Dr. Mestechkina is quoted in this article written by Laura Donovan about OCD/Pure-O that can manifest in pregnant women and new parents.
Scary Thoughts & A Form Of OCD Specific To Postpartum Parents
In January 2018, a new mother named Jessica Porten showed up at the E.R. concerned about the scary thoughts she had been having. She told a nurse, "although I would never hurt myself or my baby, I'm having violent thoughts and I need medication and therapy to get through this." The next thing she knew, the police showed up.
“I leave the E.R. at midnight, my spirit more broken than ever, no medication, no follow up appointment, never spoke to a doctor,” Porten wrote in a Facebook post that went viral. “This was a 10-hour ordeal that I had to go through all while caring for my infant that I had with me. And that’s it. That’s what I got for telling my OB that I have PPD [postpartum depression] and I need help. I was treated like a criminal and then discharged with nothing but a stack of Xeroxed printouts with phone numbers on them.”
Porten’s story spoke to a lot of women. In the aftermath, she spoke to Romper's Ashley Stoney about the shortcomings of the health care system, where new mothers are concerned: "We should not be expecting any mothers with postpartum depression or any form of of mental illness to advocate for themselves, and yet the social worker literally looked me in the face and said, 'You need to advocate for yourself on this.'"
Porten's treatment is enough to discourage any new mom from speaking out about strange feelings she might be having after birth. I know this because I found myself having similar thoughts and concerns.
For the duration of my pregnancy last year, I was fixated on protecting my unborn son and felt I wouldn't be at peace until he was finally in my arms. On the morning of my scheduled C-section last August, however, my obsession with keeping him safe took a swift, dark turn: I was plagued with intrusive thoughts — sometimes called "scary thoughts" — about hurting this child that I loved more than anyone else in the world. I didn't feel comfortable being alone with him, and I was haunted by visions of dropping him as I was wheeled into the recovery area, and tossing him into my apartment building's trash chute upon our return home.
How do you tell someone that this is indeed the best day of your life, but you can’t stop thinking about making it the worst by doing the most horrifying thing imaginable? While my husband, mom, and in-laws enjoyed cradling him in the postpartum room, this special day was clouded by a type of OCD that I’d wrongly assumed was out of my life.
I was re-experiencing "pure OCD" (commonly referred to as "Pure-O"), a scarcely discussed form of OCD that causes someone to dwell on disturbing intrusive thoughts. I've previously written about the ways in which intrusive thoughts disrupted my life before having a child, and my fear last year was that they would be unbearable after my son's arrival.
The most common forms of intrusive thoughts are sexual, violent, or religious-oriented, per the nonprofit Intrusive Thoughts, which functions as a resource and community for those affected. My experience could also be considered postpartum OCD, which can impact people who have had OCD prior to childbirth and pregnancy, as well as those who have not. A study in the Journal of Reproductive Medicine found 11% of women had OCD symptoms at two weeks postpartum — vastly higher than incidences in the general population, which is estimated to affect 2-3% of people.
New moms, for example, might imagine drowning their baby in the bath, touching the child inappropriately during diaper changes, or flinging him or her down a flight of stairs. For some, it's easy to pass off these thoughts as nothing more than a misfire in the brain, but these thoughts can hold a lot of weight for people who are constantly bombarded by such images. Rose Bretécher, author of the lauded memoir Pure and a long-time sufferer of sexual intrusive thoughts, said in a 2013 article for The Guardian that having such thoughts can feel like you're keeping a major secret or hiding a body in the backyard.
It’s not surprising that my intrusive thoughts returned with the new addition to our household. Between the sleep deprivation, the drugs, the adrenaline, the physical trauma I’d endured from surgery, and mastitis brewing in my ducts, I had a lot going against me on the day of my son’s birth, especially as someone who has struggled with OCD and pure-O throughout life.
Women who have OCD symptoms prior to pregnancy or birth are "much more vulnerable" after the fact, according to Dr. Tatyana Mestechkina, Ph.D., a licensed clinical psychologist who specializes in evidence-based treatment of OCD and pure-O, and spoke to Romper over the phone. She adds that even happy life circumstances that bring dramatic changes, such as the birth of a child, can trigger OCD symptoms.
"I've also seen patients who actually haven't had any OCD symptoms before, until they were pregnant or postpartum," Dr. Mestechkina says. "That is definitely something that is consistent with what I see clinically."
"This is not just about women with postpartum depression or postpartum anxiety," Karen Kleiman, an international maternal health expert and the founder of The Postpartum Stress Center tells Romper by phone. "Every single mom will experience these negative, unwanted, scary thoughts about harm coming to their baby."
Every woman who has ever had a baby ... is at risk to have this kind of significant anxiety.
The author of several books on postpartum mental health, Kleiman published a book earlier this year, Good Moms Have Scary Thoughts: A Healing Guide to the Secret Fears of New Mothers, specifically to address this widespread phenomena. Moms can have a broad range of scary thoughts, from fears of doing harm to their babies, to concerns that something dreadful could happen to their children. Her book includes illustrations of some of these thoughts.
"Once we normalize it, once we get it out there, once we say this happens to everybody, number one it's easier to talk about and number two it can reduce anxiety," Kleiman says.
Unlike the work she has done on postpartum depression (affecting around 1 in 5 new mothers), Kleiman says this book is "geared towards every woman who has ever had a baby, because she is at risk to have this kind of significant anxiety."
Kleiman adds that the perfect storm of hormonal changes and sleep-deprivation after birth can give our anxiety surrounding these thoughts a life of its own.
"Anxiety takes on a whole new level, and so when we have these scary thoughts, sometimes the distress is so high that we can't think about anything else. They can take on some obsessive or compulsive nature. They can interfere with our functioning."
In hopes of ending the stigma surrounding these thoughts, Kleiman started a social media campaign called #SpeaktheSecret and created a section on her website dedicated to letting moms share their scary thoughts anonymously. As of writing this article, there are over 700 anonymous thoughts posted on the site.
“OCD is a profoundly sensitive condition to hormonal variability, predominantly in women, but to some degree in men, so OCD explosions tend to occur during extreme human periods of hormonal variability,” says Dr. Stephen Phillipson, Ph.D., a licensed clinical psychologist.
Speaking to Romper by phone, Dr. Phillipson says adolescence is usually when the onset of OCD occurs, but hormone variability during and after pregnancy can create the conditions for all forms of OCD. "It makes perfect sense that OCD will kind of emerge — not just pure OCD about harming the child, or [thoughts of] 'Oh, I don't love the child,' but all forms of OCD are very prevalent after delivery.”
Because anyone can have intrusive thoughts — even people without OCD — it’s normal for new dads to have these thoughts about their new baby as well. In January 2018, Dr. Jonathan Abramowitz, a clinical psychologist and professor at UNC-Chapel Hill, Ph.D., told Men’s Health reporter Natasha Pretsky that he’d had thoughts of beating his baby girl while patting her on the back during a feeding.
Dr. Mestechkina says that she's worked with people who have been plagued with intrusive thoughts for months, years, and even decades, and have lived in terror that they're malicious individuals the whole time. It can damage relationships and careers, and because OCD is not very responsive to logic or reason, treatment can be challenging, she explained.
"When that false alarm signal is going off, [it's] not doing a great job communicating with the logical, rational part of our brain," Dr. Mestechkina says. "That's why most people with OCD are completely able to use logic and reason to navigate through life successfully, but when it comes to OCD, all that goes out the window no matter how many people in their life, or even trusted professionals say, 'Hey, you're probably the least likely person to harm yourself, or your child or your partner.' When it comes to OCD that might feel nice and reassuring short-term, but then their minds are usually right around the corner saying, 'But what if they're wrong? What if this time it's different?' And it just kind of goes on and on and on."
The difference between people with postpartum OCD and psychosis is that those who have intrusive thoughts don’t want to have these thoughts.
Perhaps the most frightening aspect of my postpartum OCD experience was not knowing whether I truly was experiencing harmless intrusive thoughts once again, or if something more serious was at play, such as postpartum psychosis. I told myself that a thought is just a thought, but when does a thought actually make mothers kill their children? The difference between people with postpartum OCD and psychosis is that those who have intrusive thoughts don’t want to have these thoughts, and they’re actively trying to push them out of their brains.
Someone with psychosis, however, is under the spell of a “fixed delusion,” Dr. Phillipson says. “Their thoughts perhaps about their baby being the devil and they need to do the world a favor and eliminate the devil from growing up is very, very different from a mom having a [vision of] pillow suffocation or genital-oral contact with a newborn baby, and then going into a highly distressed panic or guilt infusion and seeking relief."
Kleiman notes that "these thoughts are not associated with an increased risk of actions taken or harm to infants."
"I'm happy to say that there's not if that much of, if any, an overlap [between intrusive thoughts and psychosis], other than the thoughts can be similar, but rarely are they identical,” Dr. Phillipson says.
One of my fears about divulging my situation was that my son could be taken away, a common concern among moms with postpartum mental health issues.
Meghan Joel Perri, a 29-year-old mother from Beaverton, Oregon, tells Romper that her intrusive thoughts started five years before she became a mother, and she's reluctant to share too much about it for fear of losing her child.
"The intrusive thoughts are still pretty terrible," she says. "I struggle with suicidal thoughts. I stopped breastfeeding when my baby was 9 months to try different medications. I have definitely been scared to speak out, with fear of having my baby taken away or scaring my spouse."
Coming forward about one’s intrusive thoughts to someone ill-equipped to understand or assist can pose problems, as when Porten drove herself to the E.R. and was taken into custody, so Dr. Phillipson says it’s important to exercise caution about who you share your intrusive thoughts with when you’re already in a vulnerable state like I was postpartum.
“You've got to be really careful who you describe this to,” he says. “Before you start opening up about your brain's creativity, you want to really know your audience and you want to interview the person and make sure that they understand the nature of an intrusive thought versus someone who may actually be a risk to the innocent child, because I've had some very, very upsetting dialogue with patients who were desperate and confessed and disclosed some of these intrusive thoughts and they had very, very upsetting misinterpretations and very upsetting consequences of disclosing to people who were not qualified to really distinguish what was going on.”
Dr. Mestechkina has similar advice, noting that fears of being viewed as a true threat is a major barrier for many people who need help.
"My recommendation is always to make sure that the person sees somebody who specializes in treating OCD, but particularly the pure-O subtype," Dr. Mestechkina says. "People who have that expertise will be much more likely to be able to correctly assess and diagnose them and then provide them the adequate treatment for that."
Dr. Mestechkina specifically recommends finding someone who specializes in doing exposure and response prevention therapy (ERP), and acceptance and commitment therapy (ACT), which are both different types of cognitive behavioral therapy.
"What's really tough about OCD, like I was saying before, is that the treatment is very counterintuitive in a lot of ways, and what most people think would be helpful for intrusive thoughts, such as using logic and reason, actually sometimes feeds into the intrusive thoughts, so 'exposure and response prevention' isn't about showing your brain that you're not likely to act on these thoughts, but it's more about doing practice doing exercises to show your mind that these thoughts are no longer going to be relevant in your life," Dr. Mestechkina explains.
What they should do is say 'if you are having thoughts that are scaring you, you need to talk to this therapist.'
Kleiman says it's not surprising that there's a gap in health care provider knowledge about intrusive thoughts after birth, as that's not their area of expertise. Though a doctor or a nurse might be somewhat familiar with these scary thoughts, "they aren't psychiatrists," she says.
Kleiman agrees that it would benefit health care providers to be educated about the nature of scary and intrusive thoughts postpartum. "A lot of [these healthcare providers] are not psychiatrically trained and they don't feel like it's within the scope of their practice to say to a mom, 'Oh, that's fine. You're having a thought about your baby falling off the balcony and smashing its head? That's fine, don't worry about it,'" Kleiman says. "Health care providers get a bad rap because they don't know what to do with this information, but in fairness, they shouldn't know. What they should do is say 'if you are having thoughts that are scaring you, you need to talk to this therapist.'"
She wants to see every health care provider equipped with a list of resources for maternal mental health support.
Lifestyle adjustments can bring improvements. Perri tells Romper that she has been able to manage her intrusive thoughts to some degree through diet changes, exercise, and taking vitamins and supplements. She also feels talking to friends and family has made a difference.
"It takes away a lot of the power," she says, adding that using logic can sometimes help as well. "Like: my baby touching my ribs will not hurt him."
I hope to have another child sometime within the next year or so, and if I’m lucky enough to expand our family in this way, I’ll be better prepared for the intrusive thoughts during round two. I’ll know that even if they present themselves, they don’t mean I want to do any harm to anyone, and hopefully I can enjoy my first few days of parenting in a way that wasn’t an option for me the first time around.
If you or someone you know is experiencing depression or anxiety during pregnancy, or in the postpartum period, contact the Postpartum Health Alliance warmline at (888) 724-7240, or Postpartum Support International at (800) 944-4773. If you are thinking of harming yourself or your baby, get help right away by calling the National Suicide Prevention Lifeline at 1-800-273-8255, or dialing 911. For more resources, you can visit Postpartum Support International.