Belinda looks at her 9-day-old son and feels the tears well up again. She’s surprised at how her moods have swung from joyful to sad and back over and over again since his delivery. “This isn’t how I expected to feel,” she whispers to the soundly sleeping infant in her arms. “I thought I would be so happy once you were finally here.”
Rosa can’t believe her daughter is already 3 months old: a bright-eyed, precocious infant who has gained weight and met many developmental milestones early. Rosa herself has had a much more difficult time since Carmen’s birth, experiencing persistent insomnia, problems eating, and waves of doubt and confusion about her own identity. “I don’t even know who I am anymore. Sometimes I feel like a robot,” she admits. “I go through the motions of caring for the baby, relating to my husband, and doing my job at work, but I don’t feel anything. It’s even hard for me to think sometimes. My mind seems all fogged in.”
Liz has been avoiding her family and friends for almost six weeks because she believes they will see how evil her newborn is. When Liz looks at the baby these days, she’s aware only of how wrinkled and defective Tracey seems compared to other smiling, cooing babies on television. The voices tell her the baby isn’t normal, and that a good mother wouldn’t have brought such a bad child into the world. She knows the voices are right. She knows when they tell her that the baby should never have been born they’re only trying to help her make a decision about what to do next.
Belinda, Rosa and Liz are three of the more than 400,000 American women who will experience a postpartum mood disorder this year. But their illnesses, like many other psychological and medical conditions that are lumped together in popular discussions, have much less in common than is generally believed.
Three Chameleon-Like, Complex Conditions
Cheryl T. Beck, D.N.Sc., professor at the School of Nursing at the University of Connecticut, Storrs, and co-author of Postpartum Depression Screening Scale, describes the psychological disorders that mothers develop following the birth of a child as “chameleon-like” in their complexities and varying presentations.
“These disorders take a different form and have a different shade of emotional coloring for each mother,” Beck explains. “What they share is an onset or diagnosis linked to the birthing experience.”
Beck describes the conditions as the “blues,” postpartum depression and postpartum psychosis.
The “baby blues,” Beck and other experts say, are a common reaction to the birthing experience that occurs hours or days after delivery in up to 85 percent of women. It’s a period of wide mood swings, insomnia, and, at times, uncontrollable weeping sometimes for no apparent reason. Belinda’s experience typifies the “baby blues,” and if her experience is like most new mothers’, she will be emotionally back on her feet and enjoying the challenges of motherhood in two weeks or less.
“Teetering on the Edge”
Postpartum depression, in contrast to the quickly developing and time-limited period of depressed or “blue” affect, occurs in 10 to 13 percent of new mothers, and its appearance may be delayed for several weeks or months after delivery. When it occurs, its effects can be deep and pervasive.
Typically such depressions persist for months after they begin. Rosa’s experience is a common one, but the disorder can take many forms with wide variations in maternal concerns, symptoms, affective responses and behaviors.
In a 1993 article in Nursing Research, Beck described such depressions as “teetering on the edge.” She notes that new mothers experiencing them exhibit at least one, and often many, of the following characteristics, all of them relating to a sense that they have lost control of their lives as they spiral into increasing levels of loneliness and despair after giving birth:
- Feelings of loss of self. Some new mothers feel they no longer know who they are, says Beck. They describe themselves as feeling “like robots,” with no positive feelings or “going through the motions” of living, with no emotional connection to their husbands or other family members, and no sense of identity or purpose.
- Feelings of guilt or shame. New mothers struggling with a burden of guilt or shame may also perceive themselves as bad mothers, incapable of caring for their infant or undeserving of having a child or loving spouse. Beck says some carry a “suffocating burden of fear or guilt at the thought they may harm their infant,” although such thoughts are seldom acted on.
- Overanxious and insecure. New mothers who are overanxious may feel they lack mothering skills and can’t do anything right with their new infants; some are afraid they are losing their minds. They may experience paralyzing bouts of terror and fear.
- Concern about harming self. As the sense of losing control builds, some new mothers may become concerned that they will harm themselves.
- Difficulties eating or sleeping. Achieving pre-pregnancy or pre-delivery levels of food consumption or sleep is often difficult for new mothers, over and above sleep pattern alterations associated with meeting their infant’s care needs. Some mothers cannot sleep even when their infant is asleep and not requiring their care.
- Difficulty thinking. Some depressed new mothers often complain that their thinking is unclear or disconnected. They also report difficulty concentrating, or maintaining a focus on people or activities that were previously pleasurable. “Some women communicate that this feels like ‘the fog is rolling in,'” explains Beck.
- Wide swings in mood or affect. Postpartum depression is like a mood roller coaster for some women, as they swing from the heights of elation and joy to the depths of despair and sadness, at times cycling up and down rapidly and often. They may be more irritable and more easily angered or upset than in the period before pregnancy or delivery.
California Congresswoman Lois Capps noted in a May 1999 Mother’s Day press conference announcing sponsorship of a bipartisan resolution on postpartum depression that hundreds of thousands of American women experience these issues every year and many “don’t even know they need help. This condition can put a tremendous strain on family relationships, at a time when families should be experiencing the joy of the birth of a child.”
Postpartum psychosis is a different entity altogether from postpartum depression, although the two are often inappropriately linked in the public’s understanding of the mood disorders following pregnancy. Liz’s beliefs, thought processes and reactions to her infant are unfortunately typical.
As Margaret Spinelli, M.D., assistant professor of clinical psychiatry at Columbia University’s College of Physicians and Surgeons in New York City, N.Y., explains, postpartum psychotic behavior usually occurs with little warning and “is associated with hallucinations and delusional beliefs about the infant.”
As Spinelli points out in an article in the November 1998 Journal of Gender-Specific Medicine, this condition constitutes a “psychiatric emergency requiring hospitalization” and, because new mothers suffering from the condition frequently believe they must kill the new baby, “the infant must be protected from the psychotic mother and her infanticidal tendencies.”
Postpartum psychosis fortunately is the least common of the three conditions, occurring about once or twice in every 1,000 births. Like other psychotic conditions, the symptoms are very exaggerated and may include insomnia, religious preoccupations, agitation and bizarre feelings or behavior in addition to the delusional thoughts and sensory hallucinations, typically auditory or visual in character.
As Karen Kleiman, M.S.W., director of the Postpartum Stress Center in Rosemont, Pa., explains, “Postpartum psychosis is not simply a worsening case of postpartum depression. It’s a totally distinct psychological disorder. In the most severe cases of postpartum depression, the concern is that a woman may harm herself. In postpartum psychosis, the woman must be regarded as a threat to her infant.”
Women who have experienced a postpartum psychosis following one pregnancy have 100 times the risk of experiencing such a psychosis after subsequent births.
Real, Treatable Illnesses
In her practice in suburban Philadelphia, Kleiman has helped thousands of women navigate the sometimes troubled waters between giving birth and a return to emotional health. Like Beck and Spinelli, she believes appropriate treatment for postpartum psychosis is immediate psychiatric hospitalization at the onset of symptoms, while the best approach to postpartum depression is early detection linked to the appropriate type and amount of antidepressant medication and psychological counseling and support.
In the case of the “baby blues,” Kleiman notes that even though the mood disorder may be brief and self-limited in other words, that the woman will recover with little or no outside intervention such professional support can be reassuring and useful.
“I believe women should trust their instincts when it comes to being concerned about how they feel emotionally after delivery,” Kleiman says. “If they feel something is wrong with them, there probably is. Even if they tell their mothers or friends, their husbands or their doctors and are given reassurance that everything is fine and normal, they should persist in seeking help with feelings that are troubling. Whether their postpartum mood disorder is mild, moderate or severe, it’s a real illness that can be treated.”
For information about the postpartum mood disorders, access the national support group Depression After Delivery.