So there was this mother who, when home alone, would avoid carrying her baby into the kitchen, just in case she accidentally popped him in the oven. She avoided taking him into the laundry because what if the washing machine suddenly looked inviting? She would ring people while she played with the baby because if someone else could hear her she wasn’t likely to be accidentally hurting the child; and she avoided balconies, banisters, and bridges just to be sure she wouldn’t throw the infant over.
This week is Post Natal Depression Awareness week, and I wanted to take the opportunity to raise awareness about a lesser-known condition experienced by some new mothers: Perinatal (pregnancy and post birth) Obsessive Compulsive Disorder (PN OCD). Most people are fairly familiar with the stereotypic presentation of OCD, but that it can specifically impact on the perinatal period is not well-known and discussed. When I found out about it (having worked in Perinatal Mental Health for a couple of years at the time), and started talking about it, I discovered it was new information for my colleagues, most of our Child Health Nurses, many of our referring GPs, and even my own obstetrician.
Why don’t they know? Because most women with PN OCD simply are too frightened to talk about it. OCD is an “anxiety disorder” whereby a person has obsessive intrusive and unwanted ruminations (thoughts), and this may be present with or without rituals that develop to “calm down” those distressing thoughts. Most people are familiar with the image of the person who’s OCD obsessions fixate on germs, with rituals around hand cleaning, for example; or obsessions around safety paired with ritualistic checking of doors. In PN OCD the obsessive thoughts usually centre around the care of the baby, and they can be terrifying.
These thoughts present themselves as THREATS. When the thought occurs, the OCD thinker says “Oh my gosh, I’ve had this thought – if I think it, that means it could happen. I need to protect everyone from this terribly dangerous thought. I’M A THREAT”. Who wants to tell somebody else about that? It’s just plain crazy, hey?!
So along with those thoughts comes thoughts like this:
“If anyone knew what was in my head… my partner would leave me / Child Protection would take my children / I’ll be locked up…” – and so it takes tremendous courage, in the midst of that, to speak up.
Instead it’s possible rituals or other protective behaviours may emerge, such as:
- avoiding being alone with the baby
- strict and strange rules about how and where to interact with the baby
- internalised rituals, such as following a line of thought in one’s head to justify to the self that the baby is safe
At this point I want to remind you about my last post – remember how the brain LIES about things? In PN OCD this clearly goes into overdrive! Here’s the other thing that happens – the thinker FUSES with these thoughts. Fusion refers to the way the thought is interpreted – that it is seen as Real, Serious, and Important – there’s no space between the thinker and the thought – no room to evaluate, to check out other information sources, to decide if the thought is helpful or relevant. The thought becomes all-consuming, and the thinker holds tightly to it so that they can follow it around, keep an eye on it, and at all times be aware of what that thought might be doing and how dangerous it could be.
Of course, fusion with thoughts is not exclusive to OCD! We all do it – some of the time. The problem occurs when fusing with an idea gets in the way of us living the life we want to be living – in the case of PN OCD, being able to connect and be present with the baby, being able to fully engage in the joys (and frustrations!) of parenthood, participating in life. A mother without PN OCD may notice the thought “what if I drop the baby” at the same time she has the thought “must defrost sausages for dinner”. Her mind quickly dismisses the first thought as irrelevant and unimportant, and she may barely be aware the thought was even there. The woman with PN OCD will forget to defrost the sausages, but may sit perfectly still holding her baby for the next half hour whilst she waits for the thought to stop being so dangerous. In fact, research indicates that 80% of new mothers experience the exact same thoughts as those with PN OCD some of the time. The difference is in what people do with those thoughts once they show up.
I promise there will be a skills post coming soon on how to take all these thoughts far less seriously – to attend to the ones that help us and create some space for the ones that don’t. So please be patient with me, today I just want to lift the curtain on this poorly understood condition.
Prevalance: Research in this area is extremely limited, but estimates are that 2-4% of mothers experience some form of PN OCD. For reasons already outlined, it is likely that this is a gross underestimate – many suffer in silence. There are no estimates for fathers.
Causes / Risk Factors: Again, this area is still poorly understood. The mother may not have experienced OCD at any other time before or after. There appears to be a hormonal connection for some women. It is also hypothesised that increased messages around health and safety during pregnancy, combined with a daunting sense of responsibility and obligation for the new parent may contribute. General risk factors for perinatal mental health conditions include:
- Family or personal history of anxiety and/or depression
- Difficulties or conflict in relationship with partner
- Significant stressors both before and after birth
- Limited social and emotional support
- Infant concerns
- Emergency caesarean delivery or traumatic birth
However, perinatal depression and anxiety may occur even if none of these risk factors are present, or it may not occur even if every item above is checked. Perinatal mental health conditions can be experienced by any mother or father regardless of age, socio-economic status, culture, or even awareness of perinatal mental health conditions.
Is there a risk the mother will harm her baby? No.
Sadly we have all seen the media coverage of mothers who have, in fact, been responsible for the deaths or injuries of their children – but the mother with PN OCD does not fit this profile – quite the opposite. Dr John Abramowitz, who has led research teams investigating PN OCD at the Mayo Clinic and University of North Carolina has this to say (my emphasis added, the rest of the article is here):
both [postpartum] OCD and [postpartum] psychosis can involve strange, bizarre, and violent thoughts. But the similarities stop there. In postpartum OCD, the sufferer is terrified of committing harm; so much so that it scares her to even think about harming the infant. Women with postpartum OCD resist their obsessional thoughts; meaning that they try to dismiss the obsessions, or neutralize them with some other thought or behavior. The thoughts seem as if they are against every moral fiber of their being. Consequently, the risk of someone with postpartum OCD acting on their violent obsessions is extremely low (one can never say with absolute certainty that the chances are 0%, but in this case, it’s pretty close).
In contrast, women with postpartum psychosis tend to experience their violent thoughts much differently. The violent thoughts might be perceived as consistent with the person’s world view. Hence, such women don’t try to fight these thoughts. The thoughts are usually part of delusions; lines of thinking in which the person holds strongly to bizarre beliefs such as the idea that someone (or the government) is after them, or that they have magical powers that other people don’t have. So, thoughts to harm the baby might be perceived as “a good idea.” Because people with psychotic disorders sometimes act in accord with their delusions, postpartum psychosis poses very serious risks and often requires hospitalization to ensure the safety of the mother than infant.
Treatment Options: For some women, PN OCD may remit of its own accord around the time that her hormones return to normal (this is of course impacted by breast-feeding). However PN OCD is not fun – it’s debilitating and gets in the way of parent and baby developing a normal attachment relationship. Waiting and hoping is a really rough way to go.
A review of the literature into treatment of OCD compiled by the Australian Psychological Society concluded that Cognitive Behaviour Therapy (CBT) is the psychotherapeutic intervention of choice. There have been three published studies evaluating Acceptance and Commitment Therapy (ACT, a particular branch of CBT that focusses on mindfulness, acceptance, and values-driven action), and the results are promising – for a review see here.
The use of Selective Serotonin Reuptake Inhibitors (SSRIs) and other medications as an adjunct to psychotherapy is an option that is best discussed with a sympathetic GP or psychiatrist. I am reluctant to comment on pharmacotherapy.
Diet, exercise and supplements options can also be explored with the relevant health care professionals.
It’s PND Awareness week – You can do something about this NOW
I wish someone had told me all of this when my eldest child latched for his first feed in the hospital. If I had known this THEN, I may have only gone through this once. The story at the start of this post – that’s my story – and it was the second time around before I finally had a label to explain my symptoms, and a map to get myself out.
Please consider sharing this post with any pregnant women you know, any mothers and fathers of infants, anyone who works with parents and babies. The mother you send this to might be doing just fine – but someone in her network might not be, and maybe if she shares this too, we can together raise awareness and help more women get the support they need SOONER.
Resources that can help
Most Women’s Health Services run Post Natal Depression therapy groups and individual therapy – contact your local one to find out what they provide, and what their experience is with perinatal OCD. One I’m particularly familiar with is Women’s Health and Wellbeing Services (South East Metro), which provides 1:1 therapy and also runs a FREE 10-week “ACT on Perinatal Depression & Anxiety” therapy group (no referral required). I was involved in creating and establishing this group, and it is now managed and facilitated by Psychologist Amanda Smith.
Contact your GP or Child Health Nurse – maybe take a copy of this post with you to help you explain what’s happening.
Use the “Find a Professional” link on the Beyond Blue website
Use the “Find a Psychologist” link on the Australian Psychological Society Website
Need someone to talk to NOW already
Pregnancy, Birth & Baby Helpline: 1800 882 436 (24hrs, 7 days p/week)
PANDA Helpline: 1300 726 306 (10am-5pm AEST, Mon-Fri)
Lifeline: 131 114 (24hrs, 7 days p/week)
Lifeline Suicide Helpline: 1300 651 251 (24hrs, 7 days p/week)
Ambulance / Police: 000 (24hrs, 7 days p/week)