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Postpartum Depression

Postpartum Depression

Postpartum depression (PPD) can be treated and the earlier you intervene, the easier your recovery will be. PPD can also be experienced by fathers, and adoptive mothers. Not every women with risk factors will experience postpartum depression, however if you have risk factors you would benefit from attending a consultation with me to develop a plan for support during pregnancy and postpartum.

Postpartum depression is NOT the baby blues. Baby blues is considered a normal part of postpartum adjustment, requiring no medical or psychological intervention. Postpartum depression is an umbrella term that refers to various mood or anxiety disorders which can follow childbirth. PPD can present in a number of ways depending on the predominating set of symptoms. PPD is typically an agitated depression, with symptoms of both depression and anxiety. When depressive symptoms dominate, we refer to it as postpartum depression. When anxiety is the compelling symptom, we refer to it as a postpartum anxiety disorder. Postpartum anxiety disorders include postpartum panic, postpartum obsessive-compulsive disorder and postpartum posttraumatic stress disorder.

Some experts are now comfortable using the term postpartum distress to encompass both symptoms of depression and anxiety.

Postpartum depression is the most common complication following childbirth, characterized by frequent crying, mood swings, irritability, extreme fatigue, difficulty concentrating, sleep problems, loss of sexual interest, anxiety, appetite changes, negative scary thoughts, feelings of inadequacy, hopelessness and despair. In addition, thoughts of suicide and feelings of anger, shame and guilt are often present.

Postpartum psychosis is a severe medical condition that is often misdiagnosed as postpartum depression. Psychosis occurs in 1 or 2 out of 1,000 postpartum women and is often associated with bipolar illness. The most common symptoms are severe agitation, delusional or bizarre thinking, hallucinations, insomnia, confusion, and a feeling of being out of touch with reality. Although this is a rare condition, it is always an emergency and requires immediate medical attention.

Postpartum Mood Disorders - Signs & Symptoms

What are baby blues?

Baby blues are considered a normal part of postpartum adjustment (up to 85% of new mothers!) The blues are related to the hormonal shifts following delivery. They are self-limiting and require no treatment. Symptoms generally appear within three to four days after delivery and remit spontaneously within 2-3 weeks. The blues do not interfere with your day-to-day functioning. If emotional vulnerability lasts beyond 2-3 weeks postpartum, it is not the blues.

Warning Signs

  • You feel sad and happy, alternately.
  • You feel anxious.
  • You cry more easily than usual.
  • You are weepy.
  • You feel emotional.
  • You feel overwhelmed.
  • You feel irritable.
  • You feel exhausted.
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What is Postpartum Stress Syndrome?

Postpartum Stress Syndrome is another term for an adjustment disorder. You may notice yourself struggling to get through the day with constant feelings of distress which do not resolve with reassurance or self-help measures. You may be overwhelmed by feelings of self-doubt and feel pressure to be the perfect mother who is in control at all times. Most of the time, women with postpartum stress syndrome feel like they are imposters, or like they are going through the motions without anyone noticing how bad they are really feeling. Postpartum stress syndrome can lead to depression if symptoms linger without supportive attention to them. Resource: (This Isn't What I Expected by Kleiman and Raskin)

Warning Signs

  • You feel more anxious than usual.
  • You are worried that you are not bonding with your baby the way you should be.
  • You are exhausted.
  • You are trying to "fake it 'til you make it."
  • You are overly concerned with how you are feeling.
  • You compare yourself to how other women are doing/looking/feeling.
  • You wonder if you might be depressed.
  • You may avoid social situations.
  • You are experiencing an increase in physical complaints.
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What is Postpartum Depression?

Postpartum depression is characterized by a depressed mood most of the day nearly every day. It can present with symptoms similar to baby blues, but symptoms of depression are more disruptive and last beyond the first two weeks after delivery. Onset is usually within the first three months postpartum, but symptoms can emerge any time during the first postpartum year.

Symptoms of postpartum depression can be difficult to distinguish from "normal" postpartum conditions associated with being a new mother because most new mothers are tired, overwhelmed and anxious. The determining factor is how much distress the feelings cause you and how much they interfere with your ability to function during the day.

Postpartum depression can range from mild to severe. Even mild depression requires treatment. If left untreated, postpartum depression can have serious adverse effects on you and your relationship with significant others, and on your baby's emotional and psychologic development. Your baby deserves a healthy mom.

Warning Signs

  • You are worried about the way you are feeling.
  • You feel tired all the time.
  • You are unable to sleep even when the baby is sleeping.
  • You feel inadequate and compare yourself to others.
  • You feel guilty about how you are feeling.
  • You feel nervous much of the time.
  • You are not eating as much as you usually do.
  • Your mind races with thoughts and worries.
  • You are unable to focus or concentrate on anything.
  • You have thoughts that are scaring you.
  • You are afraid if you tell anyone how you are really feeling you will be judged.
  • You worry that if anyone knew what you were thinking, they would take your baby away.
  • You are afraid that people will think you are not a good mother.
  • You are confused about how you are feeling.
  • You are obsessing about how you are feeling, what you are thinking and how your baby is doing.
  • You feel irritable and enraged some of the time.
  • You cry more often that you usually do.
  • Sometimes you think it would be better if you were not here.
  • You feel guilty or embarrassed about the way you are feeling.
  • The way you are feeling is interfering with your ability to function day to day.
  • You are experiencing physical problems like headaches, stomach aches, dizziness, unexplained pains.
  • You have way more anxiety than you usually do.
  • You have lost pleasure in doing the things that used to give you pleasure.
  • You are consumed by how you are feeling.
  • You wonder why nothing you do seems good enough.
  • You are afraid to be alone.
  • You are worried that you might be over attached or not attached enough with your baby.
  • You wonder if you will ever feel better.
  • You have thoughts of disappearing, sleeping forever, running away, waking up someplace else.
  • You are having suicidal thoughts and believe your baby would be better off without you.

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What is Postpartum Anxiety?

Postpartum Anxiety is the presence of excessive worry during the postpartum period. While anxiety is normal during the postpartum period too much worry can make you feel tense and irritable more of the time, than not.

Warning Signs

  • Your heart is racing, palpitating, skipping beats.
  • You have a sense of pending doom.
  • You have pressure or pain in your chest.
  • You feel preoccupied with uncontrollable worries.
  • You have thoughts that are scaring you about your baby, about yourself, about your partner and anyone you love.
  • You ruminate about your physical wellbeing or the health of your baby.
  • You are consumed by "what ifs" and feel anxious about future events.
  • You have lost your appetite, nothing tastes good.
  • You are exhausted.
  • Thoughts race in your head.
  • You have difficulty sleeping.
  • You find it challenging to quiet your mind.
  • Relaxing feels impossible.
  • You questions your decisions.
  • You overthink, overanalyze, over process everything.
  • You have an increase in physical symptoms, such as nausea, dizziness, blurry vision.
  • You having feelings of being "unreal" or dissociated from self or the environment.

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What is Postpartum Obsessive Compulsive Disorder?

Postpartum OCD is an anxiety disorder characterized by obsessive, intrusive thoughts, images or urges which may or may not be accompanied by compulsive behaviors. These unwanted thoughts appear "out of nowhere" and are extremely distressing. You might be worried that if you tell anyone about the thoughts you are having, something terrible will happen, like someone will take your baby away. While it is understandable that you would worry about these thoughts because they feel so bad, these thoughts are a common manifestation of acute anxiety and are not associated with any negative outcomes. Most new parents experience unwanted negative thoughts about their infants, even women who do not have OCD. The anxiety you feel about these thoughts tells us that they are anxiety-driven and this is a symptom that is very treatable.

Warning Signs

  • You have scary thoughts of hurting your baby (stabbing, suffocating, sexual abuse, dropping).
  • You might experience some of these common obsessions:
  • The idea that your baby could die while sleeping in the crib.
  • The thought or image of dropping the baby from a high place.
  • An image of your baby dead.
  • Unwanted impulses to shake or yell at your baby.
  • Thoughts of drowning your baby during a bath.
  • You are afraid that you might inadvertently harm your baby through your inattentiveness.
  • You are preoccupied with thoughts of harm to your baby from exposure to medications, environmental toxins, germs, crowds, chemicals, foods.
  • You worry that you will be responsible for something horrible happening to your child.
  • You are afraid you are making bad decision which may lead to a catastrophic outcome.
  • You may avoid certain places, things, or actions for fear harm may come to your baby.
  • You may check, count, clean, repeatedly to reassure yourself that things are in control.
  • You find that you ask the same things repetitively and are not reassured by what you are told.
  • You have lost your appetite.
  • You have difficulty sleeping because the of the thoughts whirling around your head.
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What is Postpartum Posttraumatic Stress Disorder?

Postpartum PTSD is an anxiety disorder that can follow an experience involving a threatened, perceived or actual serious injury or death to you or your baby. Witnessing an event involving death and reacting with horror or feelings of helplessness contribute to the definition of trauma. Examples of trauma which can lead to PTSD after childbirth are: history of previous sexual trauma, birth trauma related to medical complications or injury, birth loss or NICU experience, or any unexpected outcome.

Warning Signs

  • You have nightmares of the traumatic event.
  • You have flashbacks of the traumatic event.
  • You are angry.
  • You have pervasive anxiety.
  • You cannot sleep.
  • You cannot concentrate.
  • You feel emotionally numb.
  • You avoid things or places that remind you of the traumatic event.
  • Your anxiety is triggered by cues of the traumatic event.
  • You re-live the traumatic event in your mind which causes you to become more agitated, more irritable, more distressed.
  • You may feel detached.
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What is Postpartum Panic?

Postpartum panic is when the anxiety manifests as distinct periods of intense fear. These periods are often marked by subsequent fear and avoidance of another attack.

Warning Signs

  • You cannot breathe.
  • Your heart is racing, palpitating, skipping beats.
  • You feel weak and lightheaded.
  • You feel terrified for no particular reason.
  • You feel numbness or tingling and wonder if you are becoming paralyzed.
  • You are terrified of losing control.
  • You wonder if you are going insane.
  • You feel like pacing as a result of excessive negative energy.
  • You are afraid you will die.
  • You are having thoughts that are scaring you.
  • You are worried about your ability to be a good mother if you have these unwanted thoughts.
  • You believe your physical symptoms are dire and perhaps you should go to the emergency room.
  • You believe no one understands how bad you feel or how scared you are.
  • You are fearful of having an anxiety attack.
  • You avoid places or things because you are fearful you will panic.
  • You are unable to calm yourself.
  • You have been told you are overreacting or majorly misinterpreting your bodily sensations.
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What is Postpartum Bipolar Disorder?

Bipolar disorder during the postpartum period is characterized by periods of extreme highs (mania) and lows (depression).

Bipolar I is primarily distinguished by the presence of manic episodes, while Bipolar II is characterized by hypomanic episodes. Although postpartum hypomania may not be associated with major impairment in functioning, it is not uncommon for it to be linked with a subsequent, significant depression.

If you have a history or family history of bipolar disorder you are at an increased risk of experiencing an episode during pregnancy and postpartum. You are also at risk for postpartum psychosis so please inform your healthcare providers so you can be carefully monitored.

Warning Signs

  • You experience persistent elevated or irritable moods (hypomania).
  • You have a family history of bipolar disorder in a close relative.
  • You feel you need less sleep.
  • You feel more energetic than usual.
  • You feel abnormally talkative or hyper.
  • You are being told that your speech is pressured and you are not talking like yourself.
  • Your irritability is interfering with your relationships.
  • You experience periods of severe depression.
  • Your thoughts race and you seem to be thinking faster.
  • You feel overconfident or unusually social.
  • You feel quick to anger or chronically irritable.
  • You are told by others that your behavior is problematic.
  • You have started a new antidepressant and feel strangely good.
  • You have a heightened interest in sex or spending money.
  • You are told you are not acting like yourself.
  • You are told that your overly inflated sense of self interferes with work or relationships.
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What is Postpartum Psychosis?

Postpartum psychosis is the least common, but most serious, postpartum mood disorder. It affects one to two per thousand deliveries and typically appears within the first month after delivery. The presence of psychotic symptoms necessitates aggressive medical treatment and most likely, hospitalization. Psychosis is strongly associated with bipolar disorder; therefore, if you have a personal or family history of bipolar disorder you should be carefully assessed.

Warning Signs

  • You report seeing things that others do not see.
  • You believe things that others say are not true.
  • You hear voices other than your own (often religious in nature) telling you to do things (often telling you to harm your baby).
  • Your thoughts race constantly.
  • Your speech is rapid.
  • You are paranoid and question the loyalty or intentions of those closest to you.
  • You feel extraordinarily agitated.
  • You are told by others that you are not in touch with reality or the word "bizarre" is used to describe your thinking.
  • You have difficulty expressing yourself and have trouble making sense to others.
  • You do not understand what others close to you are telling you.
  • You are unable to sleep or you do not feel the need to sleep.
  • You have suicidal thoughts.
  • You have thoughts of directly harming your infant.
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What If I Am Having Scary Thoughts?

It might help you to know:

  • Scary thoughts are a very common symptom of postpartum depression.
  • Scary thoughts are negative, repetitive, unwanted, intrusive thoughts that can bombard you at any time. They can come out of nowhere.
  • Scary thoughts can come in the form of thoughts ("what if I burn the baby in the bathtub?") or images (picture the baby falling off the changing table).
  • Scary thoughts can be indirect or passive (something might happen to the baby) or they can imply intention (thoughts or images of you throwing the baby against the wall).
  • Scary thoughts are NOT indication of psychosis. They may make you feel like you are going crazy but you are not.
  • Scary thoughts can be part of a postpartum OCD diagnosis (postpartum Obsessive-compulsive disorder) or they may occur in the absence of a full blown diagnosis.
  • If you have a history of OCD or tend to be a worrier or describe yourself as overly analytical or perfectionist, you may be at increased risk to experience this symptom. Then again, you may have NO history of any anxiety symptoms.
  • Scary thoughts will make you feel like you're a bad mother. They will make you feel guilty and ashamed. Try not to beat yourself up about this. Remind yourself it is a symptom. It is not about who you are.

The nature of these thoughts:

  • Scary thoughts typically focus on your baby, but can also center on thoughts about you, or your partner.
  • Scary thoughts can range from mild to unbearable.
  • Scary thoughts can be intermittent or constant.
  • Scary thoughts may be fleeting or they may race in your head throughout the day or keep you from falling asleep at night.
  • Scary thoughts may or may not be accompanied by compulsive behaviors (e.g. excessive checking).

    Some examples of scary thoughts:
  • "What if I drop my baby when I go down the steps?"
  • "What if I burn the baby in the bathtub?"
  • "I'm afraid I might take one of the knives in my kitchen and stab the baby" Or, "What if I slip and one of the knives falls on my baby."
  • "I can picture myself driving off the road with my baby in the car."
  • "I think my family would be better off without me."
  • "I'm having sexual thoughts about my baby."
  • "I can see terrible graphic violent things happening to my baby."

What you can do:

If you are worried about the thoughts you are having, that's a good sign. Of course you're worried. It's a terrible burden to feel so attached and loving toward your baby and have such scary thoughts at the same time. Having these thoughts probably make you feel enormously guilty. (You might think, "A good mother wouldn't be thinking such awful things.")

But good mothers DO think bad thoughts when they are struggling with depression and anxiety. If these thoughts do not feel consistent with who you are, if they seem totally out of character for you, or if you know they are irrational and make no sense, it shows that the thoughts are obsessive symptoms of acute anxiety.

Remember that these thoughts are NOT about who you are. They are symptoms. Your brain is playing a trick on you. The more you focus on them, the more you are telling your brain to believe them and the more you empower these thoughts. Try your best to distract yourself. Tell yourself that it's okay you're having these thoughts, nothing bad is happening and that you won't always feel this way. Keep your brain busy with other things. As silly as it may sound, it works. Focus on brain tasks, such as puzzles or other games that make you concentrate. Get up and out, take a walk, listen to upbeat music, dance, fool your brain into doing something else. It's hard, but it can help.

Scary thoughts can be so disturbing that it's hard to tell anyone how you are feeling or what you are thinking. Believe it or not, you might actually feel better if you tell someone you trust that you are having these thoughts. No one is going to take your baby away. No one is going to think you're a bad mother. Tell someone you trust that you don't feel good and that you know these thoughts are symptoms of depression. Let them reassure you that you will be okay when you get the treatment you need. Let them remind you that you are loved and safe.

The good news is that these thoughts are symptoms that are treatable and respond well to both medication and supportive therapy. This is why it's so important to ask for help. Talk to your partner. Talk to your doctor. Don't let your fear get in the way of you getting the help you need. Reach out to someone who understands. You deserve some relief. Do what you need to do to feel better.

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Self Help

Women and families who struggle with anxiety and depression after the birth of the baby can feel out of control and helpless. We know that feeling vulnerable can make it difficult to ask for help. But we also know that reaching out for support can empower a family by providing information, understanding and tools for intervention.

Psychotherapy for postpartum depression is a well established treatment, but for a number of women, it can be hard to attend weekly sessions. Additionally, some women hesitate to take medications while nursing or at all because of the side effects or because they would rather not be on medication for many personal reasons. When considering other treatments, families should remember that the evidence continues to support the efficacy of psychotherapy and/or antidepressant drug therapy for the treatment of postpartum depression. The use of alternative treatments however is becoming increasingly popular due to the fact that they are readily accessible and generally well-tolerated. Again, we caution families not to rely on alternative therapies as the sole course of treatment for anything other than a mild depression. Alternative approaches are best used as adjuncts to methods such as therapy and/or medications in which effectiveness has been well documented.

Some options include:

Omega-3 polyunsaturated fatty acids have been shown to offer health benefits to pregnant and nursing mothers.

Light therapy, often used for seasonal affective disorder, is another intervention that may be preferred by women who are interested in non-medical treatments.

Massage therapy, acupuncture, and relaxation techniques are wonderful ways to improve mood.

Exercise has been shown to reduce mild to moderate depression and anxiety.

Hypnotherapy, a longtime useful tool for childbirth preparation, can be an effective intervention for an agitated postpartum depression.

Support groups can decrease the isolation and stigma that depressed mothers often feel and can provide an important outlet for self-expression and unconditional support.

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Are You Tired of Pretending You Feel Fine?

It can be exhausting to keep up appearances when you are feeling depleted and depressed. When you have a baby to take care of on top of that, life can feel unmanageable and out of control. Some women who experience depression or anxiety after childbirth may believe this is just what being a mother must feel like. They may think something is wrong, but not know exactly what. Or they may think that postpartum depression is something that happens to other women.

Postpartum depression and anxiety is much more common than you might think and can occur anytime during the first postpartum year. One out of every 7 women who gives birth experiences symptoms of a clinical depression that requires treatment. While there is no single cause for postpartum depression, it likely results from a combination of biological (your brain and body), genetic (your family history), psychological (your personality and make-up) and environmental (external stressors) factors in your life.

In addition, while pregnancy has traditionally been thought of as a time of emotional wellbeing, recent studies indicate that 10% to 15% of women experience clinically significant depressive symptoms during pregnancy.

Many women make the mistake of waiting too long in the hopes that things will get better on their own. Postponing treatment can lead to harder-to-treat symptoms and a lingering illness. Postpartum depression and anxiety is very treatable. If you are worried about the way you are feeling, tell someone. Talk to your partner. Talk to your healthcare provider. Do not let feelings of shame or embarrassment get in your way. Do what you need to do to help yourself heal so you can feel like yourself again.

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This educational material is provided by Postpartum Stress Centre in Philadelphia, PA,

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Mary Joan Brinson, Certified EFT Therapist
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