We Should Not Need a Courtroom: Part Two

This is Part Two of a four-part essay. Start with Part One.

Part Two: What We Should Have Known First

The difference between postpartum depression, anxiety, OCD, and psychosis is the first thing the culture should have known before this summer, and most people did not.

The baby blues are common. They can include crying, irritability, worry, and feeling overwhelmed. They are usually mild and resolve within about two weeks.

Postpartum depression is a clinical depression, and it can be serious. It can interfere with sleep, concentration, functioning, caregiving, and the ability to feel connected to the baby. It does not always look like visible sadness. Sometimes it looks like anger, numbness, shame, or continuing to do everything that needs to be done while feeling almost nothing.

Postpartum anxiety can happen with depression or on its own. A mother may feel unable to stop anticipating danger. She may repeatedly check whether the baby is breathing or remain unable to sleep even when someone else is caring for the baby.

Postpartum OCD can bring violent, unwanted thoughts or images involving the baby. The mother is usually horrified by them and may hide them because she is afraid of what they mean about her. She may begin checking, avoiding, asking for reassurance, or creating rituals intended to keep the baby safe.

Intrusive thoughts can also occur without OCD. The concern grows when the thoughts become persistent, distressing, disruptive, or connected to compulsive behavior.

The distinction between OCD and psychosis is important. In OCD, the thought feels foreign to the mother. She does not want it, and she is frightened by it. In psychosis, a person may experience a delusion as true and have little awareness that she is ill.

A mother with postpartum OCD may avoid bathing her baby because she is terrified by an image of drowning the baby. She is trying to prevent the feared event. A mother experiencing psychosis may believe something about the baby that is untrue but feels completely real to her.

From the outside, both situations may involve disturbing thoughts about a baby. Internally, they are very different experiences.

Postpartum psychosis is rare, occurring after roughly one to three of every thousand births. It usually begins quickly, most often within the first days or weeks after delivery. It is a psychiatric emergency.

The earliest signs can be quieter than hallucinations or an obvious delusion. They may include irritability, confusion, rapidly changing moods, unusual energy, faster speech, agitation, or sleeping very little without appearing tired.

The symptoms can also change quickly. A woman may seem markedly unwell and then have a period in which she appears lucid. Family members and clinicians may interpret those periods as evidence that she is fine or that the earlier behavior was intentional. Periods of lucidity can be part of how the illness presents.

Postpartum psychosis is closely associated with bipolar-spectrum illness. A history of bipolar disorder or a previous episode of postpartum psychosis increases the risk. At the same time, many women who experience it have no previously recognized psychiatric history. For some, the postpartum episode is the first visible presentation of a bipolar-spectrum condition.

That means the woman may not know what is happening. Her family may not know. They may be trying to distinguish ordinary exhaustion from mania, anxiety from obsessive fear, and sleep deprivation from the beginning of a psychiatric emergency.

Most families have never been taught how to make those distinctions.

Women are told about gestational diabetes. They are warned about preeclampsia and hemorrhage. Many leave the hospital without the same clear information about postpartum mental illness, what symptoms require immediate attention, or where to go for help.

A great many people learned about postpartum psychosis for the first time from a courtroom.

If you have experienced violent or frightening intrusive thoughts and have been afraid to disclose them, the thoughts alone do not mean that you want to act on them. Tell a clinician who understands perinatal OCD. It is common and treatable.

If someone becomes confused, delusional, paranoid, unusually energized despite little sleep, or disconnected from reality after giving birth, seek emergency psychiatric care.

Part Three, The Stay-at-Home Jurors, comes Monday.

For free, confidential support during or after pregnancy, call or text the National Maternal Mental Health Hotline at 1-833-852-6262. Call or text 988 during a mental health crisis. If someone is in immediate danger or appears to be experiencing postpartum psychosis, call 911 or go to the nearest emergency department.