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A Project of the Center for Perinatal Emotional Wellness, Inc.
| Hope --- Encouragement --- Information |
By David E. Miller, M.D., Ph.D., Medical Advisor to Moms Supporting Moms
On the order of 40 to 50 percent of new mothers will suffer significant emotional and physical
symptoms in the year post partum that interfere with her best mothering ability, stress
important relationships and represent unnecessary suffering for the mother and her family.
Fortunately, they are highly treatable and often resolve as rapidly as they develop.
Psychiatric Diagnosis in General
We sometimes hear “That’s just psychobabble! Psychiatry has a diagnosis for everyone!”
That’s partly true – and partly not true.
One source of confusion is our usage of similar terms for both description and diagnosis. We
use the expression “I’m depressed” to describe anything from a “bad hair day” to complete
immobilization, precisely because a depressed mood is a universal experience to some
degree. But to qualify for a DSM IV-TR diagnosis of Major Depressive Disorder a person must
be “depressed” almost every day for at least two weeks and meet four or five other significant
criteria. Remarkably, the Post Partum Mood Disorders, usually referred to as Post Partum
Depression, are often experienced as anxiety, insomnia, and other moods or affects not at all
similar to what we usually mean by “I feel depressed.”
Another difficulty is our primitive state of knowledge about the way our brain functions to
produce mind, personality and our sense of awareness of self. At our current state of
understanding, we can only describe patterns of symptoms and behaviors that seem likely to
arise from similar patterns of nature, nurture and stressors. The difference between a
psychiatric “disorder” and merely a description of the character next door depends on the
degree of disability he or those around him experience from the particular group of behaviors.
One can envision three levels of diagnosis in medicine. I will use heart disease as an example.
The lowest level simply names common groupings of symptoms. Thus, crushing chest pain
that radiates into the jaw and arm with a sense of foreboding might be termed a “chest
seizure.” A second level of sophistication adds signs and measurable observations such as
cardiac enzymes, EKG patterns and response to appropriate medications. Call that a “heart
attack.” The highest level of diagnosis includes naming and describing the underlying
pathophysiology, such as, atherosclerotic cardiovascular disease with X% blockage of
particular coronary arteries and Y% loss of cardiac muscle or of output of the heart. That
would be a “myocardial infarction.”
Although we are learning exciting things about how brain functioning leads to our experience
of “mind,” psychiatric diagnosis is still largely in the lowest, descriptive stage. Thus, although
the spectrum of disturbed emotional states following childbirth ranges in severity from a
couple of days of “Baby Blues” to murderous psychosis such as that suffered by Andrea Yates,
it is by no means clear that one leads to another nor that they are even related. The official
catalog of definitions of psychiatric disorders, the DSM IV-TR makes no attempt to describe
symptom complexes unique to the postpartum period other than to allow the modifier “with
postpartum onset.” Thus, Post Partum Depression (PPD), Post Partum Psychosis, Post Partum
Mood Disorder (PPMD), and Post Partum Disorder are lay designations that have no official
meaning in psychiatry, to insurance companies or to an employer’s human resources
department.
What is abundantly clear is that mood disorders occurring around the time of childbirth are
painful, debilitating, interfere significantly with important family relationships and parenting
ability, and can have profound effects on subsequent child development. Many of them evoke
tremendous shame, guilt and social isolation because of the myth in our culture that childbirth
magically bestows on a woman infinite patience, wisdom, physical endurance, and an
immediate, mystical bond to her infant. Most importantly, all are highly treatable and many
respond quickly to appropriate interventions. Regrettably, many women are never diagnosed
because of stigma and ignorance surrounding PPMD.
Catalog of Emotional Disorders Post Partum
Psychosis
We know that psychotic episodes occur in the year post partum at the rate of one or two per
thousand deliveries and that this incidence has held constant for at least two hundred years
and across many cultures and demographic groups. They are properly diagnosed as the
underlying disorder, such as Major Depressive Disorder with psychotic features, Bipolar
Affective Disorder with psychotic features, Schizophrenia, etc.
We also know that among women with a potentially psychotic mental illness, the probability
of a psychotic episode in the three months after delivery is some thirty fold greater than in any
other three month period of their illness. But while pregnancy clearly triggers psychotic
episodes in vulnerable individuals, it is not at all clear that it causes the underlying psychotic
disorder. Most sufferers have histories of mental illness in other contexts.
Major Depressive Disorder
There is also abundant evidence that Major Depressive Disorder (MDD), as defined by the DSM
IV-TR, occurs at about the same incidence postpartum as it does in reproductive-age women
exclusive of pregnancy, about 11 to 12 percent in the United States. The onset and resolution
are not significantly different although the treatment is constrained by pregnancy and
breastfeeding.
PPMD
A number of questionnaires have been developed to evaluate women’s subjective sense of
mental health or disability, notably the Edinburgh Postpartum Depression Scale (EPDS) and a
Postpartum Depression Inventory by Cheryl Beck. These have been proven to reliably identify
women who meet criteria sets for MDD but they also highlight a larger number of sufferers
whose symptoms do not match the requisite criteria for MDD but who are nevertheless very
disabled. Their symptoms may include combinations of uncontrollable crying, tremendous
anxiety to the point of being unable to eat or to function, insomnia, irritability and sometimes
frightening, intrusive thoughts or images, often involving harm to the baby.
Up to 90% of women will admit, in retrospect, to a few hours or days of emotional
tenderness, crying spells, or extreme anxiety, usually beginning within the week after delivery.
In up to 40% of women, these symptoms last a significant number of days or weeks and may
trigger a downward spiral of anxiety, insomnia, inability to eat and difficulty in meeting their
responsibilities as parent and partner. Some of the most intense suffering occurs in women
who are plagued by intrusive thoughts of harm to their baby. The resultant intense guilt,
shame and anxiety leads to further social isolation and symptoms of depression.
Sometimes, the particular grouping of symptoms may actually meet criteria for DSM IV-TR
diagnoses of Obsessive Compulsive Disorder, Generalized Anxiety Disorder or of Acute Stress
Disorder/Post Traumatic Stress Disorder. In fact, it is my opinion that Acute Stress
Disorder/Post Traumatic Stress Disorder is the closest definition in DSM IV-TR that captures
what goes on in PPMD. Unfortunately, it has been so tailored to fit returning war veterans
that many severely affected post partum women do not meet the strict criteria.
I view PPMD, as I have defined it, as a spectrum of individual manifestations of psychological
responses to the overwhelming experience of becoming a parent. In a sense, it is labor pain of
the psychological birth of a new mother. And when it is excessive, prolonged or debilitating, a
young mother deserves effective intervention just as we have come to intervene for the relief
of labor pains at the physical birth of her child. And just as pain relief in labor must be tailored
for safety to mother and infant and not interfere with the course of labor, interventions for
PPMD must be designed to relieve symptoms without interfering with breast feeding or the
critical mother/infant interaction which we now know is central to infant brain and personality
development.
PPMD often does not look or feel like depression! Many women first experience loss of self-
confidence and anxiety followed by insomnia or panic attacks. Then may come inability to
eat, unprovoked crying spells, fear of being alone and worst of all, thoughts or visions of harm
to their infant that are frightening, unbidden and provoke intense shame and guilt in the
mother. This can cause her to withdraw from support people and increases her sense of
isolation.
Many women who experience intrusive thoughts with PPMD fear they are becoming
psychotic. The intensity of their reaction to the intrusive thoughts or images is precisely
because these women are NOT psychotic. They know the images are not in character and are
passionately motivated to see that harm does NOT come to their infant. The thoughts may
actually be driven by an over-inflated sense of personal responsibility. Yet because the
thoughts are so out of character and seem foreign, they fear they are becoming insane and
that they might lose control and actually instigate the things they fear. They may compulsively
hide knives, avoid stairs, scrub door handles for germs or refuse to step out on the patio
depending on the content of their thoughts or images. Their horrible images are exaggerations
of reasonable precautions, e.g., don’t walk too close to the edge, don’t leave knives where
they might fall off the counter, be cautious to not trip going down the stairs, and don’t let the
baby eat off the floor. They are unreasonable in degree but are not psychotic.
Treatment and Recovery
Mental health professionals place great emphasis on a three pronged bio-psycho-social
approach to effective interventions. Consider the treatment of insomnia and sleep
deprivation in a new, breast feeding mom of an infant who is nursing 1 ½ hours every 2 hours.
It does no good to offer her a sleeping pill if there is no one available to relieve her of some of
the feedings. She needs a social intervention. If she then can’t sleep because she doesn’t
believe anyone else knows how to properly take care of her infant, she needs a psychological
intervention. Finally, when both social and psychological restructuring is accomplished and
she still lies awake with mind racing, she needs biological (pharmacological) assistance. A
similar approach can be taken to each of her symptoms, often with rapid and gratifying
results.
Remember that psychiatric diagnosis is simply a catalog of a particular group of symptoms.
Sometimes, a genetic or biochemical basis is believed to be present. Often, an individual
personality has simply been pushed beyond its ability to cope. This, I believe, is often the case
in PPMD. Symptoms occur because of physical and emotional exhaustion. Prompt, effective
intervention and support can lead to rapid recovery, prevent chronic damage to relationships
and preserve a woman’s ability to be the best mother of which she is capable.
Whether or not her symptoms correspond to one of the DSM IV-TR diagnostic poker hands is
not particularly relevant other than for insurance reimbursement. The important issues are
her degree of distress and the extent of her disability. The appearance of symptoms implies a
mother has reached the limit of her psychological resilience. The sooner effective social,
psychological and medical interventions can be identified and implemented, the more quickly
she can recover and the less likely there will be permanent scars to relationships and parenting
effectiveness. The good news is that the vast majority of emotional suffering in the post
partum period does not represent severe or persistent mental illness and is readily treatable
with gratifying results.
David E. Miller, M.D., Ph.D.
Member -- American Psychiatric Association
Fellow -- American College of Obstetricians and Gynecologists
On the order of 40 to 50 percent of new mothers will suffer significant emotional and physical
symptoms in the year post partum that interfere with her best mothering ability, stress
important relationships and represent unnecessary suffering for the mother and her family.
Fortunately, they are highly treatable and often resolve as rapidly as they develop.
Psychiatric Diagnosis in General
We sometimes hear “That’s just psychobabble! Psychiatry has a diagnosis for everyone!”
That’s partly true – and partly not true.
One source of confusion is our usage of similar terms for both description and diagnosis. We
use the expression “I’m depressed” to describe anything from a “bad hair day” to complete
immobilization, precisely because a depressed mood is a universal experience to some
degree. But to qualify for a DSM IV-TR diagnosis of Major Depressive Disorder a person must
be “depressed” almost every day for at least two weeks and meet four or five other significant
criteria. Remarkably, the Post Partum Mood Disorders, usually referred to as Post Partum
Depression, are often experienced as anxiety, insomnia, and other moods or affects not at all
similar to what we usually mean by “I feel depressed.”
Another difficulty is our primitive state of knowledge about the way our brain functions to
produce mind, personality and our sense of awareness of self. At our current state of
understanding, we can only describe patterns of symptoms and behaviors that seem likely to
arise from similar patterns of nature, nurture and stressors. The difference between a
psychiatric “disorder” and merely a description of the character next door depends on the
degree of disability he or those around him experience from the particular group of behaviors.
One can envision three levels of diagnosis in medicine. I will use heart disease as an example.
The lowest level simply names common groupings of symptoms. Thus, crushing chest pain
that radiates into the jaw and arm with a sense of foreboding might be termed a “chest
seizure.” A second level of sophistication adds signs and measurable observations such as
cardiac enzymes, EKG patterns and response to appropriate medications. Call that a “heart
attack.” The highest level of diagnosis includes naming and describing the underlying
pathophysiology, such as, atherosclerotic cardiovascular disease with X% blockage of
particular coronary arteries and Y% loss of cardiac muscle or of output of the heart. That
would be a “myocardial infarction.”
Although we are learning exciting things about how brain functioning leads to our experience
of “mind,” psychiatric diagnosis is still largely in the lowest, descriptive stage. Thus, although
the spectrum of disturbed emotional states following childbirth ranges in severity from a
couple of days of “Baby Blues” to murderous psychosis such as that suffered by Andrea Yates,
it is by no means clear that one leads to another nor that they are even related. The official
catalog of definitions of psychiatric disorders, the DSM IV-TR makes no attempt to describe
symptom complexes unique to the postpartum period other than to allow the modifier “with
postpartum onset.” Thus, Post Partum Depression (PPD), Post Partum Psychosis, Post Partum
Mood Disorder (PPMD), and Post Partum Disorder are lay designations that have no official
meaning in psychiatry, to insurance companies or to an employer’s human resources
department.
What is abundantly clear is that mood disorders occurring around the time of childbirth are
painful, debilitating, interfere significantly with important family relationships and parenting
ability, and can have profound effects on subsequent child development. Many of them evoke
tremendous shame, guilt and social isolation because of the myth in our culture that childbirth
magically bestows on a woman infinite patience, wisdom, physical endurance, and an
immediate, mystical bond to her infant. Most importantly, all are highly treatable and many
respond quickly to appropriate interventions. Regrettably, many women are never diagnosed
because of stigma and ignorance surrounding PPMD.
Catalog of Emotional Disorders Post Partum
Psychosis
We know that psychotic episodes occur in the year post partum at the rate of one or two per
thousand deliveries and that this incidence has held constant for at least two hundred years
and across many cultures and demographic groups. They are properly diagnosed as the
underlying disorder, such as Major Depressive Disorder with psychotic features, Bipolar
Affective Disorder with psychotic features, Schizophrenia, etc.
We also know that among women with a potentially psychotic mental illness, the probability
of a psychotic episode in the three months after delivery is some thirty fold greater than in any
other three month period of their illness. But while pregnancy clearly triggers psychotic
episodes in vulnerable individuals, it is not at all clear that it causes the underlying psychotic
disorder. Most sufferers have histories of mental illness in other contexts.
Major Depressive Disorder
There is also abundant evidence that Major Depressive Disorder (MDD), as defined by the DSM
IV-TR, occurs at about the same incidence postpartum as it does in reproductive-age women
exclusive of pregnancy, about 11 to 12 percent in the United States. The onset and resolution
are not significantly different although the treatment is constrained by pregnancy and
breastfeeding.
PPMD
A number of questionnaires have been developed to evaluate women’s subjective sense of
mental health or disability, notably the Edinburgh Postpartum Depression Scale (EPDS) and a
Postpartum Depression Inventory by Cheryl Beck. These have been proven to reliably identify
women who meet criteria sets for MDD but they also highlight a larger number of sufferers
whose symptoms do not match the requisite criteria for MDD but who are nevertheless very
disabled. Their symptoms may include combinations of uncontrollable crying, tremendous
anxiety to the point of being unable to eat or to function, insomnia, irritability and sometimes
frightening, intrusive thoughts or images, often involving harm to the baby.
Up to 90% of women will admit, in retrospect, to a few hours or days of emotional
tenderness, crying spells, or extreme anxiety, usually beginning within the week after delivery.
In up to 40% of women, these symptoms last a significant number of days or weeks and may
trigger a downward spiral of anxiety, insomnia, inability to eat and difficulty in meeting their
responsibilities as parent and partner. Some of the most intense suffering occurs in women
who are plagued by intrusive thoughts of harm to their baby. The resultant intense guilt,
shame and anxiety leads to further social isolation and symptoms of depression.
Sometimes, the particular grouping of symptoms may actually meet criteria for DSM IV-TR
diagnoses of Obsessive Compulsive Disorder, Generalized Anxiety Disorder or of Acute Stress
Disorder/Post Traumatic Stress Disorder. In fact, it is my opinion that Acute Stress
Disorder/Post Traumatic Stress Disorder is the closest definition in DSM IV-TR that captures
what goes on in PPMD. Unfortunately, it has been so tailored to fit returning war veterans
that many severely affected post partum women do not meet the strict criteria.
I view PPMD, as I have defined it, as a spectrum of individual manifestations of psychological
responses to the overwhelming experience of becoming a parent. In a sense, it is labor pain of
the psychological birth of a new mother. And when it is excessive, prolonged or debilitating, a
young mother deserves effective intervention just as we have come to intervene for the relief
of labor pains at the physical birth of her child. And just as pain relief in labor must be tailored
for safety to mother and infant and not interfere with the course of labor, interventions for
PPMD must be designed to relieve symptoms without interfering with breast feeding or the
critical mother/infant interaction which we now know is central to infant brain and personality
development.
PPMD often does not look or feel like depression! Many women first experience loss of self-
confidence and anxiety followed by insomnia or panic attacks. Then may come inability to
eat, unprovoked crying spells, fear of being alone and worst of all, thoughts or visions of harm
to their infant that are frightening, unbidden and provoke intense shame and guilt in the
mother. This can cause her to withdraw from support people and increases her sense of
isolation.
Many women who experience intrusive thoughts with PPMD fear they are becoming
psychotic. The intensity of their reaction to the intrusive thoughts or images is precisely
because these women are NOT psychotic. They know the images are not in character and are
passionately motivated to see that harm does NOT come to their infant. The thoughts may
actually be driven by an over-inflated sense of personal responsibility. Yet because the
thoughts are so out of character and seem foreign, they fear they are becoming insane and
that they might lose control and actually instigate the things they fear. They may compulsively
hide knives, avoid stairs, scrub door handles for germs or refuse to step out on the patio
depending on the content of their thoughts or images. Their horrible images are exaggerations
of reasonable precautions, e.g., don’t walk too close to the edge, don’t leave knives where
they might fall off the counter, be cautious to not trip going down the stairs, and don’t let the
baby eat off the floor. They are unreasonable in degree but are not psychotic.
Treatment and Recovery
Mental health professionals place great emphasis on a three pronged bio-psycho-social
approach to effective interventions. Consider the treatment of insomnia and sleep
deprivation in a new, breast feeding mom of an infant who is nursing 1 ½ hours every 2 hours.
It does no good to offer her a sleeping pill if there is no one available to relieve her of some of
the feedings. She needs a social intervention. If she then can’t sleep because she doesn’t
believe anyone else knows how to properly take care of her infant, she needs a psychological
intervention. Finally, when both social and psychological restructuring is accomplished and
she still lies awake with mind racing, she needs biological (pharmacological) assistance. A
similar approach can be taken to each of her symptoms, often with rapid and gratifying
results.
Remember that psychiatric diagnosis is simply a catalog of a particular group of symptoms.
Sometimes, a genetic or biochemical basis is believed to be present. Often, an individual
personality has simply been pushed beyond its ability to cope. This, I believe, is often the case
in PPMD. Symptoms occur because of physical and emotional exhaustion. Prompt, effective
intervention and support can lead to rapid recovery, prevent chronic damage to relationships
and preserve a woman’s ability to be the best mother of which she is capable.
Whether or not her symptoms correspond to one of the DSM IV-TR diagnostic poker hands is
not particularly relevant other than for insurance reimbursement. The important issues are
her degree of distress and the extent of her disability. The appearance of symptoms implies a
mother has reached the limit of her psychological resilience. The sooner effective social,
psychological and medical interventions can be identified and implemented, the more quickly
she can recover and the less likely there will be permanent scars to relationships and parenting
effectiveness. The good news is that the vast majority of emotional suffering in the post
partum period does not represent severe or persistent mental illness and is readily treatable
with gratifying results.
David E. Miller, M.D., Ph.D.
Member -- American Psychiatric Association
Fellow -- American College of Obstetricians and Gynecologists
| Postpartum Mood Disorders |