Part Two in a Series: Risk Factors and Types of Perinatal Mental Illness for Birth Professionals

Read Part One in this series . . .

Risk Factors for Perinatal Mental Illness (saaay what – so many??)

Etiology: Bio-psycho-social

Current research does not give us a crystal clear cause for perinatal mood disorders. It seems that a convergence of biological, psychological and social (biopsychosocial) factors play a role in the intensification of anxiety and mood disorders during the childbearing year.

In other words, it is likely that a mixture of past mental health issues, hormonal changes and stressors from your current situation create a vulnerability to a mood disorders in the childbearing year (Kleiman & Wenzel, 2011; Kleiman, 2009; PSI, 2009; Puryear, 2007; Nonacs, 2006; Kendall-Tackett, 2005).

Listed below are some of the commonly acknowledged risk factors. I tried to group them into bio/psycho/social categories, but as you can see, there is much overlap.

Biological / Psychological

  • A personal history of a mental illness in her lifetime, ie, depression anxiety, PTS/PTSD, OCD or bipolar disorder (may have been diagnosed & treated or was undiagnosed & untreated) (previous PPD history increases risk to 50 – 80 % risk of recurrent PPD, as compared to 10- 20% risk w/o a prior episode)
  • A familial history of depression or anxiety disorders, etc (undiagnosed/diagnosed)
  • Premenstrual syndrome/disorder. A woman with a heightened sensitivity to her hormonal cycle, may be more vulnerable to the hormonal changes of pregnancy & birth.
  • A heightened sensitivity to hormonal fluctuations of pregnancy and childbirth.
  • Going through a traumatic birth. Traumatic birth occurs on a continuum from disappointing care to painful natural birth to life rescue efforts during the birth (huge topic)
  • Her infant is born premature (both the birth and the NICU experiences can be traumatic)
  • A history of extensive infertility treatments, trauma from necessary medical procedures
  • A history of previous miscarriages (can accompany infertility tx or not)
  • Unresolved feelings about termination of an earlier pregnancy
  • Her infant is born with a disability.
  • Her infant is stillborn, or a history of previous stillbirth

Social / Psychological

  • Poverty is a big risk factor for the development of perinatal mental illness.
  • Lack of social support: geographical move, a non-supportive family structure (alcoholism, etc), or a major change in job (ie, from career to SAHM).
  • Unhealthy current family dynamics: Occurs on a continuum from feelings of disconnect, poor communication & relationship skills, different parenting styles, bullying, to domestic violence
  • Domestic Violence creates a complex history of trauma/PTS/PTSD
  • Personal history of sexual abuse or sexual assault creates a complex history of trauma/PTS/PTSD.
  • Past family dynamics: Unresolved issues from childhood regarding parenting and being parented interferes with the transition to parenthood (huge topic -can cause major anxiety and depression)
  • Major life stressors, such as an accident or death in the family.

Differential Types of Perinatal Mental Illness

An accurate diagnosis?

I’ve gotten feedback (thank you Lara!) that I need to acknowledge not all sadness and stress in new mothers should be considered pathological, ie, needing diagnosis and treatment. So I’d like to publicly say that being a mom, caring for a newborn, can be overwhelming and that sleep deprivation can be a big factor in destabilizing a person emotionally, and some support for a new mom such a hard job can go a long way. Debra Flashenberg, CD(DONA), LCCE, wrote an article for Lamaze about her friend’s personal experience with a perinatal mood disorder.

The thing about any mental illness is that it exists on a broad continuum from “adjustment” behavior to varying degrees of “abnormal” behavior, where the person becomes so disorganized in their daily living that it does warrant treatment, Where that line is, is not always obvious, and requires discernment and sensitivity to individual needs.

The clinical presentation of the diagnoses below often overlap and/or co-occur. Diagnosis is sometimes not simple, and may be confounded by a prior history of depression, anxiety, post-traumatic stress influenced by previous life experiences.

Simpler depression and anxiety can be diagnosed and treated in primary care. A psychiatric consult is necessary for more complex cases. Licensed mental health professionals can diagnose and treat a broad range of mental disorders. Optimal treatment is usually a combination of medication, therapy and social support, tailored to individual needs.

Not all of the following categories of perinatal mental illnesses are recognized by the Diagnostic and Statistical Manual of Mental Disorders (DSM). But, many practitioners in perinatal mental health, including authors of the references to this article, recognize these differential diagnoses in clinical practice.. There is currently an active discourse in creating these new diagnoses.

Rates of perinatal mood disorders occurrence:

  • 85% suffer baby blues
  • 15% suffer depression
  • 10% suffer postpartum anxiety
  • 3 – 5% postpartum OCD
  • .1% postpartum psychosis
  • 1 – 6 % postpartum (birth) trauma – PTSD

Alphabet soup: BB, PPD, PPA/PPOCD, PP, PTSD/CB

These categories may seem confusing, but, as a childbirth educator, you don’t have the burden of diagnosis, this is for educational purposes.

BB – Baby Blues. Not a mental illness. The baby blues self-resolve and are normal. Occurs in the first two weeks or so after birth, goes away by itself. Not a mild form of postpartum depression.

PPD – Postpartum Depression.

Symptoms: If weepiness, sleeplessness, low self-esteem, change in appetite, feelings of being abandoned, alone, anger (rage), listlessness continue past two – three weeks, may be indicative of PPD. May have thoughts of self-harm or of harming the baby. In general, women who are depressed after birth who actually attempt and commit suicide are those who have histories of previous psychiatric events or previous suicide attempts. But, whenever harming behaviors are mentioned, please take it seriously. Some specialists believe PPD can overlap BB and can occur anytime in the first year. If the sad feelings are dragging on past the two-three week delimiter, it is best to seek help, rather than continue to suffer painful debilitating symptoms while also caring for an infant.

PPA/PPOCD – Postpartum Anxiety/OCD – PPA/PPOCD.

Some research suggests that some women who develop PPA/PPOCD have a heightened sensitivity to hormonal levels, in particular oxytocin, and this sensitivity may over-stimulate natural maternal behaviors, thus increasing maternal behaviors to over-protectiveness (Driscoll and Sichel, 1999). Other researchers believe the pre-existence of perfectionistic/rigid thinking styles may predispose a woman to PPA / PPOCD (Kleiman & Wenzel, 2011).

Symptoms: A pervasive anxiety that expresses itself as over-concern for the baby, over concern about germs, cleanliness, sleep arrangements, parenting skills and the normal attachment process. The mom becomes hyper-vigilant. She may bring baby to the hospital or doctor over and over again. She may develop checking behaviors such as checking to see if the blankets around the baby are folded properly, checking to see if the baby is breathing over and over again. She may engage in checking and counting rituals (counting the ceiling tiles, right angles, etc), which help her feel safe & soothed. She ay have scary thoughts about harming the baby or herself may occur. As in PPD, these must be taken seriously.

PP – Postpartum Psychosis. Separate disorder from PPD/ PPA/PPOCD

Most significant risk factor for PP is previously (un)diagnosed bipolar disorder, a previous psychotic episode or a family history of schizophrenia. Healthcare provider screening and prevention is extremely relevant to PP. Women are most susceptible in the first thirty days after childbirth. Postpartum psychosis is a psychiatric emergency. Get help immediately.


Not sleeping for a few nights in a row, delusions, speaking about nonsensical beings, thoughts about evil beings, death, intense fear, mumblings, robotic movements, acting as if she can hear words coming from somewhere else (command language), staring, flat affect, deflated speech, one word answers, catatonia, staring, paranoia. You cannot talk a person out of their psychotic delusions. Best to nod your head, say, “I understand” or “Must be hard” and GET HELP IMMEDIATELY. The person is very ill and needs help, not ridicule or fear.

Post-traumatic Stress Disorder (PTSD) Secondary to Childbirth -PSTD/CB.

Walker Karraa has written many articles about trauma and childbirth for Science and Sensibility. Like all emotional experiences, trauma is experienced on a continuum. There are two recognized diagnoses: post-traumatic stress (PTS) and post-traumatic stress disorder (PTSD), with PTSD having more long-term symptoms.

Symptoms of PTS are considered normal reactions to a traumatic event. PTS symptoms are the same as PTSD, but present to a lesser extent: dissociation, avoidance, numbing, flashbacks, hypervigilance, anxiety, depression. Normal response to trauma is considered a normal survival response, our mindbody’s way of integrating traumatizing events slowly, in small chunks. This way of ignoring things to get by, to a normal extent, is sometimes called “coping ugly.” PTS symptoms are self-limiting, and most people recover from it.

 Ayers (2004) reports 1/3 women in western world consider their birth to be traumatic and ten percent report severe symptom of traumatic stress. Dr Ayers (2004) says difficult birth experiences affects psychological health, but for majority it is self-resolved. 1% – 2% develop clinical post-traumatic stress symptoms which need treatment.

“Part Three” coming up is a guide to positive helping and suggested resources.

Do you believe you can be a positive influence regarding maternal mental health?

Do you believe it is important to be aware of perinatal mental illness?

Please share your views below. Love to hear from you!


Ayers, S. (2004). Delivery as a traumatic event: Prevalence, risk factors, and treatment for postnatal post-traumatic stress disorder. Clinical Obstetrics and Gynecology, 47(3), 552-567.

Driscoll, D. and Sichel, J. (1999). Women’s moods: What every woman must know about hormones, the brain, and emotional health. New York: HarperCollins

Kendall-Tackett, K. (2005). Depression in new mothers. New York: Haworth Press.

Kleiman, K. (2009). Therapy and the postpartum woman. New York: Routledge Press.

Nonacs, R. (2006). A deeper shade of blue. New York: Simon and Schuster.

Postpartum Support International (2009). Components of care. Seattle: PSI

Puryear, L. J. (2007). Understanding your moods when you’re expecting. New York: Houghton Mifflin Company.

Twomey, T.M. (2009). Understanding postpartum psychosis: A temporary madness. Westport, Ct.: Praeger Publishers.

Babies, Childbirth Education, Maternal Mental Health, Perinatal Mood Disorders, Postpartum Depression, PTSD , , , , ,

  1. | #1

    For me it was sleep deprivation that was hard. Neither of my kids were great sleepers and since I exclusively breast fed for the first few months I had to get up with them. (pumping milk was not my forte, unfortunately)

    Lots of info here. Thanks.

  2. | #2

    Hi Cherry! Sleep deprivation was very hard for me, too! I was terrible at pumping too! The Maternal-Child Health Consortium in NJ is having a day long seminar on Sleep Deprivation Effects on moms & infants in May…I hope to attend! Thanks, Kathy

  3. avatar
    | #3


    I suffered from PPD and PPA, and found it such a difficult thing to overcome. The sense of shame I felt at my inability to cope meant I did not open up to anyone about it for a few weeks. During this time my symptoms became quite severe. Once I finally sought help, I started the road to recovery.

    Early detection of these conditions is key, this information may assist with this. Particularly the information regarding risk factors.

    As a Chinese Medicine practitioner who was breastfeeding and concerned about medications passin through breastmilk I used acupuncture, Chinese herbs and therapy to treat my condition. I believe pregnant women and new mothers should be made aware of treatment alternatives such as these.


  4. | #4

    Hello Anna – Thank you so much for your public admission regarding your personal struggle with PPD/PPA. Such difficult conditions to cope with, in light of also having a small person to nurture at the same time, heavy responsibility we mothers (and fathers) have! I am so interested in your alternative/complementary path of healing. Research shows (as we all know from the Eisenberg research) many of us in the US are seeking complementary forms to help us heal on bodymindspirit levels. I, too, sought complementary healing for my depression after childbirth. It was twenty years ago when I suffered from severe PPD, and there was not much research on the psychotrophic drugs & the interactions in breastmilk and the effects on the infant, so I looked for other ways to heal my emotional state. There has been alot of research in this area in the past twenty years. For info about the teratogenic effects of medications on pregnancy & breastfeeding http://www.otispregancy.org is a wonderful website.

    thanks for your valued input, Namaste, Kathy

  5. | #5

    @Kathy Morelli
    Thank you Kathy! Keep up the great posts.

  6. | #6

    @Susan Breisch
    Hi Susan – I appreciate your support! take care, Kathy

  7. | #7

    Wow kathy, you put a lot of work into this great article!
    I think I had a touch of Postpartum Anxiety/OCD with my firstborn. I wrote everything down and was anxious about keeping routines just right. I also called the doctor in the middle of the night because my daughter was screaming (first time she screamed like that) When the doctor arrived there was nothing wrong with her and he suggested that I feed her. She immediately ate like she was starving. I was so embarrassed.
    “Postpartum Psychosis” I had with my second daughter due to extreme high temperature. But luckily it went away when I took meds for pneumonia. However the fear I remembered for a long time.

  8. | #8

    Hi Irene – My goodness….you have had a rocky ride with transitioning into motherhood! You are fortunate your doctor would make a house call! I have a feeling this must have been in Europe, where you hail from! Here in the US we are very much on our own. Thanks for your support and you rock!

  9. | #9


    This is an excellent overview of a potentially confusing set of terms. I think that your point that being a new mom is hard, even without a postpartum mood or anxiety disorder, is critical. If we could improve postpartum support overall, including non-judgmental screening for more serious conditions, that would be wonderful!


  10. | #10

    @Ann Becker-Schutte, Ph.D.
    Hi Ann – Thanks so much for your kind words….It can be confusing and I was hoping to simplify a complex topic and also not intimidate people…thanks, Kathy

  11. | #11

    It’s helpful to read the distinctions among different kinds of perinatal mental illness. Thank you for providing some clarification!

  12. | #12

    Hi Anna and Kathy,

    I agree that pregnant women and new moms should be made aware of alternatives to psychiatric medications. Research shows that 1/2 of our target population is looking for alternatives to medications; and some women will not seek help at all if they feel meds are their only option.

    WellPosptartum Consulting was created for that purpose. We serve women internationally, helping them see how to support healthy nervous system function and quickly reverse mood symptoms using natural methods.

    Keep up your great work spreading the word!

    ~Cheryl Jazzar


  13. | #13

    Hi Cheryl –
    I have worked as the MindBody Specialist at a hospital in the past. I ran the complementary care program. We offered many evidence-based complementary therapies for people suffering from cancer, we did not offer alternative care, only complementary care. I think it is important for consumers to know their options and to make their own choices. As a licensed counselor, it is my responsibility to recommend only those treatments that are evidence-based. When it comes to mental illness, evidence shows that often professional counseling alone is a great help. However, when counseling is not enough, (a licensed counselor/ medical professional can diagnose) there is much suffering, thoughts of self-harm, and parenting issues involved. In this case, I do not believe people should be encouraged to experiment. Having said that, yes, there is a continuum in between and consumers are adults and are free to choose what they wish to. thanks, Kathy

  14. | #14

    Hi Rachelle – Thanks for your comments! warmly, Kathy

  15. | #15

    Hi Kathy,
    Another very informative post. I think this series will be very helpful to providers. You pull together so much useful information in a clear way. Looking forward to the ways to help.

  16. avatar
    | #16

    I think I had PPA/PPOCD but not quite your definition of it, my anxiety manifested as an extreme startle reflex. Examples – my father knocked on the front door loudly to deliver an extra car seat (he couldn’t stay because he had a cold) when he left I burst into tears, hyperventilated, was shaking and was dripping cold sweat. Another time my hubby opened the shower curtain to give me a kiss but it startled me so badly I had the same overwhelming reaction, it was like having someone inside my head dumping dopamine into my brain and I couldn’t control me visceral reaction to it. I had a uncontrollable startle reflex for 4 months after my daughter was born, it wasn’t anxiety over the baby or OCD – everything else in my life was normal (no anxiety at any other time or surrounding my daughter) except my overactive startle reflex.

    The only other oddity that happened to me post partem was one night I couldn’t sleep because I heard my daughter crying except that every time I went to her, she was sleeping – every time. It took me half a dozen times of getting out of bed and going to her crib to realize the crying baby was in my head and I couldn’t turn it off. Every time I laid down and was drifting off the baby in my head would start to cry. It was so bad that I slept next to her crib that night on the floor, so that every time I heard the baby in my head crying all I had to do was look over to reassure myself that NOPE it wasn’t her. She never woke up once that night, she slept straight through, it was my brain that was wonky – that only happened one night but it was terrifying and confusing to hear my daughter crying and to go to her just to find her peacefully asleep *every time*.

    As a teen I had a short lived meth addiction (9 months) and I think that it permanently altered the dopamine structure in my brain, so that when a decade later I had a baby, I developed a very strange dopamine reaction that took months to regulate it’s self; that kinda explains my horrible startle reflex but that crying baby in my head remains a confounding mystery to me. If it had happened more than once I would have suspected psychosis but since it only happened one night, I cannot unravel why it occurred.

  17. | #17

    We actually do know a lot about the modifiable risk factors for depression, and they’re in the habits of thought (also known as cognitive distortions in the scientific literature), habits of relating (you can’t chose your family of origin but you can choose to learn new ways of relating that work better in other contexts), and coping styles. The number one risk for depression at any time is sleep deprivation and the number one risk factor that gets you the particular kind of sleep deprivation that causes depression is a ruminative coping style. Ruminating delays sleep onset but decreases REM latency interfering with the deep sleep that is necessary for good emotion regulation.
    While it is true that BD & PPD have been found in other cultures, did you know that a culture will evidence these in proportion to the extent to which they become like us? The research on how cultures become more depressed (and have more difficulties with emotion regulation in general, including Bipolar disorder) as they become more westernized is not well known. But it is clear that we manufacture depression, export it, and then also export the pharmacological cures. Ethan Watters has documented this quite well in his book Crazy Like Us. A short version is available in his NYTimes piece The Americanization of Mental Illness. As for some women being more sensitive to fluctuations in reproductive hormones I won’t argue with you about that. What I do argue is that said sensitivity is learned–a function of expectancies which our culture systematically creates and disseminates through the popular press and through medical and mental health blogs. Several years ago Lisa Barett and Eliza Bliss-Moreau did a very elegant study that shows that we attribute women’s emotions to their “nature”–she’s emotional while we attribute men’s emotions to the situation–he’s having a bad day. Their article, She’s Emotional; He’s Having a Bad Day was published in the APA journal Emotion in 2009. There is also considerable research documenting that women have more PMS symptoms when they expect to and yet men’s emotions fluctuate just as much over any arbitrary 28 day period. The only study I know of that used men as the control group in a study on PMS was done back in 1991. Again, this literature exists, is quite well done, but is not very well publicized because it does not support pharmaceutical interests and the pharmaceutical companies are the ones supporting most research nowadays. If you take a careful look at the disclosures on the researchers whose studies you quote, you’ll see that they all have big pharma funding.

  18. | #18

    @Rachelle Norman
    Hi Rachel – thanks for your input! Warmly, Kathy

  19. | #19

    Hi Oubliette – thanks so much for sharing your personal story. It sounds like you went through alot. We all have our own ways of expressing stress and anxiety, it is difficult to list all symptoms in a blog post, so it is always best to also have local professional support. I am glad to hear that it was only one night of having that auditory happening. I am most happy and truly cheer you on in your recovery from addiction. How profound the effects of chemical addiction, it showed up again in your physiology when your baby was born, I am sorry to hear that. But I am happy to hear that you are strong enuf to heal and move forward in your life. Warmly, Kathy

  20. | #20

    @Sara Rosenquist, Ph.D., ABPP
    Hi Sara – Thanks for your input about the treatment of depression – CBT as a therapeutic tool has been well documented and is actually taught by Postpartum Support International as a primary treatment tool for perinatal mood disorders. This series is informational, and this part was about risk factors. You have an interesting overview regarding the current research and its bias. thanks for your input, Warmly, Kathy

  21. | #21

    Hi there,

    I am so glad that we are talking about this. I have been worked on and off with pregnant women as a Doula/sutdent Midwife and as a Home Visitor for the last 18 yrs. Recently I had my 5th baby and was clearly reminded of the intense need for Postpartum support after watching myself fall into some really altered mental/emotional states while incountering a breast infection and a colicky baby. Last time I had run in with postapartum depression was in 1996 after my daughter Briana was born. I was treated with Chinese herbs and acupuncture by my Midwife’s husband and she treated me with a South American heat treatment called “Baking”. I truly feel that postpartum care is so important that it should become one of the main focus point’s in Maternity care. In fact I feel it should be covered by insurance companies. It would be so easy to put together a simple and effective postpartum plan together! And it would help so much. Recently I have started a blog talk on blogtalk radio and have been putting information out to the public about the importance of this topic. So thank you Kathy, I think if we all start to link together we can make a difference.

    Lisa Kiehn

  22. | #22

    Hi Lisa – Sounds amazing! Your use of complementary therapies in a mindful way is very inspired. It sounds like you know yourself well and what works for you. So it is not one size fits all. Yes, the life circumstances of lack of sleep, colicky baby, life & body changes can really change one’s mood. And if there was a prior mood disorder then the body is really set up. Let me know when you do your BlogTalk Radio. Love to hear it, thanks, Kathy

  23. | #23

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