What is PND? - What Causes PND? - How do I Recognise PND and Know Whether to Seek Help?
What is PND?
The experience of post-natal distress will be at least slightly different for everyone. Because there are no straightforward explanations or answers, reading this booklet from cover to cover in one sitting might be a challenge. There's a lot to take in, and although not all of it will apply to you, some of it may trigger thoughts and feelings you need time to sort through. Flip through the pages and digest it bit by bit, starting with the sections that catch your interest. It has long been recognized that not all women are fortunate enough to make a smooth transition to contented parenting, but until relatively recently, any form of post-natal distress was most often called post-natal depression or PND. We have come to realize, however, that many different things may underlie and trigger 'PND', that it is not necessarily depression (or even post-natal for some), and that there is value in recognizing these differences when trying to explain and address their effects. The Wellington Post and Ante-Natal Distress Support Group network uses the term post and ante-natal distress to refer to the many forms of distress that may affect women at this time in their lives. Although not everyone finds it helpful to 'label' their experience, finding a name for it that makes sense to you, may help to understand and explain it to yourself and others. Some of the other terms you may hear about or see include:
The baby blues The baby blues: a normal and short-lived experience of feeling low, moody, anxious or tearful within the first few days after birth (about the same time as the milk comes in), and thought to be related to hormonal variations. Some women also experience the pinks - a brief period of post-natal elation. Both of these may be forerunners to depression or other forms of distress if they continue for longer than several days, and become more extreme over time.
Ante-natal depression Ante-natal depression: some women become depressed during pregnancy. Others may have a depression which predates pregnancy, and which may not have been recognized up to that point. Some women have other pre-existing mental health issues that are influenced by, and influence the events and experience of pregnancy, labour and delivery, and parenting. Perhaps the most commonly recognized forms of post-natal distress are post-natal depression (PND) and post-natal psychosis (PNP), also called puerperal psychosis.
Post-natal depression Post-natal depression has been estimated to affect between 8 and 20% of post-natal women. Actual numbers are hard to determine because it varies so much in terms of severity, when it begins, how long it lasts, and its features, and is often not reported. It may begin suddenly or gradually at any time within the first year of giving birth, and be relatively short-lived or more enduring. Because it coincides with a time of great physical, psycho-emotional, and social upheaval and adjustment, and often has features such as anxiety and anger not usually associated with depression, it may be hard to identify. Women who adopt children can also experience PND, and there is growing evidence that some form of it is experienced across the cultural spectrum, although it may be understood and show itself in different ways. A leaflet for new mothers distributed by the Mental Health Foundation of New Zealand refers to whakamomori - a deep-seated underlying sadness - as a concept more relevant for Maori women. A major recent Auckland study of Pacific Island mothers by Abbott and Williams (published 2005), found PND to be very present amongst this group of women, although some significant between-group variations were noted (up to 30.9% incidence for Tongan mothers).
Post-natal psychosis Post-natal psychosis (PNP) is much less common, affecting about 1 in 1000 women after giving birth. PNP usually begins suddenly, is more extreme, and more obvious to others, but also has a much shorter duration if professional help is sought quickly. There is usually marked disorganization in speech, thinking, and behaviour at the time, but a complete return to usual patterns once treated. For some women who have experienced post-natal psychosis, depression may follow in its wake, as they deal with the significant upheaval it has caused in their lives and relationships. Once you have experienced a post-natal psychosis, there is a chance of recurrence with subsequent pregnancies. It is important to seek out some form of support during pregnancy to help reduce both the chances and possible effects of this. Another extreme form of post-natal distress is post-natal mania - characterized by irritability, enormous (and unusual) energy, busyness, grand plans, and marked inability to relax or sleep, which become increasingly problematic for others, but may not be recognized by the woman herself. Other common mental health diagnoses such as post-traumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), panic disorder, anxiety disorder, and adjustment disorder, can also be used to refer to post-natal experiences, as can the processes of grief, loss, trauma, and stress.
What Causes PND?
There is no straightforward answer. There are many theories, and some understanding of 'causes' is often linked to what you call it eg. a post-traumatic response, relationship difficulties, grief and loss, anxiety or depression, or even the ups and downs of a relatively normal adjustment to the life-change of parenting. In general though, most forms of post-natal distress arise from different contributing factors, which coincide and interact with each other, leading inevitably to secondary effects on esteem, relationships, and sense of wellbeing, if they continue for long enough. One of the important keys to recovery is to make some personal sense of it all, which can be rather like putting a jigsaw puzzle together of your life. The 'puzzle' is usually made up of different predisposing factors (your family and life experiences up to that point, and the sort of person you are), precipitating factors (more recent events affecting your experience of pregnancy, labour and delivery, and parenting), perpetuating factors (things which keep it going or make it worse), and the all-important protective factors (the skills and strengths and resources which will get you through). Here are some of the most commonly proposed contributing (predisposing, precipitating, and perpetuating) factors:
Physical/biological Hormonal and biochemical changes (including thyroid dysfunction)
Sleep deprivation and physical exhaustion
Pregnancy or post-natal recovery complicated by health issues such as hyper-emesis, gestational diabetes, pre-eclampsia, post-partum haemorrhage Reproductive Difficulty conceiving
History of miscarriage, adoption, death, or other 'loss' of a child (eg. health issues)
Birth trauma - physical and emotional (sometimes this triggers memories of earlier experiences of abuse/abandonment, even though the trigger itself can seem relatively minor to others) Emotional Unresolved issues (eg. related to identity, independence, self-worth, control, competence and achievement) from earlier experiences
Unresolved grief for loss of valued relationships, places, roles, status, health, hopes, lifestyle
History of trauma and abuse - physical, sexual, emotional - which is unresolved - whether recent, or many years ago Personal/psychological Previous or existing mental health issues - including eating disorders, alcohol or drug abuse, depression
Not feeling ready/wanting to be a mother
A big negative difference between expectations (of pregnancy, labour and delivery, the baby and parenting) and reality - resulting in a sense of incompetence, dissatisfaction, unwelcome dependence, and loss of control Family/relational Family history of mental health issues
Unsatisfactory relationship with own mother/father/caregivers - as a child, and/or now
Current relationship difficulties (with partner, children, family and friends)
Difficult 'fit' with the baby eg. hard to feed, predict, or comfort; health problems; not liking the baby, or feeling as if the baby doesn't like you
No-one to confide in or share with Practical/environmental Lack of practical and emotional support (from people you feel OK accepting this from)
Lack of experience with babies/feeling helpless and hopeless as a consequence - especially if there are no parenting models around who you trust and respect
Feeling as if you don't have the resources available to meet the demands on you (eg. time and energy, support, money, skills and knowledge) - whether actual or perceived
Stressful life events/circumstances with negative consequences Societal A society that devalues and disempowers mothers in many ways, but also seems to expect them to be able to manage everything - often in the absence of sufficient support
Pressure to 'achieve' as a parent
Conflicts between mothering and other roles (eg. work)
Stigma about expressing difficulty or dissatisfaction with mothering
Cultural differences which result in isolation and disadvantage eg. minority group, refugee, and immigrant experiences
How Do I Recognise PND and Know Whether to Seek Help?
The experience of pregnancy, labour, and delivery, and all the events that may come before and after these, represent a period of great change in the lives of women and families. It is normal to expect a period of adjustment, and short-term effects, which will vary according to your own personal circumstance, even when all is going well. Partners and other family members may also experience difficulties adjusting to the arrival of a new baby. Some women with pre-existing mental health issues may find the ante and post-natal phases particularly challenging, although this is not necessarily the case. Although there is great variability, the following categories of 'symptoms' are the ones most commonly experienced. Most people will have a mixture of these, and although listed separately, most cross over into other categories (eg. a panic attack involves thinking, behaving, and feeling).
Changes in Feeling (sometimes called mood disturbance)
Depression People usually think that depression = sadness. Although depressed people may feel (and look) sad, flat, humourless, or tearful, there are also other changes in mood that indicate a person may be depressed eg. irritability and anger, or feeling detached, numb, or robot-like (ie. seemingly not feeling).
Anger, hostility, and irritability These are frequently associated with PND. Women are often reluctant to talk to others about these feelings, because they run counter to the expectation that 'good' mothers are content and wish their children no harm, and there is a fear that these feelings are dangerous. Anger may be associated with grief, loss, and trauma, and also with feeling trapped and frustrated by the extra responsibilities and loss of personal freedom that comes with parenting. It may take the form of mild ongoing 'crabbiness' through to explosive and seemingly unexplainable outbursts. Anxiety and fear - some increase in anxiety is so common as to be a normal part of becoming a parent - that's what ensures babies are worried about sufficiently to be attended to and thus survive - but it becomes problematic when it starts to interfere with your sense of wellbeing and confidence, your ability to sleep, to concentrate and remember, and your freedom to interact with others and do what you need to.
Problematic anxiety Problematic anxiety may be:
generalized or 'free floating' ie. not attached to anything specific, just feeling keyed-up or on edge all the time
specific to particular worries and concerns eg. fears about the baby's health and development, your health, or about accidents or injury happening to loved ones
specific to particular places or situations eg. feelings of sudden unexplained panic at the supermarket, or in crowded places, or feeling unusually reluctant and afraid to answer the phone, check the letterbox, or go to the shopsGuilt and shame Guilt and shame are common feelings, for many different reasons - about not coping or knowing what to do, being a good enough parent, and for some about feeling dissatisfied despite having a healthy and much wanted baby/possessions/a good relationship/a good mother.
False, forced, and 'brittle' Some women feel as if they are only pretending to be OK (often quite convincingly), presenting a false self to the outside world to disguise how they are really feeling underneath - like wearing a mask which might crack at any time.
A sense of loss and despair This is sometimes quite hard to explain - feeling as if you have 'lost' the person you used to be, hope for the future, your ability to cope, interest or pleasure in things, your mind, your identity, your life ...
Elevated mood For some women, elevated mood/agitation/hyperactivity will be a sign that something untoward is happening to them.
Changes in Thinking
Many women report changes in thinking (especially memory and concentration) both during pregnancy and after delivery - at one level these are so common as to be considered 'normal'. This may be due to things like preoccupation with internal events and changes, concerns about the baby, and trying to juggle the tasks of daily living and adjusting simultaneously, rather than to any permanent change in your capacity to think or remember.
Women who are depressed, however, may experience changes in thinking which are more problematic, such as:
'clouding' of thinking (that 'head in cotton-wool' feeling)
slowed-down thoughts
confusion
entrenched/hard to shift negative and pessimistic thinking
difficulty concentrating, planning, and deciding
loss of confidence and sense of competence
loss of identity (not feeling/thinking like the person you used to be - and unsure you'll get her back)Women who are anxious/panicky may experience:
racing thoughts
inability to switch thinking off
repetitive thoughts which focus on worries and fears (about the baby, the self, others, the world), and which don't respond to reassuranceWomen with elevated mood may:
begin to make plans which go beyond existing (realistic) resources
believe they are capable of things which they have no realistic hope of achieving
Women who are experiencing psychosis may have:
unusual/bizarre thoughts and beliefs about the baby/others around them/the world, which begin to overtake their usual view of reality, are hard for others to follow, and lead to marked changes in usual behaviourWomen who are experiencing post-traumatic responses may have:
repeatedly replayed aspects of the traumatic/birth experience
unwelcome intrusive thoughts
disturbing dreams
They may also have seemingly unexplainable outbursts of anger, irritability, anxiety, and depression; be easily startled; feel numb, or constantly on edge and unable to relax or sleep; and avoid anything which reminds them of the traumatic events - eg. the hospital, or even the baby.
Others may find they have intrusive, obsessive and/or compulsive thoughts eg.
unwelcome 'odd' thoughts - usually disturbing or shocking and often bizarre, these thoughts have a way of popping into your head and are hard to put away again
thoughts which are linked to things you feel compelled to do - counting, particular sequences of activities, rituals, or arrangements of things in the house, or repeated checking
Although most of us have odd thoughts at times, when you're feeling OK it's usually easy to tell yourself they're ridiculous or not be worried by them - when you're feeling vulnerable it's much harder to dismiss or stop thinking them - the harder you try, the more persistent they can become.
These thoughts are usually accompanied by feeling anxious and unsafe. Thoughts of self-harm and suicide As with everything else listed here, it is really important to put these in context ie. consider them along with everything else happening to you at the time. They may range from occasional intrusive thoughts about hurting yourself eg. by scratching or cutting your skin till it bleeds, through to carefully planning how to end your life. There are many reasons for these thoughts, often based on a need to be released from the distress you are feeling, not knowing what to do or where to get support, or feeling as if nothing can change your situation. Finding someone you trust to talk to about them - someone who will neither under nor over-react, and who can help you focus on the underlying issues - is really important.
Thoughts of harming the baby and/or other children These are on a similar continuum to thoughts of self-harm - ranging from intrusive thoughts which are frightening but not necessarily dangerous (possibly indicating a paradoxical fear of being unable to protect the baby), through to being symptomatic of frustration and helplessness/being overwhelmed and unsupported, and for a very small few, a real desire to get rid of the baby from their life. Again, it is really important to talk to someone about these thoughts and feelings, put them in context, and access some good support for yourself.
Changes in Behaviour and Physical State
It is normal to have some changes in behaviour during pregnancy/transition to parenthood, but it is always important to consider the context in which these changes in experience arise. Some of them may signal a short-lived adjustment phase, others a normal response to a significant event. It is sometimes difficult to separate normal responses eg. tiredness, less energy, sleep and appetite changes, and various physical complaints, from those which signal deeper issues. Feelings of exhaustion are common with PND. This is different from the tiredness which inevitably accompanies a new baby (and perhaps a sleepless toddler), where you can still retain hope that sooner or later you will catch up - because it is accompanied by feelings of despair, as if it is the end of the world, and that you'll never be able to catch up or manage. Other women experience an excess of energy - feeling unable to sit down and rest.
Sleep disturbances Sleep disturbances are common - either sleeping much more than usual, sometimes being reluctant to get out of bed at all, or not being able to get enough sleep (difficulty getting off to sleep or waking and being unable to return to sleep), even when the baby is sleeping.
Changes in appetite Changes in appetite, as with sleep, energy, and other bodily changes, it can be difficult to distinguish appetite changes which are unrelated to 'normal' ante and post-natal factors. In general, overeating not associated with the increase in appetite that often accompanies breastfeeding, or marked lack of appetite, may be cause for concern.
Panic attacks For many women, panic attacks begin for the first time post-natally. They can be recognized by symptoms such as racing or pounding heart, rapid breathing, tightness in the chest, blurred vision, sweating, feeling hot and on edge, terrified and entrapped. People experiencing panic attacks often believe they are going crazy, or are going to die. They typically occur suddenly in busy public places (the supermarket queue is a classic example). Although they are not dangerous in themselves, they are frightening, may become more frequent and pervasive, making you reluctant to leave the house at all, and can damage your sense of safety and confidence.
Obsessive-compulsive behaviour Obsessive-compulsive behaviour often goes with intrusive thoughts, and is similarly associated with feeling unsafe or anxious, and feeling compelled to do things like washing hands repeatedly, doing or arranging things in a particular order, cleaning, checking switches are turned off excessively, or any other rituals, to help manage the anxiety.
Changes in Relationships
Partners It is normal to have some significant changes in your relationship with your partner, if you have one, when a new baby arrives - but if you have PND you may be feeling more distant, less like engaging in intimacy of any kind (talking, sex, sharing), more angry, or more withdrawn from your partner than usual. Other women may become unusually dependent and 'clingy' towards partners.
Friends and family Again you may feel like withdrawing from relationships in an uncharacteristic way - avoiding the phone, answering the door, or going out socially - or be at the other end of the spectrum, being constantly out of the house and in company, and unable to stay home alone. In addition you may find relationships with other children are affected - things which don't normally bother you may become intolerable, they may begin to behave in ways which are difficult to manage at this time, and you may be feeling more tired, irritable, angry, or distracted than usual.
The baby The picture we are lead to believe is that we will love our babies instantly - this may or may not be true, depending on factors such as your experiences of being parented as a child, your labour and delivery, the child's temperament, and the support you receive post-natally. Feeling disconnected or detached is often associated with post-traumatic experiences, either related to labour and delivery, health issues of mother and/or babies, or difficulties in other significant relationships earlier in life. Some women do not begin to feel connected to their babies for many months after delivery. Others are seemingly over-connected - unable to leave the baby alone to sleep uninterrupted, or to have time alone without stimulation. Some women may also begin to feel as if the baby or other children are out to 'get' them or make life difficult. Other strong feelings, such as anger, anxiety, and worry, may also become problematic. If you are concerned about your emotional connection to the baby or other children, it is important to consider all the things that may be contributing to this, and as with other concerns, find someone to talk to about it. Guilt, anxiety, and detachment will all make it even more difficult to notice and respond to your baby's needs in a way that makes you both feel OK.