by Neha Hudepohl, MD, & Margaret Howard, PhD
Neha Shroff Hudepohl, MD, is Assistant Professor (Clinical) in the Department of Psychiatry and Human Behavior at Warren Alpert Medical School of Brown University, and Attending Psychiatrist at the Center for Women’s Behavioral Health at Women & Infants Hospital, Providence RI.
Margaret Howard, PhD, is the Professor of Psychiatry & Human Behavior (Clinical) and Medicine (Clinical) at Warren Alpert Medical School of Brown University; and the Division Director at the Center for Women’s Behavioral Health and Director of the Postpartum Depression Day Hospital at Women & Infants Hospital, Providence RI.
This article was initially published in the Winter 2014 edition of the OCD Newsletter.
Anxiety disorders in women during their pregnancies and in the months after giving birth are often under-recognized and undertreated, and can have significant impact on the health of the mother, infant, family, and mother–baby relationship. Obsessive anxiety is a common example of this, with many mothers worrying about the safety or well-being of their infants. This anxiety can worsen dramatically in the weeks and months after delivery and takes the form of obsessive compulsive disorder (OCD). It is typically referred to as either Perinatal OCD or Postpartum OCD, solely due to the timing of the symptoms as occurring during pregnancy or after childbirth.
Difficulties with recognizing and accurately diagnosing perinatal OCD are traced to several factors. First and foremost, mothers are often unwilling to disclose their symptoms due to guilt, shame, and fear of judgment by loved ones or health care providers. In addition, many medical and even mental health providers are not adequately trained to recognize and accurately diagnose anxiety disorders in the perinatal period. While screenings now commonly occur for postpartum depression, and many providers are trained to recognize this, the same providers may miss symptoms of anxiety or mistake them for signs of depression.
How Often Does Perinatal OCD Occur?
For reasons not fully understood, the perinatal period (from pregnancy to 12 months after childbirth) is a particularly vulnerable time for symptoms of OCD to appear, whether they be entirely new symptoms or a re-occurrence of OCD after a period of remission. The study of pregnant and postpartum women with OCD is relatively new, so there is not absolute clarity regarding how common this disorder is, but there is agreement that a majority of women with OCD who give birth have significant worsening of their symptoms. Additionally, women who have never been diagnosed with OCD can develop OCD symptoms following childbirth. Major depression is the most common co-occurring disorder, and one study found that over 40% of women with postpartum major depression also experienced repetitive, intrusive, unwanted thoughts of harm befalling their infants.
What Causes Perinatal OCD?
Theories suggest that some women are susceptible to the drastic changes in hormone levels that occur during pregnancy and the postpartum period, which in turn may influence brain chemical activity (the same type of brain activity we see in anxiety disorders). It is also thought that a rapid rise in oxytocin, a hormone that is central to the mother–infant bonding process, may trigger an exaggerated “protective” response in the form of obsessive thoughts and checking rituals. Additionally, psychological factors such as a heightened sense of responsibility and increased perception of threat can lead to the obsessional anxiety that is a hallmark of OCD.
What Does Perinatal OCD Look Like?
All new mothers experience anxious thoughts. It is considered normal and part of the process of adjusting to the new circumstances. Unfortunately, these anxious thoughts can transform into thoughts and images of harming the baby, such as “What if I drop the baby over the railing? What if I drown or burn the baby in the bathtub? What if I shake the baby? ” Other thoughts involve harm coming to the baby such as “What if the baby stops breathing when I’m not watching? What if the baby catches a deadly illness?” These thoughts are generally regarded as “harming infant thoughts” and are experienced by mothers as frightening, shameful, and unacceptable. For many new mothers, these thoughts go away on their own over time, with some reassurance, and extra sleep. For others, though, the thoughts are significantly unsettling and often accompany other symptoms of anxiety or depression. When these thoughts don’t recede or begin to get in the way of day-to-day functioning, the presence of OCD must be considered.
Perinatal OCD is characterized by intrusive unwanted thoughts (i.e., obsessions) about aggression toward or a fear of contamination of the infant. These obsessions can present as intense images of injury, death, or thoughts of physical or sexual harm. What distinguishes mothers with OCD from women who actually do harm their children is that women who do harm their children are typically psychotic and often under the influence of delusions or hallucinations wherein they may not feel particular anguish or conflict over these wishes. Women with OCD experience their obsessions as highly distressing and unwanted and are horrified by them.
Related compulsions include excessive checking behaviors (e.g., frequent checking on a healthy, sleeping infant), over-attachment to the infant, excessive cleaning and washing behaviors, avoidance of the infant, seeking repeated reassurance regarding the infant’s health and well-being, and other similar types of behaviors. Attachment and bonding between mother and infant may become disrupted, with potential negative impacts on infant development.
Difficult attachment between mother and infant can show up in many different ways. At times, the mother has a difficult time being away from her child and may not allow others to care for her child. When this occurs, family members (in particular fathers) can experience significant distress. On the other hand, some women may avoid their infant entirely or refuse to be alone with their infants, for fear of acting out their obsessions and often rely totally on others to care for their child. This can also have a significant impact on mother-infant attachment, family and interpersonal stress, and infant development.
Treatment of Perinatal OCD
Many women with perinatal OCD are daunted by the very treatments likely to help them: cognitive behavioral therapy (CBT) and medication.
Women with perinatal OCD can have difficulty with some of the more challenging aspects of CBT due to the severity and nature of their symptoms. Making things worse is the profound sleep deprivation typically experienced by the majority of postpartum women, and universally by those who are exclusively breastfeeding. Fortunately, interventions such as Exposure and Response Prevention (ERP) therapy (a specific type of CBT) have been shown to be highly effective in the treatment of OCD. However, to maximize benefits from CBT, some women may need medication treatment along with CBT.
Is Medication Safe?
The decision to take medication while pregnant or breastfeeding can be a difficult one, especially for a woman already grappling with fears of contaminating her child. First-line medication treatment for OCD involves the use of SSRIs to target OCD symptoms. SSRIs are the most studied medication in pregnancy and lactation, with more studies published on the use of these medications in the perinatal period than of any other group of medication. A handful of studies have been highlighted in the popular press associating SSRI use by pregnant women to various childhood disorders, however, it is important to consider these studies in the context of all of the research. While some of these studies have been repeated, the results have not been confirmed. For this reason, it is very important for mothers to be cautious when making treatment decisions based on a single article or study. Rather, talk to a doctor (be it your psychiatrist or physician) who has experience managing medication for pregnant and breastfeeding women and who can help you fully weigh the benefits and risks.
Overall, SSRIs are considered to be relatively safe for use in pregnancy and lactation; when compared with the risks of untreated anxiety, the consensus is that medications should be used in those whose OCD symptoms are getting in the way of their day-to-day functioning. In particular, studies on the use of fluoxetine and fluvoxamine have been done in postpartum OCD and appear beneficial in symptom reduction. In general, most perinatal psychiatrists will recommend that a woman takes what has worked for her symptoms in the past.
While SSRIs are thought to be relatively safe, they are not without drawbacks. SSRI use has been linked to early delivery and smaller babies, but it is unclear what impact the severity of the underlying depressive or anxiety symptoms has on these outcomes. In up to 30% of infants exposed to SSRIs in the third trimester, there can be a short term increase in irritability, jitteriness, lethargy, and fluctuating temperature known as “poor neonatal adaptation syndrome.” This is a time-limited condition, and infants go on to show normal development through infancy. Very small concentrations of SSRIs are secreted into breast milk, limiting the exposure to the breastfeeding infant. There is no evidence of developmental delay when infants are exposed to SSRIs in breast milk, and they are considered to be compatible with breastfeeding.
While less is known about the safety of other medications commonly used to treat OCD, this does not mean that they are unsafe; rather, this means that there is less published research on their use in the perinatal patient. Another medication commonly used to treat OCD is clomipramine (this is not an SSRI but called a tricyclic medication instead because it targets brain chemicals differently than SSRIs). Clomipramine has been linked to an increased risk of cardiac (i.e., heart defects) when used in early pregnancy, but there is limited information related to this. Clomipramine also increases the risk of the previously mentioned “poor neonatal adaptation syndrome.” Studies of clomipramine levels in breast milk show minimal transfer to the infant and there is no evidence of short or long-term adverse effects on infant development.
Other medications can be used to increase the effectiveness of SSRIs in OCD treatment, especially in patients whose symptoms only partly respond. Some of these medication options include those that as a group are called “antipsychotic medication” and “benzodiazepines”. Many of these have been studied in pregnancy and in breastfeeding and are considered to be safe when the need for use is warranted. In particular, the use of benzodiazepines for immediate relief of anxiety and insomnia can be helpful in the short term treatment of women with OCD.
At the end of the day, women must weigh the pro and cons for themselves, and discuss their options with their psychiatrist or physician. Perinatal OCD is a huge obstacle to maternal bonding and infant development, and in some cases, using medication to help restore that bond maybe may outweigh the risks of the medications themselves.
Perinatal OCD is a significant and disabling illness that frequently worsens in the postpartum period with the potential for negative impact on the health of the mother. Early diagnosis and effective treatment are extremely important, with the goal of alleviating suffering in mothers and minimizing potential adverse impact on mother-infant attachment. The link between childbearing and OCD needs further understanding. Research on traditional and emerging treatments for OCD must continue with a particular focus on pregnant and breastfeeding women and the effects of treatment on their children.
Are There Intensive Treatment Options for Perinatal OCD?
Intensive treatment programs provide more structured and frequent treatment than typical once-a-week therapy sessions, and can help with more severe cases.
One such program is the Women & Infants perinatal psychiatric partial hospital program in Providence, Rhode Island. This program was established in 2000 and is designed as a mother-baby unit, with the expectation that infants of postpartum women will accompany their mothers for the duration of treatment (6 hours/day for approximately 2 weeks). The program is designed for perinatal women suffering from mood and anxiety disorders who require intensive treatment and prefer non-medication based intervention; or if medication is required, treatment is provided by prescribers with expertise in pregnancy and lactation.
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