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Scary Thoughts
It's Normal for New Parents to Worry Their Baby May Face Harm. For Some Women, Though, Such Fears Become Overwhelming

By Stacey Colino
Special to The Washington Post
Tuesday, March 7, 2006

When each of her three kids was an infant, Nichole Ahern of Chevy Chase had recurring visions of tumbling down the stairs with the baby in her arms.

Last fall, Mindy Walker of Westchester, N.Y., had fleeting thoughts of letting her infant daughter drop out of her arms.

Adele Morgan of Hillsborough, N.J., says that the challenges of caring for her first baby made her think about putting him in the microwave or throwing him off the deck when he wouldn't stop crying.

None of these women ever harmed their babies, and all are successful, loving mothers. And these kinds of intrusive, unwanted thoughts -- mild versions of those associated with obsessive-compulsive disorder (OCD) -- are extremely common among new parents.

In a study of 85 new mothers and fathers conducted at the Mayo Clinic in Rochester, Minn., researchers found that 89 percent experienced distressing, intrusive thoughts related to their infants: images of the baby suffocating or being contaminated with germs, or worries about the baby having an accident, being harmed or kidnapped.

Most new parents take these unwanted thoughts in stride, and try to neutralize them by reassuring themselves, checking on the baby or enlisting support from others, the study found. "For most parents, this is just mental noise," says Jonathan Abramowitz, a psychologist and director of the OCD/Anxiety Disorders Program at the Mayo Clinic. "They dismiss it and move on."

Abramowitz admits to having had these thoughts as a new parent himself: While burping his daughters when they were infants, he sometimes considered what would happen if he whacked them too hard. While giving them baths, he occasionally wondered how hard it would be to drown a child.

But some new parents get very troubled about these thoughts. "People tend to become more distressed by these bad thoughts if they interpret them as meaningful or if they believe they should be able to control their thoughts," Abramowitz says. "They're the ones that develop problems."

Indeed, some women -- like Morgan-- develop clinically significant symptoms of OCD during pregnancy or the postpartum period -- a phenomenon that is vastly under-recognized, experts say.

While reliable statistics on postpartum OCD are lacking, the lifetime incidence of OCD in the general population is believed to be 2 to 3 percent. What distinguishes OCD symptoms from normal intrusive thoughts is partly the extent to which these ideas are anxiety provoking, irrepressible and persistent.

"To have a real obsession, it's an intrusive, unbidden thought, idea, or image that comes to your mind that you do not want and actively try to resist," explains Gerald Nestadt, a professor of psychiatry at the Johns Hopkins Medical Institutions in Baltimore. "You can't get rid of the thought."

Shortly after Vicky Valentine Henry, of Glen Allen, Va., gave birth to her son in March 2001, she began having distressing thoughts: While driving, she'd envision stopping short and her son flying through the windshield. She had fleeting visions of drowning him in the bath.

Checking on him repeatedly during the night, to make sure he was still breathing, left her exhausted. She began feeling hopeless, worthless and guilty -- all signs of postpartum depression. But it wasn't until she saw a TV report about postpartum depression and OCD that she realized her experience was not unique. Although her obsessive thoughts and compulsive behaviors subsided by the time her son was 9 months old, Henry needed talk therapy, an antidepressant, family support and her religious faith to gradually regain her balanced mood.

"And I began thoroughly enjoying motherhood," says Henry. "I only wish it could have happened sooner." She is now a volunteer state coordinator for Postpartum Support International, a group dedicated to postpartum mental health.

Some experts believe postpartum OCD occurs primarily in women who already have the condition, sometimes in a mild and undiagnosed form.

Complicating matters, postpartum depression and OCD often go together, but many women and their clinicians focus exclusively on the depressive symptoms. Yet a study at Case Western Reserve University in Cleveland found that postpartum depression is accompanied by obsessive thoughts in 57 percent of new mothers.

The extensive media coverage of mothers who kill their kids (as in the widely reported 2001 incident where Andrea Yates drowned her five children) makes some new parents with intrusive thoughts worry whether they're headed down a similar path. In most cases they are not. But just being exposed to such stories can fuel the thoughts, Abramowitz says. "You read things in the news, and it's normal to incorporate that into your experience."

Not long ago, Diana Dell, an assistant professor of psychiatry and obstetrics-gynecology at the Duke University Medical Center in Durham, N.C., treated a woman with recurring fears during pregnancy that she might put her baby in the dryer.

"It came from some dumb thing she saw in a movie," Dell recalls. "She recognized that these thoughts were irrational . . . but just having them caused her to be anxious." With the help of medication and therapy, the mother fared well, Dell reports, and so did the baby.

There are key differences between obsessive thoughts and postpartum psychosis, explains Shaila Misri, a reproductive psychiatrist and director of the reproductive mental health program at BC Women's Hospital and Health Center in Vancouver, B.C.

Obsessive symptoms tend to be "repetitive, unwanted thoughts that the person is aware are not normal even though she is unable to stop them," she explains. With psychotic symptoms, "the repetitive, unwanted thoughts are actually delusional, and the person who is having them believes they are real." While women with OCD rarely harm their children, Misri adds, "those with postpartum psychosis are in very real danger of doing so."

But "postpartum OCD can and sometimes does evolve into psychosis, and that is why you have to watch it," Misri says. One of her patients had OCD during pregnancy, became psychotic during the postpartum period, and killed her baby. It was, Misri says, "a very extreme case."

A Silence of Shame

Many new parents overcome unwelcome thoughts without professional help. But when the obsessive thoughts or compulsions interfere with a parent's ability to function or bond with the baby, or if they cause considerable anxiety and distress, it's time to seek help, experts say.

Yet there's often a "don't ask, don't tell" dynamic surrounding this subject in the physician's office, experts say. While many doctors screen for postpartum depression these days, few ask about intrusive thoughts, Misri says. Meanwhile, new mothers often feel guilt and shame and stay silent.

"A lot of times people are afraid to mention these symptoms because they think if other people knew, they'd lock them up or take the baby away," Dell says. "When I ask [new mothers] if they're having unwanted, intrusive thoughts, they are often quite relieved to hear that this happens to other people and that there are probably some biological reasons for this . . ."

Postpartum OCD is diagnosed like any other form of OCD -- according to criteria published in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). Treatment for mild cases generally involves cognitive behavioral therapy, a form of talk therapy that helps patients identify and control irrational thoughts. For more severe cases, antidepressant or antipsychotic drugs are often used.

The trouble with CBT "there's a time issue for someone who's trying to take care of a baby and is very sick," says Dell. "Medications can give a more rapid response."

Says Nestadt, "The very sad thing is that many people who have experienced an onset or exacerbation of OCD during pregnancy or the postpartum period and didn't receive or respond to treatment may be unwilling to have other kids after the experience. . . . To have OCD and worry constantly day after day is dreadful." ยท

Stacey Colino last wrote for the Health section about milder versions of bipolar disorder. Comments: health@washpost.com.

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