By Krista Post, MA, LP
Holding her 9-month-old son, a young mother cries in my office as she describes thoughts of drowning her child. A new mother, just two weeks postpartum, shamefully explains that her own mother is now changing all her baby’s diapers—she is terrified she might sexually harm her daughter. These women fear that I will call Child Protective Services. They fear they will “snap” and harm their children. Saying these thoughts out loud feels incredibly risky and shameful. After all, how could a mother think such things?
Constant and persistent intrusive thoughts and images—along with the avoidant and compulsive behaviors that accompany them—plague up to 11% of pregnant and postpartum women (Brandes et al., 2004; Miller, 2013). These thoughts may be as simple yet relentlessly debilitating as an obsessive fear of germs, leading to excessive cleaning and use of hand sanitizer. Or, they may involve intrusive violent, sexual, or morbid thoughts that cause deep shame and terror.
These thoughts are not psychotic or perverse—they are symptoms of perinatal OCD. They disrupt the mother-baby bonding process, isolate women from their loved ones, and precipitate secondary anxiety symptoms and major depression.
The Overlooked Side of Perinatal Mental Health
Awareness of perinatal mental health has grown tremendously over the past decade. It has become part of everyday conversation to refer to postpartum depression simply as postpartum, as in: “My best friend suffered from postpartum.”
Recently, the U.S. Preventive Services Task Force recommended that physicians routinely screen women for perinatal depression during pregnancy and the postpartum period (Siu, 2016). Many states have adopted laws requiring mandatory depression screening for postpartum women. And yet, perinatal anxiety disorders remain overlooked.
Even when her baby is sleeping, another mother has not slept for more than two hours at a time—constantly checking, terrified that her baby might die of SIDS. One mother, a psychologist, has startling images of hanging herself or being committed to the state hospital.
These experiences are not uncommon: 15-21% of pregnant women experience moderate to severe symptoms of depression, and up to 21% of postpartum women suffer from depression (Wisner et al., 2013). If you are poor, African American, or a teenager, your risk of postpartum depression increases to 60% (Earls, 2010).
Despite these statistics, perinatal anxiety is often ignored or not taken seriously. Many of my patients tell me they were screened for depression at every prenatal visit but were never asked about their symptoms of anxiety—symptoms consistent with panic disorder, generalized anxiety disorder, OCD, or PTSD. These include panic attacks, excessive worry, obsessive thoughts and compulsions, traumatic flashbacks, difficulty sleeping, hyper-vigilance, and an exaggerated startle response.
And if we don’t ask, women don’t tell. This is especially true of pOCD. What woman wants to admit that she has stopped bathing her baby out of fear? That she has locked all the knives and scissors in the trunk of her car to protect her child? Women with these terrifying thoughts assume they are going crazy. They fear that speaking up will lead to being committed or having their children taken away.
The Misdiagnosis and Trauma of Perinatal OCD
I continue to meet women in my practice who sought help from their doctors, only to be hospitalized as psychotic—separated from their babies, unable to breastfeed them. These women are traumatized and discharged feeling more “crazy” than when they were admitted. The reality? The actual risk of a woman with intrusive thoughts acting on them is virtually zero (Miller, 2013; Fairbrother & Abramowitz, 2007). These thoughts are simply manifestations of anxiety.
When a woman is deeply distressed by the thoughts and images she’s experiencing, they are called ego-dystonic thoughts—they go against her values and beliefs. Her fear of these thoughts is actually a good sign. She vigilantly avoids activities or situations she believes could put her baby at risk. Her fear distinguishes her from someone experiencing psychosis.
Women with postpartum psychosis, on the other hand, actively believe their delusions—these thoughts are ego-syntonic. Andrea Yates, who drowned her five children in a bathtub in 2001, believed she was saving them from going to hell. Within her delusion, she was committing a loving act.
Postpartum psychosis occurs in only 1-2 out of 1,000 women (Sit et al., 2006; Nonacs, 2005). While only 4-5% of postpartum women have delusions related to harming themselves or their child, there is a 5% risk of suicide and a 4% risk of infanticide (Sit et al., 2006). This is why postpartum psychosis is considered a medical emergency requiring immediate treatment.
Hope and Healing
One mother I saw had recurring, horrifying images of strangling her baby. She told no one. For six months, she avoided looking at her daughter and always carried her facing outward. This obsessive-compulsive experience is the result of a complex body-mind chemistry set to high alert. The hormonal transitions of pregnancy, birth, and breastfeeding pose a significant risk factor for the onset or exacerbation of OCD. The prevalence of perinatal OCD is twice that of OCD in the general population (Fairbrother & Abramowitz, 2007). Clearly, the disorder makes it difficult to tap into the rich joys of motherhood—let alone lead a normal life.
The good news? Treatment for perinatal OCD is available. When clinicians recognize a mother’s symptoms, she can receive the help she needs. Increasingly, OBs, nurses, midwives, and doulas are being trained to recognize and treat perinatal mental health disorders. More and more therapists—many of whom have experienced difficult perinatal adjustments themselves—are specializing in treating and supporting mothers with pOCD and other perinatal mood and anxiety disorders.
If you or someone you know is struggling, reach out to PHA Wellness today—help is available.
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About the Author:
Krista Post, MA, LP, is a psychologist practicing in Minneapolis, Minnesota. She is the clinical director of The Postpartum Counseling, Infertility, & Perinatal Loss Center, a clinic specializing in perinatal mood and anxiety disorders, infertility, and perinatal bereavement. Krista is a founding member and former director of Pregnancy & Postpartum Support MN (PPSM) and currently serves as a Minnesota state coordinator for Postpartum Support International (PSI). She provides training and supervision for therapists seeking expertise in reproductive and perinatal mental health.