Intrusive thoughts postpartum are scary. I have had several patients describe their fears to me – fears that they might do something to harm their baby because these intrusive thoughts pop into their minds. The thought of dropping the baby, the thought of throwing the baby down the stairs or out the window, the thought of injuring the baby.
Often, women are very hesitant to bring this up to anyone. First, for fear that they will be viewed as a bad mother. Second, for fear that their baby might be taken away. Neither will happen!
A physician is considered a mandatory reporter, meaning if I receive information that a child is being harmed, I must contact protective services. However, never have I done this when a woman describes ego-dystonic (meaning, the thoughts are scary and do not feel like the right thing to do) intrusive thoughts like this. The fact that these thoughts are scary and ego-dystonic is actually reassuring. It means you are not likely to harm your baby at all. You are more likely to engage in avoidance behaviors to keep everyone safe.
Yet by avoiding your baby, while you believe you are keeping the baby safe, you are hurting the attachment between mom and baby. During the critical postpartum period, it is essential for mom and baby to bond in a secure and meaningful way, as this will set the child up well for developing in a healthy way later in infancy, in childhood, and as an adult.
Intrusive Thoughts are Common
Intrusive thoughts do not necessarily means a diagnosis of OCD, however. As many as 50 – 65% of new parents experience intrusive thoughts related to infant safety or harm. Some studies note as many as 90% of postpartum women have mild, transient intrusive thoughts. It is important to know that postpartum intrusive thoughts and OCD can happen to fathers as well.
There have been some interesting studies that have looked at intrusive thoughts and asked participants to describe them in severity. Most describe them as “passing,” though some report “repetitive,” and a smaller portion engage in activity/behavior around the thoughts.
The majority of obsessive and compulsive behaviors postpartum are subclinical. One study found that only half of women reporting OCD symptoms postpartum actually met the criteria for true Obsessive-Compulsive Disorder. Yet while they may not meet criteria for a formal diagnosis, they are still suffering. In this particular group, many of these “subclinical” women struggled with significant symptoms of depression and anxiety.
The Impact of Intrusive Thoughts
Postpartum, the intrusive thoughts often relate to harm befalling the infant, including thoughts of harming the infant, leading to compulsive avoidance or checking behaviors (meaning leaving the room or leaving the baby or repeatedly checking when it is not necessary). This can significantly impact a postpartum woman’s ability to rest and rejuvenate during this vulnerable time.
If you are checking throughout the night that the baby is breathing, rather than sleeping, you will not be able to rest during the however short windows of time that you have. And that lack of rest can predispose to other mental health issues such as depression. Perhaps this is why 40% of women with OCD also experience postpartum depression.
Similarly, if the intrusive thoughts you have are about doing something harmful to the infant, you might find yourself avoiding your baby, which impairs the attachment and bonding relationship.
If you find yourself over-protective or extra vigilant due to these intrusive thoughts, it may also affect the relationship between your baby and your partner. If anxiety is much too high to allow the baby to be cared for by anyone other than yourself, then your partner does not have a chance to bond.
The Psychology behind Intrusive Thoughts
The psychology literature described two types of bias that can make intrusive thoughts distressing. First, an intrusive thought passes through your mind. This happens all the time. For example, if you are standing and waiting for the train, the thought of falling in front of it might pass through your mind. This does not mean you want to harm yourself and in fact you might take a small step backwards. When the train arrives, you get on and think nothing more about it.
Similarly, if you are bathing your infant, the intrusive thought pops in that the baby might drown or even that you might do something to make that happen. If you are predisposed to OCD, however, it is difficult to let that thought go the same way that the thought about the train was released. Instead, you might succumb to the probability bias – the notion that merely thinking about something increases the likelihood it will happen. This is not true.
Thinking about your baby drowning does not increase the chance that he will, and neither does thinking about the train make that scenario more likely. But a woman with OCD might get stuck on this thought and due to that bias have to do something to compensate – perhaps avoid ever bathing her baby.
The second is the morality bias – the notion that merely thinking about something bad is the equivalent of doing the bad action. Thinking about dropping your baby is not the same as doing so. But if a mind is predisposed to OCD, it views those two things the same way and tries to compensate, perhaps by avoiding the baby.
When Intrusive Thoughts are a symptom of Postpartum OCD
Unlike other types of OCD, postpartum OCD symptoms often come on suddenly, usually within the first two weeks postpartum. Worsening of OCD occurs in 29-50% of women postpartum. And new onset OCD happens for women postpartum in 11-47% of cases.
Another way to look at the data is that postpartum women have almost a two-fold risk of OCD compared to the general population. Biologically, the explanation for this higher risk is related to the interaction of gonadal hormones (estrogen and progesterone) with neurotransmitters in the brain.
When Intrusive Thoughts are actually dangerous
We discussed the ego-dystonic thoughts of OCD – thoughts that are distressing to a person and feel not a part of their usual personality. In contrast, patients who suffer from postpartum psychosis might have ego-syntonic thoughts of harming themselves or their infant. These are thoughts that feel like they are the right thing to do. For example, this might be the certainty that because the world is evil and trying to cause the family harm, killing the baby is in the baby’s best interest.
Additionally, when a woman has a history of certain personality disorder traits, such as impulsive behavior, self-harm behaviors, and unstable sense of self, the risk that she might do something to harm the baby is elevated.
Neither of these conditions is associated with the intrusive thoughts of OCD.
Treatment for OCD postpartum
There are many verified successful treatment options for OCD in general, which can be adapted for the postpartum mom. The first is psychotherapy. Two types in particular are effective: cognitive-behavioral therapy (CBT) and exposure and response prevention (ERP). The CBT helps a woman better manage her cognitions and some of the biases we discussed above. Cognitive behavioral therapy is very effective for OCD, with some studies noting as much as a 60-70% reduction in symptoms.
ERP teaches how to tolerate the distress of the obsessive/intrusive thought without engaging in the compulsive or avoiding behavior and with repeated practice, decreases the levels of anxiety.
The second treatment option is medication management. Selective serotonin reuptake inhibitors (SSRIs, discussed in detail in this article) are effective, as are some other types of older antidepressants (such as tricyclic antidepressants).
The important point is that there are treatment solutions for women whose intrusive thoughts are significantly interfering with their ability to enjoy the postpartum period and care for themselves and their babies.
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Forray, A. Onset and exacerbation of obsessive-compulsive disorder in pregnancy and the postpartum period. (2010) Journal of Clinical Psychiatry 71(8): 1061-68.
Abramowitz, J.S. Obsessive-compulsive smptoms in pregnancy and the puerperium: A review of the literature. (2003) Anxiety Disorders 17: 461-478.
Miller, E.S. et. al. Obsessions and compulsions in postpartum women without Obsessive Compulsive Disorder. (2015) Journal of Women’s Health 24: 825.
Russell, E.J. Fawcell, J.M. Mazmanian, D. Risk of obsessive-compulsive disorder in pregnant and postpartum women: A meta-analysis. (2013) Journal of Clinical Psychiatry 74(4): 377-385.