There is growing awareness of perinatal depression, but anxiety disorders are more common and often overlooked, affecting up to 30% of pregnant women. There is less awareness still of perinatal obsessive compulsive disorder (OCD), yet up to 40 out of 100 anxious and/or depressed women also report obsessional, intrusive thoughts of harming the baby.
A 2012 meta-analysis reported a significantly higher risk of OCD in pregnant and post-partum women than in non-pregnant women. Important risk factors include genetic, hormonal, neuroendocrine and immunological.
Those prone to anxiety by temperament or pre-existing anxiety or impulse control disorders are more vulnerable to developing OCD. Trichotillomania, body dysmorphic disorder, skin picking disorder and hoarding disorder are often co-morbid with OCD.
Working women, particularly those with perfectionistic tendencies, are often susceptible. They often strive to excel, upholding themselves to relentlessly high (and unrealistic) self-standards; the unpredictability and early chaos of motherhood can rattle their sense of competence and make them question their self-worth. An exaggerated sense of accountability increases shame and guilt over perceived minor failures.
Although they know that many anxieties are irrational, they are compelled to go to extreme lengths to prevent the perceived threat of harm. This then creates a cycle of anxiety and, sometimes, counterbalancing compulsions.
These mothers tend to suffer in silence, unable to share their sense of failure in carrying such a responsibility to keep the dependent baby alive. They are driven to conceal their problems, worrying if they disclose obsessional thoughts their babies will be placed in care.
Obsessional thoughts post-partum can include ruminations of harm to the infant, but these are not associated with actual harm (unlike the delusions in a psychotic disorder). Therefore, it is important to distinguish obsessive ruminations from delusions and provide reassurance to suffering mothers, who are usually less likely to intentionally harm their babies due to associated avoidant behaviours.
Obsessional thoughts, impulses or images can feel very disturbing during an already vulnerable life transition, further heightening anxiety and fear, which may develop into avoiding the baby while questioning her fitness to parent. The anxious ruminations can overwhelm the mother’s coping defences, resulting in shame and torment and, if left untreated, lead to suicidal ideas.
Many new mothers with OCD are understandably too ashamed or embarrassed to confide in others, or to seek help. Often, they will not share their fears even with their partner or health professionals. Importantly, the ruminations and compulsions often divert the mother from interacting with her baby, potentially resulting in attachment disruption and behavioural disturbance in the infant.
Anguish increases with the hungry, screaming baby’s escalating rage while kept waiting for the mother, who may become avoidant of holding them, or keep the baby waiting for the next feed as feeding bottles and equipment are laboriously sterilised. The tormented parent may become hypervigilant, constantly checking their baby is safe or breathing when asleep. Compulsive rituals such as these may temporarily calm the mind, but often feel shameful and stressful.
Prevention and treatment
Generally, pregnant women welcome inquiry about their emotional wellbeing. This can bring relief and reduce feelings of stress and isolation, mitigating societal pressure to be happy and excited at this time. Introducing discussion early as part of routine antenatal care reduces stigma and increases the chance that problems will be identified early enabling helpful psychoeducation.
Organic screening is important for identifying any underlying biological determinants that may be contributing, (e.g. thyroid dysfunction, iron deficiency anaemia, vitamin D, B12 and folate deficiencies), especially in new onset depression or anxiety postnatally.
Providing a ‘safe non-judgmental space’ is paramount to engendering a trusting therapeutic relationship. Clinicians are often unaware of their own powerful capacity to represent or trigger positive or negative images of the internalised ‘maternal imago’ (e.g., arouse fear, self-criticism or create a comforting experience).
Reassurance that intrusive thoughts of accidental or deliberate harm to the baby, accompanied by guilt or shame in harbouring such thoughts, is common, and will be valued. This can be normalised as a symptom of perinatal anxiety or depression. Sensitive assessment of suicidal and infanticidal ideation dictates the appropriate level of supervision, whether at home with family support, in secondary health services, or in an inpatient psychiatric mother and baby unit.
Helping a mother understand the underlying causes of her suffering improves self-esteem and promotes confidence during a potentially frightening time, when she is in a state of transformation.
Each woman’s representations of her mental image of an archetypal or idealised mother in pregnancy are unique – a composite of derivations of her emotional autobiography, psychosocial situation and unconscious make-up.
Irrational concerns can be overcome by safely exploring the parent’s fears in psychotherapy.
Cognitive behavioural therapy (CBT) is particularly effective in helping people with OCD by gradual exposure and managing anxieties without resorting to compulsive rituals.
Short-term anxiolytics such as Lorazepam, with or without SSRI agents, may be useful. Individualised risk benefit analyses are needed when weighing indication for psychotropic drugs in the perinatal period, accounting for the risk of untreated illness on the mother and foetus or infant.
Author competing interests- nil