The Difference Between Postpartum Anxiety, OCD and Psychosis
May 02, 2023 Victoria Pelham
As you’re washing your newborn, a sudden thought crosses your mind: What if they slip under the water? Later, you’re pushing their stroller down the sidewalk and unintentionally imagine letting go. You panic.
Terrifying, intrusive thoughts like these almost never mean you want to harm your baby, explains Dr. Eynav Accortt, director of the Cedars-Sinai Reproductive Psychology Program. In fact, these thoughts were evolutionally developed to help parents be careful and keep their child safe. And they’re overwhelmingly common, affecting about seven in 10 new parents.
It’s natural to worry during pregnancy and early motherhood. While bringing a new life into the world has many highs, the massive physical, mental, hormonal and lifestyle shifts—and responsibility to protect your child—can take a hefty toll on exhausted parents, causing the “baby blues.” Baby blues, however, is transient and goes away without any intervention within two weeks post-delivery. If these feelings last longer than two weeks, the fear becomes debilitating, jeopardizing quality of life, parental bonding and development—and we’re no longer talking about the baby blues.
Perinatal mood and anxiety disorders are the main pregnancy and childbirth complication, according to the Anxiety & Depression Association of America, and likely underdiagnosed. About one in five birthing people develops a mental health condition around pregnancy.
They exist on a spectrum, Dr. Accortt says, and are nothing to be ashamed of.
When fears take over
Pregnant women usually worry about the health of the developing fetus, their partner and themselves, as well as childbirth and changing body image. Anxiety can jump in the first trimester as they adjust to pregnancy.
After birth, parents are on high alert in early months when infants are most vulnerable, especially if they had health complications. You might also feel guilt about how well you are parenting or if you aren’t happy all the time.
“Motherhood is really, really hard,” Dr. Accortt stresses.
The American College of Obstetricians and Gynecologists notes that maternal anxiety usually spikes right after delivery and up to six weeks postpartum but can emerge at any time until a baby’s first birthday, including breastfeeding transitions or the return of your periods.
Pay attention to how stress is affecting you, such as if you are eating and sleeping enough. Excessive, persistent worry could be a sign of a perinatal anxiety disorder, especially if it interferes with your life. Are you staying home or avoiding triggers, such as your baby’s baths?
Anxiety can also have physical symptoms, such as chest pain, head and stomach aches, dizziness or a racing heart. Panic attacks cause similar sensations, as well as shortness of breath, shaking or sweating. These heart attack-like reactions can last a few minutes to an hour.
About 6% of women develop anxiety in pregnancy and 10% postpartum, according to Postpartum Support International.
And some studies have found a link with earlier (or preterm) birth.
While the COVID-19 pandemic opened up more mental health conversations, social stigma often still keeps moms quiet. If you’re struggling, the first step is to share with a trusted person.
“The more you have these thoughts and keep them to yourself, the bigger they get—like a balloon,” Dr. Accortt says. “But the moment you tell your mom, sister, partner or therapist, it puts a pin in them, deflates them and you feel better.”
A support or therapy group such as those offered by Cedars-Sinai’s Reproductive Psychology Program (many virtual) or Postpartum Support International (PSI) can give you an outlet for reassurance and serve as a reminder that you’re not alone. The Health Resources and Services Administration also has a National Maternal Mental Health Hotline in English and Spanish.
Anyone who’s reached a mental health or suicidal crisis should call the 988 Lifeline immediately.
Less widely understood, obsessive-compulsive disorder (OCD) is regularly overlooked in new moms—even though it’s a common complication for 3% to 5% of women. It can appear for the first time or get worse around pregnancy.
And it’s among the most disabling health conditions.
Perinatal OCD amplifies unwanted, irrational thoughts. Most sufferers dread accidentally or purposefully hurting their baby, whether by contamination, dropping them, drowning, choking or inappropriate touch. These intense fears can cause visual images where the person might even see their child dying.
“Those thoughts are not who they are or something they want to do,” Dr. Accortt stresses. “They would never act on it.”
People with OCD, though, believe that the presence of these thoughts means they’re capable of harm—and become wracked by overwhelming shame and fear.
These symptoms don’t resolve with time, sleep or reassurance like for other new parents but instead get stuck in a loop.
That leads to rumination (repeatedly trying to think their way out of anxiety) or compulsions to find relief from alarming ideas. Parents might obsessively wash their hands or clean to get rid of germs, check on their sleeping baby endlessly, ask others about their health or count or pray excessively. Alongside rituals, mothers might become overly attached to their baby—or avoid them completely out of fear.
“The more you have these thoughts and keep them to yourself, the bigger they get—like a balloon. But the moment you tell your mom, sister, partner or therapist, it puts a pin in them, deflates them and you feel better.”
Postpartum psychosis—a medical emergency
Postpartum psychosis (PPP) is “not just severe postpartum depression,” despite widespread misconceptions, but a true psychotic disorder, Dr. Accortt emphasizes.
PSI notes the extremely rare diagnosis affects about 1.5 out of every 1,000 birthing parents.
The main symptom is seeing or hearing things that aren’t there. Other postpartum mental health conditions usually don’t cause hallucination, except when a new mom is severely sleep-deprived—and will recover with a few days of rest.
PPP patients can also develop delusions, paranoia, mood swings and hyperactivity or not sleeping at night at all. Partners and families should be aware of these signs.
The disorder creates a disconnect from reality, so patients can’t tell the difference between their mind and the voices—which could tell them their child is better off without them. That raises the risk for suicide (5%) and infanticide (4%), making it a medical emergency.
“It’s important to listen to and believe women who say they’re having scary thoughts,” she stresses.
Managing perinatal mental health
Parents in active psychosis should not attempt to keep parenting as usual. An emergency department visit—followed by intensive inpatient psychiatric care, including psychotherapy and antipsychotic medication—is crucial. Alert all your mental health providers to ensure care connection.
Most people with PPP have a personal or family history of bipolar disorder, schizophrenia or a psychotic disorder. See a reproductive psychiatrist early in your reproductive journey if you have any of these conditions, Dr. Accortt stresses. They will coordinate your care and encourage you to stay on antipsychotic and mood-stabilizing medications throughout pregnancy, because the chances of PPP skyrocket if you discontinue medicine.
Perinatal mood and anxiety disorders are treatable, she underscores.
If you’re struggling with severe anxiety, panic, obsessions or compulsions most of the time and for more than a month, a reproductive psychologist can evaluate your mental health and offer specialized care.
That usually involves a selective serotonin reuptake inhibitor (SSRI) alongside cognitive behavioral therapy, exposure and response prevention (the gold standard for OCD), interoceptive exposure (for panic) or cognitive processing therapies (for PTSD). Start with four to five sessions before deciding if a treatment or therapist will work for you, Dr. Accortt encourages.
A perinatal psychologist can also help those with existing anxiety disorders or risk factors weigh the pros and cons of staying on antidepressants when pregnant and breastfeeding or starting preventive mental healthcare.
Getting help can allow you to enjoy your baby’s snuggles again—without fear—and create a safe, calm home that has ripple effects for your child and your family’s future.