Book Review: Understanding Your Moods When You're Expecting

This is a review of Understanding Your Moods When You're Expecting, by Lucy J,. Puryear, M.D.

Puryear is a psychiatrist specializing in women's reproductive mental health at Baylor in Texas, and she's seen tons and tons of women at all stages in pre-conception, pregnancy, and postpartum problems. She says she initially thought she was going to be an ob-gyn, but found that she'd have no ability to help women with their moods and emotions during the pregnancy because of the limitations of the system, so she switched to psychiatry. Now she works with women before, during, and after pregnancy.

The wonderful thing about this book is that Puryear continues to emphasize that it's normal and acceptable to feel depressed, scared, angry, and even hopeless during pregnancy. That, to me, is a huge step, that a mass-market publisher has published an entire book talking about women's negative feelings in a way that validates us. Those of us who have been depressed during pregnancy know that it's such a turbulent mix of mega-hormones, life changes, and emotional vulnerability that depression is a reasonable response from our bodies. But it's still so important to hear that it's normal from the medical establishment (which for years told us we should be happy and glowing, that serious nausea was "only morning sickness," and made us feel like we were going to be bad mothers if we didn't absolutely love pregnancy). So I'm thrilled that this book is out there.

Puryear writes with an easy, authoritative tone. The book is full of anecdotes about her patients, most of whom she treats with talk therapy, some of whom she treats with anti-depressants. She emphasizes the need for family support, which could be critical for a reader who was trying to hide her depression from family and friends because she was scared of their reaction to it. She also covers some interesting topics, like how to process pregnancy body changes if you have a history of eating disorders and body dysmorphia. The section on telling postpartum psychosis (having persistent thoughts of harming your children) vs. postpartum OCD (having persistent thoughts that something bad is going to happen to your children and trying to prevent it) is extremely important and will probably result in hundreds of women getting treatment for PPOCD who otherwise would have thought they would be seen as monsters.

There are a few things I wish were different about the book, though. The most glaring things for me are that she doesn't talk enough about alternate treatments for mood disorders and her section on breastfeeding is a big cop-out.

She does have a very brief section on St. John's Wort and Omega-3s during pregnancy, but not postpartum. She also doesn't mention any other treatment options for pregnancy or postpartum, even things that we know about--massage, B-complex vitamins, exercise, etc. It doesn't really surprise me, since she's an MD so her focus is on talk therapy and medical treatments, but it would have been nice to have this be a big book of what-to-do as well as a big book of you're-normal-and-you-can-get-through-his.

My real beef is with the section on breastfeeding, which I just think wasn't completely researched. There is evidence from all over the world that both mothers and babies do better when they are supported in their efforts to breastfeed. It should be treated as a normal part of the process, and we should be giving women all the tools and support we possibly can to help them have successful breastfeeding experiences. But Puryear seems to approach nursing as an expendable option, the first thing to go when a woman feel stressed postpartum. The anecdote she uses tells of a woman who comes in with a 6-week-old who isn't breastfeeding very well, and she's afraid she isn't making enough milk. She's tired and stressed out and her husband's at work all the time. (Sound familiar? Growth spurt at 6 weeks, fear of low supply, worst phase of baby crying and fussiness?)

Instead of saying a) we need to get you to see a great, IBCLC lactation consultant right now to figure out why the baby's not nursing well and whether you're actually having supply issues, b) we need to get you some help at home, and c) your husband is going to have to take a night shift or two with pumped milk or formula so you can get some sleep, Puryear tells her to stop breastfeeding. Now of course it's OK not to nurse your baby. But to me this sounds like a patient coming in with a broken toe and the doctor saying "Let's amputate the foot." Why not deal with the core issue, which is lack of support, to help the mother get some rest and either get the nursing straightened out or know she had all the support she could have before stopping?

So. In general I think this book is great, and is a vitally-important step in having the medical establishment and society at large treat women's mood disorders during pregnancy seriously. But if you're entertaining any thoughts at all of nursing, skip that section in this book. Make sure you've done some research before you give birth and have the phone number of an IBCLC lactation consultant on your refrigerator and don't hesitate to call if you're having any nursing issues at all. It doesn't guarantee that you'll be able to nurse successfully, but at least you'll have a fighting chance. 

Link here to my series on Preventing PPD.

Comments

[Elizabeth]

Moxie, I just have to say something about the way you phrased the sentence comparing Postpartum Psychosis and Postpartum OCD. I had PP OCD. The difference between that and PP Psychosis is NOT that in one you have thoughts of harming your baby and with the other you have thoughts of something bad happening to your baby. People with PPOCD often have intrusive thoughts about anything and everything bad that could possibly happen to the baby, including the possibility of harming the baby themselves. What makes this different from psychosis is that they *know* the thoughts are screwy, they HATE them in fact, and are fraught with anxiety over the fact that these images pop up in their brain. PPOCD does *not* lead to psychosis. People with PP psychosis are delusional and do not know that they are sick, do not know that the thoughts they are having aren't based in reality.

It's a really, really important distinction. Someone w/ PP Psychosis needs immediate, immediate help and a family member or friend will probably have to be the one to provide it, b/c most sufferers will not realize how ill they are. PP OCD should be evaluated and treated with meds if necessary (for mine cognitive strategies helped me get through it) - but it is NOT at all the same as psychosis.

I fear the way you phrased things could spiral someone suffering from PP OCD into a panic!

Here is a good link to the differences between the different types of postpartum mental issues.

http://www.kristensguide.com/Family/Pregnancy/postpartum_disorders.asp

[Elizabeth]

Sorry, my post sounds a little shrill - just to be clear, Moxie, I'm so glad you posted that there is a big distinction between PPP and PPOCD, and that the book points this out. I just think it's important to be as precise as possible about what PPOCD is and isn't b/c it can be very, very scary to have these intrusive awful thoughts and if you then think you might be psychotic - ah, not good.

I have OCD, the non postpartum kind (well-controlled, have done cognitive therapy and sometimes meds since my early 20's) and so I was ready and waiting for my PPOCD issues when they popped up. I can only imagine how terrifying it would be to have this happen when you have never had any OCD-type issues before.

However, online (since this is not the type of thing one chats about IRL) I have come into contact with many, many moms who were never diagnosed with PPOCD or anything else, but who had these scary thoughts. I think a *little* of it is probably even within the range of normal - a sort of overextension of that protective mama bear instinct; the brain on overdrive trying to imagine any threats so as to ward against them. It's a spectrum, like most of these types of issues.

So, I encourage anyone who suspects PPOCD to get help, but also realize that you are far from alone. And, the decision whether to medicate this condition is of course an individual one, but my experience (without meds, just therapy) was that the PPOCD symptoms lessened gradually as my baby got older and by the time she was 1, they were petering out. So, having this occur does NOT mean a lifelong issue.

Sorry to go on at such length! Thank you for reviewing the book, Moxie - although the BF info sounds really deplorable (sadly, this is how most psychiatrists feel, though - postpartum issues? wean and start meds).

[Kathy]

I think that one of the problems with the treatment of OCD is that we've all heard of the compulsive hand washers and light switch flippers, but you don't hear much about the obsessive end of the disorder. For me, I've never had a compulsive symptom that anyone could see, but the thought process goes something like this:

I'm walking in the mall on the second floor, near one of those balconies with a railing, carrying my baby or pushing the stroller. I worry about dropping my coffee (or whatever) over the edge. Then I worry about tripping and accidentally dropping my baby over the edge, or falling over the railing with her. THEN I worry that I'll throw her over the edge. (And when I say "worry," I mean vividly picture.) I have trouble dismissing the increasingly scary thoughts.

I used to worry that I would accidentally jump in front of the subway train, and had to stand way back from the edge of the platform. The idea that I might be suicidal and not realize it was far worse than the worry that I might be pushed or accidentally fall in front of a train. And I couldn't stop random thoughts about "what if" from continuing along with more and more absurd scenarios, some too shocking or embarrassing to admit publicly.

Luckily, I got help in college, and the psychiatrist was able to convince me that I wasn't suicidal/homicidal, just that my anxiety was so out of control, I couldn't trust myself. However, when you are tortured with imagining yourself doing terrible things, it's very scary and easy to believe that you could be a danger.

I agree that it would be hell to have this particular brand of anxiety disorder for the first time with a new baby. I would worry about whether or not I could be trusted with my baby, and I'd be afraid to seek help, for fear that my baby would be taken away.

This book review is such perfect timing for me, because my play group helped me today to try to sort out the anxiety I've been having. How much is normal hyper-vigilant mama bear instincts kicking in? How much is the sleep deprivation and postpartum hormonal craziness? How much is post-traumatic stress from a scary birth experience? Could I be having side effects from Reglan? (And yes, as someone with a history of anxiety, I probably shouldn't be on Reglan at all, but that's another story.)

When you're a new mom, and you don't feel the way you think new moms are supposed to, it's hard to know what's normal. I'm so glad someone wrote a book that can help with that!

Elizabeth, thank you for that link! My hospital gave me a PPD worksheet, but although I think that depression and anxiety disorders are related, my OCD symptoms slipped through the cracks of that depression screening.

[Kathy]

Oh, and here's another resource on PPD and PPOCD:

http://www.postpartumprogress.typepad.com/weblog/

[lydia]

Not sure I'm with you about the breastfeeding, Moxie. In my experience, quitting breastfeeding at 3 months was the best thing, and freed me up to start to enjoy being a mother. Here's the important qualification, though: I was ambivalent about BFing from the beginning of my pregnancy and had decided to commit to three months only. So when I quit, after three months of intense pain (I preferred labor) it was with a sense of having "made it" - in other words, no guilt. And yes, I really did have plenty of support. 3 lactation consultants said we had a fine latch, a doula came and tried some thrush treatments, and my husband and parents helped hold the colicky girl through day and night. Nobody could help me sleep, though, because I was dreading the next time I'd have to nurse.

So in a way, my experience isn't totally relevant because a doctor like Puryear telling me to quit wouldn't have made any difference. I just worry that if a woman is struggling and not enjoying breastfeeding, telling her that it's crucial that she continue and all she needs is more support is just piling on the misery. OTOH, if breastfeeding is the most important thing to her, then by all means she should be helped in that. I guess it's similar to Moxie's idea of a "good birth:" the breastfeeding isn't the point, respecting the mother is.

BTW, I'm still BFing my second child at 6 months. Just like before, my pain started lessening at around 10 weeks. The difference is, he LOVES nursing. My first preferred the bottle (really, she did. It wasn't nipple confusion). My point? I think I have one...I'm a little tired from nursing all night...oh yeah, just that breastfeeding is nice work if you can get it but I really don't think it's the most important thing about mothering. IMHO.

[Moxie]

Lydia, I totally agree with you, that breastfeeding isn't the most important part of mothering. But the experience you have with breastfeeding is important. And by not giving women good, solid, decent support and instead just telling them to quit, that's not helping women.

I think the important difference in your story is that you had great support. If you have great support and it still doesn't work out, you know you did everything you could. If no one helps you nurse, and just tells you to quit, you're left with the feeling that you couldn't nurse and that somehow it's your fault. It's blaming the victim by patronizing her.

[wavybrains]

This book came at a critical part of my pregnancy for me. The part about having a plan to prevent PPD was really key, and her sample plan gave me good talking points for both my doctor, my therapist, and my husband. Her writing style was easy enough that I could read DH sections,and he "got" it. I have a long history with depression, and had a really rough first/second trimester, so a lot of this book simply validated what I was already experiencing and treatment decisions that my doctors and I made--but that validation was really important. All too often people assume that pregnant women should be glowing and happy, and don't recognize depression or talk about preventing PPD. I agree with you on the breast feeding thing, but I simply included that in my plans--like okay, how *can* we make sure that I am sleeping AND eating AND breastfeeding. Baby should be here any day now, so I look forward to seeing if we've laid a good foundation for preventing another relapse.

[AmyinMotown]

Thanks for this-and I agee with Lydia, 100 percent. Reading other commenter's comments, I am thinking I may have had post-partum OCD, or at least some seriously disordered thinking. I also didn't identify with the PPD questionnaire I got at the hospital, but I sure as hell didn't feel normal either.

Also, I have to give you lots of thanks for the Omega-3 recommendation. I went off my antidepressant and was feeling fine, but started the fish oil and I really do feel great. I was depressed in my last pregnancy near the end and I feel much more "nromal" this time out.

[m]

My nana's twin had post-partum psychosis and was hospitalized and ended up staying there for basically the rest of her life (from the 1940s until she passed in early 2000s). Things are obviously much, much better now for women, but stuff like that scares me. I was lucky with my first that I didn't have any PP stuff (other than regular baby-blues), but I'm pregnant again and you never know. My great-aunt had five (?) kids and it didn't 'strike' until the last one. I think I'm going to look through this book just to get a better idea of what might be lurking in my genes. Thanks for bringing it up.

[marypoppins]

Totally second what Elizabeth said at the start. I personally suffer
from OCD and was particularly affected when my first child was born. I had really awful intrusive thoughts and suffered a bad case of PPD but this was NO WAY PSYCHOSIS, which I have thoroughly researched. Fortunately, I was able to manage it with cognitive therapy and used CT successfully even with my second child, 2 years later.

Please Moxie be careful how you phrase certain things in the future. If I had read that phrase ( the difference between PPOCD and psychosis) 3 years a go, I would have really freaked out. This is the last thing we want new mothers to do

[rachel]

I agree with what everyone has been saying about breastfeeding. I had a lot of support, but things were still not going well at for a variety of medical and supply and latch-related reasons, and I was quite literally a wreck. I felt like if I couldn't do this one thing I shouldn't be a mother. I didn't even feel like I had a right to fall in love with my baby since I was failing at that. And yes, I do really wish I had had even better or more effective support, so we could have made it work, but in the end I switched to formula after 3 weeks, and it saved my mental health and my bond with my baby. I just wish there was more support for that side of the story--that women could be strongly supported and well taught in breastfeeding, but that there was more acknowledgment in the breastfeeding community that it's hard and it doesn't work for everyone, and that sometimes even though it could have worked through effort and sacrifice, mental health has to come first.

[Robin]

Oh my gosh, my son is 4 months old and I think I have been suffering from PPOCD this whole time and not knowing what it was or that there even was such a thing. The mall balcony example above is EXACTLY the type of thing that has on constant playback for me since he was born. I have had bouts of depression & anxiety in the past but haven't taken meds for about 5 years. I never thought I was on the OCD spectrum until right now, reading this. Just this past weekend I was in a fit of tears because I couldn't enjoy spending time with my son while there were dirty dishes in the sink and laundry to be done and oh my god is that a speck of dirt on the rug??? It sent me overboard. I remember one time when my son was just a few weeks old, and the 4th of July was drawing near. It was about 3 am and I was up trying unsuccessfully to nurse him (btw to the person above who couldn't sleep due to dreading feedings, I feel you on that!) and there must have been some kids in the neighborhood setting off some fireworks. I thought it was gunfire and went into hyper-panic mode and to some degree I feel like I've been there ever since. Thank you so very much for posting this. I am calling my midwife today and seeking a referral to get some help.

[Melissa]

I'm going to check out this book.

I'm in my first trimester (nearing the end) and am suffering from terrible, unrelenting morning sickness. After Reglan and Compazine, Zofran is helping a bit as is B vitamins. But, instead of joy at my planned, long-awaited pregnancy, I've been feeling blue that I can't really enjoy it. You can't really venture out when you're upchucking regularly.

[Lucy Puryear]

Thank you for the wonderful review of my book Moxie, and it is wonderful to read so many responses from women who are trying to get information about topics that no one talks about.

Let me be clearer about my thoughts with breastfeeding if I wasn't so in the book. I totally agree women should be supported in breastfeeding with any and every thing out there. I also reccomend lactation consulants, etc. However, the biggest point I was trying to make was that for SOME women breastfeeding doesn't work out and they need support to stop and not be made to feel guilty (which some doctors are very guilty of). Hope that clarifies my position and for the next edition I'll look at that section in particular!

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a psychiatrist specializing in women's reproductive mental health and director of the Baylor Psychiatry Clinic at Baylor College of Medicine, notes that pregnancy and motherhood are hard work both physically and psychologically. Yet, the author points out, most obstetricians and gynecologists have no training in psychological disorders, and women are often left to attend to their emotional issues without support. Puryear offers an informative resource that takes women from before conception to postpartum, drawing on her own practice and personal wisdom as the mother of four as well as current research.