Perinatal Mood and Anxiety Disorders:

Commonly referred to as “postpartum depression” or more simply “postpartum,” perinatal mood and anxiety disorders actually encompass a wide array of presentations beyond simply depression and may be diagnosed anytime during pregnancy, after birth (typically within the first year), and in people besides the birth mother, including dads, adoptive parents and surrogates. These concerns can also impact people grappling with infertility, pregnancy loss, abortion, or infant death.

Major Depression: Perinatal depression in many ways is the same as regular depression - people often report changes in mood, appetite, sleep, energy level, concentration, and interest in activities they used to enjoy. But perinatal depression is also unique in that people may also feel overwhelmed by the responsibilities of caring for a new baby, have thoughts or feelings that “don’t feel like me” about both themselves and the baby, or experience severe anxiety and/or panic attacks. Perinatal depression is more likely if you’ve been depressed before, but it can also surprise people with no history at all. It can also occur with the first baby, the second or third, or with all pregnancies. It is, however, unique and separate from the baby blues, which is commonly referred to as “the non-disorder.” The baby blues affect 60-80% of new mothers and is the consequence of hormonal changes and acute sleep deprivation. It usually peaks 3-5 days after delivery and lasts between 2 days and 2 weeks. Tearfulness and exhaustion are common, but women are predominantly happy and can “see the light at the end of the tunnel.”

Generalized Anxiety: Excessive, uncontrollable worry is the hallmark of generalized anxiety. For some, it is a lifelong problem and for others it may develop it may develop during the perinatal time frame (conception through one year post-birth). In the context of pregnancy and parenting, worry tends to be focused on one’s health or the baby’s health. Worry is difficult to control and may be accompanied by ruminating on persistent thoughts. Physical symptoms are also common, including muscle tension, restlessness, irritability, poor concentration, and fatigue. There aren’t many personality traits associated with mental health diagnoses, but perfectionism is one trait that significantly increases the likelihood of both perinatal depression and anxiety. And as mentioned above, perinatal depression is more likely to be associated with anxiety (including the generalized type described here and the panic described below) than depression occurring outside the context of pregnancy and parenting.

Panic: Panic attacks are an abrupt surge of fear and discomfort that typically peaks within a few minutes. Symptoms closely resemble what you might imagine a heart attack to feel like (which is why they are sometimes confused with one another) - shortness of breath, chest pain, racing heart, numbness or tingling, and feeling like you are choking. But there are other symptoms as well, including temperature changes, dizziness, irritability, nausea, and fears of going crazy or dying. Some panic attacks have an identifiable trigger, such as feeling like you’ve failed or disappointed your child, whereas other panic attacks seem random. Panic attacks ultimately aren’t harmful, although they definitely don’t feel great and can be scary. One of the most helpful tactics can be reminding yourself that the panic isn’t dangerous and will pass if you let it.

Obsessions and Compulsions: Obsessions are recurrent and persistent thoughts, urges, or impulses that cause anxiety; and compulsions are repetitive behaviors or mental acts (like counting) that a person engages in to decrease anxiety. It’s easy to see how they fit together, but sometimes a person may just have one or the other. And perinatal women are almost twice as likely to develop the related disorder, Obsessive Compulsive Disorder (OCD), than others in the population. The most common obsession relates to the new baby being harmed and is frequently accompanied by a lot of “what if” thinking. And even though intrusive thoughts like these happen to everyone (don’t believe me - what is the automatic, uncontrollable thought that pops into your head when you imagine driving behind or next to a log truck or auto transport trailer?), new parents often feel a huge amount of guilt or shame and are horrified by these thoughts because they relate to harm coming to their baby. As a consequence, parents often become hypervigilant and take precautions, like refusing to walk up and down the stairs while carrying the baby, to minimize the likelihood of harm. But the trick here is remembering that thoughts are just thoughts - they don’t have power. And no, you’re not “crazy” if you’re having these types of thoughts. As I mentioned earlier, we all have intrusive thoughts sometimes. And if you asking the question, chances are you’re not :)

Trauma: In the context of labor and delivery, an event that involves actual or threatened death or serious injury to the mother or infant, or the woman being stripped of her dignity is considered to be traumatic. This includes emergency C-sections, hemorrhage, premature or still birth, long labor, vacuum extractions, 3rd or 4th degree tears, and failed pain medication among other scenarios. This also includes witnessing any of these things, hearing medical staff talk about the mother in overly clinical terms or as if she is not there, or even the mother being left naked and uncovered with no concern for her dignity as a person. About 1/3 of births involve some form of trauma; however, only a subset of these parents develop Post-Traumatic Stress Disorder (PTSD). Whether or not PTSD develops depends on what happens after the trauma. If you develop intrusive nightmares, flashbacks, or memories; develop some level or emotional or physical avoidance; experience cognitive or emotional impairment; and develop heightened vigilance or a quick startle response, these are all indicators of PTSD. Common themes of postpartum PTSD include the abandonment of the mother as a person and patient and feelings of powerlessness. Fortunately, postpartum PTSD is just as treatable as regular PTSD.

Bipolar: Bipolar diagnoses differ from depressive ones on the basis of elevated and euphoric (or even irritable) mood states that last at least 4 days and up to a week or more. These mood states are commonly accompanied by a decreased need for sleep, racing thoughts, enhanced productivity, and increased energy. A common theme with bipolar diagnoses is that they are often misdiagnosed as depression as people don’t often seek treatment when they are feeling “up,” but instead when they are feeling low. And without a thorough history, providers can miss the presence of these elevated states. So if what I’ve described sounds like you or someone you love who is pregnant:

1) Seek support from a licensed healthcare professional during pregnancy and after birth. And be sure to mention the presence of these “high” states to ensure you receive the appropriate diagnosis and the best care from your provider. The risk of relapse is high for pregnant women and new mothers so professional assistance is crucial. This is particularly important if you are taking or plan to take medication as incorrect medication (e.g., antidepressants) can cause bipolar relapse.

2) Do NOT stop your medication without speaking to your prescriber. Discontinuing medication more than doubles the risk of relapse during pregnancy. While I know that the idea of taking medication while pregnant can be scary, it’s important to weigh the pros and cons of doing against the pros and cons of leaving a bipolar diagnosis untreated (see below) with a professional to make the best decision for your family.

Psychosis: Perinatal psychosis is probably one of the most scary diagnoses to consider a loved one having. I say loved one here, because unlike moms with OCD who are all too aware of their intrusive thoughts, moms with psychosis often do not think of their intrusive thoughts as problematic and may even be tempted to act on them. This is why when asked, “Am I crazy?” I typically reply that asking the question typically means, “No.” Fortunately perinatal psychosis is rare, only affecting 1-2 in 1,000 postpartum women. The potential repercussions of untreated psychosis, however, are very high, including suicide and infanticide. Onset is usually within two weeks after birth. Discontinuation of bipolar medication, sleep deprivation, birth of your first baby, past loss, obstetric complications, and personal/family history of bipolar episodes and psychosis are all risk factors. If this sounds like someone you love:

1) Do NOT leave them alone. This means day and night, especially with the baby. If this person is alone, with or without the baby, right now, go be with them or call someone (perhaps a neighbor) to sit with them. If mom or baby is in immediate danger, meaning an attempt at suicide or infanticide is imminent or has happened, call 911.

2) Seek treatment. Some cases of psychosis can be managed outpatient with supervision as I’ve described above. Others require inpatient treatment. Fortunately for us in North Carolina, we have one of three Perinatal Psychiatry Inpatient Units in the country at the UNC School of Medicine in Chapel Hill.

Note: Information on these pages is provided for educational purposes only.  It should not be taken as a substitute for care from a licensed healthcare professional.