Postnatal anxiety: Under-recognised, over-shadowed, and misrepresented
Postnatal anxiety occurs at higher rates than postnatal depression - but there's a lack of understanding about the condition, says Psychology Lecturer Dr Vicky Fallon in this guest post for our #betterpostnatalcare campaign.
Psychology Lecturer at the University of Liverpool
Posted on: Tue 09-May-17 08:55:30
(23 comments )
If you were to ask the vast majority of mothers what comes to mind when they think about postnatal mental health problems, the first words out of their mouths would be "postnatal depression".
It's a common problem, affecting more than one in every 10 women within a year of giving birth, and is predominantly characterised by a persistent feeling of sadness, loss of interest, and lack of energy.
A quick internet search of "postnatal depression UK" pulls up around one million pages of information. The NHS, Royal College of Psychiatrists and Mind top the hits, providing accessible and evidence based advice for prospective and new mothers. Health professionals are advised by policy to ask brief questions to new mothers to identify possible depression after birth. As a result, mothers are generally in a good position to seek treatment if the signs and symptoms of postnatal depression arise.
However, through my research with postnatal women, I have realised that there is another aspect of postnatal mental health that I hear about just as frequently as depression: post-natal anxiety. Many of the mothers I have worked with share their experiences of 'worry', 'concern' and 'anxiety'. Childbearing, as a period of substantial biological and psychosocial change, can be expected to elicit some anxiety. This can serve to protect the baby and help a mother to cope with the unpredictable nature of the postnatal period. However, there is a tipping point.
When anxiety becomes irrational or excessive, and results in emotional and physical discomfort that affects day to day life, it is thought of as abnormal and pathological. Research has demonstrated that postnatal anxiety is linked to a range of negative outcomes for mother and baby. In terms of the mother, those with postnatal anxiety are less sensitive towards their infants and feel like they cannot cope as well with their babies. Furthermore, their babies are at a higher risk of insecure attachment, delayed cognitive development, and lower social engagement.
Mothers with postnatal anxiety are less sensitive towards their infants and feel like they cannot cope as well with their babies.
Whilst postnatal depression and anxiety can co-occur, research studies examining postnatal anxiety demonstrate that it also occurs independently and at higher rates than postnatal depression. However, there is little information available to reflect this. An internet search for "postnatal anxiety UK" pulls up a quarter of the results that were generated for postnatal depression.
Worryingly, the NHS and NICE do not recognise postnatal anxiety as a distinct disorder, and consequently there is no current guidance which exclusively addresses postnatal anxiety for either health professionals or mothers.
The brief questions that health professionals use for postnatal depression have no mention of anxiety. We have since developed a new questionnaire (The Postpartum Specific Anxiety Scale) to reflect the anxieties that women commonly face in the postnatal period. Our research shows that the questionnaire reliably and accurately identifies women with a clinical diagnosis of anxiety, but it still needs more work before it can be implemented as a screening tool in the UK.
The deficits in information and screening of postnatal anxiety raise a number of concerns. Mothers who are both anxious and depressed can only be diagnosed with depression. Mothers with pure anxiety may be misdiagnosed with depression. Even worse, there is potential for both mother and health professional to assume that mothers are functioning normally simply because they are not depressed. All of these scenarios delay or prevent the appropriate management and treatment of symptoms of anxiety, which may have serious consequences for both mother and baby.
The evidence base for postnatal anxiety is starting to grow, but what should mothers know in the meantime?
First, mothers should be aware that symptoms of anxiety are often mislabelled as postnatal depression. Mothers should seek professional help if their quality of life or their experience of motherhood is being compromised, even if their symptoms do not correspond with those of postnatal depression. Finally, mothers may also benefit from understanding that symptoms of anxiety in the postnatal period may not be the same as anxieties occurring at other times of life; often they are specific to the mother and baby.
Ultimately, we need to make sure that mothers are aware of the condition, and that health professionals identify and screen for postnatal anxiety in the same manner as postnatal depression.
If you, or someone you know may be suffering from postnatal anxiety, speak to your GP or health visitor. If they can't help, they'll know someone in your area who can. Encourage your partner to seek help if you think they might be having problems. Don't struggle alone hoping that the problem will go away.
Click here find out more about the Mumsnet Campaign for Better Postnatal Care
By Vicky Fallon
Very interesting read, thankyou. Nice to have evidence base and research info
I was diagnosed with PND but actually the largest component was anxiety. I fixated on certain things (particularly the health of my baby - I thought he was going to die) and felt out of control and like I couldn't cope. It was a very frightening time for me and for people who cared about me because I know I appeared irrational and out of control (dragging the whole family to the GP Surgery at the weekend because I thought there was something seriously wrong with the baby). I spent hours googling things that might be wrong with him and might be wrong with our breastfeeding (another obsession, together with having him weighed far too often, again becUse I thought something was seriously wrong and he would die).
I was lucky to have access to a perinatal psychiatry CPN from before the birth (I was referred due to previous PND). I really didn't know that there wasn't even an official diagnosis for post natal anxiety outside a PND diagnosis. I don't think it would have made a big difference for me as my problems were recognised and I had good treatment but it could do for others.
Friends and I were repeatedly told that postnatal depression often has anxiety as the main symptom. I've often had anxiety be an effect of depression (and both likely to be down to ASD), so had figured it wouldnt matter if they weren't distinguished.
Are there different treatments for anxiety vs depression? If the likely result is "try antidepressants; you'd benefit from therapy but none is available in the next six months", in either case, will separating the diagnoses help?
I had this within days of my DS being born. The midwife thought I was fussy and made me feel self conscious and neurotic. I didn't speak about it to the health visitor and only went to the Dr when my son was 10 months old. I had CBT and it helped. I think mine was triggered by the sudden hormone changes. I'm pregnant again and I'm going to be proactive this time and speak to my gp about it before the birth.
Interesting. I have anxiety and it was really bad after DC1, I wish I had sought help at that time.
The info that anxiety can be bad for the baby DC is upsetting.
I had anxiety but it was never diagnosed or treated because everyone kept asking if I was depressed and I wasn't and didn't fit the criteria for pnd. Consequently I had a pretty awful first 6 months.
I think mine was brought on by a bad birth - I think mothers that have births should automatically be followed up - in my area there nothing and even though I had a week long labour where my dc nearly died I was treated like a mum who had popped one out in 7 hours and left alone overnight (husband not allowed to stay) and not offered any support on feeding or my recovery whatsoever. The treatment of mothers post birth in this country is truly shocking.
The sad thing is like another pp said I had been diagnosed would there be any treatments available with a useful time frame? I doubt it on the current NHS.
Great work mumsnet highlighting this important topic.
Postnatal anxiety sounds exactly like me with my first dc. I was slightly paranoid, (exacerbated by lack of sleep) and generally had a miserable time of it constantly. I didn't seem to be enjoying motherhood like my other first time mum friends and more importantly I don't think I bonded properly at all. Feeding was terrible.
8 years on and I still don't have the closeness I have with my second dc. I feel so sad about it.
I think one difficulty here is that "anxiety" is sometimes used by hcps to dismiss women's feelings in particular: "She's a very anxious patient" is code for "it's all in her head". Certainly I have had this experience in trying to seek help for physical problems, and I believe many women who suffer from endometriosis, hormonal conditions, bad reactions to contraception etc, experience the same.
I wonder if some women are therefore not keen to embrace the diagnostic label of "anxious" as it may then lead to genuine concerns being dismissed.
I have had problems with anxiety in the past, and had cbt. Now my second baby is well into the 4 month sleep regression and as I get less and less sleep I can feel my anxiety rising. I keep having terrible, anxious dreams which wake me up before the baby, and sometimes, despite being exhausted, I can't sleep from worry. But as previous posters have said is there really any support to be had? All the children's centres near me have been closed by the council so whereas with my previous child I could get out and meet other mums it is really hard to do with this baby. There is only one regular group near me (still a drive away), once a week and that is not free. Honestly, I just get the sense that the government doesn't care about children what with cuts to things like this plus cuts to school funding, and with so little funding, I don't get the sense that there is any help to be had until you're very very ill, which I hope won't happen to me.
It seems that the only thing this government cares about is money (well, unless we're talking brexit in which case it doesn't seem to matter how much it's going to cost) - so I think a study looking at the cost of dealing with very serious pnd for parent and child long term, compared with the costs of proven early intervention (e.g. through better postnatal care, children's centres etc) is what's needed.
Should have said pnd and anxiety!
johnny is spot on - it's often used to belittle and dismiss :/ the state of postnatal care in the uk is shocking and I think exposes a deep streak of misogyny- women are mere vessels and we should just put up and shut up. Ditto care for HG, spd etc. A man presenting with daily 20x vomiting would be on a trolley and a drip pronto. A pregnant women is told to shove off and eat fucking ginger cookies. 😡
Interesting read - I suffered from (still do) huge anxiety after the birth of ds. It manifested as horribly graphic Intrusive thoughts of him coming to harm that just crippled me, along with severe OCD. I'm finally having proper therapy for it and we will see...
the poster above who asks if there's therapeutic value in separating the diagnoses asks a very interesting question. I personally think there is, but it's a complex issue and each patient is different.
It's good you are campaigning - the state of postnatal care in the uk is woeful.
If I can say as well that the answer is not the usual cheap NHS 'solution' of cbt.
right now it's being pushed as a panacea for all ills because it's cheap and can be administered by hcps with very little training. It's good in some situations, don't get me wrong, but I think it can be useless or even actively harmful in many others. There's a small but solid and increasing body of work showing it's ineffective in the mid to long term and doesn't produce the same changes in biomarkers that other more established therapies do.
Good luck with it - I fear you're on a hiding to nothing with the current state of the NHS.
anatidae - very interesting - could you elaborate on the other therapies you mention? I'm asking as I've been given the strong impression in the past that cbt is all there is....
I'm not currently in the uk so I am accessing therapies through a different route.
Cbt has a host of issues in my opinion. It takes its starting point as 'you have faulty thoughts' (this is a gross oversimplification but hey ho) then almost conditions you to 'think differently ' in response to a situation or stimulus.
That can work well for some things - phobias, irrational thought patterns etc but if the problem is trauma , a situation or a more deep seated problem it simply doesn't work. It's working to mask a symptom not uncover the root of the problem. Actual therapy comes in many different flavours - I think my chap is some kind of integrational psychodynamic type. Anyway it's not a quick fix - it's very hard work 😓
I have been offered cbt when I lived in the uk - I found it patronising and useless - it seemed to have the starting point of 'you think this way and you're faulty.'
I've worked in clinical science (including trials for depression) for many years and I know depression and anxiety is much more complex than that. It's not as simple as 'faulty brain chemistry' or 'faulty thoughts.' It's a complex mix of situation and reaction.
In many cases depression and anxiety can be seen as a perfectly normal reaction to a terrible situation. Anxiety itself postnatally is understandable- you're suddenly vulnerable and in sole charge of this tiny vulnerable thing. Mothers who saw danger in every tree were probably more likely to have their infants survive than those who were oblivious to danger. Anxiety then can be seen as a normal and adaptive state - what's pathological about it is the degree to which the danger perceived - most of us live rather safe banal lives.
Anyway I'm rambling. Cbt is a pile of bollocks. Try any other talking therapy - psychodynamic, psychotherapy whatever works for you. The key is to find a therapist you can trust.
I had post natal anxiety with DD1. It was picked up by my HV who was fab. I did not score highly on the Edinburgh PND scale at all. I was seen by a clinical psychologist within three weeks for a course of ACT therapy. I found it very effective.
However, I think it has had an impact on DD1's attachment alongside a host of physical issues that meant her needs for feeding, sleep and comfort were not met until she was 7 months old.
Anatidae - thank you, I find that evolutionary explanation helpful. In my case I definitely went overboard in an environment that was ultimately safe and my baby is now a sturdy toddler.
Anatide my 'anxiety' saved my baby's life so not even something that happened in history - mothers do still need to be hyper aware today. If I had gone on anti anxiety drugs and ignored her very subtle symptoms (which drs initially said were in my head but then realized weren't) she would have died.
It's not that unknown, though. I was first commissioned to cover it for a mainstream baby magazine about eight years ago and have written about it for professionals since.
I am the author of the post. Thank you all for your comments and feedback. To respond to a couple of specific queries:
Not Citrus: This is a really interesting point and there is no simple response. At present, they are treated in the same manner (i.e. CBT and/or SSRI's, SNRI's) but this may be partly due to the fact that many are misdiagnosed with depression. It may also be partly due to the fact that depression and anxiety do co-occur (but not always!). The efficacy of treatments specifically for postnatal anxiety is understudied because it is so under-recognised. This needs to change. As recognition grows, so will the evidence base. I think separating the diagnoses would help in other manners too though - mothers would be more likely to seek help and access support if there was information available that corresponded with their symptoms. They would feel less alone knowing that their symptoms have a label. They would also be less likely to go completely undiagnosed and untreated because their symptoms do not fit that of PND.
Johnny McGrath: You raise a very good point. The fact that some level of anxiety is normal and adaptive after birth can lead some people to believe that the individual is “just a worrier” and that their anxieties do not have clinical significance. The issue is when the mother’s quality of life or their experience of parenthood is being compromised because of anxiety - then the consequences are equally as problematic as depression. However, if there was more information and training available to health professionals about postnatal anxiety as a distinct issue, this may help counteract such dismissive responses and get more women who are experiencing clinical anxiety speaking up?
Anatidae: I agree that not all treatments work for all people and we should try to avoid a “one size fits all” approach. I also agree that this is a challenge within our current system.
Dr Vicky Fallon
anatidae thanks - very interesting and as many have said being anxious isn't necessarily 'faulty' thinking in the postnatal period, so if cbt starts from that assumption it's not appropriate. In fact, health professionals positively encourage anxiety when it comes to some things - lots of advice about SIDS for example.
vickyfallon thanks for writing this - are there any studies looking at the costs of early intervention versus benefits (and possibly extrapolating cost savings from long term problems when no help given until problems very advanced)?
This post prompted me to speak to my HV about my anxiety, the fact I'm not sleeping well (because baby isn't) and having very anxious dreams when I do which sometimes prevent me going back to sleep. The options She said might be available were anti anxiety medication, which she implied were not compatible with breastfeeding (which I am very keen to continue as I find it easy, enjoyable for me and baby and actually quite relaxing when it's not in the middle of the night! The idea of having to sterilise and wash bottles every day fills me with dread!) , cbt, or talking therapy. We didn't discuss how long I'd have to wait for the cbt or talking therapy.
What I really want is someone I trust to have the baby while I sleep - I feel much less anxious and better able to cope when I get a few hours extra and am not responsible for the baby at the same time as trying to sleep. DH does what he can, but works long hours and is the sole earner. We have no family or close friends nearby (only recently moved when I got pregnant). On the recent thread about postnatal wards, some women who'd had their children decades ago said their babies were taken off to a nursery so the mums could sleep - sounded fantastic. I was in terrible pain and got virtually no sleep on the postnatal ward, so not a great start.
starstar that is very interesting (and thank goodness you did notice.)
I've also noticed a big drop in what I can only term my higher cognitive functioning- I can only attribute that to 1. Lack of sleep and 2. The fact that my focus is entirely on my child. The point you raise is very interesting- you DO need to be very aware and alert constantly. Hyper awareness is something I've never really seen spoken about but it's something I have experienced - waking at tiny variations in temperature or breathing for example. It's certainly not the same set of pressures we've faced in the past (predation for example) but there's still a lot to be wary of.
I'm very glad your baby is ok.
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