When Does Normal Worry Become Postpartum Anxiety?

Welcome back to So Glad You Asked with Dr. Ruta Nonacs and Allie Hales! We’re starting off this season with such an important episode. We talk all the time about postpartum depression but what about postpartum anxiety?

In this advice-packed episode, Dr. Ruta and Allie sit down with Nicole Amoyal Pensak, PhD, Clinical Psychologist, and Author of the book RATTLED, How to Calm New Mom Anxiety with the Power of the Postpartum Brain. They discuss how the new mom's brain changes and what that means for mental health. Plus, Dr. Ruta shares tips for distinguishing normal worry from postpartum anxiety.

If you’re preparing for the postpartum, have a history of anxiety, are caring for a loved one with postpartum anxiety, or just looking to learn about matrescence, this episode is for you.

Recommended Resources:

• Rattled by Nicole Pensak
• Postpartum Support International
• Learn more on our Resource Hub

Disclaimer: This podcast is not intended to be a substitute for professional medical care. The views, thoughts, and opinions shared today are the speakers’ own. **Trigger Warning** postpartum depression, anxiety, and OCD.

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So Glad You Asked with Dr. Ruta Nonacs is brought to you by the MGH Center for Women's Mental Health and the J. Willard and Alice S. Marriott Foundation. 

Transcript

Listener 1 00:00:00

Hello, My question was after starting an SSRI for postpartum anxiety specifically OCD type, what is the recommendation for considering weaning coming off the medication, particularly if the OCD symptoms were probably there before having the baby and just became exacerbated? Uh, thank you so much.

Dr. Ruta Nonacs 00:00:19

Welcome to So Glad You Asked, the show where real moms bring us their toughest questions. I'm Dr. Ruta Nonacs, a perinatal psychiatrist at Mass General Hospital with over 30 years of experience supporting the mental health of moms and helping them navigate the emotional highs and lows and the often unexpected challenges that come with planning a family, pregnancy, and motherhood.

Allie Hales 00:00:41

And I'm Allie Hales, a mom of four. I know what it's like to scour the internet wide awake at 2 a.m. with a million questions, wondering if what I was experiencing was normal. That's why we created this show. It isn’t just for real moms, it's by Real Moms. Every episode is a conversation led by you. Your questions, your experiences, your mental health front and center.

Dr. Ruta Nonacs 00:01:04

And we don't just listen, we provide real evidence-based answers and reliable resources from trusted experts. Because moms don't just deserve support, they deserve solutions.

Allie Hales 00:01:15

You've probably heard of the baby blues and many people are starting to recognize the signs of postpartum depression. But there is a very confusing in-between that many of us live in. It's the place where you feel constantly on edge, hypervigilant, honestly just rattled. I remember the feelings I had during those early weeks with each baby so clearly. I would constantly check the baby monitor, I had to heart-I had a hard time falling asleep even when I was completely sleep-deprived, constantly wondering, is this just part of being a mom? Is something actually wrong with me? Am I supposed to feel this worried all the time? Am I just tired? It turns out there is a very real biological reason for that feeling, and it's a conversation that's long overdue. Today we are pulling back the curtain on postpartum anxiety. We're asking the questions that so many mothers are quietly asking themselves. When does normal worry cross the line? What do I do when intrusive thoughts start to feel scary? How do I get support without people thinking I'm a bad mom? To help us navigate postpartum anxiety, we've brought in a true heavy hitter. Dr. Nicole Pensak is a Harvard and Yale trained clinical psychologist and the author of Rattled. She's not only an expert, she's lived this herself. Today she's here to help us rethink mommy brain and show us how the postpartum brain can actually become a source of strength, resilience, and growth. Nicole, we're so excited you're here.

Dr. Ruta Nonacs 00:02:44

We're so lucky to have you here, and we've been trying since last season to get you here, and uh family illness and snowstorms have intervened. And so, here we are. We're glad to have you but also congratulations on your book. Like, it's a lot of work that you put into that book to make it this wonderful blend of your clinical wisdom and personal experience and sort of the experiences of the patients you see. So, congratulations. I don't know when you would have had time to write the book, but thank you. And it'll definitely be something that I recommend to lots of my patients who are pregnant or postpartum. But before we get into the bad things your brain can do after delivery. I wanted to talk about matrescence, which is something that a lot of people are talking about these days, even though it's not in the dictionary yet. And so you described this as a developmental and neurocognitive change that a mom's brain goes through during pregnancy and the postpartum period. And I was wondering if you could talk a little bit more about what's going on in a mom's brain after the birth of a baby.

Nicole Pensak 00:03:53

First of all, thank you so much for having me. I'm so excited to be here. And thank you for bringing recognition to this important topic. Matrescence is really a developmental phase where your brain changes rapidly, fine-tuning and priming itself for new learning. It is shedding useless neural networks, creating new neural networks that make mothers more attuned to their babies. So basically, it's to give moms a leg up in caregiving. And the process happens pretty rapidly. I say that matrescence is like adolescence, except adolescence can last fifteen years. You know, you develop over time. We have a lot of preparation for adolescence. Parents understand what they're going to be going through. Teens understand. When it comes to matrescence, the developmental phase of becoming a mother, we have virtually no education for moms on what they're about to go through and society as a whole. So Rattled, writing Rattled was really my answer to that, to give a science-based informed roadmap to this developmental phase.

Dr. Ruta Nonacs 00:05:01

In terms of being an external observer, what do people see as moms are going through matrescence? What behaviors mark that transition?

Nicole Pensak 00:05:12

So you will see a mom, well, you don't see her be primarily preoccupied with taking care of the baby, but that's what's going on internally. And then the behaviors display that, right? So they're going to be protective. They're going to soothe. They're going to nurture they're gonna feed. They're going to anticipate the baby's needs, right? They're going to plan, right? It's this increased mental load all about the baby. And so that's what you'll see externally. And it's kind of remarkable because moms are doing this all at once and in any given moment.

Allie Hales 00:05:46

I think it's interesting. I really hadn't heard of matrescence until reading your book and thinking of becoming a mother in that way. For me personally, growing up, I didn't really babysit. Like I didn't really interact with a lot of kids and I was always really worried about how, I knew I wanted to have children someday, but I just didn't know how I would be as a mom because I just felt like I didn't have a lot of experience with kids. Like even conversations I would have with other kids, I felt like were really awkward. Like I didn't know what to say to them. I did, you know, I wasn't I didn't feel like it was a natural thing for me. I guess I feel like sometimes society feels like you know, women it might come to them naturally or a woman herself might feel like it should come to her naturally. And how does that, you know, harm women or cause anxiety? At least for me, I know it did. And what would you say to that mom who's, you know, nervous about this, feeling like it won't be natural?

Nicole Pensak 00:06:43

So, it is such a disservice to women to send a message that this should just be natural, right? Because really, we know that maternal instinct is anything but natural. It's actually more trial and error learning, on the job training, and you're rising to every relentless challenge and need that the baby has. And so your brain is continuing to develop more and more each time you learn your baby and respond and attune and pick up cues. And so this happens over time. And so we need to reassure mothers that it can be overwhelming at first with all of these new responsibilities and things to think about, and to be patient and know that during matrescence, it's really an adaptation and it takes time for this to happen. And so to be patient with yourself and give yourself some grace to learn because it's like a new full-time job that's really intensive and there's no manual until now.

Dr. Ruta Nonacs 00:07:45

But I think um we do see a lot of moms including myself and Allie who are planners, so we read a lot and there's sort of the sense that if we read enough books we'll know how to handle it, and that's simply not true.

Allie Hales 00:07:59

I for one just, I related so much to like so many parts of your story. Like especially, I think, you know, all of us, I think anyone listening to this podcast is probably a planner trying to figure out, you know, like what is coming down the road or what they're experiencing currently. I experienced and I saw in your book you mentioned up to 90% of moms experience some kind of intrusive thoughts. Like I thought I was the only one to ever have those thoughts. And then last season was the first time I realized it was not just me. And I just am curious like, okay, the brain's going through all these amazing changes, you know, maybe it's going a little bit into overdrive with the intrusive thoughts. I'm just wondering if you can speak to that a little bit and how it fits in, you know, with roadblocks and how your brain is changing.

Nicole Pensak 00:08:48

Right. So the brain is basically adapting to all of these new responsibilities and taking care of a completely dependent infant. And so you're going to have a lot of thoughts about how to protect the baby, protect it from danger, uh and anticipate its needs and respond. So with that, I think the response with the incredible responsibility, it's not surprising that most parents would feel would experience some intrusive thoughts. You know, about ninety percent do. Uh however, they're not sticky, right? They sort of come into your brain and then they go away and you can usually get over it, right, and move forward and they're not really causing a lot of distress. It's sort of just like maybe a little alert, you know, or a little overwhelm of adjusting to the responsibility. But when it becomes really sticky, when you can't stop thinking about it, when it's really distressing, you know, we look at this on a continuum. Then we think about, okay, maybe it's time to get some treatment or to talk about it with a provider.

Dr. Ruta Nonacs 00:09:54

And just to add sort of my clinical experience to that, I sort of compare it to Teflon and Velcro. Um, if those thoughts slide on through like Teflon, you're okay, that's normal, and if they get stuck, like Velcro, you think about um talking to someone. The other things to kind of note are if you're not leaving the house because you're afraid of something happening. If you're changing your behaviors within the house, like I have uh moms who hide all their knives, they won't go up and down the stairs with a baby because the intrusive thoughts keep coming in. Those would also be reasons to ask for help. Or if these thoughts are keeping you up at night, that's also a big deal. And you have to keep going back and forth and or is my baby breathing? Um and you have to keep going back and forth to check on the baby. Those would be sort of my clinical signals.

Nicole Pensak 00:10:48

Yeah, absolutely. I mean, I think when the intrusive thought interferes with behavior and functioning and turns into more of like compulsive behavior, then you're talking about benefiting from treatment. So, and I see that in my practice as well. All of those protective behaviors and avoiding going down the stairs and checking the baby's breathing. So, yeah, spot on.

Allie Hales 00:11:13

And I was just wondering too if you could speak to your top kind of recommendations for an expectant mother, family, you know, about to go through this, um, you know, what readers can expect from your book Rattled and how that plays into it. Just kind of what your recommendations are for people preparing to go through this change.

Nicole Pensak 00:11:33

So I have three major recommendations, and so I laid out the book that way in terms of the roadmap to this phase of development. And so the first part is like I said the proactive postpartum, um, mental health care planning and having your team in place so that that can be streamlined and you can get treatment as quickly as possible and as effectively as possible and also work towards preventing the development of postpartum. 

And then the second part is really understanding matrescence and that this is a developmental phase, and even though physically you become a mom overnight, the adaptation takes a lot longer. And everything changes. Your physical changes, social changes, emotional changes, identity changes, even relationship changes. And so to sort of prepare yourself in that way, and in the book I talk about the new mom emotional experiences in terms of mom rage, mom guilt, mom shame, baby bonding is a big one, relationship dissatisfaction. It's really challenging for couples during this time. It's a lot of stress and to normalize but also provide evidence-based strategies on how to cope and what to think about. 

And then the third component of the book and the third um thing I recommend for everyone. And it doesn't really get talked about a lot, but to understand matrescence as an incredible opportunity that is often missed. Right? And so, no matter what happens early on in the experience, whether you have birth trauma, whether you have postpartum, whether it's just sort of you don't experience those things, but it's just a stressful time, you can get to a place of thriving and feeling better than ever. And I talk about how to really think about how to use these brain changes to your advantage and how to nurture the process, protect your brain, use the coping strategies, and come out thriving. I talk about post-traumatic growth, which I don't think is talked about at all right now in birth trauma, but there is some research that suggests that mothers can experience post-traumatic growth even after birth trauma. And to understand that and to think about this as an incredible opportunity and given the brain changes while they are prolific and incredible, it also places you in a vulnerable time when you're vulnerable to experiencing postpartum. So it's nothing wrong that you did. It's just the brain's going through too many changes. And so to think about that and to also use the strategies and go through the book to think about, you know, really becoming better than ever.

Allie Hales 00:14:15

I love that, and I think you're right. It's not talked about enough, just all of the wonderful things that can happen with the changes. Um, my son is ten, so we've started talking to him more about going through puberty and adolescence, and it is something that we're actively preparing him for. Like we're talking to him about it, we're explaining what's going to happen, like, you know, you can always come and talk to us about, you know, whatever it is you're experiencing- like we are definitely in that active preparation phase. And you're right, like it doesn't happen in the same way for most moms. Like you don't hear about all of the amazing things that are going to happen, but also the hard things too. And so I think the work that you're doing is incredible in highlighting, you know, the growth that you can have, but also the challenges.

And so, I guess I'm just curious if someone works through the roadblocks and is applying what you're teaching in Rattled, what does that thriving mommy brain with the rebrand look like?

Nicole Pensak 00:15:16

It looks like feeling better than ever, newfound meaning and purpose, enjoying being present with your kids as much as possible. And uh really just getting into flow with them, feeling comfortable. It's not really the ... I mean, it's also being able to up the ante and take on more challenges so that you continue to develop in that mindset. 

So I often say that you know, motherhood is great training also for returning to work, right? You're learning great skills in leadership, in client satisfaction, in anticipating and planning and preparing, and handling a lot of stress. When you take it all together, you're a great return on investment for going back to work. And I also think about Rattled as a great resource for employers. I think we're doing parental leave all wrong and need to prep parents in that way and companies have this opportunity to do so. But it's really about thriving and not necessarily an absence of mental health symptoms. I think you'll still have the new mom- the worries, right, that are going to come up. They're not going to be sticky, but you know how to cope, right? It's not interfering with your functioning and you know, understanding that this is a really challenging time in general. But you can also feel great.

Allie Hales 00:16:38

One thing I appreciate is just how you your book is such a great- I'm referencing it because it's right next to me over here.

Nicole Pensak 00:16:45

Oh, thank you.

Allie Hales 00:16:46

One of the things that I um have learned really liked about your approach is you offer, you know, practical tips and ways that you can improve on your own, but I I really appreciate too that you acknowledge like, look, like you don't have to just white-knuckle it, you can go and talk to someone. And I really appreciate that your approach is practical, like provides things that I can do to try and improve it, but also, you know, brings in all medical and science resources as well. And I just think being able to have everything available is what helps, you know, break down those roadblocks as what you were talking about and I really appreciate that approach. I feel like sometimes it's either like too far on one side or too far on the other. So I'm curious too, just your given your personal experience going through it yourself, like how has it changed for you when you're working with your clients when you were, you know, before you had kids and then after.

Nicole Pensak 00:17:43

I mean, it changed everything. But first of all, thank you for saying what you said. I mean, that was very intentional in the book. I wanted to take the science, the high quality science that we have to date and translate it to the layperson because moms don't really have time to read PubMed. And so we need to get this information out there to the layperson. So I tried to make it, you know, engaging and validating with also disclosing like, hey, like if I'm an expert clinical psychologist and I went through postpartum, you know, what's happening out there, you know? 

Um, and so your question as to how it has impacted my work with patients, I mean, it really does, uh, help me empathize as well as validate what's going on. I also can see it clearly when it's happening, right? It's made me a better, you know, diagnostician, and I have, you know, just been able to help parents prepare more proactively, uh, and also I'm much more attuned to the postpartum, like checking in with my patients depending on their risk factors early on, like I'm not waiting, you know, a month to check in with them, especially if they have bipolar or something more risky. Um then I would check in with them, you know, a day, a couple days after delivery. You know, so it's really um just made me more, it's improved everything.

Dr. Ruta Nonacs 00:19:09

So, I really agree with what you were saying about sort of setting up a mental health team when you're pregnant at some point so you're ready. And I think I totally agree with you, this is not like an argument, but I think as mental health providers, we see the planners, we see people who are taking care of their mental health, but what do you think we have to do to help moms in this country prioritize their mental health? So maybe they don't have a history of depression or maybe they have untreated anxiety. How do we get them to a place where they'll really prioritize their mental health and set up a team even if they don't think there's a need or the need is very low?

Nicole Pensak 00:19:52

Right. That's always the struggle, right? I think there's still a stigma. I think we need to do a better job with messaging. I think we need to explain matrescence, right? We need to make that, you know, sort of public knowledge in a way just like we understand adolescence, we need to understand matrescence as in the brain is vulnerable to experiencing postpartum, you know, in this phase and it doesn't mean you're doing anything wrong. It's just the way the brain is changing and making you vulnerable. 

I think that, you know, for me, I never considered medication, right? And so I had it on standby. I had my prescriber on standby just in case. And I walk the walk in that sense because I understand how you can feel hesitant to set that up. But the thing is, is that we really do have a maternal mental health crisis. We are not catching enough women. Hopefully one day, I said in my book, by the time, you know, I'm older, hopefully we'll have streamlined mental health care as part of standard of care when taking care of a mother and a newborn, right? And have that preparation. But right now we don't. So unfortunately, again, the onus just falls on mothers to sort of set that up. But really to normalize that, to have more providers talking about this as part of their standard education and preparing because, I mean, it's amazing when you're about to deliver a baby, when you're meeting with your providers, it's all about taking care of the baby. What's going to happen? There are baby classes. And it's like, wait a minute, no one's talking about this huge developmental phase, and we really need to make this more, uh, mainstream. Absolutely.

And I think that will help, you know, take the pressure off, reduce the stigma, but also like it doesn't mean you have to take medication. It just means that you have it as a safety net so that you're not having to scramble last minute because if you have postpartum depression or anxiety, it's really hard to problem solve in the moment and figure out what you need. It also takes time to figure out who you want to work with. It takes time to get an appointment, figure out who takes your insurance. I mean, you don't have time for that after you have a baby. So that's why I'm saying just set it up, whether you think you need it or not. And you know, you likely won't, but unfortunately, a lot of women do. And if it's already there, I think it'll make it easier to access that care.

Allie Hales 00:22:15

I think that's such good advice because at least for me, I felt like postpartum, I wasn't going to find a new provider or like have time or like the headspace to be able to do that. Like it just kept getting pushed off, pushed off, pushed off. And I've talked to friends who have taken the route of like they already had someone set up and they called their provider and they immediately got put on medication and weeks later they were feeling almost back to their normal selves. And of course, that's not the situation for everyone, but for a lot of my friends who did take medication, that was their experience, that it really improved dramatically within a matter of weeks. And I wish that I had had that set up beforehand because that could have, you know, my situation, I could have gotten rid of those roadblocks a lot sooner. So, I think that advice should be noted by everyone listening.

Dr. Ruta Nonacs 00:23:07

So. Just a plug for Postpartum Support International. Many people don't have their treaters lined up, but Postpartum Support International maintains lists of providers in different geographic areas and they're often a good start if you don't know where to go, and they're also a great source of information. You know, we don't want you to diagnose yourself, but there is a wealth of information at their website at postpartum. net. So they're a really great resource to start with.

Nicole Pensak 00:23:36

Absolutely, and I recommend them all the time. I tell [my patients] they have a group for everything and um you know, so that's great. I also tell, I mean, this is what I say. I say once you pee on that stick, set up your mental health care team because it goes kind of fast and uh there's a lot to do. And so the same way you would set up a pediatrician appointment for the baby right after birth, you set up your check-in as well. And also, I talk about various risky time points. So when you start to wean from breastfeeding, that's another vulnerable time period where the hormonal dip can be so strong that that can be a vulnerable point for postpartum. So when you have a mental health provider guiding you and checking in at these vulnerable time points, we're more likely to catch more women because it's not only just right after birth. You know, I know you know this. I'm just saying that this postpartum can happen anytime within the first year and even two years out. I mean, that that cutoff is really arbitrary.

Allie Hales 00:24:36

Being Rattled isn't a sign of failure. It's often a sign of matrescence in motion. It's your brain expanding, adapting, and recalibrating to this entirely new role. The vigilance, the sensitivity, the constant scanning, those shifts are part of how we biologically attach and protect. But understanding the science of the postpartum brain and the identity shift of becoming a mother is only half the battle when you're the one awake at 2 a.m. trying to quiet your thoughts.

Because here's the thing, matrescence explains why so much feels intense, but it doesn't mean you're supposed to white-knuckle your way through it alone. One thing I love about Nicole's work is her reminder that there are many things we can do to care for our mental health in this season, but diagnosing ourselves should not be one of them. You don't need the perfect language, you don't need to decide whether it's anxiety, OCD, or just hormones. You don't need a clinical label to justify getting support. All you need is the awareness that something feels off. If you don't feel like yourself or you're not enjoying this as much as you thought you would, that's reason enough to talk to someone.

Let the professionals do their jobs. You already have enough to carry. So now we're moving from the roadmap of the postpartum brain and the theory of matrescence into the real life questions our community is asking. You've been just so incredible to talk to and we have a bunch of questions from our community that they wanted to ask. The first question is: “How does perinatal OCD affect the mother, the baby, and the entire family ecosystem?”

Nicole Pensak 00:26:11

So what happens to the mother when she has perinatal OCD is that potentially she's just less sensitive to attuning to her baby. She can be overwhelmed and experience a lot of distress and be preoccupied. However, the good news is that it doesn't really affect baby bonding at all. So I think that can be reassuring in a sense that while you're not, you know, completely as sensitive as you would be without OCD, uh it's not going to in general affect baby bonding. Um but there's just a lot of, you know, distress that comes with having OCD and you can get really preoccupied by protecting the baby and even avoidant behaviors, but also you can put rules on your family. Like maybe you prevent them from visiting or being involved with the baby because you're worried about contamination. So it really does affect, you know, the whole ecosystem.

Dr. Ruta Nonacs 00:27:10

I think it's just like a tremendous level of distress, and I think at the center of any obsession or compulsion is reality. So, yeah, we do worry about our babies getting sick and we do worry about health issues with our babies. So, it can be hard with the family because they say, oh, mom's just being protective and some of those symptoms don't get flagged as really affecting the entire family. And you know, the whole family can get kind of engulfed in these rituals that go around OCD. So I think it can be very difficult to sort of justify, uh, getting treatment because these are some, in some realm, a normal thought, but they cause a lot of distress. So I think keeping your eye, you know, your mind on what levels of distress are occurring is really important.

Nicole Pensak 00:28:01

Those are great points, and I also would love to add that, um, so we're talking about brain changes and this matrescence and being attuned to your baby. So actually, postpartum OCD is much more common in mothers compared to the general population. So it occurs in about eight percent of mothers, and then compared to the general population, it's one to two percent. So we need to think about this vulnerability as it is, you know, your brain is working towards making you worry about the baby, anticipate, protect, prevent, right? It's adaptive in a way, but it kind of just goes overboard to causing extreme, uh, distress. And also that postpartum OCD is a hundred is like completely curable if it's only postpartum onset. Uh, compared to if you have OCD prior and then it's, you know, OCD and postpartum, it's we think of OCD as not being curable but treatable. Um, but if it's just the perinatal postpartum onset, uh, then it is curable. So I think that's helpful to know.

Allie Hales 00:29:03

That actually is perfect for our next question. “After starting an SSRI for postpartum OCD, how long should you stay on medication? What is the clinical recommendation for weaning off the medication, especially if OCD symptoms were there prior to delivery?”

Nicole Pensak 00:29:18

It's a great question. So, the clinical recommendation would be to think about being on the medication for at least six months. However, I think about it in terms of to prepare my patients to be on it for at least a year because I want them to get a really good dosage of also the CBT plus exposure and response prevention. And I think giving that time for them to really do exposure work and get a good dose of CBT treatment, then I think it can really help and protect when you are weaning off the medication gradually and working with, you know, your prescriber to do that safely.

Allie Hales 00:29:56

That goes right into our next question also. So our next question is, “I have postpartum OCD and I have been doing CBT for about six months. I'm still struggling with thoughts about something bad happening to my baby. Sometimes I'm afraid to be with the baby. What should I do?”

Nicole Pensak 00:30:14

Well, that's a great question as well. I would say the first thing to do is to talk to your provider and tell them exactly how you're feeling that you're still suffering and give the provider an opportunity to adjust the treatment accordingly. A lot of my patients, I up the treatment sessions to twice weekly for OCD where they're doing exposure work. I would look more carefully at the exposure work that they're doing and really center uh some of the exposure work around being with the baby. Because if she's avoiding, then that means she sort of hasn't completed CBT treatment. There's still a lot of work to be done. And then also to think about adding medication because medication is great because it can also have a synergistic effect with the therapy. It can help you tolerate the exposures and actually you can take on more challenging exposures. Thus

you know, improving your brain and improving your resilience. And so, that might be a consideration. Uh, I would also think about any comorbidities that might be interfering uh with progress, but also to normalize that it does take time in therapy, right? So six months isn't like, you know, I would say it's not the ... I prepare my patients for a year of cognitive behavioral therapy. And then also I would talk to the family to see if there's any accommodating with the avoidant behaviors at home.

Dr. Ruta Nonacs 00:31:34

I think that's incredibly eloquently said. I think sometimes when I see patients for medication, they've been enduring such intensive systems for a really long period of time, and the medications can really help turn down the volume so that they can engage in cognitive behavioral therapy because if your brain is screaming at you about these things, you can't even think clearly and be able to engage in the hard work that CBT does take. Um, but I think through the experience, you're basically adding some strategies to your toolkit. So you might be on medication, it turns down the volume, but you're still working. It's not like it took those thoughts away. And CBT is synergistic and can allow you to kind of have new strategies other than avoidance or repression of those thoughts to deal with the anxiety you may feel in certain settings.

Nicole Pensak 00:32:32

I think that's a great point in terms of turning down the volume, right? We don't want to mute it because then there's no opportunity to work on those thoughts and the actual, um, CBT treatment. So, depending on this patient and how distressing these thoughts are, I can also, I would reframe it as these are opportunities for you to practice your strategies that you're still having, right? And to think of it as such because we're never, we're not going to like mute it because then we won't have opportunities to practice the skills that we learn. And that's not the point of medication anyway. To think about that as well, I think is really important.

Dr. Ruta Nonacs 00:33:06

I think there was a question about intrusive thoughts that I think is really important for moms. They are not answering certain questions on the Edinburgh Postnatal Depression Scale or the EPDS because they're afraid of what those questions will lead to and what the doctors will think of them. I was wondering if you could just speak to how you talk about being honest on those questions, and what would happen if they say yes on one of the questions.

Nicole Pensak 00:33:37

If the provider is very well educated in perinatal mental health, the provider is going to normalize these intrusive thoughts because they know that 90% of parents experience them and that potentially do a more nuanced, have a more nuanced conversation about it. It's not like, oh, you fill this out and you say, I'm having thoughts of harming my baby and the provider freaks out and takes the baby away. Um, but I think obviously moms are afraid of that, they're afraid of the stigma. But this is why we also need to educate providers and also, um, have them, you know, refer elsewhere to a perinatal specialist if they feel like they're, if they, if they're not equipped to have this conversation and to do a more just nuanced diagnosis for referral.

Dr. Ruta Nonacs 00:34:26

That's the world we're looking for where your providers are educated and if they have questions, you know, there are perinatal access programs in almost every state where OBs can get backup if they have a question about a case. OB providers can also look at the information on Postpartum Support International. So, you know, we're working to educate those frontline providers, but I think we still have a ways to go.

Nicole Pensak 00:34:53

Agree. And that's also why I wrote Rattled, because it's intention for providers as well to give you a comprehensive understanding of postpartum, what that looks like, what normal mom worries look like, validating these intrusive thoughts that occur, and to understand the whole process and also the latest science that we have and the opportunity to support the mother through this incredible developmental phase.

Allie Hales 00:35:18

Our last question that we had is, “For the mom who is struggling with distressing intrusive thoughts and is terrified of how her mental health might affect her bond with her baby, what does she need to know?”

Nicole Pensak 00:35:30

That it likely won't affect bonding with the baby long term. It's very distressing in the moment and again, it may make you less sensitive to responding to your baby, but from what we see in the literature, it's not really affecting baby bonding. I actually tell my, I think I wrote this in the book also, like fake it till you make it. Your baby can't tell if you're like having a fake smile. Um, there were plenty of days when I did that early on because I was so scared that I had to sort of put on a front for my baby and uh that's okay. Uh, so fake it till you make it and get some help.

Dr. Ruta Nonacs 00:36:08

Just as long as you get help. That's the part I would want to emphasize.

Allie Hales 00:36:12

And just to add in, I just I feel like, you know, there's so many improvements that need to be made in this space, and I feel like Rattled and the work that you've done in your book is a huge step forward for moms and providers in just better understanding this transition and how we can improve it and on all on all ends.

Nicole Pensak 00:36:29

Oh, thank you so much. This was a wonderful conversation and thank you for having the podcast as well. I mean, you're really, you know, bringing light to these issues, but bringing the science also, um and the quality information that we so need because there's so much noise out there, right? And mothers need really good quality information.

Dr. Ruta Nonacs 00:36:47

As we've learned from our guest Dr. Nicole Pensak, your brain goes through a profound biological transition in early motherhood. Although mommy brain often gets a bad reputation, these changes are actually adaptive. They help you become more attuned to your baby's needs and better able to anticipate and respond to potential threats. In many ways, your brain is rewiring itself to protect and care for your child. If there is one thing we hope you take away with you from today's conversation, it's this:

The distressing or intrusive thoughts that so many new moms experience are not a sign that you're a bad or an uncaring mother. These thoughts are not something to be ashamed of. Instead, they are often your brain's way of preparing you for worst-case scenarios so that you feel ready to protect your baby. But sometimes, this protective instinct can get stuck in overdrive. When that happens, these thoughts can be overwhelming and may interfere with your ability to function, to connect with your baby, and to enjoy this time. New moms are especially vulnerable to depression and anxiety after the birth of a baby. But these conditions are treatable, whether through therapy, medication, or simply reframing what mommy brain really means. You don't have to suffer alone. You are not alone. Help is available, and you are already the mother your baby needs.

Thanks for tuning in. As a reminder, please note that this podcast is not intended to be a substitute for professional medical care. The views, thoughts, and opinions shared today are the speaker's own. Your feedback and questions drive this show, so feel free to send us an email at podcast@womensmentalhealth.org or leave a voicemail at 617-643-9232.

Allie Hales 00:38:50

You can find additional resources at our resource hub at sogladyouasked.org. This show is executive produced by Dr. Lee Cohen, produced by Mike Brown and Peri Barest, and edited by Mike Brown. This is So Glad You Asked with Dr. Ruta Nonacs and Allie Hales, brought to you by the MGH Center for Women's Mental Health and the J. Willard and Alice S. Marriott Foundation. Listen and subscribe wherever you get your podcasts.