This World is Not Flat: Anxiety Disorders in Pregnancy by Walker Karraa, MFA, MA, CD(DONA)

This excellent article on anxiety disorders is available for download here. The author Walker Karraa offers an in-depth Perinatal Anxiety Workshop which was well-loved at Open Arms. Email her directly for more information.

This World is Not Flat: Anxiety Disorders in Pregnancy, Walker Karraa, MFA, MA, CD(DONA)

Imagine you are sitting in your care provider’s office, and next to the scary “universal pain chart” with the not-so-happy faces getting progressively more distressed and discolored, is this chart:

1 in 8 pregnant women will develop an illness that poses these risks:

  • preterm birth (the leading cause of infant mortality and disability in US)1,2,3
  • low birth weight4
  • low APGAR scores5
  • a more difficult labor and delivery with increase of PTSD symptoms related to birth6,7,8,9
  • increased chance of Postpartum Depression/Anxiety Disorders after birth10,11
  • newborn may have increased agitation12,13
  • jittery infants up to 6 months after delivery14
  • breastfeeding difficulties15
  • · child may develop learning and attention disorders later in childhood 16,17,18

Genetic Disorder? Pre-eclampsia? STD?

Nope. Perinatal Anxiety Disorder.

Current estimates are that depression and anxiety effects anywhere from 5% to nearly 25% of pregnant women ( 1 in 8 ) will have a mood or anxiety disorder.19,20,21 Nearly half of that figure amounts to the depression women feel post pregnancy because of excessive weight, a slouch stature, etc. But these can, more often than not, be tackled through weight loss programs. For pregnant women with anxiety disorders, high levels of cortisol cross the placenta and have long term effects noted long after birth.

With my first pregnancy, I began developing symptoms of depression and anxiety shortly after my second trimester. I knew something was wrong, and had both physical and emotional symptoms that were getting progressively worse. At the time (ten years ago), my providers didn’t know to ask about depression and anxiety during pregnancy—and I did a damned good job covering it up. My illness went untreated, and I ended up suffering PTSD in labor and developing severe Postpartum Depression and Anxiety after the birth. I was three months postpartum before my illness got severe enough, and life threatening, before any of us knew I needed immediate medical treatment.

Anxiety in pregnancy and birth is universal and normal. It is a normal reaction to a physically and emotionally stressful, life-altering event. Secondly, an anxiety disorder in pregnancy is a medical illness, not a character flaw or personality trait. Its etiology is currently traced to an interplay of hormonal, genetic, environmental and immunological systems of the body23,24—not the half shot of espresso in your latte, your character, or your inability to relax in your irritating prenatal yoga class. Newer research is looking at the role increased oxytocin around the time of birth in influencing the onset of Perinatal Anxiety Disorders (PAD).25 Bottom line, it is not your fault.

Symptoms of Anxiety Disorders

Anxiety in pregnancy is normal. But when anxiety in pregnancy is significant enough to cause physical, emotional, and cognitive distress–a perinatal anxiety disorder may be occurring and you need help.26

Pec Indman, EdD, MFT and co-author of the award winning book, Beyond the Blues: Understanding and Treating Prenatal and Postpartum Mood/Anxiety Disorders” offered this in a recent interview for this blog:

While it’s normal to have some worries during pregnancy (for example, “Will my baby be healthy?– or, “ Will I be a good mom”?)–women with anxiety find the worry gets in the way of enjoying the pregnancy and other aspects of life.  Women with anxiety may also have appetite changes (often difficulty eating), and find that the worry makes it difficult to fall asleep.  Some women experience panic episodes during pregnancy.  These are times of extreme anxiety where there may be hot or cold feelings, difficulty breathing or a smothering sensation, numbness or tingling in the fingers or around the mouth, a racing heart, and a feeling of loss of control.

There are several types of anxiety disorders that occur in pregnancy and postpartum, including Generalized Anxiety Disorder, Obsessive Compulsive Disorder, Panic Disorder, and PTSD.  You can learn more about each type at under “Get the Facts”. But generally, symptoms of an anxiety disorder in include:27

  • Excessive, ongoing worry that impacts your day to day activities
  • Thoughts of worry regarding the future, or catastrophic events occurring
  • Insomnia
  • Poor appetite
  • Physical restlessness, inability to sit still
  • Dizziness, hot flashes, nausea
  • Panic attacks

Risk Factors

Research shows that there are some risk factors that may predispose some of us to anxiety disorders in pregnancy, and can be discussed with your care provider, partner, family or trained professional. Risk factors include:28,29

  • Family history of anxiety disorders
  • Personal history of depression or anxiety
  • Thyroid imbalance

What do you do if you have symptoms or risk factors for an anxiety disorder in pregnancy?

  1. Get help. Talk to a care provider. If you can’t talk yourself, find someone you trust to do so with you. The risks are too great. Pec Indman, EdD, MFT shares:

If a woman is struggling during pregnancy it is essential to get help.  Talk to a trained (many providers have not been trained in this area) and understanding professional.   There are lots of kinds of effective treatments including counseling (in particular Cognitive-Behavioral Therapy and Interpersonal Therapy), social support, exercise, Omega-3 fatty acids, acupuncture, and medication.

Regarding women currently on medication, Pec continues:

Women who are on medication for depression, bipolar disorder, or anxiety, should consult with a prenatal (or perinatal) mental health expert before stopping medication.  We know that over 50% of women who stop their medication before, or when they are find out they are pregnant, become ill again.  Many medications can be taken during pregnancy and will help prevent a relapse.30

  1. Ask your care providers (OB/GYN, midwife, Nurse Practitioner, Family Practitioner) if they are trained in depression and anxiety in pregnancy. One tip I give women is to phrase it this way: “If I develop depression or anxiety during pregnancy or after, how will you be able to help me?”, or “How do you help women who develop anxiety or depression in pregnancy?” If it is too difficult to do that, ask a trusted friend, partner, or family member to go with you to your next appointment and help you approach your care provider. Write a list of questions and concerns before you go. Calling ahead to let the front office know you need extra time in your appointment is also a good idea.

What if? If your only option is a care provider who is not trained in this area, go to Postpartum Support International (PSI) for excellent resources to take with you to your appointment, or to find local support systems, or call the warm-line for volunteer support on getting help in your area: 1-800-944-4773. If making that call, or going online is anxiety producing, ask a trusted friend, partner, or family member to go online for you, or with you, to PSI and get the information you need.

  1. GET A TRAINED DOULA!!! Birth and postpartum doulas can help you get through birth and postpartum adjustment. I strongly suggest you hire a doula who has training in this area (birth doulas are not required to know this information, and postpartum doulas often receive little and/or outdated training on anxiety and depression disorders in pregnancy). Some good questions when interviewing doulas are:
  • What training do you have in anxiety and depression disorders in pregnancy?
  • If I get depressed or anxious, how will you know and how will you help?
  • What local resources do you give to clients?
  • How do you feel about anti-depressant medication during pregnancy and breast feeding? Any doula who is completely “anti-medication” for any medical illness needs to turn in their birth ball and get with the program (it’s a blog, I can say things like that)!! They do not have the skills to help you. Go to PSI and ask therapists in your area for referrals to doulas with experience.

Nothing Flat about  this world of Anxiety Disorders

Pec Indman notes, “Healthcare professionals used to think pregnant women didn’t experience depression or anxiety.  We also used to think the world was flat!  Thinking has changed about a lot of things.”

Just as thinking and care regarding birth has changed, health care providers are starting to get it regarding mood and anxiety disorders in pregnancy. But much like our births, women have to raise our voices to raise awareness, and in turn get the care we so desperately deserve and need, for our brains and our reproductive systems.

With my second pregnancy, I knew before I peed on the stick—based on my first pregnancy, I had significant risks for depression and anxiety, that it was a physical illness, and that the risks to me and my baby were real and needed to be avoided. I was extremely fortunate to have the financial access to good, trained providers—they are forever in my heart. And I went through a mind field of providers who didn’t know current research and made me feel like a bad mother until I found the ones who “got it”. I firmly believe when given the right information regarding our bodies and particularly our pregnant bodies, we do a damn good job to learn more, discuss with those who could help us with treatment, and make the best informed choices for our lives. Once we remind ourselves and our care providers that our brain and uterus inhabit the same body and need the same kind of care, we will be part of the move to see that the world is not flat.

A special thanks to Pec Indman, EdD, MFT for her contribution to this article, humor, and support.

Walker Karraa, MFA, MA, CD(DONA) is a certified birth doula (DONA), and maternal mental health advocate. She holds a Masters degree in Clinical Psychology (Marriage and Family Therapy) from Antioch University Seattle, and a BA and MFA degree in dance from UCLA. A survivor of postpartum depression and PTSD secondary to childbirth, Walker passionately advocates for the advancement of perinatal mental health in the birth community. She is a warm-line volunteer and member of Postpartum Support International (PSI). She is a member of the LA County Perinatal Mental Health Task Force, and presents trainings to doula organizations on perinatal mental health and doula intervention. She lives in Sherman Oaks, CA with her husband and two children, and is a humble practitioner of Mahayana Buddhism.; Twitter @allbelly;

Pec Indman EdD, MFT is a mom with over 20 years experience as a perinatal mental health psychotherapist and educator.  She is the chair of education and training for Postpartum Support International, and co-author of the award winning book, Beyond the Blues.  An updated edition will be available the end of Oct. 2010.  Beyond the Blues, Understanding and Treating Prenatal and Postpartum Depression & Anxiety.


1 Perkin, M.R., Bland J.M. et al. 1993. The effect of anxiety and depression during pregnancy on obstetrical complications. Journal of Obstet Gynaecol 100:629-34.

2 Wadwa, P.D., Sandman, C.A. et al. 1993. The association between prenatal stress and infant birth weight and    gestational age at birth: a prospective investigation. Am J Obstet Gynecol 169:858-64.

3 Orr, S. T., J. P. Reiter, D. G. Blazer, and S. A. James. 2007. Maternal prenatal pregnancy-related anxiety and spontaneous preterm birth in Baltimore, Maryland. Psychosomatic Medicine 69 (6):566-70.

4 Ibid.

5 Ibid.

6 Beck, C. T., 2004a. Birth trauma: In the eye of the beholder. Nursing Research 53, 28-35.

7 Beck, C. T., 2004b. Post-traumatic stress disorder due to childbirth: The aftermath. Nursing Research 53,           216-224.

8 Keogh, E., S. Ayers, and H. Francis. 2002. Does anxiety sensitivity predict           post-traumatic stress symptoms following childbirth? A preliminary report. Cognitive Behavioral Therapy 31 (4): 145-55.

9Kelly, R. H., J. Russo, and W. Katon. 2001. Somatic complaints among pregnant women cared for in obstetrics: Normal pregnancy or depressive              and anxiety        symptoms amplification revisited? General Hospital Psychiatry 23 (3):107-113.

10 Lee A.M., Lam S.K. et al. 2007. Prevalence, course and risk factors for antenatal anxiety and depression. Obstet Gynecol 110:1102-1112.

11 Rambelli, C., Montagnani, M.S. et al. 2010. Panic disorder as a risk factor for post-partum depression: results from the perinatal depression-research and screening     unit study. Journal of Affect Disord,122(1-2):139-143.

12Coplan, R. J., K. O”Neil, and K. A. Arbeau. 2005. Maternal anxiety during and after pregnancy and infant temperament at three months of age. Journal of Prenatal and Perinatal Psychology and Health 19 (3):199-215.

13Tagle, N., Neal, C., Glover, V. 2007. Antenatal maternal stress and long term effects on child neurodevelopment: How and why? Journal of Child Psychology and Psychiatry, 48, 245-261.

14 Ibid.

15Britton, J.R. 2007. Postpartum anxiety and breastfeeding. Journal of Reproductive Medicine, 52:689-695.

16 Weinberg, M. Tronic, E.Z. 1998. The impact of maternal illness on infant development. J Clinc. Psychiatry 59(suppl 2):53-61

17O’Connor, T. G., J. Heron, and V. Glover. 2002. Antenatal anxiety predicts child behavioral/emotional problems independently of postnatal depression. Journal of the American Academy of Child and Adolescent Psychiatry 41 (12): 1470-77.

18 Ibid.

19 Onunaku, N. 2005. Improving maternal and infant mental health: Focus on maternal depression. National Center for Infant and Early Childhood Health Policy at              UCLA.

20 Knitzer, J., Theberge, S., Johnson, K. 2008. Reducing maternal depression and its impact on young children: Toward a responsive early childhood policy framework.  National Center for Children in Poverty, Project Five Issue Brief 2.

21 Gaynes B., Gavin, N., Melter-Brody, S., Lhor, K., Swinson, T., Gartlehner, G., et al. 2005. Perinatal depression prevalence, screening accuracy, and screening outcomes: Summary, evidence report and technology assessment, No 119. AHRQ Publication No. 05-E006-1.

22 Ibid.

23 Altemus, M. 2001. Obsessive-compulsive disorder during pregnancy and postpartum. In: Yonkers, K., Little., B. (eds) Management of psychiatric disorder in pregnancy. Oxford University Press, NY, pp 149-163.

24 Stein, D.J., Hollander, E., Simeon, D., et al. 1993. Pregnancy and obsessive-compulsive disorder. Am J Psychiatry 150:1131-1132.

25 Bartz, J.A., Hollander, E. 2008. Oxytocin and experimental therapeutics in autism spectrum disorders. Progressive Brain Research, 170:451-462.

26 American Psychiatric Association. 2000. Diagnostic and statistical manual of mental disorders (4th ed, text revision). Author, Washington, DC.

27 Ibid.

28 Lee A.M., Lam S.K. et al. 2007. Prevalence, course and risk factors for antenatal anxiety and depression. Obstet Gynecol 110:1102-1112.

30 Cohen, L.S., Altshuler, L.L. 2006. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA, 295:499-507

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