A Psychologist’s Step-by-Step Guide to PMADs & the Baby Blues

The physical changes that take place during pregnancy are well, obvious. Your growing bump, your bigger bra size, and perhaps even a glowing complexion. But the emotional and mental changes that happen are far less noticeable, leaving the 20% of new mothers suffering from Perinatal Mood and Anxiety Disorders, or PMADs, suffering in silence—and alone. Westport, CT-based Perinatal Psychologist Emma Levine, PhD is on a mission to change that. We sat down with Dr. Levine of Perennial Wellness, who we are honored to have on our Expert Advisory Panel, to lift the veil on PMADs, learn how to prevent them in the first place, and what to do if you think you’re in the 20%.

Can you define PMADs for us?

Perinatal Mood and Anxiety Disorders (PMADs) encompass the full range of distress a woman may experience from pregnancy through the first year postpartum. PMADs are distinguished from the “baby blues,” which are experienced by 80% of new mothers and are thought to be a normal and temporary reaction to the hormonal shifts that follow childbirth. Symptoms of the baby blues include: mood swings, tearfulness, irritability and a sense of overwhelm, but mothers experiencing the baby blues still typically feel able to function and begin creating a bond with their infant.  

By contrast, research indicates that 20% of new mothers experience a PMAD, which is a diagnosable mental health disorder. In fact, PMADs are the most common complication of pregnancy, more common than gestational diabetes, preterm labor, and low birth weight.  

What are signs a new mom may be experiencing a PMAD?

Intrusive thoughts are common during the perinatal period, and are actually experienced by 90% of all new mothers (primarily about their infant being harmed). When the blues symptoms or intrusive worry thoughts do not pass, or when anxiety becomes so intense or pervasive that a woman has trouble functioning in daily life, she is likely experiencing a PMAD.

Unfortunately, women are often reluctant or afraid to tell their providers about their mood symptoms because they feel fearful or afraid of judgment. It’s so important that women recognize that their experience is common and they are not alone, and their symptoms do not reflect who they are as mothers. PMAD symptoms are unlikely to resolve without appropriate therapeutic support and intervention, which is why it’s so important we continue to destigmatize PMADs and make access to quality care more accessible!

What are the differences between different PMADs?

There are a few different mental health diagnoses that are considered PMADs if they develop during pregnancy or within the first year postpartum.  

Major Depressive Disorder (MDD; experienced by 7-15% of mothers) is characterized by:

  • feelings of sadness, guilt, irritability, and anger; exhaustion
  • inappropriate guilt or feelings of worthlessness
  • low excitement about the baby
  • difficulty sleeping
  • intrusive negative thoughts such as “Everyone is better at this than I am” or “I never should have gotten pregnant.”

Generalized Anxiety Disorder (GAD; experienced by 7-10% of mothers) is characterized by:

  • persistent worry, or “hypervigilance,” that interferes with a woman’s daily enjoyment
  • intrusive thoughts, often related to baby’s health and safety that feel urgent to the mother
  • difficulty distracting themselves from their worry, resulting in a sense of feeling “wound up” or irritable 

Obsessive Compulsive Disorder (OCD; experienced by 3-5% of mothers) is characterized by:

  • obsessions (unwanted intrusive thoughts that stick in your head and repeat over and over in a loop)
  • compulsions (behaviors intended to reduce distress or worry, but become anxiety inducing themselves)
  • feelings of irritability or anger
  • difficulties bonding with one’s baby*

*so long as the thoughts they are experiencing are upsetting, or inconsistent with their values, these thoughts pose no increased risk of harm to their baby. 

Panic Disorder (experienced by 1-5% of mothers) is characterized by:

  • physical symptoms, such as palpitations, dizziness, or chest pain; constant worrying
  • intrusive negative thoughts 

Posttraumatic Stress Disorder (experienced by 6-10% of women) develops for some women when they have a traumatic experience that threatens their own or baby’s life, and results in:

  • avoidance of trauma-related thoughts or feelings
  • physical arousal
  • intrusive thoughts (including flashbacks)

Who’s at a higher risk of experiencing PMADs?

There are a number of variables that have been shown to increase a woman’s risk of developing a PMAD, and I encourage women to think of these risk factors along two dimensions: modifiable and nonmodifiable risk factors.  Let’s focus first on nonmodifiable risk factors:

The biggest predictor of PMAD development is a woman’s personal history; specifically, a prior history of depression or anxiety, or anxious symptoms in pregnancy.  Related, research on heredity indicates that a woman is 4x more likely to develop a PMAD if her sister had a PMAD. From a hormonal perspective, some women are more sensitive to the normal variations in hormone levels that occur in the peripartum period. After all, the dip in levels of estrogen and progesterone postpartum is the biggest crash a woman will experience in her lifetime!

Other nonmodifiable risk factors include fertility challenges, an unplanned pregnancy, a history of abuse, and other life stressors such as relationship stress and financial insecurity.  I often explain to women in my practice that these risk factors can be mitigated by applying evidence-based tools and techniques that have been shown to reduce the risk of PMAD development and to help women cultivate a rested and prepared postpartum experience. 

What can an expecting mom do to prevent PMADs during pregnancy?

There are numerous tools and techniques that women can implement to cultivate a prepared postpartum. I encourage women to:

1. Prepare for their birth experience by reflecting upon their preferences and fears—it’s quite normal to worry about childbirth!  Research indicates that while the mode of delivery (e.g., vaginal or cesarean) does not increase risk of PMAD development, the degree to which a woman’s birth experience deviates from her expectation does increase risk.  I encourage women to let go of the idea of a “birth plan,” and instead, to develop flexible birth preferences that account for different possible birth experiences.

2. Tune in to the emotions of feeding their baby. As with a woman’s birth experience, how a mother feeds her baby (breastfed, formula, or combination) is not correlated with PMAD development; however, the development of a PMAD is 4x more likely among women who want to breastfeed but struggle to do so. Breastfeeding is not nature’s way of testing your abilities as a mother—your baby’s wellness depends on feeding, sleeping, and bonding!  To this end, I encourage women to catch common thinking traps that show up around breastfeeding, such as catastrophizing (“I’m never going to be able to do this right!”) and emotional reasoning (“I’m not a capable mother”).

3. Develop a plan for sleep restoration postpartum in advance, such as creating a log-off ritual wherein women adapt a wind down routine that primes their body to produce melatonin on schedule so that they are drowsy at bedtime. I urge women to put a plan in place to ensure they get protected sleep postpartum, which is at least 4 hours of off-duty, uninterrupted sleep.  For many women, this means that they ask a support partner for help with one nighttime feed, or if they are exclusively nursing, their partner can bring them the baby and take over changing diapers and other care.

4. Explore their dynamic with their partner by creating dialogue around their expectations of one another with regard to the division of emotional labor in the home and the ways they can support one another when feeling depleted.  

What should a new mom do if she’s experiencing a PMAD now? 

If you are struggling during the peripartum period, your first job is to practice self-compassion.  You are navigating a moment of body changes, hormone shifts, and a reworking of how you feel emotionally and how you fit into your world.  New mothers sacrifice so much of themselves in the early days, which is why it’s so important to take care of yourself!

Prioritize sleep.  Restorative rest postpartum is the most protective factor in ensuring hormonal recalibration and mood regulation. 

Mobilize your support system. Postpartum is a time to lean in to your vulnerability and to ask those who love and care about you for specific forms of help and support, such as bringing over a warm meal or holding your baby for an hour so you can shower.

Learn how to rest.  Postpartum is a time when slowing down – even just five minutes of stillness – and accepting support are critical. 

Make space for your relationship.  Keep the lines of communication open and prioritize just five minutes a day to check-in and connect with one another.

Most importantly, give yourself permission to receive professional help. PMADs rarely remit on their own, and there are so many forms of support available for the peripartum community.  Speak with a cognitive behavioral therapist who can help you cultivate strategies to manage your intrusive thoughts and mood symptoms.  Explore the broader community of care providers who are eager to support you in taking care of yourself so that you can experience joy in mothering.  

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