Eficacia de la Terapia Cognitivo-Conductual en el Manejo del Estrés Prenatal e Impacto en el Cortisol y Desarrollo Infantil

El objetivo general de la presente Tesis Doctoral fue investigar la eficacia de la Terapia Cognitivo-Conductual (TCC) para el afrontamiento del estrés en mujeres gestantes, aplicada en modalidad presencial y telemática. La tesis reúne siete estudios publicados en revistas indexadas en el Journal Citation Report (JCR), divididos en dos bloques de objetivos. El primer bloque, titulado “Eficacia de la TCC en mujeres embarazadas y efectos en la descendencia” cuenta con dos objetivos específicos: 1) analizar si existe una relación entre los niveles de cortisol en el cabello y/o el estrés psicológico durante la concepción y las primeras semanas de embarazo con respecto al sexo del feto; y, 2) evaluar la eficacia de la TCC en la reducción del estrés en mujeres embarazadas a nivel psicológico y hormonal, y cómo dicha eficacia se relaciona con el neurodesarrollo y cortisol del bebé. Los estudios 1 y 2 abordan estos objetivos específicos. Los resultados del estudio 1 mostraron una asociación entre niveles más elevados de cortisol en cabello el momento de la concepción y las primeras semanas de embarazo y una mayor probabilidad de tener un feto femenino. Sin embargo, no se halló relación entre el estrés psicológico de la madre y el sexo fetal. De este modo, los resultados de la investigación parecen respaldar las teorías explicativas que sugieren que las concentraciones de cortisol en el momento de la concepción tienen un papel importante en la determinación del sexo del feto. El estudio 2, un seguimiento de un ensayo controlado aleatorio, incluyó dos grupos de mujeres embarazadas: uno que recibió TCC para controlar el estrés durante el embarazo y un grupo control que recibió los cuidados habituales. Los resultados mostraron que, los bebés del Grupo de Terapia (GT) presentaron menor concentración de cortisol en cabello al nacer, pero no se encontraron diferencias significativas entre los dos grupos en relación con los niveles de cortisol a los 6 meses. Con respecto al neurodesarrollo, los resultados revelaron que los bebés de los GT presentaban un mayor nivel de neurodesarrollo cognitivo y motor a los 6 meses de edad. A modo de conclusión del primer bloque, los estudios 1 y 2 revelan que existe una relación entre la concentración de cortisol de la madre durante el momento de la concepción y los primeros meses de embarazo y el sexo fetal. Por otro lado, la TCC para el afrontamiento del estrés es eficaz, aplicada durante el embarazo, en la reducción de estrés y síntomas psicopatológicos, y además, podría tener implicaciones en las concentraciones de cortisol de los bebés a corto plazo y en el neurodesarrollo motor y cognitivo a medio y largo plazo. El segundo bloque de objetivos se titula “Eficacia de la TCC en gestantes implementada de manera telemática durante una crisis sanitaria” y aborda tres objetivos específicos mediante cinco estudios. El primer objetivo específico del segundo bloque se enfocó en analizar la salud psicológica perinatal durante la pandemia, tanto en el transcurso del embarazo como después del parto. Para la consecución de este objetivo se llevaron a cabo los estudios 3 y 4. Por un lado, los resultados del estudio 3 mostraron que el grupo de mujeres gestantes durante la crisis sanitaria presentaban mayores niveles de sintomatología depresiva y de ansiedad fóbica, así como, mayores niveles de estrés percibido en comparación con aquellas mujeres gestantes antes a la misma. En esa misma línea, los hallazgos del estudio 4 revelaron que las mujeres que dieron a luz durante la pandemia presentaban niveles más altos de depresión, ansiedad, hostilidad, ansiedad fóbica, somatización, obsesiones y compulsiones, sensibilidad interpersonal y psicoticismo El segundo objetivo específico del segundo bloque, consistió en investigar la interacción de la resiliencia, estrés y ansiedad en mujeres embarazadas en dos situaciones de estrés diferentes: antes y durante la pandemia de COVID-19. Para abordar este objetivo se llevó a cabo el estudio 5, en el cual se estudió la relación entre la resiliencia psicológica, estrés percibido, estrés específico del embarazo y ansiedad, del mismo modo que en los dos estudios previos, a través de dos cohortes de mujeres gestantes: el primero evaluado antes de la pandemia; y, el segundo evaluado durante la misma. En ambos grupos, se observó que la resiliencia disminuía los niveles de estrés específico del embarazo y el estrés general percibido, así como la sintomatología de ansiosa. Asimismo, el estrés específico del embarazo y el estrés percibido presentaron correlación entre ambos y, éstos a su vez, predecían el aumento de los síntomas de ansiedad. El tercer y último objetivo específico del segundo bloque se focalizó en estudiar la viabilidad y eficacia de la TCC para el control del estrés en mujeres embarazadas, aplicada telemáticamente durante la pandemia. Para alcanzar este objetivo se llevaron a cabo los estudios 6 y 7. A través de ambos estudios, se comprobó que la TCC para el control del estrés aplicada de manera telemática en mujeres gestantes es viable y eficaz en la reducción de los niveles de estrés y sintomatología psicopatológica de ansiedad, depresión y obsesiones-compulsiones, así como, en el incremento de la resiliencia. A modo de conclusión del bloque 2, las situaciones de crisis sanitarias como las pandemias, que implican restricciones en la movilidad y el contacto social, desembocan en un aumento del estrés y los síntomas psicopatológicos en el periodo perinatal. No obstante, la resiliencia psicológica puede actuar como un factor protector contra el aumento del estrés y los síntomas ansiosos, tanto en situaciones de crisis como en contextos ordinarios. Por último, un programa de intervención psicológica basado en la TCC para el manejo del estrés, aplicado de manera telemática, puede aumentar los niveles de resiliencia psicológica y reducir los niveles de estrés psicológico y los síntomas psicopatológicos en mujeres gestantes. En resumen, los resultados obtenidos en los dos bloques de objetivos demuestran que la TCC es efectiva en la reducción del estrés y los síntomas psicopatológicos en mujeres embarazadas, tanto en modalidad presencial como telemática. Además, se encontró una relación entre las concentraciones de cortisol materno durante la concepción y los primeros meses de embarazo y el sexo fetal. La intervención con TCC también mostró implicaciones en las concentraciones de cortisol en los bebés a corto plazo y en su neurodesarrollo motor y cognitivo a medio y largo plazo. Por otro lado, durante situaciones de crisis sanitaria, como pandemias, el estrés y los síntomas psicopatológicos en el periodo perinatal aumentan. No obstante, la resiliencia psicológica puede actuar como un factor protector contra el aumento del estrés y los síntomas ansiosos en contextos de crisis y situaciones ordinarias. En este sentido, la aplicación de un programa de intervención psicológica basado en la TCC para el manejo del estrés de manera telemática puede mejorar la resiliencia psicológica y reducir los niveles de estrés y síntomas psicopatológicos en mujeres embarazadasThe general objective of this Doctoral Thesis was to investigate the efficacy of Cognitive-Behavioral Therapy (CBT) for stress coping in pregnant women, applied in face-to-face and telematic modalities. The thesis compiles seven studies published in journals indexed in the Journal Citation Report (JCR), divided into two blocks of objectives. The first block, entitled "Effectiveness of CBT in pregnant women and effects on offspring" has two specific objectives: 1) to analyze whether there is a relationship between cortisol levels in hair and/or psychological stress during conception and the first weeks of pregnancy with respect to the sex of the fetus; and, 2) to evaluate the effectiveness of CBT in reducing stress in pregnant women at the psychological and hormonal level, and how this effectiveness is related to neurodevelopment and cortisol in the baby. Studies 1 and 2 address these specific objectives. The results of study 1 showed an association between higher levels of cortisol in hair at the time of conception and the first weeks of pregnancy and a higher probability of having a female fetus. However, no relationship was found between maternal psychological stress and fetal sex. Thus, the research results appear to support explanatory theories suggesting that cortisol concentrations at the time of conception play an important role in determining the sex of the fetus. Study 2, a follow-up of a randomized controlled trial, included two groups of pregnant women: one that received CBT to manage stress during pregnancy and a control group that received usual care. The results showed that, the babies in the Therapy Group (TG) had lower hair cortisol concentration at birth, but no significant differences were found between the two groups in relation to cortisol levels at 6 months. With respect to neurodevelopment, the results revealed that the TG infants presented a higher level of cognitive and motor neurodevelopment at 6 months of age. To conclude the first block, studies 1 and 2 reveal that there is a relationship between the mother's cortisol concentration during conception and the first months of pregnancy and fetal sex. On the other hand, CBT for stress coping is effective, applied during pregnancy, in the reduction of stress and psychopathological symptoms and, in addition, it could have implications on infant cortisol concentrations in the short term and on motor and cognitive neurodevelopment in the medium and long term. The second block of objectives is entitled "Effectiveness of telematically implemented CBT in pregnant women during a health crisis" and addresses three specific objectives through five studies. The first specific objective of the second block focused on analyzing perinatal psychological health during the pandemic, both during pregnancy and after delivery. In order to achieve this objective, studies 3 and 4 were carried out. On the one hand, the results of study 3 showed that the group of pregnant women during the health crisis presented higher levels of depressive symptomatology and phobic anxiety, as well as higher levels of perceived stress compared to those pregnant women before the crisis. Along the same lines, the findings of study 4 revealed that women who gave birth during the pandemic had higher levels of depression, anxiety, hostility, phobic anxiety, somatization, obsessions and compulsions, interpersonal sensitivity, and psychoticism. The second specific objective of the second block consisted of investigating the interaction of resilience, stress and anxiety in pregnant women in two different stress situations: before and during the COVID-19 pandemic. To address this objective, study 5 was carried out, in which the relationship between psychological resilience, perceived stress, pregnancy-specific stress and anxiety was studied in the same way as in the two previous studies, through two cohorts of pregnant women: the first evaluated before the pandemic; and the second evaluated during the pandemic. In both groups, resilience was observed to decrease levels of pregnancy-specific stress and general perceived stress, as well as anxiety symptomatology. Likewise, pregnancy-specific stress and perceived stress correlated with each other and, in turn, predicted the increase in anxiety symptoms. The third and last specific objective of the second block focused on studying the feasibility and efficacy of CBT for stress management in pregnant women, applied telematically during the pandemic. In order to achieve this objective, studies 6 and 7 were carried out. Through both studies, it was proven that CBT for stress management applied telematically in pregnant women is feasible and effective in reducing stress levels and psychopathological symptoms of anxiety, depression and obsessions-compulsions, as well as in increasing resilience. To conclude block 2, health crises such as pandemics, involving restrictions in mobility and social contact, lead to increased stress and psychopathological symptoms in the perinatal period. However, psychological resilience can act as a protective factor against increased stress and anxious symptoms, both in crises and in ordinary contexts. Finally, a CBT-based psychological intervention program for stress management, applied telematically, can increase levels of psychological resilience and reduce stress levels and psychopathological symptoms in pregnant women. In summary, the results obtained in the two blocks of objectives demonstrate that CBT is effective in reducing stress and psychopathological symptoms in pregnant women, both in face-to-face and telematic modalities. In addition, a relationship was found between maternal cortisol concentrations during conception and the first months of pregnancy and fetal sex. The CBT intervention also showed implications on cortisol concentrations in infants in the short term and on their motor and cognitive neurodevelopment in the medium and long term. On the other hand, during health crises, such as pandemics, stress and psychopathological symptoms increase in the perinatal period. However, psychological resilience can act as a protective factor against increased stress and anxious symptoms in crisis contexts and ordinary situations. In this way, the application of a CBT-based psychological intervention program for stress management in a telematic manner can improve psychological resilience and reduce levels of stress and psychopathological symptoms in pregnant women.Tesis Univ. Granada

Giving birth during a pandemic: From elation to psychopathology

Ministry of Economy, Knowledge, Business and University of the Junta de Andalucia, Grant/Award Number: A-CTS-229-UGR18; European Regional Development Fund (ERDF); Spanish Ministry of Science, Innovation and Universities, Grant/Award Number: 18/00617Objective: To compare the postpartum psychopathological symptoms of women who gave birth before the pandemic with those who gave birth during the pandemic. Methods: A total of 212 women participated in the study, of which 96 gave birth before the pandemic and 116 during the pandemic. Psychopathological symptoms, postpartum depression, perceived stress, and resilience were evaluated. Results: Women who gave birth during the pandemic had higher scores on somatization, obsessions and compulsions, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, and psychoticism. In addition, perceived stress was the common predictor of an increase in these symptoms. Conclusion: Postpartum is a complicated period in a woman's life. Many psychological adaptations take place and women may be subject to psychological alterations during this period. In addition, women who gave birth during the COVID-19 crisis may show greater psychological vulnerability, due to the specific situation experienced during the pandemic. The COVID-19 pandemic may have played a role in the increase in psychopathological symptoms after childbirth. Detecting possible symptoms postpartum plays a crucial role, because it allows intervening and preventing the development of psychopathologies.Ministry of Economy, Knowledge, Business and University of the Junta de Andalucia A-CTS-229-UGR18European CommissionSpanish Ministry of Science, Innovation and Universities 18/0061

Stress and Psychopathology Reduction in Pregnant Women through Online Cognitive Behavioural Therapy during COVID-19: A Feasibility Study

Background: The global pandemic has affected the psychological health of the population, including pregnant women. Due to the difficulty of offering conventional therapies to reduce stress in this population, studies are needed to show the effect of online therapies. Therefore, the objective was to test the effect of online cognitive behavioural therapy in pregnant women during the pandemic on the main variables of stress and psychopathology. Methods: The sample consisted of 16 pregnant women who participated in a weekly cognitive behavioural intervention for 8 weeks. Prenatal concerns, general stress, stress vulnerability, resilience and psychopathology were assessed. Results: The results show a reduction in prenatal concerns, perceived stress, stress vulnerability and psychopathology, as well as an increase in resilience. Conclusions: Online cognitive behavioural intervention may be effective in pregnant women, so it is important to conduct a randomised controlled trial to certify these findings.Frontier Project “A-CTS-229-UGR18” of the Ministry of Economy, Knowledge, Business and University of the Junta de AndalucíaEuropean Regional Development Fund (ERDF)Spanish Ministry of Science, Innovation and Universities, FPU program - 18/0061

The psychological impact of the COVID-19 pandemic on pregnant women

This work was supported by the Frontier Project "ACTS229UGR18" of the Ministry of Economy, Knowledge, Business and University of the Junta de Andalucia, cosupported by funds/European Regional Development Fund (ERDF) - a way to build Europe. Beside, Mr. Jose Antonio PuertasGonzalez has been awarded with an individual research grant (Spanish Ministry of Science, Innovation and Universities, FPU program, reference number 18/00617) .The aim was to examine the psychological effects caused by the COVID-19 pandemic on pregnant women, as well as the factors influencing these effects. The study design was cross-sectional and the participants were 200 pregnant women. The first group called the Pandemic Group (PG) included 100 women who were evaluated with psychological assessment instruments during the COVID-19 pandemic. The second group titled Pre-Pandemic Group (PPG) consisted of 100 women who were evaluated prior to the pandemic. Perceived stress, prenatal concerns and psychopathological symptoms were evaluated and compared. Pandemic Group scored significantly higher than Pre-Pandemic Group in the depression dimension of the SCL-90, in the phobic anxiety dimension, and in the Perceived Stress Scale. In addition, insomnia, along with having recently suffered the loss of a loved one explained 25% of the score variance in the depression dimension of the SCL-90. Insomnia also explained 13% of the variance of the results found in the Perceived Stress Scale. The fear of contagion by COVID-19 increased the scores obtained in the phobic anxiety dimension, explaining 11% of the variance. Thus, the COVID-19 pandemic could produce an increase in psychopathological symptomatology and stress, which can lead to negatively affecting pregnant women's mental health.Ministry of Economy, Knowledge, Business ACTS229UGR18Junta de AndaluciaEuropean CommissionSpanish Ministry of Science, Innovation and Universities, FPU program 18/0061

The determining number of Kneser graphs

A set of vertices S is a determining set of a graph G if every automorphism of G is uniquely determined by its action on S. The determining number of G is the minimum cardinality of a determining set of G. This paper studies the determining number of Kneser graphs. First, we compute the determining number of a wide range of Kneser graphs, concretely Kn:k with n≥k(k+1) / 2+1. In the language of group theory, these computations provide exact values for the base size of the symmetric group Sn acting on the k-subsets of {1,…, n}. Then, we establish for which Kneser graphs Kn:k the determining number is equal to n-k, answering a question posed by Boutin. Finally, we find all Kneser graphs with fixed determining number 5, extending the study developed by Boutin for determining number 2, 3 or 4

How prenatal cortisol levels may differentially affect the neurodevelopment of boys and girls

Producción CientíficaBackground: Prenatal stress could have serious consequences on maternal and fetal health. In this sense, some studies have stated that maternal HCC during pregnancy could contribute to sex-specific effects on infant neurodevelopment, following the Developmental Origins of Health and Disease Hypothesis. Aim: This study aimed to determine whether maternal hair cortisol concentration (HCC) during each trimester of pregnancy and postpartum could predict the neurodevelopmental outcomes of their 12-month-old offspring, with sex-specific differences considered. Study design: longitudinal. Subjects: The study involved 93 pregnant women and their babies. Outcome measure: Hair samples collected during each trimester and postpartum and The Bayley Scales for Infant Development III was used to assess the infants' abilities. Results: The results showed that maternal HCC during the first and second trimesters could predict language and motor abilities. However, when discriminated by sex, only females' cognitive, expressive language, and fine and gross motor skills were predicted by cortisol, not males. Conclusions: These findings support the idea that non-toxic levels of cortisol can positively influence infants' neurodevelopment

A General Lower Bound for the Domination Number of Cylindrical Graphs

In this paper, we present a lower bound for the domination number of the Cartesian product of a path and a cycle that is tight if the length of the cycle is a multiple of five. This bound improves the natural lower bound obtained by using the domination number of the Cartesian product of two paths that is the best one known so far

Characterizing levels of reasoning in graph theory

This work provides a characterization of the learning of graph theory through the lens of the van Hiele model. For this purpose, we perform a theoretical analysis structured through the processes of reasoning that students activate when solving graph theory problems: recognition, use and formulation of definitions, classification, and proof. We thus obtain four levels of reasoning: an initial level of visual character in which students perceive graphs as a whole; a second level, analytical in nature in which students distinguish parts and properties of graphs; a pre-formal level in which students can interrelate properties; and a formal level in which graphs are handled as abstract mathematical objects. Our results, which are supported by a review of the literature on the teaching and learning of graph theory, might be very helpful to design efficient data collection instruments for empirical studies aiming to analyze students’ thinking in this field of mathematics

A theoretical analysis of the validity of the Van Hiele levels of reasoning in graph theory

The need to develop consistent theoretical frameworks for the teaching and learning of discrete mathematics, specifically of graph theory, has attracted the attention of the researchers in mathematics education. Responding to this demand, the scope of the Van Hiele model has been extended to the field of graphs through a proposal of four levels of reasoning whose descriptors need to be validated according to the structure of this model. In this paper, the validity of these descriptors has been approached with a theoretical analysis that is organized by means of the so-called processes of reasoning, which are different mathematics abilities that students activate when solving graph theory problems: recognition, use and formulation of definitions, classification, and proof. The analysis gives support to the internal validity of the levels of reasoning in graph theory as the properties of the Van Hiele levels have been verified: fixed sequence, adjacency, distinction, and separation. Moreover, the external validity of the levels has been supported by providing evidence of their coherence with the levels of geometrical reasoning from which they originally emerge. The results thus point to the suitability of applying the Van Hiele model in the teaching and learning of graph theory