Perinatal Intrusive Thoughts
Many childbearing parents and their family members experience unwanted and unexpected thoughts, referred to as “intrusive thoughts,” during the perinatal period. These thoughts are common, and - though disturbing - do not meet criteria of a disorder. Intrusive thoughts which don’t resolve over time may be a precursor to obsessive compulsive disorder (OCD).
Obsessive Compulsive Disorder (OCD)
OCD is characterized by recurrent, persistent “intrusive” unwanted thoughts (obsessions) and/or repetitive, ritualistic behaviors (compulsions) that occur as a response to distress caused by obsessions (American Psychiatric Association, 2013).
Four common categories of obsessions and common compulsions include:
- Contamination - obsessive thoughts about contamination and illness, and cleaning compulsions
- Order/symmetry - symmetry obsessions, and ordering, arranging, repeating and counting compulsions
- Responsibility for harm - obsessions about causing or preventing harm, and checking, reassurance seeking and related compulsions (American Psychiatric Association, 2013; Olatunji, Ebesutani & Abramowitz, 2013).
- Unacceptable thoughts - aggressive, sexual, religious and somatic obsessions, and checking compulsions
Perinatal OCD
There is a higher incidence of OCD in pregnancy and during the postpartum than in the general population (Fairbrother et al., 2021). During the perinatal period, content of intrusive thoughts or “obsessions” is often related to accidental or intentional harm coming to the baby. The content of intrusive thoughts creates anxiety or distress, and the compulsions (rituals) that follow serve to reduce that distress. Compulsions may involve reassurance seeking, checking, and cleaning rituals which may or not be observable. Mental rituals which may not be observed like counting, silently repeating “special” words or numbers, and self-reassurance may also be present, and have the capacity to interfere with functioning just the same.
It is important to note that although obsessions often contain alarming content they do not represent a psychotic process and it is very unlikely that the thoughts will be acted upon. Avoidance of triggering situations is common, and will ultimately worsen the symptoms over time if not addressed. 70-100% of all new moms have intrusive thoughts of infant harm, and about 50% of all new moms have intrusive thoughts about intentionally harming their infant. Perinatal OCD is present in about 2 to 3% of all parents, though recent studies believe the number may actually be higher.
Other Symptoms and Features Can Include:
- Anxiety
- Fear
- Agitation
- Panic Attacks
- Social Isolation
- Hypervigilance
- Apprehension
- Guilt
- Depression
Perinatal OCD in Non-childbearing Parents
Fathers and other non-childbearing parents are not immune to new onset of intrusive thoughts and OCD during the perinatal period (Abramowitz et al., 2001; Coelho et al., 2014; Maina et al., 1999; Torresan et al., 2013).
Harm/Aggressive/Sexual Obsessions
Women with a postpartum-onset of OCD are more likely to endorse aggressive obsessions than postpartum women without OCD (Challacombe et al., 2016; Forray et al., 2010), women with pregnancy-onset OCD, and women with OCD unrelated to pregnancy (Uguz et al., 2007a). This suggests that changes in the type of primary obsessions can occur throughout the course of pregnancy and birth.
- For those with pregnancy-onset OCD, aggressive obsessions may center on the fetus or newborn (Maina et al., 1999; McGuinness, Blissett & Jones, 2011; Miller et al., 2013; Sichel, Cohen, Dimmock, & Rosenbaum, 1993; Uguz et al., 2007a; Uguz et al., 2007c; Zambaldi et al., 2009; Challacombe et al., 2016), including thoughts of accidentally or intentionally harming the infant as well as thoughts of sexually abusing the infant (Challacombe et al., 2016).
- Postpartum women with OCD in general, whether new- or prior-onset, are nine times more likely than women with pregnancy-onset OCD and healthy controls to endorse aggressive obsessions (Forray et al., 2010).
Regardless of onset, it is important to note that aggressive obsessions are unwanted/feel intrusive or hard to control, and cause those experiencing them a significant amount of distress (i.e. they are egodystonic). This is an important clinical distinction for differential diagnosis.
Common Perinatal Intrusive Thoughts (Obsessions) and Responses (Compulsions)
| Intrusive Thoughts (Obsessions) | Responses (Compulsions) |
| Drowning baby | Avoid bathing infant; Require another adult present to bathe child; Avoid being alone with infant; Attempts to suppress thought; Reassurance-seeking |
| Cutting baby | Avoid sharp objects while caring for child; Stop cooking with knives; Remove sharp objects from home; Attempts to suppress thought; Reassurance-seeking |
| Sexually abusing baby | Avoidance of changing diapers, Avoid being alone with infant, Avoid bathing baby, Confessing; Attempts to reassure self; Reassurance-seeking |
| Dropping baby | Have another caregiver carry baby downstairs; Avoid walking with child |
*This list is not exhaustive and demonstrates a few common obsessions and compulsions. Individual symptoms may be highly varied.
Misidentification of OCD by Professionals is Common and Troubling
- As many as half of non-psychiatrist physicians may misidentify OCD, with 80 percent misidentifying harm obsessions. (Glazier, Swing & McGinn, 2015).
- Nearly 70 percent of perinatal health practitioners did not accurately identify obsessions of harming the infant, and 30.8% misidentified these symptoms as psychotic (Mulcahy et al., 2020).
Differentiating Perinatal OCD from Psychosis
| Common Symptom | OCD | Psychosis |
| Thoughts/Beliefs | Described as unwanted intrusive thoughts, mental images, or urges | Visual, auditory, or olfactory stimuli (hallucinations) or delusions (beliefs) |
| Response to Thoughts | Attempts to prevent harm, increase certainty, or alleviate distress in the form of compulsions | Thoughts are not always bothersome (may be ego-syntonic) but delusions are not based in reality; may act on delusions or command hallucinations |
| Repetitive Behaviors | Compulsions to alleviate distress or uncertainty or prevent a feared catastrophe | May be present as a response to delusions or hallucinations, not typically a means of reducing distress |
| Reality Testing | Insight typically observed | Delusions may be present |
| Symptom Presence | Consistent | May wax and wane |
Misidentifying aggressive obsessions may lead to harmful interventions.
In one study, 58% of perinatal health professionals recommended contraindicated strategies including:
- Violence risk assessment-44.3%
- Having someone else care for the child-6.8%
- Involvement of child protective services-9.1%
- Prohibiting the mother from being alone with the infant-18.2% (Mulcahy et al., 2020).
- Prescribing anti-psychotic agents rather than CBT and/or SSRIs (Glazier, Swing, & Mcginn, 2015).