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Prenatal and Postnatal OCD

Prenatal and Postnatal OCD

Obsessive–Compulsive Disorder (OCD) during pregnancy and after having a baby has, until recently, received relatively little research attention, despite being a significant problem that is now thought to affect 2–4% of all new mothers.

Some women develop OCD for the first time either during pregnancy or shortly afterwards, whilst others find that pre-existing OCD symptoms become worse.

Where OCD occurs during pregnancy this is referred to as prenatal or antenatal. It might alsobe referred to as perinatal if the OCD occurs during the period around birth (five months before and one month after). The word ‘perinatal’ is a hybrid of the Greek ‘peri’ meaning ‘around or about’ and ‘natal’ from the Latin ‘natus’ meaning ‘born’. Here in the UK, prenatal is perhaps the term you will be most familiar with.

Where OCD occurs after giving birth it is known as postnatal or postpartum OCD. Generally here in the UK postnatal would be the term used (postpartum is more frequently used in the US). Postnatal actually means ‘after birth’ in Latin.

The increase in the frequency of OCD is likely to be related to the fact that pregnancy and early parenthood is a time when mums are naturally focused on the safety of their developing child and feel uniquely responsible for them. During pregnancy women will read and hear many guidelines encouraging them to be more careful about their diet and behaviour, and frequent messages about the safety of various activities for their baby in the short- and longterm. Most women become a lot more concerned about protecting their baby and about how their actions can impact on their unborn child. It is also a time of increased stress, major physical change and transition to a new role which can increase vulnerability to developing difficulties.

Some fathers may also experience postnatal OCD because of their feeling of responsibility to protect their new baby, a strong indicator that hormonal factors are just part of the story.

In mothers with prenatal/postnatal OCD, the focus of the obsessions and compulsions is very similar to other forms of OCD, but usually the obsessions focus on the fear of purposely harming their newborn baby, or somehow being responsible for accidental harm.

It is important to note that the occasional experience of all of these worries is absolutely normal and indeed very common in mums and mums-to-be. However, some people find themselves so distressed that they will take measures to manage their anxiety or prevent their fears coming true. In this way the thoughts and behaviours can interfere significantly with their well-being and their experiences of pregnancy and parenting.

Perinatal OCD usually revolves around significant fear of harm coming to the infant, with worries frequently focused on accidentally harming the child, the child becoming ill or deliberately harming the child. It is important to note that the occasional experience of all of these worries is absolutely normal and indeed very common in mums and mums-to-be. However, some people find themselves so distressed that they will take measures to manage their anxiety or prevent their fears coming true. In this way the thoughts and behaviours can interfere significantly with their well-being and their experiences of pregnancy and parenting. It is the extent of, and response to, the worries rather than just having them, that becomes the problem.

For example, in pregnancy a woman may be very concerned that something she eats or touches may cause harm to the unborn baby. This may cause her to avoid and restrict foods, places and situations well beyond the recommended guidelines in order to keep as safe as possible, or at least feel that she has done everything in her power to do so. She may spend large amounts of time cleaning and washing and ask those around her to do the same. Women with such concerns may seek excessive reassurance from friends, family and professionals that the baby is developing satisfactorily and that her behaviour is ‘safe’. Unfortunately she will seldom be reassured by the answers given. After the birth, these concerns may revolve around other illnesses of childhood, with mums taking measures such as excessively checking their child when asleep so that she then does not sleep or relax at all herself.

Another common theme of perinatal OCD is thoughts of harming your own child. After the birth, many parents experience occasional fleeting thoughts that they may deliberately harm their baby, but are able to dismiss these as meaningless. Whilst many new mothers will have these thoughts of harming their baby, others with OCD interpret the very fact that they have these thoughts as meaning that they may act on them and become frightened about their potential to harm their child in a moment of madness. They may then avoid contact with the baby or take special measures to stay ‘safe’ around them such as hiding knives and sharp objects in the home.

Mothers with OCD do not act on their thoughts of harming their baby. If anything, most mothers with OCD go to extreme lengths to prevent the perceived threat of harm, which is what leads to the repetitive cycle of anxiety and fear.

The symptoms of prenatal and postnatal OCD vary widely from individual to individual, and like other forms of OCD, some mothers will experience many other symptoms related to OCD.

Whilst the list below is not exhaustive, it offers an insight into some of the common obsessions seen in prenatal and postnatal OCD:

  • intrusive thoughts of stabbing the newborn baby
  • intrusive thoughts of suffocating or drowning the newborn baby
  • unwanted images of throwing or dropping a baby
  • disturbing thoughts of sexually abusing a child
  • fear of accidentally harming a child through carelessness
  • intrusive thoughts of accidentally harming the foetus by exposure to medications, chemicals, or certain foods
  • fear of being responsible for giving a child a serious disease such as herpes or AIDS
  • fear of making a wrong decision (i.e., getting inoculations, feeding certain foods, taking antidepressants) leading to a serious or fatal outcome.

The list below (again, not exhaustive) offers an insight into some of the common compulsions seen in prenatal and postnatal OCD:

  • excessive washing of baby clothing
  • avoiding changing soiled nappies for fear of sexually abusing the baby or inadvertently touching them in an inappropriate way
  • excessive washing or sterilising of the baby’s bottles
  • excessive washing of other family members clothing
  • avoidance of feeding the baby for fear of accidental poisoning
  • isolating the baby from other people out of fear they might contaminate the baby
  • constant checking on the baby
  • hiding or throwing out knives, scissors, and other sharp objects
  • repeatedly asking family members for reassurance that no harm or abuse has been committed
  • avoidance of certain foods or medications for fear of harming the foetus
  • monitoring of self for perceived inappropriate sexual arousal
  • repeatedly and excessively checking on the baby as they sleep
  • mentally reviewing daily tasks and events in an attempt to get reassurance that one hasn’t harmed or been responsible for harm to the baby

These can have the result of leaving the mother feeling overwhelmed by the obsessions and the compulsions and this can also leave the mother with trouble sleeping because of the obsessive thoughts.

It may be particularly difficult for mums first to recognise their experiences as OCD and second to seek help due to the shame and secrecy associated with the illness, especially at a time when they themselves and those around them expect them to feel happy. As there is often a lack of awareness of OCD during pregnancy and postnatally, people are rarely asked about these experiences by professionals.

Despite recent breakthroughs in awareness, understanding and treatment of OCD, many GPs and mental health professionals may still not recognise the symptoms of OCD or even know how to correctly treat the disorder. Therefore, it’s important that you learn to recognise the behaviours and symptoms associated with it and, if seeking help for yourself or someone you care for, to understand which are the most appropriate treatments for OCD, how to access treatment on the NHS, or how to locate a suitably qualified therapist who is trained to treat the condition if private treatment is sought.

Unfortunately, prenatal/postnatal OCD is quite often misdiagnosed as being postnatal depression which often is co-morbid with the OCD, often as a result of the OCD. This can also happen because the person with OCD is often reluctant and embarrassed or even ashamed to talk about these thoughts and feelings because of a fear of being labelled ‘mad’, or being thought to be a risk to their newborn baby.

Everyone, from family members to friends, expects a new mother to be joyful; the impact of postnatal OCD goes far beyond the actual OCD symptoms. It can leave a new mother devastated and exhausted. In very severe cases, if left untreated it can negatively impact a mother’s ability to care for her child which creates potential for bonding problems and can cause depression. It can also have a devastating impact on the relationship with the mother’s partner, because of the extreme anxiety being experienced.

Knowing when to start a family is of course a very personal decision. How you are coping with your OCD is part of the equation; other factors may include how your partner will cope with any potential change in your health and how balanced your world is. Knowing that being pregnant and becoming a mother alters your hormone balance means you are forearmed with the knowledge that you will need to look after yourself more in a general sense – for example plenty of rest, good nutrition, exercise and low stress triggers.

For most mums who have OCD the most significant impact is on their quality of life as they try and cope with significant levels of distress and anxiety during pregnancy and beyond. The symptoms of OCD can make mums less available for their child both mentally and physically. Preoccupation with thoughts of danger and harm can prevent the person enjoying this special time of life and they may feel guilty and disappointed that they are not being the parent they wanted to be.

More directly, if a person is spending large amounts of time engaging in obsessional compulsions they will most probably have less time for other parenting tasks, such as playing with their child. Depending on a person’s fears, particular developmental stages of the child may present challenges, such as crawling around in potentially messy areas and mixing with other children.

OCD can be very difficult for family members of those suffering, who may be asked to provide reassurance or follow obsessional rules themselves. Often, mums worry about their child picking up on their fears and developing obsessional behaviours themselves, which can happen in some extreme cases, but is usually rare.
We do not know very much about the long-term impact of untreated parental OCD on children; however it is clear that many people manage to be excellent parents despite struggling with their own concerns. If you have OCD, it is best for everyone in the family if you seek help for yourself at the earliest opportunity which can help reduce and reverse any impact of the problem on you and those around you.

Perinatal and postpartum OCD is indeed a serious, but equally a very treatable medical condition. Receiving the very highest standards of care, support and treatment for OCD, and sticking to the treatment plan, are the key to long-term recovery from OCD, so that you and your newborn can enjoy a healthy OCD-free time of precious loving moments such as hugging and having fun together.

Kylie after the birth of one of her childrenOCD-UK chair, Kylie Cloke first experienced OCD whilst pregnant with her first child, click here to read Kylie's story.

Treatment of Prenatal or Postnatal OCD
Most women with postpartum OCD are strongly aware that their obsessions and compulsions are problemmatic, but they are often scared to seek treatment in case it means that they are deemed to be an unfit mother. However, if you think that you might be suffering from postpartum OCD, it's vital to seek treatment as soon as possible to ensure that it doesn't interfere with the time when you are bonding with your baby and spill over into other areas of your life.

The National Institute for Health and Clinical Excellence (NICE) guidelines for supporting and treating antenatal and postnatal mental health illnesses state that severe OCD in pregnant and postnatal women can be a serious problem for the mother, her baby and her family – initial treatment should generally be with psychological therapy.

They actually go on to say that women requiring psychological treatment should be seen for treatment normally within one month of initial assessment, and no longer than three months afterwards.

Fortunately, the treatment of prenatal/postnatal OCD is essentially the same as other aspects of OCD by using Cognitive Behavioural Therapy (CBT). In many cases, CBT alone is highly effective in treating OCD, but for some people with OCD a combination of CBT and medication is more effective.

Medication usually takes the form of antidepressants that act on the serotonin system, known as SSRIs (selective serotonin re-uptake inhibitors). Medication may reduce the anxiety enough for a person to start, and eventually succeed in therapy, but for pregnant or postnatal mothers this needs to be a carefully considered option as to whether the potential benefits of taking medication for the mother outweigh the possible risks to the developing foetus. It is thought that SSRIs can also be transferred to the baby through breast milk, although there’s currently no evidence to suggest that this would cause any problems in the long term. The NICE guidelines make the following medication recommendations:

  • A woman with OCD who is planning a pregnancy, or is already pregnant, should be treated according to the NICE clinical guidelines on OCD, unless she is taking medication alone.
  • Stopping the drug and starting psychological therapy should be considered. If she is not taking medication, starting psychological therapy should be considered before drug treatment and if she is taking Paroxetine (Paxil and Seroxat), it should be stopped and consideration given to taking a safer antidepressant.
  • A pregnant woman with OCD who is planning to breastfeed should be treated according to the NICE clinical guidelines on OCD, except that the use of a combination of Clomipramine (Anafranil) and Citalopram (Cipramil) should be avoided if possible.
  • A women who may have a new episode of OCD while breastfeeding should be treated according to the NICE clinical guidelines on OCD, except that the combination of Clomipramine (Anafranil) and Citalopram (Cipramil) should be avoided because of the high levels of the medication transferred through the breast milk.

If you are planning to become pregnant, it is important to discuss this beforehand with your GP or psychiatrist if possible. They will be able to advise you on the safest forms of treatment during pregnancy and breast-feeding. If you discover you are pregnant whilst already taking medication, do not stop the medication; instead make an appointment with your GP as soon as possible and ask to be referred to your local prenatal mental health service. The decision of medication during pregnancy and nursing needs to be weighed up in terms of the severity of the symptoms and the overall impact on your quality of life, with CBT being the preferred treatment of choice.

Left unchecked and untreated OCD will mushroom and feed upon itself and can have the power to consume if left unchallenged so it is important to seek professional medical advice and support the moment you recognise that your symptoms are interfering with your life.

Should you find you have difficulty accessing CBT during or after pregnancy then OCD-UK’s advocacy service may be able to help you pursue access to treatment.

Maintaining Recovery
Maintaining recovery for any ailment can be just as challenging as overcoming it initially. OCD is no any different – maintaining your recovery requires time and attention. So, what can you realistically do to help yourself? The following tips and techniques are designed to help you:

REACH for Recovery

  • Read, revise and be informed about OCD and CBT: allow this to be a natural part of your world,  for example having a cup of tea and reading for 20 minutes once a week.
  • Eat well: eat a healthy balanced diet – use our nutritional advice below.
  • Active: take regular exercise, a brisk 10-minute walk, a couple of times a week is a great way to start and you can take baby with you – fresh air often settles them.
  • Challenge your fears: try and include regular exposure exercises learned through CBT in your world – again challenging but not overwhelming
  • Have a good night’s sleep: of course this can be very difficult especially with a little baby – and even more so with an energetic toddler! If sleeping is a problem in your house then allow time to rest during the day.

Be an OCD–free mum
If you feel yourself leaning towards OCD rituals, find yourself an ‘OCD-free mum’ and try modelling your behaviour on them, i.e. when you find yourself in a situation where you would conduct rituals imagine you are your ‘OCD-free mum’ and then act as she would. The most important thing is to focus on recovery and enjoy your pregnancy and newborn baby and to remember that you’re not alone.

Thank you to Maria Bavetta, Dr Fiona Challacombe, Kylie Cloke and Diana Wilson for their help in compiling this information.

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