Perinatal OCD

Having a baby brings many changes and this can be stressful. Many pregnant women and new mothers have a normal (and probably helpful) rise in obsessive or compulsive-like symptoms (1). Most mothers feel that having a baby is a huge responsibility. It is normal to worry about your child's wellbeing and to want to protect your baby. You may be more careful about avoiding risks in pregnancy or after birth.

You may worry if you have normal, but unexpected, thoughts about your baby being harmed. Many mothers have these, but do not find them to be a problem.

For some, these normal worries can trigger or worsen symptoms of OCD. The symptoms can interfere with life. They will usually bother you for at least an hour a day, and often much more than that.

The main symptoms of Perinatal OCD are:

Obsessions

These are unwanted thoughts, images, urges or doubts. These happen repeatedly and can make you very distressed. Common examples are:

• Intense fear that something is contaminated by germs or dirt. You find yourself worrying that  your baby will be harmed by contamination.
• Worries about something you did or didn’t do. You may worry that you have left your doors or windows unlocked, or not sterilised your baby’s bottle correctly.
• An image (a picture in your mind), or a thought, of harming someone. You may worry that you will accidentally or deliberately harm your baby, including sexual and violent thoughts. We know that people with OCD don't become violent or act on these thoughts.
• Perfectionism. You may try to get everything exactly “right”.

• You may feel anxious, fearful, guilty, disgusted or depressed.
• You feel better (in the short term) if you carry out your compulsive behaviour. This doesn't help for long.

Compulsions

These are the things you feel you need to do to reduce your anxiety, or to prevent what you fear from happening. They include:

• Rituals - e.g. washing, cleaning or sterilising repetitively and excessively. This can take up so much time that it stops you doing other things you need to do.
• Checking - e.g. repeatedly checking your baby throughout the night to ensure he/she is breathing.
• Seeking reassurance - repeatedly asking others to tell you that everything is alright.
• Correcting obsessional thoughts by counting, praying or saying a special word over and over again. This may feel as though it prevents bad things from happening. It can also be a way of trying to get rid of unpleasant thoughts or pictures in your mind.
• Avoiding feared situations or activities. Someone with OCD will often avoid things that may trigger obsessions or compulsions. If you have perinatal OCD, you may avoid nappy changing, or hide all your knives. You may not attend mother and baby groups. Some women avoid spending time alone with their baby.

In Perinatal OCD, symptoms are often focussed on the baby. However, obsessions and compulsions can focus on many different things.

Although mothers with OCD may fear harming their baby, they are not a risk to their babies. There are no recorded cases of people with OCD acting on their obsessional thoughts. However, OCD can cause problems if you have to avoid lots of things or, for example, excessively use cleaning products. Suicidal feelings are rare, but other problems such as severe depression can cause difficulties in bonding with your baby.

Perinatal OCD can be mild or severe and can affect a range of experiences and care-giving tasks. It can affect your confidence, your relationship with your partner² and your overall quality of life.³ You tend to sleep badly, feel tired and feel depressed.⁴ 

Most women with OCD can care for their baby and other children well, despite their symptoms. For some it can be very disabling and can have a major impact on them and their families. If this happens, you may need a lot of practical help and support.

Perinatal OCD may also stop you from enjoying your pregnancy and being a mother as much as you would otherwise have done. Fortunately, it is very treatable. You should see your GP as soon as possible if you think you have Perinatal OCD and are not already having treatment.

Recognising Perinatal OCD

A woman with Perinatal OCD will often realise that her symptoms are unreasonable or excessive, although this can be harder to see if you are very anxious. You may worry that your symptoms mean that you are a bad mother, or that you are "going mad". It can make you feel embarrassed or ashamed. You should try not to worry about this. Perinatal OCD is an illness and can be treated. It's not your fault.

Sometimes Perinatal OCD is not diagnosed – but it is important that your GP or psychiatrist identifies OCD so that they can distinguish it from other disorders. These may include postnatal depression or postpartum psychosis. Once your Perinatal OCD is recognised, you can get the right treatment.

Many women experience mild mood changes after having a baby. It is common to feel many different emotions. Over half of new mothers will have the 'Baby Blues'.

This usually starts 3 to 4 days after birth. You may have mood swings. You may burst into tears easily. You can feel irritable, low and anxious at times. You may also over-react to things. It usually stops by the time your baby is about 10 days old. You don't need treatment for Baby Blues.

Women can have many different mental disorders in pregnancy and the postpartum period, just like at other times.

Depression and anxiety are the most common mental health problems in pregnancy. They affect 10-15 in every 100 women.^5,6 For further information, see our leaflet on 'Mental health in pregnancy'.

Postnatal depression

This affects 10 to 15 in every 100 women after childbirth.⁵ The symptoms are similar to those in depression at other times. These include low mood and other symptoms lasting at least two weeks. Women with depression can experience obsessional thoughts.

Perinatal OCD is quite different from depression. Many women have a sense that, if the OCD improves, then any depression will also lift. Some women with Perinatal OCD may also have depression, which requires treatment in its own right. For further information, see our page on 'Postnatal Depression'.

Postpartum Psychosis

This is the most severe type of mental illness that happens after having a baby. It affects 1-2 in 1000 women ⁷ and starts within days or weeks of childbirth. It can develop in a few hours and can be life-threatening, so needs urgent treatment.

There are many symptoms that may occur. Your mood may be high or low and there are often rapid mood swings. Women often experience psychotic symptoms. They may believe things that are not true (delusions) or see or hear things that are not there (hallucinations).

The illness always needs medical help and support. You may have to go into hospital. Ideally, this should be to a specialist Mother and Baby Unit where you can go with you. For further information, see our page on Mother and Baby Units.

Although postpartum psychosis is a serious condition, the vast majority of women make a full recovery. For further information, see our page on 'Postpartum Psychosis'.

About 1 in every 50 people has OCD at some time in their lives (8). At any one time about 1 in every 100 people has OCD.⁸

OCD affects 2 in 100 women in pregnancy⁹ and 2 -3 in every 100 women in the year after giving birth.⁹

Perinatal OCD may be more likely in first time mothers but you can have it during or after any pregnancy. If you have had OCD before, you are more likely to get perinatal OCD.¹⁰

There are lots of factors that might cause someone to develop perinatal OCD. Hormones may be a factor for some women. OCD can also run in families.

Lots of different genetic differences can be involved in whether and how someone develops OCD. At the moment, it isn’t known if perinatal OCD has the same genetic risk factors as OCD. Perinatal OCD has also been reported in fathers.^11,12

For about a third of women who already have OCD, pregnancy and childbirth can make this worse.¹⁰ For some women, pregnancy and birth have no impact or can even improve symptoms.

If you have OCD for the first time in pregnancy, it may get better soon after birth. However, it can continue, and keep coming back later in life if you do not get the right treatment.

If perinatal OCD starts after your baby is born, it can happen very suddenly days or weeks after giving birth. For some women, the onset is more gradual.  If you have OCD in your first pregnancy you are more likely to have it again in your second pregnancy.¹⁰

The help and treatment you need depends on how severe your perinatal OCD is. Your GP, midwife and health visitor can help you decide what kind of help you need.

Everyone can try the self-help suggestions below. If this is not enough, you may benefit from a talking therapy or medication (see below). Your GP can advise you about these treatments.

Some women with perinatal OCD will need help from mental health services. In some areas, there are perinatal mental health services. These are specialist services for women who are pregnant or in the first postnatal year. Your GP, midwife or health visitor can refer you. This is usually only needed for women with more severe illnesses. For more information, see our page on Perinatal Mental Health Services.

If you cannot look after yourself or your baby, or if you have plans to harm yourself, you should be seen urgently by:

• your GP
• a mental health service
• your local Accident & Emergency Department

Rarely women may need admission to hospital. In that case, you should usually be admitted to a specialist Mother and Baby Unit with your baby. See our page on Mother & Baby Units for more information.

Self-help

Tell someone how you feel. It can be a huge relief to talk to someone understanding. This may be your partner, a relative or friend. If you can't talk to your family and friends, talk to your GP, health visitor or midwife. They will know what help is available in your area.

Learn about OCD. Become an expert on the disorder and how it makes you feel. You can learn to recognise the physical and mental symptoms common in OCD. This will help when you are feeling challenged with an OCD fear.

Self-help workbooks. You can use these on your own or with professional guidance. Homework will aid your recovery.

Maintain energy levels and general wellbeing. Recovery requires a lot of energy. Take every opportunity to get some sleep and rest. Think about what really needs doing now and what can wait. Accept offers of help from family and friends. This will mean you focus on getting better.

Self-help groups. Attend a group with other mothers who have perinatal OCD, run by someone who is an expert on OCD. This will help you to realise you are not alone. The group can become a support group during your recovery.

Don't blame yourself. It's not your fault.

Don't use alcohol or drugs to control your anxiety.

The two main treatments are Cognitive Behavioural Therapy and Medication.^12-16 These can be used alone or in combination.

Cognitive Behavioural Therapy (CBT)

This is a talking therapy. CBT helps you examine patterns of thoughts and behaviour that distressing you. You will usually see a therapist on a weekly basis. Sometimes you can attend a full course of sessions over a shorter period. For further information, see our page on OCD with further details of CBT for OCD.

Medication

Antidepressants are used to treat OCD. There are several antidepressants you can try. The ones most commonly used for OCD are called Selective Serotonin Reuptake Inhibitors (SSRIs). Sometimes other medications are added. For further information, see our page on Antidepressants.

Is medication safe in pregnancy and breastfeeding?

Decisions about whether or not to take medication in pregnancy, or when breastfeeding, are not straightforward. You need to decide what is best in your individual case. It is important to discuss medication with your GP or psychiatrist. They will give you information to help you decide what is best for you and your baby.

If you have OCD and are planning a pregnancy, you should talk to your doctor before you become pregnant. However, many pregnancies are unplanned. In that case, you should see your doctor as soon as you know you are pregnant. It is very important that you don't stop medication suddenly, unless your doctor tells you to. Stopping treatment suddenly can cause people to relapse quickly. It can also cause side-effects.

Many women need to take medication in pregnancy and when breastfeeding. This can be for mental or physical health problems. Many women take antidepressants in pregnancy and when breastfeeding.

Your doctor can help you to think carefully about the advantages and disadvantages of medications in pregnancy or when breastfeeding. Some medications have been used in pregnancy for many years. In many cases, we simply do not have enough information to be absolutely sure that a treatment is safe. In order to decide what is right for you, you should think about:

• How unwell have you been in the past?
• How quickly do you become unwell when you stop medication?
• Medications you have taken before:
  • which medication has helped you most?
  • have some medicines caused side-effects?
• Up-to-date information about the safety of medications in pregnancy and breastfeeding. Discuss this with your doctor.
• How easy or difficult is it to access CBT in your area? Discuss with your doctor.
• What might happen if you are unwell during pregnancy or after birth? This may include:
  • Not taking good care of yourself.
  • Not attending antenatal appointments. This means you may not get the care you need.
  • Using more alcohol or drugs. This can be harmful to your unborn baby.
  • Needing a higher dose medication if you become ill. Sometimes you may need two or more medications to treat a relapse. This might be more risky for your unborn baby than if you take a standard dose of medication throughout pregnancy.
  • Needing in-patient treatment.
  • Finding it more difficult to care for your baby.
•  If your illness is not treated, this may be more harmful for your baby than the effect of medication. For example, some research studies have found babies are more likely to have low birth-weight if their mother has depression in pregnancy.¹⁷ There is no information available about how untreated OCD affects your unborn baby. 

Understand OCD. Read about the disorder and learn about the symptoms. A mother suffering from Perinatal OCD may appear to be very rigid. However, she is just trying to get through the day.

Be supportive. Sometimes a mother may feel ashamed to admit she is unwell. She may worry about the stigma of having a mental illness. Support her to find out more information about perinatal OCD. This will help to normalise the disorder.

Make time for yourself. Being around a mother with Perinatal OCD, and a baby or child too, can be exhausting. Ensure you are also looking after yourself.

Be reassured: mothers with Perinatal OCD are not at risk of acting on their thoughts.

Level of involvement. Families often get involved in the compulsions of OCD. Having a good understanding of what is driving these can really help mother and partner to limit this.  If the mother has therapy, it may be useful to become involved in the homework tasks. Suggest attending one session so you can understand what you can do at home. This may include encouraging exposure to something the mother fears. It may mean saying ‘no’ to assisting compulsive rituals.

For more information, see our page on Perinatal OCD for carers.

• Break Free From OCD - Dr Fiona Challacombe, Dr Victoria Bream Oldfield and Prof Paul Salkovskis ISBN 978-0-09-193969-4

• Cognitive Behavioural Therapy for Dummies – Rob Willson and Rhena Branch ISBN )-470-01838-0

• Overcoming Obsessive Compulsive Disorder – David Veale & Rob Willson ISBN 1-84119-936-2

• Dropping the Baby and Other Scary Thoughts – Karen Kleiman and Amy Wenzel ISBN 978-1-138-87271. 

1. Fairbrother N, Woody SR. New mothers' thoughts of harm related to the newborn. Arch Womens Ment Health. 2008; 11: 221-9.
2. Challacombe FL, Salkovskis PM, Woolgar M, Wilkinson EL, Read J & Acheson R. Parenting and mother-infant interactions in the context of maternal postpartum obsessive-compulsive disorder: Effects of obsessional symptoms and mood. Infant Behav Dev. 2016; 44:11-20.
3. Gezginc K, Uguz F, Karatayli S, Zeytinci E, Askin R, Guler O et al. The impact of obsessive-compulsive disorder in pregnancy on quality of life. Int J Psychiatry Clin Pract. 2008;12:134-137.
4. Fairbrother N, Thordarson DS, Challacobe FL & Sakaluk JK. Correlates and Predictors of New Mothers’ Responses to Postpartum Thoughts of Accidental and Intentional Harm and Obsessive Compulsive Symptoms. Behav Cogn Psyhcother. 2018; 46; 437-453
5. Woody C, Ferrari A, Siskind D, Whiteford H, Harris M. A systematic review and meta-regression of the prevalence and incidence of perinatal depression. J Affect Disord.2017; 219 :86-92.
6. Dennis CL, Falah-Hassani K, Shiri R.Prevalence of antenatal and postnatal anxiety: systematic review and meta-analysis. Br J Psychiatry. 2017;210 :315-323.
7. VanderKruik R, Barreix M, Chou D, Allen T, Say L, Cohen LS. The global prevalence of postpartum psychosis: a systematic review. BMC Psychiatry. 2017; 17 : 272.
8. Ruscio AM, Stein DJ, Chiu WT & Kessler RC. The Epidemiology of Obsessive-Compulsive Disorder in the National Comorbidity Survey Replication. Mol Psychiatry. 2010; 15 : 53–63.
9. Russell EJ, Fawcett JM, Mazmanian D. Risk of obsessive-compulsive disorder in pregnant and postpartum women: a meta-analysis. J Clin Psychiatry. 2013; 74 :377-85.
10. Guglielmi V, Vulink NC, Denys D, Wang Y, Samuels JF, Nestadt G. Obsessive-compulsive disorder and female reproductive cycle events: results from the OCD and reproduction collaborative study. Depress Anxiety. 2014;31 :979-87.
11. Abramowitz JS, Khandker M, Nelson CA, Deacon BJ, Rygwall R. The role of cognitive factors in the pathogenesis of obsessive–compulsive symptoms: A prospective study. Behav Res Ther. 2006; 44: 1261-1374.
12. Lindsay R. Standeven, Gerald Nestadt, Jack Samuels, Chapter 7 - Genetics of perinatal obsessive–compulsive disorder: A focus on past genetic studies to inform future inquiry, Editor(s): Jennifer L. Payne, Lauren M. Osborne, Biomarkers of Postpartum Psychiatric Disorders, Academic Press, 2020, 95-109
13. National Institute for Health and Care Excellence (NICE) Clinical Guideline 31. Obsessive Compulsive Disorder. London; NICE: 2005.
14. National Institute for Health and Care Excellence (NICE) Clinical Guideline 192. Antenatal and postnatal mental health: clinical management and service guidance. London: NICE; 2014.
15. McAllister-Williams RH, Baldwin DS, Cantwell R, Easter A, Gilvarry E, Glover V et al. British Association for Psychopharmacology consensus guidance on the use of psychotropic medication preconception, in pregnancy and postpartum. J Psychopharmacol. 2017; 31: 519-552.
16. Marchesi C, Ossola P, Amerio, A., Daniel BD, Tonna M, De Panfilis C. Clinical management of perinatal anxiety disorders: A systematic review. J Affect Disord. 2016; 190 :543-50.
17. Challacombe F, Salkovkis P, Woolgar M, Wilkinson E, Read J & Acheson R. A pilot randomized controlled trial of time-intensive cognitive-behaviour therapy for postpartum obsessive-compulsive disorder. Effects on maternal symptoms, mother-infant interactions and attachment. Psychol Med. 2017; 47: 1478-1488.
18. Grote NK, Bridge JA, Gavin AR, Melville JL, Iyengar S, Katon WJ. A meta-analysis of depression during pregnancy and the risk of preterm birth, low birth weight, and intrauterine growth restriction. Arch Gen Psychiatry. 2010;67 :1012-24.