You’re just hormonal… You’re just sleep -deprived… You just need to relax… It’s all in your head… These are just some of the things women with postpartum anxiety hear when they try to talk about their feelings. But here’s the thing—it’s not “just” any of those things, and it’s certainly not all in your head.
If you’ve never heard the term postpartum anxiety (PPA) you’re not alone. This mental health mood disorder is the nasty sister of postpartum depression (PPD), and many people within the medical community aren’t even aware of it. Why is that? Unlike postpartum depression, which has been well-studied, there has not been substantial research devoted to postpartum anxiety. The lack of research means that there is no screening tool like there is for postpartum depression and so it gets missed by OBs, midwives, and primary care providers who are seeing women in the postpartum period.
It’s normal to have worries if you’re a new mom—after all, as mothers our main job is to love, nurture, and protect our children, and with that comes a great responsibility. But if you’re wondering what is considered normal worry versus something that might require you or someone you know to seek professional help for PPA, there is a distinction.
The main difference is being able to differentiate between a potential risk or threat, versus a threat that is not real. For women with PPA, their body and mind are in overdrive with intrusive and unrealistic thoughts. Women with PPA feel overwhelmed by simple tasks, are anxious, resentful, irritable, and angry. It can be a clue that you need something: support, reassurance, appreciation, rest, validation, connection, or meaningful stimulation.
Postpartum anxiety can occur any time in the first two years of your child’s life. For many mothers it starts later on, around five to seven months postpartum, well after you’ve seen your OB or midwife for screening and a postpartum assessment. How long it lasts usually depends on the person and whether or not she gets the treatment and support she needs.
From the research that does exist approximately 10 percent of new mothers experience PPA. As a nurse practitioner, mother, and friend of many new mothers I honestly believe this number is a gross under-representation of the percentage of women who are actually experiencing PPA. Again, due to the lack of research, lack of screening for this mood disorder, and underreporting of symptoms by new mothers I believe this number is likely significantly higher. In fact, 91 percent of new mothers experience scary, intrusive thoughts . There is greater risk for PPA if you have a family or personal history of mood or anxiety disorders, you lack sleep (which many new moms experience), you lack support (either real or perceived), you or your baby experienced a medical complication, you experienced fertility challenges, you’re sensitive to hormonal shifts, or you’re prone to being self-critical.
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In the time immediately following the birth of a child, there is usually a surge of adrenaline that keeps new moms going. Once that surge dissipates, the lack of sleep from caring for a newborn infant can start to take a toll on sleep and mood. Depending on your delivery, vaginal or c-section, there can be an increased risk for mood disorders like PPD and PPA. Women who have c-sections or require Pitocin (synthetic oxytocin) are at higher risk for PPD and PPA. Oxytocin is a hormone secreted from the pituitary gland that promotes contraction of the uterus during and after labor, but more importantly, it is called the love hormone because it promotes feelings of love and bonding between mother and baby. In The Nursing Mother’s Companion , (what I refer to as the Bible of breastfeeding) Kathleen Huggins, RN describes how the use of Pitocin limits the amount of endogenous oxytocin that is released at the time of birth.
Although the neurobiology of PPA is not fully understood, hormonal changes are a big contributor. In the book Pregnancy: The Psychological Experience , Dr. Arthur Coleman describes that while women are pregnant, the placenta secretes a hormone called progesterone. In addition to helping support the growth of a human, it also has anti-inflammatory properties and anti-cancer properties (which is why women who have had at least one pregnancy are at lower risk of breast cancer ), but it also crosses the blood-brain barrier and converts to allopregnanolone, which has a calming effect on our brains.
When you deliver your baby and your placenta, there’s a sudden drop in your body’s progesterone levels. For women who are not breastfeeding their period returns within six to eight weeks, and so, with regular periods comes ovulations and your body making progesterone again, which supports your mood. For women who are breastfeeding, their period might not return from anywhere between four to eighteen months after giving birth. No period means no ovulation, which means no progesterone. While our adrenal glands make some progesterone, the constant stressors of parenting, as well as lack of sleep, can cause the adrenal glands to shift from producing sex hormones like progesterone to stress hormones like cortisol . Increased cortisol levels are associated with anxiety and perpetuate sleep disturbances.
Non-biological causes of PPA include lack of support, whether that is real or perceived, as well as a previous disposition to anxiety prior to pregnancy.
So why is postpartum anxiety postpartum depression’s nasty sister? They have many qualities that overlap and often co-exist. For women who are screened for PPD and able to get the treatment they need, they will often also be able to address PPA with treatment.
Key differences are that PPD more often involves sadness, crying, suicidal thoughts (suicide is the number one cause of death of new mothers in the postpartum period), fatigue , feelings of hopelessness or helplessness, and lack of interest in your baby. Where PPD and PPA overlap include changes in appetite, sleep disturbances, poor concentration, inability to care for self, and isolation.
There are several complications of PPA including postpartum rage, postpartum panic attacks, and postpartum OCD (PPOCD). A woman experiencing postpartum rage has outbursts of anger, has a short fuse, is irritable, and easily triggered. Dr. Libby Coleman, co-author of Pregnancy: A Psychological Experience , relates this to unmet needs, lack of support, burnout , relationship challenges, isolation, and the struggle to adjust to motherhood. All the more reason to get the treatment you need so you can identify the underlying cause of your postpartum anxiety and work to correct it.
Postpartum panic attacks can seriously limit a woman’s ability to function, and disrupts her ability to care for herself and her child. The three distinct fears that women with postpartum panic disorder have include fear of death, fear of having lost control, and fear that they are unstable or perceived as such.
Other women may suffer from postpartum obsessive compulsive disorder (PPOCD). One does not need to be previously diagnosed with OCD to experience this. What makes this unique is that the intrusive thoughts become obsessions or repetitive unpleasant thoughts or mental images related to the baby. Some women compulsively do certain behaviors over and over to reduce intrusive/ compulsive thoughts. Behaviors include constantly cleaning, rearranging, or compulsively checking things related to safety or security. Mothers with PPOCD are often afraid to be left alone with their infant or are hypervigilant about protecting the baby.
If you or someone you know has at some point said “I don’t feel like myself,” that is a red flag that treatment is needed. Because motherhood comes with a certain level of worry, most women with PPA are placated and their feelings are minimized, but it is important to advocate for your health.
This mood disorder can greatly impact a mother’s mental health and the family dynamic, most especially including a woman’s relationship with her partner or other children in the family. Symptoms like sleep disturbances, increased heart rate, and changes in appetite can also result in adverse physical health conditions such as high blood pressure, weight gain, fatigue, headaches, and imbalances with blood sugar.
Recovery is not linear, and will, in fact, involve some ups and downs. That is why having support from family, friends and other mothers, as well as mental health professionals and your health care provider is so important. Having a setback does not mean that you will end up in a dark place again. With treatment comes new coping skills to hone in on when triggers present themselves.
At Parsley Health, our patients work closely with their provider and health coach to help prepare them for the changes that come after birth. Together we take an in-depth look at your hormones, thyroid health, and micronutrients needed for a healthy pregnancy as well as a healthy recovery postpartum. We’re also able to utilize specialty testing that takes a closer look at your gut microbiome, which is responsible for making 95 percent of the mood-stabilizing neurotransmitters in the body, as well as your adrenal function/ stress hormones.
From there, we can make recommendations on safe options to support a healthy microbiome if you’re nursing, such as use of a pre-/ probiotic, or ways to manage anxiety safely with the help of magnesium glycinate, nutrition, meditation , movement, and sleep optimization.
We will often make referrals to an appropriate mental health professional that specializes in postpartum mood disorders, as well as helping them find a local mom-group for additional support.
In the event you need medication, Parsley Health providers can use genetic testing to determine which class of antidepressants (which can also be used for anxiety) you would best respond to. Not all antidepressant or anti-anxiety medications are safe to use while nursing, and we will ensure if you are breastfeeding you are able to get the treatment that is safe for you and your baby.
If you’re pregnant and concerned about postpartum anxiety, Parsley’s providers can prepare and educate you on the changes that occur after becoming a mother. I often speak to women about their birth plan. I recommend women labor with a doula, if possible. In The Doula Book: How a Trained Labor Companion Can Help You Have a Shorter, Easier, and Healthier Birth , Dr. Marshal Klaus details the significant data that shows women who labor with a doula have a shorter duration of labor, require fewer interventions during labor, have lower c-section rates, have higher rates of breastfeeding up to six months postpartum, and—you guessed it—have lower rates of PPA and PPD. Of course, having a doula at your birth might not be financially feasible for everyone, in which case I recommend expecting parents (yes your partner too) complete childbirth education classes, as well as reading books about breastfeeding and what to expect with your body and your baby during the first year of life prior to the birth of your child.
If you are reading this right now and identify with postpartum anxiety, please know that you are not alone and you do not have to live with these feelings. At this moment you can take control by deep breathing, grounding yourself and focusing on your senses, getting a change of scenery—even if it’s walking into a different room in your home, call someone, put on music that makes you feel good, or write out your feelings. Most importantly observe your feelings without judgment, focus your attention on one task, talk to someone, and do your best to find humor when possible.
Annie Shaltz, NP, is a board-certified Adult-Gerontological Primary Care Nurse Practitioner. She earned her master’s degree from NYU as a nurse practitioner with a holistic specialization, which exposed her to a wide array of healing modalities, including functional medicine. Annie marries her clinical expertise with her holistic nursing background, sense of humor, and compassion.