OCD around childbirth

Introduction

During pregnancy and around childbirth, strongly distressing thoughts can arise and feel frightening. Very few people never have thoughts like these, but for some they develop into a major problem. It is often a problem people keep to themselves while trying to understand why the thoughts are there and trying to prevent them from coming up. What is distinctive in this situation is that the way the thoughts are handled becomes a large part of the problem, and this can develop into OCD, in Danish described with the terms obsessions and compulsions.

When OCD develops after childbirth, it is called postpartum OCD, often abbreviated ppOCD, or in Danish efterfødsels-OCD. Parents with postpartum OCD often experience unwanted aggressive or sexual thoughts about their baby. Becoming a parent means taking responsibility for protecting and caring for a new, fragile life. That can be both overwhelming and frightening, and it can be difficult to understand how aggressive or sexual thoughts can arise about the little person for whom one feels such deep love.

What is postpartum OCD?

For some mothers and fathers, becoming a parent can trigger postpartum OCD. It is a common anxiety-related condition in which a person experiences violent and disturbing thoughts, images or impulses. Symptoms can begin suddenly after the new baby has arrived, or existing OCD symptoms can intensify with the new responsibility of parenthood.

Postpartum OCD can involve all forms of OCD symptoms, but the most common themes are thoughts about causing harm or thoughts of a sexual nature. Harm thoughts can involve both fear of causing harm by accident and fear of doing so deliberately.

Commonly occurring thoughts

Unwanted violent thoughts

An example of unwanted violent thoughts could be a mother of a baby with colic who, frustrated by the baby’s crying, gets an image of herself throwing the baby out of an open window from the third floor of the apartment building. The thought appears unexpectedly and causes anxiety and distress, and the mother becomes very frightened and upset that she has had the thought. She may think: “Why am I having this thought? Does it mean I might be capable of harming my child? What if I lose control and throw my child down the stairs? A decent mother would not have thoughts like this.” Afterwards, she may avoid going near the apartment windows while carrying her child, or hold the child extra tightly against her body near windows. She may have to repeatedly reassure herself that all the apartment windows are closed, or she may now become afraid of going to her child when the child cries because she fears the thoughts will return, or that she could do something impulsive or dangerous. She may try to get others to look after the child if possible, while also feeling great guilt and sorrow about this.

Unwanted sexual thoughts

Another common type of thought is unwanted thoughts of a sexual nature about one’s own child. They will often be strongest around nappy changes or bathing. They can occur as thoughts, such as “What if I touch my child in an inappropriate way?” or “What if I become aroused by it?”, as images involving sexual scenes, or as a feeling of an impulse to do something sexual in relation to the child. As a result of this thought, a person may think: “What kind of person gets thoughts like this? Does it mean I am a paedophile, or that I could harm my child? This is sick. I should not have thoughts like this. What would others think if they knew what I was thinking?” This creates an experience of shame and fear, which gives rise to anxiety and avoidance behaviour, and which then maintains the OCD.

Unwanted thoughts about danger to the child

A third common type of thought is a recurring fear that something has happened to the baby, for example that the child is lying in the pram and has stopped breathing or is choking on something. The mother or father may think: “It is my responsibility to prevent any kind of harm to my child. If I have a thought that something may have happened to my child, I have to check immediately. The slightest hesitation could have fatal consequences. Any decent parent would do that. If I have a thought and do not follow up on it, and my baby dies, it will be my fault.” These thoughts, and the way the thoughts are interpreted, can then mean that the pram and other things have to be checked countless times. Each time, the shocking possibility that the child is dying is introduced. That would be exhausting for any parent.

How do I notice if my partner or relative has postpartum OCD?

External signs that OCD may be involved can include the following:

• avoiding holding the child or sitting with the child
• excessive washing or sterilising of bottles and other things the baby puts in its mouth
• excessive washing of baby clothes, family clothes, and cleaning of the surroundings around the baby
• isolating the baby to prevent family members or others from “contaminating” or “infecting” the baby
• constantly checking the baby, such as the baby’s breathing, safety and so on
• the parent in question seeks reassurance from others about being a good mother or father, or that a given action has not harmed the child

The external, visible signs can be “the tip of an iceberg” filled with obsessions and compulsions, but they can also be completely within normal behaviour. There are large individual differences in how much cleaning, hygiene precautions and supervision people aim for in everyday life and around a newborn. The above therefore does not necessarily have to be a sign of OCD, but it should be a cause for concern.

Postpartum depression and postpartum OCD

Postpartum depression and postpartum OCD often occur together, but both the person who is depressed and the professionals treating them often overlook that OCD is involved. An American study showed that postpartum OCD occurred alongside postpartum depression in 57% of cases.

Many people feel ashamed of the thoughts and keep them to themselves. They try to get rid of them through attempts at thought control, but contrary to the intended effect, trying to control the thoughts intensifies the unwanted thoughts. This often happens both in terms of frequency and intensity, and the thoughts spread to more and more situations.

It is also important to be aware that the experience of the thoughts and the subsequent way of handling them is an enormous burden at an already demanding time, because of the new little family member. This can result in depression-like reactions where the real problem is the OCD.

Why does postpartum OCD develop?

Research cannot tell us this conclusively. Often, there will have been an unrecognised OCD problem before the onset of postpartum OCD. The vast majority of parents experience unwanted thoughts about harming their child, and if a person already has a tendency to develop OCD, it will often show itself here.

Postpartum OCD is far more common than previously assumed. An American study, referenced at the end of this article, shows that around 10-11% of women experience OCD after childbirth. Unfortunately, there is no corresponding measurement for men, but it must be assumed that the rate is also high.

Treatment of OCD

OCD can be treated effectively with targeted cognitive behavioural therapy. Medication is also possible and can have some effect, but it is often unwanted because of breastfeeding. The results of well-delivered cognitive behavioural therapy are also so good that it is a strong first choice. In severe cases, it will be necessary for this to be carried out by a specialist in OCD.

Pregnancy OCD

It should be noted that there is also a larger group of women, and men, who experience distressing and unwanted thoughts in connection with pregnancy, and distressing thoughts about being able to harm the foetus. This might be through food intake, bacteria, or perhaps thoughts that take on a magical character. For example: “If I see a disabled person, then my child will also become disabled.” It can also be a distressingly intense focus on everything having to be optimal around the foetus and the pregnancy, where a sense of fragility and repeated catastrophic thoughts keep the focus fixed on this. “If the baby’s conditions are not 100% optimal all the time, then it is my fault if the baby becomes disabled or is miscarried.” This may, for example, relate to the mother’s condition, sleep, food intake, vitamin supplements, exposure to pesticides in everyday life and so on.

Postpartum OCD and men

The article has primarily focused on postpartum OCD with the mother as the starting point. This is a stylistic choice made for the sake of readability. It should be mentioned, however, that men also experience OCD related to pregnancy and childbirth. Many of the themes can be the same as those illustrated in the article, but a larger proportion develop secondary OCD problems where the focus is directed more towards other factors than directly towards the child. For example: “To keep my family safe, I must not start actions at specific times of day” or “By thinking about or seeing certain words, I bring misfortune to us.” This indirect postpartum OCD can also occur in women, but in practice a greater number of secondary OCD types are seen in men.

For those interested in the research

An American study from 2009 (Miller et al., 2009) followed 461 women in the period after childbirth to examine the prevalence of OCD symptoms in a general population sample. The 461 participants in the study came from an ordinary maternity clinic in the United States. Tests for anxiety, depression and OCD were carried out 2 weeks and 6 months after childbirth.

At 2 weeks after childbirth, 11% of the women tested positive for OCD symptoms. At 6 months after childbirth, half of these still had OCD, while an additional 5.4% had developed new OCD symptoms. The new group with OCD symptoms, 5.4%, also had indications of depression and anxiety at the 2-week assessment, and there was a clear correlation between these two measurements.

OCD is generally estimated to affect between 2-3% of people over their lifetime, while this study shows that between 10-11% of women experience OCD symptoms above the diagnostic threshold after childbirth. The study therefore demonstrates that the problem is far more widespread than previously assumed, and that there is good reason to believe that OCD is often overlooked.