Takeaway: In this vulnerable post, Dr. Julie gives a primer in the risk factors, symptoms, and treatment options for Postpartum Anxiety (PPA). She also gets vulnerable and shares her own experience with Postpartum Anxiety (PPA) and identifies the risk factors, warning signs, and signals of PPA that her expansive team of medical professionals overlooked when she was a new mom. She shares so that you know that you’re not alone, and that even an expert in women’s mental health is not immune to Perinatal Mood and Anxiety Disorder (PMAD).

Postpartum Anxiety (PPA) is more common than most people realize. It happens to about 1 in 10 women according to the statistics, but perinatal mental health providers like me believe the number is actually higher because so many women are not diagnosed. It often overlaps with Postpartum Depression (PPD) and many women who are diagnosed with PPD later realize that they also have PPA. In this post, I’m going to walk you through:

The risk factors for developing Postpartum Depression (PPD) and Postpartum Anxiety (PPA)
The symptoms of PPA
How women are screened for PPA
The signs and signals of PPA that I experienced
Ways you get can support if you’re experiencing PPA

Let’s dive in!

Risk Factors for Developing Postpartum Anxiety

A risk factor is a medical, mental health, or social experience you’ve had prior to becoming pregnant or during your pregnancy that makes you more likely to develop a Perinatal Mood and Anxiety Disorder (PMAD) such as Postpartum Anxiety (PPA) or Postpartum Depression (PPD).

Here is a checklist, adapted from literature written by Dr. Wendy Davis of Postpartum Support International (2014), that can help you identify risk factors of PPP and PPD, which often overlap:

It is difficult for you to ask for help. You normally take care of yourself.
Before your periods, you usually get tired, overwhelmed, or very cranky.
You’ve been depressed or anxious in the past.
You felt depressed or anxious while you were pregnant
Your mother, sister, or aunt was depressed or very nervous after their baby was born.
Sometimes you don’t need sleep, have lots of ideas, or find it hard to slow down.
Your family is far away.
You feel lonely.
You don’t have many friends nearby that you can rely on.
You are pregnant right now and you don’t feel happy about it.
You don’t have the money, food, or housing that you need.
You have a history of thyroid problems or diabetes
You had a difficult time getting pregnant or experienced miscarriage
You were pregnant with multiples

If you identify with two or more of the items on the above list, you have risk factors for developing Postpartum Depression (PPD) or Postpartum Anxiety (PPA). That means that you are more likely to experience depression or anxiety in the first after having your baby, but it doesn’t mean that you will.

From my perspective, being at risk of PMAD means that you and your support network - whoever that includes, from your partner to your close friends to your medical team - should take extra care to look out for signs and signals for depression and anxiety while you are pregnant and during the first few years of each of your children’s lives.

What is Postpartum Anxiety?

Postpartum Anxiety is a specific type of anxiety that begins during the first year of your child’s life. It’s more than feeling anxious or worried. It is persistent and gets in the way of your daily life, disturbs you, and impacts the way you feel about yourself and being a parent.

PPA can impact anyone. You’re more likely to experience it if you have risk factors, but it truly can feel like it comes out of nowhere. It’s important to know that it is treatable, and that with the right support, you can feel better.

What are some symptoms of Postpartum Anxiety?

Every woman’s Postpartum Anxiety (PPA) is different, so the list here is not exhaustive. You may have symptoms of PPA that are not included in this list and that bother you.This list is here to help you better understand your experience and can serve a starting point for a conversation with your healthcare team.

feeling like something bad is going to happen
constant worry
fear of being separated from your baby or allowing someone else to care for your baby
scary, disturbing, unwanted thoughts (sometimes called intrusive thoughts)
racing thoughts
insomnia, including difficulty sleepiing
low appetite
feeling irritable and angry
having a hard time sitting still
physical symptoms like panic attacks, feeling shaky, dizziness, feeling out of breath, hot flashes, nausea

How are women screened for Postpartum Anxiety?

A screening is a short list of questions that identifies symptoms. Ideally, all pregnant and postpartum women would be screened for postpartum depression (PPD) and postpartum anxiety (PPA) as a routine part of their postnatal healthcare. However, the research tells us that many medical providers avoid these screenings because they don’t know how to support a woman who is struggling.

Most of the time, you will be offered this screening on paper or on a computer. Screenings ask multiple choice questions, and your job is to answer them as honestly as you can. Your honest answers give your healthcare provider the best opportunity to support you, and we know that women who get support get better.

What screening tools do you recommend for PPA?

In my clinical therapy practice for postpartum women, I screen women using two tools + I talk with each women to understand parts of her experience that the screening tools don’t capture. This is best practice care.:

The first tool that I use is the Patient Health Questionnaire-9 (PHQ-9) which screens for anxiety. It is not specific to PPA, and a PPA-specific screening tool has not yet been developed. This tool is helpful but may miss important parts of your experience, so I always follow up with questions and discussion.
The second tool I use is the Edinburgh Postnatal Depression Scale (EPDS) which screens for postpartum depression (PPD). It is also helpful for PPA because many women who experience postpartum depression also experience postpartum anxiety.

Because Postpartum Mood and Anxiety Disorders (PMADS) can show up at any time during the first year of your baby’s life, it’s important that you are screened at different times during that first year. Each healthcare practice has its own standards. Here at Nurturing the Sisterhood, we offer you a screening during pregnancy, at 6-weeks postpartum, at 6 months postpartum, and again when your baby turns one!

Dr. Julie’s Story of Postpartum Anxiety (PPA)

If you’ve been following me on Instagram, regularly read this blog, or have worked with me in therapy, you know that I faced infertility and recurrent pregnancy loss. Regardless of my risk factors or any other experiences in my life, this put me at higher risk of developing a PMAD such as postpartum anxiety (PPA) or postpartum depression (PPD), but my care team never once discussed it with me after I brought it up at a routine reproductive medicine appointments. Each time I was assured that my screenings were normal and I was encouraged to “worry about it if it happened”.

Because my pregnancy was a “high risk pregnancy,” I worked with an expansive team that included my reproductive endocrinologist, my OBGYN, and a maternal fetal medicine doctor. I had weekly medical appointments throughout my pregnancy, regularly visited the emergency department with complications, and had extra medical visits postpartum because of my dangerous delivery. And still, no one ever broached the subject of PPA with me.

My Risk Factors

Because I am a therapist for pregnant women and mothers, I knew that I was at high risk for postpartum anxiety before I even started trying to get pregnant. I worried about it immensely (can you tell I have anxiety) and did everything I could to stay mentally well during my pregnancy and postpartum. These are the risk factors that worried me:

My pre-pregnancy health history. First, I have experienced high-functioning anxiety my entire life, which automatically places me at higher risk of PMADs. Secondly, I have several family members who experienced postpartum depression (PPD), which also increases risk. Thirdly, I have thyroid disorder.

My history of recurrent pregnancy loss. If you’ve lost a pregnancy, you’re at higher risk for PMADs during each subsequent pregnancy. My history of miscarriage placed me at higher risk.

Going through fertility treatment also placed me at higher risk.

Experiencing a high risk pregnancy during a time of social isolation. If you’ve been there, too, you know it’s stressful, especially after facing recurrent miscarriages. On top of the medical risks, there are many appointments, emergency hospital visits, and you face many unknowns. Additionally, my pregnancy took place during stay-at-home orders and I was instructed to avoid public spaces and social gathering throughout my pregnancy (plus I was on bed rest!).

Experiencing birth trauma. To avoid triggering anyone, I will leave it at birth trauma. But know that going through a dangerous birth raises your risk, just as it did mine.

Having a child with medically complex issues. Two days after we came home from the hospital, we rushed J to the emergency department and sat there all night long. He was having major digestive issues, and they were scary. It took more than 6 months of specialist appointments, scheduling a surgery that ended up being canceled, and lots of trial and error before he was diagnosed with an autoimmune disorder that is now well-managed. At the time, it was scary. The stress of this situation put me at higher risk for PPA.

My Postpartum Symptoms

Looking back, it’s difficult to pinpoint the time my postpartum anxiety (PPA) started, and I was lucky that it never got severe. I credit this to my therapeutic knowledge, my long history of participating in my own therapy, and my supportive partner who gave me lots of breaks and allowed me to rest + extend my maternity leave.

The biggest outward signal of my PPA was weight loss. I simply couldn’t eat, because I felt nervous, and I often didn’t feel hungry. On top of that, I was on an incredibly restrictive diet because of J’s medical issues. Strangely, I was complimented for the weight loss at every medical appointment I attended, even when I began to weigh less than I did before I was pregnant. No one attributed this to anxiety.

Other signs of postpartum anxiety (PPA) that I faced included not wanting to leave J alone with anyone unless I was also home, being incredibly and somewhat neurotically organized, over-reading about J’s development, late night shopping and scrolling on social media to learn how I could do a better job as a mother, avoiding my emotions + stuffing them somewhere I didn’t need to consider them, and trying to people-please everyone around me. I also greatly limited the people who had access to J for fear of him getting ill, and most of my friends and family didn’t meet J until he was over 6 months old. As a result, I became socially isolated and felt lonely. The isolation allowed me to take full control of J’s schedule, care, and situation but it negated the social support I needed.

My Takeaway

Without my specialized training in perinatal mental health, I’m not sure that I would have recognized my own PPA. It took me months to recognize that I was experiencing it, because even trained therapists have a difficult time with processing and uncovering their own reality (most therapists see another therapist for help with this!)

My experience alerted. me to the extreme lack of mental healthcare that is offered to women, and I found it alarming. Most women interact far less with the medical system, which means less opportunities for screening and support. I found this reality to be so impactful that I decided to start my own therapy practice, Nurturing the Sisterhood, that is just for women who are pregnant and postpartum. I believe you deserve a space that is just for you, so I created it.

What to Do if You Think You Have Postpartum Anxiety

Postpartum Anxiety (PPA) began to lift for me when my biggest stressor, J’s illness, was diagnosed and he began to get well. It was a huge sigh of relief. Once this happened, I felt able to explore a social support network, allow a childcare provider to care for J so I could have more breaks, and learn to cope with, rather than stuff, the anxious distress I felt. This period of time coincided with my body recovering from the birth trauma I endured, and I was able to exercise again which helped my mental health in an incredible way. Within a few months, I felt back to myself again. And I am so grateful.

When you notice that you’re experiencing PPA, it can be difficult to know what to do. Here are some different ideas:

Ask the friends and family you trust to help you take breaks. This is really, really important. Without rest, it’s nearly impossible for anyone to experience mental wellness. If you don’t want a break from your baby, that’s okay. Ask for a different type of break. A break from the dishes, the laundry, or grocery shopping can also free up space for you to rest.
Call your healthcare provider. Choose the provider you trust, whether that be your primary doctor, your OBGYN, your midwife, your doula, your lactation consultant, or your therapist. Explain that you think you are experiencing postpartum anxiety and ask them to support you with connecting to resources. If you don’t think you can make the call yourself, as your partner or a close friend to call on your behalf. You
Check out Postpartum Support International’s Resources. These include support hotlines, no-cost support groups, education resources, and more.
Consider Therapy. Working with a therapist who specializes in PMADs like postpartum anxiety and postpartum depression is incredibly helpful. Look for a specialist in perinatal mental health or maternal mental health. She can help you shift your focus from the anxiety to caring for your physical, mental, and emotional wellbeing.

Note: If you are experiencing a mental health crisis, you should call 911, 988, or go directly to your emergency department. You deserve to get immediate support, and waiting is not appropriate for emergencies.

Therapy Can Help You Overcome Postpartum Anxiety

Postpartum anxiety (PPA) is much more common that most women realize, and it is also incredibly under-supported and under-diagnosed. If you believe that you are experiencing PPA, I want you to know that you’re not alone. Treatment is available, and you will feel better again with support.

Therapy can be a valuable tool for navigating the way anxiety impacts your everyday experience of being a mom and the challenges it creates in your ability to feel well and whole. Having a safe space to share your complex feelings, identify the challenges anxiety creates for you, and develop strategies to lessen the impact of your anxiety will help. We can work together to find the coping skills and solutions that will work for you and your family.

Get in touch to learn more about counseling with me and see if my care is a good fit for you.

The Signs and Signals of Postpartum Anxiety (PPA) that my Medical Team Missed