Getting Help for Postpartum Anxiety
Written by: the Editors of goop
Published on: June 7, 2018
Updated on: June 7, 2018
Reviewed by: Catherine Birndorf, M.D.
Anxiety is essential to survival. Say there’s a lion charging your way. You’ll be very grateful for the hormones that make you move as fast as you can to get the hell out of the way. That’s nonpathological anxiety, and it’s perfectly appropriate in certain, lion-charging situations.
Having a baby, for many parents, also evokes a healthy amount of anxiety. After all, newborns don’t come with an owner’s manual. But what happens when anxiety symptoms—whether they are mental (apprehension, dread, worry), physical (chest tightness, shortness of breath, sweatiness), or both—interfere with life? Psychiatrist Catherine Birndorf, who runs the Motherhood Center in New York City, says that a sense of extreme alertness can morph into an unhealthy state of hypervigilance. She’s walked many mothers (including a goop one) through the difficult and scary period of dealing with postpartum anxiety to the other side.
(For more from Dr. Birndorf on postpartum anxiety, listen to her episode of The goop Podcast.)
A Q&A with Catherine Birndorf, M.D.
What’s the difference between postpartum depression and postpartum anxiety? Why is postpartum depression so recognized while many have never even heard of postpartum anxiety?
“Postpartum depression” (PPD) has become a catchall phrase for any and all postpartum struggles beyond what seems “normal.” Anxiety disorders get bundled up and obscured within this phrase as well. Additionally, postpartum anxiety (PPA) disorders are less well studied than PPD.
Up to 80 percent of new moms will have baby blues—hypersensitivity and mood swings that occur between two days and two weeks after birth and resolve on their own without requiring any medical intervention. About 10 to 20 percent of women experience actual PPD.
PPD is defined as a clinical depression that begins anywhere from four weeks to six months or even one year postpartum, but it can feel different than the depression you might experience at other times in life. Both share disturbances in sleep, appetite, concentration, and energy and can come with feelings of guilt, worthlessness, and hopelessness. Unlike major depressive disorder (MDD), PPD is often described as an anxious state. Many women with PPD don’t identify with feeling “depressed” at all, which is why it can sometimes be hard to diagnose. Most women with PPD will describe anxiety as one of their most notable symptoms.
“‘Postpartum depression’ (PPD) has become a catchall phrase for any and all postpartum struggles beyond what seems ‘normal.’”
The simple answer is that PPD is depression in the postpartum period, and PPA is a description of all the anxiety disorders that may occur in the postpartum period, like: generalized anxiety disorder, panic disorder, and obsessive compulsive disorder (OCD, which has now officially been moved to a category of its own). We are getting better at diagnosing these different anxiety disorders postpartum, which is beginning to help distinguish between PPA and PPD.
One other note: Depression and anxiety are close cousins. The comorbidity, or overlap, between the two diseases is consistently over 50 percent. People often are confused when we use antidepressants—like Prozac, Zoloft, Lexapro—to treat not only depression but also anxiety. These medications are the primary treatment for anxiety yet are called antidepressants, which can be confusing. The fact that one medication is used to treat both ailments is more evidence of the close relationship between the two illness states.
How can a mother know whether her anxiety is unhealthy?
Anxiety is an internal signal that something is awry. Now, that doesn’t mean that it’s accurate. It may be off because your biological system is off or because it’s being activated by external stimuli—but it’s still a call that you need to act. People who are anxious live in that heightened alertness a lot of the time, more than they should, and find themselves struggling to not be anxious.
For mothers, and for anyone struggling with anxiety, it has to do with the amount of anxiety, the intensity of it, and how distressed they are by it—that’s what defines a disorder versus normal anxious feelings. It becomes a problem when it’s interfering with their life and causing them a great deal of distress.
“One of the questions I almost always ask new moms is this: When the baby is sleeping—or when the baby is safe in someone else’s hands—are you able to rest or sleep?”
As a quick and dirty diagnostic tool, one of the questions I almost always ask new moms is this: When the baby is sleeping—or when the baby is safe in someone else’s hands—are you able to rest or sleep? When a mother answers that she can’t relax because she’s watching the baby, worrying about the baby, or generally too amped even when the baby is totally safe, then I know the line has probably been crossed and it’s interfering with her life.
Are women who have been diagnosed with anxiety or mood disorders before having a baby more likely to develop postpartum anxiety? Does family history have an impact?
Yes. Women who have anxiety or mood symptoms during pregnancy or who have a history of an anxiety or mood disorder are more likely than those who have never experienced either to have PPD or PPA. There still seems to be a myth that pregnancy is protective for a woman’s mental health, and so it’s not uncommon for pregnant women who are suffering to show up in my office and say they are there to make sure they don’t have postpartum depression, for example. And the truth is, they are already having it antepartum. A large number of PPD cases start during pregnancy, so when the baby is born, things go from bad to worse. Antenatal screening for mood and anxiety disorders is very important yet not done often enough, so many women don’t know that they could be treated for their illnesses while pregnant and then not have the problem in the postpartum period.
Are first-time mothers more likely to get postpartum anxiety than those with a kid or two under their belts?
If you have always been an anxious person or have a diagnosed anxiety disorder, you are more likely to have PPA whether it’s your first child or not. (The same is true of depression.) Often PPA is an extreme or more intense version of your usual anxiety—whether that’s obsession, worry, or panic attacks. It’s important to note that a certain amount of anxiety—especially for first-time moms who haven’t done this before—is normal. It’s when those worries and preoccupations become more consuming or distressing that a problem may exist.
Can you explain intrusive thoughts? Are they ever normal?
Some people occasionally have what we call ego-dystonic thoughts that are scary and upsetting. Even women who don’t have anxiety or depression or any kind of psychological challenges can have intrusive, disturbing, sometimes violent thoughts about harm coming to the baby or about hurting the baby. And people don’t talk about it because they think if they say it out loud, someone will think they’re a bad mother, or worse, if they tell their doctor they’ve had these disturbing thoughts, the doctor will call child protective services on them. These thoughts are not totally abnormal, but they are super disturbing. And as long as a mother is disturbed by them, the likelihood of her ever acting on them is rare.
If she’s having them all the time and isn’t able to stop, then it’s more likely a part of the OCD picture. That’s a different story. But it’s important to know that even people who have garden-variety anxiety, or depression, or even no illness at all, can have very dark thoughts, like walking in front of a bus.
What effect does anxiety have on the bonding process with your baby?
Anxiety can certainly affect mom-and-baby bonding. And it can go either way: A mother can feel overly attached or the opposite, under-attached. If a mother feels overly attached—so anxious that she can’t be separate from the baby or always needing to be on top of things—then there’s this inability to separate. On the other hand, some women are so anxious, they feel like they don’t know what to do at all, so they may stay clear of the baby. Everything in between is also possible.
“A lot of anxious moms end up imposing their anxiety onto the baby—they must be cold, they must be hungry, they must need a nap—when in reality, it’s the mother’s need to act on her own anxiety.”
If a mom is busy managing her own anxiety—the physical symptoms, or the dread, or the fear, or the constant worry—then it may be hard for her to be attuned to the baby, and it may impair her ability to bond in a healthy way. Anxiety is a major distraction, which may make it hard to be in the moment with the baby, to be present and attuned to the baby’s needs. In the best of circumstances, you want to be present with the baby and follow along with their natural cues to meet them where they are. A lot of anxious moms end up imposing their anxiety onto the baby—they must be cold, they must be hungry, they must need a nap—when in reality, it’s the mother’s need to act on her own anxiety. This misattunement can leave the relationship between mom and baby off-kilter. There’s potential for attachment to be more complicated because there’s not an ease with which the mom can see the baby for who the baby is.
What is the treatment?
For more mild cases of anxiety or depression, women may be fully treated by engaging in talk therapy. There are many different kinds of psychotherapies, and they may be done individually or in a group setting. For the more moderate to severe cases of PPD and PPA, women often need to add a medication to their treatment regimen. Typically, antidepressants—like the SSRIs Prozac, Zoloft, Lexapro, etc.—are used and work very well. They are well studied and considered relatively safe for use during pregnancy and while breastfeeding. It’s important that women consult with a knowledgeable health care provider (like a reproductive psychiatrist) about what they can take during this time. Often a combination of therapy and medication is the quickest way for women to get better and treat their PPD or PPA.
Are there any coping mechanisms new mothers can put into effect right away to help manage postpartum anxiety?
First and foremost, coping begins with a mother recognizing and admitting that there’s an issue. If she doesn’t believe it, she’s unlikely to do anything about it, whether it’s therapy or reaching out to a sympathetic family member, friend, partner, or doctor. It should be someone who can be a sounding board, someone who will listen with empathy and no judgment. There are online support groups, however going the online route can send someone who is anxious into an unnecessary tailspin. Looking for healthy coping skills, like taking a walk, finding an exercise class, reading, or listening to a meditation app, can go a long way—anything that’s calming to the system.
“Coping begins with a mother recognizing and admitting that there’s an issue. If she doesn’t believe it, she’s unlikely to do anything about it.”
An anxiety disorder is a medical condition. Seeking help is important because the condition won’t necessarily go away on its own. A mother can’t just pull herself up by the bootstraps and say, “I’m going to will it away or just ignore that it’s happening altogether.” People get into all kinds of unhealthy coping behaviors to manage their anxiety, like avoiding all situations that may make them anxious. The thing about anxiety is that it’s highly treatable, but it’s best to speak with a professional who knows how to approach treatment with different kinds of therapies—and medication, if needed.
How can partners, friends, and caretakers support a new mother going through a hard time? What are the right things to say or do?
A good place to start is by asking, in a very nonjudgmental, empathic way, “How are you doing?” Make sure that you’re asking with a real intent to understand how they feel. By giving someone the opportunity to speak freely and authentically, you’re letting them know that you can tolerate whatever they’re going to say, without reacting (“Oh my god, that’s so scary!”). Your first job is to listen empathically, to be curious, and to be kind.
Then you can say something like, “I would love to figure this out with you.” People are generally slow to ask for help, so be specific with your offer, whether it’s to bring over dinner, accompany her to a doctor’s appointment, or take care of the baby while she goes to the gym one day. You’re not being pushy; you’re showing that you mean it.
Can postpartum anxiety affect men?
Becoming a father is an identity shift. While men aren’t the ones delivering the baby, they are also going through an enormous life change. If they’ve had anxiety in the past, they can have it again or anew. Postpartum anything tends to be less common in men just because women are twice as likely as men, during childbearing years, to have anxiety or depression, statistically speaking. But it can absolutely affect them, and they often get forgotten. Dr. Daniel Singley, whom I work with on the board of Postpartum Support International, works with dads to help them help their wives but also to make sure that they are getting cared for and know how to get themselves help.
Dr. Catherine Birndorf is a clinical associate professor of psychiatry and obstetrics/gynecology and the founding director of the Payne Whitney Women’s Program at the New York-Presbyterian Hospital/Weill Cornell Medical Center in Manhattan. She specializes in reproductive mental health and cofounded the Motherhood Center in NYC, for pregnant and postpartum women who need extra support. She’s also at work on a new book about the emotional side of pregnancy and postpartum.
The views expressed in this article intend to highlight alternative studies. They are the views of the expert and do not necessarily represent the views of goop. This article is for informational purposes only, even if and to the extent that it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice.