Postpartum obsessive compulsive disorder

Pregnancy and the postpartum period are associated with an increased risk of developing or worsening obsessive-compulsive disorder (OCD) symptoms.

In general, obsessive thoughts refer to the intense fear of accidentally or intentionally harming the baby, resulting in compulsive monitoring behaviors to ensure that the newborn is well, rituals such as compulsive prayers, or seeking reassurance about one’s own and the child’s condition. This feature allows OCD to be distinguished from forms of psychosis.

It has been found that those with postpartum OCD do not wish to harm their child in any way, but rather are frightened by their obsessions and the possible harm to the infant that could result. It has been shown that this subtype of OCD can also occur in fathers and their partners, albeit in a subclinical form.

Postpartum OCD may be underdiagnosed or misdiagnosed due to the lack of standardized screening and the potential stigma associated with reporting symptoms by pregnant women or new mothers. Without treatment, OCD symptoms often persist and continue to affect the mother’s quality of life and interactions with her baby.

Symptoms of postpartum OCD

Obsessions:

  • Fears and images of the baby dying in its sleep or suffocating and not being able to save it.
  • Fear of accidentally hurting the baby by falling from a height or causing illness.
  • Unwanted thoughts or impulses about hurting the baby, such as shaking, drowning, yelling, or stabbing.

Obsessions:

  • Repeatedly checking on the baby to make sure he or she is okay.
  • Repeatedly praying for the child’s health and well-being.
  • Hiding sharp objects.
  • Repeatedly going over daily activities to make sure you have not harmed the child.
  • Avoiding the child for fear of hurting the child.

Compared to other subtypes of OCD, the presence of obsessions is less common.

Causes of postpartum OCD

The scientific literature is currently rather limited. Epidemiologically, the prevalence of the disorder is estimated to be 2.9% prenatally and 7% postpartum, with a peak incidence around 8 weeks postpartum.

The postpartum onset of OCD has generally been described as the onset of symptoms within 12-26 weeks after delivery, but some women have a rapid onset (within days) after delivery.

The etiology of OCD during pregnancy and postpartum is unknown, although biological, psychological, and environmental hypotheses have been proposed.

Proposed risk factors include:

  • hormonal changes and immune dysregulation
  • pre-existing mood, anxiety, and personality disorders
  • gestational diabetes
  • dysfunctional beliefs about threat, responsibility, control, and uncertainty
  • pregnancy and postpartum stressors
  • general psychosocial stressors and lack of social support.

Little is known about the relationship between pregnancy characteristics, obstetric complications, and perinatal OCD. Several studies have reported an association with primiparity, obstetric complications, cesarean delivery, and younger maternal age at delivery.

Further research is needed to clarify the possible relationship between pregnancy/obstetric characteristics and the development of perinatal OCD.

Despite considerable efforts to elucidate the genetic basis of OCD, it remains unclear how genetic and environmental risk factors interact and converge at the molecular level, in the epigenetics of OCD.

Functional neuroimaging studies suggest the involvement of the prefrontal cortex – thalamus – striatum (neural circuits responsible for decision making, response inhibition, and error detection), as well as the contextual influence of perinatal trauma (such as maternal hypertension and prepartum hemorrhage).

However, additional neural circuits are thought to be involved.

Diagnosis and treatment of postpartum OCD

The level of insight (awareness of the disorder) appears to be quite low. Because the obsessions are not perceived as intrusive and the compulsions are seen as useful strategies to protect the infant/newborn, spontaneous access to clinical treatment is more difficult.

Currently, there are no common clinical tools specific to this syndrome. The Yale-Brown Obsessive-Compulsive Scale and the Perinatal Obsessive-Compulsive Scale are the most widely used self-report scales.

Comorbidities are most common with

Treatment of postpartum OCD

In general, treatment of postpartum OCD can be done on an outpatient basis; inpatient treatment may be indicated for women who are at risk for suicide, who are unable to provide adequate self-care, or who have a comorbid psychiatric disorder.

Among the many cognitive-behavioral therapies currently used to treat OCD, the most widely used is Response Prevention Exposure (ERP), which involves

  • systematic comparison of anxiety-provoking situations and their activating stimuli
  • suspending compulsive rituals that are functional to the immediate reduction of anxiety/discomfort.

Through imaginative visualization sessions or in a concrete setting (the patient’s living/working environment), the progressive presentation of stress-inducing stimuli that the subject gradually learns to tolerate.

Psychoeducational intervention with the family is also useful in order to reduce the negative experiences of daily life, which are often responsible for the exacerbation of the disorder.

Given the remarkable link between the specific disorder and the wandering mind (the mind that wanders between thoughts), the practice of mindfulness proves crucial in breaking the cycle between intrusive thoughts and the reinforcement of compulsions.

Therefore, it is critical that therapy be tailored to the patient’s individual characteristics and life context.

The pharmacological approach uses selective serotonin reuptake inhibitors (SSRIs), although monoamine oxidase inhibitors and neuroleptics may also be used.

Postpartum OCD – Unwanted thoughts about accidents

Another common symptom of postpartum OCD is recurrent intrusive worry that something bad will happen to the baby.

For example, a parent may have recurring thoughts or intrusive images of the baby suffocating or choking in the crib and think, “It is my responsibility to prevent any harm from happening to my child. If I have such a thought, it is important that I check every time to make sure my child is okay. That is what a good parent should do. If I fear such things and don’t check, something bad will happen and my child’s death will be my fault.

In response to these thoughts, it is possible for the parent to perform numerous checks to make sure the child is okay.

This can happen several hundred times a day. Each time a new doubt creeps in, the parent feels compelled to check again, just to be sure.

Postpartum OCD – Unwanted sexual thoughts

A third very common symptom of postpartum OCD is unwanted sexual thoughts about the baby.

These usually occur during diapering or bathing and may consist of thoughts (e.g., “What would happen if I touched my baby inappropriately? What if it aroused me?”), sexual images involving the baby, or impulses to act in a sexually inappropriate way.

For example, a father with these kinds of obsessions might think, “What kind of person has thoughts like this? Does this mean that I am a pedophile or that I might be able to molest my child? These are sick thoughts. I should not have such thoughts.

In response to such unwanted thoughts, the father may begin to avoid the child.

Avoidance may be particularly pronounced in situations where the child may be seen naked (e.g., changing diapers, bathing, dressing).

Parents with postpartum sexual obsessions often avoid physical contact with the baby (e.g., hugging the baby, holding the baby on their lap) or being alone with the baby.

Behavioral Characteristics

In the previous examples, a spontaneous and unexpected thought creates a fear that the parent is a threat to the child or may act in a way that endangers the child.

Parents with postpartum OCD have no desire or intention to harm the baby, but the appearance of an unwanted or threatening thought causes them to question their own intentions, morality, or fitness for parenthood.

Despite these fears, postpartum OCD is not associated with an increased risk of harm to children or infants.

As with all forms of OCD, it involves rituals and avoidance behaviors in response to obsessions, such as checking behaviors, washing behaviors, situational avoidance behaviors, and mental rituals.

These behaviors perpetuate the symptoms of the disorder because they prevent the disconfirmation of false beliefs related to the obsessions themselves.

Given the way postpartum OCD works, the more intensely the parent examines the unwanted thoughts, the more the parent exacerbates the disorder. The more the person tries to understand why these thoughts occur or to find ways to make them stop, the more the thought will recur.

Parents with severe postpartum OCD may have unwanted thoughts about their child almost constantly.

The symptoms can cause the parent to dread spending time with the child, which can affect bonding and destroy the parent-child relationship.

Because aggressive obsessions and sexual obsessions are in stark contrast to how new parents feel they “should” feel, the symptoms of OCD often cause a great deal of guilt, shame, and confusion.

Because of the nature of the symptoms, postpartum OCD often leads to extreme isolation, alienation, and depression, and is sometimes a trigger for parental separation or divorce.

Although many people are aware of the existence of postpartum depression, very few are familiar with postpartum OCD, but it affects about 2.6 percent of mothers.

The symptoms of this disorder can be so disturbing that few are able to articulate what they are experiencing. They fear the looks of horror and disgust from loved ones, the possibility that their children will be taken away from them, or that doctors will declare them “crazy” and hospitalize them.

The reality is that postpartum OCD, like other forms of OCD, is treatable. The first-line treatment is cognitive-behavioral therapy, which includes techniques designed specifically for this type of symptom.

Some characteristic fears of postpartum OCD

The most common symptoms of postpartum OCD include fears of accidentally or intentionally harming one’s child.

  • Fear of acting on an unwanted impulse and hurting or killing the baby.
  • Fear of stabbing your baby.
  • Fear of beating your baby to death.
  • Fear of suffocating your baby.
  • Fear of shaking your baby to death.
  • Fear of losing control and drowning the baby during bath time.
  • Fear of being sexually inappropriate with the baby while changing diapers, bathing, or dressing the baby.
  • Fear of secretly wanting to molest the child.
  • Fear of touching the baby inappropriately.
  • Fear of being sexually attracted to the baby.
  • Fear that one’s irresponsibility will lead to the child’s death.
  • Fear of accidentally poisoning the baby by not cleaning the bottle or toys properly.
  • Fear of accidentally exposing the baby to chemicals (e.g. cleaning products).
  • Fear that your baby will die suddenly (e.g., Sudden Infant Death Syndrome) if you do not supervise him or her.
  • Fear that your baby will suffocate or that your baby will suffocate because of your negligence.

References

  1. APA . Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; Washington, DC, USA. Text Revision (DSM-V-TR)
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  4. Fairbrother, N., Collardeau, F., Woody, S. R., Wolfe, D. A., & Fawcett, J. M. (2022). Postpartum Thoughts of Infant-Related Harm and Obsessive-Compulsive Disorder: Relation to Maternal Physical Aggression Toward the Infant. The Journal of clinical psychiatry83(2), 21m14006. https://doi.org/10.4088/JCP.21m14006
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  6. Mahjani, B., Bey, K., Boberg, J., , Burton, C. (2021). Genetics of obsessive-compulsive disorder. Psychological Medicine, 51(13), 2247-2259. doi:10.1017/S0033291721001744
  7. Ojalehto, Heidi , Abramowitz, Jonathan , Hellberg, Samantha , Buchholz, Jennifer , Twohig, Michael. (2020). Adherence to Exposure and Response Prevention as a Predictor of Improvement in Obsessive-Compulsive Symptom Dimensions. Journal of Anxiety Disorders. 72. 102210. 10.1016/j.janxdis.2020.102210.
  8. Paul, I., Saraf, G., Chandra, P. S., , Reddy, Y. (2020). Obsessive compulsive-disorder and reproductive life events. Asian Journal of Psychiatry, 52, 102124
  9. Walker, R., Blackie, M., & Nedeljkovic, M. (2021). Fathers’ Experience of Perinatal Obsessive-Compulsive Symptoms: A Systematic Literature Review. Clinical child and family psychology review24(3), 529–541. https://doi.org/10.1007/s10567-021-00348-2
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