Pregnancy and birthing are very special and transformative moments. Both are emotionally charged experiences that are as magical as they are complex, a bridge to another phase of life, a new geography where wonder, excitement and stressful demands converge. For some women, however, the profound biological changes and life transitions of maternity impact emotions, which can often trigger the onset of psychiatric symptoms or worsen those that predate pregnancy. Decades of research have shown that one such condition, depression, occurs in up to 25% of women in the postpartum (PPD). Awareness of PPD has consequently translated into timely diagnosis and treatment for millions of women at risk. While postpartum depression has achieved an iconic status as the central psychological challenge for women, little attention has been given to anxiety during this stage of a women’s life. Over the past 10 years, however, researchers have increasingly turned their attention to perinatal anxiety disorders. This new generation of data has shown that pre and post-natal anxiety disorders/symptoms occur, at least, at the same rate as depression.
It is well established that women experience anxiety at far greater rates than do men. Large sample studies have shown that more than a third of US women will meet criteria for at least one clinical anxiety disorder at some point in their lives. Not surprisingly, the rates of maternal anxiety are also high but do vary widely across studies (15-45%). Researchers attribute this variation to different types of assessments used, different points in time measured and lack of uniform protocols and diagnostic criteria across studies and countries. It is important to note that, during maternity, less severe obsessive compulsive symptoms (OCS)- occur at 4 times the rate of clinical OCD. Finally, as in the general population, anxiety and depression also often occur together and overlap in complex ways during pregnancy and in the postpartum. Current research is looking at how to tease out primary depression from the mood depletion that is, in fact, secondary to untreated anxiety.
In spite of this new body of data, it is curious but also concerning that maternal anxiety continues to be clinically grayed out, under diagnosed and often just overlooked. In trying to understand why, I think it is important to consider two points: one, concerns the reality that medical education and medical practice, too often, still overlook the psychological dimensions of patients. Exceptions to this can be found at times in pediatrics or sensitive physicians; but they are exceptions. As a result, behavioral health is rarely an integral part of our medical care. Consequently, when a woman begins her obstetric journey, the information needed for adequate behavioral health assessment and preventative care is not in place. Unless a woman has received some form of psychological evaluation or treatment in the past, mental health screening during pregnancy and/or in the postpartum is the only opportunity to identify behavioral health risk and/or conditions.
Another problem is that in general anxiety is still trivialized more than it is recognized as a serious psychological condition that can deplete and disable. As noted earlier, in maternity, postpartum depression has gained status as an important mental health concern. Unfortunately, because of it’s second tier status, many of the behavioral health questionnaires used in obstetrics to not thoroughly screen for anxiety. If these screening tools do not adequately evaluate prenatal anxiety or postpartum obsessional anxiety syndromes this last opportunity can be missed.
In terms of risk, studies show that women entering maternity with a prior diagnosis of anxiety or depression are more likely to experience an increase or recurrence of symptoms compared to women not previously diagnosed. However, it is important to note that even women with no prior diagnosis, can develop some mild, moderate or even severe anxiety at any point during pregnancy or following childbirth Examples of other factors that can be associated with an increased risk of maternal anxiety include: first pregnancy, premenstrual dysphoric disorder (PMDD), prior history of abortion and/or miscarriage, obstetric complications and medical conditions, unplanned pregnancies, lack of support of partner/spouse and socioeconomic or other life stressors.
- Obsessive compulsive type symptoms-of lesser severity and lasting less than 6 months
- Obsessive Compulsive Disorder
- Generalized Anxiety Disorder
- Panic Disorder
Not surprisingly, maternal anxiety themes involve the health, well-being and safety of infant, self and family. This usually gives rise to adaptive anxiety characterized by heightened awareness and appropriate vigilance.This normal reaction can become problematic if assumptions of danger occur by default when, in fact, there is no evidence of such a threat in reality. The many fears, worries and behaviors in maternal anxiety generally remain organized around themes of protection but follow a changing developmental path through the different phases of maternity from pregnancy, continuing into delivery and the postpartum and- at times beyond. Below I have listed common fears and fear-driven behaviors that can occur during pregnancy and postpartum:
- Fears, worries and obsessions
- Chemical or environmental contaminants
- Bacterial contamination
- Viral contamination
- Congenital disease and fetal development
- Miscarriage/birthing/delivery/pain tolerance
- Mother’s health and well-being, including weight
- Need for a just right environment
- Panic symptoms
- Behaviors and actions
- Avoidance of activities/situations/people
- Excessive sanitizing, washing/cleaning
- Excessive reassurance-seeking, mental reviewing
- Constant reassurance-seeking from family or friends.
- Excessive reassurance seeking from OBGYN
- Excessive planning and need for control
- Panic related safety behaviors
In The Postpartum
- Fears, worries and obsessions
- Sudden Infant Death Syndrome (SIDs)
- Infant safety fears
- Fear of infant choking
- Fear of infant suffocating
- Fear of accidents
- Infant health: fear of diseases or illness
- Fear of Autism
- Fear developmental delays
- Distrust ability to care for infant
- Doubts about breast feeding and appropriate bonding
- Fears about one’s own health
- Obsessional need for symmetry, arranging and order.
- Concerns about dropping the baby or accidentally harming the infant
- Panic symptoms
- Unacceptable “thoughts” of harming or mistreating infant. ( See “ The Shadow World” below)
- Behaviors and actions
- Checking infant’s breathing excessively or uncontrollably at night.
- Excessive and repeated checking of situations or activities for signs of danger.
- Avoidance of all activities or situations where contamination or infection are feared.
- Excessive, cleaning, sanitizing.
- Forcing others who come in contact with infant to excessively clean and sanitize.
- Not allowing others to visit the home or not allowing others to have physical contact with the infant when there is no evidence of risk
- Refusing to go out in public or irrationally limiting going out.
- Excessive reassurance seeking from medical providers, family and friends regarding the infant’s wellbeing
- Persistent and uncontrollable internet checking for reassurance
- Need for perfectionistic order and imposting rigid rules and order
- Panic related safety behaviors
- Avoiding time alone or doing certain activities with the infant (in response to intrusions of harm.
Anxiety disorders that occur during maternity have the same characteristics as those seen in the general population, and therefore CBT and Inferential Based Approach (IBA) methods are also used to treat perinatal anxiety. However, it is important that the unique developmental moment and self narratives of maternity be incorporated into treatment. Over time, examples of how I treat the most common types of maternal anxiety seen in my practice will be added to this page. For the moment, I have chosen to present a description of what I consider to be one of the most challenging postpartum psychiatric conditions a woman can experience: repugnant, tormenting intrusions and unacceptable thoughts.
The Shadow World: Tormenting Postpartum Obsessions
I get pictures in mind of my baby downing ..what if I really want to do this ?
I have been worrying a lot about dropping my baby. Does this mean I really want to drop her ?
The thought of hurting my baby is terrifying. This cannot be normal. Maybe this means I am going crazy ?
Maybe I am turning into one of those women I have seen on the news, and I can’t tell my doctor I am having these, thoughts, she might take my baby away.
- Women with postpartum obsessions develop a fear of self that drives them into a kind of private hell without compass or companion
In my opinion, obsessional OCD, in general, is probably the most under-diagnosed psychiatric syndrome, owing to the morally repulsive nature of the obsessional themes. For postpartum women, this stigma increases exponentially given the theme of infant care. Consequently, rarely, will postpartum obsessional women seek help, fearing that their baby will be taken away, that they will be reported to social services or hospitalized. Worst yet, many women suffering these obsessions often will not disclose even to close friends or family, fearing that they will be viewed as dangerous, crazy, unfit to parent or even abandoned. Women with postpartum obsessions As a result, too often, treatment is very delayed or not received at all.
Preventative education is the best defense against maternal anxiety in general; but it is especially critical in postpartum obsessions. Excessive washing and checking can reach a point of debilitating severity and can certainly cause great suffering and embarrassment. But at least these types of OCD are more visible and not morally stigmatized.Tormenting postpartum obsessions are hidden from sight and there is an enormous barrier to reaching out Oftentimes, the only lifeline for a woman suffering from tormenting obsessions is information. Yes, information!
Knowledge about this syndrome, what it is, how it works, how it deceives and, most of all, what it IS NOT, can empower a woman to come forward and seek treatment. A sad paradox here is that obsessional OCD is very responsive to good cognitive and behavioral therapy. As I have described on the Obsessive Compulsive Disorder page of this site, I have seen great success using the Inferential Based Approach to treat OCD, in general and tormenting obsessions in particular. Whatever the CBT approach used, women suffering in the shadows, should come forward and seek consultation with a trusted medical or mental health provider.