The postpartum period is a time of heightened emotional experience and expression. Any sensation or feeling (whether it be a symptom or not) has the potential of intensifying during this time. Bodies are fatigued, systems are worn down, and nerves are frayed. Because of this, symptoms may not always be what they appear to be.

Sometimes the symptom speaks for itself; a mother with negative intrusive thoughts about her baby needs immediate treatment for relief. Other times, a symptom may not be so clear—for instance, a mother who states she is crying all the time.

One of the primary reasons postpartum depression is often misdiagnosed is the ambiguity of symptoms. This is due to the potential overlap of symptoms with those generally considered to be within “normal” expectations for the postpartum adjustment period. Examples of those that overlap the most would be fatigue, loss of libido, moodiness, weepiness, changes in weight, sleep disturbance, and low energy. Consequently, when carrying out an assessment, it is not the feeling (or symptom) per se, it is the frequency, intensity and duration of that feeling. Or, put another way, how much is that feeling interfering with her ability to get through the day?

All new mothers cry. All new mothers are tired. We know this to be true, it is absolute and undisputed. So when a postpartum woman tells her doctor that she’s exhausted and weepy, an untrained provider might assume this is the normal course of events. Furthermore, when this provider reassures mom that this is to be expected, she may be momentarily reassured. But if she is experiencing postpartum depression, her fatigue and weepiness is something else entirely. As her symptoms persist or get worse and do not resolve as her doctor implied, the assurance quickly dissolves into 1) my doctor has no idea how I feel or what to do about it, or 2) something is really wrong with me then.

If all new mothers cry, how do we tease out which crying is symptomatic? One key intervention is to asses the frequency, intensity and duration of any emotion or symptom. For example, we want to find out how much or often is she crying (frequency), how hard, bad or intense is she crying (intensity), and for how long (duration).

A new mother reports she isn’t sleeping at all. But what does that really mean? We need to break it down. How much sleep is she actually getting? How much sleep does did she require before she had the baby to function well? Is she able to sleep when her baby sleeps? Is her mind racing when she is trying to sleep? Does she awaken from sleep because her baby is crying or because she is having a panic attack? Is her interrupted sleep still totaling more than 5 to 6 hours? Is she getting less than four hours of sleep total for the night? Our greatest concern here, other than the fact that she’s exhausted, is sleep deprivation. Sleep deprivation can and will exacerbate all other symptoms and, if left unattended to, can contribute to rapid decompensation.

In these ways we can see how important it is to consider each symptom as a specific and complex expression that needs to be understood within the appropriate context.

Screening tools are good, but they are not always enough.

copyright 2012 Karen Kleiman, LSCW 
Adapted from Therapy and the Postpartum Woman (Routledge, 2009)

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