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Postpartum Depression: Diagnosis and Treatment
Postpartum Depression: Diagnosis and Treatment

Section 10
New Parents with OCD

CEU Question 10 | CEU Test | Table of Contents | Depression
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In the last section, we continued our discussion of anxiety.  This included untreated anxiety, when a child is truly at risk, and ghosts in the nursery.

Do you have a client who suffers from obsessive fears of accidentally hurting her baby?  Does she engage in ritualistic behavior to avoid the possibility of accidentally injuring the baby? 

In this section, we will discuss obsessive-compulsive disorder.  This will include prenatal and postpartum OCD and preventing potential dangers of prenatal and postpartum OCD.  If you are already familiar with obsessive-compulsive disorder, you might use this section as a review.

Obsessive-compulsive disorder, or OCD, is a psychiatric illness that affects 2 to 3% of the general population, with symptoms sometimes beginning as early as age 8.  The "obsessive" component of the disorder refers to the person’s experience of recurrent, unwanted, intrusive, negative thoughts that produce an enormous amount of distress.  The person knows these thoughts are not normal yet has no control over them despite all efforts to resist.  The obsessions can take on many themes, including concerns about or fear of contamination, aggression or violence, symmetry, sex, religion, and death or illness.

Because these thoughts are so disturbing, the person who experiences them engages in ritualistic behaviors designed to avoid the anxiety they produce.  Those acts, the "compulsive" component of the disorder, which might include checking, praying, repeating, counting, and hand washing, then become so compelling that they themselves effectively take over the person’s life.

According to the DSM, obsessions are defined by four characteristics, including recurrent, persistent thoughts, impulses or images, which are intrusive and inappropriate, causing marked anxiety; thoughts, impulses or images that are not simply excessive worries about real-life problems; the person who attempts to ignore, suppress, or neutralize the thoughts with some other thought or action; and the person recognizes obsessive thoughts to be a product of his or her own mind.

Compulsions are defined by two characteristics, including repetitive behaviors, such as hand washing, that the person is driven to perform in response to an obsession and the behaviors or mental acts are aimed at preventing or reducing stress.

♦ Prenatal and Postpartum OCD
First, let’s discuss prenatal and postpartum OCD.  I have found that obsessive, intrusive thoughts of women and their partners can follow the birth of their babies, even if they have no previous psychiatric diagnosis. 

Some of these include thoughts of suffocation, such as "Maybe my baby rolled over and died from SIDS," thoughts of accidents like "I think of the neighbor’s dog attacking my baby," unwanted ideas of or urges toward intentional harm such as "Would she be brain-damaged if I threw her out the window?"  thoughts of illness or losing the infant, unacceptable sexual thoughts such as "I thought about the baby’s genitals," and, finally, contaminations. 

In healthy, new parents, even though thoughts like these may be common, they are generally not intense.  The thoughts usually happen in passing, and they do not involve accompanying compulsive or ritualistic behaviors.  Full-fledged obsessive-compulsive disorder is quite different.

Women with preexisting symptoms of OCD often experience a worsening of their symptoms in pregnancy.  Mina, for example, was a client of mine who had been seriously afflicted with OCD since the age of fourteen.  She became pregnant while beginning treated with an SSRI in combination with regular visits to a psychologist for cognitive behavior therapy.

Being in a stable, happy marriage and seeing many of her contemporaries and peers becoming pregnant, Mina decided to become pregnant.  Luckily, she was wise enough to continue both her medication and her therapy.  One of Mina’s obsessions before becoming pregnant had been the thought that she would sexually touch other women.  During pregnancy, this obsession turned into "What if I sexually touch my baby?"

As it happened, when she had an amniocentesis Mina learned that she was carrying a girl.  The thought that she might accidentally sexually touch her baby girl persisted throughout Mina’s pregnancy, and after she gave birth, I had to make some home visits and literally stand by her side to help her with the diaper changes until, with several weeks of this exposure therapy, Mina was able to change her daughter’s diaper without help.

With or without accompanying compulsive behaviors, however, the obsessive thoughts of women during pregnancy or postpartum generally involve the baby.  Anxiety-provoking thoughts of actually harming the child are most common and may involve obsession about stabbing the newborn with a knife, harming the infant while he is sleeping by accidentally shaking, strangling or choking him, or inadvertently sexually molesting him by touching him inappropriately. 

Some of my clients tell me that many of these thoughts are accompanied by horrific, frighteningly vivid images of how the baby gets hurt.  For example, some visualize mistakenly throwing their child into the microwave or down a flight of steps, or accidentally driving him into oncoming traffic.

♦ Preventing Potential Dangers of Prenatal and Postpartum OCD
Second, in addition to prenatal and postpartum OCD, let’s discuss preventing potential dangers of prenatal and postpartum OCD.  OCD, either during pregnancy or postpartum, may lead to the mother avoiding her baby, and when that happens, attachment and bonding issues become critical.  But these unfortunate consequences can be avoided if the illness is detected by primary health care providers during the pregnancy. 

I would go even a step further and say that some clients who exhibit symptoms of prenatal or postpartum depression may also be experiencing symptoms of OCD, because, as you may know, clients with OCD do not often openly talk about their illness.  They are often very afraid that their babies will be taken away, they are usually filled with shame, and they need to feel safe in order to share their feelings.

Do you have a client who struggles with obsessive thoughts who is pregnant or considering pregnancy?  Might she benefit from hearing this section in your next session? 

In this section, we have discussed obsessive-compulsive disorder.  This has included prenatal and postpartum OCD and preventing potential dangers of prenatal and postpartum OCD.

In the next section, we will discuss Post-Traumatic Stress Disorder and Postpartum.  This will include PTSD and pregnancy and childbirth and PTSD.

Peer-Reviewed Journal Article References:
Abramowitz, J. S., Deacon, B. J., Olatunji, B. O., Wheaton, M. G., Berman, N. C., Losardo, D., Timpano, K. R., McGrath, P. B., Riemann, B. C., Adams, T., Björgvinsson, T., Storch, E. A., & Hale, L. R. (2010). Assessment of obsessive-compulsive symptom dimensions: Development and evaluation of the Dimensional Obsessive-Compulsive Scale. Psychological Assessment, 22(1), 180–198.

Blum, L. D., Horenstein, A., Carper, M. M., Stange, J. P., Cohen, J. N., Doyle, A., & Smith, V. (2020). A new instrument to assess counterdependency, evaluated in the context of postpartum depression. Psychoanalytic Psychology. Advance online publication. 

Comer, J. S., Furr, J. M., Kerns, C. E., Miguel, E., Coxe, S., Elkins, R. M., Carpenter, A. L., Cornacchio, D., Cooper-Vince, C. E., DeSerisy, M., Chou, T., Sanchez, A. L., Khanna, M., Franklin, M. E., Garcia, A. M., & Freeman, J. B. (2017). Internet-delivered, family-based treatment for early-onset OCD: A pilot randomized trial. Journal of Consulting and Clinical Psychology, 85(2), 178–186. 

Cordes, K., Smith-Nielsen, J., Tharner, A., Katznelson, H., Steele, H., & Væver, M. (2017). Reflective functioning in postpartum depressed women with and without comorbid personality disorder. Psychoanalytic Psychology, 34(4), 414–421.

Kita, S., Hayashi, M., Umeshita, K., Tobe, H., Uehara, N., Matsunaga, M., & Kamibeppu, K. (2020). Intimate partner violence and maternal child abuse: The mediating effects of mothers’ postnatal depression, mother-to-infant bonding failure, and hostile attributions to children’s behaviors. Psychology of Violence, 10(3), 279–289. 

Kudinova, A. Y., Woody, M. L., James, K. M., Burkhouse, K. L., Feurer, C., Foster, C. E., & Gibb, B. E. (2019). Maternal major depression and synchrony of facial affect during mother-child interactions. Journal of Abnormal Psychology, 128(4), 284–294. 

Online Continuing Education QUESTION 10
What are some examples of disturbing thoughts that new parents might experience, that may be intensified in clients with OCD? To select and enter your answer go to CEU Test.

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