Although I lived with a bipolar diagnosis years before my own crisis with mania and depression during pregnancy, I was intrigued by both the familiarity and foreignness of postpartum bipolar.* As I began to do more research, I stumbled across Dyane Harwood’s memoir Birth of a New Brain: Healing from Postpartum Bipolar Disorder (2017). The title was the first thing that grabbed me. While my first hospitalization for mania and psychosis took place when I was 18, I could resonate with the concept of my brain being reborn. To me, the tree on the cover of Harwood’s book symbolizes this new brain. Like branches of a tree struck by lightning, neural networks are altered at the most fundamental level during the defining moment of rupture in the bipolar brain. That first manic episode and subsequent battles with extreme highs and lows impact the way we think, feel, and move through the world. The behavior changes and personality quirks associated with mercurial moods create a crisis of identity that can take several years to reconcile.
Associated with the birth of a new mother,** mommy brain is a real thing. In Birth of a New Brain, Harwood quotes Harvard-trained psychiatrist Dr. Shimi Kang and author of The Dolphin Parent who states,
“Human neuroscience has shown that a mother’s brain changes dramatically during her first pregnancy… One can say that a new mother has a different brain than before delivering her child.”Dr. Shimi Kang
Adding the birth of a bipolar brain on top of that can create a high level of neurodivergence, or as Harwood put it, “Since my brain was affected by pregnancy and bipolar disorder, my gray matter must be very different!” (p. 207).
Bipolar: One of Many Perinatal Mental Illness
One of the most powerful aspects of Birth of a New Brain is how vividly it paints a picture of one of the various manifestations of mental illness around the time of childbirth. Contrary to the Amazon blurb which describes postpartum bipolar disorder as “an unusual type of bipolar disorder and postpartum mood and anxiety disorder,” Harwood lays down the facts that bipolar is one six primary perinatal mood and anxiety disorders birthing people encounter between pregnancy and postpartum. While perinatal bipolar may be rare with “postpartum mania [a key symptom of bipolar] occurr[ing] in approximately one or two births in a thousand,” it certainly is not unusual. Harwood cites Dr. Alain Gregoire, perinatal psychiatrist and founder of Maternal Mental Health Alliance in the UK demonstrating that, in fact, 50% of women with bipolar disorder are first diagnosed in the postpartum period.
“The postpartum period carries the highest risk of developing bipolar disorder in the human lifetime.”Dr. Alain Gregoire
The causes of perinatal bipolar are unknown although sleep deprivation, genetic predisposition, and fluctuations in hormones are what Dr. Gregoire calls the “Trifecta from Hell.” (Harwood, 2017 p. 10). Additionally, 50-70% of women with a pre-existing bipolar diagnosis experience a recurrence of symptoms during the postpartum period. There is also a high risk of relapse during pregnancy, especially if bipolar medications are discontinued. Compared to the general population, women are also 100 times more likely to experience postpartum psychosis if they have had a previous psychotic episode.
Birth of a New Brain shows that it is important to make a distinction between postpartum bipolar and postpartum psychosis. Some women with no history of mental illness may experience a discrete episode of postpartum psychosis unaccompanied by symptoms of mania or depression indicative of bipolar. This is simply because anyone can become psychotic after long periods of stress without sleep. The physical strain and exhaustion of pregnancy and childbirth puts the body-mind in a vulnerable position and 24/7 newborn care and feeding around the clock is often blow that makes the bow break. Psychosis does not go hand-in-hand with all presentations of bipolar either. And then in some case, like mine, a person may have a diagnosis of “bipolar with psychotic features” creating the opportunity for future episodes of depression and mania with possibility for psychotic features accompanying each.
The misdiagnosis of perinatal bipolar can have damaging consequences. While this was not Harwood’s experience, it is important to note that diagnosing a new mom with bipolar after experiencing one episode of psychosis can be quite damning. Bipolar is a costly lifelong illness often requiring daily medication and regular appointments with a therapist and psychiatrist. Despite how far we have come with mental health awareness, there is still stigma attached to bipolar disorder. So, this diagnosis can needlessly disrupt a person’s life if it is not the right one. Skilled and patient doctors are needed to decipher whether postpartum psychosis is a singular event or if indeed there are symptoms of bipolar present.
Harwood has her own experience with misdiagnosis which is fairly common. She explains how she had symptoms of bipolar prior to her pregnancy which were mistaken for depression. It is estimated that 1 in 5 women develop postpartum depression (PPD) and 1 in 10 may be misdiagnosed with depression if clinicians do not identify manic or hypomanic symptoms. This can be especially harmful when someone with bipolar is given antidepressants because of the increased likelihood of triggering mania when they are not prescribed along with mood stabilizers and/or anti-psychotics. The delay in an accurate diagnosis prevents early intervention to reduce the severity of future episodes and have all the right resources prepared to enter the vulnerable period of pregnancy and postpartum.
Motherhood & Mental Illness
Integrating new motherhood is challenging enough, simultaneously integrating a whole new identity as person with a mental illness is often too much to process at once.
To make matters worse, Harwood demonstrates how hard it is to get care as a manic new mom because no one suspects mental illness when a mother has high energy levels. Hypomania can lead to a lot of productive activity — cleaning, cooking, and writing. Harwood even mentions how she breastfed her first baby during “all hours of the day and night” (p. 107). Knowing how hard breastfeeding can be, people must have thought she was nailing motherhood.
Postpartum hypomania is a misleading condition. A new mother’s happy mood doesn’t raise red flags. I wasn’t psychotic nor was I depressed. None of my maternity center nurses and obstetricians detected my hypomania.Dyane Harwood, Birth of A New Brain (2017 p. 11)
On the flip side, Harwood also writes about her challenges with breastfeeding, bonding with her baby, and being present with her husband and toddler after her second pregnancy. Her distractibility and debilitating symptoms, including hypergraphia (the uncontrollable urge to write), made it difficult to care for herself, let alone other people. This also put a strain on her marriage.
Although her behavior frustrated her husband, “[he didn’t regard] her behavior as extreme enough for psychiatric attention” (p. 107). Sadly when people cannot tell that something is wrong, they cannot intervene early when we still have some self-awareness to realize the problem and course correct. Usually by the time people realize that things are not ok, the situation has escalated to the point where we cannot fully cooperate in seeking or receiving help. This often results in the introduction of carceral care — police being called, physical and/or chemical restraints, being forced into an involuntary hospital stay, and temporary separation from our children with the threat of permanent loss of custody.
Unfortunately, Harwood was not exempt from this kind of treatment. She had the heart-wrenching experience of having to leave her newborn to participate in medical treatment after her husband called the police for a “wellness check” because there were no other alternatives to Harwood receiving urgent mental health care. However, the institutionalization Harwood endures is counter-productive, given that being separated from one’s newborn is not conducive to healing. Mothers feel guilty alone in psych wards not being able to breastfeed and bond with their babies. This form of treatment is often punitive considering both the direct and indirect messages patients receive about being an unfit parent. Child Protective Services are only one report away, all it takes is a proactive and prejudiced psychiatric staff member to start the process.
I am grateful to Harwood for her labor writing Birth of a New Brain. In addition to her lived experience, the book is well-researched, providing evidence-based information about postpartum bipolar disorder and provides an abundance of resources throughout and even more in the appendices. This stigma towards mothers experiencing mental illness is the very reason why more mothers do not seek support when they first start experiencing symptoms. I am sure Harwood’s book is helping to change that.
As a bipolar native who is unfamiliar with the postpartum onset experience, I now have a greater appreciation for the range of perinatal experiences with bipolar disorder. My main frustration has always been the way conversations about mental health and reproduction exist in siloes. Often mental illness is not central in discussions about pregnancy and parenthood. In turn, there is little discussion of support around childbirth and family building in the psychiatric survivor/consumer/mad liberation/peer mental health movement. Thankfully Birth of a New Brain brings those two worlds together.
*For more on the language distinctions between perinatal and postpartum visit the post Language Matters: Perinatal vs Postpartum.
**This post discusses perinatal mental illness, perinatal meaning the period between pregnancy and postpartum. Given that not all people who give birth and experience perinatal mental illness do not identify as women, “women” and “mothers” is used interchangeably with “birthing people” and “parents.” While mental health statistics focus on women, they may not accurately represent and incorporate birthing people of all gender identities.
Image Credit: Original photograph by Keana Parke, graphic design by Nadia Mbonde
Image Description: A photograph of Dyane Harwood, a smiling white brunette woman wearing a pink dress, standing in the sun holding a copy of her book Birth of a New Brain: Healing from Postpartum Bipolar Disorder. Her image is framed by a pastel olive green circle against the backdrop of vibrant leafy green branches basking in the sun.