Anxiety

Postpartum Anxiety Starts as an Adaptive Response to a Baby

Labelling postpartum anxiety a mental illness shames parents and doesn't help.

Posted Oct 24, 2020

Sharon MtCutcheon/Unsplash
Of course parents feel anxious when they meet their tiny human.
Source: Sharon MtCutcheon/Unsplash

New parents feel anxiety for a very good reason. They are suddenly responsible for the life of a fragile infant, so anxiety shows up to help parents pay attention. Anxiety is an adaptive response that provides inexperienced parents with the energy they need to come up a steep learning curve. Postpartum anxiety is valuable, but somehow it gets a bad name, and all too often is pathologized. In fact, researchers have increasingly called into question the way anxiety is labeled a mental disorder when it could be more properly understood as an adaptive response to adversity.

New parents are often shamed for feeling anxious and protective of their tiny humans. But shaming them for what is a normal and necessary response is definitely not helping. That’s why I asked Dr. Mary Kimmel, an expert on the biology of postpartum mood changes to weigh in. But before we get to her comments, it is crucial to understand what postpartum anxiety is for.

Postpartum anxiety is a necessary and adaptive part of the human experience and should not be stigmatized. It has an important function, including showing us when parents need help. Part of that help must include social support, which we are less likely to provide as a society if we call it a disease.

It’s true that in a minority of new mothers and fathers that anxiety becomes dis-regulated and we call it clinical postpartum anxiety. But that just means that they need some help.

The problem comes in the way that when parents need that help, they are then labeled with “mental illness.” That label makes many parents afraid to talk about it, and even parents with normal levels of anxiety are afraid to admit to it in case they get diagnosed with a disease.

In other words, we are making parents anxious about their anxiety. Our current labeling system creates a sense of shame around anxiety that can cut parents off from healthy interaction. In fact, when parents can embrace their anxiety about their baby and interact with it in an open way, they can in some cases avoid it getting to the point that we would call it clinical postpartum anxiety. But that’s not going to happen if parents are ashamed.

Speaking of shame, it is certainly true that some parents feel relief when we call it mental illness because that means it is not their fault. And it isn’t. But for other parents, that label carries a stigma.

How is postpartum anxiety helpful?

Postpartum anxiety, at least as a feeling, is so universal that pediatricians look for it. When pediatricians see first-time parents who are not anxious, we get worried. Experienced parents will feel much less anxiety with their second newborn, and that makes sense. But if a new parent is missing a least a little anxiety, pediatricians get concerned about the welfare of the baby.

Anxiety happens in part when the autonomic nervous system activates the sympathetic nerve. This puts us into a “mobilized state,” getting us ready for action and watching for danger. This makes parents more alert or even hyper-alert, noticing all of their baby’s cues and helping them learn what those sounds mean. It’s why new parents worry about every little thing: they are supposed to. They don’t yet know what’s okay and what is not.

And anxiety is also there to help parents recruit social connections. When a new parent has loving support around them, those people are more likely to jump in and assist when that parent expresses anxiety. A phrase like “I’m just so worried about” often prompts friends and family to offer soothing advice or help.

Nevertheless, postpartum anxiety is a dreaded and often stigmatized experience for parents. While both mothers and fathers experience it, women are more likely to be called neurotic or crazy new mothers. Being a worried father carries a more positive association with being loving. New parents are often afraid to admit to their anxiety, afraid their concerns about their baby will be dismissed. No-one seems to be telling them that parents need anxiety.

Postpartum anxiety is part of a biological system.

Dr. Mary Kimmel wants mothers to understand that they need anxiety and the goal is not to get rid of it. She is an assistant professor at UNC Chapel Hill, medical director of the North Carolina Mental Health MATTERS, and co-director of the perinatal psychiatry program, where they take a unique interdisciplinary approach to helping moms whose postpartum anxiety has gone too far.

Postpartum anxiety starts as a good thing. Dr. Kimmel likes to talk about car seats. “We need anxiety to motivate us to get the car seat,” she says, “But we also can’t let anxiety keep us from taking our children out to do things.” So there is a right amount of anxiety.

Anxiety in the postpartum period is part of a biological system, it happens for a reason. According to Dr. Kimmel, a number of systems in the body are adapting to take on the challenge of parenting. For instance, the autonomic nervous system adapts to allow for blood flow changes in the mother, but that’s the same system that often regulates our anxiety. The immune system also changes during pregnancy and creates inflammation to prepare for delivery. “For example, cortisol remains elevated for a time after delivery. Immune system changes lead to anxiety, which likely does have a [useful] role just as sickness behavior and healing from an infection,” Kimmel says. “Sickness behavior” helps us avoid exposing ourselves to infections.

After the baby comes, the mother’s biology has to adapt quickly. “Some of the systems are plastic and trying to rebalance.” In addition, “there are evident brain circuitry changes in becoming a parent,” she says. "Then you add in factors such as sleep deprivation. I tell moms it is helpful to be more on guard because you are trying to protect the baby, yourself and family.”

Dr. Kimmel refers to the work of Jon Abramowitz and Linda Chaudron when she talks about how common obsessive thoughts or intrusive thoughts are. “I tell moms I think them of as “parent brain”—our systems attempts at ensuring we are finding the right amount of vigilance.”

Postpartum anxiety is good, up to a point.

If postpartum anxiety is natural and necessary, then parents should not be stigmatized for experiencing it. And it can help parents who are suffering from a clinical level of anxiety to get better if they know that it’s not because something is wrong with them. Negative labels can make it harder for people to recover because they can encourage people to make it part of their identity. Instead of “I am mentally ill with postpartum anxiety,” it is much more helpful to say, “I am experiencing an adaptive and natural postpartum anxiety response that has become dysregulated.”

The problem comes in when that anxiety gets dysregulated. “For some [parents] this is hypervigilance [which] keeps them from doing things they want, keeps them from functioning,” explains Kimmel. She gives examples of when parents become so worried about dropping their children on the stairs that they won’t go up and down the stairs. Or when parents become so upset about intrusive images of a knife in the baby’s soft spot that they tell their spouse to take all the knives out of the house, and then they can’t cut up vegetables for dinner.

“We know the history of trauma or past history of anxiety or depressive episodes increases the risk of perinatal mood and anxiety disorders and I think this is your system experiencing a new dynamic period and given the past trauma is primed to be more hypervigilant during dynamic periods,” says Kimmel. 

When postpartum anxiety gets to this point, which happens in about 10% of mothers, parents need help, and Dr. Kimmel’s program provides it in a number of ways. While that care might include anti-anxiety medication, the UNC Perinatal Inpatient Unit focuses on providing mothers with a feeling of safety. Therapies include fun, art, yoga, talk therapy, and biofeedback, which helps women get in touch with their bodies and get back into a state of regulation. Family members also get support, which then helps them support the mother.

What support do parents need?

Dr. Kimmel believes that the way new parents often feel dependent is also useful. “I tell parents we aren’t meant to parent alone and perinatal anxiety is a way that our systems force us to realize our need for others to help and support us.” She believes that families need more resources and support during this time than they typically get in America. She suggests paid maternity and paternity leave longer than the typical 8 weeks, home-visit programs, parent support programs, and spouse and family support. “These things give mothers a chance to move through the numerous changes without having to add additional stress and expectations on top of that.”

However, she also points out that even in the U.K. where many of these services exist, such as widespread home-visit programs, the rate of severe postpartum anxiety in mothers is about the same as in the U.S. She does not want mothers to ever feel like postpartum anxiety is their fault. “I think it is important to note that we also see women who have created excellent support for themselves and the baby and they can still get perinatal anxiety and depression. If anything I think those are the women more likely to get the needed medical attention to require.  A woman with less support may find it harder to get the care she needs.”

And that maybe the point. Supporting new parents with better leave policies and social programs can help us notice who is switching from an adaptive amount of anxiety to an unhealthy one and help them before it gets worse. Because unfortunately, untreated anxiety often leads to depression.

Are we saying then that when women end up with such severe mood changes that they need to be hospitalized we can’t call that mental illness? Not at all. Clearly that is a form of illness and it deserves all the support and treatment any other illness deserves. But knowing that all of this starts for a good and adaptive reason may help people see themselves in a better light as they recover.