Postpartum OCD: Diagnosis, Causes, and Treatment
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“And I keep on – stabbing him in the stomach and then move the knife to his throat, and I stab him again and again. There’s blood everywhere, on my hands and arms and on the kitchen counter. I’m covered in his blood...,” shares a very distraught new mother near the end of your first appointment with her.
She goes on to reveal that she has been having very disturbing thoughts of harming her three-month-old son for about a month and a half. She’s convinced that she will act on these thoughts and, consequently, has been limiting her contact with him.
Her husband, whom she recently asked to remove all of the sharp objects in the home, has had to take over nearly all of the caretaking duties. These violent thoughts tend to revolve around stabbing, but they have recently come to include drowning and suffocation.
Based on what you’ve heard, you may be tempted to alert authorities, because it appears that her baby’s in danger. But, before you do so, perhaps consider that this mother is not homicidal but, in fact, suffering from an underrecognized and often untreated form of obsessive-compulsive disorder (OCD) known as postpartum OCD (ppOCD).
How do I know it’s ppOCD and not something else?
OCD is an often misunderstood and misidentified neuropsychiatric disorder. The public [1] and, surprisingly, even medical [2] and mental health professionals [3] have great difficulty identifying the disorder in its various forms because it has become primarily (and stereotypically) associated with symmetry and contamination concerns. The disorder, however, has a variety of presentations, with taboo presentations—that is, those that are sexual, religious, and violent in theme—more misdiagnosed and stigmatized than other presentations. [4]
Much of the research on postpartum psychiatric illness has focused on postpartum depression, but little attention has been given to ppOCD, a condition that is more common in mothers than previously thought. [5]
Like OCD, ppOCD is characterized by recurrent, unwanted, and upsetting obsessions and repetitive mental or behavioral compulsions that reduce anxiety or attempt to prevent feared outcomes. Unlike typical OCD, which usually has a gradual course, ppOCD has an abrupt onset or worsening of obsessive-compulsive (OC) symptoms following the birth of a child. [6]
Mothers who experience ppOCD have obsessions about their child being intentionally or unintentionally harmed. They may have thoughts of stabbing, drowning, or sexually abusing their baby and so will perform compulsions or engage in avoidance to prevent harm. [6] For example, to prevent sexual abuse, mothers suffering from ppOCD may avoid bathing their baby. If mothers with ppOCD muster up the courage and disclose their obsessions to significant others and relatives or medical and mental health professionals, it is likely that they will be viewed as either psychopathic, homicidal, or sexually deviant.
However, most, if not all, mothers who suffer from ppOCD are not psychopaths, murderers, or pedophiles. The key difference is that mothers with ppOCD are very upset that they have such troubling obsessions and view them as highly incongruent with their morals and sense of self. They even go to great lengths to save their baby from harm via compulsions and avoidance. Significant anxiety, incongruence with one’s morality and sense of self, and compulsive and avoidant behavior are hallmark features of OCD and ppOCD that should be considered when making a diagnosis.
Special care should be taken when considering a diagnosis for a mother presenting with intrusive thoughts of harming their child. A misdiagnosis can be devastating not only because it prolongs suffering due to the use of ineffective and inappropriate treatments but also because it may inadvertently reinforce the mothers’ fears and thus worsen their ppOCD. [7] To help with the identification of ppOCD, a measure [8] has been developed specifically to assess for the condition.
What causes ppOCD?
It is not completely understood what causes the onset or worsening of OC symptoms during the postpartum period, but there are biological and psychological models that have attempted an explanation.
Biological models theorize that an increase in OC symptoms is caused by shifts in hormone levels (e.g., estrogen) that occur before, during, and following birth. [9] It is believed that hormonal changes lead to deficient serotonin functioning in the brain, which is in line with the already established serotonin hypothesis of OCD. [10] However, these models fail to provide an explanation for the interesting finding that fathers, too, experience a significant increase in OC symptoms in the postpartum period. [11]
A cognitive-behavioral model of ppOCD [6] theorizes that both mothers and fathers are at risk of developing OC symptoms during the postpartum period because there is an increase in the responsibility for a helpless and valued child that makes it more likely for misinterpretation of the significance of obsessions and an overestimation of threats to the child.
The cognitive-behavioral model goes on to theorize that ppOCD is maintained when catastrophic misinterpretations of obsessions go unchallenged (e.g., “Because I’m having these thoughts about my baby, that means I am a psychopath that will eventually murder them”) as the parent continues to perform compulsions or engage in avoidance.
What treatments are available for ppOCD?
If misdiagnosed and left untreated, ppOCD has the capability of negatively impacting the bond between parent and child. [12] Fortunately, there are safe and effective treatments for this condition that are supported by extensive research.
Exposure and response prevention (ERP), a form of cognitive-behavioral therapy, is considered the gold standard treatment of OCD, because it has the most research support which has shown it to be more effective than other psychological treatments. [13]
ERP requires patients to repeatedly expose themselves to feared situations or objects (e.g., knives) and then refrain from performing compulsions or avoidant behaviors so that they can learn over time that their catastrophic expectations are inaccurate—for example, through ERP, a mother can learn that she will not lose control and stab her baby even if she holds a knife near them.
Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), are also effective in treating OCD. [14] SSRIs are considered the first-line pharmacological treatment of OCD and, through research, it has been shown that larger dosages and longer use of SSRIs are often required to effectively treat the condition. [13] SSRIs work by increasing serotonin functioning in the brain.
References
[1] McCarty, R. J., Guzick, A. G., Swan, L. K., & McNamara, J. P. H. (2017). Stigma and recognition of different types of symptoms in OCD. Journal of Obsessive-Compulsive and Related Disorders, 12, 64-70.
[2] Glazier et al. (2015). Half of obsessive-compulsive disorder cases misdiagnosed: Vignette-based survey of primary care physicians. Journal of Clinical Psychiatry, 76(6), 761-767.
[3] Glazier, K., Calixte, R. M., & Rothschild, R. (2013). High rates of OCD symptoms misidentification by mental health professionals. Annals of Clinical Psychiatry, 25(3), 201-209.
[4] Durna, G., Yorulmaz, O., & Aktaç, A. (2019). Public stigma of obsessive compulsive disorder and schizophrenic disorder: Is there really a difference? Psychiatry Research, 271, 559-564.
[5] Miller, E. S., Hoxha, D., Wisner, K. L., & Gossett, D. R. (2015). Obsessions and compulsions in postpartum women without obsessive compulsive disorder. Journal of Women’s Health, 24(10), 825-830.
[6] Fairbrother, N., & Abramowitz, J. S. (2007). New parenthood as a risk factor for the development of obsessional problems. Behaviour Research and Therapy, 45, 2155-2163.
[7] Challacombe, F. L., & Wroe, A. L. (2013). A hidden problem: Consequences of the misdiagnosis of perinatal obsessive-compulsive disorder. British Journal of General Practice, 63, 275-276.
[8] Lord, C., Rieder, A., Hall, G. B. C., Soares, C. N., & Steiner, M. (2011). Piloting the perinatal obsessive-compulsive scale (POCS): Development and validation. Journal of Anxiety Disorders, 25(8), 1079-1084.
[9] Guglielmi, V., Vulink, N. C. C., Denys, D., Wang, Y., Samuels, J. F., & Nestadt, G. (2014). Obsessive-compulsive disorder and female reproductive cycle events: Results from the OCD and reproduction collaborative study. Depression and Anxiety, 31, 979-987.
[10] Bar, L. C., Goodman, W. K., & Price, L. H. (1993). The serotonin hypothesis of obsessive compulsive disorder. International Clinical Psychopharmacology, 8(Suppl. 2), 79-82.
[11] Abramowitz, J., Moore, K., Carmin, C., Wiegartz, P. S., & Purdon, C. (2001). Acute onset of obsessive-compulsive disorder in males following childbirth. Psychosomatics, 42(5), 429-431.
[12] Brandes, M., Soares, C. N., & Cohen, L. S. (2004) Postpartum onset obsessive-compulsive disorder: Diagnosis and management. Archives of Women’s Mental Health, 7, 99-110.
[13] American Psychiatric Association. (2007). Practice guideline for the treatment of patients with obsessive-compulsive disorder. Retrieved from https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/ocd.pdf
[14] Pittenger, C., & Bloch, M. H. (2014). Pharmacological treatment of obsessive-compulsive disorder. Psychiatric Clinics of North America, 37(3), 375-391.
