Postpartum Psychosis: A Closer Look at Scary Thoughts

I work with parents through the postpartum period, and I recently took some additional training specifically on postpartum psychosis. I learned a lot, but two things in particular were important reminders. The first was how easily we can oversimplify the difference between intrusive thoughts and psychosis, especially when we focus too heavily on whether a thought is distressing. The second was how much we can learn by asking the question: what has changed?

Both felt worth sharing because postpartum psychosis can be incredibly scary to hear about, especially when the postpartum period can already come with strange thoughts, enormous emotions, and very little sleep.

It’s Not Just Whether It's Distressing

Postpartum psychosis is a serious psychiatric condition that can involve significant changes in thinking, perception, mood, and behavior, including hallucinations, delusions, paranoia, confusion, and changes in mood, energy, or sleep. It most often begins soon after delivery, usually within the first few weeks, although later onset can occur. It can develop quickly, and symptoms may fluctuate or wax and wane, meaning someone may seem more like themselves at times. Postpartum psychosis is a psychiatric emergency that requires immediate evaluation and treatment. It is also treatable.

Postpartum psychosis is different from postpartum depression, anxiety, and OCD. It isn’t simply postpartum depression that has become more severe. These are different clinical conditions, although symptoms can sometimes overlap. One distinction I really want new parents to understand is that having a scary or disturbing thought about your baby does not automatically mean you’re experiencing psychosis.

Intrusive thoughts can happen during the postpartum period and can be incredibly upsetting. You might suddenly picture dropping your baby, have an unwanted image of hurting them, or imagine something terrible happening. With postpartum OCD, these thoughts are typically unwanted and inconsistent with what you actually want or believe. These thoughts are distressing. With this distress, sometimes the anxiety can become as much about having had the thought as it is about the thought itself, leaving you wondering, “Why did I think that? What does that say about me?” You may be horrified that the thought even crossed your mind and become very worried about what having it means, leading you to avoid certain situations, check constantly, or seek reassurance that your baby is safe.

That distress is an important part of how we understand intrusive thoughts and OCD, and I worry that this distinction sometimes gets simplified too much into “if the thought scares you, it’s OCD; if it doesn’t, it’s psychosis,” which isn’t the whole story.

You may have limited insight into what’s happening, or believe something is true that isn’t. That doesn’t mean the experience feels calm or comfortable. You can be deeply frightened by what’s happening and still be experiencing psychosis.

So while a thought being distressing matters, it just isn’t the whole picture. What matters more is the thought itself, and your relationship to it. Does it feel like your own thought, even though you hate having it? Does it feel like something you’re being told to do? Do you believe you need to act on it, or that something will happen if you don’t? Are things around you suddenly taking on a meaning they didn’t have before? Do you believe something about your baby that people you trust are telling you isn’t true? These are some of the questions that help sort out what you’re experiencing.

Two people can both say, “I’m having scary thoughts about my baby” and be describing very different experiences underneath that sentence. The distinction between an unwanted intrusive thought and a delusional belief is an important one, and there’s rarely just one question that sorts out which one it is.

You don’t have to figure out what category a thought belongs in before you talk about it, and you definitely don’t need the right clinical language. Tell your care providers exactly what happened, i.e. what the thought said, what it felt like, what you’re afraid it means, and whatever part you’ve been holding back because you’re worried how it’ll sound. Those are usually the details that help most.

What Has Changed?

The other piece I was reminded of is the importance of asking not only what is happening, but whether you’re experiencing or responding to it differently than you usually would. This can be especially tricky in the postpartum period because postpartum psychosis can involve changes in sleep, mood, energy, thinking, and behavior, but having a baby changes all of those things, too. New parents are tired and can certainly be anxious, emotional, irritable, forgetful, overwhelmed, and generally not feel quite like themselves. What can be especially telling is when you’ve been exhausted, anxious, overwhelmed, or under significant stress before, but something about how you’re thinking, feeling, or behaving this time is different.

Sleep is a good example. There’s a real difference between “I’m exhausted and desperately want to sleep, but my anxiety won’t let me” vs. “I’ve barely slept for days, but I don’t really feel like I need to.” Both sound like “I’m not sleeping,” but they’re describing very different experiences. That difference doesn’t diagnose anything on its own, but it gives us more information about what might be going on.

Partners, family members, and friends can be so helpful here because they’re often the people who can recognize when something feels or looks different. You probably know what your partner looks like tired, anxious, overwhelmed, or running on very little sleep. If something feels different this time, say that to their doctor or another healthcare provider, even if you can’t explain exactly what feels off. Saying “Something has changed. This doesn’t feel like her” is important information, especially because the person experiencing the symptoms may not realize how much has changed.

Putting This Together

The first thing someone tells us is often only part of what’s going on. A scary thought, a change in sleep, or simply not feeling like yourself can mean very different things, which is why it’s so important not to make assumptions based on one piece of the experience. Whether a thought is distressing matters, but it doesn’t tell us everything. And sometimes one of the most important pieces of information is simply that something about this person feels different than before.

You don’t need to know what it means before you reach out. Tell the whole story, including the part that feels hard to explain or that you’re nervous to say out loud. Your OBGYN, primary care provider, your baby’s pediatrician, or a therapist or psychiatrist trained in perinatal mental health are all places you can start. They can help you make sense of what you’re experiencing and determine what kind of support or evaluation you may need.

Postpartum psychosis is a psychiatric emergency and requires immediate medical evaluation. If you are concerned that you or someone you love may be experiencing postpartum psychosis, seek urgent medical care rather than waiting for a routine appointment.

This post reflects my own understanding after additional training on postpartum psychosis and isn’t intended to diagnose or provide individualized medical advice.

This post draws in part on additional training I completed on postpartum psychosis through Repro Psych Academy, created and taught by reproductive psychiatrist Katrina Furey, MD.