‘There is no way to be a perfect mother, and a million ways to be a good one’ Jill Churchill

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 What is Obsessive Compulsive Disorder?

Obsessive Compulsive Disorder is an anxiety disorder characterised by:

a) recurrent, unwelcome thoughts, images, ideas or doubts, (obsessions)

b) related behavioural or mental acts (compulsive rituals) to suppress or neutralise the distress or prevent a feared outcome

c) significant functional impairment in a number of domains

Although the specific content of obsessions and compulsions may vary from patient to patient, a common factor is high levels of responsibility for preventing harm or mistakes.

Zambaldi et al wrote in Comprehensive Psychiatry 2009 that the cognitive behavioural model of OCD suggests that patients with OCD attach exaggerated significance to unwanted, intrusive thoughts which are in fact experienced universally and misinterpret them catastrophically.

According to some studies, OCD is the fourth most common mental disorder after depression, alcohol and substance misuse, and social phobia with a lifetime prevalence in community surveys of about 2–3% (Robins et al., 1984).

Statistics regarding OCD are often thought to be an underestimate, as the disorder is often kept secret or hidden from all but the sufferer. They often find it embarrassing or distressing to talk about, and feel guilty or ashamed for having such thoughts and rituals.

Perinatal and postnatal OCD

Until recently OCD in pregnancy and after having a baby had received very little research attention. However recent studies suggest that OCD is more common at this time than other times in life. Some people develop OCD for the first time either during pregnancy or afterwards, whilst others find that pre-existing symptoms worsen. This increase in the incidence of OCD is likely to be related to the fact that pregnancy and early parenthood is a time when mums are naturally focused on the safety of their developing child and feel particularly responsible for them. The normal stress and uncertainties of becoming a parent can also play a role.

Perinatal and postpartum OCD usually revolves around significant fear of harm coming to the infant, with worries frequently focused on accidentally or deliberately harming the child or the child becoming ill. It is important to note that the occasional experience of all of these worries is absolutely normal and indeed very common in mums and mums to be. However, some people find themselves so distressed that they will take measures to manage their anxiety or prevent their fears coming true. Depending on the worries, this could involve compulsive behaviours such as cleaning, praying, rumination or avoidance of activities or even of spending time with the baby. In this way the thoughts and behaviours can interfere significantly with their wellbeing and their experiences of pregnancy and parenting. It is the extent of and response to the worries, rather than just having them that becomes the problem.

Fairbrother and Abramowitz 2007 proposed that the perinatal period lowers the threshold for OCD development/exacerbation by bringing with it a sudden increase in responsibility for a vulnerable and highly cherished infant; but it can also cause the misinterpretation of normal intrusive infant-related thoughts, overestimation of an apparent threat and evoke a range of responses including avoidance, concealment, attempts to suppress the upsetting thought, over checking, and safety-seeking (prayer) behaviour that function to reduce obsessional distress as well as the perceived risk associated with the intrusive thought.

The conclusion of this study is that women have increased risk of OCD or obsessive compulsive symptoms in the postpartum period. Consideration must also be given to the barriers to treatment seeking and treatment provision. For this reason all women, particularly women with previous psychiatric history, somatic disease, or with complications in pregnancy or at the birth should be carefully screened for OCD in the postpartum period.

Common obsessions

Obsessions can be focused on anything from germs to symmetry. When OCD presents itself during motherhood, the responsibilities for the life and well-being of a helpless infant may be experienced as a chronic stress. This stress could result in exacerbation of OCD since fear of being responsible for harm coming to others is a theme to many OCD symptoms. (Journal of Clinical Psychiatry 1997).

Obsessions i.e. intrusive thoughts will enter into all of ours minds, most of us will either not even notice or not attach any significance to them, a little like a train that passes through a station and doesn’t stop. A mother with OCD will attach so much attention to any intrusive thought which suggests a perceived risk of harm coming to her child, that her train stops at the brightest station. I.e. she will give it an unhealthy amount of attention.

Examples include:

 - Fear of contamination to the mother, child or anyone in contact with the child e.g. perceived risk of HIV, food poisoning

 - Intrusive thoughts, images, doubts of harm e.g. risk of abuse/aggression if not careful

 - Doubts that harm could come to child e.g. bottle steriliser not working

 - Perfectionism e.g. everything around the house has to be a certain way.

Of course this list could continue, however it illustrates the breadth of the various obsessions mothers could have.

Common compulsions

To try and eradicate the anxiety attached to the obsessions, mothers with OCD will act out rituals to ensure their child is safe and no harm will come to them. In fact, this makes the OCD worsen. Although the anxiety attached to the obsession reduces short-term it returns stronger and stronger. This means that potentially the mother is acting out rituals for a significant amount of her day.

Again the following list is just a few examples of how compulsions manifest themselves in mothers:

 - Hyper vigilance when meeting new people or going to public toilets, this will include avoidance of touching other people, planning a day out around toilet breaks and using excessive wet wipes and hand sanitisers

 - Hiding anything sharp around the house

 - Constantly checking the gas is turned off, the petrol pump is working correctly

 - Waking earlier than necessary and going to bed later than necessary to ensure the house is ‘just so’

 - Constant reassurance seeking from friends, family members and maybe health professionals that the child is unharmed. 

The Impact of having OCD as a mother

Currently, the media report OCD as a fashionable disorder and it is often used inappropriately in everyday conversation e.g. ‘I’m a bit OCD, that’s my OCD.’ The reality is that it can have a significant impact on both the mother and the family as a whole.

Postnatal obsessions may be accompanied by overt compulsions such as checking and washing. Situational avoidance (e.g. steering away from knives, bathing a child) and covert behaviours (thought suppression attempts, prayers) aimed at neutralising the obsession or preventing a feared catastrophe appear to be more common. This means that the mother will be acting strangely and will not play an active part in family life and in the community. Behaviour Research and Therapy: New Parenthood as a risk factor for the development of obsessional problems Fairbrother & Abramowitz 2006.

Overcoming OCD

OCD varies widely in terms of its severity, but for some people it can be a very disabling condition, which has a major impact on not only their life but also the lives of those closest to them, including their children. Fortunately, OCD is also a very treatable condition and you should therefore see your GP as soon as possible if you think you have OCD and are not already receiving treatment.

Cognitive Behaviour Therapy – What is it?

The most effective treatment by far for OCD is cognitive behaviour therapy (CBT), and this should always be the first line treatment, as there is much evidence to support its use. This is safe for mothers and mothers to be to receive. Many people are offered other psychological treatments but, other than behaviour therapy and cognitive behaviour therapy, there is no evidence that such treatments are effective. CBT is a short term, structured, problem focused and goal directed form of therapy.

It helps identify and understand how certain patterns of thinking and behaviour can maintain OCD. OCD makes people believe that something terrifying will happen if they do not carry out their rituals or do not avoid certain situations. In CBT, these frightening thoughts are tested in a safe, planned and structured way, so that an alternative, less threatening explanation is identified.

A technique called ‘Exposure and Response Prevention’ has been found to be an important part of CBT. This involves confronting the situations that are anxiety driven without avoiding, checking or carrying out other rituals. This can seem a frightening prospect, but it is usually done in a gradual way, with the support of the therapist and is an important part of getting over OCD.

Towards the end of a course of CBT, the therapist should help identify methods to best stop the problems returning in the future. This is known as ‘relapse prevention’ and is another important aspect of treatment. The general idea is that, by the end of therapy, sufficient understanding, skills and knowledge of OCD and OCD prevention will have been gained so that the patient can act as their own therapist. Some people also find it helpful to have occasional ‘booster’ sessions at a later date.

According to the NICE Guidelines if for some reason, after being treated successfully for OCD the OCD returns, access to therapy can be given straight away – instead of being put on a waiting list.

CBT can be delivered by an appropriately trained therapist at a GP surgery, however is usually offered by a CBT trained psychologist or nurse therapist from the local mental health team. The amount of therapy sessions will depend on the severity of the disorder and whether the therapy will be one-to-one or group.

Some people choose not to wait for a CBT trained therapist on the National Health Service. If that is the case make sure that the therapist is accredited by the British Association of Behavioural and Cognitive Psychotherapies (BABCP). This can be checked by using the ‘Find a Therapist’ register on their website (www.babcp.com).

Medication

Coupled with CBT, some sufferers may require medication. According to the National Institute for Health and Care Excellence (NICE) during conception, pregnancy and the breastfeeding stage, mothers suffering from OCD may be offered psychological treatment instead of, or before, medication. If they are already taking medication they should be offered a safer drug.

Please note if they wish to breastfeed they should not usually be offered a combination of drugs called clomipramine and citalopram.

For further specific details for mothers and mental health please see the NICE Guidelines CG31 and CG45.

See below for CG31 - this provides information specifically about OCD

http://publications.nice.org.uk/obsessive-compulsive-disorder-cg31

See below for CG45 - this provides information specifically about antenatal and postnatal health 

http://publications.nice.org.uk/antenatal-and-postnatal-mental-health-cg45

Summary of research data

 Health visitors and midwives are the primary target audience for OCD education as OCD for mothers is at its highest prevalence at the postnatal stage. Studies suggest prevalence rates of between 2.5% and 9%. This compares with a general population rate of 1.1 %, suggesting a considerably increased risk of developing OCD in the postpartum stage (Fairbrother & Abramowitz, 2007). Some people develop OCD for the first time either during pregnancy or afterwards, whilst others find that pre-existing symptoms worsen. Wenzel et al 2005, Uguz et al 2005, Zambaldi et al 2009.

Retrospective studies of individuals who develop obsessive compulsive disorder have found that pregnancy and childbirth are the most consistently cited triggering events for OCD onset or exacerbation. Buttolph & Holland 1990,Ingram 1961,Lo 1967; Mania, Albert,Bogetto, Vaschetto & Ravizza (1999); Neziroglu, Anemone & Yaryura-Tobias 1992; Pollit 1957)

Symptoms can be severe, distressing and time consuming and left untreated are likely to persist (Arnold, 1999, Uguz et al, 2007). Symptoms of the disorder may adversely affect the mother-child relationship. Untreated psychiatric disorders can disrupt the family environment and have unfavourable short and long term effects on child development. It is important to identify those at risk for postpartum disorders, and recognise the symptoms and treatments of these problems. Abramowitz, Schwartz, Moore and Luenzmann 2002

It is therefore crucial that clinicians consider symptoms of obsessive compulsive disorder presenting in the postpartum period as potential signs of illness rather than dismissing these symptoms as ‘reactive adjustment’ to motherhood. Sichel, Cohen, Rosenbaum and Driscoll 1993

Women with previous psychiatric history, somatic disease, or with complications in pregnancy or at the birth should be carefully screened for OCD in the postpartum period.

Relative to depression, anxiety has been a neglected area in perinatal diagnosis. Researchers are now becoming increasingly aware of this gap and the prevalence and risks of untreated maternal anxiety (Matthey, 2001). Concluding that parents are functioning well because they are not depressed is incorrect. No clinical psychiatric assessment would be considered complete without enquiring about anxiety symptoms, and screening measures offered perinatally must include such disorders. It is important to assess for obsessions and compulsions in postpartum women who present with anxiety and/or depression.

Many women suffer alone, not knowing what the disorder is. Abramowitz found that a prevention programme offering information about OCD was associated with significantly lower levels of obsessions and compulsions than in a control condition and the prevention programme group also reported decreasing levels of cognitive distortions.