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Perinatal obsessive-compulsive disorder needs better recognition and treatment

This is the second week of our Maternal Mental Health series, which is dedicated to perinatal Obsessive-compulsive disorder (OCD). In honour of OCD Awareness Week, we are publishing two blogs, one from Maria Bavetta, co-founder of the charity Maternal OCD, about her personal experience of dealing with and overcoming perinatal OCD, and another by King’s College London researcher Dr Fiona Challacombe that focuses on what we know about this condition and the challenges that need to be addressed in research in order to help treat these individuals.

My name is Fiona Challacombe, I’m a clinical psychologist and researcher in the field of perinatal mental health. For many years I have been researching and working with perinatal OCD, which occurs at the time of pregnancy or after having a baby. This was an almost unknown issue when I began work in this area about 15 years ago when almost everything was considered to be postnatal depression (depression occurring after childbirth). We have come a long way since then, but perinatal OCD can sometimes still be met with misunderstanding, which can get in the way of treatment.

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OCD is a condition whereby unwanted thoughts (also known as obsessions), which might be verbal, images or urges, occur in a person’s mind that makes them worried about a potential danger. Importantly, this is a danger that they could either cause or prevent, which leads to particular actions (compulsions) to prevent this danger, or at least, try and do as much as they possibly can to prevent it. The danger may be external, for example, some form of contamination that could cause illness, or it can be internal, such as a thought that you could harm someone close to you.

We know that these types of thoughts are very common and most people experience them, but research has shown that parents of young babies are very likely to experience these thoughts frequently, especially in the early months. This makes sense, as it is a time when many parents are preoccupied with their baby’s safety and getting things right as they learn on the job, often feeling very uncertain and sleep-deprived. We know that parental thoughts of accidentally causing harm to the baby (“Is the bath water too hot?” “What if I drop her?”) affect nearly all parents. We also know that about half of new parents will also say that they experience unpleasant intrusive thoughts of doing deliberate harm (“What if I abuse my baby?” “What if I put them in the microwave?”).

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The theory behind this is that there is some kind of evolutionary protection mechanism that throws up all sorts of ideas of possible threats that keep parents safety-focused at a time when their babies are most vulnerable in the early months. But we all experience such thoughts from time to time.

While most parents find the thoughts mildly unpleasant, and some may even engage in avoidance or other responses, these won’t become excessive, and the thoughts become less frequent. However, for others, the thoughts become very difficult to dismiss, and they begin to try too hard to respond to them. This is due to interpretations about what the thoughts mean, for example, that each one is a signal that cannot be ignored or they would be irresponsible, or that having the thought itself may mean that they are a bad person.

It is this level of meaning that distinguishes someone who has OCD and is spending time and effort trying to prevent harm, from those who respond differently. This idea is very important for clinicians to be able to make a correct diagnosis and distinguish OCD from other problems that may also involve intrusive thoughts of harming the baby and can be associated with increased risk, such as psychotic depression or postpartum psychosis. This is not the case for people with OCD. Getting this wrong can be very detrimental as it prolongs the problem and causes considerable distress for parents.

People with perinatal OCD have often had OCD before, or perhaps some symptoms of OCD that don’t meet the full threshold for a disorder in the past, but the perinatal period provides a new context that ups the ante in terms of both responsibility and stress. For those who have experienced OCD in the past, it is not uncommon for it to morph, to now revolve around the baby and caregiving. Usually, this is the focus for those with a new incident disorder at this time.

OCD affects about 1–2% of people at any one time, and our research shows that it is much more common in pregnancy and increases postnatally, possibly affecting up to 7% of women. It’s clear that some non-birthing partners also experience perinatal OCD but we do not have good prevalence figures yet. However, this demonstrates how important the perinatal context is.

We do know that only a relatively small percentage of people with perinatal OCD seek treatment — this may be due to fears of being misunderstood, or a lack of accessible treatments.

A type of talking therapy called cognitive-behaviour therapy (CBT) is a very well-evidenced treatment for OCD, and it is acceptable to women, who generally prefer psychological therapies in the perinatal period.

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We have tested out time-intensive versions in our clinic, where we deliver the whole course of treatment in twelve hours over two weeks followed by more spaced-out follow-ups. In our treatment trial, this format worked well for women with postnatal OCD, with many commenting that it allowed them to focus on therapy and put it into practice. Organising childcare around four afternoons rather than twelve weeks was much easier!

We need more research on the best way to deliver therapy for perinatal OCD, and how best to treat those women for whom the OCD is more longstanding, perhaps starting before they have a baby, in order to put them in the best position for parenting.

Our research trial also showed that OCD did not affect mother-infant attachment, but it certainly impacted the woman’s daily life and enjoyment of parenting, leaving many with feelings of guilt that they had even been unwell at this time. These feelings persisted even when the OCD symptoms improved, so more support for women around parenting in addition to the treatment of their difficulties could make for the ideal treatment package.

We have come a long way in raising awareness, but these difficulties remain. The increasing knowledge of perinatal OCD and unwanted intrusive thoughts amongst parents and healthcare professionals should help to prevent difficulties for some women and get those who need it into treatment more quickly.

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