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.
Any anxiety disorder can persist, worsen, improve-or sometimes start-during pregnancy and/or in the postpartum. Given the themes of maternity, however, the anxiety conditions most commonly seen are:
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:
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.
Many people experience intrusions-words, phrases, thoughts or images that occasionally flash through the mind. The content of these can be mundane or can involve themes we find disturbing, such as aggression, blasphemy or sexuality. Most people quickly dismiss these as meaningless, mental noise and just move on. These fleeting mosquitos of the mind can, however, become tormenting obsessions for a small percent of the population, who find these intrusions so unsettling that they begin to fear them. Obsessional OCD, characterized by this type of self distrust, can be quite disruptive, as it can drive the sufferer underground, seeking refuge in silence and avoidance.
As described above, anxiety is likely to increase during new parenthood. Given the abrupt hormonal shifts, the sudden pulse of responsibility and the heightened sense of the newborn’s vulnerability, such intrusions occur my frequently in the postpartum. As with other types of maternal fears, unwanted intrusions in the postpartum, center on the well-being of the newborn, but with a cruel twist: postpartum intrusions usually involve fears of infant death or fears of actually intentionally harming one’s infant through acts of aggression, violence or even unthinkable sexual behavior. Given this repulsive content, the maternal mission and the significant there can be a lower threshold for dismissing such intrusions as meaningless.
New research currently being conducted in Canada suggests that, in fact, postpartum intrusions of harm toward the newborn are not uncommon. Fortunately, not all women experience these; and if they do, most can ride through the storm. Some, however, can interpret such intrusions as meaningful and possibly representing something they might actually want to do. This is the point of cross over from intrusion to obsession, and this is the shadow world of tormenting postpartum obsessions.
- Women with postpartum obsessions develop a fear of self that drives them into a kind of private hell without compass or companion
That’s been one of my mantras — focus and simplicity. Simple can be harder than complex; you have to work hard to get your thinking clean to make it simple.
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.