Dr. Tatyana Mestechkina answers common questions about perinatal OCD.
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“What if I lose control and throw my baby out the window?” “What if I felt aroused when changing my baby’s diaper/breastfeeding?” “What if I hurt my baby last night but forgot about it?” “What if my baby ingests a toxic chemical from their toys and dies?”
These are actual examples of distressing and anxiety-provoking intrusive thoughts that new or expecting parents diagnosed with obsessive-compulsive disorder (OCD) have shared during psychotherapy sessions.
The perinatal period, or the time before and after birth, is a time that can be exciting and joyful. It can also be a difficult transition that comes with great stressors. These can include getting less sleep, having less time for self-care and pleasurable activities, changes in sex life, and financial demands.
Many parents also experience challenges in balancing their work, family and personal life, and integrating their new role as a parent. Times of pregnancy and postpartum can also be times of hormonal fluctuations and imbalances (e.g., progesterone, serotonin and oxytocin).
Therefore, it is no surprise that such a significant life event can be associated with greater vulnerability to mental health challenges such as OCD. Those who already experience OCD, or are at risk for developing this disorder, may be more likely to experience intrusive thoughts related to their child and these thoughts can be accompanied by great anxiety and distress. This may manifest as perinatal OCD.
The perinatal period, or the time before and after birth, is a time that can be exciting and joyful. It can also be a difficult transition that comes with great stressors.
There has been progress towards bringing more awareness and understanding to the diagnosis and treatment of postpartum depression. However, much less attention and research has been directed towards the experience of perinatal OCD. Here are some common questions answered.
How common are intrusive thoughts during the perinatal period? Intrusive thoughts are quite common for new and expecting parents. Some studies suggest that as many as 90% of new mothers experience unwanted thoughts related to their child during pregnancy or shortly after birth!
Do new and expecting fathers experience intrusive thoughts as well? Absolutely! While there is more focus on postpartum mental health challenges for mothers, fathers also experience similar thoughts. Dr. Jonathan Abramovitz and his colleagues found that more than two thirds of new fathers surveyed also experienced intrusive thoughts before and shortly after the birth of their child!
What is the difference between typically occurring intrusive thoughts parents experience and those occurring in perinatal OCD? For most, these thoughts are deemed meaningless and simply pass. This experience may be a sign of OCD if the thoughts come with a “false alarm system” or a surge of anxiety. Parents may misinterpret these thoughts as dangerous and fear that they may act upon them, even though these thoughts are irrational or extremely unlikely to occur.
For example, a parent has an image of harming their baby and then thinks “Oh my god! Why would I think such horrible things… what’s wrong with me…am I actually capable of such an act?” New parents may spend considerable time and energy attempting to avoid, get rid of or rationalize these unwanted thoughts. For example, they may try to list all the reasons why they love their child, hide objects that can be used as a potential weapon and avoid spending time alone with their child. This experience may cause significant levels of distress and their reaction to these thoughts may impair their ability to function.
Why are new and expecting parents more vulnerable to perinatal OCD? There are several theories for why this may occur. Dr. Nichole Fairbrother and Dr. Jonathan Abramowitz have explored various explanations for perinatal OCD. They proposed that while most people experience unwanted thoughts throughout their lives, parents may be more vulnerable. New parents often experience an increased sense of responsibility for their child’s well-being and place great value on keeping their child safe.
Additionally, newborn babies are inherently more helpless and vulnerable. This may lead new parents to be more vigilant of potential threats and then misinterpret harm-related thoughts about their babies as important and dangerous. Then, when they engage in behaviors such as avoidance, reassurance-seeking and checking compulsions, this gives those thoughts more relevance and teaches the brain that they are “helpful”. This then increases the likelihood that these thoughts will come up more frequently and intensely.
From an evolutionary perspective, our ancestors who were on high alert and extra vigilant were more likely to keep their babies away from danger. In this way, some level of parental hyper vigilance may have been an adaptive trait that helped offspring to survive.
Will I act on these intrusive thoughts? Patients coming into session with perinatal OCD often feel scared and confused. Intrusive thoughts and images may be incredibly disturbing and anxiety-provoking. As parents have no intent of acting upon them, it leads them to question why such thoughts showed up in the first place.
Some worry that they may be “losing their minds” or fear they may be capable of acting on their intrusive thoughts. They may fear that these thoughts are an indication that they are an unfit parent. The reason for this distress is that these thoughts of harm are typically very much outside of their values systems, in which their children’s safety is usually one of the most important things to them.
In fact, these individuals may go to great lengths to avoid danger ensure their children are safe. They may try desperately to get rid of or disprove these thoughts and reassure themselves that they do not actually want to act on them. Interestingly, these intrusive thoughts are present for a reason: to keep them from acting on them! It is the brain’s way of reminding us of the dangerous stuff we could do to try to ensure we don’t do it. Again, these thoughts are very prevalent during pregnancy and postpartum and their presence alone is not any indication that their child/children are in any actual danger. An assessment from an OCD expert can help confirm this diagnosis and differentiate it from other mental health challenges.
What exacerbates intrusive thoughts and feelings? When we treat intrusive thoughts and feelings as if they are important or dangerous, we give them more relevance in our lives.
A parent may respond to an intrusive thought or image with physical behaviors (e.g., checking on a child repeatedly, hiding knives, or avoiding changing the child’s diapers) or mental acts (e.g., attempts to push away or stop thoughts, rumination). They may also spend significant amounts of time trying to reassure themselves or get reassurance from others (or the internet) that these thoughts are not accurate.
By responding to these thoughts as if they are truly threatening, the mind believes that these thoughts must be valid and it is being “helpful” by continuing to send these alarm signals. This then increases the likelihood that they may continue to show up, elicit attention, and feel even more threatening.
For example, if a parent experiences the thought “what if I lose control and poison my son?” and then they respond by throwing out all the chemicals and cleaning products in the home (possible means of poison), this then sends the message to their mind that this was a legitimate threat and reinforces the idea that throwing out the chemicals is keeping their child safe. Therefore, the mind may become extra vigilant of other possible ways of poisoning the child and may continue sending more “suggestions” for how to avoid this. This can lead to more compulsive behaviors.
When we treat intrusive thoughts and feelings as if they are important or dangerous, we give them more relevance in our lives.
What are common obsessions and compulsions in perinatal OCD?
THEME: EXCESSIVE RESPONSIBILITY TO PREVENT A TERRIBLE EVENT FROM HAPPENING TO THEIR CHILD
Obsession: Fear that child may be exposed to germs or toxins that may lead them to become ill and/or die Compulsions:
Repetitive washing of hands, bathing their child excessively, washing items that their child comes into contact with, excessive use of hand sanitizer
Hiding away or throwing out chemicals in the house such as bleach
Researching ingredients in objects such as sheets, clothes or toys to make sure they don’t have toxic chemicals
Obsession: Fear that their child will stop breathing or choke while sleeping Compulsion: Checking multiple times that their child is still breathing and alive while they are sleeping Obsession: Fear that some accident will occur, resulting in harm or death of their child Compulsions:
Checking, often multiple times that candles are not lit, stoves, toasters and all other appliances are turned off
Excessive praying or superstitious rituals (e.g., counting or tapping) based upon presumption that action will prevent accident from occurring
Obsession: Fear that their child was molested by someone such as a family member, other parent or nanny Compulsions:
Asking for reassurance from them
Trying to replay interactions they may have had with that person
Checking their child for any physical signs of abuse
THEME: FEAR OF LOSING CONTROL AND HARMING THEIR CHILD
Obsession: Fear of losing control and throwing, shaking, punching, stabbing, smothering, burning, drowning or dropping the child Compulsions:
Avoiding being alone with their child
Hiding or throwing away possible weapons (e.g., knives, scissors,razors)
Seeking reassurance from loved ones and/or the internet that they would not be capable of such things and are a “good person/good parent”
THEME: SEXUAL-RELATED THOUGHTS
Obsession: Fear that they are attracted to, or are aroused by their child or that they may molest their child Compulsions:
Avoiding being alone with their child
Avoiding changing diapers, bath time, breast feeding or undressing child
Seeking reassurance from the internet
Checking and assessing whether they have experienced sexual arousal (e.g., a groinal response) when with their child or thinking about them
Obsession: Fear that they may have committed pedophilic act and forgotten or blacked out Compulsions:
Keeping detailed notes on how they spend their time, checking call/text logs to account for all time that has passed to try to ensure that they didn’t do this while blacked out
Seeking reassurance from others that they did not commit any pedophilic act
Why is it important to seek treatment for perinatal OCD? Seeking treatment is not only important for the mental health of the parents but also for their children. Studies have shown that postpartum OCD symptoms are associated with lower mood and less confidence for mothers. Mothers who experience postpartum OCD report more marital distress, less perceived social support and are less likely to breastfeed. This may also affect how responsive they are to their child and therefore can affect their ability to create more secure bonds with their babies.
It is important to let go of the stigma of OCD-related intrusive thoughts. Because of the often taboo nature of them, many parents do not share them with others and experience loneliness, tremendous shame, and confusion. They may believe that they are the only ones experiencing these thoughts and images. They may fear negative judgment if they share their concerns or even that authorities will take away their child.
While this article in itself can serve as some form of reassurance that the experience described may be part of perinatal OCD, it is natural that subsequent questions and doubts will arise (e.g., “Is what I am experiencing actually OCD?”). It is important to seek a mental health consultation with a licensed professional who specializes in OCD, particularly perinatal OCD.
What kind of treatments are there for perinatal OCD? Treatment for perinatal OCD and anxiety is available. Exposure and response prevention (ERP/ExRP), a form of cognitive-behavioral therapy (CBT) is considered the “gold standard” treatment for OCD.
Acceptance and commitment therapy (ACT) can also help supplement ERP/ExRP. They can be very effective in helping parents develop strategies to manage these difficult thoughts and feelings and be more present in their lives and with their child/children.
First, the clinician assesses and diagnoses these symptoms. Then, they provide psycho-education about what the person is experiencing. This can include learning about how OCD manifests and what they are doing that may reinforce and maintain these false alarm signals. The patient then learns different strategies for how to manage the OCD episodes and to create distance and independence from the intrusive thoughts and feelings. They can practice treating them as irrelevant and make decisions independent of them.
Through practicing ERP/ExRP and ACT, patients can learn to go towards some of the uncomfortable thoughts and triggers while practicing managing the difficult feelings that come up, and refraining from engaging in rituals. The goal of treatment is to make more choices in line with values and fewer choices in line with giving relevance and power to the intrusive thoughts and images, and being more in the now of their lives. A skillful therapist can provide immense guidance and support in this process.
Additionally, it may be helpful to consult with a psychiatrist who specializes in perinatal OCD to discuss possible medication options. It is important to speak with a specialist who is well-versed in ways that certain medications may interact with a fetus or a newborn if one is breastfeeding. It may also be helpful to work with a psychiatrist who is willing to collaborate with a therapist as part of a treatment team. Reaching out to get help is courageous and can be the difference between a very challenging pre and post pregnancy experience and a more mindful experience.