child & youth Mental Health Series Today’s topic : Stigma, Mental Health and Babies – Oh My! A personal experience with postpartum OCD. Speaker: Dr. Liisa Johnston Date: June 20, 2018
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LJ 32y/o G2P2 - vacuum assisted VBAC at 39 weeks - Postpartum hemorrhage and endometritis - Discharged 36 hours after birth - No previous psych history - Prior c section at 35 weeks for placental abruption - No meds - No allergies - Family psych history: mother with GAD, maternal grandfather SUD, - paternal grandmother with previous psych admission for “difficulty coping” after loss of husband
Stigma
LJ 5 weeks postpartum, woke up convinced we had bedbugs (we did not) For one month, most of the day spent Checking - Cleaning - Laundry rituals - Reassurance seeking - Thinking, thinking, thinking… - Not sleeping -
DSM 5 Criteria A. Presence of obsessions, compulsions, or both B. Time consuming (eg. more than an hour per day) or cause clinically significant distress or impairment C. Not attributable to the physiological effects of a substance or another medical condition D. Not better explained by symptoms of another mental disorder
DSM 5 Criteria Obsessions: 1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress 2. The individual attempts to ignore or suppress thoughts, urges, or images, or to neutralize them with some other thought or action (ie. by performing a compulsion)
DSM 5 Criteria Compulsions: 1. Repetitive behaviours or mental acts that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly 2. The behaviours or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviours or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive
Postpartum OCD in men?? It exists, but we won’t be discussing it today!
Clinical Presentation Often missed ?pressure on new mother to suppress negative emotions - ?lack of awareness of the issues - ?healthcare providers fail to inquire about mental health - Abramowitz et al., 2003
Clinical Presentation Most frequently obsessions of contamination or aggression toward the - child Can also include symmetry/exactness and religiousness - Lead to: - Compulsive cleaning - Avoidance of child - Excessive checking on child - confession/reassurance seeking - Russell et al., 2013; Speisman et al., 2011
Clinical presentation 50% of women report abrupt onset of symptoms, while the other half - report gradual onset Of women with previous diagnosis of OCD: - Clear that large portion of women tend to have significant worsening of symptoms - following the birth of their baby Speisman et al., 2011
DDx Postpartum OCD vs. Postpartum Depression 1. Nature of the thoughts a. Obsessions tend to trigger fear of consequences b. Depressive ruminations tend to be melancholy or contain negative cognitions 2. Content of the thoughts a. Obsessions tend to have more bizarre and nonsensical content b. Depressive thoughts tend to focus on actual circumstances 3. Focus of the thoughts a. Obsessions are generally focused and specific b. Depressive ruminations tend to drift from one topic to another Speisman et al., 2011
DDx Postpartum OCD vs Postpartum psychosis 1. Presenting symptoms: a. Psychotic symptoms are not present in OCD b. Psychosis tends to include hallucinations and/or delusions that involve dangerous content regarding the safety of the infant as well as agitation and bizarre behaviour 2. Distress from symptoms: a. Obsessive thoughts are generally quite distressing in OCD b. Aggressive thoughts in postpartum psychosis are typically not distressing and do not result in fear Speisman et al., 2011
Importance of identification Untreated OCD in caregiver can affect the wellbeing of the entire family Affect provision of care - Interfere with mother-infant bonding - Rituals can take away from caregiving duties (time consuming) - Russell et al., (2013)
What about harm? Aggressive thoughts related to the child are very distressing WOMEN WITH OCD ARE NOT AT INCREASED RISK OF HARMING THEIR INFANTS! Russell et al., (2013)
What about harm? Not diagnostic for OCD - 65% of new parents have obsessional thoughts - concerning the harming and safety of newborns Normal aspects of new parenthood! - Need to determine the degree of associated distress - and/or functional impairment
What’s “Normal”? Zambaldi et al. (2009) Prospective study, interviewing 400 women throughout - postpartum period (2-26 weeks) 58.3% had some obsessional thinking - 42.3% had some compulsivity -
What’s “Normal”? Miller et al study (2015) 461 women screened with YBOCs at 2 weeks and 6 - months postpartum 52 (11.2%) screened positive for OCD - 173 (37.5%) had some obsessionality and/or compulsivity -
What’s “Normal”? Likely some degree of obsessionality and adaptive compulsivity is beneficial in - the newborn period Miller et al. 2013.
PREVALENCE Russel et al. metaanalysis: Women are 1.5-2 times more likely to experience OCD during or following pregnancy
Prevalence 1.08% for women in general population - 2.07% during pregnancy - 2.43% in postpartum period - Russell et al., (2013)
Relationship to postpartum depression Possible relationship between depression and severity of obsessive-compulsive - symptoms Higher number of obsessions - More aggressive obsessions - Depression severity positively related to time spent/day on intrusive thoughts, interference of these - thoughts on functioning, and lack of control over intrusive thoughts Important because postpartum depression is more highly recognized than - postpartum OCD Speisman et al., 2011
But Why? Sociobiological and Evolutionary Theories Intrusive thoughts regarding infant safety are adaptive, - and parents are more sensitive to possible threats (more anxious)- these adaptive behaviours may trigger obsessional thoughts in those who are predisposed Speisman et al., 2011
But why? Biological factors Hormonal changes? - In 3rd trimester, progesterone and estrogen rise well over maximum menstrual cycle levels and return to - follicular levels within the first week after childbirth (and estrogen and progesterone are pro-serotoninergic) We know... - 21-22% of outpatients report onset within 1 year of menarche - Retrospective reports- 5.7-39% women new onset OCD in pregnancy, 0-50% in postpartum period - 8-46.1% of women experience exacerbation of OCD during pregnancy, and 29-50% in postpartum period - 20-49% of women with OCD experience exacerbation premenstrually - Russell et al., (2013) -
But why? Psychological factors (Cognitive Behavioural Theory) Fairbrother and Abramowitz- believe that “heightened sense of - responsibility and increase perception of threat...result in greater likelihood of misinterpreting benign thoughts as threatening” Russell et al., (2013)
But why? Fairbrother and Abramowitz Four Hypotheses: - Due to increase in responsibility of new baby- overestimate possibility of harm to infant - Those who feel increased sense of responsibility and overestimate threat will exhibit more - severe symptoms Those who misinterpret or grant significance to normal intrusive thoughts about infant safety - will have more severe symptoms Those who take precautions to avoid acting on thoughts will have more obsessional - thoughts compared to parents who do not Speisman et al., 2011
Treatment Similar as OCD in other times of life - CBT (exposure/response prevention) - SSRI - Mild to moderate symptoms: CBT alone - Severe: combination - BUT keep in mind - Sudden onset - Unclear course - Patient preference - Breastfeeding - We need more studies... - Speisman et al., 2011
Psychosocial Treatments E/RP- provoke anxiety and distress in short term, anxiety will habituate after prolonged and repeated exposures Fear hierarchy - Psychoeducation (role of CBT, how avoidance and rituals perpetuate distress, commonality - of worrisome thoughts) Imaginal exposures - In vivo exposures - Speisman et al., 2011
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