When Worry Isn’t Just Worry: Differentiating Postpartum Anxiety, Postpartum OCD, & Postpartum Depression

Becoming a mother is one of the most exciting—and terrifying—transitions in a person’s life. It is riddled with uncertainty, anticipation, and novelty. Some worry and anxiety are completely normal. You want to do a good job. And everything is brand new.

Postpartum struggles are often invisible.

There is no step-by-step guide that works every time, even though some claim they will.

But sometimes the worry becomes relentless. When the worry begins to interfere with day-to-day life—when outside walks stop, bathtime is avoided at all costs, or leaving the house feels impossible—it may be time to take a closer look.

With my oldest son, I had no idea what to expect. After nursing, he would cry incessantly for at least 45 minutes without fail. Every worry ran through my mind: Is this normal? What am I doing wrong? Why won’t he stop crying? How am I already such a bad mom?

Some of these worries are common and understandable. And the twisted part to my story is that there was something more, he was allergic to dairy, soy, and nuts (even though doctors kept telling me he was just colicky). So, after that discovery my anxieties were reinforced and quickly shifted into something never-ending. I desperately wanted sleep but felt like I could not turn off. I loved my baby so much I could not stand to be away from him. That was normal, right? What if my partner missed a spot when washing the bottles? I should wash them again. What if my baby feels abandoned if I’m not the one who picks him up? No one else can hold him: It has to always be me. What if I fall asleep and can’t hear him crying? I should stay awake. These worries become increasingly scary with mental images of all the "what ifs."

Over time, these worries turned into anxiety—and then into rituals. I had to sing “You Are My Sunshine” three times, then stand up from the chair, then sing it one more time. After that, I had to sway him while counting to 60 before putting him in his crib. If I didn’t do it exactly this way, I was convinced he wouldn’t stay asleep.

At the time, I was seeing my own therapist—someone I had worked with for years. But the primary thing she knew to screen for was postpartum depression. Because I felt connected to my baby and was attentive to his needs, I didn’t meet the criteria. So, on paper, I was just fine. The truth is, I also had no idea that anything beyond “normal mom worries” might be happening. As a licensed therapist myself, I didn’t realize that postpartum depression is only one of many mental health challenges that can occur during the perinatal period—the time from conception through the first year after birth.

It was at that time I decided to get certified in Perinatal Mental Health still not knowing that my experience was not "normal."

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What's "Normal" Postpartum Adjustment vs. Something More?

Many birthing classes go over the "Baby Blues" to prepare mothers for the rapid hormonal shifts that occur during those first 1-2 weeks postpartum. These quick hormonal shifts can result in heightened emotional sensitivity, tearfulness, and sporadic mood swings.

One minute we are snuggling our newborn; the next we are sobbing about the dust on the baseboard.

However, when these symptoms continue, intensify, or being interfering with day-to-day tasks, something more may be going on.

Here's a brief overview of other challenges that may occur after the "Baby Blues" time frame ends:

Postpartum Anxiety (PPA): 15-20%

PPA can look different for every mom, the common thread being constant and excessive worry.

But this can be nuanced. In my case, the worry felt justified because there was a legitimate allergy. These worries are often believable and tied to real-life concerns, which can make it difficult to determine when they become excessive.

Other symptoms include racing or intrusive thoughts, feeling restless or on edge, and physical symptoms of anxiety like tight chest, racing heart, nausea, and insomnia.

What It Often Sounds Like:

• “I can’t stop thinking something bad will happen.”

• “I replay everything I did wrong or might have forgotten today.”

• “My brain won’t turn off.”

Postpartum OCD (PPOCD): 3-5%

PPOCD creeps into more of the scary, intrusive, unwanted thoughts. These thoughts can be violent or disturbing and may be accompanied by mental images or visualizations. These thoughts go against the mother's values which creates extreme distress.

Remember, these thoughts do not define you as a mom.

For example, I often saw images of accidentally dropping my son when walking down the stairs.

PPOCD often includes rituals or compulsions, like the bedtime one I described earlier. Avoidance and reassurance-seeking can also be compulsions.

Importantly, research shows no evidence of a greater risk of harming the baby with PPOCD.

What It Often Sounds Like:

• “What if I drop the baby?”

• “What if I snap?”

• “Did I just accidentally shake him too hard?"

Postpartum Depression (PPD) - 15-20%

PPD can look very different than PPA. Rather than constant worry, there is more often numbness and disconnection from baby, self, or others.

Other symptoms include loss of joy/interest, overwhelming hopelessness, irritability, isolation and withdraw.

PPA and PPD can happen simultaneously, but sadness and depletion are experienced most.

What It Often Sounds Like:

• “I don’t feel like myself.”

• “I am supposed to be happy… but I’m not.”

• “Why am I not connected to my baby?”

• “I can't do it today-you do it.”

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Why Distinction Matters

Treatment of PPA, PPOCD, and PPD approaches differ slightly, so it is important to determine which is most challenging. For PPA, treatment often includes cognitive work, nervous system regulation, and calming strategies. The most effective treatment for PPOCD is called exposure and response prevention (ERP). For my case, it would have looked like putting baby down after only singing the song one time or only counting to 10 instead of 60. Slowly indicating that this ritual was not in fact based in real-life and the baby can sleep without it. For PPD, emotional processing and behavioral activation can be most effective.

Having an accurate diagnosis and remembering that you are not alone can reduce shame. And for many moms, they experience overlap between PPD, PPA, and PPOCD, and that is okay.

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Knowing When to Reach Out for Support

If symptoms last for more than two weeks or if they interfere with your day-to-day, then reaching out is encouraged. This may look like worry and sadness keeping you from sleep, bonding with baby, eating, bathing, etc. Additionally, when thoughts become scary or isolation and shame start to take over, and there are feelings that others are better off if you aren't there, support is essential.

Remember, 15-20% of new moms experience one of the above. You are not alone. And help is available.

Perinatal Mood and Anxiety Disorders are not character flaws, they are medical and emotional conditions that occur more frequently than we know. For many, support is never received due to shame and silence, so the more awareness the more help the more relief.

Individual & group counseling can be tremendously helpful with addressing these conditions. Finding therapists who specialize in Maternal Mental Health is key, as was in my case as well. Here are some things to look for:

• Postpartum Support Virginia Preferred Provider - defer to your state's Postpartum support division which can be found on the Postpartum Support International website

• PMH-C credentials - this indicates that the therapist is certified in perinatal mental health and has completed specialized training and testing

• Blue Dot Safe Spot - if a practice has this indication, all employees including administration has been trained in perinatal mental health.

Photo of me 3 weeks postpartum. You would never have known what is behind the smile.

At Mile by Miles Counseling, we have all completed the training to be a Blue Dot Safe Spot. Jenna Miles, Lauren Shaulis, and Eloise McCorkle are all preferred providers for Postpartum Support Virginia.

We also offer seasonal postpartum support groups. Our next Behind The Smile group will be starting April 8th. Registration is open until Friday, April 3rd.

I am 1 in 5. You are not alone. And you do not have to endure the struggles alone!