‘Bonding Disorders’

Emotional Rejection of the Infant

Ian Brockington

Published by Ian BrockingtonISBN 0-9540633-8-4© Ian Brockington

Eyry Press, BredenburyMMXVIII

Dedication

This book is dedicated to mothers and infants

who have suffered from a disorder not recognized

by many ‘perinatal’ psychiatrists

Preface

Mother-infant ‘bonding’ disorders are the most specific disorders that the speciality of mother-infant psychiatry must address. They are more frequent than the other major psychiatric complications of childbear-ing, and have the most severe effects on the child. For over 40 years I have striven to get them on the agenda of ‘perinatal psychiatry’.

When writing a recent review * 1, I realised that only 62 cases had been described in the literature, of which 25 were published in Motherhood and Mental Health 2. This could be a reason why this phenomenon is so little recognized. I decided to publish descriptions of as many cases of which I still had records. The emphasis of this book, therefore, is on the description of mothers’ experiences; it does not supplant the general account given in Chapter 6 of Motherhood and Mental Health, which covers the normal mother-infant relationship and methods of observation and measurement.

These 100 cases are a motley ‘opportunity sample’, and in most cases, the observations were unsystematic. Nevertheless, they provide more information than has hitherto been available. A book mainly com-posed of case histories makes hard reading. I make no apology for this: it was important to put them on record, to supply the deficit, and correct the mistaken idea that these disorders are rare. The reader can select those of personal interest.

Reviewing this material, I searched for an improved clinical grading. The concept of ‘threatened rejection’ used in the Anglo-New Zealand study 3 set a threshold for clinical concern, indicating the need for the exploration of the mother-infant relationship, and for timely inter-vention to prevent progress to ‘established’ rejection. But it did not address another threshold – concern for the safety of the child. This requires a focus on the mother’s anger.

I am deeply grateful to Dr John Kitching and Dr Morwenna Collins for the Foreword. There is unwarranted shame and stigma associat-ed with all maternal mental illness, but much more when it affects a mother’s emotional response to her child; in their courageous de-scription of Morwenna’s experiences, they are reaching out to many mothers who suffer in silence and isolation.

* All references are listed at the end of the book.

Foreword

The book you are holding is a special one. It contains the secrets of the last absolute taboo in our society. Its secrets are those which de-stroy women and families and cause untold misery and yet it cannot be discussed or is simply not deemed credible by those whose job it is to diagnose.

Our knowledge of it is deeply personal and painful. Even writing this preface is an act which causes us pain.

We are both doctors and had been married for some time before my wife fell pregnant. My wife is a very caring individual, who has al-ways worked hard and then spent her free time volunteering with the church and various children’s groups. We are also smallholders who keep sheep.

Anyone who has ever held a lamb will tell you it that it is a heart-melt-ing experience. The sweet face, the bleating, the way their tails wizz around when they feed; and yet any shepherd will also tell you that one of the major causes of death in lambs is that their mothers simply reject them. No one knows why. Much of shepherding in the lambing season is based around trying to get some ewes to accept the lambs they have just borne, or failing that, trying to get another ewe to adopt those lambs. Anyone who deals with animals will tell you the same story. Mothers in nature can and will reject their young for no reason which is obvious to us.

We are animals, and yet we set ourselves above and apart from the beasts of the field, believing instead in an iconography of maternal love which runs unbroken - from countless images of Madonna and Child to the scarred Harry Potter, saved from the evil Lord Voldermort by the oldest and strongest magic there is: a mother’s love.

We were overjoyed when my wife became pregnant with our son. Most of our friends already had children. We thought that we knew what to expect. We were prepared for sleep deprivation, smelly nap-pies, midnight feeds and baby blues. We believed that it would all be worth it because a newborn baby’s smell, it’s babbling and gurgling and smile would awaken the deep magic of legend and the joy all parents know. Only it didn’t. It opened a chasm, a raw jagged hole of empti-ness, bewilderment, alienation, hate and pain. There was no love.

My wife felt only felt anger, resentment, wild mood swings and dark, dark thoughts. There was also fear. Fear of what she might do. She looked for help. There was no help. Those who visited saw only what they wanted to see - a new life, a new family, have a cuddle, take a photo and move on. In public we looked like the “perfect family”. At home nothing could be further from the truth. If my wife quietly mooted to friends something didn’t feel “quite right”, then people re-coiled, as this couldn’t be. After ten months of despair she plucked up courage to speak to the health visitor and then the GP. Noises were made about possible post natal depression, but more likely tiredness. General counselling was the only thing on offer. I, and they, simply didn’t understand.

My wife struggled on, unable to explain to her GP, to her friends, to me or to herself what was wrong. But clearly something WAS dread-fully and horribly wrong. During this time I felt that I was at fault and demonised. I couldn’t understand my wife’s pain. I sat in our sheep shed, bottle feeding one of our orphan lambs, wondering what was happening, unable to help and unable to make the connection between what was going on in my home and what was going on in front of me.

In desperation my wife turned to the internet for a diagnosis (some-thing we always tell our patients never to do). Night after night and hour after hour, for months she searched until she came across Prof Brockington. It was her interaction with him that saved her and us and gave us an inkling as to what the root cause was.

We are now ten years down the line. The experience is still raw in our hearts and the knowledge of what has and could have been is still one that fills us with horror. Yet the most extraordinary thing is that we have yet to meet a Health Care Professional who recognises Bond-ing Disorders as an entity, despite the evidence in front of their eyes and their knowledge of its existence throughout the rest of the animal kingdom. It would seem the last taboo left in our world is still intact. We see it every day and yet we still refuse to accept that the concept of a universal and undying mother’s love is not in every circumstance universal at all. Please open your eyes. Recognise this as a truth. See it. Diagnose it and help to treat it.

John Kitching & Morwenna Collins

Contents

Pages

Chapter 1 Introduction 1-9

Chapter 2 The syndrome 11-55

Chapter 3 Differential diagnosis 57-77

Chapter 4 Course and response to treatment 79-89

Chapter 5 Associations 91-123

Chapter 6 Unusual circumstances 125-137

Chapter 7 Conclusion 139-142

References

Index

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1

Introduction

A brief history

The material

An introductory illustration

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A brief history

The first hint of the emotional rejection of infants is found in reports of babies deliberately starved to death. This was first noticed in the 18th century in a series of 85 cases of infanticide in Königsberg 4, which included these two brief descriptions of death from extreme neglect:

A mother called Maria Blömckin gave birth to a female infant on November 23rd; the baby girl died on December 8th (15 days later). Necropsy showed emaciation, an empty rectum and the skin rotted by foul urine (pages 127-8). A 3-month old child was drowned in a well. It weighed only 8 lb and had little fat and an almost empty gut. It was alive when thrown in. The mother was never found (pages 233-7).

This is not an extremely rare event: over 80 have been reported, in-cluding a series of 13 from Düsseldorf 5. These reports were written by pathologists, and most lack information about the perpetrator and her circumstances; but the following 19th century case from Fulda in the German Land of Hesse 6 has much evidence of emotional rejec-tion, with deliberate starvation of the baby:

A child died at the age of six months. The corpse weighed 6½ lb, with no trace of fat and a completely empty gut. His mother was dominant, the father weak-willed. She completely lacked human sympathy and motherly feelings; the children were just a burden to her. She threatened to kill her eldest son (who was reared by his grandparents) because he surreptitiously tried to feed his baby brother some milk. It was rumoured that earlier children had died the same way.

In the early 20th century, Oppenheim 7 introduced the term ‘hatred of children’ (misopädie); he described five mothers, two of whom hated their infants from birth.

A 36-year old with tocophobia married on condition she would never become pregnant. She was bitterly angry when she con-ceived. Afterwards, she was cold and indifferent, and unable to cuddle or kiss her daughter, who seemed like a foreign being. Her husband had to employ another woman to care for her.

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A 36 year old ‘tomboy’, with a prejudice against children, made a suicide attempt on her wedding night. During her 1st pregnancy, she threatened to drive a nail into the foetus, but bonded to the newborn. She reacted with the same fury to the second pregnancy; she hated the child, who remained at home. She refused to see the third child, who was admitted to an institution.

Luft (1964) 8, in his account of 44 mothers with postpartum depres-sion, drew attention to feelings of alienation from the infant, which he considered to be a disturbance of the instinctive bond between mother and child. In 1984, with Eileen Brierley 9, I published a case of intense rejection, cured, after three years of fruitless antidepressant treatment and psychotherapy, by four sessions of play therapy. Motherhood and Mental Health 2 reviewed the pathological mother-infant relationship with 140 references, the only comprehensive account so far written. I updated this account in reviews written for the journal Psychopathol-ogy in 2011 and 2016 1 10.

The material

The Anglo-New Zealand study 3, which investigated 205 mothers referred to mother-infant services in Birmingham and Christchurch, found that 22 suffered from ‘established rejection’ of their infants, 30 from ‘threatened rejection and 17 from severe pathological anger. These categories were defined as follows:

Established rejectionA, B or C were required:A The mother expresses dislike, resentment or hatred for her child. Sometimes this was expressed in the terms, “I wish it had been still born”, or “it has ruined my life”.B She has expressed the desire for permanent relinquishment of care.C She has experienced a wish that the child disappear – be stolen, or die from sudden infant death syndrome.

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Threatened rejectionThe mother lacks a positive emotional response to the baby and, in addition, has betrayed a wish to surrender the care of this child. The main difference between ‘threatened’ and ‘es-tablished’ rejection is the permanence of this relinquishment. In mothers with threatened rejection, the wish for transfer of care is temporary, and they have no wish for its ‘disappear-ance’.

Severe anger In addition to loss of verbal control or impulses to harm the child, there has been at least one assault on the infant.

If these estimations of frequency are correct, about one quarter of mothers referred to mother-infant services have this degree of disor-dered relationship with their babies. I worked on psychiatric mother & baby services for 14 years - 5 years in Manchester, 9 years in Bir-mingham, and 3 months in Christchurch, New Zealand. Since my service in Birmingham peaked at 500 referrals/year, I will have cared for well over 2,000 mothers. Several hundred of these will have suf-fered from threatened or established rejection. Unfortunately, under the multitudinous burdens of an ordinarius, my records were woefully incomplete, and the material available to me now, 17 years after retire-ment, is limited to 125 cases, from the following sources:

11 student case commentaries (16 cases):These had a detailed personal history and mental state; two also had the two-hour Birmingham Interview 11.

Illustrative cases from Motherhood & Mental Health 2 (21 cases):Almost all had no information except the brief summary; those that could be identified, and had records, are listed elsewhere.

A file of letters from my Birmingham service (30 cases):Most had the letters alone; a few had extensive files.

Medico-legal reports (12 cases):These were comprehensive, with an interview and a review of all available records.

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The Anglo-New Zealand study: All had routine clinical interviews and a Birmingham Inter-view. All 28 Birmingham cases and 9 Christchurch cases were interviewed by me.

The unpublished Masters Thesis of J B Robinson 12 (9 cases):The summaries given in his Appendix are laconic, using terms like ‘unwanted pregnancy’ and ‘rejection’ unsupport-ed by the evidence; all had follow-up interviews several years later.

The provisional classification is as follows:

Established rejection 54Threatened rejection 46Severe pathological anger without evidence of rejection 11Cases illustrating the differential diagnosis 14

ProcedureIn the attempt to improve the classification and definitions, I conduct-ed a cross-case analysis, comparing the narrative description of all symptoms. I proceded as follows:

• I summarized all the cases• In each case, I noted any relevant symptoms, possible

causal associations and unusual circumstances• I considered each symptom and feature in turn• I sought to define thresholds for clinical concern and dan-

ger to the infant.

Illustrative casesEach case is summarized at length only once; any clues to identity have been removed, and the cases identified by a letter and number, as listed below:

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S Student case commentary

M Illustrative case from Motherhood and Mental Health

C Clinic letter

L Medico-legal report

N Christchurch case from Anglo-New Zealand study

A Birmingham case from Anglo-New Zealand study

R Case summarized in Robinson’s Masters thesis

For economy of wording, these labels are used as nouns. Most topics have at least one full case, followed by excerpts from other cases.

An introductory illustration

The following is one of sixteen cases documented by medical students as ‘case commentaries’ during their final year 10-week attachments, or essays in their 3rd year Special Study Modules. This is the case com-mentary of Matt Daniel, one of two using the Birmingham Interview.

S12’s own mother suffered from postpartum depression. She herself had a history of anorexia nervosa and depression (treat-ed in hospital). She had a road accident with head injury, fol-lowed by a seizure, anosmia, impaired memory and cognition, and post-traumatic stress disorder. She was also admitted to a private clinic with alcoholism. She was perfectionist and house-proud. A ‘career woman’, trained as a nurse and with a university degree, she was employed as a sales representative, and married to the manager of a family business.

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Late in her 4th decade, she and her husband decided to have a child. She was pleased about conception, but was anxious about the normality of the child, coping with motherhood, the lack of support and the possibility that the baby would be re-moved by social services. She felt under pressure to have a son. In the second trimester she developed pain in her back, which had been injured in the road accident, and, when treated in hospital, suffered a pulmonary embolism, treated by warfa-rin. She disliked her ‘fat and ugly’ pregnant appearance, which she disguised, and hated people talking about the baby. As the pregnancy progressed she regretted their decision, saying, “Why on earth am I having this child?” She felt antagonis-tic towards the baby because of her physical problems and the loss of her job; she hated foetal movements, and, although she equipped a nursery, did not interact with the child. Her rela-tionship with her husband deteriorated to the point of physical violence. She became depressed with early awakening.

At 41 weeks gestation, after a 48-hour labour, she was deliv-ered by emergency Caesarean section (because of failure to progress in the first stage); there were problems with epidural anaesthesia and she suffered “terrible” pain, nausea and loss of control. This experience preyed on her mind. Her baby’s face was accidentally ‘gashed’ during the surgery. She was disappointed with her parturient experience and angry with the obstetric staff about the delay in performing the operation, the cut on her baby’s face and the unfriendly and unhelpful attitude of the midwives.

After the birth she was in pain for days. She was disappoint-ed by the failure of breast-feeding, and annoyed by the sing-ing of three ‘Asian’ mothers who shared her ward. Returning home after six days, she had no support from her husband. She struck him several times. Her own family gave “tremendous” practical support, but relations with her husband’s family broke down completely; they went away on holiday, and her husband had to look after the business. Pain continued, and at 4 months she had surgery for a retained placenta.

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Her depression continued, and she began to hear voices, say-ing, “You are a terrible woman. You would be better off dead”. Twice she drove to a motorway bridge and looked over, con-sidering suicide. From the start she had no special feelings about the infant – “He could have been anyone’s baby”; she felt more attached to the cat. He was a difficult colicky baby, who screamed a lot, and was impossible to pacify. She wished she had not given birth and felt trapped as a mother. On two occasions, in an attempt to escape, she drove far away to fami-ly or friends - once 100 miles in her night-dress, leaving a note that she was not coming back. She felt much better away from the baby. She often shouted at him to shut up, and had an im-pulse to shake him. There was some ambivalence, however – on better days she enjoyed playing with and bathing him. She said, “I suppose I do love him”.

Referred to the mother-infant service when her son was six months old, she said, “I don’t want to see my son”. For the last two weeks her mother, who lived far way and had a disabled husband, had taken over as the main carer. During the delay in admitting her to the mother & baby unit, she again drove to the motorway bridge. On the first day she quarrelled with the nursing staff and took her own discharge. That night she tried to hang herself at home and was committed to another hospital. The observation ended at this point.

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Comment

This woman had much evidence of emotional rejection of her infant – a lack of positive feelings, improvement when away from him and attempts to escape, but this was not extreme - she never expressed ha-tred, a wish for relinquishment or for the death of her son. The points of interest are:

She had a history of multiple psychiatric disorders. This is un-usual – only three other mothers had a cluster of other mental illnesses. Eating disorders and alcoholism are discussed later (pages 120-121).

She had a number of the risk factors discussed in Chapter 5.

She was perfectionist and house-proud.

She had evidence of unwanted pregnancy, including dysmor-phophobia for her pregnant appearance and hatred of foetal movements. She had a difficult delivery, with excessive pain and loss of control, ending with emergency Caesarean. It was followed by post-traumatic stress disorder and querulant symptoms.

She had a colicky baby who screamed a lot.

She suffered from depression starting during pregnancy and reaching a psychotic level in the puerperium, with auditory hallucinations and suicidal actions.

It is regrettable that we have no information on the outcome of this case, which is true of many others in this series.

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2The Syndrome

The maternal emotional response

EstrangementAversionHatred

The desire to escape

Feeling better away from the infantAvoidance

Gaze avoidanceRunning

Wish for temporary transferWish that the baby be stolenAbandonment of the babyWish for relinquishment

Relief by death

Wish for the death of the childThe mother’s wish for her own death

Anger and maltreatment

Forms of maltreatmentPathological anger

The relationship of anger to rejection

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The maternal emotional response

In this chapter I have used italics to indicate the relevant symptom.

Estrangement

Twenty-two mothers complained that the infant seemed a stranger, not their own baby. In the following example, the pregnancy was unwanted, and the mother had other evidence of threatened rejection (a desire to run away):

M11 stated that her pregnancy was planned, but she was “only doing it for the sake of her husband”. She told no one except her own mother, because she did not want people to know or be “happy for her”. At one point she thought the foetus had died, and felt relieved. At quickening she felt nothing. She “never ever felt she was pregnant” and had no interaction with the foe-tus. “I just tried to blanket it out”. At 24 weeks she asked for a termination. “All I could see was gaol bars – a prison sentence. I just had to forget about it”. She was depressed throughout the pregnancy. After artificial rupture of the membranes and a forceps delivery, her only feeling was relief. She did not want her baby on the breast. She felt trapped, and during the first two weeks her husband had to take time off work because she could not cope. Every few days she felt an urge to “walk out and continue walking”. Fortunately her daughter was a good baby who cried little, and gradually positive feelings devel-oped. By seven months she said tearfully, “I suppose there is something there. I do not feel any overwhelming instinct, but I do love her. I never rejected her, never wanted her adopted, but I still do not feel she is mine. I am looking after her as if for somebody else, as if I was baby-sitting”.

Three other mothers felt they were baby-sitting or child-minding: one said she felt like the baby’s sister, one thought the midwives had given her another mother’s child, and one felt she was looking after her baby for somebody else, who would come to take her.

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Nine mothers said they did not feel that the baby was their own, ex-pressing this in graphic terms:

“I felt totally detached from him”. “It was like meeting a stranger”. “He could have been anyone’s baby”. “He felt like an alien object”.“I often looked at the baby and wondered who he was”. “I could have picked it up at Tesco’s”.

In four mothers, the sense of alienation was more than a feeling – there was an element of delusion. One could not believe it was her own baby. One told a midwife that the baby was not hers, and if she could give it away she would be glad. Another expressed the irrational be-lief that (NAME) was not her daughter, and there must have a mix-up in the hospital. One said, “She could not possibly be mine; I felt I had not even been pregnant”. Almost all these mothers had other signs of rejection.

I excluded two mothers, with the same complaint for which there were other explanations:

C9, when her baby was given to her, refused him, saying that she had not been pregnant, and he could not be her baby. She felt confused and could not work out whether or not she had been dreaming [parturient confusion].

L8 complained that everyone else was taking over “and I felt he wasn’t mine” [competition for the care of the baby].

Kumar 13 described 44 mothers with disorders of mother-to-infant bonding, recruited through correspondence; his paper had the ti-tle, “Anybody’s child”. This common and apparently mild symp-tom should be recognized as a harbinger of danger: these mothers had above average rates of anger against the child – 71% shouted or screamed at the baby, and 20% perpetrated severe abuse.

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Aversion

Some mothers openly expressed their dislike of the baby, as in this instance:

C11 presented complaining of sexual abuse as a child. She was born to a Sikh family in the Black Country, one of three siblings, and had a poor relationship with all members of her family, and with her husband’s family. Her parents were old, distant and unloving, and her childhood miserable. Beginning at the age of eight, and continuing for several years, she was subjected to abusive touching by her much older sister’s hus-band; she was unable to tell anyone and wanted to shoot him. At school she was academically bright, but was bullied, and left early. At 18, her parents took her to India for an arranged marriage. Her husband emigrated to Britain, where he even-tually obtained work as a bus driver, while she took a degree course. As a consequence of an unplanned pregnancy, she gave birth to a son, whom she described as “the only person I love”. At 25, she had a second planned pregnancy, and was delivered of a daughter by Caesarean section. She did not feel the same about her; indeed she did not like her baby, who cried a lot more, with a cry that was loud and distressing. She could not hold or cuddle her, and sometimes wished she had never had her. She felt angry, would often shout at her, felt like slap-ping her and actually shook her one night.

A simple statement of dislike was rather uncommon in this series. Only four other mothers expressed this level of aversion, not amount-ing to hatred. One reacted to the newborn with “repulsion”, and “did not like the child”. One disliked the child, who was constantly griz-zling and squealing. One disliked her “scrawny” baby; it made her sick to touch him. The fourth mother’s feelings “bordered on hate”; she shunned him, never played with him, and always had his face turned away from her.

Certain other symptoms seem to express rather similar sentiments – complaints about the smell or ugliness of the baby. Beauty is in the eye of the beholder, and all babies are smelly at times, so these state-ments refer to the mother’s emotional response. This is an example:

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S9 had a family history of depression: her mother was de-pressed and made a suicide attempt, and her sister had two episodes of postpartum depression, with delayed bonding. At the age of six she was upset when her grandparents died. Her parents argued and threw things at each other, and, when she was eight years old, her father had an affair with her mother’s best friend and her mother left him; she had to care for young-er siblings until, four months later, they went to live with her father’s new partner and her two daughters. She was always closer to her father, even though she disliked being held, and was put in a shed if she cried. She was shy, hated school and had difficulty making friends or expressing her emotions. She was fussy and house-proud. She obtained work as a nurse, and, at the age of 24, married a professional man, a marriage that was not consummated for several months. She had wanted a child for years, and was angry with her husband for his infertil-ity, and for saying he would not be able to love a baby that was not his. She had a history of mild depression at time of stress, such as when her husband’s infertility was disclosed. After two years fertility treatment, she became pregnant by donor insemination, and was overjoyed; she made extensive prenatal preparations fitting out an elaborate nursery with drapes she made herself. Labour was induced at 42 weeks, and her son delivered by emergency Caesarean Section under epidural an-aesthesia (for foetal distress). She was upset by the birth cir-cumstances and often thought about it. “I feel such a failure: I couldn’t get pregnant without help and I couldn’t even manage to give birth properly”. Breast-feeding was “disgusting” and too painful. Her son was “horrid and ugly and I just didn’t want him”; her husband did most of the caring because she had no interest, feeling as if the baby didn’t belong to her – “I could have picked it up at Tesco’s”. When her husband returned to work she cared for him competently but without pleasure. Over the next few weeks she became increasingly upset, feel-ing trapped and unable to escape from the baby, who cried all the time. Seven weeks postpartum she became depressed, with fleeting thoughts of suicide; she required up to a bottle of wine at night to fall asleep. She felt better away from the baby, and when she returned to work. She had thoughts of giving him away, but no wish for his death or to hurt him. She shook him

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once when he would not stop crying. At 10 weeks, in the moth-er & baby unit, she felt criticised: “I am in hospital because I don’t love my baby”. Nursing staff noted that she held her son at a distance, showing no emotional response to him and avoid-ing eye contact. “I think I would die if I had to have him in my bed”. She hated washing his penis – “I’ve always hated them”.

Five other mothers expressed similar feelings: one had a ‘scrawny baby’. One said her second twin “looked disgusting” and was “a mucky baby”. One simply said of her son, “He is so ugly”. One could not stand her daughter’s smell. One said her son was “ugly, grizzly and horrible”. This symptom had the highest levels of physical abuse – all but one had perpetrated frank abuse, which was severe in four.

Hatred of the baby

This is one of the cardinal symptoms of severe rejection. It was most clearly expressed by this mother:

C26 was the middle sibling of a family of three. Her child-hood had been happy until, at 14, her parents divorced and she went to live with her father, upsetting her mother. Friendly and stable, she married a supportive man, and also had the sup-port of her parents. At the age of 32, after a planned and wel-comed pregnancy, she gave birth to a son; labour was induced, and an epidural anaesthetic was only partly successful, so that she had a 23-hour ‘barbaric’ labour. Immediately afterwards, she became low-spirited and no longer wanted the baby. She blamed him for everything – the failure of breast-feeding, the deteriorating relationship with husband, even having to sell her oven. She felt better away from him, and preferred to leave him in his cot and sit in another room “as if he wasn’t there”. She wanted to leave the house and run away, because she was frightened that she would ‘flip’ and harm him. She wished he would die a cot death – “something I knew I would not be blamed for, and nobody would know how I hated him”. She repeated this phrase – “I hated him”. She had an impulse to throw him out of a window, and admitted to throwing him on the bed or a chair. She became depressed, lost over two stones

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in weight, and considered parking the car and killing herself with the exhaust fumes. She described “those terrible nights when I was awake for hours, with a deep deep despair”. But at four months her feelings changed. “I picked him up and sat with him, and that morning felt so different - I realised he was mine and I loved him, and I adore him now, the most precious thing in the world - my whole life”. For a year she was unable to tell anyone how she had been feeling. In the aftermath she was left with the guilt about having hated him. “I feel so deep-ly ashamed. I am frightened he might know how I felt towards him when he grows up. I can’t bear to visit friends, and see them happy with tiny babies. Every time I see babies on the television, I cry because of the way I felt towards my baby – such a terrible hate.” When he goes to his grandmother, she is frightened that the feelings against him will return. She wants to move house to leave all these memories behind. She was much affected by a television programme, and wrote at great length about her experience and wish to help others. She was foregoing the possibility of having other children, because she needed to make it up to this son, and sought help because of her worries about becoming pregnant again.

There are fourteen other cases in this series. Nine mothers simply said they hated the baby. One often shouted at her baby, “I hate you”. One told her husband that she hated the baby. One hated the second of twins; he was “ruining her life”. The mother described in our 1984 paper 9 said of her son, “I can’t bear him. I don’t want to know him. I even hate him”. Finally there was a mother with an intense hatred of her daughter, who referred to her as “the bitch”.

The desire to escape Feeling better when away

This symptom is an indication that the mother feels trapped, and wants relief from the drudgery of nurturing an unloved child. This is an example:

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C32, in her childhood, had a poor relationship with her critical father and resented her mother’s exclusive attention to him. She was perfectionist and chronically depressed, had difficul-ty controlling her appetite and became obsessed with running. Nevertheless she held down a well-paid job. Her marriage was in difficulties and on the verge of separation. She never in-tended to have children, saying, “I don’t really like children, and don’t know why people have them”. She was devastated to find, at 11 weeks gestation, that she was pregnant, and was upset to have to give up her job. For the first three months she refused to believe it, and finally accepted it only three weeks before parturition. She tried to hide her ‘lump’. She dreaded the baby’s kicking and did not communicate with it in any way, regarding it as a parasite inside her. She was anxious about the birth (“a total unknown”); it was painful, and she required an emergency Caesarean section under epidural anaesthesia. She had some unspecified complaints about the obstetric team. She did not look at the newborn, did not like to have her in the same room and developed no feelings for her. She did not recognize herself as her mother, and told a midwife (but not her husband) that she did not want her. She had symptoms of postpartum panic – did not know what to do when the baby cried and was anxious if left alone with her; her stomach tightened and she started to shake whenever she heard her crying. She felt fine when out of the house. She said she could get in a car and drive off, but would not consider adoption because her husband wanted her. She shouted at her once, but was able to delegate care to her husband, mother and mother-in-law. She presented three weeks after the birth with depression and self-hatred.

Nine other mothers said they felt better when away from their babies; one said, “When she’s not there, I feel great”.

Five mothers found relief by return to work. This is an example, which graphically illustrates several other features of this disorder, including suicidal plans, anger with the child, and professionals’ poor recognition of the disorder.

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C9 This mother’s childhood was abusive, but she dealt with this issue many years ago. There was much evidence that she loved children. After 16 years of happy marriage and five miscarriages, she stopped trying to conceive, and then be-came pregnant. Because of the fear of miscarriage, she had scans every two weeks. But her feelings about the pregnancy changed. At 18 weeks she contracted a Salmonella infection, and the obstetric team thought the foetus had died; this was the only time she felt any connection with it. During the third trimester she was planning to leave home after the birth, be-cause she “did not want to stay around the baby”. She was in tears when she finally realised that “it was really going to happen” and “did not want it to”. Labour began at 42 weeks, conducted at home. After 24 hours, meconium appeared in the liquor, and she had an emergency Caesarean Section, under general anaesthesia. When she came round, she felt confused and could not work out whether or not she had been dreaming [parturient delirium]; she refused the baby, saying that she had not been pregnant, and could not have given birth. Her son needed resuscitation and developed jaundice; treated by her side with a light box, he screamed for four days. An attempt at breast-feeding failed because he would neither suck nor swal-low. She felt nothing towards him – just empty. On day 6 she took her own discharge, feeding the infant with a syringe; he vomited frequently and failed to gain weight. At five weeks, breast-feeding was achieved, but he had apnoeic attacks. It was then that she began to have thoughts of killing herself and her baby. She knew that “something was not right”, but it did not seem to fulfil criteria for postnatal depression. He was a good, smiley baby who slept a lot, but she “just never felt any connection with him”. She had an unpaid job, which she hated - baby-sitting with no time off. She “ just wanted the situation to end”, and, at four months, would spend several hours/day ru-minating how she could kill herself or the baby, planning how and when; killing herself seemed more socially acceptable than leaving, while killing the baby would lead to a gaol sentence. Only breast-feeding stopped her leaving home, although she made detailed plans, organising finances and housing. Visiting friends (so that he was often being cared for by someone else) helped; when this support failed (because they were away), she shouted at him and on several occasions handled him roughly

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when he cried; it required enormous self-control to walk away. She had never felt such enormous anger before – “it sat around me like a cloak on my shoulders or a great ball in my hands, and was so powerful”; she kicked walls, or punched the floor or the bed. If she managed to be kind to the baby, she was vile with her husband or the cat. At five months she sought help and, after treatment in a children’s hospital, her son’s breathing disorder stopped and he gained weight. “During all this time I never loved him; I just felt protective and responsible”. As his health improved, she employed a nanny and returned to work; she was terrified of upsetting the nanny, because if she left she would not know what to do. She arranged to spend as little time with him as possible, and at work was able to forget she had a baby, and never missed him. “When people spoke about him, it took a second or two to realise they were talking about my baby”. She loved her work and was not depressed, though she dreaded waking up and having to do it all again the next day. She continued to think of killing him (about once/week) and herself (slightly more often). With all her experience, she was skilled in playing with the baby, but, if he cried, she went back to resenting or hating him. She often imagined what it would be like if he died: everyone else would be upset but truthfully (she suspected) it would have very little impact on her, and she would just go back to her old life. She felt ashamed when she spoke with other mothers about their children, and they spoke with such love and hope, and she could not be part of all that – she did not have any such interest in her son. She felt sad that this lovely little boy deserved a mother who loved him. He seemed to know that she did not love him. The mother-infant relationship problem affected their marriage - her husband said she had robbed him of the pleasure of being a new parent, and he was worried by her threats to leave and fears that she would hurt the baby. After eleven months she read Claudia Klier’s paper 14 and wept for the first time, because she was at last able to put a name to the disorder. She filled out the Postpartum Bonding Questionnaire, and had a score of 28 on factor 2, and 4 on factor 4. She read a chapter in the Stone Menkin book 15, where she was helped by reading accounts of mothers with similar experiences, and learning “that there was light at the end of the tunnel”.

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Four other mothers said they felt better when, to get away from their babies, they returned to work. One said she felt like a different person at work, and one who said, “I’ve got to escape from this kid”, felt per-fectly normal back at work.

Avoidance

Some mothers escape the baby by avoiding it in the house, as in this case:

A25 had a happy childhood. Her father died ten years ago, and her mother from cancer two weeks before referral. Like her father (a ‘workaholic’) she was perfectionist. She had Crohn’s disease, and an ileostomy, with a recent flare-up. At the age of 36, after she had been married ten years and much wanted to become pregnant, she conceived; she was excited but fright-ened. Prepartum bonding was normal, but she was sleepless with anxiety about parturition, and this reached the level of panic in the final stages. The birth was traumatic, requiring ventouse extraction. In the puerperium she was sleep-de-prived. She was agitated and confused about how to look after the baby, feed her, change her nappies and sterilize equipment [puerperal panic]. She had depressive symptoms with suicidal ideas. She improved with anti-depressants, then, six weeks after the birth, deteriorated and attempted to poison herself. In hospital she was treated with ECT. Two months later she relapsed for the second time, expressing the idea that the baby was dead and that her husband had stolen their money. She looked perplexed, vacant and remarkably retarded, and often failed to reply. At this stage it emerged that her husband had a girl-friend and they had decided to separate. She had loved her baby “to bits”, but now said she no longer wanted to have anything to do with her. She refused to feed or care for her, and neglected her when she was crying. The infant made her feel agitated and angry. She shouted at her and had the impulse to shove a dummy in her mouth. She spoke about giving the baby up.

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Four other mothers had this symptom. One refused to touch her son. A second shunned her son and never played with him. The third could not look at him, or be in the same room. The fourth could not toler-ate the presence of her infant. It is necessary to distinguish between avoidance due to aversion, and phobic avoidance; this difference is illustrated by three cases in Chapter 3 (on pages 58-61). All the five mothers described above had much evidence of aversion.

Gaze avoidance

Robson 16 showed, in normal mother-infant dyads, that mutual gazing becomes an absorbing activity; the visual contact puts the mothers at ease, and makes them feel recognized in a personal and intimate way, while the infant becomes so absorbed that it will forget to suck. If, therefore, the mother avoids eye gaze, the disturbance is severe. The following mother graphically illustrates this symptom:

M23 held a highly responsible position, was the devoted moth-er of a 3-year old, and wanted another girl. She conceived again, but, when the scan showed a boy, began to feel negative about the pregnancy, buried herself in her work and ignored it. After an easy labour, she felt empty and disappointed. “I did not want to think about the baby”. She developed a sheaf of depressive symptoms, including loss of weight and memory difficulties. In spite of breast-feeding, she did not enjoy her baby. She was referred eight weeks later because she had not bonded, and was tearful and withdrawn. She said:

“It is like he isn’t my baby. I feel quite cold and empty towards him – he is just a baby that needs looking after. I am starting to resent him. I don’t think of him as a person. I don’t like to look at him if he looks at me. It’s his eyes. I can’t look at him. I don’t know why.”

She could not be persuaded to look at him, touch him or stroke his hand. She felt like running away, or leaving him in the park, where someone would take him. She sometimes got an-gry with him, and had an impulse to put a hand over his mouth or shake him; she had to leave him for several minutes to main-

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tain control, would shout at him and shake the pram. She recovered after in-patient treatment; bathing with her infant seemed particularly helpful. In spite of improvement in ‘bond-ing’ and ECT, her depression continued for months.

Eight other mothers complained of, or were observed to suffer from, gaze aversion. Two stated they could not look at the child, or only with difficulty; one went further and said she “could not bear to look at him”. Another said that to look at him made her cringe. In three mothers this behaviour was obvious: one always has his face turned away from her. In the other two, nursing staff or the medical student noted the lack of eye contact. This symptom was frequently asso-ciated with anger – 86% shouted or screamed at the baby and 29% perpetrated severe abuse.

Running

This is a prominent symptom, present in 25 mothers; 16 had an im-pulse to escape in this way, and nine acted on it. In the first group, there is this mother:

A13 was out of touch with her father, a heroin addict with a diagnosis of ‘schizophrenia’. Her mother abused alcohol. Her parents spent more time in the pub than with their five children. She was a lonely child, who had to cook for herself. Over-weight, she was picked on at school. She used to cut herself as a form of self-harm. She was house-proud, sweeping the floor 60 times/day. At the age of 21, she started her first abusive re-lationship, and gave birth to a son. This man was sent to prison for raping her. She met another man, and had a planned preg-nancy, then changed her mind and hoped for a miscarriage. She suffered from hyperemesis gravidarum. In the sixth month her partner was imprisoned for affray. There was no problem with prepartum bonding, but she was depressed, felt suicidal and worried about her son. She had rages, arguing with every-body, and threatened to stab a stranger in the street, for which she received a police caution. Various people rallied round – her partner’s mother made all the preparations, his sister and a neighbour attended the hospital with her. When she went into

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labour, she became confused, lost a lot of blood and thought she was going to die. She gave birth to another son, who devel-oped a respiratory infection. The new-born was feeding every 90 minutes and she had hardly any sleep. She felt numb, tense and depressed. “I was a walking dead person”. She worried about cot death, having lost a sibling that way. Depression deepened with the loss of two stones in the first 3 months, and she lay awake much of the night. She abused cannabis and Ecstasy. She was often excessively angry without provoca-tion. She felt nothing for her demanding baby, except panic. She felt totally detached from him, and at times thought he was not hers. She thought of running away permanently, and considered adoption. She shouted at him, and twice threw him roughly on to the bed. He spent a lot of time with his grand-parents, and she could not wait for him to go back to them; in fact her partner’s mother took over completely in the six weeks before presentation.

Of the others, nine simply expressed the idea of running away. Two were explicit about their destination – to run away to her brother who lived over 100 miles away, or to her father in another country. One told her partner she would go away and leave them together. One said she would have liked to emigrate to Australia to get away from her son, and one every few days felt the urge to “walk out and continue walking”. One felt like putting her daughter in the cot and “going far far away”.

Of the nine who took action to escape, this is the best example:

M22 had much evidence of mental illness in the family: a ma-ternal aunt hanged herself, and two of her six siblings were admitted to a psychiatric hospital. As a child, she was scape-goated, starved and beaten by her parents, sexually abused by several men including her brothers, and, because of a speech impediment, bullied at school. At the age of 12 she developed bulimia nervosa, and later abused ethanol, cannabis and glue. Diagnoses of hysterical or borderline personality disorder were made. During all her pregnancies, she was subjectively and objectively well. At 18 she gave birth to her first child. At 20, she was hitting herself with stones, burning her face with cig-

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arettes, cutting her arms, jumping from windows and taking overdoses (50 in all). At 21 she was raped by a brother, and at 24 by two men. She contracted a stormy marriage; her moth-er-in-law was a powerful woman who provided financial and emotional support. She obtained work for St John’s Ambulance and as a police woman. At 22 she gave birth to her 2nd child. Several months later she became depressed and ran away 12 times. She threatened to kill the baby, and attempted suicide by strangling, hanging, drowning and exfenestration. Admitted to hospital without the baby three times, she was given two courses of ECT; she was noted to be euthymic in hospital. Af-ter weeks of negotiation and another suicide attempt, it was agreed to admit her with her baby - the hospital administrators complained about the high cost of one-to-one supervision. Ten days treatment, however, was sufficient: with the guidance and support of nursing staff, the problem evaporated. Although she later relapsed, she remained well for months. Her further his-tory, with evidence of menstrual mood disorder is summarized elsewhere 17.

Of the others, one ran away several times, leaving the baby with his fa-ther. One rushed out of the house on two occasions. One drove off in the car, but was recalled by a telephone call and ultimatum. One was forever running off – walking out of the house and “driving around for two hours or so”. One was intercepted at a travel agency, making ar-rangements to fly to France. The last mother, in an attempt to escape, twice drove far away to family or friends - once 100 miles in her night dress to a female friend, leaving a note that she was not coming back. There is a differential diagnosis. This exhausted mother, with a nor-mal bond, wanted to escape temporarily:

C17, at the age of 13, sadly lost her lively elder brother from pancreatitis; after this she refused to go to school. She was constantly arguing with her parents, and left home at 17. She suffered one episode of depression, treated with anti-depres-sant medication. She worked for 12 years as a paramedic tech-nician. At 31, after two long term relationships, she settled down with a partner. Her first pregnancy was planned, but was complicated by much illness and several hospital admissions. In spite of this she bonded strongly with the foetus and was al-

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ways telling him how things were going to be when he as born and when he grew up. The birth of her son was like a dream, and she kept ‘passing out’. Afterwards, the baby was in a spe-cial care baby unit for two weeks with abnormal sugar levels and an umbilical infection. When he returned home he suf-fered from colic, cried a great deal and slept only two hours at night. After 2-3 weeks she asked her partner to take over. She seemed unable to calm or comfort him, or do anything right for him, and began to feel that he did not like her. She “wanted to get up and go” - she would have taken a bus from the coach station and gone anywhere; but she knew the baby would be safe with her partner and his family. She had no real problem in her relationship with her son - no anger and no ideas of per-manent relinquishment; indeed she was obviously very fond of the baby.

Ideas or wishes for temporary relief from care As illustrated in the last example, normal mothers, exhausted by infants’ demands, have a wish for a respite, and there is a problem in finding a threshold for abnormality. Seven mothers had private thoughts and wishes (revealed in confidential interviews) of transfer-ring child care, but not permanently. The following mother’s initial reaction was marked by anxiety, with elements of phobia, fear of cot death and obsessions of child harm; but, as she became depressed, feelings of estrangement, anger and a wish to escape took over:

A10 was a house-proud woman, in a stable relationship, and already had one daughter. She had a second pregnancy termi-nated, then accidentally became pregnant for the third time, and she took a while to adjust to it. She put on a lot of weight, became fed up with the pregnancy and looked forward to the birth. There was not much interaction with the foetus. Parturi-tion was induced at 40 weeks - an easy labour that she enjoyed. She felt well for two days, and her initial response to the baby was good. On day 4 she felt as if a cloud had come over her: concentration and memory were poor and she suffered ano-rexia and early awakening. She was extremely anxious, was constantly checking the baby and at one stage avoiding her; she had an impulse to harm herself and the baby. Nine days af-

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ter the birth she was admitted to her local psychiatric hospital, then transferred to a mother & baby unit. She often felt the baby was not hers. She no longer wanted her and regretted the pregnancy. She was unable to stand her crying and had an impulse to throw her out of the window, shake her or suffo-cate her. She felt like escaping and had thoughts of temporar-ily transferring care. On the mother & baby unit, her phobic avoidance of the baby was prominent. She recovered after a course of ECT.

Four other mothers expressed a wish to get away, or temporarily hand over care. One “just wanted to get away from all the children”, who were better off with her mother-in-law. One was actively thinking of having him fostered. The differential diagnosis from anxiety disorder and depressive ideas of unworthiness is discussed in Chapter 3. Three mothers openly expressed these wishes to their husbands or pro-fessional staff, as in this example:

N7 spent part of her childhood looking after her mother, who was disabled by rheumatoid arthritis; she became depressed when she died from renal failure. She married and gave birth to a daughter. Her husband deserted during her 2nd pregnancy, which resulted in the birth of a second daughter. In a new 10-year relationship she gave birth to a son. In spite of secondary tocophobia, her fourth pregnancy was planned. A scan showed a dangerous lack of amniotic fluid, and foetal movements stopped. At 36 weeks she was delivered of a son by emergen-cy Caesarean section under spinal anaesthetic. “It was a fluke he survived”. She returned home to heavy domestic duties, for which she had little support. After three months, in the con-text of her baby’s abdominal pain and constant grizzling and squealing, she became sleep deprived and depressed. She said, “I’ve got to escape from this kid”. In fact she returned to work, where she felt perfectly normal. Her general practitioner took no action, so she threatened him: “If you do not do anything to shut this baby up, I’ll shut him up permanently”. Bonding had been normal, but there was a secondary loss with dislike and a wish to escape; she told her husband she would like to give him away at least temporarily. Several times she shouted at him through clenched teeth, “Shut up!” but had no impulses to harm him.

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Another mother discussed with her husband leaving him temporarily with the in-laws, and a third told her health visitor that she wanted to have him fostered.

The wish that the baby be stolen or kidnapped

Three mothers expressed this wish, as in this example:

S10 was a happy person, who was reared in a family with good relationships, although her father had a ‘breakdown’, and a maternal cousin committed suicide. She helped her moth-er care for her younger sister, born when she was 12 years old. At 15, she suffered from osteomyelitis and septicaemia. She obtained work at a wine merchant’s, where she met her husband. She had a relationship with him for ten years and lived with him for four years before their marriage. She be-came pregnant through a failure of contraception, but they had planned to have children later; they discussed termination, but both developed a positive attitude and looked forward to the birth, attending antenatal classes and preparing clothes and a nursery. She liked foetal movements and often stroked her ab-domen. She was delivered of a son by Caesarean section under epidural anaesthesia, and was disappointed because she could not see what was happening. “Then I would have felt like he was more mine”. She had a severe postpartum haemorrhage, requiring another four hours in theatre and 18 units of blood, after which she was transferred to the high dependency unit for several days. She had little contact with her baby during this time. She felt shocked by everything that had happened and did not experience the euphoria she had expected. She told a visiting midwife that the baby was not hers and if she could give it away she would be glad. She told her general practitioner that she would be happy if her son was kidnapped and she never saw him again; she would prefer him to be taken away for good, so that she could return to her earlier life and work. Referred to the mother-infant service with depression and negative feelings for the baby, she said she felt ‘very dis-

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tant’ from him. Everything was “a really dark chaos” and she “just felt like a body”. She scored 19 on factor 2 of the Post-partum Bonding Questionnaire [above threshold for established rejection]. She was surprised how strongly she reacted against the baby, a huge contrast to her attitude before the birth. Ad-mitted to the day hospital, she soon improved, her score on factor 2 falling to 5. She enjoyed playing with the baby and the medical student observed the sequence of improvement: recovery from depression followed improvement in bonding, before antidepressant medication had time to have effect.

Of the other two cases, one said she wished her baby daughter would be stolen or disappear, and the other entertained ideas of family adop-tion or the baby being stolen.

Abandonment of the baby

Abandonment, as opposed to relinquishment, occurred in five cases. The following mother’s wish to escape was so strong that, not only did she leave her in shops, but contemplated combined suicide and the filicide of her other (much loved) child:

S4, whose father left when she was a child, and who had a termination at 21, became pregnant again a year after meeting a new boy friend. Three months later, he started hitting her, and she moved into her sister’s house. She gave birth to a female child. The man discovered where she was living, and renewed the abuse; on one occasion he beat her, imprisoned her for three days and raped her (resulting in a new pregnancy). Three months after the 2nd birth, her daughter suffered an epi-sode of hypoxia; in consequence, her mother watched her night and day, terrified that she might die. She became depressed, lost weight and was admitted to the mother & baby unit for six weeks. The pregnancy continued, and she went for a second termination, but remembering the trauma of her first abortion, could not go through with it. She hoped for a miscarriage, and would often hit herself in the stomach. She hated the shape of her pregnant abdomen, and blocked off all thoughts of the pregnancy. She became depressed and isolated herself. At 35

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weeks gestation, she gave birth to another female child. After-wards she said, “She’s not mine. Give her to her father”. She had no feelings for the baby, and cared for her mechanically. “It was like she wasn’t there”. She wanted to run away, hoped for a cot death, and often left her behind at the shops. She con-tinued to love her first daughter, and thought of killing herself and this child, to get away from the baby. One month after the birth, she shook the baby, told her health visitor and was admitted to the mother & baby unit; but she responded poorly to treatment, and only started to bond 18 months later, at a time when she discovered that the boy-friend was sexually abusing her first daughter, and was legally banned from seeing them.

Robinson’s thesis reported two cases of abandonment at a mother and baby unit:

R1 at the age of 21 had an unplanned and unwanted first preg-nancy. After a difficult and painful labour, she gave birth to a male child. Mother and baby were separated for several days. At reunion she felt “no bonding, no motherly instinct. It was like I had a baby who died – he didn’t feel like he was mine”. The baby was ill and was detained for five weeks. When he was discharged from hospital, she was hostile and rejecting. She attacked and injured the baby, and the National Society for the Prevention of Cruelty to Children was involved. Admitted to the mother & baby unit, she continued to reject him, failed to provide adequate care and absconded, abandoning her child. After three years in care, the child was returned home on tri-al, but the mother was unable to cope and returned him. She refused to consent to adoption. At follow-up she had married and separated, and had two subsequent children and several episodes of depression, for which she refused help.

R2 at the age of 21 was in a turbulent marriage, with frequent separations, to a violent man with a criminal record; she took an overdose after he broke her arm. During a period of rec-onciliation, she conceived her first (unplanned) child. She rejected the baby from birth, and was transferred from the maternity ward to the mother & baby unit. She continued to reject and neglect the infant and, after three weeks, took her

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own discharge, abandoning him on the unit. Back home, she found her husband living with another woman. She attempt-ed suicide by jumping from a multi-storey car park; surviving this fall, she was admitted to a psychiatric hospital for three months. A year later she was living with her parents, and in the throes of divorce proceedings. She was visiting her child in care, but had been given the diagnosis of ‘schizophrenia’ and was not considered capable of living alone.

Two other mothers felt like leaving their babies in a public place, where someone would take them.

There is, however, a differential diagnosis. The following mother ac-tually abandoned her infant in a shop, because she was angry with the father; her abandonment, deeply regretted, was manipulative.

C12, the mother of two children, became pregnant again on her partner’s insistence, and during the pregnancy had doubts about caring for the baby. Her partner abused ethanol, was aggressive when drunk and was awaiting trial for fraud. She abandoned her baby at a shop, because she was angry with him for not buying some nappies. “If he won’t care for the baby, I won’t”. She deeply regretted the abandonment, was a good mother to her other two children, and, according to the police and social services, provided excellent care to the baby.

The wish for relinquishment.

The desire to be rid of the baby altogether testifies to the strength of maternal rejection; 21 mothers confessed this wish, but only in a con-fidential interview with professional staff, as in these examples:

N3 was an only child. Her father, an alcoholic, left when she was two. Her mother, who also abused alcohol, was “not there emotionally”; there was much friction between them in her teens, and they were no longer in touch. She herself was per-fectionist, and abused cannabis and alcohol (a bottle of vodka every two days). She was in a relationship with a musician for eight years, by whom she had a daughter, followed by de-pression. She later had a termination. At the age of 25, she

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conceived for the third time through contraceptive failure, and hoped for a miscarriage. She had to interrupt her teacher’s training course. She said, “I don’t want it and I’m not go-ing to have it”. She considered adoption. She did not relate to the foetus or think much about the pregnancy. In the third trimester, supported only by her partner’s mother, she became depressed with suicidal ideas; her screaming and crying result-ed in domestic abuse. After induction, she had a hard labour, helped only by pethidine and nitrous oxide. “I could not handle it and yelled and screamed, ‘I don’t want to do this’”. Her son weighed 4 kg. She suffered some post-traumatic symptoms, and thought, “Look at my body now”. But at first she really loved him – a wonderfully attractive baby, “a big thing in my life”. She breast-fed for eight months. The baby’s reflux and colic started after 2-3 weeks, and she became sleep-deprived. Her partner left and the depression returned. She started drink-ing wine at night. After three weeks, when her son was crying with pain, there were feelings of regret, of being trapped. She thought of leaving and not coming back for a week, and of transfer to her partner’s mother. “Maybe he would be better with someone else, if they took him off my hands totally”. She would yell at him, had the urge to shake him and twice put him down forcibly and bound the blankets on him tightly.

M2 was a strong-minded woman with good relationships, who was pleased when she became pregnant. She related well to the baby within. Following the birth her son did not sleep at all. She soon became weepy and anxious. He did not seem like her own baby – “It could have been anybody’s”. She felt nothing for him, and would have been happy for someone to take him away, and never bring him back. This lasted six months. She presented during the next pregnancy, fearful of a recurrence.

C21 spent most of the time with her father after her parents’ divorce when she was seven years old. She had a low opinion of her mother, who had five children by three different fathers and gave one away to fostering; she described her as “a nui-sance and a tart”. By nature she was perfectionist, anxious, shy and sensitive. She obtained eleven O-levels, joined the civil

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service and met her husband. After two years of marriage, at the age of 26, she became pregnant. She was worried when tests raised the possibility of spina bifida. Four months pre-mature, with the help of epidural anaesthesia and forceps, she was delivered of a son, who looked like “a dead chicken”. It had all happened too quickly. Her head and body felt ‘spongy’ and she felt depressed and tense. Breast-feeding was too much trouble and strain, the baby was difficult to wind, and she had little sleep. The presence of the baby made her feel sick and tensed up, and she developed the feeling that she did not want to look after him: it was all too much work, and she wanted someone else to take over the child-care. She basically wanted him out of the house, and was not even keen for her husband to take over; the only solution was the removal of the baby. She appeared childish and immature, but responded to out-patient treatment.

Here are some other statements illustrating this secret wish:

She would have been happy for someone to pick him up and take him away, and never bring him back.

“ I am feeling terrible bad and hating myself because, when I see the baby, I wish someone would pick it up and go”.

She wanted her baby put up for adoption because she was una-ble to give him the love he needed, but both families would be horrified by this idea.

Among this group, four specified transfer to someone in the family – her sister, sister-in-law, a niece (who suffered a stillbirth at about the time of her son’s birth) or to ‘family adoption’.

The next mother went a little further – exploring the possibility of involving social services in the transfer of care:

S1 was the eldest of five children in a Roman Catholic family with good relationships. She left school with 3 A-levels and worked as a legal assistant, a job she enjoyed. She married a

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man she had known for seven years, and, after four years of happy marriage, at the age of 35, became pregnant for the first time. This was a planned pregnancy about which she and her husband were very happy. She enjoyed foetal movements. She was delivered by Caesarean section after a difficult 3-day la-bour, and was shown her son immediately. He was bottle-fed, and she had difficulty establishing a feeding routine. She de-veloped no feelings for him and, for two months, despaired of achieving them; it seemed “as impossible to love him, as to walk to the moon”. She worried about the financial burden and his effect on her marital relationship. She felt trapped, claustrophobic and wanted to run away. She made a number of extreme statements:

“I have made a big mistake by having this baby. I will never be a good mum, and it would be much better if he was taken away. I wake in the morning and wish he had a cot death. I feel nothing for him and want him adopted”.

She wanted this so much that she looked up the telephone num-ber of social services, and considered leaving her husband, so long as he took the baby. She had no hatred for the baby, and no thoughts of harming him, but just did not want him. She be-came depressed and lost two stones in weight. When the baby was nine weeks old she was admitted to the Queen Elizabeth mother & baby unit. The medical student who wrote the case commentary observed her with her happy-looking baby, and noted a lack of eye contact, lack of cuddling and ‘mechanical’ child-care. She failed to respond to play therapy, but made a good response to ECT, improving after three, and recovering from depression and the ‘bonding disorder’ after six.

The desire to escape reaches its acme when the mother takes the step of discussing permanent relinquishment, as in 19 mothers in this se-ries. Six told their medical advisors that they wanted the child re-moved. One told a midwife, one told a social worker and one told a child-minder – ““Take him if you want”. One told her mother - “Mum and I want him adopted; we can’t cope with him”. One said, and wrote

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on an envelope, that she did not want the baby any more. Seven told their husbands or partner. One of them said she would kill herself if it were not taken away. A mother not in this series would only ac-cept hospital admission if, when treatment failed, the baby would be adopted. Finally there was a poor lady, who suffered from ideas of unworthiness as a mother, who pressed for adoption of the baby, and committed suicide when her husband refused (page 62).

There were also seven mothers who actually relinquished their infants during the observation period. This example illustrates the need for preliminary discussion with both parents before treatment is attempt-ed:

M18 had been happily married for two years, although she was not conventionally feminine. At the age of 25, she had an un-planned pregnancy, which she accepted and ignored. After the birth the baby aroused feelings of rage. At three weeks she attempted to smother it, but relented. A week later she held it under the bath water until there were no bubbles, then shroud-ed him in a blanket and rang the GP. He arrived within minutes and resuscitated the baby. She was admitted to the mother & baby unit. Within a few days it became clear that she was not mentally ill, but was completely cold towards the baby. She described it as ‘a nice baby’ but it was of no interest to her. She left it crying for long periods, and on one occasion placed it on a work surface next to the hot teapot and boiling water, while she made herself a drink “to put some life into her”. She said staff could do what they wanted with it. In the discussion with her husband, he said that in his heart of hearts he had known all along that she could not manage motherhood. The child was adopted and the marriage survived.

Five others were relinquished to adoption, or removed by the child protection authorities. One, who could not bear to look at her baby, felt a weight lifted off her back when social services removed him. One mother stridently demanded that the baby be removed, and he remained in the care of his paternal grand-parents for two years until she received effective treatment.

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Relief by death

The wish for the death of the child

This remarkable symptom was surprisingly common (22 mothers). The following mother was unique in wishing for a neonatal death shortly after parturition:

S6 was herself the subject of maternal rejection, and was fos-tered at the age of five. Aged 18, she suffered a 24-week still-birth. When she became pregnant again, eight months later, she had not yet recovered and ‘hated’ the new pregnancy. “I didn’t want this baby to take the place of the first one”, she said. At this point, her partner left her. She wanted a termina-tion, but her mother threatened never to see her again. She felt angry, and physically sick when the baby started kicking. Un-der epidural anaesthesia, she gave birth after a 4½-hour labour; the infant required resuscitation. She hated him and wanted him to die. She could not bear to look at him, refused to touch him, and wished someone would take him away. He would not let her sleep and she hated him even more. At two weeks she began to abuse him, shaking him and throwing him into the cot. One night she telephoned her mother, threatening to kill him. When social workers removed him, she felt a weight lifted off her back, and was upset when he was returned to her; when he was finally adopted away she felt immense satisfac-tion, knowing that someone would give him the love she could not give.

Most, however, wished for a cot death. Of all the ways in which an infant can be lost - miscarriage, late termination, foetal death in ute-ro, stillbirth, neonatal death and sudden infant death syndrome - cot death (‘crib death’ in USA) is perhaps the most severe. The mother is usually fully bonded with the infant, and absorbed in the relationship. There is no warning or preparation, and the death is followed by a fo-rensic investigation. It is one of life’s most severe traumas and causes the most intense grieving, as described by Wendy Harman 18 from her own experience and Smialek 19, reporting her work with 350 bereaved families. I was astonished to encounter the wish for cot death for the first time in 1992:

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M8 said, “I envisaged having a beautiful baby tucked up in bed, or going for walks proudly pushing a pram. When he arrived he was beautiful, but he went only one hour between feeds, and would cry unless held. By the tenth day I was ex-hausted. One night he screamed for five hours. In the pram he would scream constantly, and strangers would stop to tell me what was wrong with him. After three weeks I felt he was the biggest mistake of my life. I considered having him adopted, and moving away to start a new life. It was only some time later that I shared my feelings with my husband, and we were surprised to learn that we had both thought that a cot death would be a welcome release.

Here is another illustrative case:

C15, after a happy and secure childhood, took a university de-gree in social administration, then trained as a social worker. She met her husband at university. She had a normal planned and wanted first pregnancy. After the birth of a son, she be-came depressed; she felt that she had ruined everybody’s life. She no longer wanted her son, did not love him, and in fact hated him. She hoped someone would take him away, or he would die from cot death or choke while sleeping. She would deliberately leave him sleeping on his front, which she believed increased the risk. She was admitted to a mother and baby unit and soon recovered. She felt very guilty about these feelings.

Seven mothers simply stated that they wished or hoped for a cot death. Four wished the child would die in the night; one of them hoped her 3rd child would not wake up, which would be “the end of the problem”. Another wished her baby “would disappear”. Another regretted that the infant had not been stillborn, and hoped she would go to the cot and find she was not there. Five others gave more details: C14 said she wished the baby was dead, like a baby in ‘Trainspotting’, who died a cot death at six weeks. C26 hoped he would die a cot death because it was “something I knew I would not be blamed for, and nobody would know how I hated him”. C31 reluctantly admitted to secret thoughts about a cot death; how easy would it be for him to drown in the bath! A21 found herself wishing for a cot death, and said, “That’s

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terrible, isn’t it; she’s perfect”. M7 amazed her local mother & toddler group, by telling the other mothers that she was hoping for a cot death.

A remarkable instance of the presence of the two extreme and con-trasting symptoms – the fear and the wish for cot death - at different phases is described in Chapter 6 (page 137).

Escape from the predicament by maternal death

Three mothers considered the extreme solution of escape through their own death.

A28 was deeply disturbed when, at the age of nine, she lost her father from motor neurone disease. Later she suffered from obsessional neurosis and depression. At 17, she met her part-ner and at 24 moved in with him. She obtained work as a probation officer. She postponed pregnancy because she was frightened of childbirth, but she lost this fear when she became pregnant, and took pride in her pregnant appearance. She was anxious about the late onset of foetal movements, and, when they came, loved them and felt close to her baby. She felt wonderful and enjoyed every minute of the pregnancy. She developed a high blood pressure and, at 35 weeks, before she had time to make preparations, was delivered by ventouse (be-cause the cord was wound round the baby’s neck). For eight days she felt brilliant, but when she returned home there were “horrendous” droves of visitors. She became sleep-deprived and depressed, and there was tension with her partner, whose life-style remained the same. Her baby was perfect, but she was “very disappointed” not to bond; she did not dislike her, but felt she was looking after her for somebody else, who would come to take her. She was worried about criticism of her mothering, and was anxious when alone with the baby. She felt trapped, wanted to run away and had ideas of temporary transfer of care. She developed an overwhelming feeling of anger and was “hell to live with”. She shouted at the baby fairly often (the neighbours heard), and (with persistent tactful enquiries) admitted to an impulse to put a pillow over her head. She came to feel that, if she died from a blood clot, she would be relieved – it would all be over.

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One mother, in order to get away from the baby, considered killing herself and a much loved elder child. Another was explicit about per-sistent and preoccupying ideas of suicide and/or filicide:

“I would spend several hours/day ruminating how I could kill myself or the baby, planning how and when”. She said that killing herself seemed more socially acceptable than deserting the home, while killing the baby would lead to a gaol sentence.

This theme is further discussed in Chapter 2 in relation to depressive ideas about motherhood (pages 62-64).

Anger and maltreatment

Forms of child maltreatment

Three forms of child maltreatment have been described – emotion-al maltreatment, neglect and physical abuse. All three are related to emotional rejection of the infant.

Emotional maltreatment

This is a concept introduced comparatively recently 20. It covers per-sistent hostility, humiliation and bullying, critical comments on the child’s performance, and conveying to the child that it is unwanted, worthless and unloved. It is thought to be the long-term consequence of untreated rejection.

Neglect

Neglect to the point of starvation, was the first indication in the med-ical press of major disturbances in the maternal emotional response. Any degree of neglect was uncommon in this series. In the following case, elements of physical abuse and neglect were both present:

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L8 described her mother, deserted by her father when she was two, as ‘a back-stabber’; they fought “like cat and dog”. Her childhood was unhappy because of frequent beatings, includ-ing those by her elder brothers. At school she was teased about her obesity, and was frightened of everything. At 14 she ran away from home for four days. At 15 she heard a voice in her head saying that no-one loved her and she should kill her-self. She took, in all, seven overdoses. At 16 she left to stay in hostels for teenagers. She was impregnated by a married man, when drunk. At two months gestation, she met a divorcé, known to be quick-tempered and uncontrollable, with a history of threats to kill and wounding; she moved in with him. Dur-ing the pregnancy she was depressed. She gave birth to a son. During the first month he had three admissions with vomiting (thought to be normal posseting); she discharged him against medical advice, and failed to keep out-patient appointments. After three months the baby sustained fractures of both fore-arm bones, which the parents reported 4-14 days later, saying that he had “slipped in the bath”. A month later he sustained a bruise on the ear, caused by “lying on his dummy” and was found to have a 10-day old fracture of the arm; his mother ad-mitted throwing him. The baby was placed with his maternal grandmother. Interviewed for a legal report, the mother admit-ted she had tried to suffocate him - she could not cope with his screaming. “From the day he was born I could not get used to him. Everyone else was taking over and I felt he wasn’t mine. I didn’t want him when he was a month old”. She wrote on an envelope, that she did not want the baby any more. Her moth-er, who discovered the lump on his arm, said she was lazy and would leave him in his night-clothes; he had not been changed or fed, and the washing was piled high. She was sufficiently concerned to ask a welfare officer to see her. The perpetrator of the injuries was not known, but both parents were found guilty of neglect.

This combination of neglect and abuse was also shown by L2 (fully summarized on page 53) who killed her child by brutal assault. An-other example of severe neglect was shown by L11, summarized in Chapter 3 under personality disorder (page 68), who neglected several children. The following mother caused the death of her infant by ex-treme neglect:

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L13 showed abundant evidence of personality disorder: from the age of 13, she was stealing from family, friends and em-ployers. At 19, after a late diagnosis of pregnancy (28 weeks) she gave birth to a daughter, whom she loved; but her care was negligent – she wore dirty nappies and smelt of sick; later, when she attended school, she was unduly concerned about her lunch box. The mother’s home-making was at the level of a pigsty. Just over a year later, again after another late diagno-sis of pregnancy, she gave birth to a son, whose birth weight was 3.25 kg (on the 50th centile). [This is an example of preg-nancy denied twice and a indication of self-deception]. From the beginning she was cold towards him; there were several statements later that she hated him. At five months she admit-ted that she could not love him and told a child-minder, “Take him if you want”. During a gap in child-minding, when she was looking after him for six weeks, he weighed 5.4 kg (be-low the 0.4 centile), and had a severe nappy rash. She failed to pay a devoted child-minder, and called her “a sucker”. At eight months another child-minder found him damp and heav-ily soiled, with faeces dried and caked into the skin; his bottle of juice was stale and disgusting. For three weeks she was again in sole charge, while working full time an hour’s drive away; his weight dropped from 7.23 kg to 3.2 kg in 22 days. At nine months, he died: his intestine was empty, but not pa-per-thin; thus death was due to dehydration. She had given no food, liquid or basic care for several days, behaving as if he did not exist. There was no remorse – her weeping was self-pity. Self-deception, depression (though not severe) and dissociation, not just emotional rejection, may have played a part in his death. There were gross professional failures on behalf of general practitioners and social services (page 77). This mother was sentenced to life imprisonment.

Pathological anger Explosions of rage are the most frequent cause of maltreatment associ-ated with emotional rejection. Although strongly related to rejection, pathological anger should be regarded as a different morbid, clinical phenomenon and come under separate scrutiny.

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Parents are frequently angry with their children, when they are diso-bedient or act in a dangerous or aggressive manner, but anger with an infant is more unusual. There are, however, a number of problems in the definition of ‘pathological anger’:

• Normal mothers – those without mental illness and with a normal emotional response to the baby – can be angered by the infant’s demands, especially in the middle of the night, and when they are hard to soothe. Normally the mother can maintain control, for example, by walking out of the room.

• Anger-based impulses to harm a baby must be distin-guished from ‘obsessions of infanticide’, where a gentle and devoted mother is besieged by fantastic images of de-stroying her child 21.

• The causes of excessive anger are legion, and much wid-er than ‘bonding disorders’, as illustrated by a number of cases in Chapter 3 (pages 64-67).

The severity of physical assault can be graded as follows:

1 Strong feelings, well-controlled, even if with difficulty.

2 Loss of control, with shouting, screaming or cursing, often with impulses to harm the infant.

3 Indirect violence, such as stamping the foot, or shaking the cot.

4 Frank abuse, such as rough handling or shaking (but without injury).

5 Severe abuse, with fractures or head injury.

6 Filicide, attempted or completed.

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Loss of verbal control

Only six mothers in this series had this as the sole anger symptom. In this example, the mother-infant relationship was not fully explored and she may have understated its severity:

A12, a Muslim doctor’s wife, had a masters degree and stable employment. The marriage was arranged. She was perfection-ist and subject to cyclothymic mood swings. At the age of 32, her first childbirth was followed by two years depression, and she was scared to have any more children. When she became pregnant for the second time (unplanned), she was miserable for 3-4 months and a termination was agreed, but too late, so she tried to provoke a miscarriage by lifting heavy weights. Her attitude of the pregnancy was negative throughout. She was tense and irritable, and had no interaction with the foe-tus. She was delivered of a second son by elective Caesarean section under spinal anaesthetic and soon became depressed. Her mother supported her, but after a month returned to India. She could not interact with her son, wanted to give him up and discussed with her husband leaving him temporarily with the in-laws. She sometimes screamed at him.

If loss of control reached this point, there were usually other anger symptoms, such as an impulse to harm the infant.

Impulses to harm

The next mother shouted at her infant, and had aggressive impulses:

A1 had an unhappy childhood, physically abused by her moth-er. She took an overdose after suffering a miscarriage. Her house was spotlessly clean and excessive cleaning continued in the puerperium. At the age of 19, after a planned pregnancy, during which she felt unusually happy and had normal prepar-tum bonding, she gave birth to a boy. She was excited about the birth and happy for the first few days; but the baby was hos-

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pitalized several times with bowel problems. After two weeks she began to suffer from sleep deprivation, and felt horrible, fat and worthless. She began to regret the lack of parties, cinema and swimming. She felt trapped, and sometimes wanted to run away or take the baby somewhere and leave him. She shouted at him a lot and had impulses to hit him.

Twelve other mothers admitted to losing control over their anger against the infant, with impulses to shove a dummy in its mouth, slap, shake or suffocate it, drown it in the bath, put a pillow over its head or throw it into the cot, against a wall or out of the window.

Indirect violence

The next level is indirect assault, as in this example:

A5 was a perfectionist professional woman, with a history of two episodes of depression. She was married to a man she had known for nine years, and at the age of 31 became pregnant for the first time. She was pleased about the pregnancy, but there was little prenatal bonding or even preparation for the birth. After the birth she felt high for two days, then her mood dropped. It was like meeting a stranger – there was no imme-diate overwhelming love. The baby was awake all night – “a total nightmare”. She did not know how it was possible to live on so little sleep, and was too tired to meet people. This depression lasted five months. On occasions she told her hus-band she hated the baby. She shouted at her several times and had impulses to shake her. One night she shook the cot. This reached its peak at three months, after which it improved; she then felt guilty about the anger she had felt, and her feelings towards the baby.

Other mothers kicked the bassinet or shook the pram.

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Rough treatment

At the next level, there is frank aggression against the baby, but with-out injury, as in this example:

A7 was a binge-drinker, which caused her to lose her hairdress-ing job. She moved in with her partner after a row with her mother. Her first pregnancy, at the age of 19, was planned, and prepartum bonding was normal. She felt “the best I have ever felt”. Labour was prolonged (27 hours) and, in spite of pethi-dine and an epidural, painful. From the start she was low and weepy, and because of headaches, moved back home, where her mother (separated, with three other children, aged 17, 13 and 9) took over for two weeks. Her partner was imprisoned for assaulting another man. Her depression was accompanied by the idea that she had bowel cancer or a brain tumour, while ‘another mind in her head’ told her she was dying [depressive psychosis]. She was permanently worried, anxious and on edge, scared to fall asleep in case she died in the night, and afraid to be left alone with the baby. She was drinking a bottle of wine every night. As for her baby daughter, she felt she was baby-sitting, and was the baby’s sister; ideas of escape entered her mind. She cared for her grudgingly, and only when her mother was unavailable. The severity of the bonding disorder was missed, even after the two-hour Birmingham Interview; a week later I discovered that she had twice rushed out of the house, and entertained ideas of the baby being stolen or adopt-ed by a family member. Frustrated by the baby’s crying, she shouted at her and felt like hitting or throwing her. She had once thrown her on the bed.

Four other mothers threw the infant onto the bed or into the cot. Nine admitted to other forms of rough treatment - gripping her son tightly, banging the baby hard on the back when winding him, putting her son down forcibly and binding the blankets tightly, grabbing him roughly, winding her daughter roughly, squeezing her arms and picking her up violently. Three confessed to rough treatment without details. These assaults were all minor, but they are clear evidence of anger beyond the threshold of control.

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Shaking without damage to the infant This is at the same level, as an assault on the child without injury, but is more dangerous. The following are two illustrative cases:

S3 had been married eleven years, and was the mother of a 7-year old, born after failed contraception. She had just start-ed a new job, and was strongly against a second pregnancy. “The pregnancy is ruining everything I have worked so hard for”. She hoped for a miscarriage, and refused to think about the future with a new-born baby. During the pregnancy she discovered that her husband was having an affair. After a two-hour water birth, she gave birth to a son, whom she breast-fed for four months. She felt trapped and ‘just went through the motions caring for him’. Her husband and daughter could stop him crying, but she could not. She became depressed. She wished for a cot death and was willing to give her baby away to anyone, and especially her niece, who suffered a stillbirth at about the time of her son’s birth. She would get angry with him, shout, shake him and throw him into his cot. At four months her daughter saw her shaking him, and asked what she was doing. This precipitated her consultation with her general practitioner and admission to the mother & baby unit. Dis-charged too soon, she had a row with her husband about his affair, and stormed out, threatening to crash the car; on return, she smashed plates, ripped paper off the wall and took an over-dose. She refused readmission, but was closely supervised by her parents. The abuse stopped at 10 months, when she began to love her son.

C31 was one of a family of ten children, whose parents were close, but “old-fashioned”. She worked at the law courts, in a hospital and as a receptionist for her general practitioner. She had a relationship from 14 to 22 before she met her partner, a jealous man who cut her off from friends and dominated her life. She gave birth to a son, and six years later, at the age of 32, had a second pregnancy; it was unplanned but warmly wel-come – she was “over the moon”, “on a high” throughout, and

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never felt happier. The birth was fine, but her son proved to be a demanding child - greedy and colicky, sleeping only 20 min-utes and crying constantly – “a scream that goes right through you; every time he cried it felt like a sharp knife sticking in my stomach”. By nature she was a person who tended to bottle up her feelings, and told no one that she was getting into dif-ficulties. After three weeks she began to become depressed, and to feel angry with him: she often shouted “For God’s sake shut up!”, had an impulse to throw him on the bed, put him down roughly a few times, put her hand over his mouth and twice briefly shook him. The only solution was to return to work – there she felt like a different person. Her partner left – they had stopped talking to each other. After five months she sought help and had a transient improvement from anti-de-pressant medication. But the depression returned; she was not eating, felt constantly nauseated and lost 6 lbs in weight. Nor-mally fit, she felt so weak she could hardly stand. She blamed the baby for all this, saying, “I can’t feel anything at all. I can’t remember what it is like to feel anything”. She felt nothing for him and could not even look at him. She often wished she had never had him, and could not imagine ever being happy with him. She wished he would “have a gastric” and go into hospi-tal. One night she sat in the bath with a razor, feeling so much anger she wanted to “rip her skin off”. After eight months he stopped wingeing, started crawling, smiling and waving his arms, and she recovered. “He’s a different baby”. But two months later his wingeing returned and she relapsed, losing her maternal feelings: more than ever she wished she had never had him, and shook him again. She wanted to escape to her brother who lived over 100 miles away, and reluctantly admit-ted to secret thoughts about cot death. How easy would it be for him to drown in the bath! She recovered a second time with day hospital treatment.

Eight other mothers shook their babies on at least one occasion, one of whom also slapped him and another put him down roughly in his cot.

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Severe physical abuse

This is defined as at least one assault resulting in injury to the infant. The following are three illustrative cases:

L5 lost her father soon after her birth, when he died from epi-lepsy. Her mother found another partner, a violent man. As a child she suffered atypical seizures, treated by carbamazepine and valproate. She was bullied at school. At the age of 19, in the context of a 6-month “on-off relationship”, during which she took no contraceptive precautions, she became pregnant. When he heard about the pregnancy, the child’s father kicked her in the stomach. In spite of this, she accepted the pregnancy and gave birth to a son. But she could not stand the baby’s crying; on numerous occasions she wanted to strangle him, and once this was only prevented by the intervention of her boy-friend. She hated her son and would pick him up roughly and throw him into the cot. She often said that she wanted to give him up, and sometimes wished “something to happen, but not cot death”. She was depressed, hating herself – “fat and ugly”, lost over two stones in weight and contemplating suicide by jumping from a bridge. After eight months she developed a normal mother-infant relationship. She then became pregnant again by another partner. She wanted to get rid of this new baby, and her main concerns were breast-enhancement surgery and worries about her partner’s fidelity. She gave birth to a daughter. After three weeks this baby was on an intensive care ward with a fractured skull, retinal haemorrhage and other cerebral injuries. “The anger made me cry, scream, shout and slam doors. I used to scream and shout at her all the time”, but she would only admit to picking her up roughly and dropping her on the floor.

L10 appeared to be a candid, good-hearted, open and honest person living under intolerable stress. She knew nothing of her family. There were five other children. Her mother had made it clear many times that she did not want her. At the age of four she was put on the at-risk register, and taken into care at her mother’s request. She read in her files that her father had

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sexually abused her, for which he had been imprisoned for 12 months. She was passed around and can only remember three of the foster parents; the longest placement was for three years in her teens with a couple who had five other children. She had no happy memories of her childhood, suffered from panic attacks and was often depressed. She used to run away to her 1st cousin, but this man killed himself two years ago. She had received absolutely no support from any person at any time in her life. At the age of 16, in the context of a three year rela-tionship with a 14-year old, she conceived, and gave birth to a daughter, her only happy memory. She was short-tempered, and a neighbour expressed concern about her heavy-handed chastisement of the child, hitting her every day with an open hand on the head, face, legs and bottom; she had been seen to swipe her three times across the face, and to throw her into a chair, screaming “Shut the fuck up!” She was much upset by a 19-week miscarriage. A year later, in the context of a two-year relationship with another partner, she had a third, unplanned, pregnancy. She and her daughter related to the foetus, and she made preparations. At six months gestation, the umbilical cord prolapsed and a second daughter was delivered by emergency Caesarean section, weighing 3 lb. In the Special Care Baby Unit the baby had apnoeic spells, and it was feared that she would not survive. The mother’s visits were infrequent and staff were concerned about her immaturity, chaotic life style and relationship difficulties. When, two months later, the baby was discharged, it screamed non-stop. After 2½ months she was taken into care, bleeding from the mouth, with a small cer-ebral contusion and fractures all over her body; the radiolog-ical evidence was of at least two episodes of violent shaking, one 10-14 days old with rib fractures. She said, “There was no bond from the start”, and admitted shaking her twice. The el-der daughter, a big, happy and lively child, was removed. Her partner started drinking, their home was petrol-bombed and the relationship ended. She was already pregnant for the 4th time.

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R9, the mother of one child, was in an unstable cohabitation. After an unplanned and unwanted second pregnancy, she gave birth to twins. One of them died from ‘cot death’ under sus-picious circumstances. The mother and surviving twin were admitted to the mother & baby unit, where she was obvious-ly rejecting the infant. After two assaults, he was taken into care. Three years later, at the age of 19, again in an unstable cohabitation, she gave birth to a daughter, whom she attacked, causing severe and permanent brain damage. The mother, sentenced to probation, was admitted to psychiatric hospital for two years. She had no contact with her children.

There were ten other cases of severe injury, including three in Robin-son’s thesis. These are the seven with details:

S2 shook her son twice, and dropped him into the cot. Her partner discovered that he had a broken arm.

S11 was shouting at the baby. At six weeks it was admitted to hospital with unexplained facial bruising, and soon afterwards suffered fractures of the ulnar, femur, tibia and humerus, as well as contusion of the brain with life-threatening swelling.

C14 could not stand the smell of her fourth child, and hoped for a cot death. Her children spent some time in care. As a result of a successful trial, they were returned to her, but six weeks later suffered several non-accidental injuries.

L6 often screamed at her son, threw him in the cot, shook him twice and threatened to kill him. At nine weeks the child pro-tection services were involved and he spent five months in fos-ter care. Returned to her, he sustained multiple bruising, and was relinquished to adoption. Nine months after the birth of the next child, she was seen smacking him in the stomach and throwing him in his push-chair. He was removed to foster care, and she threatened to kill those who had made the allegations.

L8 gave birth to a son. At 12 weeks he suffered fractures of both forearm bones (‘slipped in the bath’), then a bruise on the ear (‘lying on his dummy’); he was found to have a 10-day old fracture of the arm, discovered by his grandmother.

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L9 felt like suffocating or throttling her 6-week old son and throwing him across the room; she shook him twice. Later he sustained a skull fracture (‘dropped on a coffee table’). At three months he presented with injuries to the right leg (two weeks old), left arm and ear, bruising of the ribs and abdo-men and a corneal abrasion. He was found to have a displaced fracture of the right parietal bone, with underlying subdural haemorrhage, extensive bilateral retinal haemorrhages and a number of limb fractures. He suffered seizures and was placed on a life support machine.

A20 had impulses to smack her son in the face and had handled him roughly, picking him up by the neck. The baby became ill with ‘bronchiolitis’ but the chest radiograph showed fractured ribs. A week later he was admitted with a spiral fracture of the left humerus, a fracture of the other arm and nine rib fractures.

Abusive filicide

Three mothers threatened to kill their infants:

S6 began to abuse her son at two weeks, shaking him and throwing him into the cot. At 2am one night she telephoned her mother, threatening to kill him.

M22, who failed to bond to her second child and ran away 12 times, also threatened to kill the baby.

N7 threatened her general practitioner. “If you do not do any-thing to shut this baby up, I’ll shut him up permanently”.

Four attempted filicide:

M18, after an unwanted pregnancy, was enraged by the new born. At three weeks she attempted to smother it, but relented. A week later she held it under the bath water until there were no bubbles, then rang the GP, who arrived within minutes and resuscitated the baby.

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L7, suffering from psychosis, shouted at her daughter, and had an impulse to smother her. Later she occluded her baby’s breathing, and she was taken into foster care.

R5 was discharged after the birth to her in-laws’ overcrowded home. After a row in which she attacked her mother-in-law, she attempted to smother the infant.

R8, after a planned pregnancy, gave birth to a female child, who was detained in hospital for three weeks. When she was discharged, her mother attempted to strangle her three times and threw her to the floor saying she hated her and did not want her. In hospital, seven further assaults were recorded; in the last the baby was thrown across the room and suffered a fractured skull.

Three completed filicide. One, who starved her baby to death, has al-ready been described in the paragraphs about neglect (page 41). These are the other two:

L1 had mild learning difficulties. She was lazy and had poor personal hygiene. In her teens her problems included enuresis, social withdrawal, truancy and school refusal. A pregnancy at 14 was terminated and the 19-year old father imprisoned for unlawful sexual intercourse. At 15, by another man, she gave birth at 24 weeks to a baby who died an hour later. She became pregnant for the third time through contraceptive failure, and was shocked and angry, but was reluctant to have another ter-mination. She became proud of her pregnancy and talked to the baby. “I wanted a family even though it was a bit earlier than expected”. After the birth of a daughter, she felt burdened with her care – “never a break, not even for half-an-hour”. She had no support from her mother, who lived far away, nor from her partner, who moaned when the baby cried at night. She be-came depressed. She denied hating the baby but “felt like run-ning away from it all”. She did not transfer care, because she was afraid her partner’s mother would take over completely. She would shout “Shut up!” and once or twice shook the baby.

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There were other injuries for which she gave improbable ex-planations. At three months, her daughter died and was found to have a head injury, multiple bruises and bilateral retinal haemorrhages - injuries that required extreme violence.

L2 was also of borderline intelligence, only just able to read. There was much friction in her parents’ marriage, and disci-pline by stick, fist and feet. She had an explosive temper. She had failed to bond with her first daughter and gave birth to a second daughter. Her initial reaction to the new-born was repulsion. The child’s father did all the feeding for several months. Her general practitioner, who treated her for depres-sion, wrote, “From the start she had difficulty in bonding, not liking the child”. She felt she could give her away, but made no determined attempts to have her care transferred. At five months the baby was admitted with failure to thrive, and at nine months the mother admitted causing facial bruising. In the meantime she had already given birth to a third child, and all her children were on the non-accidental injury register. At 13 months, her general practitioner noted that the second daugh-ter had cold red feet and scabies. At 18 months, the mother lost her temper and threw her across the room; she was dead when the ambulance arrived. The mother said she had fallen down the stairs. Necropsy showed multiple bruising and skull fractures. Her husband (at sea when this occurred) committed suicide. I saw the written evidence ten years later, when asked whether she could mother a subsequent child.

The relationship of anger to rejection

TABLE 1.1 (on the next page) shows the frequency of two grades of pathological anger to various symptoms. The second column shows the number of mothers with evidence on anger, the third minor de-grees of loss of control, and the fourth severe abuse or filicide.

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TABLE 1.1

THE FREQUENCY of PATHOLOGICAL ANGER in MOTHERS with VARIOUS REJECTION SYMPTOMS

Symptom Number of mothers with this symptom

Shouting, impulses to abuse, indirect or minor assault

Severe abuse, or filicide attempted or completed

Estrangement 24 17 (71%) 5 (20%)Ugly, smelly, deformed baby 6 5 (83%) 4 (67%)Hatred 16 12 (75%) 7 (44%)Feeling better away from baby 9 3 (33%) 2 (22%)Gaze avoidance 7 6 (86%) 2 (29%)Running 24 17 (71%) 1 ( 4%)Temporary transfer 13 6 (45%) 1 ( 8%)

Relinquishment 24 16 (67%) 6 (24%)Wish for cot death 22 13 (59%) 5 (23%)Whole series 91 58 (63%) 17 (19%)

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Comment

Anger at the level of shouting, screaming or minor assaults was com-mon in this series – 63% overall, with higher levels in mothers with the expressed wish to relinquish the child (67%), estrangement (71%), running (71%), hatred of the infant (75%), perception of the infant as ugly, smelly or deformed (83%) and gaze avoidance (86%). These rates may be underestimates, because only 34 mothers were investi-gated by the systematic Birmingham Interview, and interviewed moth-ers may be reticent about admitting to losing control over anger. The rates for severe abuse are very high. Oliver 22, in his thorough pro-spective survey, obtained a figure for severe abuse of 4/1,000 births.

The involvement of the child protection services will probably not occur unless the infant has been injured, or they are alerted to a mother suffering from psychosis, learning difficulty or personality disorder. But the mother-infant (‘perinatal’) services are in a position to de-tect much milder levels of aggression, even the minor loss of control shown by shouting or screaming at the infant. This is a golden op-portunity for the vaunted preventive role of these services. It requires recognition of the symptoms discussed above. In all cases it is es-sential tactfully to explore manifestations of anger with the child, as demonstrated in the Stafford Interview 23.

Anger is the harbinger of abuse, and failure to recognize these symp-toms, and to explore the mother’s emotional reaction to the child, is culpable malpractice, placing the infant at unacceptable risk.

The definitions set out in the Anglo-New Zealand study 3 suggested two grades of severity – threatened and established rejection. There are indeed differences between the most severe cases, with (at one ex-treme) hatred and the determination to get rid of the baby one way or another, and (at the other) a degree of rejection little more that the de-lay in the maternal response, which occurs in many mothers (see page 58). But even the mildest symptoms are associated with pathological anger, and, while acknowledging a spectrum of severity, any of these symptoms should trigger the urgent precautions set out in Chapter 6 of Motherhood and Mental Health 2 (rehearsed on page 82).

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.

3

Differential Diagnosis

Introduction

Bonding delay

Anxiety disorders

Depression with ideas of unworthiness

Pathological anger without rejection

Personality disorder

Factitious disorder

Mendacious accounts

Missed diagnosis

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Introduction

Emotional rejection of a child must be distinguished from a num-ber of other disorders. They will be discussed under the headings of bonding delay, anxiety disorders, depressive ideas about motherhood, pathological anger without impaired bonding, personality disorder and factitious rejection. Finally I shall consider the role of lying, and the failure to recognize the presence or severity of the disorder.

Bonding delay

Most mothers, to varying degrees, love their infants. In a minority, perhaps 10%, there is a disappointing delay in the development of this emotional response, lasting a few weeks, as in this example:

C36, whose mother had several episodes of depression, ap-peared to be a normal person living in normal circumstances. She had worked for six years in a psychiatric hospital, and lived prosperously in a happy marriage. At the age of 29, after her first child was born, she was depressed for ten months and lost two stones in weight. For six months, she had no feelings for the infant, even though he was a very good baby. She presented when pregnant again, and considering a termination because of the fear of a recurrence.

She may have been dissembling the severity of her feelings.

Anxiety disorders

Just as puerperal panic can mimic a psychosis 2, phobic avoidance of the infant can simulate emotional rejection. In the Anglo-New Zealand study 3, there were 14 cases of severe infant-focussed anx-iety (7% of referrals to the services), including one with a complete phobia, compared with 52 cases of emotional rejection. Because of the importance of this differential diagnosis, several examples will be given. The first is a classic case of phobic avoidance of the infant:

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M24 was married to a severely disabled man; following a ve-hicle accident he suffered from visual impairment, deafness, and partial paralysis. Their 1st pregnancy, at the age of 28, was planned. But she was already very anxious, because, a few months ago, their block of flats was set on fire by a ‘schizo-phrenic’, and they were held hostage. When she was told that the baby might have Down syndrome, and might not survive, she made no attempt to bond with the foetus, and would not even buy anything for the baby. But she felt “on top of the world”. At 42 weeks, because of foetal distress, she was deliv-ered by ventouse. The epidural anaesthetic was delayed, and she suffered a lot of pain. She was terrified that her daughter would die from cot death, checked her every 10 minutes and had little or no sleep for eight weeks. She lost two stones in weight. She was unable to feed, care for, or cuddle her daugh-ter, and could not be alone with the baby, always insisting that her husband was also present. But she was forced to carry the baby upstairs, because her husband was physically unable to do it. She interacted emotionally with the baby at a distance of several feet. She denied depression and channelled her energy into obsessive house cleaning.

In the next three examples, elements of anxiety and rejection were both present:

A26 was married for ten years to an immigrant; she had a his-tory of anorexia nervosa, parasuicide and depression, and was treated with valproate for pseudo-seizures. She was already the mother of a 7-year old son. During her second, planned pregnancy, she “ate like a pig’ and gained three stones. After a normal scan, prepartum bonding prospered. She developed restless legs syndrome associated with iron deficiency, and was anxious about parturition. The birth, under epidural anaesthet-ic, lasted 16 hours. She was disturbed to see her baby born blue and requiring resuscitation. Breast-feeding failed. Her excessive weight made her feel unwomanly. For five months she suffered from sleep deprivation. Her husband was unsym-pathetic and sceptical about mental illness; she became jealous of his involvement with the baby, and suspicious about his fid-

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elity. Her elder son said she no longer loved him. She was exhausted because, through fear of cot death, she checked the baby 3-4 times at night, with her hand on its chest. She im-agined that he was ill, and was convinced he was deaf. Be-cause of this anxiety and her feelings of uselessness, she had ideas of escape and transfer of care, but objectively she was devoted to him. She shouted at him once. It was alleged that she shook the baby (rocked him roughly), and social servic-es were involved. She developed pseudo-seizures and made superficial cuts to her wrists. She defaulted from the clinic, but was brought back a few months later by a social worker, drinking heavily and threatening suicide.

A11 was one of seven children, none of whom had a positive relationship with their mother. She became depressed at the age of nine in the context of bullying at school. She obtained work in a pizza hut. She left home at 17 to live with her part-ner, by whom she had a son, whose speech was delayed and who suffered from a benign brain tumour. She then had a ter-mination of pregnancy. She jumped for joy when, at 21, she became pregnant again. She loved being ‘big’. The third tri-mester was complicated by heartburn, muscular spasms and a disappointment at work (not being appointed as chef at a new restaurant). Nevertheless, prepartum bonding was normal and her libido increased. She considered that the pregnancy had been ‘a breeze’ right to the end, and the birth of a daughter was rapid under nitrous oxide. Afterwards she was in tears with happiness. But breast-feeding failed and the family and her friends failed to rally round; the television was her only com-pany. Her first child became jealous. She was sleep deprived, and her relationship with her partner came under strain. At 2-3 weeks her daughter had surgery for a hernia. She was difficult to feed and get off to sleep, and her painful screaming last-ed 45 minutes. The mother began to suffer panic attacks, and feared she was having a stroke. Her tension reached the level of bruxism. She began to feel anxious in the baby’s presence and felt better when away from her. At the worst (5-6 weeks) she regretted the pregnancy, felt trapped and felt like running away to her father in another country. She was getting angry with the baby and both parents shouted at the baby a fair bit; she was reticent and cagey about the severity of this anger.

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N5 was never close to her mother, who had remarried after separation from a violent alcoholic man. She was abused by a family friend from 8 to 11 and received counselling. From her teens she was drinking five vodkas every night and this contin-ued during the first two trimesters of pregnancy. She worked at a fast food restaurant. At the age of 21, she became pregnant through contraceptive failure, and this was not diagnosed until 5½ months gestation, when she noticed “something moving in her stomach”; the foetus was small with little liquor, and her pregnancy hardly showed. When she informed the father of the child, he hung up the telephone. She did not feel mature enough to be a mother and had to give up her job and live-ly social activities, but it was too late for a termination. She considered relinquishment. She had meanwhile formed a new relationship, but this man was already cheating on her. She did not talk to the foetus, whose movements made her angry. Because of foetal growth retardation and lack of liquor, she was delivered @ 37 weeks by elective Caesarean section, un-der epidural anaesthesia. She was happy to see the baby, even though she was in an incubator for several days. At this stage she formed a third relationship to a man who supported her during the next year, and was also supported by her mother un-til this lady accused them of battering the baby, and broke off relations; she then moved in with her partner and his parents. She became depressed, with a fear of cot death that kept her awake at night, listening to the breathing and occasionally feel-ing her baby’s chest, resulting in 3-4 hours sleep deprivation for four weeks. Her fear of hurting the baby caused a degree of phobic avoidance. Another fear was that the baby would be sexually abused, and she checked the locks several times each night. At 10 months she was seen at the mother & baby ser-vice. She had some ambivalence, with an occasional impulse to escape temporarily, and some anger. She denied acting on this, but she grabbed him a bit roughly.

Severe anxiety involving the infant is not without risk. In the original case of the pathological fear of cot death 2 24, the mother, severely sleep-deprived, presented with filicidal impulses.

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Depression with ideas of worthlessness

The following tragic case raises questions about the distinction be-tween rejection and depressive ideas about motherhood:

M16 gave a history of being hated by her own mother. At the age of 30, she unilaterally decided to stop contraception and conceived. She enjoyed being pregnant, but became depressed six weeks after childbirth. She began to think it had been a mistake to have a baby, and wished they could return to their former happy life as a childless couple. Her depression failed to respond to treatment, and she was admitted to hospital with-out the baby for observation. She was breast-feeding. It be-came apparent that she had positive maternal feelings, but had misgivings about motherhood itself, because she feared she would behave like her own mother. She pressed for adoption, but her husband was reluctant. She absconded from the hospi-tal, filled a rucksack with stones and drowned herself in a lake.

In the next example, there was also some anger and a desire to escape:

C22 was the eldest of three daughters. Saddled with respon-sibility for her younger sisters, she said, “I never had a proper childhood”. Nevertheless she won a Duke of Edinburgh award and studied calligraphy at night school. She had a busy and responsible job. The most important event in her life was her marriage to a “lovely and golden man”. She gave birth to her first child, whom she described as “my special boy”. She suffered a miscarriage, and “desperately wanted another child”. When she conceived, she was “over the moon’. After an easy labour, she gave birth to a second son. But she could not stop thinking about the miscarriage, saying, “There should have been another baby in that cot”. Her difficulties were com-pounded by the baby’s vomiting and failure to gain weight. After a month she began to feel depressed, and at 5½ months, although she loved her baby, was shouting at him. When, at seven months, she was referred to a mother-infant service, she said she “just wanted to get away from the children”, who were better off with her mother-in-law. She began to wish she suc-cumbed to a vehicle accident, so that someone kind and loving

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would take over. She said, “I am not much of a person. I feel like an empty shell”. One day she walked out of the house without telling her husband and walked for miles. Her hus-band described her as lovely and loving, getting on well with everybody. She recovered from her depression in a few weeks.

The next mother had ideas of relinquishment, in the context of a de-pressive psychosis, with marked feelings of unreadiness for mother-hood:

A27 suffered physical abuse from her mother, for which she received treatment at the age of 12. At 15, her Nan (“the only one who loved me”) died and she grieved. She left home and moved in with her boy-friend. The pregnancy, at 17, was un-planned and a shock, but accepted. She was scared of inform-ing her mother, and, when she did, at seven months, this lady “did not want to know”; there was no further contact, but her boy-friend’s family rallied round. She was sensitive about her pregnant appearance, being “too young to be a mother”; she therefore stayed in the house. After the full-term normal birth, supported by her boy-friend’s mother, she felt happy. But she slept only two hours/night and, at six weeks, became depressed. She stayed in with the curtains drawn, so that people could not see that she was not looking after the baby as she should; she would hold conversations with her dead Nan, who encouraged her to make a better job of looking after the baby. She re-peatedly harmed herself with a broken cup, and was throwing things at the wall, imagining that people were ascending the stairs, coming for her; she was miserable and monosyllabic and barricaded herself in her room [depressive psychosis]. On one occasion, she put the baby on the floor with a ring of salt round her. Admitted to the mother & baby unit, she showed no sign of affection and considered asking her boy-friend’s mother to take over. The only sign of anger was shouting at the baby “Stop crying”. She responded to ECT.

Four other rejecting mothers felt unworthy of motherhood. One, who felt she was not ready to have children, said, “I’ll never be a good mum; it would be much better if he was taken away”. Another said,

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“It is not fair I have brought her into this world, when I don’t have the mental stability to care for her; I want to crawl under a rock and die”. A mother, who became depressed with psychotic features, said her thoughts would pollute other people’s minds, and she could harm the girls by just looking at them.

Pathological anger, without evidence of rejection

Anger is a prominent association of emotional rejection, but has other causes. In the first two examples, severe insomnia seemed important:

C6 came from a large Scots family. In her teens she was sex-ually abused by her brother-in-law and sister; the family were not supportive, and she felt her role in life was to be abused by men. At 21 she was raped, and a legal charge was unsuc-cessful. She left Scotland and met her husband in England, a wholesome, hardworking and concerned man. After six years of happy marriage, they had daughters aged four and six. Her third planned pregnancy, at 29, was welcomed, but an ovarian cyst had to be removed at four months, and she was worried about losing the baby. She gave birth to another daughter. The baby cried a great deal and had “a cry that will go right through you”. She complained that she was “walking on eggshells. One minute I am fine and the next I cannot stop shouting. I am only getting 2-3 hours sleep a night instead of 8-10. I cannot bond with her, or show any love for her”. She was at times quite angry with the baby, shouted at her, and “felt like putting a pillow over her to shut her up”. Although she once left her in the garden for half-an-hour, she had never done anything aggressive, and did not regret her birth, or reject her.

N8 had a family history of postpartum depression. Her mother was distant, and did not enjoy mothering, but she was close to her father and grandfather. She developed epilepsy at five, but was free from seizures and medication from the age of 11. She trained as a nanny. At 26, after two years of marriage, she was ‘ecstatic’ to become pregnant. Towards the end, there was friction in the marriage, because she failed to “pull her weight’

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redecorating the house; their sexual life ‘slowed’ and ideas of infidelity crossed her mind. She interacted with the unborn child, and longed to “hug and love the baby”. She gave rapid birth, with nitrous oxide, to a 3.6 Kg boy, followed by mild post-traumatic stress symptoms. Initially overwhelmed with joy, she was sleep deprived for six months and soon became depressed. She received much support from her husband’s par-ents and church friends, but she lost her libido and, when they again quarrelled over redecoration, her husband hit her and she had a seizure; he was jealous of her relationship with the baby. She had a pathological fear of cot death, and an irrational fear that the baby would be hurt by burglars. She had a normal bond, but got ‘frustrated and upset’ when woken after only 20 minutes sleep and occasionally had an impulse to shake the baby. Once she yelled at him and grabbed him roughly, and another time her husband dragged her out of the room when she was yelling at him.

In the next example, constitutional irritability may have been a factor:

C35 was a devout churchgoer. At 29 her first child was crying excessively. Loud noises always made her lose her temper. She threw pots and pans around the kitchen, threw a dummy hitting the child on the forehead and hit her head on the chang-ing mat, causing a bruise. She felt like killing the child and once put it in the refrigerator. At other times she was calm and collected; there was plenty of evidence of normal ‘bonding’.

In the next three examples, the only known factor was depression:

C19 had an unhappy childhood because her father was a diffi-cult man, who did not understand emotion. She qualified as a teacher and married a man who also refused to recognise de-pression. For the first 17 years of marriage they ran a success-ful business, and she avoided pregnancy because of tocopho-bia. She then had two children. The second, born at the age of 41, wore her out with his screaming. She became depressed and on 3-4 occasions got very angry with him - shouted at him, and on one occasion gripped him tightly. There was no other evidence of rejection and, by the time she reached the clinic, she had recovered.

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N9 had a family history of depression. Her mother had little time for her and she felt unloved. Her parents fought each other and were critical of her. She was a bit of a loner, liable to depression with some obsessional symptoms. She was married at 20. After eight years she gave birth to a daughter, followed by anxiety and some impairment of bonding. A year later, she gave birth to a second daughter, followed by depression. She was glad to become pregnant the 3rd time, but longed for the end of an “awful pregnancy”, complicated by pain in the back, groin and pelvis and insomnia. The birth, helped only by ni-trous oxide, was painful and she had some complaints against the obstetric staff. She became depressed, and felt a failure as a mother. She bonded to her son, but became increasingly irri-table with the girls, yelling and screaming at them, and shaking the 6-year old. She also shouted at the baby, and was more than once rough with him.

A29 described herself as “the big ugly elephant of a baby”, unlike her beautiful siblings, on whom everybody doted. She had a chaotic and stressful childhood, spent some time in foster care and was often in trouble at school. At 13 her strict father was in prison and she “went haywire”, abusing drugs and al-cohol. At 15, she had a termination of pregnancy. When her father was released, her mother absconded to escape his wrath, taking her with her. At 16 she married a 19-year old, and they had a son, aged two at the time of referral. Her husband spent time away and she had an affair, deserting to live with her part-ner. At 20, she had a second, planned, pregnancy, diagnosed at three months. Her mother, horrified, wanted her to have a ter-mination and return to her husband. She hated her unattractive pregnant appearance, and the new relationship came to an end. The birth was “awful” and she was angry with the midwife. The baby was blue and was rushed to the neonatal unit, where he spent several days. He cried all the time and was difficult to soothe. After two weeks, relationships with her husband and her mother broke down. She became depressed. Referred to the mother-infant service, she said, “I could not cope with his screaming. I was afraid to go near him, because I was afraid I would shake him. I would shout “Just shut up!” and scream. On 2-3 occasions she shook him. This anger took place in the context of an apparently good mother-infant relationship.

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The last example is of extreme irritability in a woman who showed much evidence of vulnerability but no overt depression:

C24 was born when her mother was 45 years old. She was a pretty, well-dressed and charming woman, who kept an im-maculate house and maintained a front with other people, but was shy and obsessional. She could not stand the mess made by children “and the little petty things they do”. She met her husband at 17, and gave birth to a son at 23. When she became pregnant for the second time, she felt ashamed of conceiving again so soon, and hid her pregnant state. Socially sensitive and worried about meeting people, her stomach was churning constantly. The clinical problem was her intense irritability with both children, then aged 14 months and three years. Her frustration was such that she threw herself on the floor pull-ing at her hair, and hit the wall with her hand. She screamed at them, shook and smacked the toddler and had occasionally thrown the baby into her cot.

In one or more of these cases, the mother-infant relationship may not have been fully explored, or the mother, ashamed of her feelings to-wards the infant, may have concealed them.

Personality disorder

In a few mothers, callous and aggressive traits may be longstanding characteristics rather than a specific response to the infant.

In the following example, the first daughter was severely neglected; there is a dearth of information about bonding, and much evidence of irrresponsibility:

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L11, at the age of eleven, was referred by her mother with be-haviour problems. At 14 she was beyond parental control, had ceased to attend school and become pregnant by a 23-year old man; this pregnancy miscarried. At 18, she became pregnant again, failed to attend for antenatal care and gave birth to a daughter. Within a year, social services were alerted to the baby being left out in the rain, inadequately clothed, and not being fed regularly. At 20 she was again pregnant and default-ed on antenatal care. An anonymous referral stated that she was hitting her daughter with a leather belt, and the baby was always covered in bruises; the toddler was afraid of her moth-er. She gave birth to undiagnosed male twins, and failed to attend for postnatal examinations. Three months later one of the twins died from cot death. The following year she was again pregnant, gave birth to a daughter, and failed to attend for postnatal examination. An anonymous referral stated that she was neglecting all her children, who were wet and soiled; the referrer has seen her kicking her elder daughter and slapping her in the face. The next year a further pregnancy was termi-nated. She set fire to her house, for which she was sentenced to three years’ probation (from which she defaulted). She be-came pregnant again. She gave birth to a son, and again failed to attend for the postnatal examination. She was sterilized. Her six-year old daughter was seen in the clinic – a sad child, whose mother was always angry, sad about the death of her grandmother and other losses; she was stealing and her school attendance was 37%. Social services were alerted anonymous-ly to the disgusting state of her house – the mother had given up. The children, who were often left alone, had run riot and destroyed most of their possessions. Her first-born was trying to clear up the mess. Given £200 by the social services to pur-chase bedding, she spent it on two weeks holiday. All children were accommodated in a residential unit.

In the second mother, the personality disorder was so severe that there was hardly any emotional involvement with the infant, who was mere-ly an incident in her career as a victim.

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A4 was born out of wedlock to an alcoholic mother, and never knew her father. She was abused emotionally, physically and sexually by her stepfather and a succession of her mother’s partners. At the age of 11, assaulted by her mother (who was charged with grievous bodily harm for cutting her back with a buckle and her head with a dish), she was taken into care, and spent time in foster homes. After setting fire to documents, she was admitted to a residential reform school. In her teens she took overdoses and slashed her wrists. She was only just literate. She led an itinerant life with many moves and unstable relationships. She was married to a soldier in the British Army of the Rhine for two years. She abused ethanol, cannabis and amphetamines. There were forensic events including stabbing, for which she was put on probation for three years. Admitted to her local psychiatric hospital three times with ‘paranoid be-haviour’ and a chaotic life style, including trashing her friend’s flat, she frequently absconded. After another arson episode she was remitted to Risley Prison, but absconded to the Irish Re-public. She may have suffered from depression (her weight once falling to 5½ stones), but there was also chronic dysthy-mia and much parasuicide. As for her obstetric history, she had two terminations of pregnancy, in addition to miscarriages. At 37, she became pregnant again, with conflicting accounts of the fatherhood, and was delivered of a male child by elective Cae-sarean section. During the first five weeks she said she would like him adopted and left him in the care of anyone who would have him. After she returned drunk from a party, he was made subject to a 72-hour police protection order. She was admitted to a mother & baby unit for a trial of mothering: she spent four hours/day away from the baby, who was then transferred to foster care under an Interim Care Order. When she visited him she was affectionate, but looked at the baby wondering who he was, and was unperturbed about his removal. She was imma-ture, irresponsible, violent, untruthful, uncooperative and quite unsuited to parenthood.

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In other cases there is a combination of personality disorder and emo-tional rejection. In the next example, there was much evidence of antisocial and aggressive traits; there was clear evidence that her first child was rejected:

L6 was the eldest of five children of a mother with multiple partners; all siblings were in foster care. She was neglected by her mother, and spent her early years in the care of her maternal grandmother, who also neglected her. At the age of six she was removed to foster care and, at eight, had ‘extreme behaviour problems’. Three foster parents were unable to cope with her, and she was transferred to a residential children’s home. She refused school, so was sent to a boarding school, where her behaviour was ‘atrocious’ - repeatedly running away, abusing alcohol and stealing cars. She was consumed by bitterness against her mother, and used to break her windows. At 18 she became pregnant and, after being kicked in the stomach, had a 24-week miscarriage. At 22, she became pregnant again. The father deserted when she refused a termination. She gave birth to a son, and, for two weeks, cared for him with the support of her mother and a former foster-mother. “It was a strain: half the time I left him to cry. I did not feel like a mother at all. From day one he was a total stranger ”. She had the full gamut of rejection symptoms including hoping that he would die in the night. She often shouted, screamed or swore at him, once threw him in the cot and twice shook him. She told her mother to come and fetch him, “or I’ll kill him”. He spent five months in foster care. At 10 months, returned to her care, he sustained five bruises and his mother admitted to shaking him. He was returned to foster care and, when she refused to allow her mother to rear him, relinquished to adoption. She became pregnant again by another man. When, at 16 weeks gestation, the pregnancy came to light, the unborn baby was placed on the Child Protection Register. She was pleased about the pregnan-cy because it gave her the chance to prove that she could be a good mother. She gave birth to another male child. Bonding was immediate and she was ‘over the moon’, but was irrita-ble – more irritable than she had ever been. Observed in two mother & baby homes, she appeared to be an amicable young

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woman, but short tempered and vengeful; she said, about a pro-fessional, “I will hunt her down and kill her”, and, “If I lose my baby because of any of you, I will rip your heads off”. She was seen shouting at her son, throwing him into his push-chair and smacking him in the stomach. She threatened to kill those who had made the allegations, and was very upset when he was removed to foster care. Admitted to a mother & baby unit for assessment, she was observed to shout and swear at her baby, and handle him roughly. Her moods changed quickly. She improved with anger management, and made progress, but the child protection agencies were rightly pessimistic.

L13, summarized on page 41, had abundant evidence of personality disorder, and starved her infant to death.

Finally there is this mother, who had no antisocial or paranoid traits, but was remarkably irresponsible:

A15, at the age of 18, was forced into a termination by her par-ents. At 21, she married a man 14 years her senior, a very con-trolling ‘father figure’, and had three children by him. When her husband refused to reverse a vasectomy, she formed a new relationship on the internet, which occupied her for 18 hours/day. At 30, she decided to abandon her family and move in with her new lover. She soon became pregnant. It was un-planned, and she was initially devastated, but later accepted it and was looking forward to the baby, although she did not relate to the foetus. Labour failed to progress, and she was delivered by emergency Caesarean section. Afterwards she suffered abdominal pain and bleeding, and was waited on hand and foot by her new partner, who was unemployed. The baby was difficult, vomited constantly and would never stop crying; at 15 weeks she still weighed only 10lb. Three weeks after the birth the mother became depressed and was throwing things at her partner. Her sister rallied round in support, but she took another overdose, drove off and had to be recalled by an ul-timatum; her sister then broke off relations, saying she was a “selfish bitch who does not care about her kids and does not deserve them”. Her relationship with the infant suffered: she said, “I can’t cope with her, can’t cuddle her; she obviously

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hates me”. She seriously considered adoption and discussed this with her partner. She was “half-disappointed” to find she was still breathing. She shouted at her, threw her into the cot and had an impulse to shake or throw her. Her partner took over the care. She gave the impression of self-centred imma-turity, more like a teenager.

Factitious disorder

In all areas of psychiatry, clinical syndromes can be counterfeit or factitious. There is this one example of pretended ‘bonding disorder’.

M1, childlike and naïve, had an unplanned, unwanted preg-nancy. Within a week of the birth she attempted suicide with a plastic bag, to the point of losing consciousness. Admitted to the mother & baby unit, she said she was a lesbian, and wanted to be a man; she hated her husband and baby, and was a nasty sadistic person incapable of a loving relationship. She want-ed the baby adopted. She was rushing around in an agitated way, and was panicky and dithery when caring for her daugh-ter. Within a week it became clear that she loved her husband. Moreover she had warm feelings and great concern for her baby: as soon as she returned to the ward, she would pick him up and cuddle him before removing her coat. She was misin-terpreting her anxiety and tension, due to lack of confidence [puerperal panic], as hostility. With nursing support, she recov-ered within a fortnight.

Mendacious accounts

The mother’s deliberate lying can hamper the diagnosis, as in these examples:

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L12, seen for a legal report, was irritable, and walked out of the interview at one point. Her own mother was a weird woman who gave her little love, would fly off the handle and “go com-pletely mad”; she walked out for three months when the patient was five, and once gave her a black eye because she refused to sleep in a room with a spider. Her father, after a great deal of fighting, left when she was six; she accused him of child sex-ual abuse. One brother was killed in a pub fracas, and another committed suicide. She loved school, obtained two A-levels and had a good career. She had a history of ethanol addiction, and was hostile about enquiries into its severity and duration, but had twice been admitted for detoxification, and once with delirium tremens. She divorced her first husband (a heroin ad-dict) when he was imprisoned for burglary and on remand for manslaughter. Her second husband was a binge drinker and there were many instances of domestic violence. She claimed that the marriage was not consummated for over a year and it was only after seven years and treatment in a fertility clinic that she conceived. She was ‘over the moon’ about the pregnancy, and bonded normally with the foetus, lying for hours rubbing her abdomen with oil, chatting to the infant and playing music. Everything was ready for the birth and she was delivered under epidural anaesthetic. The infant was in special care for meco-nium ileus, but soon recovered. Returning home, she found the house in a mess, because her husband had been on another binge. She was unable to sleep because of her fear of cot death. An Emergency Protection Order was obtained because of pa-rental ethanol abuse. Pregnant again, she developed massive oedema; nevertheless she and her daughter related well to the foetus. At 35 weeks gestation she gave birth to a boy. He was in special care for three weeks with a chest infection. When he returned home, he did not seem like her son, more like an alien object; he took 2½ hours to feed and was “ugly, grizzly and horrible”, screaming all the time. He was “the Devil in-carnate”. She often shouted at him, and say, “I hate you and wish I had never had you”. She felt she could sling him across the room or smother him, and had put him down roughly and

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briefly shaken him a couple of times. She informed her general practitioner that she did not feel right about him, and discussed adoption with her social worker. An Emergency Protection Or-der was again obtained because of drunkenness. Three months after the birth, her husband kicked her in the stomach and left; she commenced divorce proceedings. In care, the boy stopped crying and became a smiling and placid baby.

This was the history given in my interview, but, in a review of her medical records, I discovered that she had lived rough and been in prison several times. A note written five years earlier (when she was supposed to be infertile) stated that “a first child died unexpectedly four years ago and a 3-year old daughter was living with her grand-parents”. If this was true, the history she gave was fiction, and no decision should be taken about child custody until these facts were laid bare.

A20, with a family history of depression, had a strict child-hood, but did well at school and qualified as a nurse, working on a neonatal unit. At the age of 22, she met her future husband and had a termination six months later; it took her 18 months to get over this. She became pregnant again and they were mar-ried, after which they lived with his parents, who were stingy, violent, interfering and lacking in understanding. Her husband was also violent. They moved to a town where she had no social network. Her first child was born @ 30 weeks gestation, weighing 3lb 11oz. In the puerperium she became depressed. For five months she felt little for her baby, and was hitting him when he was crying for food. Meanwhile her husband was punching and kicking her with the slightest provocation and spitting in her face. In these circumstances, and still not fully well, she became pregnant again. This was “the worst thing that could have happened” and she hoped for a miscarriage. She was very sick, slept excessively and disliked her pregnant appearance. She did not relate to the foetus. She found con-doms in her husband’s bag and her family urged her to leave him. After labour lasting only eight minutes, a second pre-

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mature infant was born at 32 weeks, weighing only 1.7 kg; he spent three weeks on the neonatal unit. She was disappointed that he was born alive, and disliked him. He was a scrawny baby; she had difficulty in looking at him, and it made her feel sick to touch him. She felt trapped, and regretted the pregnan-cy. She was depressed but felt better away from him. “It’s like he isn’t mine”. She wanted to run away and wished for a cot death. She had impulses to smack him in the face and handled him roughly, picking him up by the neck. Her score on the Postpartum Bonding Questionnaire was among the highest ever recorded. He was referred to a mother-infant service, and the child protection agencies were informed. The police were twice called after more domestic violence and she moved out taking both children. This separation caused problems in the local Pakistani community. In March the baby became ill with ‘bronchiolitis’ but a chest radiograph showed fractured ribs. A fortnight later he was admitted for the third time, with a spiral fracture of the left humerus; chest radiographs showed nine rib fractures. She was still seeing staff in the mother-infant service, where she gave a mendacious account of her progress, and no-one informed them of the very serious events in her home town. On return from sabbatical leave I was involved in writing a legal report for care proceedings.

R6: at the age of 24 a happily married woman had an un-planned and unwanted pregnancy. She rejected her daughter and avoided contact as much as possible. “I became depressed if I had to stay in the house. I went out with friends every night and left my husband to look after the baby”. She was persuad-ed to accept admission to the mother & baby unit, but was dis-charged after a week. She said, “I fooled them. I knew that if I pretended to be well and looked after the baby, they would let me go. It worked”. For the next four years the mother-infant relationship remained poor; she regretted the pregnancy and blamed the child for “ruining her life”.

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Missed diagnosis

Because of the risk of child maltreatment, rejection of the infant is an emergency. But in this series of 100 cases, there were eight instances of failure on the part of general practitioners, general psychiatrists or ‘perinatal’ specialists to make the diagnosis. One example is summa-rized in full:

L9 was the fourth of five daughters born to a warm, united family. As a neonate she suffered from septicaemia and renal failure, and later had several hospital admissions with kidney problems. Quiet and shy, clumsy and uncoordinated, she was picked on and bullied at school. She was fond of her sisters’ children. She obtained work as a care assistant in an old folks home. At 20 she formed a relationship, tried to become preg-nant and was pleased when, at 24, she conceived. Prepartum bonding and preparation was normal. Parturition was “a ter-rible experience”. She was induced and, after 24 hours, de-livered by Caesarean section under epidural anaesthesia. The baby was slow to breathe and suffered from cyanotic attacks. He was not easy, cried a lot, was difficult to soothe and would not go to sleep. After 5-6 weeks his screaming was terrible, and the memory of it kept her awake. “He just didn’t feel like my baby at all”. Her feelings changed to hatred, and she want-ed him taken over by someone else – anyone else. She felt like suffocating or throttling him, or getting rid of him in some other way. Her mother took over for a week and then they both looked after him. The grandmother, a good-hearted person, confirmed that he was a fickle baby, and she would also have found mothering him very hard. “Mum and I want him adopt-ed; we can’t cope with him”. When he was six weeks old she shook him twice. Later she was charged with fracturing his skull, claiming that she had “dropped him on a coffee table”.

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She was depressed, so tense that her jaw became sore, lost a stone in weight and slept only two hours/night. She consulted her general practitioner, who failed to refer her to a specialist service, even though she felt like throwing the baby across the room. Soon afterwards her son was found to have multiple injuries, as described on page 51.

L13 has already been summarised (page 41), under the heading of neglect. Before the death of this child, there were grave professional failures on behalf of general practitioners, social workers and the po-lice. In my report I drew attention to the following facts:

• On August 26th a general practitioner, who knew that the infant (five months old) had suffered a severe loss of weight and that his mother hated him, failed to make a psychiatric referral.

• On November 23rd, another general practitioner knew that he had failed to thrive and had a severe nappy rash; his mother had problems with bonding and was moving from one area to another; he gave them an appointment in two months time.

• Between August and November social services were alerted on at least six occasions, but no child protec-tion conference was held.

• On December 10th the police, alerted by a concerned landlord, gained entry, and reported that the children were “fine”. On 21st, the baby died, weighing less than his birth weight.

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4

Course and Response to Treatment

Introduction

Spontaneous recovery

Effect of treatment

Chronicity

Recurrence

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Introduction

Nothing exposes the abject failure of psychiatry to investigate this dis-order more than the dearth of information about its natural history. For this I must bear much responsibility; I can only plead that, during the 25 years from my first case to my retirement from clinical practice, I was overcommitted to other work.

There is one unpublished follow-up study. In Manchester, Robinson 12 wrote a Masters thesis on “The Natural History of Mother-Infant Bonding Disorders” - a substantial interview study, following 75 pa-tients for 3½ years, of whom 13 had lost their children. He was able to interview 50. Five had ‘clear problems’; all expressed their continued hostility, and in addition:

One was suspected of abuse.

One confessed to frequently hitting the child.

Two went to great lengths to avoid contact with the infant.

The fifth could only cope with her infant with the assistance of a home help.

In addition, seven had ‘some problems”:

One hated her son for two years, then began to enjoy him “as any mother would”.

A second was still emotionally detached, and preferred contact “only in small doses”.

A third had affection for her child, but because of illness need-ed the help of relatives.

A fourth relapsed after treatment and required re-admission, then improved again.

The remaining three had other reasons for disappointment or dissatis-faction with their relationships with the children.

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Robinson considered that 24/50 mothers interviewed had no, or min-imal, difficulties. But his research was criticised because the moth-er-infant relationship was not directly observed, and this figure of ap-proximately 50% recovery might be optimistic. On the other hand the data collection took place in the early 1980s, when the therapeutic approach was in an early stage of development.

In the present study, few had information on the long term course; it is only possible to give examples of different outcomes.

Spontaneous recovery

The following mother recovered from a prolonged and severe moth-er-infant relationship disorder without treatment:

C34 was by nature a passive, unaggressive person. At 21 she had an unplanned and unwanted pregnancy. Her fiancé refused to allow a termination. She felt negative to the unborn child with whom she had no interaction, and made no preparations for the birth. She cared for her daughter (“a cute little thing”) but was unable to love her. She never wished to relinquish her, saying, “Even though I could not bond, I could not give her up. I was forever running off – walking out of the house and driving around for two hours or so”. She was unable to explain the situation, except briefly to friends, even to her mother to whom she had never been close. After 22 months, without any intervention, she began to form a relationship with her rather cheeky, interactive toddler. She presented at six months gesta-tion with a new unwanted pregnancy.

There are three other cases with spontaneous recovery after 18 months or two years. One said she eventually came to love a hated twin, aided by prayer. One mother, whose rejected fourth child was reared by the grandmother, came to the clinic three years later with a baby, who sat on her knee; the child had wheedled its way into its mother’s affec-tions. Although the duration of the disorder is not known, C28 gave a graphic description of her spontaneous recovery:

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“I started to feel sorry for her, and made a bigger effort. I saw her tiny face. She looked straight into my eyes and smiled. I felt she was saying, ‘It’s all right, Mum, I know how you’re feeling, but I love you and always have’. My whole body was tingling, my heart raced and I felt I was going to explode. Ever since then I have been able to hold and hug her”.

Effect of treatment

It is not the purpose of this book to set out the treatment, which was described in Motherhood and Mental Health (pages 356-360) 2 at a length of 1,000 words with seven illustrative cases. Since then there have been some treatment trials focused on the specific interventions of baby massage and play therapy (though none in rejecting mothers), but the general precautions (points 4-6 below) cannot ethically be sub-ject to controlled trials, because the outcome measure would be child maltreatment. To rehearse them briefly,

1. If the mother is contemplating relinquishment, there must be preliminary discussion with both parents of a decision to em-bark on treatment rather than surrendering the child.

2. If, as in most cases, the decision is to keep the infant, depres-sion must be thoroughly treated.

3. Meanwhile mother and baby are not separated, but treated to-gether.

4. She must be protected from the irksome burden of coping with a difficult infant

5. She must always be supported in her interaction with the child6. If there is any hint of dangerous anger, she must never be left

alone with the baby7. When mother and baby are at ease, she is helped to interact,

and specific interventions introduced.

The spectacular success of appropriate treatment was shown by this case, which was published in 1984 9:

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M19 was shy, sensitive, easily hurt, house-proud and a worrier. She met her husband through a marriage bureau. At 26 her first pregnancy was planned and the couple looked forward enthusi-astically to the arrival of the baby. She was delivered by Cae-sarean section, and saw her son 24 hours later. She doubted that he was truly hers, and even thought she had heard that her baby had died. She had a wound infection, and was disappointed not to be able to breast-feed. She became gradually more de-pressed. After three months her husband had to stay off work, because she was unable to cope. After five months she slapped and shook the baby, and had thoughts of killing him. Admitted to the local psychiatric hospital, she felt depressed, guilty and criticised for failure to mother her infant, and was treated with-out effect with ECT. At seven months she was transferred to a mother & baby unit. She said she hated her son – “I can’t bear him. I don’t want to know him.” She wished she had never had him, and stridently demanded his removal. He was placed with his paternal grand-parents, remaining with them for over two years. Relations between mother-in-law and daughter-in-law deteriorated to the point where all contact had to be forbid-den. During this time she received almost every known form of treatment – several courses of antidepressant medication, three more courses of ECT, marital therapy and psychotherapy by two gifted psychotherapists. But her depression resisted all efforts. She made several suicide attempts and attacked her husband with a knife. But he stubbornly refused to give up his marriage or his baby; his pressure alone motivated his reluctant wife to overcome her problem. Their GP gave his advice that the psychiatrists did not understand the disorder, and there was no treatment. When their son was nearly three years old, and developing reciprocal hostility to his mother, a visiting clinical psychologist explained that she understood the disorder and took over the treatment. She used participant modelling, demonstrating how to interact with the child, ask-ing the mother to copy her; at first this felt ‘artificial’, but after a few trials she could adopt the behaviour as her own. After only four one-hour treatment sessions, the mother-infant rela-tionship started to develop. As the bond became established, the depression evaporated. At follow-up a year later, without any further treatment, a normal mother-infant relationship had been maintained.

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The next example demonstrates the efficacy of simple measures in some cases:

M20, an intelligent and good-hearted mother, failed to bond to her baby. A health visitor told her that she was not playing with her infant properly, and proceeded to demonstrate how to ‘romp’ with a baby. She walked on all fours with the baby on her back, and the little boy cackled with laughter. The mother followed suit and, at the next out-patient visit said that ‘some-thing had happened’ – the felt a pang when the baby was taken to the child-minder. She recovered within a week.

In other cases, however, state-of-the-art treatment failed, as in these two examples:

C14 had several catastrophic events in her childhood: her fa-ther was imprisoned for rape, her biological mother died when she was four and a foster-father hanged himself – and she found the body. She showed much evidence of disturbance – saw a child psychiatrist at 10, was expelled from school, took several overdoses and spent two months in a detention centre for arson and shoplifting. Her adult household was disordered, both parents unemployed and on benefits, with a history of al-cohol, amphetamine and cannabis abuse. Her first pregnancy was aborted @ 25 weeks on account of anencephaly. She then gave birth to three daughters, followed by two more unplanned pregnancies. The first was terminated in January 1999. The second, at 25, led to the birth of a fourth girl. After two weeks she began to reject her. She was depressed and short of sleep, and too tired to provide child-care; her husband did most of the caring. She could not stand her baby’s smell and wished her daughter was dead, like a baby in ‘Trainspotting’ that died a cot death at six weeks. After a few weeks, she did not want her in the house, and she was transferred to a neighbour, then removed by social services; the other three children were trans-ferred to her partner’s mother. At this stage she was referred to the mother-infant service. She was seeing her son at a family centre and, according to a care worker who spent 200 hours with her, developing a good relationship. She was said to be a

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nice person, lovely with her other children, but given no sup-port by her husband. At eight months she was admitted to the mother & baby unit for assessment, and, four months after their removal, all children were returned to her. But the outcome was bad. After six weeks the children sustained several inju-ries. Two years later she was referred again in the 8th month of another pregnancy. The other three older children were await-ing care proceedings and the fourth daughter had been adopted.

R4 already the mother of one child, became depressed dur-ing her second pregnancy, which was unplanned and unwant-ed. She rejected the infant from birth, and expressed the wish that it die. Her husband was critical and unsupportive. Three months after the birth she was admitted to the mother & baby unit, where she stayed for 44 weeks without any change in her attitude to the baby. After discharge she remained depressed, attempted suicide several times and continued to be hostile to her child. Followed up 18 months later, she did not appear depressed, but her statements about the child indicated indif-ference or dislike.

One other mother, who rejected one twin, failed to respond to five months on a mother & baby unit.

Chronicity

Untreated, this disorder can be prolonged. It is then that the rejected child can become the victim of emotional abuse.

The following mother presented with ‘postnatal depression’ after the birth of the next child, but the real problem was a longstanding distur-bance in her relationship with her first-born:

M10 had a poor relationship with her father, and was blamed by both parents for their marriage, resulting from her pregnan-cy. At the age of 24, she married an understanding man. At 27, she looked forward to the birth of her 1st child with keen in-terest and good prenatal bonding, but her daughter was a mis-erable baby, who often cried, and “the times she cried I could

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not bear it”. She developed a dislike for her, and returned to work to get away. After the child began to smile, they got on rather better. Then a second child was born, with a dysplastic hip; but she immediately bonded to him. Unfortunately, worn out by the care of the newborn, she became less tolerant of her elder child. Not surprisingly, partly through sibling rival-ry, this daughter’s behaviour deteriorated and an ugly situation developed: she several times told her husband she would prefer that she be adopted away. Her irritability reached the level of smashing crockery and a threat to stab her husband.

The next case illustrates the lasting effects on the rejected child, even though she was reared by other family members for three years.

S13 was one of four children of a close Afro-caribbean family. She was an unmarried mother, living on income support, who had two children fathered by an abusive partner. Each child was a twin, the other twin being lost - the first was stillborn, the second died in utero. After her first birth she had felt numb for months, a severe depression with the loss of three stones in weight; she “wanted to be dead with her still-born child” and did not even want to look at the second twin. Years later she still felt cold to this daughter and “just wanted her taken away”. After the second birth, she bonded to her son and did not grieve for his dead sister. She again became depressed and bought matches and petrol to burn down her flat with the children inside. For the next two years, after desertion by the father, she lived alone with her two children; the daughter was jealous, an ‘evil and strange child’ who was always tormenting her little brother. The situation became unbearable and, at the age of four, her daughter said she wished to live elsewhere. She lived with relatives for three years, after which she was re-turned to her mother, but without any change in feelings. This daughter often talked to herself, with imaginary conversations with her dead brother; she was stealing from her mother. The situation came to light when the mother presented with a third (unplanned) pregnancy with a new partner.

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In two other mothers in this series, the disorder became chronic. One who hated and shunned her infant, presented at 15 months, with no al-teration in her feelings. In another mother, followed up by Robinson, the symptoms persisted for four years.

Recurrence

In this series there are several instances of recurrent infant rejection, as in this example:

S8 was trained as a neonatal nurse. At the age of 22 she became pregnant out of wedlock and had a termination; this was trau-matic and she took two years to recover. At 25, with the same man, in spite of contraception, she became pregnant again, and could not face another termination; she prayed for a miscar-riage. Their parents, in spite of differences in caste, agreed to a marriage, and this occurred at three months gestation. To some extent she enjoyed her special treatment as a pregnant woman, but hated foetal movements; she never spoke to the baby in-side, or stroked her abdomen, and felt depressed. At 31 weeks gestation she gave birth to a son weighing 3 lb, who looked small and ugly. She breast-fed for three months, but failed to bond; she would leave the baby crying for up to half-an-hour. At four months she had suicidal thoughts – “slashing her wrists to get rid of the ugliness inside her” – and received antide-pressant medication. Her husband and his family called her ‘a bad mother’ and ‘a black bitch’, and would hit her. At eight months, she had to go away for a day and, for the first time, missed her baby, then slowly developed a bond. At 12 months she became pregnant again, with the same prenatal feelings. She gave birth to a second very small baby. She said, “He is so ugly. He is always crying and never happy no matter what I do. Sometimes I wish he would die in his cot”. She attended the mother & baby unit for play therapy and at follow-up had a bond with both children.

The next mother had three episodes. Note the sparing of the 2nd infant, and the greater depression and anxiety with the 3rd episode:

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C37 had a normal childhood, and a stable marriage. After her 1st child was born, she “did not want him” and asked her hus-band to remove him; she bonded when he became ill at two months. After a daughter was born there were no problems. Her 3rd conception upset her and her husband, but she came to terms with it and bonded normally with the foetus. She was delivered by emergency Caesarean section (due to transverse lie). She was admitted to the local hospital with ‘postnatal depression’; although she had twice run away from home, the relationship disorder was not recognized. Discharged ‘well’, she “just did not want the baby”, ran away again and took an overdose. She blamed him for spoiling her plans and hoped he would not wake up, which would be “the end of the problem”. She discussed adoption with her husband. Admitted to the mother & baby unit, she promptly formed a normal relation-ship when the baby developed an upper respiratory infection. Before her 4th pregnancy, the marriage failed, but they were reconciled with an agreement to have no more children. Again an unplanned conception upset them both. But she became excited about the pregnancy and massaged the foetal foot. Af-ter delivery by planned Caesarean section of a daughter, she was elated for 24 hours, and her maternal emotional response was immediate. She then became depressed. Her fear of the infant caused severe autonomic symptoms. She ran away four times, the first time in her pyjamas, the other three in a pan-ic from hospital, on one occasion buying a railway ticket to a distant seaside resort. Her negative feelings increased and adoption was again discussed. She hoped her baby would “be-come poorly and be taken away”, but there was no hatred or pathological anger. She recovered after three months on the mother & baby unit.

M18, described on pages 132-133, had four episodes, but there are no details of the first three pregnancies.

This fourth mother twice had a relatively mild disorder:

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M3 consulted her family doctor with depression 15 months af-ter the delivery of her 1st baby by Caesarean section. She said, “I felt miles away from her, like looking at a little stranger – she could be anybody’s baby. Basically I felt there was noth-ing there – no ‘bond’. I expected something quite different. I cared for her because I had to, not because I wanted to”. She felt like running away, but never contemplated giving up the care of the infant. After struggling on for three months, she broke down and summoned her own mother to stay and help. Her husband was understanding and said, “It is just like any other relationship you have got to build up”. This state of af-fairs lasted 20 months. Finally, positive feelings developed and she “loved her to bits”. During her second pregnancy, she was terrified that the same would happen again. Unfortunately her son was born with a ‘stork mark’ on his forehead, and she was “sick with worry” over this. She developed a recurrence of the illness that followed her first baby’s birth, and was ad-mitted to the mother & baby unit, where she rapidly recovered.

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5

Associations

Introduction

Depression

Unwanted pregnancy

Factors in the child

Sleep deprivation

Distressing parturition

The mother’s experience of mothering in her childhood

The father’s outrageous behaviour

Other associations

Summary

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Introduction

In the search for the causes of this phenomenon, the evidence must come from cohort studies in the general community, and, in the full-ness of time, from neuroscientific studies of ‘the parental brain’ (as discussed in Chapter 7, see page 142). The retrospection of a mass of incomplete clinical data can only provide hints on causation. Certain associations, however, are sufficiently frequent to indicate where we might search for causes. In order of frequency these associations are:

Depression 98 casesUnwanted pregnancy 36 casesInfant behaviour (especially excessive screaming) 32 casesSleep deprivation 27 casesDistressing events during parturition 21 casesPoor mothering in the mother’s own childhood 17 casesOutrageous behaviour of the child’s father 15 cases

These will be considered in turn.

Depression

Depression is by far the most common association - so prominent that some ‘perinatal’ psychiatrists regard these disorders as part of ‘postna-tal depression’. This is a mistake for a number of reasons:

1 A mood state and a relationship are different phenomena. When seeking to understand and control disorders, the better strategy is to disentangle different elements, and focus on them separately.

2 Some rejecting mothers are not depressed. This is uncom-mon in clinical practice, but the association in referred pa-tients may be exaggerated by Berkson bias 25. The Anglo-New Zealand study 3 found that rejection was present with clinical depression in 33 mothers, and without it in 13 mothers. In the community an interview study, using the Contextual As-sessment of Maternity Experience in 85 women with a history of depression 26, found no correlation between postpartum de-pression and negative feelings about the child.

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3 Rejection and depression often have a different timing 2.

4 Problems in the relationship with the infant affect only a minority of depressed mothers. In the Anglo-New Zealand study, 33/84 mothers with mild or moderate depression had a ‘bonding disorder’. It is important to select rejecting mothers, with their much higher risks, for special attention, and not to stigmatise the others.

5 The treatments of depression and a mother-infant relation-ship disorder are different 27. Emotional rejection may respond to anti-depressive treatment, but often requires specific psy-chological treatment.

When the causes of depression and infant rejection are better under-stood, we may find that there are significant differences, for example the special importance of unwanted pregnancy in rejection.

Mothers in this series illustrate some of these points.

Two mothers, one of whom tried to drown her son, had no evidence of clinical depression. In another case there was a clear dissociation in the timing of the two symptoms, with immediate rejection of the “horrid and ugly” new-born, and onset of depression seven weeks postpartum.

A dissociation of treatment response to depression and rejection was noted in three mothers, of which this is one:

C1 had a normal childhood, one of two sisters in a happy fam-ily. Her mother was lively and loving, but somewhat critical. She was bullied at school because she was chubby. At 17 she left home when her parents disapproved of her boyfriend, and lived with him for five years until they parted amicably. She had various jobs including clerk at the law courts. She met and married her husband at 24; the marriage was happy. At 26 she had her first planned and much wanted pregnancy. In the second trimester her mother died from cancer. She had a bad time at the birth. Her son was a difficult, active child who did not sleep. “I did not think much of him at first – did not hate

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him and had no aggressive feelings, but did not like him very much. I did not fall in love with him, and wished sometimes they would take him away.” She felt better when away from him. When she suffered from headache and thought she had a brain tumour, she was treated with an antidepressant, which improved the depression but had no effect on the bonding. This relationship disorder lasted for two years: when her son started showing some affection, she developed deep feelings for him. She presented four years later with acute anxiety in the early stages of pregnancy, apprehensive about a recurrence of this problem.

Of the other two, one was a deeply depressed mother whose depression was relieved by ECT, without affecting the rejection of her daughter, which remained unresolved. The other was a mother, who presented when her son was 15 months old, no longer depressed but with no improvement in her feelings for him.

The reciprocal continuation of depression after treatment of rejection was noted in one mother, who remained depressed for months after improvement in her ‘bonding’. The close association of depression and infant rejection could be due to one causing the other. There is support for both explanations.

Rejection primary There are a few mothers whose depression was improved by bonding therapy, suggesting that the relationship disorder caused the depres-sion. This was dramatic in the mother, described in Chapter 4 (page 83), whose depression resisted three years of intensive treatment, and who was cured by four sessions of play therapy. This is another ex-ample:

C4 was born to a close family in Britain. She had a marriage of convenience to a cousin who had a poultry farm in Pakistan; he spoke no English and the Home Office refused to allow his immigration. She was unable to tolerate the climate in Paki-stan, so they lived apart. She worked as a book-keeper, living

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with her niece, mother and invalid father. She gave birth to a son, who suffered from hydronephrosis and urinary infections. His frequent crying was distressing, and there were times when she no longer wanted to see him. “I hated him and wished I could give him away. Often I would shout at him and once or twice threw him onto the bed”. Two weeks after the birth she became depressed, saying it would be better if she died, and this lasted for four months until the baby had surgical treatment. As he improved, with the development of a normal mother-infant relationship, she recovered and felt sorry for the things she had done and said.

Another mother, admitted to the day hospital soon improved, and enjoyed playing with the baby; the medical student observed the se-quence of improvement – her mood lifted after improvement in bond-ing, before anti-depressive medication had time to act.

Depression primary The curative effect of antidepressant treatment on ‘bonding disorders’ was seen in three mothers. One mother had a good response to ECT, improving after three, and recovering from depression and ‘bonding disorder’ after six. A mother not in this series recovered after one ECT. This is the third mother:

S15 was one of two children of a supportive family. She en-joyed her work as manageress for an insurance company, and was happily married. For three years, she had wanted a baby so much she would do anything for it. She suffered a miscarriage, and became depressed. When she became pregnant again she was ecstatic. It was a difficult and stressful pregnancy, with hyperemesis, for which she was hospitalized until 16 weeks gestation. Later she developed polyhydramnios. She was ex-tremely worried about the survival of her baby, and had nine scans. She had a close bond with the unborn child, watched him move and constantly talked to him. After a painful 29-hour labour, she was delivered by ventouse. She immediately bonded with her son, but he was very demanding, and she be-came depressed (with the loss of one stone in weight). After two weeks “her bond plummeted” and she lost her loving feel-

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ings, and no longer felt he was her own. She felt trapped and would like to run away. The sight of him, and the thought of having to care for him, filled her with dread and anxiety. She could not look at him, or be in the same room, and just wanted someone to take him away; he had taken away her freedom and ruined her life. Her worst impulse was to shake him, and worst action to walk away from him. Although she wished she had never had him, she feared that he might die from a cot death. For ten weeks her parents cared for him, and this helped, but she relapsed when he was returned. Admitted to the mother & baby unit, she was, at her request, treated with ECT; she recov-ered fully after four treatments.

The mother just described illustrates another reason for regarding de-pression as, in some cases, causal – the loss of a ‘bond’ when mothers became depressed. In the Anglo-New Zealand study 3, 12/206 moth-ers had this secondary loss of bond, which included severe rejection, with a wish for relinquishment or cot death. This is another example:

S5 was physically abused by her father and sexually by her brother; she was mainly cared for by her grandmother. She lost five pregnancies at about 12 weeks gestation, and had a long history of infertility treatment, including two attempts with in vitro fertilization. After abandoning these attempts, she be-came pregnant. Throughout the pregnancy she was very anx-ious; she had frequent scans and at 32 weeks gestation there was concern about foetal growth. Her interaction with the foe-tus was reduced for fear of building up her hopes. At the age of 35, after induction of labour, which lasted 18 hours, she was delivered by emergency Caesarean section. Her son needed resuscitation and vomited blood. He was irritable, screamed all the time and was difficult to soothe; even her husband found this intolerable and shouted at her to keep him quiet. She was unable to breastfeed and felt inadequate. She worried about him at night and frequently checked him. When, at 12 weeks, she sought help from her health visitor; her relationship with the baby was marked by anxiety; the lack of rejection was sup-ported by her score of 8 on factor 2 of the PBQ (within the

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normal range). As she deteriorated and became depressed, she began to be overwhelmed with feelings of irritability and resentment. She confessed to handling her son roughly, and wanted him fostered. Admitted to the mother & baby unit, her score on factor 2 was now 22 (well above threshold for estab-lished rejection). She responded to treatment of depression, and her relationship with her baby improved. But, after spend-ing some days on a medical ward for treatment of pyelonephri-tis, she dropped him and he suffered a skull fracture. She then refused contact with him, and attempted suicide several times.

In other mothers the quality of the depression suggested that it was primary. Several mothers developed a depressive psychosis, as in this example:

A2 had a history of bulimia nervosa and two episodes of de-pression. After four years cohabitation she had a planned preg-nancy. She felt better than for a long time, thinking she would be a great mother. During labour, assisted only by yoga, she felt under pressure and was unhappy about the quality of care. She gave birth to twins, one of whom was in an incubator for eight days. After the birth, she had “no time at all for myself, or any space”. The twins were small and delicate, and, afraid that she would hurt them, she was extremely anxious in their presence, and “crazy” about keeping them clean and avoiding visitors. She “just hated” the marriage and christening cer-emonies. During the honeymoon she weaned the twins and menstruated for the first time since the birth. She then became depressed, with feelings of despair, unable to think or concen-trate. She felt guilty about many things – she was “a lazy per-son who had sold her soul to the Devil”. Her thoughts would pollute other people’s minds, and she could harm the girls by just looking at them. Several times she asked her husband to allow her to die – she was harming people simply by being alive. She tried to strangle herself and made deep razor cuts on her arms, legs and neck, requiring 50 stitches and a blood transfusion. She felt indifferent to the twins and detached from them - they would be better off fostered. Repeatedly she asked for them to be taken away. “I just want to get away from them. I don’t want to see them.”

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Another mother developed a psychotic depression, accompanied by the idea that she had bowel cancer or a brain tumour; a “second mind in her head” told her she was dying.

The series also includes a few cases of bipolar depression:

A17 had a history of bipolar disorder from the age of 15, with hospitalization for cycloid and schizo-manic episodes, and long periods of suicidal depression and abuse of alcohol. At 16, she met her husband, who, for several years acted as a full-time carer. Lithium stabilised her. She gave birth to a daughter and then had a second, planned, pregnancy. Initially excited, she became depressed in the second trimester and began to wish she were not pregnant; she worried that she would not be able to bond. In the 3rd trimester, her marital relationship deteriorat-ed and her husband began behaving like a teenager. She barely spoke with him, and had no interest in bonding with the foetus. Eight days overdue, she gave birth to a son; during a painful labour, she was begging for help. “I felt my body was being taken over, like some kind of animal, badly out of control”. For several weeks she relived this experience in her head. She suffered from after-pains and mastalgia, and for five weeks was getting only three hours sleep. Three weeks postpartum she began to feel “terrible”. “I did not feel sad, I did not feel anything. My head felt empty.” She was not eating, avoided company and hardly spoke to her husband. She thought of suicide, taking the baby with her. “I thought of getting him out of the way, so I could do something to myself – horrible thoughts that we could both die.” Her son was a strange baby, who cried all the time. “I was not interested in him at all”. She was unable to play with him, and child-care was provided by her husband and his mother. She felt like running away, and transferring care temporarily or permanently. His crying made her angry and she had impulses to shake him; she treated him roughly. After admission to the mother & baby unit, she had a brief hypomanic episode.

C16 had a good relationship with her mother and stepfather. In her teens she had “a terrible temper” and left home at 18 be-cause of the unhappy atmosphere. She lived with a boy-friend and planned the pregnancy. She bonded well with the foetus.

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During parturition the pain was terrible, but she put it out of her mind. Her son was “wonderful” – she could not put him down. But, three months after the birth, she became depressed, with severe irritability and marked mood swings - at times feeling really good, spring-cleaning the house and sitting up all night, at other times unable to do anything, wanting to throw herself from their 7th storey balcony; she was unable to go out because she thought everyone was looking at her and laughing at her being overweight. She “just did not want the baby any more” and told her husband she wanted him adopted.

A third mother developed suicidal depression. Treated with ECT, she recovered and relapsed twice, expressing the idea that the baby was dead and that her husband had stolen all the money; she was remark-ably retarded and looked perplexed and vacant [Relapsing depressive psychosis in the puerperium is characteristic of puerperal bipolar/cy-cloid disorder].

Unwanted pregnancy

This is an enormous problem world wide 28, and there is an obvious connection between rejection of pregnancy and rejection of the child. But this circumstance has been somewhat neglected in clinical assess-ment and research. My 2011 review 10 cited five papers on this asso-ciation.

Over one third of the mothers in this series had one or another mani-festation of unwanted pregnancy, as in this example:

S14 was one of three children of a harmonious family. She had employment in a hospital and was already the happily mar-ried mother of two children, both of whom she loved deeply, although she took several weeks to bond to one of them. Her husband was severely injured in a road accident and, after a fortnight on a ventilator, spent five months in hospital. In the following year she lost a twin pregnancy and grieved for six months; this was followed by a miscarriage. She gave birth to a third child and then, only seven months later (at the age of 31), was devastated to find she was pregnant again. In denial, she hoped ‘it would go away’. Her waters broke early and, at

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28 weeks, she developed an intra-uterine infection. She went into premature labour, and was delivered by Caesarean section of another son. The infant’s sex was a disappointment. She was in much pain after the surgery and relived the experience, waking and sleeping. She became depressed with the loss of three stones in weight. When, after five weeks in an incubator, her son was given to her, she did not want him. Although he was a good baby, who slept 22 hours/day, she developed no maternal feelings, indeed her feelings “bordered on hate”; she felt she was merely a child-minder. She shunned him, never played with him, and always had his face turned away from her. Whenever possible she took him to her mother. She recovered from her depression, but, 15 months later, there was no change in her feelings. She wished he could be put up for adoption, because she was unable to give him the love he needs, but both families would be horrified by this idea.

Six other mothers simply stated that the pregnancy was ‘unplanned and unwanted’; in two it was due to the failure of contraception. S3 said it had “ruined everything”. S6 “hated” the pregnancy. S11 said that “nothing was further from her mind”. M11 accepted the preg-nancy only for sake of husband. C25 “tried to block it out”. C32 was devastated and refused to believe it. A12, who suffered from secondary tocophobia, was scared to have any more. A20 said it was the “worst thing that could have happened”. A23 hoped that if she did not think about it, it would not be true; she did not want the baby and wished it would disappear.

Some of these mothers wanted to have the pregnancy terminated, but it was refused or otherwise impossible, as in this illustrative case:

A24, of Indian ancestry, was born in Britain. At 13, she took an overdose in the context of friction with her father. He died when she was 16, imposing a responsibility on her for her mother and younger siblings; she grieved, became depressed and developed bulimic symptoms. She had high standards and obtained an administrative post. At 18, she was married happily (though living with her in-laws), but had no intention of embarking on motherhood for several years, and was look-

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ing forward to a stretch of life in which she enjoyed her mar-riage without excessive responsibilities. At 19, she conceived through contraceptive failure. She had difficulty in accepting the diagnosis, and required nine pregnancy tests before “it would sink in”. She wanted a termination, but her husband temporized. When, at the 12 weeks ultra-sound examination, she saw the living being inside her, she could not go through with an abortion. Foetal movements made her angry. In the 3rd trimester she became ill with placental abruption. She pressed for induction, and, at 38 weeks, gave birth under nitrous oxide analgesia; she felt drunk and did not remember the labour. De-pression set in immediately and she lost two stones in weight. Her daughter suffered from colic and screamed excessively for several weeks. She became sleep-deprived. Stretch marks were an embarrassment. For six weeks she failed to develop any positive symptoms, regretted the pregnancy, felt trapped, wanted to run away and wished her baby “would disappear”. She would occasionally shout at the baby and had impulses to slap her face and shake her; she once squeezed her arms and picked her up violently. This was all suppressed by the presence of the family and her husband’s devoted support; she put up a front, but was jealous of her husband’s attention to the baby. Relationships with her mother-in-law deteriorated and she felt an outcast in the household.

Thirteen other mothers would have wanted a termination: five were dissuaded by family or the child’s father. One wanted a termination, but her mother threatened never to see her again. One felt that a sec-ond termination would be too traumatic. One, pregnant after rape, went for a second termination, but remembering the trauma of her first abortion, could not go through with it. One other backed out at the last minute. Three decided on termination, but too late.

Other mothers hoped for a miscarriage, as in this example:

M5 presented six weeks after the birth of her daughter. She had enjoyed a happy childhood and was a high achiever, although anxious and self-analytical. She was a gifted performer, who often travelled abroad. She formed a ‘wonderful relationship’ with a divorced man, and all went well until she conceived.

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She decided on a termination at nine weeks, but ‘got cold feet’. She hoped that the pregnancy would miscarry, and did not in-teract with the foetus. Parturition was painful and prolonged, ending with a Caesarean Section under epidural anaesthesia. Afterwards she felt resentful towards her daughter, who had interfered with her first and only real relationship. She felt tense in her presence, and wished her sister would take her over. She said, “I run away from babies, and am fine when I am at work”. After a week’s holiday she felt ‘crushed’ by the thought of returning to child care. She did not seem deeply depressed. Her failure to relate to her daughter put a strain on their relationship, and her partner issued ultimatums.

Seven others hoped for a miscarriage.; one mother prayed for a mis-carriage. One thought the foetus had died, and felt relieved. Three women tried to provoke a miscarriage by lifting heavy weights, induc-ing vomiting or hitting their abdomen.

Seven mothers blamed the pregnancy for major sacrifices, as in this example:

N4 never knew her father. Her mother suffered postpartum mental illness, and two later children were adopted away. She herself was fostered from two to five, and had a love/hate re-lationship with her mother. A step-father (“the only guy I ever liked”) was killed in a car crash. In spite of this inauspicious childhood, and heavy cannabis abuse (3ce daily), she was en-rolled in a psychology course. Her pregnancy, in the context of an 18-month relationship, was unplanned and inconvenient, and she had to interrupt her course. She wept when the diagno-sis was made, but adjusted, and her relationship with the father improved, with high libido. Her mother, excited by becoming a grand-parent, made all the arrangements. Otherwise, prepar-tum bonding and parturition were normal. She was sleep-de-prived, because the baby slept little. She found her physical appearance “horrible”, and became depressed. She had ex-travagant fears that the baby would be hit by a car or develop

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leukaemia. Her relationship with the infant was variable and ambivalent. She felt like leaving him with her mother, and, at worst (three months), discussed adoption. “I felt that hatred, a raging storm in my head, and it was a fine line before I harmed him”. She felt she could throw him into his cot; several times she shouted at him and once kicked the bassinet. By 4-5 months she was enjoying him and fully absorbed. Two months later she was pregnant again and in turmoil over termination.

Three mothers had to give up enjoyable or profitable employment, and a fourth said the pregnancy had interfered with her cherished ambition to undertake nursing training. Two mothers resented their babies, who had interfered with treasured relationships, or with a lifestyle of par-ties, cinema and swimming. Five women had some features of denial of pregnancy, as in this ex-ample:

C25’s mother was only 16 years old, and never showed the slightest interest in her; she was adopted by her grandparents, whom she regarded as parents. When, at 11, her grandfather died, she was taken into a children’s home, because her Nan could not cope. Her childhood, however, was reasonably hap-py, and she was close to her mother’s younger sisters. She often truanted. She had her first children (twin sons) at 17. When she was already the mother of four children from three relationships and living alone, she discovered that she was in the 6th month of her fourth pregnancy; her symptoms were thought to be due to a tube infection. She tried to “block out” the pregnancy, which was “like a dream”. At parturition she would not face the fact that she was in labour, as if it was not happening. When the baby was born, she said, “Move it”. She failed to bond (“There was nothing there”), and consulted her general practitioner, who wrote that she felt unable to cope with a new baby as well as the others, and was not sure about her feelings about the new born; she pushed the baby away when it was crying, and had impulses to “throw him against a wall”. But she took the matter into her own hands, saying, “I have got to face the fact that he is there”. The family and a friend rallied round, taking over much of the care. She became closer to him, and reflected, “How could I ever have thought that”.

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There were four other possible cases. S14 was devastated to find that she was pregnant again and hoped ‘it would go away’. L13 had two late diagnoses of pregnancy - see page 41. N5 noticed “something moving in her stomach” at 5½ months gestation. C32 refused to be-lieve the diagnosis of pregnancy, and only finally accepted it three weeks before parturition.

Evidence of rejected pregnancy in the third trimester is more impor-tant, because nearer in time to the puerperium. Prepartum bonding, that is, interaction by speech, singing and massage with the baby with-in, is common in normal mothers. My 2016 review 1 cited ten papers reporting a correlation between prepartum and postpartum bonding. In this series, 15 mothers had no signs of prepartum bonding, but nor-mal mothers are sometimes too preoccupied with home-making and the care of older children to take much notice of the unborn child. Failure of prepartum bonding can also be due to anxiety about the survival of the child; for example, an anxious mother was told that the child might have Down syndrome, and might not survive, so made no attempt to bond with the foetus. In a few mothers, ignoring the foetus and shutting the pregnancy out of their minds, was consistent with negative attitudes. This is an example:

C7 had some difficulties in learning, and was bullied at school. At the age of 17 she became pregnant and, under pressure from the family, had a termination, from which she never fully recovered. She had a loyal and supportive husband and was already the mother of three children, two of whom had con-genital or acquired abnormalities (none severe). She had not wanted the fourth pregnancy, which was the decision of her husband, and after the birth was sterilized. Throughout, the foetus “felt like an alien”. She made preparations only at the last minute. She gave birth to a daughter, who was born with a palatal defect and “screamed for four months”. She regret-ted the birth, developed no feelings for the infant, and would “gladly have handed her over to someone else”. Some months later, after the operation on the palate, when the baby regressed to babyhood, the mother became depressed and tearful. She felt angry that she had received no help with her problems in the days after the birth. She was a warm-hearted and emotional woman, and the lively home was full of children and kittens.

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Ten mothers reacted with hostility to foetal movements, which was found, in the Anglo-New Zealand study 3, to predict postpartum rejec-tion. The following is an example of a mother who had impulses to attack the foetus:

C5 was one of four children of a broken home. She received no affection from her own mother and never wanted children; the only person who showed affection was her step-father, who died ten years ago. She obtained three ‘A levels’ and worked in a day nursery and old people’s home. By nature she was a determined, tough lady. After living for 5-10 years with her partner, she became pregnant by mistake. She decided against termination, but was strongly antagonistic to the pregnancy. She had impulses to harm the baby within by striking her ab-domen or jumping down the stairs. In spite of that she bond-ed to the foetus, talked and sang to him. After the birth she initially regarded her son as ‘fantastic’, but he proved a very difficult baby, who during the first three months did not sleep and screamed for hours. She ran away several times, leaving him with his father, and shook him violently three times.

Four said they hated the foetal movements, or they made them feel angry. One “dreaded them” - she regarded the foetus as “a parasite inside her”. One felt physically sick when the baby started kicking. One said that foetal movements made her feel ‘bitchy”, and she had impulses to hurt herself so they would stop. Two of these mothers per-petrated frank foetal abuse, such as hitting themselves in the stomach.

The 36 mothers described above had the strongest evidence of un-wanted pregnancy.

Another negative prenatal symptom is dysmorphophobia for the preg-nant state, as in this illustrative case:

A8 had been married 14 years and was the mother of two sons. She wanted a little girl, and, at the age of 30, after hesitating for six years, embarked on another pregnancy. But she ‘knew’ it was another boy and wanted a termination, then backed out at the last minute and induced vomiting in the hopes of harming

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the infant. She hated her pregnant appearance especially her varicose veins, and avoided food. She had to give up work, which she enjoyed. At 20 weeks she was devastated to dis-cover that she was indeed carrying a male child. She made no preparations and did not interact with the foetus. She would not even bother to come down at Christmas to open the pre-sents. She wanted to jump into the canal or smash her car. During parturition she suffered a ruptured uterus and bladder, and was lucky to survive. She was saved by Caesarean section, followed by sterilization. This was a frightening experience and she suffered some post-traumatic symptoms. Afterwards she looked “horrible, a mess”. Her relationships deteriorated, and she wanted to jump off a high building. She said, “God hates me. I shall never have my little girl now”. She did not want the baby, wished he was not there, and did not interact with him. Other family members had to feed him at night. She blamed him for everything, for ruining her life. She wished he would not wake up. She would give him away tomorrow, but her husband refused.

These are twelve other cases of prepartum dysmorphophobia. Several hid their pregnant state, or avoided company.

Factors in the child

A screaming or sleepless child

In the literature there are a number of studies 10 on the infant’s role in postpartum depression and child abuse, but none have included meas-ures of ‘bonding’. Difficult infants were a common association in the present series, mentioned by 34 (about one third) of this series. This is an example:

M13 tried for years to conceive, and eventually resorted to in vitro fertilization. Unfortunately the baby she had craved for suffered from colic and cried continuously. She failed to de-velop any feelings for him, became depressed and was actively thinking of having him fostered. He was referred for a paediat-ric opinion. Within a fortnight his physical state improved, and a normal mother-infant relationship was rapidly established.

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One mother recovered and then relapsed when her demanding baby started whingeing again. Among the others, many spoke about an in-fant that cried excessively, often in association with colic. In a few the crying continued for three, four or eight months. Several mothers complained about the distressing quality of the crying, with statements like, “The times she cried I could not bear it”, “His screaming was terrible”, “He was the Devil incarnate”. One husband found it intoler-able and shouted at his wife to keep the baby quiet.

For six mothers the problem was with sleeping. One said her daugh-ter “was a baby from Hell, who never stopped screaming and did not sleep”. Another said the baby was awake all night – “a total night-mare”. In two mothers the problem was the baby’s vomiting.

It needs to be said, however, that some mothers, even when depressed, can withstand such behaviour, maintaining a normal ‘bond’:

M15 gave birth to her first child after a painful delivery. She continued to suffer pubic pain for three weeks. Her daugh-ter “never slept” from the first day onwards. She screamed “blue murder” for four months. The mother’s depression was extreme, “like a great massive hole, from which she could not climb out. I wished I could have a car accident, or that someone would come to the door with a gun, and shoot me. I have never felt like it before, and I never want to feel that way again’. This lasted six months. In spite of all this she adored her daughter.

Prematurity

Eight infants were born at 37 weeks gestation or less:

S11 was born in India to a harmonious Hindu family, the daugh-ter of a professional man. At the age of 15, she suffered an attack of typhoid. With a background of a university course in science, she had an arranged marriage to a divorcé and before completing her degree emigrated to Britain. She was in love with her husband and optimistic about the future. At 20, after two miscarriages, she gave birth to a son. When he was only 11 months old, she was devastated to find that she was preg-

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nant again. “Nothing could have been further from my mind”. She discussed termination with her GP, but was dissuaded by her husband and his family. She accepted the pregnancy in part, and bought clothes and toys, but became depressed and very anxious. She wished she could return to India and (aided by lack of foetal movements) tried to pretend she was not preg-nant. At 29 weeks gestation, after a painful 18-hour labour, she gave birth to a daughter, followed by a postpartum haem-orrhage. The baby was nursed in an incubator for five weeks. On discharge, she screamed day and night “till she was blue in the face”, and went only one hour between feeds. The mother said, “I never felt close to my daughter, never felt any love for her”; this was mutual – the baby would not gaze into her face or smile, and would arch her back and stiffen if picked up. She wished she would be stolen or disappear. After a month she was shouting at the baby. Initially, her father cared for her, then his family took over; he noted “straight away” the drastic change in his wife’s depressive symptoms and irritability. But a few days later, the mother-in-law was also unable to cope with the incessant crying, and returned her, saying that her daughter-in-law “was a monster, not a mother”, and that was why the baby was crying all the time. After six weeks, the in-fant was admitted to hospital with unexplained facial bruising, and a fortnight later suffered other injuries, including fractures of the ulnar, femur, tibia and humerus, as well as contusion of the brain with life-threatening swelling. Both children were taken into foster care, then transferred to a paternal aunt and uncle. The mother discovered that her husband had been mar-ried before, and resented his terminating her education. His family had broken off relations. She did not appear depressed, and confessed to the bonding disorder.

Three infants were born at 37 weeks, one at 35 weeks, one at 30 weeks and (in addition to the case just described) three at 27-28 weeks. One of the mothers complained that her son looked like “a dead chicken”; it had all happened too quickly, and she did not feel properly prepared for the child. These infants all spent some time in the special care baby unit, so that mother and child were separated in the early stages.

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Illness or deformity

Six infants were born with congenital abnormalities, as in this case:

M6 was trained in sociology and psychology, and happily married; she was referred during her second pregnancy with a history of ‘postnatal depression’. She had a hard time during the first birth: induction took a week, and she suffered a post-partum haemorrhage. Her son was born with a club foot. She failed to develop any positive feelings for him. She had obses-sional impulses to harm him, and was phobic of him for several months. The situation was so bad that she would have liked to emigrate to Australia to get away from him. She gradually improved, with the support of her mother.

One other infant had talipes. The other anomalies were a ‘stork mark’ on the forehead, hydronephrosis, a palatal defect and atresia of the rec-tum. Two infants were in special care with neonatal illness – apnoeic spells and bowel problems.

Infants of the wrong sex

Four mothers were disappointed in the sex of the infant, as here:

S7 (of Indian descent) had sons aged 11, 8 and 4, and was over-joyed when, at the age of 32, she became pregnant again. At 16 weeks gestation she received the “terrible news” that the scan showed another male child. She briefly mentioned an episode of foetal abuse, but without details. After a painful labour, she took one look at the male child and started to cry. She had “no affection anywhere in her heart for him”. Over the course of the next eight months, and especially after six months, her feelings gradually changed from hatred to love. Finally she loved him more than her other children, and was jealous of her mother-in-law holding him.

A Sikh mother, with two sons, much wanted a little girl, and after hesitating for six years, embarked on another pregnancy and was dev-astated to discover that she was carrying a male child; she said, “God hates me. I shall never have my little girl now”.

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Sleep deprivation

The puerperium is notorious for sleep deprivation. But the empiri-cal research, using all-night electroencephalograms, has shown only moderate reductions, the mean sleep time falling from 7½ to 6¼ hours 29. Sleep deprivation was a rather frequent complaint in this series. After subtracting those with the pathological fear of cot death, there were 27 mothers who claimed to be sleep-deprived. Some expressed this in extravagant terms: three claimed that their sons did not sleep at all, and one said for only 20 minutes. A few quantified the sleep loss - only 2-3 hours sleep a night instead of 8-10, only three hours/night for five weeks and 3-4 hours sleep deprivation. Two claimed that sleep deprivation lasted for six months. A mother whose baby was “awake all night, a total nightmare” said she did not know how it was possible to live on so little sleep. In three mothers the loss of sleep was due to depression or physical problems.

All these claims must be accepted with reserve, because the data are unsystematic and uncontrolled. There may be a connection between sleep deprivation and irritability, but it seems less likely to be a signif-icant factor in emotional rejection of the infant.

Parturition and its complications

PainNine mothers complained of excessive pain during labour, as in this example:

A21 felt rejected by her own mother, who was depressed in the context of the failure of her marriage. She suffered some minor sexual abuse between 8 and 13. She obtained a degree in psychology and was happily married. She developed en-dometriosis, and had two miscarriages; she did not expect to carry a baby to term. She was ‘terrified’ when she became pregnant again. The pregnancy was complicated by abdominal pain and vomiting. Her husband’s behaviour changed: he be-came resentful, started drinking, smoking, clubbing and spend-ing money on himself; he often threatened to leave and she feared desertion. Labour, ending in ventouse extraction, lasted

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32 hours, and was intensely painful – she never imagined that anything could be so painful; her consciousness was impaired and she heard voices, even forgot she was in labour [parturient confusion]. She thought she was going to die. Surprisingly she did not suffer any post-traumatic symptoms, but was ex-hausted and sleep deprived with continuing perineal pain. The baby had oesophageal reflux and would scream for up to nine hours. She could not believe it was her own baby. The idea of being alone with the infant caused feelings of panic. She felt like absconding or handing over care permanently, and found herself wishing for a cot death – “That’s terrible, isn’t it; she’s perfect”. She felt like hitting out, but had never even shouted at her. She became so depressed that she considered discon-necting her air bag and driving into a lorry.

There were eight other mothers who suffered “terrible” pain. One mother bit her husband on the cheek [parturient rage]. Another, helped only by pethidine and nitrous oxide, said she could not handle it and screamed, “I don’t want to do this”. Another was begging for help; “I felt my body was being taken over, like some kind of animal, badly out of control”.

Post traumatic stress disorder (PTSD) and complaining reactions A degree of PTSD was noted in ten mothers. This complication has been reported in up to 5% of mothers in the general population, so it was more common in this series, but may not, in some cases, have been severe or persistent enough to meet widely used criteria. The fol-lowing mother developed both PTSD and pathological complaining:

N2 was reared in an unhappy family: her father was an alco-holic and her parents separated. In spite of much truancy, she obtained steady employment. She lived with her mother and a Samoan man, with whom she had a 10-year partnership. She was hirsute and pregnancy was discovered accidentally by a scan taken to exclude polycystic ovaries. She welcomed the pregnancy, but was sick for five months. She was huge and comments on her size upset her; it was difficult for her to breathe at night. Prepartum bonding was normal. At seven months her brother died from cancer and she wanted to avoid

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giving birth on his birthday; but this is what happened. During labour, she was in severe pain for seven hours. The foetal heart was slowing, so she was rushed to theatre and delivered by emergency Caesarean section under general anaesthetic. Her daughter was slow to breathe and was in intensive care for six hours; she had a difficult temperament, was troubled by colic and screamed for several months. In pain for eight weeks from a wound infection, the mother suffered post-traumatic stress symptoms, and even six months later was reliving the event. She complained about her general practitioner’s failure to deal with the baby’s reflux and colic, and was still angry six months later. These post-traumatic, complaining and physical symp-toms dominated the early puerperium. Fear of cot death re-sulted in prolonged sleep deprivation. She became depressed. She felt trapped and distant from the baby, was distressed by her lack of positive feelings and felt better away from her. She had an impulse to run away, and told her partner she would go away and leave them together. She felt angry, but her worst impulse to was shake the baby and worst action was leaving her to cry.

There were seven other cases of PTSD: one was upset by the birth “and often thought about it”; another said her unpleasant labour “preyed on her mind”; another had nightmares and flashbacks for a week; another relived the experience, waking and sleeping for several weeks.

Six other mothers had complaining reactions. One mother was se-verely disappointed with her parturient experience and angry with the “unfriendly and unhelpful” obstetric staff because of a gash on the baby’s face and the delay in performing the Caesarean section. Others were angry about the lack of support from the midwives, the painful “awful” birth or the lack of help with postpartum problems. Caesarean section

This was common in this series – 28 in all, of which 17 were emergen-cy operations. But this may not be higher than the general population. No illustrative case is, therefore, offered.

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Ante- & post-partum obstetric complications

Nine mothers had significant complications – four had wound infec-tions after Caesarean section, two had severe severe postpartum haem-orrhage. One had an ovarian cyst removed at four months gestation. One suffered from postpartum oedema of the hands and face, and could not breast-feed because of mammary oedema. One suffered a ruptured uterus and bladder, and was lucky to survive.

The mother’s experience of mothering in her own childhood

It is often supposed that one of the main causes of ‘bonding disorders’ is the ‘intergenerational cycle of violence and neglect’. It is not likely that this is a major factor, because the first child is often spared - in Kumar’s series 13 7/29 multiparous women developed ‘disorders of maternal affection’ for the first time after a later child; in this series, 32/38 multipara had normal relationships with their first child, and only five had multiple episodes involving the first child; one had two episodes affecting the second and third children but not the first.

Seventeen mothers spoke of the lack of affection they received as chil-dren from their mother or primary care-giver (who was not always their biological mother). This is an example:

L4 was the daughter of an alcoholic, who fathered children by several women. Her mother resented her and gave her no affection; she was often beaten. A sister was addicted to drugs, and had her children removed. She used to run away from home and steal. At seven, after she slashed her wrists, she was removed and placed with her grandmother, who died when she was 16. She later worked as a dental nurse, manicurist and aro-ma therapist. She suffered from poorly controlled type 1 dia-betes mellitus and also from epilepsy, myxoedema and asthma. After the birth of her first child, she became depressed with some evidence of impaired interaction, including an attempt to smother the baby. She was delivered by Caesarean section of a son; his father (who had wanted both children aborted) then left. She moved in with another man, who had been impris-

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oned for assault; he beat her and ‘fingered’ her daughter. She became homeless. She met a third man, another violent recid-ivist, and married him. She was delivered of a second son by Caesarean section. After marital rape and domestic violence, she locked her husband out, and had a brief affair with a lodg-er, then lived for a few months with a fifth man. Her 3rd child failed to thrive. Another baby died at 23 weeks gestation when she was keto-acidotic; she then took an overdose of insulin, writing a suicide note. After she smashed her elder son’s head against a door, all three children were placed on the Child Pro-tection Register. Her marriage continued intermittently, with violence. There were several instances of abuse of this son, who she claimed had attention deficit disorder from birth – he cried 24 hours/day, 7 days/week for eight months. She said of this son, “He used to be a really horrible child. I never sat him on my lap to talk to him. He used always to rub me up the wrong way and I used to say, “Why don’t you shut up? Obviously a bit of work needed to be done on bonding with him.” This was an understatement. After another pregnancy and birth the neonate was fostered, because she was considered immature and mendacious, in poor physical health and often depressed, her life in chaos.

Because this is considered to be such an important factor, here are brief details of the other cases:

S6 was herself the subject of maternal rejection, and was fos-tered at the age of five.

M10 had a poor relationship with her father, and was blamed by both parents for their marriage, resulting from her pregnan-cy and birth.

M22 was scapegoated, starved and beaten by her parents.

C5 was one of four children of a broken home; she never re-ceived any affection from her own mother and never wanted children.

C11 had a poor relationship with all family members; her par-ents were old, distant and unloving, her childhood miserable.

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C21 described her mother as “a nuisance and a tart”; she spent most of the time with her father.

L2 was disciplined by stick, fist and feet.

L7 was never close to her mother, who used to hit her; she never felt wanted at home.

L8 described her mother as ‘a back-stabber’; her childhood was unhappy because of frequent beatings.

L12 received little love from her mother, a “weird” woman who would fly off the handle and “go completely mad”; she walked out for three months when she was five, and once gave her a black eye because she did not want to sleep in a room with a spider.

N3 was out of touch with her mother, who abused alcohol, was “not there emotionally” and there was much friction between them in her teens.

N4 was fostered from two to five, and had a love/hate relation-ship with her mother, who suffered postpartum mental illness; two later children were adopted away.

A11 was one of seven children, none of whom had a positive relationship with their mother.

A13 was a lonely child, who had to cook and wash for herself; her parents spent more time in the pub than with their five chil-dren.

A21 felt rejected by her own mother, who was depressed in the context of the failure of her marriage, and later failed rela-tionships.

A23 was jealous of her brothers, who were always favoured; her mother, who had several admissions to hospital with de-pression, was hard on her.

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Five mothers were also victims of child sexual abuse and two com-plained of having to care for siblings.

Of the 17 mothers who suffered from poor mothering, eight were mul-tiparous, of whom two had ‘bonding disorders’ with all their children, and a third lied about the fate of her first two children. The remaining five had a normal relationship with the first child.

The data in Kumar’s study and the present study is of poor quali-ty. But apparently normal bonding with so many first-born children (seven in Kumar’s study and 36 in mine) is against the role of poor mothering in the mother’s own childhood; this factor is not high on the list of associations.

The behaviour of the infant’s father

There are many examples of the atrocious behaviour of the husband, partner or boy-friend. This one deserted during the pregnancy:

A23’s father deserted when she was two years old, and her mother had several admissions to hospital with depression; she always favoured her two sons (of whom this mother was jeal-ous) and was hard on her. Things began to go badly wrong for her at 14. She was unhappy at school and was thrown out of the home by her mother; she lost 1½ stones in weight and took an overdose; at 15 she was expelled for arguing and fight-ing. At 17 she became pregnant. When she informed the fa-ther, he put down the telephone and was uncontactable; later he disputed paternity, and dragged his feet about DNA testing. She hoped that, if she did not think about the pregnancy, it would not be true; she did not want the baby and wished it would disappear. She became massive and did not like people to look at her. She suffered from vomiting and back pain, and became depressed. She was delivered by emergency Caesar-ean section (for foetal distress) under general anaesthetic after an 18-hour labour – “never again”. She felt nothing for her son. She breast-fed for four months, in spite of pain. She was sleep-deprived, and became depressed, drinking a litre of cider every day. She wanted to get away and had some ideas about transferring care. She shouted at him a few times.

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There were six other cases of desertion: five left during pregnancy, one hung up the telephone when informed of the diagnosis, and two de-serted after the mother refused a termination. Another father deserted three months after the birth. Three fathers found other partners during or after the pregnancy.

Domestic violence was common, and was a prominent feature in six cases. They included a mother kicked in the stomach by the father when he heard about the pregnancy. Another father started hitting the mother at three months gestation, so she moved into her sister’s house; he discovered where she was living, and renewed the abuse, imprisoned her, beat and raped her (resulting in a new pregnancy). Two husbands ‘regressed’ when their wives became pregnant: one be-gan behaving like a teenager in the third trimester; the other became resentful, started drinking, smoking, clubbing and spending money on himself, then threatened to leave.

The husband of a Birmingham mother (not in this series) took a shot at her during the pregnancy. Another, in Manchester, visited after the birth and said, “That’s not my baby”. It must be hard to bond to an infant born in such circumstances.

Other associations

Bereavement

Losses by stillbirth or miscarriage occasionally appeared to be a factor as in this case:

A9 lost her first child from pneumococcal meningitis when just under two years old. The couple wanted another baby – the house was so quiet. The timing of her pregnancy was, howev-er, unfortunate because the expected date of birth was about the anniversary of the death. She feared a miscarriage or congen-ital abnormality, concealed the pregnancy from neighbours, ignored the foetus and made no preparations. Grieving over her daughter worsened as she cut down her working week. Worrying about having a normal baby kept her awake. Three

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days overdue, and five days before the anniversary, she was delivered by ventouse without analgesia; in her pain she bit her husband on the cheek. She had nightmares and flashbacks for a week. Her son developed a chest infection, and was admitted to special care on day 2, dehydrated and lethargic. She devel-oped a wound infection and anaemia, and passed clots, so was in hospital when she wanted to visit the grave. She continued to grieve - having another child made her loss more acute. She worried about using her daughter’s clothes for the baby. She became depressed and disorganized, with anorexia and loss of energy. For five weeks, her son screamed every night for five hours. At 10 weeks she felt no love for him and was unable to cuddle him. She said, “I don’t feel I can get close because I might lose him”. She felt particularly anxious in his presence. She felt like running away, or temporarily handing over care. She would get angry and call him “my monster”. A couple of times she had told him to shut up, but her worst impulse was to walk out. She had a high score (24) on factor 2 of the PBQ.

A3: The father of this 28-year old suffered from depression. Her mother was not very affectionate, and they clashed. But her childhood was quite happy and secure. She became a wild child ‘to gain attention’. She was married at the age of 19, and was delivered by forceps of her first child – a daughter (after which her husband left, returning when she became pregnant the 2nd time several years later). She gave birth to a second child – a son. Two years later, she had a third, unplanned and unwanted, pregnancy; the twins died in utero, and were mac-erated at birth. She was unable to come to terms with this stillbirth, which did not seem real. She became pregnant for the fourth time, again unplanned; this angered her husband and both families, and interfered with her cherished ambition to undertake nursing training. She was however determined to see it through, and was anxious about the survival of the in-fant, especially in the third trimester, when she slept little. She was obsessive about housekeeping. After early induction and an easy birth, though tinged with sadness, she gave birth to a second daughter. Afterwards she felt blank. Her husband was overjoyed but ceased to help after a week’s paternity leave, and she had no help from her mother. She breast-fed for six

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months and was sleep deprived. Her womb prolapsed and was repaired surgically; in the women’s hospital she heard about a baby born too prematurely and every time she closed her eyes, saw the faces of the twins. She considered that she had “paid a high price for having another baby; my body’s the one that is different”, and occasionally blamed the newborn child. The marital relationship deteriorated – he masturbated in her presence; she felt embarrassed about her weight gain. She felt low and could not concentrate even on a women’s magazine. She sometimes blamed the baby for her physical symptoms. “There’s a block there somewhere”. She preferred working in the garden to playing with her, and had occasional ideas of es-caping. She shouted and swore at her daughter, and sometimes left her to cry but would not dream of hurting her. “I would not be without her, but I’ve got a lot of problems because of her”. Obsessions and grief were the main feature.

Five other mothers were bereaved. Three lost close relatives during the pregnancy or puerperium. Apart from A3 (just described), one other experienced a stillbirth:

S6 suffered a 24-week stillbirth eight months earlier. When she became pregnant again, she had not yet recovered and ‘hat-ed it’, saying, “I didn’t want this baby to take the place of the first.

Two mothers had severe reactions to a miscarriage:

C20 lost an infant with trisomy 18 at 18 weeks. She never recovered from the loss of this child (whom she named); as an animal lover she had looked forward to caring for a handi-capped infant, and felt cheated.

C22 suffered a miscarriage, and “desperately wanted another child”. When she conceived, she was “over the moon’, but after the birth could not stop thinking about the miscarriage, saying, “There should have been another baby in that cot”.

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Friction with in-laws

The following mother had a difficult relationship with her mother-in-law:

C2 was born into a prosperous family in the Punjab, and was warmly attached to her father. The family used to take holi-days in England and moved here when her father died in her 17th year. She did well at school, and had an arranged mar-riage, which was fairly happy, although her mother-in-law, who lived with them, appeared not to approve of her. At the age of 27, after the birth of her first baby, she became depressed and irritable. “ I am feeling terrible bad and hating myself, be-cause when I see the baby I wish someone would pick it up and go”. She claimed to like the baby, but did not like looking after him. “I want to go somewhere else on my own for 3-4 weeks”. These feelings were unknown to the family.

Two other mothers mentioned poor family relationships. One had a poor relationship with all members of her family, and with her hus-band’s family. A single mother was discharged from the maternity hospital to her in-laws’ overcrowded home; after a violent row, she attacked her mother-in-law and attempted to smother the infant.

Antecedent mental illness (apart from depression)

A history of psychological disorders was common, but may be equally common in the general population.

Seventeen were perfectionist and houseproud, and two had been treat-ed for obsessional disorders. It is possible that anankastic (obsession-al) traits are a risk factor for various mental disorders linked to preg-nancy, but this has never been investigated.

Three mothers had a history of anorexia or bulimia nervosa. One of these made many suicide attempts and harmed herself by self-cutting, cigarette burns and head-banging, then developed bulimia nervosa.

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Another mother showed much evidence of early disturbance – saw a child psychiatrist at 10, was expelled from school, took several over-doses and spent two months in a detention centre for arson and shop-lifting.

Thirteen mothers abused alcohol and/or other ‘substances’, at some stage, as in this example:

A16 had a happy childhood and made friends easily. She un-dertook a college course in travel and tourism but failed to finish because of a vehicle accident. She abused cannabis, ecstasy and amphetamines. She had an on-off partnership lasting four years, receiving no support from the man. They planned the pregnancy, but she considered a termination be-cause she was thinking of leaving. She had much morning sickness, and, in mid-pregnancy, pain. Because of a pelvic fracture and spinal problems sustained in the accident, she had a 37-week planned Caesarean section, and was delivered of an infant weighing only 2.7 kg. In the puerperium she developed a pelvic infection and other physical problems, had hardly any sleep and found breast-feeding “a horrible experience”. Her partner threatened to move out because she was not coping. She became depressed. “I thought the baby would make me happy, but all my drives have just gone”. She was frightened, tense and “scared to death” of being with her daughter, who was “too much responsibility” [puerperal panic]. She was afraid of harming the baby, and did not want to be left alone with her. Her daughter was “a nightmare”, who cried a lot and was always feeding. “She does not feel like my baby”. She felt trapped, and was starting to regret having her. “I don’t want to be with her, but I don’t want to be rid of her. I want her to be with someone I know. I would be happy to have her if someone is helping”. She had been winding her roughly and felt like shouting at her. Her score on the PBQ factor 2 was 20 (above the threshold for established rejection).

Among the other twelve cases, three abused several ‘substances’, three cannabis as well as alcohol and the rest ethanol alone; two had been admitted to hospital for detoxification.

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Apart from parturient delirium (four mothers), only the following two mothers suffered from a non-affective psychosis:

L7 was the last of a family of five, born 12 years after the fourth; she was never close to her mother and never felt want-ed. She was immature, timid, and ‘afraid of her own shadow’ or swallowing her tongue. She was unhappy at school, and had difficulty holding down jobs. At 16 she moved in with her future husband. At 24 she gave birth to a son, and, three years later, to another son. At 28 she had the first of seven admissions to hospital: she heard critical voices talking about her and believed her conversations were being tape-recorded, that she could see into the future, could influence television and was Diana, Princess of Wales. She was treated with depot flupenthixol. A pregnancy was terminated. At 37, she nagged her husband into having another baby, but, in mid-pregnancy changed her mind, felt like an incubator and wanted an abor-tion. She was sensitive about her pregnant appearance (“an el-ephant”) and developed gestational diabetes. She gave birth to a daughter. The baby was “too much trouble”, and she would kill herself if it were not taken away. “When she’s not there, I feel great. When she is there, I feel trapped”. She wished the infant has been stillborn, and hoped she would go to the cot and find she was not there. She shouted at her, and had an impulse to suffocate or drown her. Admitted to a mother & baby unit, there was some improvement, but her bond was vacillating and precarious, with frequent demands for adoption, which was opposed by her husband. After she had attempted to occlude the baby’s breathing, her daughter was removed to foster care.

R3 was already the mother of one child, living with the child’s father. As soon as her second pregnancy was diagnosed, she left her partner without telling him, returned to her parents and had no further contact, behaviour similar to that after her first child was born. She rejected the child from birth, and was admitted to a psychiatric mother & baby unit. During her admission there she twice abused the infant, who was removed and placed for adoption. She remained on an acute psychiatric ward for six months. At follow-up seven years later, she had thrice been readmitted with a diagnosis of ‘schizophrenia’.

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Summary

This review of associations, based on unsystematic data, suggests that depression, unwanted pregnancy and infant screaming are likely to be causal. The role of sleep deprivation, parturient stress and the moth-er’s own history of poor mothering is less cogent.

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6

Unusual circumstances

Ethnic minorities

Unusual backgrounds

Multiple pregnancy

Infertility

Effect on the family

Presentation at the next pregnancy

Bonding failure and the fear of cot death

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Ethnic minorities

Fifteen mothers in this series were from ethnic minorities – eleven from the Indian sub-continent (Hindu, Sikh and Pakistani), two Maori, and two Afro-caribbean. This is a Maori mother:

N1 was sexually abused as a child. She had mitral valve dis-ease, rheumatoid arthritis, systemic lupus and sarcoidosis. She had been depressed for years, with bulimia. At the age of 25, after she had been with her partner for six years, her heart function improved and she stopped contraceptives. She was happy about conception, but regretted the pregnancy with the sickness, and, feeling fat and ugly, tried to hide it. Her arthritis flared up and she became sleep-deprived. Her libido increased, and she required intercourse 3-4 times/day. Foetal movements made her feel ‘bitchy”, and she had impulses to hurt herself so they would stop. Bulimia continued and she was obsessive about house-cleaning. She was delivered by emergency Cae-sarean section under epidural anaesthesia (for foetal distress). She hated herself for her failure to give birth naturally. Af-ter the birth she suffered from oedema of the hands and face, and could not breast-feed because of mammary oedema. The scar was uncomfortable and her dysmorphophobia worsened. Sleep deprivation continued for two months. She cried when she looked at the baby – “She could not possibly be mine. I felt I had not even been pregnant”. From day 3 she was “bawling her eyes out” and just wanted to sleep, with ideas of driving over a cliff. “It is not fair I have brought her into this world, when I don’t have the mental stability to care for her. I wanted to crawl under a rock and die”. The baby would sleep for less than an hour and scream for hours. For four months there were no positive feelings. “I felt like putting her in the cot and go-ing far away”. She sometimes wished for cot death. “I knew I would grieve, but it would go away and I could start all over again”. She had impulses to suffocate her and had shaken her twice. After four months her feelings spontaneously improved.

It is known that these disorders also occur in Japanese mothers 30 31.

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Unusual backgrounds

‘Bonding disorders’ are no respecter of persons. A number of moth-ers in this series have belonged to caring professions, or shown much evidence of high moral standards and public-spirited attitudes. They have included highly religious women, a barrister, two neonatal nurses and a scout leader. This is an example:

A18 was herself rejected by her mother (who doted on her el-der brother), and reared by her grandmother. Otherwise her childhood was normal, and she was close to her father. She left school without qualifications and worked as a nanny, then mar-ried. After giving birth to three children, she undertook some training and became the coordinator of an organization to help mothers. She also cared for several elderly and sick relatives. She took in foster-children. At one stage she suffered from depression and abused alcohol. After several miscarriages and the termination of a pregnancy for a congenital abnormality, she gave birth to two daughters. The second was a “desperate-ly wanted” planned pregnancy and she was excited when she conceived. During the pregnancy, she was unwell with vari-ous disorders including antenatal bleeding. Interaction with the foetus was normal. At 37 weeks she went into premature labour and had to have an emergency Caesarean section under spinal anaesthetic because of transverse lie. She bled severely and was disappointed about the delivery. Afterwards she felt numb and empty, and, as far as the baby was concerned, this flatness continued. Due to anaemia, she was breathless and too tired to care for the baby. Her husband and daughter (a nursery nurse) did the caring, and there was no pathological anger. Still depressed, she returned to her work, feeling guilty about not wanting to handle the baby, whom she ignored. She never did anything at all for her, and, when away from home, never gave her a thought – she made no phone calls and the baby never crossed her mind. She said with equanimity, “If she died from cot death, that would be another one gone”. She presented as a cheerful woman, complaining of this lack of affection for the infant.

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Multiple pregnancy

Six mothers had twin pregnancies. In two there was a different re-sponse to the twins:

S2 was already the mother of two daughters. She became preg-nant again, and, under pressure from her husband, had a termi-nation. Her 4th pregnancy was also unplanned and unwanted, but she felt that another abortion would be too traumatic, and hoped for a miscarriage. At seven weeks gestation, her attitude changed, and she bonded well to the babies inside, enjoying foetal movements and talking to them. At 37 weeks, after 32 hours in labour, she was delivered by emergency Caesarean section, to the ruin of her hopes of a natural birth. The second twin looked “disgusting”, and she had flashbacks of this image even nine months after the delivery. The twins were in incu-bators for seven weeks, and the second twin was so ill that she held him only once. When they arrived home, she hated the second twin. The first twin was her dream child, but the second was a ‘mucky baby’, demanding and sickly, crying constantly unless held; he often vomited and had diarrhoea. To look at him made her cringe. She did not see him as her own child; he was ruining her life, and she wished that someone else would take over his care, or that he would suffer a cot death. She said, “He brings out the worst in me, and controls my thoughts and actions”. She felt better when he was not there. After she had shaken him twice, her partner discovered that their son had a broken arm. She failed to respond to five months treatment on a mother & baby unit.

S16 was one of twins; her mother has a ‘nervous breakdown’ and there were frequent parental arguments. Trained as a nurse, she met her husband at church. Her first pregnancy led to the birth of twins; she failed to bond to one of them, a troublesome baby who cried loudly and persistently. Her feelings amounted to hatred, and lasted over a year - she was often angry and once shook the child, resulting in deep guilt. Eventually she came to love this child, aided by prayer. The second pregnancy was her best experience of motherhood; after the birth, the couple did

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not intend to have any more. The third pregnancy was a mis-erable time; she did not acknowledge the foetus, but was ‘des-perate to get her out’. The birth was ‘traumatic’; she was angry with the lack of support from the midwives and nearly wrote a letter of complaint. Breast-feeding was demanding of her time. She became depressed, and felt ‘numb’ towards her baby daughter, who was difficult to please especially later when she developed colic. She was often angry with her, wondered why they had her, and at times felt like running away.

The next two mothers rejected the surviving twin: S13 had two children fathered by an abusive partner. Each child was a twin, the other twin being lost - the first was still-born, the second died in utero. After her first birth she felt numb for months, a severe depression with the loss of three stones in weight; she “wanted to be dead with her still-born child”, had no feelings for the surviving infant, and did not even want to look at her. Years later she still felt cold to this daughter and “just wanted her taken away”. After the second birth, she bonded to her son and did not grieve for his dead sister.

R7, who already had two children, gave birth to twins, one of whom was stillborn. She herself was transferred to a medi-cal ward with kidney failure. After her discharge she became depressed, and was hostile to the surviving twin. “She would wind me up in a way the other children couldn’t. I don’t know why. Sometimes I would just take my tablets and go to sleep, just to get out of her way. I was afraid I would hurt her”. Admitted to a mother & baby unit, she showed severe rejection, and remained rejecting and hostile when discharged eight weeks later. Because of her fears of injuring the baby, her daughter was transferred to relatives. After several overdoses, the mother was hospitalized alone. When she recovered from depression, the baby was returned to her care, and attended a day nursery; but her hostility persisted. At follow-up two years later, the mother was still prone to depressive episodes and still easily irritated by the child.

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The following mother probably rejected both twins:

R9, after an unplanned and unwanted pregnancy, gave birth to twins. One died from ‘cot death’ under suspicious circum-stances. The mother was admitted to the mother & baby unit; she was rejecting the surviving infant.

I saw a mother (whose records were no longer available) who rejected triplets, born after infertility treatment.

Infertility

It is remarkable that a mother, as just mentioned, can reject a baby achieved after years of infertility. This is another example:

C29’s childhood was overshadowed by the tantrums of her el-der sister. She described herself as “a whirlwind; it is hard to get me to sit down”. At 16 she became pregnant and relin-quished her son. She qualified as a nurse, and rose to a senior status. She obtained a psychology degree, was much involved in church activities, ran, painted and grew organic vegetables. She developed Crohn’s disease, resulting in major operations and an ileostomy, after which she suffered her first episode of depression. She was married at 22, but, after seven years, her husband, whom she had supported throughout his college edu-cation, walked out, leaving a note: “I love you but cannot live with you”. She picked up the pieces and soon afterwards met her second husband. She was infertile due to polycystic ova-ries and blocked fallopian tubes, but embarked on an attempt to conceive by in vitro fertilisation: eleven ova were removed, but three failed to implant, and only one frozen embryo survived and resulted in a viable pregnancy. Both parents related well to the baby in the womb. She was in labour for a week, and, when the cord prolapsed, delivered by emergency Caesarean section and nearly lost the baby. But her daughter “was a baby from Hell, who never stopped screaming and did not sleep”. She regretted having her and several times said she did not want her, and, in spite of breast-feeding, would prefer someone else to take over. She sometimes shouted at her and was tempted to hit her. With treatment, she recovered in eight months.

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The next mother suffered a bonding delay (not rejection) after several disappointments:

C20, in her teens, suffered from anorexia nervosa, then bulim-ia. She overcame this problem, obtained a university degree and became a lay reader. She married an ordinand. During the first five years of marriage, she was infertile. Treated with clomiphene for anovulatory cycles, she conceived. An infant with trisomy 18 was born at 18 weeks. She never recovered from the loss of this child; as an animal lover she had looked forward to caring for a handicapped infant, and felt cheated. She again became pregnant with clomiphene and lost the infant at nine weeks, due to a blighted ovum. In the next year a third baby was lost at 20 weeks, the cause unknown. When, with clomiphene, she became pregnant for the 4th time, she was un-able to relate to the foetus, and denied feeling any foetal move-ments until 23 weeks gestation. She made no preparations for the birth, because she dared not think that the baby would live. When she gave birth to her daughter, she was non-plussed. “It did not seem like my baby, but somebody else’s”.

Three other mothers with a history of infertility (S5, S9 and M13), whose full details have already been described, rejected their infants.

Effect on the family

In a number of cases, emotional rejection of an infant caused trouble in the family. The following mother was described in Motherhood and Mental Health:

M9, an immigrant doctor with a 7-year old son, greatly desired another child, and became pregnant. She visited a fortune-tell-er, who told her that the child would be handicapped. She de-cided to have a termination, which was interdicted by her hus-band. A female infant was born with atresia of the rectum. The mother developed an intense hatred for her, referring to her as ‘the bitch’, and was, in turn, rejected by her husband, his fam-ily and her son. She became deeply depressed, and developed

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the delusion that she was changing into a monkey, pleading not to be sent to a zoo, where she might be impregnated by another monkey. ECT relieved the depression, but the rejection of her daughter remained unresolved, and family discord continued for years.

There are ten other cases. In five, the marriage or partnership came under strain or ended. In the others, it was the in-laws who took against the mother.

Protection by caring relatives or friends

As explained in Motherhood and Mental Health, one of the emergen-cy measures that must be taken, when rejection is threatened and es-pecially when there is any sign of anger with the infant, is to relieve the afflicted mother of the care of a fractious baby. There are many in-stances in this series where the intervention of friends or relatives has protected the infant from the wrath of the mother. This is an example:

M21 had three children. Two lived with their father. The third, aged two, lived with her and her own mother, who provided most of the care. She accidentally became pregnant for the fourth time. She considered a termination, but was persuaded to continue. The pregnancy was difficult and the birth unpleas-ant. She again “did not take to the baby”, and felt better when away. She refused to look after her daughter, and, as before, care was taken over by her mother, who was completely toler-ant of her daughter’s behaviour. In the mother & baby service she was offered day hospital treatment; she immediately had a panic attack and rushed out to her mother, who was waiting outside. The mother came in and explained that her daugh-ter was “not maternal”; she worked in a confectionary shop and brought the children cakes. “I look after the children”, she said. They were advised that there was no need for her to parent this baby, and no hurry in deciding whether and when she should take over some responsibility. She attended the clinic for support. After some weeks she was able to feed the baby and change nappies when she felt like it, while the grand-

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mother undertook most of the care. She continued to refer to her daughter as ‘the baby’ and never used her name. The first birthday was a crisis, but she was again reassured that the situ-ation was under control. A further crisis occurred when the fa-ther found a new partner, because she had been punishing him for the pregnancies. Three years after her referral, she came to the clinic with a baby, who sat on her knee. “It’s [NAME]!” she said triumphantly. The child had wheedled its way into its mother’s affections.

These are two more examples:

A6 had received treatment for obsessional hand-washing. She had been in a relationship for eight years, but suffered from tocophobia. Nevertheless she had a planned pregnancy. At 40 weeks she went into labour, and, after 19 hours, was deliv-ered by emergency Caesarean section because of face-to-pubis presentation. She felt happy for two days, but was troubled by the failure of breast-feeding, abdominal pain, and the baby’s excessive crying and failure to sleep. She had much help from her 70-year old mother, who had eight children. She worried about cot death and watched her son all the time. She bond-ed immediately, but lost her positive feelings, and (after four nights without sleep) began to regret the pregnancy, and want-ed to get away. She occasionally felt angry with the baby, had an impulse to throw him on the floor and once banged him on the back when winding him. Her mother took over.

A14 was already the mother of nine children. She again had a planned pregnancy, very much wanted. She was delighted to be pregnant again, but in mid-gestation began to regret it be-cause her husband was in trouble at work and they risked los-ing their house. She failed to bond with the foetus. Her mood may have been elevated in the 3rd trimester, when she was tire-lessly active in spite of sleep deprivation; this continued for a week after the birth. She was delivered of her tenth child by elective Caesarean section. The infant had talipes, and she was disappointed to have another girl. “They handed me the baby and I went flat”. After two weeks she became depressed, with terrible morbid thoughts. She felt crushed, could not get any

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food down, was crying all the time and shaking with anxiety. She often spent the day in bed, and could sleep 24 hours. She had no interest in the children, who were all going to die. She improved, then relapsed, once with premenstrual deterioration and recovery at menstrual bleeding “like switching on a light” [probably bipolar disorder]. She remained “very distant from the baby”, who felt like another mother’s child, for whom she was baby-sitting. She said, “I don’t think about her ever”. It crossed her mind to send her away to a childless friend. There was no anger. Her church networks rallied round, and her hus-band and 14-year old daughter looked after the baby.

There were twelve other babies who were cared for by others – five by the husband, two by his mother, and one each by her own mother, her sister, her daughter, other relatives or a neighbour. I had another patient, whose records were not available, whose three sisters took over the care of the baby.

Presentation at the next pregnancy

It is a testimony to the suffering of these mothers that some presented, not in the throes of the disorder, but later, when they became pregnant again. This is an example:

C13 was born into a happy family; she worked as a secretary at a hospital. She had a good relationship with her husband. She was upset by a miscarriage, but, within a year, was pleased to conceive again; she bonded normally with the foetus. After the birth her son did not sleep at all, and she became depressed, and, in spite of treatment, remained depressed for months. The baby “did not feel like her own. It could have been anybody’s baby”. She did not love him, and felt nothing for him. She would have been happy for someone to pick him up and take him away, and never bring him back. She had, however, no feelings of hostility or rejection. This lasted for six months. She presented in the second trimester of her next pregnancy. She was well, but concerned about a recurrence.

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Five other mothers presented during the next pregnancy, apprehensive about a recurrence, and one mother considered a termination.

The role of breast-feeding

Only one mother lost her ‘bond’ after she had to wean the baby:

A22 had a history of depression. She became pregnant, as planned, in the context of a 9-year partnership. She cried with pleasure when she conceived. She loved being fat and feel-ing the baby move, and was always laughing and joking. Her libido improved. She was ‘petrified’ about parturition, being small. In fact she did not suffer: there was foetal distress and she was delivered by emergency Caesarean section under gen-eral anaesthetic. Her husband’s sister, who was childless, was the first to hold her son. In the puerperium abdominal infection and pain persisted for 10 weeks, resulting in hospitalization. She was upset not to feel much emotion, especially witnessing the joy of another mother on the ward. Her son did not resem-ble her, and she joked that he had been switched. But these feelings passed, and she enjoyed breast-feeding. Bonding was normal. Her sister-in-law was a second mother to him. At ten weeks she required antibiotics and was instructed to wean the child. This broke her heart. She had failed to give natural birth, was not the first to hold him and breast-feeding was one thing she could do well. The sense of loss could not have been worse if someone had died. She felt a failure. She lost her bond, and felt disconnected, could not be bothered with him. She considered handing him over to her sister-in-law. When he refused a bottle, she screamed at him.

It is remarkable, indeed, that breast-feeding, which might foster ‘bonding’, was not always protective. Five rejecting mothers breast-fed for 3-8 months. One, who said that only breast-feeding stopped her leaving, breast-fed for years. The mother who committed suicide was breast-feeding.

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‘Bonding’ failure and the fear of cot death

The pathological fear of cot death is the most common of the spe-cific postpartum anxieties, the main focus in 12% of the Anglo-New Zealand series 3. There is a sharp contrast between this fear and the bizarre symptom of a wish for cot death. It is remarkable that six mothers had this fear and rejection at different stages:

C23 had a happy childhood, but her father became aggressive after developing hypertension and diabetes. Although intelli-gent, she was a rebel at school. She attended college for busi-ness studies, where she met a man of a different ethnic group; when she was 19, they eloped without the knowledge and con-sent of their families. After eight years of happy marriage she conceived an unplanned but welcomed pregnancy. She had high expectations. She gave birth to a son at 37 weeks. Shortly afterwards, the baby choked and stopped breathing for a few seconds. From then on she suffered a perpetual fear that he would die from a cot death. She became depressed. In the second month there was a crisis when she had a transient idea of smothering her son. This made her aware that she had no feelings for her baby, felt trapped and wanted to escape. She even discussed adoption with her husband.

Five others with a pathological fear of cot death later became de-pressed and rejected their infants:

S5 worried about her son at night and frequently checked him; she became depressed and began to be overwhelmed with feel-ings of irritability and resentment.

N2 suffered from a fear of cot death resulting in severe sleep deprivation; because her daughter screamed for several months, she became depressed, felt trapped, distant and distressed by the lack of positive feelings. She had an impulse to run away, and told her partner she would go away and leave them.

A10 was extremely anxious and constantly checked the baby. When she became depressed, she did not want her any more, regretted the pregnancy, felt like escaping and had thoughts of transferring care; unable to stand her crying, she had an im-pulse to throw her out of the window, shake or suffocate her.

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A13 worried about cot death, having lost a sibling that way. She became deeply depressed with the loss of two stones in weight, felt nothing for her demanding baby, felt totally de-tached and at times thought he was not hers. She thought of running away permanently, considered adoption, shouted at him, and had twice thrown him roughly on to the bed.

The fifth is a remarkable example of a mother who had both the fear and the wish for cot death:

N6 gave birth to a son, then suffered five miscarriages, includ-ing one @ 18 weeks and one late termination (for tuberculosis). She had a 4-year relationship with a man in prison. Because of these losses she did not react to the news that, at the age of 37, she had again conceived. She informed her mother at 5-6 months gestation – to meet with disapproval (because the preg-nancy was out of wedlock). She suffered from vomiting and back pain, and her attitude became more negative. She did not relate to the foetus and much of the time did not feel pregnant, although she was embarrassed about her size. At 37 weeks gestation she gave birth to a second son. She had complete amnesia for her labour. The early puerperium went well; for three weeks she could cuddle and kiss the baby. She travelled to the North Island to meet her partner’s relatives - a wonderful experience, but her first son became jealous and his behaviour deteriorated. From the start she was extremely anxious about cot death, and would check the baby 200 times night and day, her sleep being reduced to three hours/night. She became de-pressed, losing all energy and appetite, and would sit in a chair or lie in bed all day. She felt unworthy to be a mother. She accused her partner of having an affair, and felt jealous of his relationship with the baby. Her baby was hungry and demand-ing. She began to feel disconnected, had a distressing lack of feeling, felt trapped, and unable to do the things she wanted to. She no longer wanted the baby and twice felt like running away. She wished for his death – “If the others did not survive, why should he?” When he would not stop crying, she had an impulse to drown him in the bath and shake him.

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7

Conclusions

Status of the syndrome

Research suggestions

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Status of the syndrome

It has been difficult to persuade ‘perinatal’ mental health profession-als to recognize the existence, severity and frequency of ‘bonding disorders’. For example, Stephen Pilling, a professor of clinical psy-chology and Chair of the National Institute of Clinical Excellence Guidelines on Antenatal and Postnatal Mental Health (2007), wrote 32 that mother-infant relationship disorders “were outside the scope of the guideline which focused on maternal mental health”.

Psychiatrists and psychologists sometimes get entangled in disputes over terminology. Whether or not emotional rejection of an infant is a disease, a mental health problem, a disability or a disorder depends on the definition of these terms. At a more basic level these emotions and behaviours are phenomena or entities – things we can recognize and identify; they should evoke the universal scientific response – description, naming, definition (with the distinction from other phe-nomena), diagnosis and measurement, the investigation of frequency, prognosis and effects, and the search for causes and interventions. The disturbances of emotional response described in this monograph cannot, in any sense of the word (even the biological sense of threat-ened survival) be regarded as normal. Anger and hatred are less ob-viously a concern for psychological medicine than depression and anxiety; but the agenda of the mental health services is set by public demand, not by dogma. These disorders are squarely in the clinical domain, because mothers, with nowhere else to turn, seek help from us; they receive treatment, often with full success. They are mor-bid, clinical phenomena. Helping professions cannot refuse available treatment, and must find concepts that correspond accurately to the experiences of sufferers, and channel patients towards effective in-terventions.

Professor Pilling was wrong to assert that these disorders are outside the scope of the maternal mental health services. Emotional rejection of the infant is not only within the baileywick of these services, it is their most specific disorder, with the greatest danger to the health and safety of the infants. Whatever the definition of ‘maternal men-tal health’, specialist teams in mother-infant (‘perinatal’) psychiatry must recognize, teach and become expert in their diagnosis and treat-ment; failure to do so is culpable malpractice, putting infants at risk.

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Research suggestions

Description of the syndrome

Although this is the largest data base so far assembled, it is woeful-ly incomplete. Only a minority of rejecting mothers had the 2-hour Birmingham Interview, and none had systematic observations. To provide an authoritative description of this syndrome requires a large series, from a community sample or complete clinical collection, all of whom had a combination of routine clinical investigation, a thorough interview and systematic observations by the staff of a day-hospital or in-patient unit, or the home observations advised by Ainsworth 33. Definitions, screening questionnaires and brief videotaped observa-tions can be validated against this more complete documentation of the disorder.

Cohort studies

With the Stafford Interview 23 we have an ‘instrument’ which can be used, together with self-rating questionnaires, in cohort studies of mothers randomly selected from the population, followed from mid-pregnancy for several years. Since the morbid phenomena have a frequency of 1% or less, it is necessary to focus on high-risk groups, and unwanted pregnancy is the most obvious and available category of mothers at elevated risk. The data collection should proceed in four stages:

1 As a first stage, screen a random sample of mothers in early pregnancy, focusing on pregnancy planning; this would result in an approximately equal number of planned and unplanned pregnancies.

2 In the 3rd trimester, mothers with unplanned pregnancies are interviewed, with screening questions that address attitudes to the pregnancy and prenatal bonding; this would result in a large group of mothers who accepted the pregnancy, and a smaller number whose attitudes were persistently negative.

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3 These preliminary stages result in three groups – a random selection of planned pregnancies, a random selection of un-planned but accepted pregnancies, and a complete group of unwanted pregnancies.

4 After the birth, the three groups are followed for several years, comparing the incidence of depression, infant rejection, pathological anger and child maltreatment. This strategy can also assess the predictive power of the antecedent factors dis-cussed in Chapter 5.

The parental brain

The mother infant relationship resides in a sequence of cerebral events. During the last ten years, a number of studies have used function-al magnetic resonance imaging, or similar tools, in normal mothers reacting to photographs or films of their infants, smiling or crying. The cerebral process is complex. Brain activation is widespread, in-volving areas of the frontal and temporal cortex and insula in sensory analysis, and cortico-limbic circuits in the emotional response.

These studies of ‘the parental brain’ are beginning to be extended to depressed mothers. Up until 2016, only one study had included meas-urements of maternal ‘sensitivity’ 34. The rapid and complete recovery of many rejecting mothers could allow a comparison of pathological and normal reactions in the same mothers at different stages. Even a single case study would be of great interest. It could yield a marker, useful in the confirmation of a clinical diagnosis. It would transfer this disorder from a disputed behavioural syndrome to a neuroscientific entity.

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7 Oppenheim H (1919) Über Misopädie. Zeitschrift für die Gesamte Neurologie und Psychiatrie 45: 1-18.

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12 Robinson J B (1983)The natural history of mother-infant bonding disorders.Unpublished Masters thesis, University of Manchester.

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15 Brockington I F (2008) Maternal attachment and bonding disorders. Chapter 2 in S D Stone & A E Menken (editors), Perinatal and Postpartum Mood Disorders, New York, Springer, pages 17-39.

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18 Harman W V (1981) Death of my baby. British Medical Journal 282: 35-37.

19 Smialek Z (1978) Observations on immediate reactions of families to sudden infant death.Pediatrics 62: 160-165.

20 Trickett P K , Kim K, Prindle J (2009) Emotional abuse in a sample of multiply maltreated, urban young adolescents: issues of definition and identification. Child Abuse and Neglect 2009; 33: 27-35.

21 Chapman A H (1959) Obsessions of infanticide. Archives of General Psychiatry 1: 12-16.

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24 Weightman H, Dalal B M, Brockington I F. Pathological fear of cot death. Psychopathology 31: 246-249.

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26 Bernazzani O, Marks M, Bifulco A, Siddle K, Asten P, Conroy S (2005)Assessing psychosocial risk in pregnant/postpartum women using the Contextual Assessment of Maternity Experience (CAME).Social Psychiatry & Psychiatric Epidemiology 40: 497-508.

27 Forman D, O’Hara M, Stuart S, Forman L, Larsen K, Coy K (2007) Effective treatment for postpartum depression is not sufficient to improve the developing moth-er-child relationship. Development & Psychopathology 19: 585-602.

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Index

NotesThe following have been omitted or simplified• Bonding, emotional rejection of child, mother-infant relationship, which are the themes

of this monograph • Pregnancy and its three trimesters• Medical, surgical, pathological, obstetric or gynaecological disorders and their

treatment, mentioned only once or twice; these were grouped under single headings – Gynaecological disorders, Infections, Medical disorders, Obstetric complications and Treatment of medical disorders

• 23 psychiatric disorders in a different speciality, and their treatment, mentioned only once or twice

• 38 miscellaneous items mentioned only once or twice• Towns and countries.

Abandonment of infant 11 22 29-31 44 69Absconding 30 62 69 70Adoption 3 29 30 36 50 70 85 102 103 115 122 130Alcoholism, see Ethanol abuse Ambivalent infant relationship 8 61 103Anaesthesia

Epidural 7 15 16 18 28 33 36 45 59 61 73 76 102 126General 19 112 116 135Spinal 27 43 127

Anankastic personality 6 9 15 18 21 23 26 31 32 43 44 59 67 83 118 120126

Anger: In general, see irritability

grading 53 54 Management 71with foetus or infant 2-5 11 13 14 18 20-23 26 35 36 39-55 57 58 60 61

64-67 82 97 98 102 103 112 118 129 132 133 136 140 142

Anglo-New Zealand study 3 5 55 58 92 93 96 105 136Anorexia nervosa, see Eating disorders Antidepressant treatment 3 21 25 29 47 82 83 87 93-95 97Anxiety:

In general 24 40 45 49 59 67 72 122 132 140Infant-focused 26 33 38 45 57 58 60 65 88 89 96 97 111 118 121Prepartum 7 94-96 104 108Postpartum 32 60 66 76 134

Apnoeic attacks 19 29 49 76 109 136Assault on child 4 13 16 20 24 30 32 36 40 42 43 45-47 48-51

52-55 61 63 65 68-75 77 80 83 85 95-98 101 108 113-115 121 122 128 133 137

Arson 59 68 69 84 86 121Auditory hallucinations 8 9 40 111 122Avoidance of infant 11 14 21-22 97 100

Phobic 22 27 58 61 96 109

Baby massage 82Baby-sitting (child-minding) 12 19 34 41 45 84 134Bathing with infant 8 23

Bereavement, see Grief Berkson bias 92Bipolar disorder 98 134Birmingham Interview 4-6 45 55 141 Breast-feeding 7 12 15 16 19 22 32 33 46 59 60 62 83 87 96 116

118 121 129 130 133 135Bulimia nervosa, see Eating disorderBullying at school 14 23 24 39 40 48 60 76 93 104

Caesarean section 14 28 34 43 61 69 76 83 88 89 100 102 106 112-114 121 133

Emergency 7 9 15 18 19 27 49 71 88 96 112 116 126-128 130 133 135

Care or protection order 48-50 69 73 74 85Causation 92Child maltreatment:

in general 11 23 39 76 82 142emotional 39 69 85neglect 2 21 23 39 52 53 67 68 70 77 87 113physical abuse, see Assault on child (any grade of severity)sexual abuse 14 24 30 49 61 64 69 73 96 110 114 116 126

Child guidance clinic 68 84 121protection authorities 30 35 40 50 55 71 75 77Protection Register 48 53 70 114stealing 3 11 28-29 45 108

Childhood, Unhappy 14 19 24 40 43 49 53 62 65 66 113-116 Chronicity 79 85-87 129 Cross-case analysis 5Cohort studies 92 141Colic 8 9 26 27 32 47 101 106 107 112 129Complaining reaction 7 9 18 66 97 104 111 129Community (population) studies 55 92 111 112 141Conception, reaction to 7 21 52 62 64 73 76 95 102 109 110 119 126 127

133-135Congenital abnormality 7 54 55 59 86 89 104 109 117 119 127 131 133Cot death, see Sudden Infant Death syndromeCourse 39 79 81-82 85-89Criminal record 19 23 30 39 41 45 49 52 66 68 69 73 74 84 113 114

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Danger or risk to infant 5 13 20 35 55 61 93 140 Death of infant or child 20 74 77 117

See also sudden infant deathof mother 38 62 84 107 111 129of mother’s own mother 21 27 93

Defaulting from treatment 40 60 68Delay in maternal response 55 57 58 99 131Delusions 13 21 45 63 97-99 122 131 Denial of pregnancy 13 18 19 41 61 99 101 103-104 116Depression:

In general 6 15 18 25 27 30 38 44 49 58-60 66 69 74 91-99 114-116 118 123 126 127 129 130 135 140 142

Prepartum 7 9 12 23 29 32 40 85 87 98 108 116Postpartum 3 6 8 9 15 16 18 19 21-29 31-34 37 38 41 43 44 46

47 52 53 57 58 61-63 64-66 71 74-76 83-86 88 89 92 93 95 97-102 104 106 107 109-113 118-121 126 127 129 133 134 136 137

Psychotic 9 45 63 64 97-98 122 131Desertion by father of the child 27 29 31 32 36 40 48 61 70 86 110 116-118Desire for child (strong) 15 21 62 93 95 127 131 133Diagnosis,

Definitions 3-5 55 111 140 141Differential 5 57-72 140Failure to 18 41 57 58 76-77 88 140

Dislike of child 3 11 14-16 22 53 75 85 86 94 102 103 113Dissociation between depression and rejection

93-95 100 132Divorce or separation 21 30 31 40 47 66 71 73-75 105 107 111 114 122 130

132of parents 16 32 45 61

Domestic violence 7 23 29 30 32 48 65 70 73-75 83 86 87 114 117 129Drowning 2 35 44 47 51 93 122 137Dysmorphophobia 7 9 29 44 48 63 66 67 74 101 102 105-106 111 116

119 122 126

Eating disorders 6 9 18 24 59 97 100 120 126 131Electro-convulsive therapy 21 23 25 27 34 63 83 94-96 99 132Emigration or immigration 14 24 25 59 69 94 107 109 131Epilepsy 6 48 51 59 60 64 65 77 113Escape from child care 8 9 11 12 15 16 17-27 29 30 32 34 38 44 45 47 51

52 54 55 60-63 71 73 75 81 88 89 96 98 101 105 111 112 115 116 118-120 126 129 133 136 137

Estrangement (from infant) 8 11 12-13 15 22 24 26-30 32 38 40 45 54 55 69 70 73 75 76 83 89 96 100 111 121 126 128 131 134 137

Ethanol abuse or addiction 6 9 15 23 24 31 32 45 49 60 61 66 69 70 73 84 98 111 113 115-117 121 127

Ethnic minorities 86 125 126 136Exhaustion of mother 25 26 37 60 111Extra-marital ‘affair’ 15 21 30 46 60 61 66 74 114 117

Factitious disorder 57-60 72Failure to thrive 19 53 62 71 77 114Family history of mental illness 6 15 24 28 64 66 74 102 115 118 128Filicide:

In general 2 40 42 52-54 71attempt 35 40 42 51 52 54 93 113 120 122thoughts 19 20 29 30 39 61 65 76 83 86 98 122 126 136 137threat 2 25 27 36 50 51 70

Flashbacks 112 118 128Foetal abuse 3 29 102 105 109

death in utero 12 19 36 86 114 118 129distress 15 19 59 112 116 126 135movements 7 9 12 18 28 34 36 38 61 87 101 105 108 126 131

135scans 19 22 27 59 96 101 109

Follow-up (outcome) 5 9 30 80 82 83 85 87 122 141 142Forceps delivery 12 33 118Foster care 49 50 66 69-71 84 97 102 103 106 108 114 115 122

127See also Temporary transfer of care, Care Orders, Removal of child

Fractures 40 42 49-51 75 108 121 128Frequency 4 54 55 140

Friction (or unhappy relationship):between parents 15 53 66 73 128with children 60 86 132with partner 7 16 18 20 30 31 38 46 49 60 64-66 71 74 87 98

102 106 107 110 119 121 131 with in-laws 7 14 52 74 83 87 101 108 118 120 131 132with family of origin 14 18 25 31 32 40 45 48 63 66 69-71 91-93 98 100

102 114-116 118 120 131-132 137

Gaze avoidance 11 14 16 18 22-23 34-36 47 54 55 75 86 96 100 108General practitioner 27 28 35 46 51 53 73 76 77 83 103 108 112 Grandmother 8 17 40 50 63 68 70 76 81 84 89 96 98 102 103 109 113 118 127 132-134Grandparents 2 15 24 35 64 74 83 96 103Grief 36 38 63 99 100 111 117-119 126 129Guilt, self-hatred 17 18 31 33 37 44 48 83 95 97 120 126-128Gynaecological disorder 64 110 111 113 119 130

Haemorrhage 28 101 108 109 113 127 Retinal 48 51 53 77

Hatred of infant or children 2 3 9 11 16-18 36 37 41 44 47 48 52 54 55 62 72 73 76 77 80 81 83 87 95 100 103 128 131 140

Head or brain injury 6 42 48-53 76 97 108Health visitor 28 30 84 96High-risk group 141 Higher education 5 6 14 37 43 80 107 109 110 121 130 131 136 Home observations 141Hospitalisation without infant 25 27 30 50 62 69 83 88 95 115 116 122 129 135

Impulses to harm infant 4 8 14 16 21 22 26 27 32 38 42-45 47 48 51 52 54 64 65 72 73 75-77 96 98 101 103 105 111 130 133 136

Induction of labour 12 15 16 26 32 76 96 101 109 118Infant care, by an older sibling 15 62 116 134

Competition for 13 52Delegation of 15 18 19 24 26 45 53 59 62 63 72 75 76 84 86 96

98 100 102 103 106 108 121 127 132-133Infanticide, see FilicideInfection 19 24 26 28 76 100 103 117 121 Infertility 15 74 106 125 131

Treatment for 15 73 96 106 130-131Insomnia 17 21 24 32 63 64 66 76 117 118

of infant 26 44 47 76 94 102 105-107 110 126 130 133 134Intensive care 26 28 48 49 51 73 74 97 100 108 109 112 118 128Irritability 23 24 38 43 47 49 53 64-67 70 71 73 86 97-99 108

110 115

Jealousy, between siblings 60 86 115 116 137Conjugal 46 48 64 137over infant 59 65 101 109 137

Learning disability 52 53 55 104Loss of employment 7 18 61 103 106Lying 53 57 58 72-75 114 116 Magnetic resonance imaging 142Malpractice 55 140

Marriage, Arranged 14 43 83 94 107 120Medical disorder 6 7 19 21 26 27 33 38 41 51 59 60 66 76 77

97 98 111 114 118 122 126 127 129 136 Medical student contributions 4 6 23 29 34Medico-legal reports 4 6 40 73 75Memory impairment or loss 6 22 26 101 137 Miscarriage 19 36 43 49 62 68 69 70 95 96 99 107 110

117 119 127 131 134 137Hope for 23 29 31 43 46 74 87 101 102 105 128

Mood better away from infant 8 9 11 15 16 18 54 60 75 94 112 122 128 132on return to work 15 18 20 21 27 47 86 102

Mother & baby admission 16 25 27 29 30 34 35 37 46 50 63 69 71 72 75 80 83 85 88 89 96-98 122 128-130 141

day hospital 29 47 87 95 132 141Mother-infant services 3 4 8 28 55 58 61 62 66 75 77 84 132 140Mother’s own mothering 91 92 105 110 113-116 122 123 127Multiparity, infants spared 113 116 Multiple pregnancy 17 50 68 85 86 97 99 103 118 119 125 128-

130

Nanny 20 64 127 Nausea aroused by infant 14 36 75 105Neonatal death 36 52

illness 30 44 51 60 73 75 76 95 111 112 118 128Neuroscientific studies 92 Nitrous oxide 32 60 65 66 101 111Nursing observations 23 141

training 6 15 74 87 103 118 128 130

Obsessional disorder 38 61 66 67 119 120 133Obsessions of child harm 26 42 109Obstetric complications 7 23 61 95 96 106 113

teams 7 12 13 18 19 28 34 66 97 112 129Overdose, see Parasuicide Panic, Postpartum 18 21 58 72 121Parasuicide 25 30 40 43 46 59 69 71 84 88 100 113 116

120 121 129Parental brain 92 142Parturient confusion 13 19 24 111 122

rage 111 118Parturition:

Excessively painful 9 16 18 21 30 32 45 59 66 76 91-93 95 98 99 102 107-112 118 123 129

Prolonged 7 34 45 102 128 130Perfectionism, see Anankastic personality‘Perinatal’ psychiatrists 76 140Pethidine 32 45 111Personality disorder 24 41 55 57 58 67-72 Play therapy 3 34 82-84 94Police 23 31 75 77Postpartum Bonding Questionnaire

(PBQ) 20 29 75 96 118Post-traumatic stress disorder 6 7 9 15 32 65 98 100 106 111 112 118

PregnancyPlanned 7 12 14 16 23 25 27 34 37 43 45 46 52 59 62

66 83 93 97 98 121 126 127 133 135 141 142Unplanned 14 26 28 30 31 35 43 46 48-50 52 61 63 71 72 75 81

84-88 99-102 105 107 108 118 128 130 132 136 141 142

Unwanted 5 9 12 18 30 32 36 43 46 50 51 72 74 75 81 85 91-93 99-106 108 118 119 123 128 130 141 142

Premature birth 33 49 52 73 74 87 100 107 108 119 127Prepartum bonding 7 12 18 21 23 25 26 32 43-45 49 52 59-61 64 71 73

74 76 81 85 87 88 95 96 98 102 104-106 117 127-131 133 134 137 141

Preparation for birth 15 28 44 59 73 76 81 104 106 108 117 131Psychologists 83 140 Psychosis (except depressive) 52 55 58 98 122Psychotherapy 3 83 132

Random sample 141 142Rape 23 25 29 64 84 101 114 117 Recurrence 79 87-89

Fear of 17 32 58 89 94 125 134-135Regretting pregnancy 7 8 14 27 32 34 37 44 47 60 62 75 83 96 98 100 101

104 121 122 126 130 133 136Rejection of infant

Established 3-5 55Threatened 3-5 12 55 132

Relapse 21 25 47 80 96 99 107 134Relief at removal of child 12 35 36-39 102 108Religious devotion & practice 65 128 130 131 134Relinquishment of child:

Completed, see AdoptionWish for 4 9 11 12 15 18 21 24 28 29 31-37 40 41 43 45

46 48 52-55 61-63 69 72 74 76 82-84 86 88 94-96 98-100 103 104 106 111 120 122 128-130 134-137

Removal of child 7 36 49 68 71 80 84 113 129Response to new born 26 29 53 70 109

to treatment 79 82-85 142Resuscitation of infant 19 35 36 51 59 66 76 96 112

Sacrifices for pregnancy 102-103‘Schizophrenia’ 23 31 59 122School expulsion 84 116 121

refusal 25 52 70 Screaming of child 8 9 14 15 19 26 27 37 40 47-49 60 64-66 71 73 76

85 87 92 95 96 98 101 104-108 111 112 114 118 121 123 126 128 130 132 133 136

Secondary loss of bond 21 27 47 95-97 133 136 137Self-cutting, self-harm 23-25 60 63 67 69 120Shaking infant 14 16 30 46-47 49-52 60 66 67 70 73 76 83 105 126

128Shouting or screaming at infant 8 13 14 17-19 21-24 27 32 38 42-48 50 52 54 55 60

62-67 70-73 95 101 103 108 116 119 121 122 130 135 137

Sleep deprivation 21 24 27 32 33 36 38 44 59-61 64 65 84 91 92 98 101 102 110-112 116 119 121 123 126 133 136 137

Smell of infant 14 16 50 54 55 84

Social services 7 31 33-37 60 68 74 77See also Child Protection

Spontaneous recovery 17 81-82 126 133 Stafford Interview 55 141Starvation of infants 2 39 52 71 77 114Sterilization 68 104 106Stigma 93Stillbirth 3 33 36 37 46 86 117-119 122 129Substance abuse or addiction 23 24 31 66 69 73 84 102 113 121Sudden Infant Death syndrome 36 50 68 127 130 137

Fear of 24 26 29 38 59-61 65 73 96 110 112 125 133 136-137Wish for 3 9 11 16 30 34 36-38 46 47 50 54 70 75 84 85 87 88

96 106 111 122 126 128 136 137 Suicide:

attempt 3 8 9 15 21 25 31 72 83 85 97 114see also ParasuicideCompleted 35 49 53 62 73 84 135Impulses or plans 8 11 15 17-21 23 26 29 30 32 39 40 48 87 98 99 106

111 126Threat 34 60 122

Support for mother 7 23 25 32 42 61 63 65 70-72 80 82 89 101 103 104 109 121 133

Lack of 27 48 52 59 60 74 85 112 118 129Surgery 64 95 104 119 130

Termination of pregnancy 12 26 28 29 31 36 43 52 58 60 61 66 68-71 74 81 84 87 100-105 108 113 117 121 122 127 128 131 132 135

Theft 41 68 70 86 113See also Child-stealing

Threat to kill 23 50 71Tocophobia 2 18 21 27 38 59 65 100 133 135Transfer of care,

Temporary 4 11 26-28 33 36 38 43 54 60 63 97 98 116 118 136See also fostering, removal of child Permanent, see Relinquishment

‘Trapped’ 8 12 15 17 32 34 38 44 46 60 75 96 101 112 121 122 136 137

Treatment of emotional rejection 55 82-85 93 94 132 140of medical disorder 7 28 48 97 131 of neonatal illness 20 95 104

Truancy 52 68 103 111

Ugly infant 14-16 54 55 87 93 128 Unworthiness as a mother 34 35 39 57 58 62-64 137Urgent precautions 55 82Ventouse delivery 21 38 59 95 110 118Vehicle accident 6 7 59 62 99 107 121Vomiting by infant 19 62 71 107 128

Weight loss 16 17 22 24 29 34 47 48 58 59 76 86 95 100 101 116 129 137

Wound infection 83 112 113 118 135Wrong sex, Infant of 7 22 100 106 109 133

Bookbinding note

This monograph was typed by the author, using Times New Roman as the main font, with Garamond [between square brackets] for comments within the case descrip-tions.

The text was arranged in ten booklets using InDesign CS4, and printed on 90g/m2 acid-free Five Seasons recycled bookwove from John Purcell, using an OKI 9655DN LED laser printer.

The booklets were sewn, and bound between split archival mill-boards.

The headbands were sewn with silk, with the bead on the edge.

The bookstock was bound in Heritage Buckram from Ratchford Ltd (Stockport), completed in MMXVIII.

This exemplar is no.