I spotted them in the waiting room easily. She was wearing crisp khakis and a clean white shirt, short hair neatly combed, touches of makeup on her cheeks alongside a tight expression. Her husband was clean cut and looked athletic though his blue jacket was slightly rumpled. He looked tired as a small infant slept in the baby carrier next to him. They both rose up quickly as I approached and Mr. J. extended his hand as he said, “We are so glad you could see us today. We are not sure what to do.”
Once inside my small resident’s office, Mrs. J. shared that she had been having thoughts of harming her baby, now three months old. She explained that these thoughts flashed into her mind and caused her a great deal of distress. When she was working with a knife in the kitchen, she thought that she could cut the baby and would see images of her bloodied child in front of her. When she was changing the baby, she imagined it careening off the table and had the thought that she could intentionally drop the infant. While she and her husband had wanted a child and planned carefully for the right time, she now wondered if she had made a mistake. Feeling ashamed and disgusted with herself, she said ‘I want those thoughts to go away.’
The notion of a mother harming their own child stokes strong emotions in most people. As a resident many years ago, I could feel myself tense up as I continued the assessment of her symptoms, taking care to note if she had signs of psychosis, depression or suicidal ideation, trying to make certain that the baby was not at risk. She was clear that she had no intention of harming the baby, had no hallucinations or delusions and she did not want to die, although she said she was becoming discouraged. Fortunately, during my prior year of residency I heard a lecture by a Dr. Sichel who was a specialist in women’s mental health and had a come across a series of women in her practice who presented in a very similar way. Dr. Sichel described their symptoms in an article for the Journal of Clinical Psychiatry as all experiencing an onset of intrusive, aggressive obsessions during the first postpartum weeks. These women did not want to harm their babies, but they were very distressed by the intrusive aggressive thoughts they were experiencing. None of these women engaged in visible compulsions or rituals but they avoided stimuli that triggered the obsessions (e.g. the knife or the baby). In her lecture she explained that the women she had followed did not act on their obsessions, though they feared that they would. She characterized their presentation as consistent with obsessive compulsive disorder (OCD).
Obsessive Compulsive Disorder is defined as having obsessions or compulsions that are distressing and interfere substantially with a person’s usual functioning or take up a lot of time (over an hour a day). Obsessions are thoughts, images or impulses that occur over and over again and feel out of the person’s control. The person does not want to have these thoughts, and recognizes them as inappropriate or disturbing, knowing they do not make sense. Sometime the obsessions are associated with feelings of fear, disgust or needing to act in a particular way that feels ‘just right’. Compulsions are repetitive behaviors (e.g. excessive washing or checking) or mental activities (e.g. praying, counting, saying a particular phrase or mantra in a specific way) that a person does to neutralize the obsessions or make them go away. The compulsions do not help permanently but can ease the person’s anxiety for a brief amount of time.
Obsessive Compulsive Disorder is estimated to have a general population prevalence of 2%. Men and women experience the disorder in roughly equal numbers, although some think women have a slightly higher prevalence of 3.1 %. Men have an earlier average age of onset (15 years) while women have two peaks of onset with the larger one occurring between 22 and 32: prime childbearing years. Early studies looking at people’ s recollections for major life events that corresponded with the onset of OCD symptoms found high percentages of people citing pregnancy or the birth of a child. However, these retrospective types of studies are not always reliable. More recent studies looking at non- clinical groups of post-partum women have found ranges of 2-9 % of women meeting criteria for Obsessive Compulsive Disorder, confirming the sense that there is a high prevalence of OCD at this time, but certainly larger and more comprehensive studies need to be done.
Many reports and studies confirm that OCD that starts during the peri-natal period frequently include obsessions which are aggressive, sexual involve fear of contamination. The obsessions often include fears related to the fetus or baby. Compulsions commonly include checking as in the mother who could not sleep because she was checking her baby every 10 minutes to see if she was breathing, or cleaning to neutralize fears of contamination or illness that might befall the baby. Some women begin to avoid caretaking as an effort to avoid intrusive thoughts, or due to anxiety that they may act on the obsessions. When symptoms include aggressive obsessions, women are often are secretive about these thoughts and imagine that other people or the authorities would think they are unfit to care for their children.
Ms. J. reported that she had been increasingly fearful of being around her daughter and had been relying more and more on her mother who had been visiting to care for the child. She had not shared the thoughts she was having with her mother, as she was worried that she was not the good mother she had thought she would be and concerned that others would see her as unfit. What her mother and husband observed was that Ms. J. was worried about the baby and was very concerned about keeping his room and belongings clean and germ free. Mr. J. explained, ‘It seemed a little overboard but _______ was always a little bit of a neat freak.’ Ms. J. elaborated that she had in fact been quite successful at work because of her organizational skills and she also liked things to be planned. She thought that at times that tendency might have been a bit excessive–explaining how in the course of general cleaning she liked to touch up the baseboards with paint when she found a wayward scuff.
Ms. J. had also felt anxious about breast feeding and found it overwhelming to know if her baby was full or getting the right amount of nourishment despite repeated reassurance from the pediatrician that her daughter was growing beautifully. She did not tell them that she was also alarmed by the intrusive aggressive thoughts she sometimes got while nursing. After about two months she decided to wean the baby and use formula. Her mother often fed the baby for her as Ms. J. described feeling more and more anxious about her ability to care for the baby and spent more time engaged in keeping the house and baby supplies organized. She tried to keep up appearances and would spend time around her daughter provided her mother or husband was close by. Things came to a head when her mother needed to return to the West Coast and her husband was supposed to be at work. Panicked on the prior Sunday night she had begged him to stay home with her the following day. He had reassured her that she was doing a fine job, that she was very capable and that she could call him if needed. It was only then that she talked more openly about the thoughts she had been having.
In reality, unwanted intrusive aggressive thoughts are actually fairly common. A paper by Jennings and Pepper compared 100 women with postpartum depression with 41 post-partum women who were not depressed. They found that 41% of the depressed and 6.5 % of the non-depressed women experienced obsessive-compulsive symptoms. (OCS) Other investigators have found that more than 50% of a sample of new mothers reported thoughts of unwanted, intrusive thoughts of intentionally harming their newborns and all of the 91 women reported some intrusive thoughts of accidental harm. Another study showed community samples of new parents of both genders with high percentages having some intrusive aggressive thoughts. As with the non-postpartum population with OCD, the key feature in those who manifest OCD is not the existence of intrusive thoughts but the way they interpret them. Typically, the women with OCD give these thoughts greater significance, are more alarmed by them and take steps to neutralize them through avoidance or various compulsions. For example, they would try to avoid care taking, or would try to suppress these thoughts which in turn actually serve to increase the severity of the obsessions. Clinically the difference in subjects with an OCD diagnosis is that the obsessions are longer lasting, more frequent and cause greater distress or discomfort.
It is not clear why so many women experience OCD after childbirth. Perhaps the high prevalence of these types of aggressive thoughts occurring at the same time as the heightened sense of responsibility for a child creates the right environment for OCD to emerge in certain people. There is some evidence in animal models of OCD that symptoms fluctuate in association with estrogen levels with symptoms worsening with withdrawal of estrogen, similar to the quick reduction of estrogen levels in postpartum women. There may be a subset of women in whom the hormonal changes around childbirth lead to the emergence of OCD. It has long been recognized that the serotonin system is involved in OCD pathology and reproductive hormones such as estrogen modulate serotonin in the brain. However, the fact that some men also develop OCD or exacerbation of OCD in this setting bolsters the recognition that there are multiple factors involved.
Treatment for OCD during the perinatal period currently follows recommendations for OCD at other times with a few modifications. A mainstay of OCD treatment is a form of Cognitive Behavioral Therapy called Exposure and Response Prevention (ERP). In that form of therapy, the person with OCD is guided to expose themselves to the feared object or situation (germs, uncertainty, disturbing images or thoughts) without engaging in the types of neutralizing behavior or mental activity mentioned above. When the obsessions are of an aggressive or sexual nature this is sometimes done with the use of scripts that describe the dreaded scenarios or images or exposure to objects associated with the obsession that the person may have been avoiding. Patients are also trained to tolerate the discomfort of having certain kinds of thoughts and to learn to recognize their discomfort as a component of their OCD. Medications are also helpful in OCD treatment with first line medication being agents that enhance serotonin such as serotonin reuptake inhibiters. Obviously given the possibility for transmission of medication through breast milk, a discussion about the risks and benefits of medication treatment needs to include a consideration or whether or not to breastfeed. It should be assumed that all medications are transmitted via breast milk. There is limited data on the long-term impact of these medications on the child. Fortunately, many of the medications used for OCD treatment have been detected at very low levels or below the threshold for detection when infant blood levels have been measured and in general infants whose mothers have taken SSRIs and other related medications have tolerated it well. Of course, any decision regarding taking medication should involve a discussion with the treating clinician to address the specific considerations for that person. For women who have OCD and are planning for a pregnancy or who discover they are pregnant, careful consideration needs to go into the decision whether to continue medication through pregnancy. The data about the specific medication needs to be weighed against their history and severity of illness off medication. Although there is substantial awareness about the potential side effects of medications, there is less appreciation for the impact of maternal stress and anxiety on the developing fetus and on the pregnancy. Untreated OCD during pregnancy is also a risk factor for postpartum depression as well. Some women do well off medication during pregnancy but may experience an exacerbation post-partum. Optimally the women with a diagnosis of OCD will take the opportunity to consider her options and preferences in advance of becoming pregnant while medication reduction or changes can be considered and when CBT skills and other therapy can be introduced if this had not been done before.
In Ms. J.’s case she had weaned her baby and wanted to start medication along with therapy. She had a trial of paroxetine that helped reduce her overall anxiety level and made it easier for her to implement ERP to fight back against the OCD symptoms. Even once her symptoms had subsided significantly, she felt discouraged and somewhat sad about the experience she had had in the early months of motherhood. Ms. J. was an accomplished person who set high standards for herself and believed that if she worked hard, she would be successful. Prior to becoming a mother, she had determined that anything short of perfection was not acceptable. As a new mother, however, she was confronted with the reality that no amount of reading or preparing guaranteed that she would always have the baby satisfied or her home under control. The intrusive thoughts she was having amplified the belief that she was failing as a mother. Addressing these beliefs helped her gain confidence and pleasure in her new role.
In recent years, celebrity memoirs and media attention have focused attention on postpartum depression. Even now, 15 years since I met Ms. J peri-natal anxiety disorders go unrecognized by many individuals. This is unfortunate because of the toll that untreated anxiety disorders takes on the woman as well as on her entire family. Hopefully with increased awareness, more women and their families will realize that there is help for these conditions as well.