Did you know that new mothers’ brains are wired to respond to any sign of infant distress or discomfort? In many ways, new moms are living in a constant state of high alert. In fact, pediatrician and psychoanalyst, D.W. Winnicott, coined the term “primary maternal preoccupation” back in the 1950’s to describe the special mental state of the mother in the perinatal period. This state involves a greatly increased sensitivity to and focus upon the needs of her baby. Winnicott said that this preoccupation, while obsessive in nature, enables the mother to read her baby’s signals and meet her baby’s needs.
When you add in factors like sleep deprivation, hormonal changes, new responsibilities, and lack of time for yourself, it’s easy to understand how new mothers can experience symptoms of anxiety and depression. Postpartum depression is the most common complication of pregnancy and childbirth affecting 15-20% of women.
Although “postpartum depression” is the more recognized name, Perinatal Mood and Anxiety Disorder (PMAD), is the more comprehensive term since symptoms may begin any time during pregnancy or after the birth of a child. In addition, the term postpartum depression causes many people to believe that depression is the only symptom to look out for. It is important to note that feeling depressed is only one of many different symptoms a new mother with PMAD may experience.
Although PMAD affects so many expectant and new mothers, many suffer in silence for fear of appearing weak or being judged by others. Women may even fear that if they tell someone how they are feeling, they will be viewed as a bad mother, or worse yet, that their baby will be taken away from them.
It’s very important to understand that PMAD can affect any woman regardless of her culture, age, income, race, or education. If you find yourself suffering from PMAD you must remember that you did nothing to cause this! You are not a weak or bad mother! Understanding the causes and symptoms of PMAD is essential so that you can seek help. With the right treatment and support, a woman with PMAD can regain her health and begin to enjoy her role as a new mom.
Let’s address some of the most common questions surrounding perinatal mood and anxiety disorders:
1. What is the difference between a normal postpartum adjustment period and a perinatal mood and anxiety disorder?
Becoming a new parent is stressful, and having some difficulty adjusting to parenthood is completely normal. In the beginning, postpartum depression can look a lot like “the baby blues.” Both are most likely caused by the hormonal, emotional, and environmental changes that occur during pregnancy and after childbirth. The biggest difference between the two is the duration, frequency and severity of the symptoms.
We know that approximately 80% of new moms will have some degree of the baby blues. They may cry easily, feel stressed, and worrying more than they typically do. They might even have some very big emotions. Baby blues, however, will usually subside within the first few weeks after the baby’s birth. If it’s lasting longer than that, it could be PMAD. The second thing to be mindful of is how frequent and severe are these symptoms? If your symptoms are affecting your overall well-being and making it so that your life is feeling unmanageable, then even if you’ve only been experiencing symptoms for a short time, you may be suffering from PMAD.
2. What are the signs and symptoms of perinatal mood and anxiety disorders?
It’s important to note that PMAD can first appear during pregnancy and up to a year after giving birth. A postpartum mood or anxiety disorder may set in soon after childbirth or come on suddenly months after your baby has arrived.
Common symptoms include:
• Sadness and depression
• Loss of pleasure
• Anger and irritability
• Feeling overwhelmed
• Strong feelings of shame and guilt
• Feelings of hopelessness or worthlessness
• Difficulty concentrating and making decisions
• Lack of concern for yourself
• Changes in appetite
• Changes in sleep (for example, not being able to sleep even if your baby is sleeping)
• Thoughts of suicide
In addition, some women who suffer from PMAD have feelings of being disconnected from their baby or worry about hurting their baby. Intrusive thoughts about hurting your baby are unwanted, distressing thoughts, images, impulses, or urges that pop into your mind. For example, the thought of throwing the baby down the stairs or out the window, is an intrusive thought.
Please know that while intrusive thoughts are scary and very upsetting to have, they do not mean you are actually going to harm your baby! If the thoughts are ego-dystonic, meaning they are inconsistent with your beliefs and personality, then they do not put you at risk for harming your baby. As many as 50 – 65% of new parents experience intrusive, ego-dystonic thoughts related to infant safety or harm.
It is only if one’s thoughts of harming their baby are ego-syntonic, meaning they are consistent with their world view and not causing the person distress, that they are considered delusional and representative of psychosis. In this case it is extremely important to seek help immediately. An example of an ego-syntonic thought might be a new mother’s paranoid belief that the world is evil and trying to cause her tremendous harm. Therefore, in her state of mind, killing her baby is in the baby’s best interest.
3. What causes perinatal mood and anxiety disorders?
Hormonal, emotional, and physical changes related to pregnancy, childbirth and becoming a parent can cause PMAD. Let’s look at each one:
- Hormonal changes: During pregnancy, various hormonal levels elevate dramatically, particularly progesterone and estrogen. They also drop dramatically after childbirth. Furthermore, the number of endorphins produced by the placenta during pregnancy drops significantly after birth. In addition, there tends to be fluctuations in serotonin levels (the mood stabilizing hormone). Weaning from breastfeeding as well as the return of menstruation alter the biochemical balances in the body which can contribute to PMAD as well. Lastly, thyroid levels can drop after delivery and this can cause symptoms of depression.
- Emotional changes: Depression and anxiety, in addition to its biochemical nature, is an emotional response to loss. Any transition, even one’s we want and choose, have an element of loss involved. Having a baby often brings loss of freedom, sleep, time to self, time with your partner, etc. New parents are getting used to a new identity, a new normal, as well as trying to manage the stress of taking care of and being responsible for a newborn. All of these things can take an emotional toll.
- Physical Changes: Coping with the physical pain from pregnancy and delivery, as well the physical ramifications of chronic sleep deprivation can be major contributors to PMAD.
4. What puts someone at risk for PMAD?
There are a number of factors combined that put a woman at risk for PMAD. These include:
• Having a previous history of depression or other mood disorder, or if mood disorders run in your family.
• Having a history of having PMAD with a previous child. Women who have had PMAD following a previous pregnancy have a 50% chance of reoccurrence.
• Any major stressors currently going on in your life (like a pandemic!)
• Feelings of ambivalence about the pregnancy
• Having a history of severe PMS or premenstrual dysphoric disorder
• Women who are especially sensitive to hormonal changes
• Having a complicated pregnancy or delivery/having a traumatic birth experience
• Medical complications for you or your baby
• History of early loss, trauma or abuse
• If you are currently experiencing relationship difficulties
• If you lack a social support system
• Chronic sleep deprivation
• Having a high-needs or extremely colicky baby
• Abrupt discontinuation of breastfeeding
5. Is PMAD preventable?
Risk factors do not cause PMAD. What risk factors do is make you more vulnerable to it. So even though you may not be able to prevent PMAD, it is very important to look at the areas in your life which may put you at greater risk. Understanding these factors can help you take steps to strengthen your resilience. Having resources and a support system in place can help to establish a sense of control over the situation.
Studies show that proactive behavior will lower your risk of PMAD. That is why it is so important to be informed and involved. Take steps to understand and deal with areas of vulnerability in your life. Let your doctor and your partner know what risk factors concern you. Perhaps go to counseling ahead of time to gain insight, self-awareness and coping tools. Prepare your relationship with your partner before baby arrives by discussing your expectations about how things will look once the baby is here. Have a support system in place (for example: talking with a postpartum doula or baby nurse) before the baby arrives so that you can have easy access to help and support once your baby is here.
6. Are there different forms of perinatal mood and anxiety disorders?
Although we are most familiar with postpartum depression, which is one form of PMAD, there are actually several different forms of perinatal mood and anxiety disorders that women may experience. In addition to postpartum depression there is postpartum anxiety, postpartum panic disorder, postpartum obsessive-compulsive disorder, and postpartum post-traumatic stress disorder. As stated previously, these can occur during pregnancy and up to one year after childbirth. Postpartum psychosis (PPP) is the most severe form of PMAD, but fortunately it is also the rarest form. It occurs in 0.1% of women. The onset is very sudden and severe, normally within the first 4 weeks after giving birth. The most consistently identified risk factor is personal or family history of bipolar disorder or psychosis. Symptoms are characterized by a loss of touch with reality and can include:
• Hallucinations and/or delusions
• Bizarre behavior
• Suicidal thoughts
• Ego syntonic thoughts of hurting the baby
• Rapid mood swings
Postpartum psychosis is a medical emergency and should be treated immediately.
7. Can men get PMAD?
Yes, it is called PPND (Paternal Postnatal Depression) and it is very real.
Approximately 14% of men experience postpartum depression after the birth of a child. Like PMAD in women, it is caused by hormonal, physical and emotional changes related to having a baby. Yes, men experience hormonal changes during their partner’s pregnancy and in the postpartum period.
Testosterone levels decrease, while estrogen and prolactin levels increase. Researchers speculate that this may be nature’s way of helping fathers’ bond with their babies. While the hormonal changes aren’t as severe as what women experience, these shifts along with sleep deprivation and the emotional stress all contribute to PPND.
Fathers who have PPND are usually struggling with the transition to fatherhood. They may be experiencing a lot of pressure in their new role, feeling a big increase in responsibility, and fear or uncertainty about the future.
8. If a new mother is experiencing PMAD, how can her partner and family help?
The most important thing a partner can do is to remind the person who is suffering from PMAD that this is temporary, it will not last forever, and it is not their fault. A partner can be the one to actively search for help and call resources. In addition, a partner can take on extra tasks such as doing additional chores or finding physical help (for example: a babysitter, housecleaner, postpartum doula, etc.). It is also important that a partner get support during this time. A lot of responsibility is being put on their shoulders, and therefore, they are at an increased risk of getting depressed.
If you are a family member or friend, ask new parents what they need. If they say “nothing,” then offer up something anyway! For example, “I’d really love to help in some way. Would it be okay with you if I dropped off some meals that you can put in the freezer?”
Lastly, do not assume that a new mom is doing well if she is tending to her appearance. Sometimes women suffering from PMAD will work hard at looking good to feel more in control, but that doesn’t necessarily mean they are feeling good on the inside.
9. What are treatment options for PMAD?
A. PMAD is treated differently depending on the type and severity of symptoms. Treatment options include (but are not limited to) antidepressant and/or anti-anxiety medications, hormone therapy, psychotherapy, TMS, and participation in support groups for emotional connection and education.
TMS stands for Transcranial Magnetic Stimulation and is a noninvasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression. TMS is typically used when other treatments haven’t been working.
If you are pregnant or breastfeeding, please do not assume that you can't take medication for depression, anxiety, or even psychosis. Talk to your doctor. Under a doctor's supervision, many women will take medication during pregnancy and while breastfeeding. This is a personal decision to be made by you and your doctor only.
In terms of psychotherapy, what is usually recommended for treating PMAD is some type of short-term, solution-based therapy. For example, cognitive-behavioral therapy, dialectical behavior therapy, or interpersonal psychotherapy.
10. What are some helpful tools in dealing with PMAD?
The more you care for your mental and physical well-being, the better you’ll feel.
• Get the rest your body needs. Chronic sleep deprivation is a major trigger for PMAD. Do whatever you can do to get as much rest as possible. Enlist the help of your partner, family members, a postpartum doula or night nurse. Nap when the baby naps. I know it is tempting to want to get a lot done when the baby is sleeping, but if you are sleep deprived, it is important for you to make up whatever sleep you can while your baby naps. At nighttime, try to get a 4-hour uninterrupted stretch of sleep. If you are breastfeeding and you have introduced the bottle, let someone else give the baby one bottle of pumped breastmilk during the night so you can get more uninterrupted rest.
• Set aside a little bit of time for yourself. It doesn’t have to be a ton of time, but little breaks to have a cup of tea, or take a long shower, listen to music, meditate, whatever it is that relaxes you, can be extremely rejuvenating. Think of the metaphor of the flight attendant telling their passengers with children that if the oxygen masks come down, they need to put the mask on themself before helping their child. If you run out of oxygen, you can't help anyone else. You need self-care so that you can be available to your baby.
• Nutrition. Eating small amounts of protein and complex carbohydrates throughout the day can help stabilize your blood sugar which can help stabilize your mood. Look for food’s rich is complex carbohydrates, magnesium, calcium, folate and omega 3 fatty acids. Staying hydrated helps lessen anxiety. Caffeine, on the other hand, can raise it. Alcohol is a depressant. Eating healthy and drinking water is very important. Sometimes that means accepting meals from friends, or temporarily using a food service. Gifting new parents a food delivery service for a certain length of time makes a great present!
• Get out of the house. New moms tend to isolate AND we’ve been in a pandemic! This makes things challenging! But studies show that sunlight lifts your mood and increases vitamin D production. So, try to get at least 10 to 15 minutes of rays per day.
• Exercise. Exercise gives you a boost of endorphins. Some studies suggest that moderate exercise may be as effective as medication when it comes to treating depression! No need to overdo it. If you can, take a long walk, live stream your favorite exercise class, dance in your living room, whatever brings you joy.
• Get emotional support. When you’re feeling depressed and anxious, it’s more important than ever to stay connected to family and friends-even if you’d rather be alone. Keeping silent only makes your situation worse. Let your loved ones know what you need and how you’d like to be supported. Share what you’re experiencing-the good, the bad, everything-with at least one person. You need one person who is willing to listen without judgment and offer reassurance and support.
• Join a group for new mothers: Even if you have supportive friends, it’s a great idea to reach out to other new moms. It’s very reassuring to connect with those who are currently in your shoes. At the Pump Station, our new parent groups provide moms with the community they need.
• Physical Support: Don’t be afraid to ask for physical help when you need it! Having someone who can help out with baby care, housework, or run errands for you, can make a huge difference!
• Keep a journal: Write down your thoughts and feelings. Letting everything out on paper can release stress and help you process your emotions.
• Pay attention to your expectations: Are they realistic? How are you talking to yourself? Are you treating yourself with empathy and compassion, or with criticism and judgment? Try to be aware of this, and if you find you are judging yourself due to having a very high or even unrealistic expectation, try to reframe your thought process and lower your expectations! Practice loving-kindness.
11. Where do I go for help?
Don’t be afraid to reach out to your OB/GYN or family doctor. In addition, the following resources have comprehensive information about PMAD and many offer provider directories as well:
Maternal Mental Health Now
Postpartum Support International
PSI Perinatal Mental Health Provider Directory
National Postpartum Depression Hotline
1-800-PPD Moms (773-6667)
OCD Center of Los Angeles
Specializing in the treatment Postpartum OCD
Please remember, if you think you might be suffering from PMAD, you did nothing to cause this. Reach out to a caring professional. There is a road to recovery, and you don’t have to walk it alone.
By Jill Campbell, Psy.D.