This story was originally published on June 18, 2019 in NYT Parenting.
It’s 3 a.m., and I’m sitting in lukewarm bath water, counting my breaths to make sure I’m still alive. My chest feels like it might crack open, and I’m the kind of tired where my body is asleep but my mind is wide awake. Thoughts buzz through my head, keeping me in a perpetual state of fight-or-flight tension. When will my 3-week-old stir, demanding my breast again? How will I endure, even for one more night, the smothering, torn-in-half pressure of caring for my son while attempting to care for my own depleted body?
This is how I felt four years ago when I had postpartum anxiety: desperately needy while being desperately needed.
On a biological level, experts believe mood changes in the postpartum period are, in part, a response to the sudden drop in progesterone and estrogen levels after giving birth. But it’s not necessarily the hormone levels themselves that make new moms vulnerable to anxiety or depression.
“The predominant theory 15 years ago was that women who developed postpartum mood disorders experienced excessive hormonal changes, but studies show there’s no significant difference in their absolute hormone levels,” said Dr. Patricia Widra, M.D., a clinical assistant professor of psychiatry at the University of Maryland. “The current working theory is that it’s not specifically the hormones, but an individual’s brain chemistry response to the hormones.”
Postpartum anxiety affects about 10 percent of new mothers, so it’s not unusual — though it is complex and its symptoms are varied. While my anxiety left me feeling trapped in my body, author Jessica Friedmann’s felt more like dissociating. “When the anxiety hits, I find myself floating outside my own skin, wanting desperately to find a way back inside,” Friedmann wrote in her memoir, “Things That Helped.”
Affecting one in seven women, postpartum depression, which has often functioned as a catch-all term for mental illness during the postpartum period, has historically been more commonly screened and diagnosed. But many mothers, including Friedmann and myself, toggle between depression and anxiety; one mother’s constant worrying may surface feelings of hopelessness, while another mom’s sense of detachment from her baby may cause her anxiety. In one study, 14 percent of women who screened positive for postpartum depression also had an anxiety disorder.
This combination of anxiety and depression among new moms is pervasive enough that women’s mental health providers and reproductive psychiatrists are increasingly abandoning the term “postpartum depression” in favor of the more inclusive “perinatal mood and anxiety disorders” (PMAD), which captures more of the spectrum of psychiatric conditions for which pregnant and postpartum women are at risk. PMAD is an umbrella term, encompassing mood disorders like clinical and bipolar depression as well as anxiety disorders like generalized anxiety, obsessive-compulsive and panic disorders.
“Postpartum depression is a catchphrase we have used, but I think it’s always referred to people who have both sadness and worry at a clinical, diagnosable level,” said Dr. Alexandra Sacks, M.D., a reproductive psychiatrist in New York and author of “What No One Tells You: A Guide to Your Emotions from Pregnancy to Motherhood.” “Within the field, there’s a consensus that when people present with depression, they often really have more anxiety symptoms. We don’t necessarily think of anxiety and depression as two different diseases, because worry is so common during pregnancy and the postpartum [period].”
While a woman’s mental health history can increase her risk for PMADs — I had a previous diagnosis of Generalized Anxiety Disorder, which likely heightened my susceptibility — Dr. Sacks also cited physiological and psychosocial factors. “Exhaustion and hormones, coupled with the tremendous changes in routine and identity that come with becoming a mother, just plant the seed for worry,” she said. “There are so many things to worry about as a new mother, but for many women, that awareness of how fragile a baby is can flip the switch of worry that’s really hard to turn off.”
But there’s a difference between vulnerability to the everyday stressors of new motherhood and diagnosable, clinical anxiety. Dr. Widra, who developed the postpartum screening program for Georgetown Medical Center’s Ob-Gyn Department, described anxiety as a spectrum: While some anxiety can be motivating and keep us vigilant, too much of it can be impairing.
By the time my son was 3 months old, I was impaired. I couldn’t escape from the sensation that I was being suffocated. My anxiety ballooned into near-daily panic attacks and obsessive worries about my own health and the baby’s safety. The sound of my son’s howls left me in a state of nearly unbearable physical agitation. On one visit to the pediatrician’s office, I had a panic attack so severe that my husband had to Uber over from work and take us home.
To manage clinical postpartum anxiety, Dr. Widra recommended talk therapy and, in severe cases, anti-anxiety medication. “Cognitive-behavioral therapy is very effective in treating anxiety during pregnancy and postpartum, and the only risks are time or money. When someone isn’t going to go to therapy or their anxiety is so severe they can’t go to therapy, we might recommend an anti-anxiety medication.”
There is some evidence that using anti-anxiety medications while pregnant or breastfeeding can pose risks to babies but, according to Widra, untreated anxiety can be equally detrimental. Stress is known to negatively affect milk production, which can perpetuate the cycle of anxiety for new moms, and untreated anxiety can have long-term effects on families.
“We sometimes see families where a mom has had anxiety since her child was a baby, and now that child isn’t allowed to go outside,” she said. While this is an extreme example, according to Widra, “anxiety can create a contagious environment.”
When I reached the point where I could hardly leave my house, I found a therapist who specialized in parental anxiety. Expressing my anxious thoughts took the edge off the panic but, most days, I still felt like I was drowning in my son’s needs.
“There’s no shame in what you’re experiencing, but this doesn’t have to be normal,” my therapist assured me. We agreed that increasing the dose of the anti-anxiety medication I was already taking would be a good first step. I talked with my Ob-Gyn and, after only a few weeks on the new dosage, I began to emerge from the fog. The worries didn’t entirely disappear, but I no longer felt trapped under their weight.
Four years have passed since my postpartum anxiety diagnosis. I get more sleep, and my hormones are about as balanced as they’ll ever be. The shifting demands of parenting keep me vigilant but, when anxiety surfaces, my body feels like a safer place to be. And most of the time, so does motherhood.
Ashley Abramson is a freelance writer in Minneapolis, where she lives with her husband and two young sons.