With the arrival of her third child, Katie Kavulla expected to be physically and emotionally exhausted. After all, what new mother doesn't feel somewhat frayed at the ends? She was even alert to the signs of postpartum depression because she'd experienced some of the symptoms after the birth of her second child. But this time was different. "My anxiety level was overwhelming," says the Seattle mom. "I'd get hot and sweaty and irritable, and I turned into a late-night worrier. It was like there was a scrolling list of concerns going through my mind, and I had trouble sleeping. That wasn't like me."
Because she didn't feel depressed, however, Kavulla didn't know what was happening. "I wanted to put a label on what I was feeling and I couldn't, which only added to my frustration," she recalls. Finally, after talking to the pediatrician during a well-baby visit, she realized she was suffering from postpartum anxiety disorder, a cousin to postpartum depression (PPD) that affects about 10 percent of new moms, according to the American Pregnancy Association. Unlike PPD, which can cause mothers to experience extreme sadness or even disinterest in their newborn, postpartum anxiety symptoms manifest themselves mainly in the form of worry. "You constantly feel worried and on edge," says Sarah Gottfried, M.D., author of The Hormone Cure. "I think of postpartum anxiety as the loss of the normal sense of balance and calm, and postpartum depression as a loss of heart."
"Like postpartum depression, which can make women feel tired all the time, postpartum anxiety (PPA) can involve physical symptoms, also. Changes in eating and sleeping, dizziness, hot flashes, rapid heartbeat, and nausea can all be signs of PPA, as well as the inability to sit still or focus on a particular task at hand. For the majority of women, these feelings kick in sometime between birth and baby's first birthday, but in some cases, they begin much earlier. "Twenty-five to 35 percent of postpartum anxiety cases begin during pregnancy," says Ann Smith, CNM and President of Postpartum Support International. Smith also notes that, while most women start feeling on edge shortly after giving birth, a particularly stressful life event, or even weaning, can trigger PPA months later.
Unfortunately, postpartum depression is the disorder that's talked about most, so many moms, such as Kavulla, aren't sure what to think once they start experiencing these worrisome feelings. "We call postpartum anxiety the hidden disorder because so few moms recognize it and it goes undiagnosed," says Jonathan Abramowitz, Ph.D., associate chairman of psychology and director of the Anxiety and Stress Disorders Clinic at The University of North Carolina at Chapel Hill. "It hasn't been discussed or studied much, even though it's a lot more common than postpartum depression." In a study that tracked 1,024 women during the first three months after they gave birth, researchers from the University of Heidelberg in Germany found that more than 11 percent fell victim to postpartum anxiety disorders, while roughly 6 percent developed postpartum depressive disorders. The two often go hand in hand too—about half of women who have PPD also have anxiety. "If you're anxious and it's getting in the way of your life, you may begin to feel depressed about that and vice versa," Abramowitz says.
"Some worry is adaptive—anxiety is a natural response to protect one's baby, and often that's expressed with hyper-alertness and hyper-vigilance," says Margaret Howard, Ph.D., director of postpartum depression at Day Hospital at Women & Infants' in Providence. That's why, according to the Mayo Clinic, 89 percent of new parents find their minds racing: What if the baby suffocates? Or slips under the water during a bath? What if someone breaks into the house and snatches her? "For most parents, this is just mental noise," says Abramowitz. "They learn to dismiss it, so the thoughts stop cropping up."
On the other hand, if you know your worries are irrational (say, you have an intense fear that your baby will get hurt if you don't hold him), but you can't get them out of your brain, that suggests you may be tipping the scale. The same is true if your anxiety leads you to dread everyday situations (like driving with baby), if panic attacks come out of the blue, or if it interferes with your ability to function (because you check on him throughout the night). "Anxiety is a problem when it overshoots reality," Howard says.
The condition often results because of a variety of triggers, experts say. For starters, "there's a huge hormonal shift—estrogen and progesterone levels increase 10- to 100-fold during pregnancy, then fall to essentially zero within 24 hours of delivery," explains Elizabeth Fitelson, M.D., director of the Women's Program at the Columbia University Department of Psychiatry. In the days that follow, you're dealing with sleep deprivation, changes to your relationship, and new schedules and responsibilities, including round-the-clock care of a newborn. Add to that society's expectation that this should be one of the happiest times in your life and that you should know what to do instinctively, and it's no wonder so many mothers start to come unglued.
While any new mom can develop postpartum anxiety, those who are especially vulnerable include women with a personal or family history of anxiety or previous experience with depression, certain symptoms of PMS (such as feeling weepy or agitated), eating disorders, or obsessive-compulsive disorder (OCD). Women who have had a miscarriage or stillbirth are more susceptible to postpartum anxiety and depression with a subsequent healthy delivery, according to a study by the University of Rochester in New York, because they're so worried something else might go wrong. Personality may also come into play: "Moms with postpartum anxiety often describe themselves as Type A, sensitive, or easily worried," says Sherry Duson, a family therapist in Houston who specializes in treating those with pregnancy and postpartum mood and anxiety issues.
Unlike the baby blues, which last about two weeks, postpartum anxiety doesn't always go away on its own. It's crucial to seek help if anxiety is disrupting your sleep or you're constantly preoccupied with worries. "In moderate to severe untreated cases, postpartum anxiety can last indefinitely," Smith says. "Perinatal mood disorders don't always disappear on their own. In fact, in some cases, if left untreated, they can set women up for a lifelong bout with mental illness." Fortunately, there are a number of postpartum anxiety treatments out there, but the onus often falls on you to bring it to a doctor's attention. When researchers at Massachusetts General Hospital in Boston screened 491 mothers for postpartum anxiety or depression six weeks after they gave birth, 17 percent had one or the other; yet the majority of them had not been diagnosed. "In mild cases of any perinatal disorder, the first thing that should be tried is a combination of support and therapy," Smith notes. "Sometimes just having someone to talk to or give you a break from baby duties makes a big difference."
If you're feeling overwhelmed with worry, tell your ob-gyn or pediatrician and ask for a referral to a therapist who has experience with perinatal mood disorders or a psychologist who specializes in cognitive behavioral therapy (CBT). "It gives you the skills to change the thinking and behavior patterns that lead to anxiety," Abramowitz explains. For instance, if you tend to think the baby has a serious illness at the first sign of a sniffle, CBT can help you develop a more realistic outlook (could be a cold!). "This isn't about positive thinking," says Abramowitz. "It's about being rational."
An expert can teach you techniques to help you relax, such as meditation, progressive muscle relaxation, and mindfulness training. Done before bedtime, they can set you up for a good night's sleep (which can ease anxiety). Exercise can also relieve anxiety by helping you feel more empowered, Howard says. Six weeks of resistance training or aerobic exercise led to a remission rate of 60 percent and 40 percent, respectively, among women ages 18 to 37 with generalized anxiety disorder, a study done by The University of Georgia finds.
For more severe cases of postpartum anxiety, therapy, support, and medication may be recommended—even if you're nursing. "The use of medications needs to be determined on a case-by-case basis," Dr. Fitelson says. "Your mental health and your ability to take care of and bond with your child are so important that at some point they take precedence over the low or theoretical risk to your baby of taking an antidepressant."
That's what convinced Julianna Lewis (not her real name) to take medication when her firstborn was 3 weeks old. "I was anxious about my ability to care for him, nursing, his sleep schedule—everything," says the mother of three in Houston. "I couldn't enjoy my time with him." Her doctor prescribed a commonly used medication, and within a month she was symptom-free. Before her twin girls were born, a little more than a year later, Lewis worried that her anxiety would come back, so on her doctors' advice, she started taking the medication again right after delivery with positive results. "If you've taken an antidepressant or anti-anxiety medication in the past and it worked, that's what you should go with again," Smith says. "Don't try to reinvent the wheel." If you're worried about how a particular medication may affect your baby, InfantRisk.com is a great resource for learning about how different medications affect babies and nursing moms.
Regardless of whether your anxiety falls on the moderate or more severe end of the spectrum, it's better to seek help sooner than later. Think of it this way, Dr. Fitelson says: "Taking care of yourself is taking care of your baby."