Ask a new mom about her actions after giving birth, and you’ll hear a range of behaviors that would probably sound odd to most non-moms. Watching the baby’s breathing, checking the baby monitor dozens of times, keeping an eye on the front door for potential intruders. To new moms these actions are likely all too familiar. The anxiety that comes with motherhood is something many new moms feel but rarely discuss. And perinatal anxiety – that is, anxiety during pregnancy and the postpartum period – has received limited attention from researchers and health professionals, according to a 2017 review article in The British Journal of Psychiatry, despite the fact that it is highly prevalent. We are, after all, suddenly responsible for tiny, helpless, precious humans. Who wouldn’t be anxious? This can all lead a mom to wonder, how much anxiety is too much?
Protecting our babies: some physiological explanations
Entering pregnancy, mothers experience a ramping up of their stress systems in order to help them care for and protect their new little beings, explains Mary Kimmel, M.D., Assistant Professor and Medical Director of the Perinatal Psychiatry Inpatient Unit at the University of North Carolina, Chapel Hill, and mother of two. “The main hormone from the stress system is cortisol, and that actually increases across pregnancy to support the development of the baby, but it also functions in this role of trying to help mom find the right amount of stress or anxiety once the baby comes,” says Kimmel.
Researchers are working to understand how hormones and neurological reactions foster feelings of protectiveness. By using functional magnetic resonance imaging (fMRI) to observe brain activity in new parents, for instance, researchers at Yale University observed that when new parents heard their babies cry, the parents often experienced an anxious neural response in brain areas associated with obsessive-compulsive disorder (OCD) and with emotions such as empathy. As Anna Abramson and Dawn Rouse report in “The Postpartum Brain,” the researchers believe this neural response is evolutionary and primal: after childbirth, a period of high alert, or vigilant watch, was necessary in order for parents to protect their babies from all sorts of environmental dangers.
At the University of Denver’s Family and Child Neuroscience Lab, under Director Pilyoung Kim, Ph.D., researchers are studying the brain activity of first-time mothers for patterns that are linked to their anxiety or depressive symptoms. Researchers found greater connectivity between the amygdala (the brain’s almond-shaped masses of gray matter associated with emotional awareness) and frontal regions in the brain in mothers with higher levels of postpartum anxiety. “Heightened amygdala activity has been linked to greater fear responses or threat detection and anxiety symptoms,” explains Amy L. Anderson, doctoral candidate at the University of Denver. “Our finding of increased connectivity between the frontal regions (PFC) and amygdala potentially indicates that even in the absence of threat stimuli, mothers with higher levels of anxiety may still be activating regions of their brain that react to heightened emotions or anxious states.”
Defining postpartum anxiety
Defining postpartum anxiety can be difficult, explains Kimmel, since each woman is unique and some women worry more than others. “We all fall on a spectrum, in terms of our personality. It’s not good or bad where you fall, but wherever you fall, if you have no anxiety, that can be problem for you at certain times, and having too much anxiety can be a problem. That makes it harder to define postpartum anxiety. When is it a separate thing from how you are just working within the world?”
Sarah,* who has a 22-month-old daughter, believes she suffered from anxiety after her daughter was born although she never sought treatment. “I was really worried about keeping my daughter alive and her breathing. I kept the lights on in the house at night. I must have checked her breathing 20 times a night.” Sarah did not feel depressed, but she felt exhausted since checking her daughter’s breathing so often interrupted her own sleep. And she had no way of knowing whether checking her daughter’s breathing that often at night was normal. Only after her daughter grew older and less fragile did her worries dissipate and did Sarah come to believe she’d been suffering from anxiety. “When I compare myself to my peers who had newborns at the time, many women seem much calmer and less neurotic about their babies and their breathing,” she says.
Similarly, Katherine, who has a four-and-a-half-year-old daughter and 6-month-old son, worried about keeping her daughter alive. “I was constantly worried she was going to die,” adding that as a new mother, her lack of mastery over caring for babies left her feeling on edge all the time. “I couldn’t calm myself down when she cried. I had a visceral reaction to it.” Katherine’s anxiety about her baby caused her to become anxious about her own health. A psychologist by training, she recognized her anxiety was interrupting her life and causing her to not enjoy spending time with her daughter, which prompted her to seek treatment and medication.
The many forms of anxiety
About 85 percent of women experience some type of mood disturbances after having their babies, according to the Massachusetts General Hospital (MGH) Center for Women’s Mental Health. For the majority of these women, the disturbances are short-lived and mild. However, for about 10 to 15 percent, the disturbances develop into more severe symptoms of anxiety or depression.
Anxiety can be generalized or specific and affect a mom in a number of ways. A mom may suffer from constant worry, racing thoughts, sleep disturbances, or a feeling something bad will happen. The anxiety may get to a level where she never feels comfortable letting someone else take over, or it could be the other extreme: she is so anxious about doing something wrong she becomes paralyzed and unable to be left alone with her child. Specific anxieties include agoraphobia, literally “fear of the marketplace,” Postpartum Panic Disorder, or Postpartum Obsessive-Compulsive Disorder (OCD), a form of anxiety where moms experience obsessions, or intrusive, upsetting, often very frightening thoughts, and ritualistic behaviors or compulsions.
For Jennifer, mom of a two-and-a-half-year-old daughter, her obsession centered on harming her daughter while feeding her. “I was afraid to feed her because I was afraid to stab her,” says Jennifer. “I was afraid to hold a fork anywhere near her.”
Worries about harming their children are very common obsessions for new mothers, particularly in the postpartum period, says Kimmel. According to the non profit organization Postpartum Support International (PSI), these frightening obsessions are anxious in nature and have a very low risk of being acted on. “One mom’s example was the mom thought, ‘oh, my child can fit in the microwave, what a weird thought, oh my gosh, that’s horrible I was thinking about that,’ and she got stuck on that thought,” says Kimmel. “If you were worried about the microwave then you stop going into the kitchen, you can see how that can be negatively impactful.” Similar are obsessive thoughts about knives in the kitchen. “If you’re having that worry about knives in the kitchen, and that’s keeping you from cooking, and cooking is a thing you love, clearly, that’s gotten to a place that needs to be addressed,” she explains, adding that when a mom’s stress system over-responds – when the anxiety makes her feel uncomfortable, when it keeps her from being able to enjoy things, or when it keeps her from doing things she wants to do – that the woman should seek treatment.
But even Jennifer, who had a history of OCD, had difficulty talking about her thoughts. “I was so worried that if I told people what I was thinking that it would happen or that I wanted it to happen. I was afraid to talk about it because I was afraid they would call Child Protective Services on me.” Jennifer says she feels fortunate her longtime psychiatrist “picked” it out of her and can only imagine how many women, who do not have longstanding care and treatment, are suffering. “Even though I had a history of OCD, I did feel ashamed. How could I be a decent person and have these thoughts about my child?”
Anxiety with or without depression
Thanks to the media and to ongoing education, it may be fair to say many women know about postpartum depression (PPD), but many do not know they can suffer from postpartum anxiety alone, without depression. Anxiety is often subsumed under the umbrella term “postpartum depression,” which means recognizing you may be suffering from anxiety may be difficult if you are not feeling depressed. Plus, “little attention” has been given to postpartum anxiety by clinicians and researchers possibly because of the overlap between depression and anxiety symptoms, according to The MGH Center for Women’s Mental Health.
“Part of where it can be hard for some moms is they don’t recognize as being depressed be-cause they don’t feel depressed,” says Kimmel. “They don’t feel sad. They don’t feel like they’re not enjoying things, they just feel overwhelmed with worry.” She added that when moms are feeling really anxious and overwhelmed, they may begin to feel depressed, too. “That’s why it can be hard to piece the two apart because you can begin to feel a lot of the symptoms of depression, such as guilt and feeling hopeless, when you feel so anxious and worried.”
For Lisa,* who has a three-month-old daughter and was diagnosed with PPD, a lot of her PPD was anxiety-driven: she was on high alert, she would wake up in the middle of the night to stare at her daughter to ensure she was alive, and she had sudden fears she’d drop her daughter while carrying her. Then there were the socks. “When I put socks on my daughter, every time, I was scared I was going to pull one of her toes off,” she says, explaining she had such irrational fears, and she knew they were irrational, but she couldn’t stop them. Eventually, Lisa’s husband found her crying in the bathroom. “I couldn’t even explain why,” she says. “I was so overwhelmingly sad.”
But Jennifer, who had braced herself for PPD, was caught off-guard when she was met with anxiety. “I was bracing myself for possible PPD but never about panic attacks about my daughter and obtrusive thoughts about my daughter,” she says. “I’d read a lot about PPD, but the hospital never asked me the right questions. They didn’t notice I was panicking every time I was alone with my daughter.”
Unlike PPD, a classic screening tool does not exist for postpartum anxiety. Instead, a combination of screening tools are used, such as the Edinburgh Postnatal Depression Scale (EPDS), used for PPD, and the Patient Health Questionnaire (PHQ-9), but these may not detect all symptoms, such as OCD symptoms, which are predominant. Accordingly, these tools may not identify all women with clinically relevant anxiety. “We’re still trying to figure out how to get at some of these diverse groups of symptoms that may be going on,” says Kimmel. Only recently, in 2014, did researchers in Western Australia develop the Perinatal Anxiety Screening Scale (PASS), a 31-item questionnaire – the first survey to date – to detect perinatal anxiety.
But even if women, themselves, recognize they are suffering, finding the right treatment can be difficult. Lisa, who suffered from PPD, was told by her daughter’s pediatrician that she needed to get help. But when Lisa contacted her prenatal care provider, she had to wait over two weeks to talk with a therapist, at which time she was told she had PPD. Lisa’s provider told her that she would be prescribed medication on the condition Lisa find a different provider for postpartum care and that the medication could take six to eight weeks to kick in. “I felt like no one was helping me from a medical perspective,” says Lisa. “So I got angry and channeled that anger to figure out how to help myself.” For Lisa, helping herself meant being honest about her feelings and talking about them: she decided to stop lying that having a baby was all wonderful. “The more I talked about it, people said, ‘oh, I felt that way, too.’ So why don’t more people talk about it?” she asks. “We don’t, as women and mothers, talk about it enough. We’re left feeling like something’s wrong with us.”
Moms need time to talk about their experiences so they can find and receive the support they need. “We’re moving towards this system of these really short [medical] appointments,” says Kimmel, “and we need to have time. These are hard things to talk about.” Kimmel suggests that a multidisciplinary approach – a team of people who can address the mom’s unique needs and background and offer the most effective support, whether that’s medication or therapy such as cognitive behavioral therapy or mindfulness – is important.
One resource is Postpartum Support International, which provides a network of volunteers in each of the 50 states to contact for support. Anyone may call its toll-free Warmline (1-800-944-4773) for basic information and resources. It hosts “Wednesday Chats for Moms” and “First Monday Chats for Dads,” free live phone sessions where parents can connect with other parents and talk to experts.
Thankfully, more steps are being taken to increase awareness and to address the many facets of maternal health. In 2015 the American College of Obstetricians and Gynecologists began recommending clinicians screen women at least once during the perinatal period for depression and anxiety symptoms. And in 2016, Congress passed groundbreaking legislation, enacted as part of the bipartisan 21st Century Cures Act in December 2016, to fund screening and treatment programs for maternal depression. Some states, like New Jersey, Illinois, and West Virginia, already require screening of new mothers for postpartum depression.
Steps are being taken. Still, many more need to be.
For information on additional perinatal mood disorders, visit Postpartum Support International.
*Names have been changed per requests not to be identified.