Pregnancy: Perinatal anxiety disorder

As soon as the clock struck 12 at the start of my third trimester, I started experiencing frightening physical symptoms that resulted in insomnia, severe anxiety, and panic attacks. This blog post recounts the details of those first few weeks of my perinatal anxiety disorder and how I eventually I went from panic to peace (hint: thank goodness for meds!).

Today at 36 weeks + 2 days pregnant, I feel like I can finally take a deep breath and look back on the start of my perinatal anxiety disorder, what I now consider one of the hardest periods of my life. But before I start, let me give you a little lifetime Kristen context.

A lifetime of anxiety

Anxiety has been that unwanted backseat driver in my life for as long as I can remember. Long before pregnancy and infertility challenges, I’ve had to confront anxiety’s controlling commands (“Don’t forget to put your blinker on!” “Are you sure you want to take that exit?”) through counseling and lots of personal work.

I’m sure my anxiety has stemmed from that other unwanted backseat driver, perfectionism. I’ve always striven to be perfect in all that I do (exhausting much?). Just take a look at my academic career. I had well above a 4.0 in high school. Started college with sophomore standing after completing the International Baccalaureate (IB) program. Double majored in undergrad. Went to the #1 graduate school in the country for my specialty. I’m tired just thinking about it all.

My parents and teachers recognized my relentless drive along the way and did all that they could to chill me out. I remember once in fourth grade, I forgot my homework assignment. I was devastated. Kids who forgot their homework had to write their name on the board in the “Ketchup” (catch up) section and the stay in from lunch to complete missed work. I’m pretty sure I cried as I made my way to the board to write my name. As I returned to my desk, I remember my teacher, Mr. Garland, say to the whole class, “I’d like everyone to look at Kristen and give her a round of applause because she finally missed one assignment!” The whole class cheered for me and my rare occasion of academic imperfection. This was a moment of healing that I’ve always remembered - forever etched in my mind - a moment that helped launch me into decades of learning to live with anxiety and perfectionism.

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Befriending anxiety and perfectionism

Over the years, I’ve learned (or have started to learn) how to befriend these two presences. Understanding that they mean well and, at the core of it, want the best for me. They strive to help me be accepted and loved. They think that their commands to be hyper-vigilant and in a state of fight-or-flight help keep me safe and protected. I’ve learned to appreciate anxiety and perfectionism’s intent in my life. To accept them. To hug them and thank them for their concern. And through this, their backseat driver voices have softened, allowing me to enjoy the quiet hum of the engine as I drive however and to wherever I choose.

Before pregnancy, for the first 33 years of my life, I was able to manage my anxiety through therapy. I never needed meds, but I was pro-meds for those who needed them. In general, I am pro-taking care of your mental health via whatever avenue works for you. If you have diabetes, no one shames you for needing to take insulin. If you have asthma, no one shames you for needing to take an inhaler. If you break your arm, no one shames you for needing a cast. I feel the same about mental health - counseling, medication, inpatient hospital stays, journaling, meditiation - whatever works for you to help you feel more centered, more yourself, I’m all for it.

Since the start of this infertility roller coaster in fall 2017, I’ve felt equipped to manage my anxiety. I’ve talked about it. I’ve blogged about it. The anxieties that came with infertility or this high risk pregnancy (at first) never got to a point that I needed to consider other ways to take care of myself. That was until I was hit by a truck on August 18, 2019, at 29 weeks pregnant. I started experiencing the most insane physical symptoms that I didn’t associate with anxiety or panic disorders. Difficulty breathing and racing heart and arrhythmia that interfered with my sleep. My anxiety skyrocketed because I felt like I couldn’t breathe. And as a person having asthma since I was 4-years-old, needing to get steroids shots and nebulizer treatments in the ER as a kid, not being able to breathe is a scary, scary feeling.

But the symptoms felt so physical

I had my first ever panic attack starting at 29 weeks pregnant, but still, the impetus of these panic attacks felt so physical in nature. For my own sanity and healing, I’m going to do my best to piece together the this timeline.

  • August 18-19, 2019: I woke up suddenly in the middle of the night not being able to breathe. I had a headache and was lightheaded. I thought my difficulty breathing related to asthma, allergies, GERD, and decreased lung capacity with the baby taking up more and more space. This resulted in my first ever panic attack.

  • August 20, 2019: Third night in a row that I woke up suddenly unable to breathe with my heart-rate skyrocketing. I called the on-call maternal fetal medicine (MFM) nurse practitioner (NP) in the middle of the night, and she suggested that I go into the Labor and Delivery unit of my hospital to get monitored. Cory and I went into the hospital at 1:30 AM. Baby and I were completely healthy, and my vitals were perfect. Even though everything checked out, the next few nights continued to be sleepless.

  • August 24, 2019: More severe difficulty breathing in the middle of the night with a raging panic attack. Up until this point, I had tried the following medications to help me sleep: Benadryl, Hydroxyzine Pamoate (a prescription antihistamine also used to treat anxiety and insomnia), and a magnesium supplement called “Calm” from Sprouts. I had also tried every other sleep strategy under the sun including decreased screen time before bed, warm milk, bath before bed, mindful meditations, books on tape, white noise, listening to TV/movies/podcasts as a I fell asleep, and mantras. Nothing helped. Nada.

  • August 28, 2019: After work, I had an appointment with pulmonologist who ruled out asthma and allergies as the culprit of my nighttime breathing issues. She told me to go to the emergency room (ER) immediately after my appointment to rule out a pulmonary embolism (PE). A PE was ruled out in the ER, but the on-call OB noticed I was having contractions every 5 minutes unbeknownst to me at 30 weeks + 6 days. I was admitted to Labor and Delivery overnight for monitoring and to control the contractions. I was started on Procardia (generic: Nifedipine), a medication to stop contractions. This medicine helped stopped the contractions progress into anything serious.

  • September 3-4, 2019: I still had difficulty sleeping and was feeling desperate. I was prescribed Xanax (generic: Alprazolam), an anti-anxiety benzodiazepine, before bed. I slept maybe 2 hours max both nights that I took a Xanax before bed. No help.

  • September 5, 2019: I was then prescribed Ambien (generic: Zolpidem), an insomnia medication. I slept maybe 2-3 hours max with Ambien on board. Neither Xanax nor Ambien helped me sleep. What the heck was going on? To this point, I hadn’t had a good night’s sleep in 19 days. Almost 3 weeks of nearly ZERO sleep. I was going insane! I even started to have panic attacks during the day that grew increasingly worse when the sun started to set - everything about the nighttime made me anxious now that I associated the dark of night with no sleep and panic attacks. Even driving home from work made me feel anxious because I knew that’s where I had my panic attacks.

Panic attacks

So what did my panic attacks feel like? Simply, like I was dying. I felt like I was suffocating. I couldn’t sit still. I was hot and sweaty, but I was freezing with goosebumps. It was all-consuming. The majority of my panic attacks were in the middle of the night, but towards the end, they started carrying over into the morning, especially after nights with little to no sleep. In the morning when I was getting ready for work, I had a hard time washing my face or taking a shower because my sensory system felt overwhelmed by the water in my face. It felt like the water would interfere with me being able to breathe. I couldn’t listen to music or podcasts. They felt too overwhelming to my ears. Driving to work, the air blowing on my face from the vents felt too overwhelming to my skin.

  • September 6, 2019: Despite taking Procardia to control my contractions for the previous ten days, I was still having contractions every 5-6 minutes all day at work. My NP told me to go into Labor and Delivery for monitoring again. I was monitored for several hours in the evening. Contractions were consistent but they weren’t changing my cervix or launching me into labor. They increased my frequency of Procardia to every 3 hours instead of every 6. I also opted to stay overnight to try to get a good night’s sleep. Being monitored by nursing + Ambien resulted in my first “good” (5ish hours) night’s sleep in nearly 3 weeks.

Zoloft, a life-saver

That night in the hospital, I also started the medication that changed my life: Zoloft (generic: Sertraline). Zoloft is “an antidepressant belonging to a group of drugs called selective serotonin reuptake inhibitors (SSRIs). Sertraline affects chemicals in the brain that may be unbalanced in people with depression, panic, anxiety, or obsessive-compulsive symptoms.” (source: www.drugs.com).

Before starting Zoloft that night, I had the opportunity to speak with the on-call OB in the hospital for nearly 30 minutes about the effect of Zoloft on my growing baby in-utero and the effect of Zoloft on breastfeeding. Quick and dirty summary: the benefits greatly outweigh the minimal risks of Zoloft on the baby in-utero. Risks include mild transient (i.e., a couple days) withdrawal symptoms after birth like fussiness and more irritability. There is also the risk of persistent pulmonary hypertension in newborns (my doc had never seen this in his career), which is now not as much of a concern based on current research. Also, Zoloft has been shown to have no adverse impacts on long-term neurodevelopment. My doctor said that he would feel completely comfortable and safe recommending Zoloft for his wife (back when she was in her child-bearing stage) or his daughter now.

My doctor also said that Zoloft has been shown to not cross over into breastmilk at all. There were a couple hypotheses for why Zoloft doesn’t cross over, including my body filtering out the medication before it gets into my breastmilk or the molecule being too big to get into breastmilk (don’t quote me on this). Bottom line, recent research has shown that Zoloft does not get into breastmilk.

After nearly three weeks of experimenting with asthma, allergy, and sleep meds with no success, I started to realize, with the help of my amazing MFM team, that these middle-of-the-night physical symptoms were actually triggered by anxiety. What I needed was a medication to help control my anxiety. To someone on the outside looking in, especially retrospectively, this might seem like a no-brainer. But to me, living it and feeling the symptoms night-after-night for weeks, this was mind boggling to me. I assumed the physical symptoms caused the anxiety, but the anxiety actually caused the physical symptoms.

Initially, it was hard to realize that anxiety was causing the physical symptoms and not the other way around. We live in a culture that underestimates (and undervalues) the power of the mind and mental health on our physical body. Even more, what I’ve realized is that anxiety is “physical.” It impacts the neurochemistry of my brain, and that is absolutely physical. No different than asthma’s impact on my lungs.

I started to sleep better after only two days on Zoloft, whether due to placebo effect or the small changes in my neurochemistry that two doses of Zoloft offered. My NP told me it would take 1-2 weeks for Zoloft to really start helping. By day 10 of Zoloft, I was back to sleeping about 7 hours/night! Ever since then, I’ve been sleeping well. My panic attacks have disappeared. I still have anxiety, but it feels like my normal anxiety level - what you’d consider an appropriate amount of anxiety to be in your third trimester of a high risk pregnancy or on the brink of parenthood for the first time ever!

Speaking of being on the brink of parenthood, Cory and I had our 36 week appointment with my MFM a couple days ago, and we have some updates about baby’s position, my blood pressure (a temporary preeclampsia scare), and C-section scheduling. I’ll write more about this in an upcoming blog post!

And now some questions for you!

  • How do you manage anxiety?

  • Have you ever had a panic attack?

  • Would you ever be willing to share your mental health story as a guest writer? “Anything that's human is mentionable, and anything that is mentionable can be more manageable. When we can talk about our feelings, they become less overwhelming, less upsetting, and less scary. The people we trust with that important talk can help us know that we are not alone.” -Fred Rogers

The climax of my insomnia and panic attacks were at 30 and 31 weeks. You can see it in my poor eyes. I look exhausted.

The climax of my insomnia and panic attacks were at 30 and 31 weeks. You can see it in my poor eyes. I look exhausted.

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