So Glad You Asked with Dr. Ruta Nonacs and Allie Hales

RESOURCE HUB – POSTPARTUM ANXIETY

Listen to Our Podcast

We hope you enjoyed the So Glad You Asked podcast episode on postpartum anxiety featuring Dr. Nicole Pensak.  This is a great discussion about anxiety in the early postpartum period, focusing on how mom’s brains change after the birth of a child.  If you haven’t listened yet, you can find the podcast on Spotify, Apple, or wherever you get your podcasts.

But there’s more…

To supplement the information provided on the podcast, we have created a comprehensive, evidence-based curated set of resources for you to explore.  The resource hub provides up-to-date, clinically relevant information and resources for patients, families, and healthcare providers.

Learn More About Postpartum Anxiety

A curated collection of articles and other resources to help you better understand what you’re experiencing — and what can help

What is postpartum anxiety?

Postpartum anxiety is a condition in which worry, fear, and physical symptoms of anxiety become persistent and interfere with a person’s ability to function after having a baby.  Unlike typical new-parent worry, postpartum anxiety feels constant, excessive, and hard to turn off, and often comes with symptoms like feeling tense, trouble sleeping, or panic attacks.

How common is postpartum anxiety?

Recent research suggests that about 1 in 5 women experience a diagnosable anxiety disorder during pregnancy or the postpartum period.womensmentalhealth+2
Some studies indicate that clinically significant anxiety symptoms are as common, or even more common, than postpartum depression.

How is postpartum anxiety different from “normal” worry or the baby blues?

Normal postpartum worry is usually intermittent, tied to specific situations, and improves as confidence grows.  Postpartum anxiety is more intense, more persistent, often causing intrusive thoughts, trouble relaxing, and avoidance of certain activities or places.

How is postpartum anxiety different from postpartum depression?

Both conditions can involve low mood, irritability, sleep problems, and difficulty concentrating, so they often overlap.  While postpartum anxiety is dominated by excessive worry and physical symptoms of anxiety and postpartum depression is more associated with sadness, loss of interest, and feelings of guilt or worthlessness, postpartum depression and anxiety often occur together.

What are typical symptoms of postpartum anxiety?

People with PPA often describe feeling “on edge” all the time, with intense worry, difficulty relaxing, trouble sleeping, and a constant sense of dread. Distressing, intrusive or “worst-case scenario” thoughts about harm coming to the baby are common.  Physical symptoms include loss of appetite, stomach upset, headache and heart palpitations.

What about scary or intrusive thoughts of harm coming to the baby?

Intrusive, unwanted images or thoughts of accidental or intentional harm coming to the baby are common in postpartum anxiety and OCD. These thoughts are ego-dystonic (they feel upsetting and “not me”), and the presence of these thoughts alone does not mean a parent will act on them; however, they are very distressing and are an important reason to seek help.

When does postpartum anxiety usually start, and how long can it last?

Symptoms can begin during pregnancy or any time in the first year after delivery.  Without treatment, symptoms may persist for months or longer, but with appropriate care, most people experience significant improvement.

What is postpartum OCD, and how is it related to postpartum anxiety?

Postpartum OCD involves intrusive, unwanted thoughts or images (obsessions) and repetitive behaviors or mental rituals (compulsions) aimed at reducing anxiety, often centered on the baby’s safety.  Postpartum OCD is considered an anxiety disorder, and it is commonly treated with CBT that includes exposure and response prevention, often in combination with SSRIs.

Who is at higher risk for postpartum anxiety?

Risk is higher in people with a history of anxiety or depression, previous postpartum mood or anxiety disorders, or a family history of these conditions.  Other contributors include traumatic birth, medical complications in the parent or baby, high levels of stress, lack of support, and sleep deprivation.

Can postpartum anxiety happen without depression?

Yes. Postpartum anxiety can occur on its own, without meeting criteria for postpartum depression.  That said, postpartum depression and anxiety frequently occur together. 

How does sleep affect postpartum anxiety?

Sleep deprivation both worsens anxiety and makes it harder to cope with intrusive thoughts and worries.
Anxiety can also interfere with falling or staying asleep, creating a self?reinforcing cycle of poor sleep and heightened anxiety.

How is postpartum anxiety treated?

Effective treatments include evidence?based psychotherapy (especially cognitive?behavioral therapy) and, when indicated, medication such as SSRIs or SNRIs.  Treatment plans are individualized based on symptom severity, co?occurring depression or OCD, medical history, and whether the parent is pregnant or breastfeeding.

Which medications are commonly used, and are they safe in breastfeeding?

SSRIs (such as sertraline and citalopram) are among the best?studied and most commonly used medications for postpartum depression and anxiety.  Information on the use of SSRIs and SNRIs while breastfeeding is reassuring, and the risk of adverse events in the nursing infant is very low. 

What non?medication strategies can help?

Non?pharmacologic approaches include: cognitive?behavioral therapy, psychoeducation, support groups, mindfulness or relaxation strategies, and structured sleep and rest plans.

When should someone seek urgent or emergency help?

Urgent or emergency evaluation is needed if someone has thoughts of harming themselves or their baby, feels they might act on intrusive thoughts, is unable to care for themselves or their baby, or has symptoms that suggest postpartum psychosis (such as hallucinations, delusions, or severe confusion).  These situations are uncommon but serious, and immediate assessment through emergency services, an on?call clinician, or crisis line is essential.

Postpartum anxiety can show up in your thoughts, emotions, body, and behavior. It can look a little different for everyone, but here are some common signs:

Thoughts

  • “What if something terrible happens to my baby?”
  • “What if I miss a sign that she’s sick?”
  • “I’m not cut out for this – I’m a bad mom.”
  • “If I relax, something will go wrong.”

Your mind may feel like it’s always racing, jumping from one worry to the next.

Emotions

  • A constant feeling of worry, nervousness or dread
  • Feeling tense, on edge, or unable to relax
  • Irritability or anger (often toward yourself or loved ones)
  • Guilt or shame about not enjoying motherhood the way you thought you would

Physical Symptoms

  • Trouble  falling or staying asleep – even when the baby is asleep
  • Racing heart, sweating, shaking, or shortness of breath
  • Upset stomach, nausea, loss of appetite, or rapid postpartum weight loss
  • Muscle tension, headaches, or feeling restless and unable to sit still

Behavior

  • Repeatedly checking on your baby (breathing, temperature, monitor)
  • Feeling uncomfortable being alone with the baby or feeling anxious about leaving the baby with others
  • Constantly seeking reassurance from your partner, family, doctors, or online groups
  • Over?researching every decision (feeding, sleep, baby behavior, products) – and still feeling unsure or stuck 

Beyond the Worry: 7 Lesser-Known Signs of Postpartum Anxiety — Explores the less recognized ways postpartum anxiety can present, including rage, insomnia, intrusive thoughts, compulsive checking behaviors, and emotional rigidity. (Postpartum Support International (PSI))

Why Do I Feel So Angry? The Hidden Side of Postpartum Anxiety — Discusses postpartum rage as an overlooked symptom of postpartum anxiety and depression, examining how sleep deprivation, hormonal changes, and stress can contribute to intense anger and irritability after childbirth. (healthline.com)

During pregnancy and the postpartum period, anxiety may take many different forms.  Especially during the postpartum period, depression is often accompanied by anxiety symptoms.  Many women with anxiety may simultaneously experience symptoms of several different types of anxiety disorder (e.g. GAD and OCD).

Generalized Anxiety Disorder (GAD)

This is the most common type of anxiety disorder during the pregnancy and postpartum period.  Individuals  with GAD describe feeling  worried or “on edge” most days and unable to relax.  Often the anxiety is focused on the pregnancy or health of the baby; however, many different things can trigger anxiety, including work, money, or family. The anxiety is difficult to turn off and makes it more difficult to enjoy oneself.  GAD is often accompanied with physical symptoms like trouble sleeping, decreased appetite, muscle tension, or feeling restless.

Panic Disorder

Panic disorder involves sudden “rushes” of intense fear or discomfort, called panic attacks. During an attack, people may experience heart racing, shortness of breath, dizziness, or fear that they are losing control or dying, even when there is no real danger.

Agoraphobia

Agoraphobia is a fear of being in places where it might feel hard to escape or get help if anxiety or panic symptoms emerge. People may avoid crowded stores or public transportation.  During the postpartum period, agoraphobia is most commonly seen as a fear of  leaving home alone because this feels unsafe.

Obsessive-Compulsive Disorder (OCD)

OCD includes unwanted, intrusive thoughts or images (obsessions) that create anxiety, and repetitive behaviors or mental rituals (compulsions) performed to reduce the anxiety. Examples include repeated checking, asking for reassurance, cleaning, or counting, even when the person knows it doesn’t fully make sense. During the postpartum period, many mothers experience intrusive thoughts about harm coming to the baby; these thoughts can be so intense that some will avoid being alone with their baby. 

Social Anxiety Disorder

Social anxiety disorder is a strong fear of being embarrassed, judged, or rejected in social or performance situations. Everyday activities—like talking to other parents at a playgroup, eating in public, or speaking in a meeting—can feel overwhelming.

Specific Phobias

Specific phobias are intense fears of particular objects or situations, such as driving over bridges, flying, needles, or certain animals. The fear is much stronger than the actual danger and can lead people to go out of their way to avoid the trigger.

Posttraumatic Stress Disorder (PTSD)

PTSD can develop after a person experiences or witnesses a very frightening or life?threatening event. People may have upsetting memories or dreams, feel “on guard” much of the time, and avoid people, places, or situations that remind them of what happened.

More information on Anxiety Disorders

What are Anxiety Disorders? (American Psychiatric Association)

Anxiety Disorders (National Institutes of Mental Health)

Anxiety Disorders (Association for Behavioral and Cognitive Therapies)

Types of Anxiety Disorders (Psychiatry Advisor)

First of all, everybody has intrusive thoughts. These are normal: unwanted thoughts or images that just pop into your head.  

  • You are waiting to cross a busy street, and you see a bus heading for the intersection. As you set foot into the crosswalk, an image flashes before you – the bus running the light and crashing into you.
  • You are carrying the baby down a long set of stairs, and you ask yourself, what would happen if I tipped?

These are obviously distressing thoughts.  Most of the time, they float out of your brain, and you are able to go about your daily life.  

Although these intrusive thoughts are a common experience, the postpartum period is a time when new mothers are particularly vulnerable to intrusive thoughts and, because these thoughts typically focus on some type of harm coming to the infant, they are particularly frightening.

Here are some facts that might surprise you: 

  • Between 70 and 100% of new mothers report having intrusive thoughts of infant-related harm
  • As many as half of all new mothers report intrusive thoughts of harming their infant on purpose

It can be particular to let go of these intrusive thoughts.  Experts believe that when individuals are pregnant or caring for a young child, the immense responsibility leads to a sense of heightened danger, and those thoughts that would have normally quickly exited your brain end up sticking.  Your brain is like Velcro, and sometimes, no matter what you do, these upsetting thoughts keep coming back.

Importantly, having intrusive thoughts does not mean that you are a bad parent or that you want to harm your child; in fact, these thoughts are typically experienced as frightening and deeply upsetting. Sometimes these thoughts are so distressing that they can affect your behavior.  For example, you may not trust yourself and may avoid being alone with your baby.  You may be afraid to leave the house for fear of something happening to your baby.

If you notice that intrusive thoughts are affecting the way you live and your ability to enjoy yourself, consider sharing these thoughts with someone you trust: your partner, a friend, or your doctor.  Similarly, if intrusive thoughts are making it more difficult to sleep or eat, talk to someone.

Postpartum obsessive-compulsive disorder (OCD) is a type of perinatal anxiety disorder characterized by intrusive, unwanted thoughts and compulsive behaviors that emerge during pregnancy or after the birth of a child. These intrusive thoughts are often disturbing and may involve fears of accidental or intentional harm coming to the baby. Mothers with postpartum OCD are typically horrified by these thoughts and go to great lengths to prevent harm, engaging in behaviors such as excessive checking, reassurance seeking, cleaning, avoiding certain activities, or mentally reviewing situations repeatedly. Despite how frightening these thoughts may feel, they are ego-dystonic, meaning they are inconsistent with the mother’s values and desires. Women experiencing postpartum OCD are not more likely to harm their babies; in fact, they are often highly vigilant and protective caregivers.

Unfortunately, postpartum OCD is frequently misunderstood, even among healthcare providers, leading many women to suffer in silence out of fear, shame, or concern that they will be judged as dangerous or unfit parents. Intrusive thoughts are actually common during the postpartum period, but in postpartum OCD these thoughts become persistent, distressing, and difficult to dismiss. Misconceptions about postpartum OCD can delay diagnosis and treatment, particularly when symptoms are confused with postpartum psychosis, a very different and far less common condition. With appropriate treatment — including cognitive behavioral therapy, particularly exposure and response prevention (ERP), and sometimes medication — postpartum OCD is highly treatable, and many women experience substantial improvement in symptoms.

Understanding the Signs of Postpartum OCD — Explains how postpartum OCD can cause distressing intrusive thoughts, compulsive checking behaviors, and avoidance rituals, while emphasizing that these thoughts are ego-dystonic and do not mean a mother wants to harm her baby.

Everything You Need to Know About Postpartum OCD — Reviews the symptoms, triggers, and treatment of postpartum OCD, including intrusive fears related to infant safety, excessive checking, and the distinction between postpartum OCD and postpartum psychosis.

Living a Horror Movie: Navigating Misconceptions About Postpartum OCD

5 Misconceptions About Perinatal and Postpartum OCD

Postpartum anxiety is highly treatable, and you do not have to “tough it out” or wait for it to pass on its own. Many women improve with talk therapy alone, and others need a combination of therapy and medication, especially if symptoms are severe, getting worse, or interfering with sleep, bonding, or daily functioning.

Lifestyle changes are especially important – like getting more help at home and more consistent sleep – can be particularly helpful but are not a substitute for care when anxiety is really taking over.harvard+3

Cognitive behavioral therapy or CBT is one of the most effective therapies for postpartum anxiety, including postpartum OCD. In CBT, you work with a therapist to identify the connections between your thoughts (“If I fall asleep, something terrible will happen to the baby”), feelings (surges of fear, guilt), and behaviors (staying up all night checking, avoiding going out). Together you practice:

  • Challenging anxious thoughts and replacing them with more balanced ones.
  • Gradually facing fears (for example, stretching the time between “checks” on the baby) in a safe, supported way.
  • Learning concrete coping tools such as breathing, grounding, and problem-solving skills you can use at 3 a.m. when worry spikes.

Exposure and Response Prevention or ERP is a specific type of CBT used to treat OCD. It helps people gradually face feared thoughts, feelings, or situations while learning to resist the urges or rituals that OCD creates.

Medication can also play an important role for many parents with postpartum anxiety, particularly when symptoms are moderate to severe or not improving with therapy alone. The most commonly used medicines are antidepressants called SSRIs (such as sertraline, fluoxetine, citalopram, or paroxetine), which are well studied for anxiety disorders and are compatible with breastfeeding, as only low levels reach the baby through milk. Sometimes other medications are used short term—such as benzodiazepines for acute, intense anxiety or panic, or beta blockers for the physical symptoms of anxiety—while an SSRI is starting to work. Your clinician will weigh your symptoms, past treatment response, pregnancy or breastfeeding status, and your preferences to create a plan that feels as safe and individualized as possible for you and your baby.

Many obstetric providers screen for postpartum depression using the EPDS, but anxiety can look different and may not always be picked up unless we look for it specifically.

Screening tools are short questionnaires that can help you better understand what you’re feeling. They don’t give a diagnosis, but they can help flag when it might be time to check in with a clinician. A few commonly used tools include:

Each tool has strengths and limitations. For example, the GAD-7 tends to do a better job identifying anxiety, while the PASS looks more closely at how anxiety shows up specifically during pregnancy and postpartum. It’s also important to know that most of these tools don’t pick up postpartum PTSD, which can occur after a difficult or traumatic birth.

If you take one of these screenings and your score is high, it’s not a diagnosis—it’s a signal to look more closely. You don’t have to figure this out on your own. Consider sharing how you’re feeling (or your results) with someone you trust, and reach out to your obstetric provider, primary care clinician, or a mental health professional. You can also find support through Postpartum Support International (http://postpartum.net). Postpartum anxiety is common and very treatable, with options like therapy (including CBT) and, when needed, medication that can be safely used during pregnancy or breastfeeding.

The Perinatal Anxiety Toolkit (University of North Carolina) – An excellent fact sheet providing information on postpartum anxiety, including symptoms and detailed information on treatment.

Perinatal Mental Health Conditions (Postpartum Support International) This article reviews Perinatal Mental Health (PMH) conditions, including prevalence, symptoms, risk factors, and potential treatment options.  

Postpartum anxiety is invisible, but common and treatable – Harvard Health Publishing

Maternal anxiety: To what extent is it normal? Postpartum Support International

Where to Turn for Support and Professional Care

 Learn how to find trusted and reliable professional care and community support

 

Urgent or emergency evaluation is needed if someone has thoughts of harming themselves or their baby, feels they might act on intrusive thoughts, is unable to care for themselves or their baby, or has symptoms that suggest postpartum psychosis (such as hallucinations, delusions, or severe confusion).  These situations are uncommon but serious, and immediate assessment through emergency services, an on?call clinician, or crisis line is essential.

  • Call 911 if you are in an immediate crisis, e.g., in imminent danger of harm to self, others, or have overdosed.
  • 988 is the Suicide and Crisis Lifeline. 
  • The National Maternal Mental Health Hotline 1-833-TLC-MAMA (1-833-852-6262 can be used for non-crisis specialized perinatal mental health support and resources. The National Maternal Mental Health Hotline is available 24/7, in English and Spanish, and 60 other languages by request.
  • The Postpartum Support International Helpline 800-944-4773 is a warmline that connects callers with support volunteers and PSI resources

This is a good place to start when you are looking for help because you already have a relationship with that provider and your OB is likely to be connected to providers and other resources in your community.  The obstetric service may have mental health professionals who provide services in their office.  The hospital may also offer support groups for expecting and new moms. Some OBs are also comfortable prescribing medications for perinatal mood and anxiety disorders.

Psychotherapy can be provided by licensed mental health professionals, including psychologists, licensed clinical social workers (LCSWs), licensed professional counselors (LPCs), and psychiatrists who specialize in therapy. It is important to look for professionals with experience in perinatal mental health to ensure specialized care.  In some cases, OBs may also prescribe medications for perinatal mood and anxiety disorders.  Some of these providers may have a Perinatal Mental Health Certificate (PMH-C); however, there are many excellent providers who have experience in the treatment of perinatal mental health issues who do not have this certification.

  • Postpartum Support International maintains an online directory of qualified perinatal mental health professionals in the US, Canada, and Australia.
  • Psychology Today also maintains a list of mental health providers available for in-person or telehealth visits.

Psychiatrists, nurse practitioners, and physician assistants have the authority to prescribe medication; their prescribing rights vary by state.  Some of these providers may have a Perinatal Mental Health Certificate (PMH-C); however, there are many excellent providers who have experience in the treatment of perinatal mental health issues who do not have this certification

  • Postpartum Support International maintains an online directory of qualified perinatal mental health professionals in the US, Canada, and Australia.
  • Psychology Today also maintains a list of mental health providers available for in-person or telehealth visits.

Support may come from many different places, including family, friends, neighbors, other moms, and your community.  Support groups, whether in-person or virtual can be immensely helpful in decreasing the isolation many moms feel and can help moms learn about other resources and to connect with their community.  There are also specialized groups that support women with specific backgrounds or needs.

  • Postpartum Support International offers over 50+ FREE and virtual support groups led by trained peer facilitators.  Many of these groups cater to specific populations, for example military moms or individuals with fertility challenges
  • Your local hospital may also offer support groups
  • Postpartum Support International volunteer coordinators can help  you find support resources in your community
  • Postpartum Support International also offers a Peer Mentor Program that pairs individuals in need of support with a trained volunteer who has also experienced and has recovered from a perinatal mood or anxiety disorder

Listen to Our Podcast

So Glad You Asked features discussions and interviews with experts and real moms

Real Stories & Perspectives

Personal stories and insights from other mothers

 

Hearing personal stories from other mothers who have lived through perinatal mood and anxiety disorders can be incredibly validating and grounding. When you’re in the thick of it, it’s common to feel isolated, ashamed, or convinced you’re the only one struggling, and that sense of being “the only one” can make it harder to reach out for help. Honest first-person stories can reduce that isolation, put words to symptoms that are hard to describe, and show that treatment and recovery are possible. 

At the same time, these narratives can include descriptions of distressing thoughts and difficult experiences; the following stories may contain details that some readers find upsetting, so please read at your own pace.

This is by no means a comprehensive list of personal stories.  You can find other personal essays on the Postpartum Support International website and at Amplifying: Survivors Speak Out (Mass PPD Fund)

Stories of Hope: Overcoming Postpartum Anxiety, Depression, and OCD (PSI Survivor Stories)

Danielle discusses how what began as a joyful, deeply wanted pregnancy gradually shifted after birth into postpartum anxiety, depression, and OCD that left her feeling empty, overwhelmed, and unlike herself.

A Labor & Delivery Nurse Shares Her Postpartum Anxiety Story (Happiest Baby)

Many women don’t know about postpartum anxiety; it’s important for all expecting mothers to learn about mental health challenges that can arise during pregnancy and after birth.

A Mother’s Story: Postpartum Anxiety and Suicidal Thoughts and the Need to Do More Than Screen (Policy Center for Maternal Mental Health)

After a complicated pregnancy and delivery, Emily discusses her experience with postpartum anxiety , intrusive thoughts, and suicidal ideation.  Her story highlights how difficult it can be to access treatment.

Coming Soon

This is by no means a comprehensive list; if you would like to share a book that has been helpful to you, please send us a note at podcast@womensmentalhealth.org.

Rattled, How to Calm New Mom Anxiety with the Power of the Postpartum Brain

Dr. Nicole Pensak shares her own experiences and those of her patients to help new mothers feel informed, validated, and guided through the transitions women undergo after the birth of a child

Expert Insights

For you and your providers, evidence-based perspectives and expert opinions to deepen your understanding and inform your care

Practical Strategies

Tips, tools, and advice for navigating everyday challenges

 

There are many simple tips and tools that can support your mental health, but they are not a substitute for professional care. Self-help strategies—like brief grounding or breathing exercises, gentle movement, limiting late-night “doom scrolling,” and setting small, realistic goals for the day—can help dial down anxiety in the moment and make symptoms feel a bit more manageable. Keeping a short mood and sleep log, identifying one support person you can text or call, and building in quick opportunities for recovery — taking a shower, having a snack, or spending a few minutes outside — can also complement therapy or medication. These tools work best as part of a bigger plan you create together with your clinician, so if anxiety is getting in the way of sleep, bonding, or day-to-day functioning, reaching out for evaluation and treatment is still essential.

Urgent or emergency evaluation is needed if someone has thoughts of harming themselves or their baby, feels they might act on intrusive thoughts, is unable to care for themselves or their baby, or has symptoms that suggest postpartum psychosis (such as hallucinations, delusions, or severe confusion).  These situations are uncommon but serious, and immediate assessment through emergency services, an on?call clinician, or crisis line is essential.

  • Call 911 if you are in an immediate crisis, e.g., in imminent danger of harm to self, others, or have overdosed.
  • 988 is the Suicide and Crisis Lifeline. 
  • The National Maternal Mental Health Hotline 1-833-TLC-MAMA (1-833-852-6262): For non-crisis specialized perinatal mental health support and resources. The National Maternal Mental Health Hotline is available 24/7, in English and Spanish, and 60 other languages by request.
  • The Postpartum Support International Helpline 800-944-4773 is a warmline that connects callers with support volunteers and PSI resources

The Cleveland Clinic has an excellent collection of articles on mindfulness and relaxation strategies that can help reduce anxiety symptoms.

13 Grounding Techniques for When You Feel Overwhelmed (Cleveland Clinic)

Body Scan Meditation for Beginners: How To Make the Mind/Body Connection (Cleveland Clinic)

Put Intention Behind Your Walking Meditation

How Guided Imagery Helps You Relax

Try Five-Finger Breathing for Deep Relaxation

Coming Soon

Coming Soon

Support may come from many different places, including family, friends, neighbors, other moms, and your community.  Support groups, whether in-person or virtual can be immensely helpful in decreasing the isolation many moms feel and can help moms learn about other resources and to connect with their community.  There are also specialized groups that support women with specific backgrounds or needs.

  • Postpartum Support International offers over 50+ FREE and virtual support groups led by trained peer facilitators.  Many of these groups cater to specific populations, for example military moms or individuals with fertility challenges
  • Your local hospital may also offer support groups
  • Postpartum Support International volunteer coordinators can help  you find support resources in your community
  • Postpartum Support International also offers a Peer Mentor Program that pairs individuals in need of support with a trained volunteer who has also experienced and has recovered from a perinatal mood or anxiety disorder