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| Emotional Disorders In Pregnancy and Postpartum |
| 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 are highly treatable, interfere with her best mothering
ability, stress important relationships and represent unnecessary suffering for the mother and
her family.
The most frightening and dangerous of these is post partum psychosis. It is also, fortunately,
the most rare. We know that psychotic episodes occur in the year post partum at the rate of
one or two per 1000 deliveries and that this incidence has held constant for at least 200 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. It is not at all clear that
isolated psychotic episodes occur post partum which are only associated with pregnancy.
Most sufferers have histories of mental illness in other contexts.
There is also abundant evidence that Major Depressive Disorder (MDD), as defined in 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.
A number of questionnaires have been developed to evaluate women’s subjective sense of
emotional well-being; 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. They also highlight a larger number of sufferers
whose symptoms do not match the requisite criteria for MDD but who are nevertheless
disabled.
Up to 90% of women will admit, in retrospect, to a few hours or days of emotional
tenderness, crying spells, or anxiety, usually beginning within the week after delivery and often
referred to as “baby blues.” In up to 40% of women, however, these symptoms last a
significant number of days or weeks and may trigger a rapid 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 lead to further social
isolation and symptoms of depression. These are the syndromes to which we refer as Post
Partum Mood Disorder (PPMD). Sometimes, the particular grouping of symptoms may actually
meet criteria for DSM IV-TR diagnoses of Obsessive Compulsive Disorder (OCD), Generalized
Anxiety Disorder(GAD) or of Acute Stress Disorder/Post Traumatic Stress Disorder (ASD/PTSD).
PPMD, as I have defined it, is a spectrum 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. 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 breastfeeding or the critical mother/infant
interaction which we now know is central to infant brain and personality development.
PPMD often does not look 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. 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. 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 imagine. 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 concerns which
are unreasonable in degree but are not psychotic.
Post partum depression is considered by some to be synonymous with MDD and anything
short of meeting criteria for MDD trivialized as baby blues. My purpose in adopting the term
PPMD is to encourage recognition of the spectrum of stress responses in the postpartum
period and appreciation of the disability they represent. They are highly treatable by
appropriate bio-psycho-social interventions and often resolve nearly as rapidly as they arise if
recognized and treated effectively.
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 are highly treatable, interfere with her best mothering
ability, stress important relationships and represent unnecessary suffering for the mother and
her family.
The most frightening and dangerous of these is post partum psychosis. It is also, fortunately,
the most rare. We know that psychotic episodes occur in the year post partum at the rate of
one or two per 1000 deliveries and that this incidence has held constant for at least 200 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. It is not at all clear that
isolated psychotic episodes occur post partum which are only associated with pregnancy.
Most sufferers have histories of mental illness in other contexts.
There is also abundant evidence that Major Depressive Disorder (MDD), as defined in 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.
A number of questionnaires have been developed to evaluate women’s subjective sense of
emotional well-being; 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. They also highlight a larger number of sufferers
whose symptoms do not match the requisite criteria for MDD but who are nevertheless
disabled.
Up to 90% of women will admit, in retrospect, to a few hours or days of emotional
tenderness, crying spells, or anxiety, usually beginning within the week after delivery and often
referred to as “baby blues.” In up to 40% of women, however, these symptoms last a
significant number of days or weeks and may trigger a rapid 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 lead to further social
isolation and symptoms of depression. These are the syndromes to which we refer as Post
Partum Mood Disorder (PPMD). Sometimes, the particular grouping of symptoms may actually
meet criteria for DSM IV-TR diagnoses of Obsessive Compulsive Disorder (OCD), Generalized
Anxiety Disorder(GAD) or of Acute Stress Disorder/Post Traumatic Stress Disorder (ASD/PTSD).
PPMD, as I have defined it, is a spectrum 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. 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 breastfeeding or the critical mother/infant
interaction which we now know is central to infant brain and personality development.
PPMD often does not look 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. 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. 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 imagine. 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 concerns which
are unreasonable in degree but are not psychotic.
Post partum depression is considered by some to be synonymous with MDD and anything
short of meeting criteria for MDD trivialized as baby blues. My purpose in adopting the term
PPMD is to encourage recognition of the spectrum of stress responses in the postpartum
period and appreciation of the disability they represent. They are highly treatable by
appropriate bio-psycho-social interventions and often resolve nearly as rapidly as they arise if
recognized and treated effectively.
David E. Miller, M.D., Ph.D.
Member -- American Psychiatric Association
Fellow -- American College of Obstetricians and Gynecologists
A Project of the Center for Perinatal Emotional Wellness, Inc.