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You may have heard of postpartum depression or PPD, but did you know that while it is one of the most common perinatal mood and anxiety disorders (PMADs), it’s only one of many mental health complications that can arise during the perinatal period?
Perinatal mental health challenges can come with a wide range of symptoms that can surface anytime during pregnancy or within the first year of parenting. As a Perinatal Mental Health Specialist, I hope that by providing information on the less common perinatal mood and anxiety disorders, folks who may be struggling – and their loved ones – can understand a bit more about what they are experiencing, know that they are not to blame, and that help is available.
About 6% of birthing people develop anxiety during pregnancy, and about 10% develop anxiety postpartum. This can be experienced on its own or can be experienced in addition to depression.
Symptoms of perinatal anxiety include:
• Constant worry—persistent, overwhelming, disruptive worry—usually about the baby
• Feeling that something bad is going to happen or feelings of dread
• Racing thoughts or the feeling like someone can’t turn off their brain
• Disturbances of sleep and appetite; difficulty sleeping when someone has the chance to sleep
• Inability to sit still or restlessness
• Irritability, low frustration tolerance, rage
• Physical symptoms like hot flashes, sweating, and nausea
Some parents may experience perinatal panic disorder, which is a form of anxiety and is characterized by heightened nervousness and panic attacks. During panic attacks, individuals may experience chest pain, difficulty breathing, dizziness, racing heart, claustrophobia, and/or numbness and tingling in their extremities.
Risk factors for perinatal anxiety include:
• A personal or family history of perinatal anxiety, other PMADs, or other mood or anxiety disorders
• Psychosocial factors, such as financial struggles, lack of access to resources, racism and oppression, or a major life stressor like a job loss or move
• Relational factors, such as lack of partner support, relationship stress, or interpersonal violence
• Higher stress parenting situations, such as parenting multiples, being a teen parent, being a single parent
• Perfectionistic personality type
• Pregnancy/birth/baby related: experiencing a traumatic birth or a medically complicated pregnancy, previous miscarriage or loss, NICU stay, trouble or pain with breastfeeding, having a baby who is overly fussy/hard to soothe, persistent lack of sleep
Perinatal anxiety is often a protective instinct on overdrive, and is also often in combination with reactions to stressful life situations. As a therapist, I find that contextualizing anxiety can help clients understand how their worries may make sense given the stressful factors in their lives.
Treatment options for perinatal anxiety
Fortunately, perinatal anxiety is treatable. Treatment options for perinatal anxiety include psychotherapy (including a wide range of therapeutic tools and approaches) and medication options as well.
If you have any of these risk factors or are experiencing the above symptoms, contact your healthcare provider or Postpartum Support International (PSI) for help. PSI also offers peer support groups for folks struggling with perinatal anxiety.
Perinatal Obsessive-Compulsive Disorder (OCD)
OCD is a form of perinatal anxiety and is characterized by obsessive thoughts, also called intrusive or “scary” thoughts, or compulsions. About 3-5% of new parents will experience perinatal OCD, regardless of whether they have a history of OCD prior to the perinatal period.
Intrusive or “scary” thoughts are persistent, repetitive, unwanted thoughts that can appear at any time and are usually focused on the baby. These thoughts are rooted in anxiety and are not delusional or an indication of psychosis; in other words, people with perinatal OCD know that these thoughts are not true and often experience horror and shame related to these thoughts.
Compulsions are the other primary component of perinatal OCD, where the parent may do certain things over and over again in an attempt to reduce their fears and obsessions. This may include things like needing to clean constantly, check things repeatedly, and/or, count or reorder things.
Parents with perinatal OCD may experience:
• Obsessive or scary thoughts
• A sense of horror and shame about their obsessive or scary thoughts
• Fear of being left alone with the baby or specific fears about harm to the baby
• Hypervigilance in protecting the baby
Pregnant people and new parents with postpartum OCD are often distressed by scary thoughts and are very unlikely to ever act on them; rather, these individuals are much more likely to go to great lengths to avoid triggers and avoid what they fear could be harmful—stairs, the bath, the stove, etc. Because of this, as a therapist, I don’t worry that someone experiencing scary thoughts will act on them; rather, I worry that someone’s world will get very small – they will not bathe the baby, take the baby down the stairs, take the baby outside, drive the baby in the car, etc.
Treatment for Perinatal OCD
Fortunately, perinatal OCD can be treated, and new parents can experience some relief from the group of anxious thoughts and compulsions. Talking about scary thoughts can help clients feel less alone and less ashamed; many clients are horrified by intrusive thoughts, and working with a therapist who can provide some insight into what they are and why they may be happening can bring some relief for clients.
There are many therapeutic approaches to deal with perinatal OCD, and medication can be helpful too. Talk to your healthcare provider or call PSI to learn more about your options. PSI also offers a peer support group for folks experiencing perinatal OCD.
About 9% of birthing people experience postpartum PTSD after giving birth. Most often, this is caused by a trauma during the birth or postpartum. These traumas could include, but are not limited to:
• Unplanned or emergency C-section
• Prolapsed cord
• Use of vacuum extractor or forceps to deliver the baby
• Baby going to the NICU
• Severe complication or injury related to pregnancy or childbirth, such as postpartum hemorrhage, hysterectomy, severe preeclampsia or eclampsia, perineal trauma (3rd or 4th degree tear)
• Feelings of powerlessness, lack of bodily autonomy, poor communication and/or lack of support and reassurance during the delivery
• Experiencing obstetric violence, racism, or discrimination during the birth process
People who have experienced a previous trauma, such as sexual assault or other form of violence, are also at a higher risk for experiencing postpartum PTSD.
To be clear– you may have experienced a trauma during pregnancy or birth that was not explicitly named on this list, and it is important to remember that trauma is a subjective experience; a birth trauma can be any experience that you perceive to be traumatic. No one else can decide what was traumatic for you.
PTSD symptoms include:
• Flashbacks, nightmares, and/or intrusive images or re-experiencing of the birth or other previous traumas
• Hypervigilance, irritability, feeling on edge or easily angered
• Difficulty sleeping or concentrating
• Anxiety or panic attacks
• Feeling numb, detached or disconnected from reality
• Desire to avoid anything associated with the birth, including people, places, pictures, and details about the birth
As a therapist, I see many folks suffering with perinatal PTSD without anyone naming it for them. People who have experienced a medically traumatic pregnancy or a traumatic birth and who are suffering with posttraumatic stress symptoms will often show up to therapy and say, “everyone keeps telling me that it’s ok, but I do not feel ok” or “everyone kept saying that everything is fine because my baby is healthy, but I keep replaying the birth in my mind…”
These folks often feel invalidated and unseen; alternatively. Just because you have a healthy baby or the terrible thing that could have happened did not happen doesn’t mean that everything is fine; many truths can exist at the same time.
Treatment for Postpartum PTSD
If you are suffering with posttraumatic stress symptoms, please know that help is available. Treatment options include talk therapy and also trauma-specific therapeutic approaches; contact PSI or your healthcare provider to learn more about your options. PSI also offers peer support groups for folks who experienced a traumatic birth, as well as a birth trauma support group specifically for BIPOC.
Perinatal Trauma and Race
It’s also important to highlight the relationship between race, racism, and perinatal trauma: Black birthing people are 3 to 4 times more likely to die in the perinatal period compared to white birthing people. They also experience pregnancy-related complications at disproportionately higher rates and experience systemic and interpersonal racism and bias within the medical system. Black birthing people are also 4 times more likely to experience postpartum PTSD compared to non-Black birthing people and are . Also, disparities in both mortality and negative health outcomes during birth worsened during the COVID-19 pandemic.
Bipolar mood cycles might be identified for the first time during pregnancy or postpartum. People with Bipolar Disorder experience lows (depression) and highs (mania or hypomania). These moods go beyond what many folks experience as typical moodiness of pregnancy or early parenting; with Bipolar Disorder, moods last for at least 4 days and interfere with someone’s functioning and relationships. There are two types of Bipolar Mood Disorders– Type I and Type II. With Type I, the manic (or elevated) mood is more extreme and is often easier to detect, whereas with Type II, the manic mood is less severe while the depression may be more severe. The risk factors for developing a bipolar mood disorder during pregnancy or postpartum are having a personal or family history of bipolar mood disorders.
Symptoms of Bipolar Disorder may include:
• Periods of having a depressed mood (with Bipolar II, the depression is typically more severe)
• Periods where mood is much better than what is normal or typical for that person
• Reduced need or minimal need for sleep
• Rapid speech
• Racing thoughts and trouble concentrating
• Periods of increased energy
• Anxiety or irritability
• With Bipolar I, people may also experience grandiosity (an excessive sense of self importance), impulsivity/poor judgment, or delusions (beliefs that are not real; these can be grandiose or paranoid)
During pregnancy and postpartum, Bipolar depression can look just like a very severe depression, or it might look like anxiety. Treatments that only address the depression and do not address the manic part of the mood cycle may actually exacerbate symptoms; consequently, it’s important to work with a mental health provider who will take a thorough mood history and assess whether you have a history of any of the symptoms that occur during the manic part of the mood cycle. If you need assistance finding a perinatal mental health specialist, contact PSI or check out their provider directory. As a therapist, I have seen how important it is for clients to be thoroughly evaluated by a trained perinatal mental health professional so that Bipolar Disorders can be diagnosed and treated. Fortunately, there are treatments for Bipolar Disorder, and perinatal psychiatrists can discuss the risks and benefits of mood stabilizing medications during pregnancy and lactation. PSI also offers a peer support group for birthing people experiencing Bipolar Disorders.
Postpartum psychosis is an emergency and requires immediate assessment and treatment by a trained perinatal mental health professional. If you are disturbed by your thoughts or worried that you might be experiencing psychosis, please call 988 right away or go to the emergency room so that you can access the care and treatment you need. Similarly, if your partner or loved one is exhibiting symptoms of psychosis, please call 988 or bring them to the emergency room.
The vast majority of people experiencing psychosis don’t harm themselves or their babies; however, the risk of danger to them and their baby must be taken seriously because a person experiencing psychosis is not in touch with reality, and the delusions and hallucinations seem real to them at the time.
The onset of psychosis is often sudden, usually in the first few days or weeks after birth. Symptoms often initially present as rapid mood swings and erratic behavior before progressing to psychotic symptoms. Symptoms can vary a lot and change rapidly, even over the course of hours; symptoms can also ebb and flow and appear less severe at times. These variations in symptoms can make postpartum psychosis challenging to identify at times.
Symptoms of Postpartum Psychosis can include:
• Delusions or strange beliefs that are not based in reality and that people around you think are out-of-character or bizarre
• Hallucinations (seeing or hearing things that aren’t there or that other people cannot see or hear)
• Not wanting to sleep, or not being able to sleep
• Feeling very irritable or angry
• Feeling agitated, overly energetic, or unable to sit still
• Feeling very depressed, withdrawn, and not wanting to be around others
• Feeling fearful, paranoid, or suspicious, like someone is out to get you
• Rapid mood swings
• Feeling detached from reality or like you are in a dream
• Erratic, strange, or disorganized speech or behavior, including confusion and impaired judgment
• Thoughts of harming yourself or your baby
• The most significant risk factor for postpartum psychosis is a personal or family history of Bipolar Disorder or a previous psychotic episode; that said, many women have no previous psychiatric history prior to experiencing postpartum psychosis.
• Researchers are working to understand more about what causes postpartum psychosis and believe that it is caused by a combination of pregnancy hormones, genetics, and various other clinical factors.
Treatment for Postpartum Psychosis:
Fortunately, psychosis is treatable and temporary. Treatment for postpartum psychosis involves hospitalization and medication. Many folks who experience postpartum psychosis benefit from talk therapy and other supports as well. Above all, it is important to remember that someone experiencing psychosis needs to be assessed and treated right away by a perinatal psychiatrist.
An important note about sleep and psychosis:
Getting enough sleep is particularly important for people with a history of Bipolar Disorder or a history of experiencing mania following minimal sleep. While a reduced need for sleep may be a symptom of psychosis, it is possible that severe lack of sleep may lead to the development of psychosis for people with a history of Bipolar Disorder. If you or a loved one have a history of Bipolar Disorder, please make a plan for postpartum sleep; also, remember the sleep and nursing are not usually exclusive, and lactation professionals can help you make a plan that includes both nursing and sleep.
Perinatal mood and anxiety disorders are the most common complication of childbirth. While perinatal mental health challenges can be exhausting and overwhelming, knowing symptoms and risk factors may help you or a loved one access treatment and support services more quickly. There are many treatment options for PMADs, including talk therapy, medication, and peer support groups. If you are struggling with perinatal emotional complications, remember that what you are experiencing is not your fault, you are not alone, and help is available.
If you need assistance in finding resources near you, contact Postpartum Support International at 800-944-4773. For immediate support, call the Maternal Mental Health Hotline at 1-833-9-HELP4MOMS. If you are in crisis call your local emergency number or the National Suicide Prevention Hotline at 1-800-273-TALK (8255).