly shown that during
the time of pregnancy and childbirth women are at an increased
risk of developing depression (Philipps and O’Hara 1991), with
an estimated 13% of women meeting criteria for MDD in the
first 3 months postpartum (Howard et al. 2014). Although the
effect of repetitive negative thinking on the onset and
Cogn Ther Res
maintenance of depression is well-documented (Nolen-Hoeksema et al. 2008), the relevance of repetitive negative thinking
for postnatal depressive symptoms is less clear. In an initial
study, Barnum et al. (2013) found repetitive negative thinking
during the third trimester of pregnancy to be predictive of
postpartum depressive symptoms 2 months after birth, but not
1 month after birth. Yet, in another study, repetitive negative
thinking during the second and third trimester of pregnancy was
not predictive of depressive symptoms within 8 weeks after
birth (Müller et al. 2013). Likewise, Raes et al. (2014) did not
find a predictive association between repetitive negative
thinking during pregnancy and maternal depression 12 and
24 weeks after birth. Differences in the assessment of depressive symptoms and repetitive negative thinking as well as
varying measurement points may account for these diverging
results. Furthermore, the studies were limited in their
explanatory power in that two studies (Barnum et al. 2013;
Müller et al. 2013) used rather small samples and repetitive
negative thinking was only assessed once during pregnancy in
all three studies. Studies with larger samples and multiple
assessments of maternal well-being and mothers’ tendency to
engage in repetitive negative thinking are required to estimate
the predictive value of the overall level of repetitive negative
thinking versus differences in the trajectory of repetitive negative thinking on maternal postpartum depressive symptoms.
Purpose of the Present Study
The aim of the present study was to determine if the overall
level of maternal repetitive negative thinking and differences in the trajectory of maternal repetitive negative
thinking predict (1) self-reported mother–infant bonding
and (2) the development of maternal depressive symptoms
after pregnancy in a non-clinical sample. On the basis of
the literature described above, we assumed that the overall
level as well as differences in the trajectory (i.e., the
development over time) of maternal repetitive negative
thinking would predict mother–infant bonding as well as
maternal depressive symptoms.
questionnaires were mailed to participants’ homes (51.6%)
or were completed online (48.4%). Participation was voluntary and there was no monetary compensation.
The initial sample consisted of 246 women (age:
M = 29.86, SD = 4.54 years, age range 20–45 years, 100%
Caucasian). Of the initial 246 women, n = 46 women
(18.69%) terminated participation either after the first
(n = 21), second (n = 5) or third assessment (n = 20). A
further n = 16 women completed\70% of all questionnaire
items and were excluded on the grounds of incomplete datasets. Thus, the final sample consisted of N = 184 women (age:
M = 30.02, SD = 4.60 years; age range 20–45). On average,
participants completed the first assessment during the 13th
week of pregnancy (M = 13.66, SD = 3.09), the second
assessment in the 26th week of pregnancy (M = 25.62,
SD = 5.05), the third assessment 5 weeks after birth
(M = 4.88, SD = 2.94) and the fourth assessment 16 weeks
after birth (M = 15.53, SD = 6.68). Table 1 illustrates sociodemographic characteristics of the study sample.
Design
Each participant was assessed four times (see above): All
participants gave informed consent prior to their inclusion
in the study. The study was approved by the Ethics Committee of the Faculty of Psychology, Ruhr-Universität
Bochum, Germany.
Measures
Perseverative Thinking Questionnaire (PTQ; Ehring et al.
2011)
The PTQ is a German 15-item self-report measure
designed to assess repetitive negative thinking which is
Table 1 Social demography
Family status
Method
Participants
Minimum age for participation was 18 years. All participants were required to speak German and had to be within
the first 14 weeks of pregnancy when included in the study.
There were no inclusion criteria with regards to diagnostic
status. That is, pregnant women could participate regardless of whether they suffered from mental health problems.
Participants were recruited via advertisements in magazines, medical practices, and via the Internet. The
Married
Stable relationship
114 (62.0%)
64 (34.8%)
Single
3 (1.6%)
Others
3 (1.6%)
Years of education
[10 years
168 (91.4%)
\10 years
14 (7.6%)
Other
2 (1.1%)
Number of children
First child
97 (52.7%)
At least one child
58 (34.5%)
No information
10 (5.4%)
123
Cogn Ther Res
perceived as pervasive, unproductive and capturing mental
capacity (e.g., ‘‘The same thoughts keep going through my
mind again and again’’). All items are to be answered on a
5-point scale ranging from 0 (‘‘never’’) to 4 (‘‘almost
always’’). The questionnaire has a good internal consistency (Cronbach’s a): a = 0.95 (Ehring et al. 2011). In
accordance, internal consistency was good in the present
sample: a = 0.95.
Edinburgh Postnatal Depression Scale (EPDS; Cox et al.
1987; German version: Bergant et al. 1998)
The EPDS is a 10-item self-report scale designed to measure maternal distress and depressive mood during the
previous 7 days and has been used for assessments before
(Murray and Cox 1990) and after (Cox et al. 1987) childbirth (e.g., ‘‘I have been able to laugh and see the funny
side of things’’). The scale assesses common depressive
symptoms but omits somatic symptoms that can occur
(independently from depression) in the context of pregnancy and during the postpartum period (e.g., change in
appetite or sleep). Each item is answered on a 4-point scale
ranging from 0 to 3. A score C13 is indicative of a
depressive state (Bergant et al. 1998). In a German population the internal consistency was 0.81 (Bergant et al.
1998). Accordingly, the internal consistency in the present
sample was good: a = 0.85.
Postpartum Bonding Questionnaire (PBQ; Brockington
et al. 2001; German version: Reck et al. 2006)
The PBQ is a 25-item self-rating instrument designed to
provide an early indication of difficulties in the mother–
infant relationship. The PBQ consists of four scales, and
each item is answered on a 6-point scale (from
0 = ‘‘never’’ to 5 = ‘‘always’’): impaired bonding (12
items; e.g., ‘‘I feel distant from my baby’’), rejection and
anger (7 items; e.g., ‘‘My baby annoys me’’), anxiety about
care (4 items; e.g., ‘‘I am afraid of my baby’’) and risk of
abuse (2 items; e.g., ‘‘I have done harmful things to my
baby’’). A higher score indicates more pathological
responses. As all participating mothers rated 0 (‘‘never’’)
on both items of the scale ‘‘risk of abuse’’, this subscale
was excluded from further analysis. Cronbach’s a estimates were mixed in a sample of German inpatients of
delivery units (Reck et al. 2006): impaired bonding
a = 0.78, rejection and anger a = 0.68 and anxiety about
care a = 0.34. The internal consistencies of the subscales
in the current sample were modest as well: impaired
bonding a = 0.80, rejection and anger a = 0.79 and anxiety about care: a = 0.56.
123
Social Support Scale (F-SozU-K-14; Fydrich et al. 2007)
The F-SozU-K-14, a German questionnaire, was used to
assess social support. This questionnaire includes 14 items
about emotional support, instrumental support and social
integration (e.g., ‘‘I often feel I am an outsider’’). Participants score their agreement on a scale from 1 (‘‘that does
not apply to me’’) to 5 (‘‘that exactly applies to me’’). High
values indicate higher levels of perceived social support.
The F-SozU-K-14 has shown good internal consistency of
a = 0.94 in a German population (Fydrich et al. 2009).
Internal consistency in the current sample was good as well
with a = 0.94.
Statistical Analyses
Demographic data were summarized using descriptive statistics. The predictive value of repetitive negative thinking for
postpartum depression and bonding was analyzed using a latent
growth curve (LGC) model (Fig. 1) which allowed disentangling the individual differences in the overall level of repetitive
negative thinking—as estimated by the intercept—from differences in the trajectory of repetitive negative thinking—as
estimated by the slope. The question of interest was whether
intercept and slope could be used as predictors of postpartum
bonding and depression. Furthermore, we sought to test whether maternal age, baseline antenatal depression and social
support were significant predictors of the intercept and the
slope.
Overall model fit was assessed using v2 as a measure of
absolute fit, and Comparative Fit Index (CFI), TuckerLewis Index (TLI), and Root Mean Squared Error of
Approximation (RMSEA) as relative fit indices. Model fit
was deemed good if CFI [ 0.95, TLI [ 0.9 and
RMSEA \ 0.08 (Hu and Bentler 1999). One hundred and
eighty-four complete datasets were used to fit the LGC
model. Descriptive data analysis was performed using IBM
SPSS Statistics 22, the LGC model was fit using R and the
lavaan package (Rosseel 2012).
Results
Descriptive Statistics
Mean and standard deviations of all study variables are
reported in Table 2.
Shape and Predictors of Trajectories in Repetitive
Negative Thinking
The overall fit of the LGC model was good (v2 = 36.283,
CFI = 0.98, TLI = 0.96, RMSEA = 0.067 (95% CI
Cogn Ther Res
Fig. 1 Overview of latent growth curve (LGC) model
negative thinking. The mean of the latent slope was
-1.97 (95% CI -2.24 to -1.69), indicating an overall
decrease in repetitive negative thinking across the four
time-points. Only n = 20 (11%) participants showed a
positive slope variable that is, an increase in repetitive
negative thinking.
Several variables were related to the overall level and trajectory of repetitive negative thinking; the intercept was
higher for participants with elevated levels of baseline antenatal depressive symptoms (est = 0.59, p \ 0.001) and lower
for high levels of social support (est = -0.21, p \ 0.01).
0.029–0.101), indicating that the model parameters could
be used to test hypotheses about the relation between
constructs. In order to test for non-linear effects, we also
specified a model with a quadratic growth-term. This
resulted in a slightly larger misfit as measured by BIC
(BIC = 12429 for the linear model, vs. BIC = 12432 for
the quadratic model) so that the final model only contained
a linear slope. This was also corroborated by the means
over the different time-points (Fig. 2).
The mean of the latent intercept was 20.88 (95% CI
19.51–22.25), indicating a moderate level of repetitive
Table 2 Descriptive and change statistics (N = 184)
Variable
T1 (during the
first 4 months
of pregnancy)
T2 (during the
second half of
pregnancy)
T3 (during the
3rd and 6th
week after
calculated due
date)
T4 (during the
3rd and 4th
month after
calculated due
date)
M
M
M
M
SD
SD
SD
SD
Edinburgh Postnatal Depression Scale
5.99
4.76
5.78
4.88
6.68
4.64
5.24
4.73
Perseverative Thinking Questionnaire
Social Support Scale-Short Version
21.03
62.83
11.66
8.77
18.60
62.20
12.78
9.98
16.88
63.09
12.35
8.50
15.04
63.08
11.95
8.99
Bonding Subscale of the Postpartum Bonding Questionnaire
6.11
5.47
5.72
5.87
Rejection/Anger Subscale of the Postpartum Bonding Questionnaire
2.35
3.09
2.12
3.07
Anxiety Subscale of the Postpartum Bonding Questionnaire
2.59
1.90
2.01
1.94
123
Cogn Ther Res
dealing with the infant, and maternal depressive symptoms
after birth. Also, the trajectory (increase vs. decrease) of
repetitive negative thinking as measured by the slope
variable predicted higher levels of postpartum depressive
symptoms (est = 0.60, p \ 0.001) and impaired bonding
(est = 0.21, p \ 0.04), indicating that an increase in
repetitive negative thinking during pregnancy was
prospectively associated with more depression and
impaired bonding.
Discussion
Fig. 2 Trajectories of repetitive negative thinking. Note: Error bars
indicate 95% confidence intervals. Dotted line indicate the linear
trajectory from the LGC model
Prediction of Depression and Bonding 3–4 Months
After Birth
Overall, the model was able to account for 65% of the
variance in depression scores 3–4 months after birth, but
only between 14 and 18% of the variance in the three
bonding scales. The individual estimates effects are given
in Table 2.
Of the baseline-covariates, only higher levels of perceived social support and antenatal depression were significantly related to postpartum bonding and depressive
symptoms. Baseline antenatal depressive symptoms were
negatively associated with bonding (est = -0.22,
p \ 0.05), indicating that low levels of baseline antenatal
depressive symptoms were predictive of impaired bonding.
Furthermore, baseline antenatal depressive symptoms were
positively (est = 0.38, p \ 0.001) and baseline social
support negatively (est = -0.139, p \ 0.04) correlated to
postpartum depressive symptoms. In addition, baseline
social support was negatively related to the rejection/anger
subscale of the PBQ (est = -0.26, p \ 0.001) and the
anxiety subscale (est = 0.12, p \ 0.035), indicating that
low social support was predictive of increased maternal
anxiety in dealing with the child and rejection/anger
towards the child after birth (Table 3).
In addition, we found that the overall level of repetitive
negative thinking was related to all aspects of bonding and
depression. Specifically, the overall level was related to
impaired bonding (est = 0.44, p \ 0.001), maternal anxiety in dealing with the infant (est = 0.33, p \ 0.01) and
rejection (est = 0.25, p \ 0.03), as well as postpartum
depression (est = 0.27, p \ 0.003), indicating that repetitive negative thinking during pregnancy was predictive of
impaired mother–infant bonding, maternal anxiety in
123
The aim of the present study was to determine if the overall
level of maternal repetitive negative thinking and the trajectory of maternal repetitive negative thinking predict (1)
self-reported mother–infant bonding and (2) the development of maternal depressive symptoms after pregnancy in a
community sample. There were three main findings: first,
the overall level of repetitive negative thinking was a
significant predictor of mother–reported impairments in
mother–infant bonding and of maternal anxiety and rejection in the mother–infant relationship. Specifically, women
who reported high overall levels of repetitive negative
thinking had higher scores on the bonding scale, that is,
they felt less close to their infant and were less likely to
report being content with having a child. In addition, they
reported feeling more anxious in dealing with their infants.
Second, differences in the trajectory of repetitive negative
thinking were also predictive of mother–reported impairments in mother–infant bonding. Specifically, an increase
in repetitive negative thinking during pregnancy was an
additional predictor of impairments in mother–infant
bonding. Third, both the overall level of repetitive negative
thinking and an increase of repetitive negative thinking
during pregnancy were predictive of postpartum depressive
symptoms.
As expected and in line with prior research (Müller et al.
2013; Schmidt et al. 2016; Stein et al. 2012; Tester-Jones
et al. 2015), high levels of repetitive negative thinking were
associated with difficulties in maternal perceptions of the
mother–infant relationship. Repetitive negative thinking
has been shown to be associated with negatively biased
thinking (Spasojevic et al. 2001), reduced self-esteem
(Ciesla and Roberts 2002), intolerance of uncertainty
(Yook et al. 2010) and with a lack of interpersonal problem
solving skills (Lyubomirsky et al. 1999). These problems
might contribute to mothers’ perceived difficulties in
dealing with the new life situation after birth, coping with
the presence of their newborn, and with feeling confident
caring for their child. Furthermore, it is likely that repetitive negative thinking leads mothers to focus their attention
more towards their own thoughts instead of focusing on the
Cogn Ther Res
Table 3 Overview of
regression parameters
Criterion
Predictor
Intercept (T1–T4)
Antenatal depression (T1)
Slope (T1–T4)
Postpartum depression (T4)
0.592
<0.001
-0.035
0.589
Support (T1)
20.208
0.004
Antenatal depression (T1)
-0.212
0.07
Age (T1)
0.069
0.51
Support (T1)
0.018
0.877
Intercept (T1–T4)
0.272
0.003
Slope (T1–T4)
0.596
<0.001
0.379
<0.001
Age (T1)
-0.03
Support (T1)
20.139
Intercept (T1–T4)
Slope (T1–T4)
PBQ-rejection/anger (T4)
0.607
0.04
0.435
<0.001
0.21
0.042
Antenatal depression (T1)
20.216
0.05
Age (T1)
Support (T1)
-0.009
-0.131
0.891
0.101
Intercept (T1–T4)
0.253
0.034
Slope (T1–T4)
0.161
Antenatal depression (T1)
Age (T1)
PBQ-anxiety (T4)
p value
Age (T1)
Antenatal depression (T1)
PBQ-bonding (T4)
Parameter estimate
-0.134
0.026
0.122
0.23
0.71
Support (T1–T4)
20.262
0.001
Intercept (T1–T4)
0.33
0.006
Slope (T1–T4)
0.093
0.368
-0.117
0.298
Age (T1)
-0.023
0.746
Support (T1)
20.173
0.035
Antenatal depression (T1)
A two-sided p-value less than 0.05 was considered significant
PBQ, Postpartum Bonding Questionnaire; T1, evaluation during the first 4 months of pregnancy; T2,
evaluation during the second half of pregnancy; T3, evaluation an average of 5 weeks after birth; T4,
evaluation an average of 16 weeks after birth
needs of their infant which can lead to reduced responsiveness to the infant (cf. DeJong et al. 2016; Stein et al.
2009). These assumptions primarily refer to interactions
between mother and child after birth. However, there are
reasons to believe that the mother–child relationship
already emerges during pregnancy. According to GlogerTippelt (1988), the development of mother–foetal bonding
can be described as an active cognitive and emotional
accomplishment of a pregnant woman. An expecting
mother is thought to develop a schema which results from
attributing characteristic traits to her unborn child. This
assignment of characteristics is based on information about
and experiences with the unborn child. Thereby, expectant
mothers create a mental image of their growing child which
strengthens mother–foetal bonding. It is possible that persistently high levels of repetitive negative thinking during
pregnancy interfere with prenatal bonding processes by
preventing expectant mothers from focusing on their
unborn child (cf. Schmidt et al. 2016). Such early disruptions might help explain the negative associations between
repetitive negative thinking and impaired postpartum
bonding observed in the present study.
Likewise, the trajectory of maternal repetitive negative
thinking was predictive of mother–infant bonding.
Specifically, an increase of repetitive negative thinking
over time was associated with impaired postpartum bonding (measured by the PBQ ‘‘Bonding’’ scale). In contrast,
there were no associations between an increase of repetitive negative thinking and rejection/anger as well as anxiety in dealing with the child. High values on these two
scales indicate potentially more severe difficulties in
mother–infant bonding than high values on the scale
‘‘Bonding’’. Only consistently high levels of repetitive
negative thinking predicted high scores on these two scales.
In line with our expectations, both the overall level of
repetitive negative thinking and differences in the trajectory of repetitive negative thinking were predictive of
postpartum depressive symptoms. Both mothers who
exhibited constantly high levels of repetitive thinking and
mothers whose tendency to think repetitively and
123
Cogn Ther Res
negatively increased over time experienced more depressive symptoms after birth. This finding extends recent
study results on the role of cognitive factors for the
emergence of postpartum psychopathology (Barnum et al.
2013). However, this result differs from the findings by
Müller et al. (2013) as well as by Raes et al. (2014) that
indicated no association between repetitive negative
thinking and postpartum depressive symptoms. These
diverging results might be due to different measuring
points as well as varying measuring instruments used in the
two studies. Müller et al. (2013) used the BDI-II (Beck
et al. 1996) to measure depressive symptoms whereas the
majority of studies, including the present one, used the
EPDS (Cox et al. 1987). The EPDS is considered more
appropriate for the assessment of depression in pregnancy
and around childbirth than the BDI-II, as the EPDS does
not assess physical symptoms of depression, except for one
item measuring sleep difficulties. This adjustment helps to
avoid attributing physical changes that could be due to
pregnancy (e.g., changes in appetite) to depressive
symptoms.
Limitations
The current study identified some relevant, and hitherto
unknown, links between repetitive negative thinking and
impaired mother–infant bonding in a longitudinal manner.
However, it should be noted that the findings are solely
based on self-report measures on repetitive negative
thinking, maternal depression, and mother–infant bonding.
There is some evidence that a mother’s perception of her
bond to her child corresponds with observable mother–
infant interactions (e.g., Hornstein et al. 2006). However,
on the basis of the self-reports alone, caution should be
exercised drawing conclusions regarding the relationship
between mother and child as well as maternal skills
(Hornstein et al. 2006; Noorlander et al. 2008). Since ours
is the first larger study of its kind, self-report measures
were chosen on the basis of cost-benefit considerations and
general feasibility. In the next step, further studies could
use more objective and complex methods such as behavioral measures of mother–infant interactions or a multiinformant approach in order to verify this association. A
second limitation of this study is the homogeneity of study
participants with respect to their socio-economic status and
cultural background. All participating women were Caucasian and most had completed at least 13 years of education. It is possible that the findings will not generalize to
mothers from different cultural and socioeconomic backgrounds. Third, we did not assess whether the participants’
pregnancies were planned/wanted. This aspect could be of
interest for future studies. Conceiving an unplanned child
123
might be a cause for repetitive negative thinking during
pregnancy as well as for impaired mother–infant bonding.
Fourth, the results should be treated with caution because
of the low variation in scores of repetitive negative thinking over time, and in trajectories between individuals.
Relatedly, relatively low levels of depression and impaired
bonding are a limitation. This may limit the generalizability of these findings to other populations, particularly
clinical samples.
Conclusion
To our knowledge, this is the first study that includes
several measuring points during and after pregnancy with
the aim of identifying the relative importance of
stable versus changing patterns of repetitive negative
thinking for maternal well-being and mother–infant bonding. The associations found in this study indicate that
supporting pregnant women to manage and modify their
thoughts might be a promising avenue to help prevent
impairments in maternal well-being and mother–infant
bonding. Specific interventions aimed at changing thought
patterns could be used to this end (Duncan and Bardacke
2010). Mindfulness-based interventions as well as psychoeducation on the role of perseverative thinking could
easily be incorporated into prenatal classes. Women who
suffer from high levels of habitual perseverative thinking
should furthermore be informed by their midwife or their
gynaecologist about the benefits of cognitive-behavioral
therapy (CBT) for perinatal distress (Wenzel and Kleiman
2015). Important components of CBT for perinatal distress
include increasing behavioral activation, facilitating the
acquisition of problem solving skills, and enhancing decisions making and communication skills. A further module
is the promotion of healthy sleep. This topic might be of
particular interest to pregnant women who often have difficulties finding a comfortable sleeping position, and for
postpartum women who are likely to get up multiple times
a night to care for their newborn (Wenzel and Kleiman
2015). Yet another major focus is on overcoming interpersonal difficulties with partners, friends and family
members.
Our findings suggest that it would be beneficial to offer
such interventions to pregnant women experiencing elevated levels of perseverative thinking as well as symptoms
of stress, anxiety, and depression early during pregnancy in
order to promote maternal well-being and the development
of a positive mother–infant relationship.
Acknowledgements The authors would like to thank all the women
who participated in this study. Thank you to Lisa Kösters for help
with data collection and data entry.
Cogn Ther Res
Funding This study was funded by a Grant from the German
Research Foundation, Deutsche Forschungsgemeinschaft (DFG) to
Sabine Seehagen (2154/4-1) and Tobias Teismann (TE747/2-1).
Compliance with Ethical Standards
Conflict of Interest Dana Schmidt, Sabine Seehagen, Gerrit
Hirschfeld, Silja Vocks, Silvia Schneider and Tobias Teismann
declare that they have no conflict of interest.
Ethical Approval All procedures performed in studies involving
human participants were in accordance with the ethical standards of
the institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
standards.
Informed Consent Informed consent was obtained from all individual participants included in the study.
Animal Rights No animal studies were carried out by the authors for
this article.
References
Bagby, R. M., Rector, N. A., Bacchiochi, J. R., & McBride, C. (2004).
The stability of the response styles questionnaire rumination
scale in a sample of patients with major depression. Cognitive
Therapy and Research, 28, 527–538. doi:10.1023/B:COTR.
0000045562.17228.29.
Barnum, S. E., Woody, M. L., & Gibb, B. E. (2013). Predicting
changes in depressive symptoms from pregnancy to postpartum:
The role of brooding rumination and negative inferential styles.
Cognitive Therapy and Research, 37, 71–77. doi:10.1007/
s10608-012-9456-5.
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck depression
inventory-second edition (BDI-II). Manual for the beck depression inventory-II. San Antonio, TX: Psychological Corporation.
Bergant, A. M., Nguyen, T., Heim, K., Ulmer, H., & Dapunt, O.
(1998). German language version and validation of the Edinburgh postnatal depression scale. Deutsche Medizinische
Wochenschrift, 123, 35–40. doi:10.1055/s-2007-1023895.
Brockington, I. F., Oates, J., George, S., Turner, D., Vostanis, P.,
Sullivan, M., et al. (2001). A screening questionnaire for
mother–infant bonding disorders. Archives of Women’s Mental
Health, 3, 133–140. doi:10.1007/s007370170010.
Ciesla, J. A., & Roberts, J. E. (2002). Self-directed thought and
response to treatment for depression: A preliminary investigation. Journal of Cognitive Psychotherapy, 16, 435–453.
Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of
postnatal depression: Development of the 10-item Edinburgh
Postnatal Depression Scale. The British Journal of Psychiatry,
150, 782–786.
DeJong, H., Fox, E., & Stein, A. (2016). Rumination and postnatal
depression: A systematic review and a cognitive model.
Behaviour Research and Therapy, 82, 38–49.
Dubber, S., Reck, C., Müller, M., & Gawlik, S. (2014). Postpartum
bonding: The role of perinatal depression, anxiety and maternalfetal bonding during pregnancy. Archives of Women’s Mental
Health, 18, 187–195. doi:10.1007/s00737-014-0445-4.
Duncan, L. G., & Bardacke, N. (2010). Mindfulness-based childbirth
and parenting education: Promoting family mindfulness during
the perinatal period. Journal of Child and Family Studies, 19,
190–202. doi:10.1007/s10826-009-9313-7.
Ehring, T., & Watkins, E. R. (2008). Repetitive negative thinking as a
transdiagnostic process. International Journal of Cognitive
Therapy, 1, 192–205. doi:10.1680/ijct.2008.1.3.192.
Ehring, T., Zetsche, U., Weidacker, K., Wahl, K., Schönfeld, S., &
Ehlers, A. (2011). The Perseverative Thinking Questionnaire
(PTQ): Validation of a content-independent measure of repetitive negative thinking. Journal of Behavior Therapy and
Experimental Psychiatry, 42, 225–232. doi:10.1016/j.jbtep.
2010.12.003.
Fydrich, T., Sommer, G., & Brähler, E. (2007). F-SozU. Fragebogen
zur Sozialen Unterstützung. Göttingen: Hogrefe.
Fydrich, T., Sommer, G., Tydecks, S., & Brähler, E. (2009).
Fragebogen zur sozialen Unterstützung (F-SozU): Normierung
der Kurzform (K-14). Zeitschrift Für Medizinische Psychologie,
18, 43–48. doi:10.1026/1616-3443.37.1.72.
Gloger-Tippelt, G. (1988). Schwangerschaft und erste Geburt.
Psychologische Veränderungen der Eltern. Stuttgart:
Kohlhammer.
Hornstein, C., Trautmann-Villalba, P., Hohm, E., Rave, E., Wortmann-Fleischer, S., & Schwarz, M. (2006). Maternal bond and
mother–child interaction in severe postpartum psychiatric disorders: Is there a link? Archives of Women’s Mental Health, 9,
279–284. doi:10.1007/s00737-006-0148-6.
Howard, L. M., Molyneaux, E., Dennis, C. L., Rochat, T., Stein, A., &
Milgrom, J. (2014). Non-psychotic mental disorders in the
perinatal period. Lancet, 384, 1755–1788.
Hu, L., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in
covariance structure analysis: Conventional criteria versus new
alternatives. Structural Equation Modeling, 6, 1–55.
Lam, D., Schuck, N., Smith, N., Farmer, A., & Checkley, S. (2003).
Response style, interpersonal difficulties and social functioning
in major depressive disorder. Journal of Affective Disorders, 75,
279–283. doi:10.1016/S0165-0327(02)00058-7.
Lyubomirsky, S., & Tkach, C. (2004). The consequences of dysphoric
rumination. In C. Papageorgiou & A. Wells (Eds.), Rumination:
Nature, theory, and treatment of negative thinking in depression
(pp. 21–41). Chichester: Wiley.
Lyubomirsky, S., Tucker, K. L., Caldwell, N. D., & Berg, K. (1999).
Why ruminators are poor problem solvers: Clues from the
phenomenology of dysphoric rumination. Journal of Personality
and Social Psychology, 77, 1041–1060.
Müller, D., Teismann, T., Havemann, B., Michalak, J., & Seehagen,
S. (2013). Ruminative thinking as a predictor of perceived
postpartum mother–infant bonding. Cognitive Therapy and
Research, 37, 89–96. doi:10.1007/s10608-012-9454-7.
Murray, D., & Cox, J. L. (1990). Screening for depression during
pregnancy with the Edinburgh Depression Scale (EPDS).
Journal of Reproductive and Infant Psychology, 8, 99–107.
Muzik, M., Bocknek, E. L., Broderick, A., Richardson, P., Rosenblum, K. L., Thelen, K., et al. (2013). Mother–infant bonding
impairment across the first 6 months postpartum: The primacy of
psychopathology in women with childhood abuse and neglect
histories. Archives of Women’s Mental Health, 16, 29–38.
doi:10.1007/s00737-012-0312-0.
Nolen-Hoeksema, S., Wisco, B. E., & Lyubomirsky, S. (2008).
Rethinking rumination. Perspectives on Psychological Science,
3, 400–424. doi:10.1111/j.1745-6924.2008.00088.x.
Noorlander, Y., Bergink, V., & van den Berg, M. P. (2008). Perceived
and observed mother–child interaction at time of hospitalization
and release in postpartum depression and psychosis. Archives of
Women’s Mental Health, 11, 49–56. doi:10.1007/s00737-0080217-0.
O’Mahen, H. A., Boyd, A., & Gashe, C. (2015). Rumination
decreases parental problem-solving effectiveness in dysphoric
postnatal mothers. Journal of Behavior Therapy and Experimental Psychiatry, 47, 18–24. doi:10.1016/j.jbtep.2014.09.007.
123
Cogn Ther Res
Pearson, K. A., Watkins, E. R., Mullan, E. G., & Moberly, N. J.
(2010). Psychosocial correlates of depressive rumination. Behaviour Research and Therapy, 48, 784–791. doi:10.1016/j.brat.
2010.05.007.
Philipps, L. H., & O’Hara, M. W. (1991). Prospective study of
postpartum depression: 4 1/2-year follow-up of women and
children. Journal of Abnormal Psychology, 100, 151–155.
Raes, F., Smets, J., van den Wessel, I., Eede, F., Nelis, S., Franck, E.,
et al. (2014). Turning the pink cloud grey: Dampening of
positive affect predicts postpartum depressive symptoms. Journal of Psychosomatic Research, 77, 64–69.
Reck, C., Klier, C. M., Pabst, K., Stehle, E., Steffenelli, U., Struben,
K., et al. (2006). The German version of the postpartum bonding
instrument: Psychometric properties and association with postpartum depression. Archives of Women’s Mental Health, 9,
265–271.
Rosseel, Y. (2012). lavaan: An R package for structural equation
modeling. Journal of Statistical Software, 48, 1–36.
Schmidt, D., Seehagen, S., Vocks, S., Schneider, S., & Teismann, T.
(2016). Predictive importance of antenatal depressive rumination
and worrying for maternal-foetal attachment and maternal wellbeing. Cognitive Therapy and Research,. doi:10.1007/s10608016-9759-z.
Shin, H., Park, Y.-J., & Kim, M. J. (2006). Predictors of maternal
sensitivity during the early postpartum period. Journal of
Advanced Nursing, 55, 425–434.
Siddiqui, A., & Hägglöf, B. (2000). Does maternal prenatal attachment predict postnatal mother–infant interaction? Early Human
Development, 59, 13–25. doi:10.1016/S0378-3782(00)00076-1.
Spasojevic, J., Alloy, L. B., Calkins, M., Cronholm, J., Gannon, T.,
Just, N., et al. (2001). Rumination as a common mechanism
123
relating depressive risk factors to depression. Emotion, 1, 25–37.
doi:10.1037//1528-3542.1.1.25.
Stein, A., Craske, M. G., Lehtonen, A., Harvey, A., Savage-McGlynn,
E., Davies, B., et al. (2012). Maternal cognitions and mother–
infant interaction in postnatal depression and generalized anxiety
disorder. Journal of Abnormal Psychology, 121, 795–809.
doi:10.1037/a0026847.
Stein, A., Lehtonen, A., Harvey, A. G., Nicol-Harper, R., & Craske,
M. (2009). The influence of postnatal psychiatric disorder on
child development. Psychopathology, 42, 11–21. doi:10.1159/
000173699.
Tester-Jones, M., Karl, A., Watkins, E., & O’Mahen, H. (2016).
Rumination and dysphoric mothers negatively affect mother–
infant interactions. Journal of Child Psychology and Psychiatry,.
doi:10.1111/jcpp.12633.
Tester-Jones, M., O’Mahen, H., Watkins, E., & Karl, A. (2015). The
impact of maternal characteristics, infant temperament and
contextual factors on maternal responsiveness to infant. Infant
Behavior and Development, 40, 1–11. doi:10.1016/j.infbeh.2015.
02.014.
Tse, W. S., & Bond, A. J. (2004). The impact of depression on social
skills. The Journal of Nervous and Mental Disease, 192,
260–268. doi:10.1097/01.nmd.0000120884.60002.2b.
Wenzel, A., & Kleiman, K. (2015). Cognitive behavioral therapy for
perinatal distress. New York, NY: Routledge.
Yook, K., Kim, K., Suh, S. Y., & Lee, K. S. (2010). Intolerance of
uncertainty, worry, and rumination in major depressive disorder
and generalized anxiety disorder. Journal of Anxiety Disorders,
24, 623–628.