The OCD Cycle

We live in a society that collectively has difficulty tolerating anxiety and accepting ambiguity. Anxiety is an emotion that is associated with a lot of negative connotations and generally leads us to quickly seek out solutions to escape the discomfort. For some people, anxiety becomes connected to everyday, seemingly neutral things such as other people, social situations, doorknobs, dogs, physical sensations, and emotions. The actions taken in attempts to evade anxiety are called safety behaviors (or within OCD, they are called compulsions). These behaviors are enacted with the hopes of decreasing distress. Unfortunately, the relief acquired from engaging in safety behaviors is only temporary. Some common safety behaviors include avoiding anxious triggers, seeking reassurance, researching, using substances, washing, counting, etc. Since these behaviors actually do work (but only in the short-term), people continue to use them. Unfortunately, continuing to rely on safety behaviors causes individuals to become trapped in the anxiety cycle and prevents them from learning that their fear was either unfounded or tolerable. Ironically, these safety behaviors and compulsions only preserve the fear in the long run. Simultaneously, reliance on safety behaviors prevents growth and corrective learning, which can severely restrict quality of life. The thoughts, situations, emotions, or body sensations that create the anxiety might be different within each presentation of OCD, but the cycle that maintains anxiety generally has low variability from person to person. Please see our previous blog entry – Understanding the Cycle of Anxiety – for further information.

What is Perinatal/Postpartum OCD?

Perinatal/Postpartum OCD is characterized by the presence of obsessions pertaining to the safety and well-being of one’s child. This type of OCD occurs during pregnancy and/or after the baby is born. Obsessions may present as intrusive thoughts, mental images, urges, and/or persistent worries and ruminations about something bad happening to the baby. Obsessional content in this subtype of OCD contains themes related to harm, contamination, sexual topics, responsibility, etc. Individuals who have this type of OCD may worry that they, or someone else, may harm the baby in some way. They obsess over the possibility that something bad may happen to the baby due to intentional actions, accidents, or poor monitoring. Experiencing feelings of fear, guilt, and/or shame is very common amongst people who have this subtype of OCD. Exposure to triggers provokes a significant amount of distress and results in the individuals seeking ways (via compulsions) to attempt to increase the baby’s safety and/or avoid contact with the baby to minimize risk. The compulsions enacted in such situations are extreme and typically time-consuming. The obsessions and compulsions present in Perinatal/Postpartum OCD are excessive, cause a great deal of emotional upset, and have the potential to impair functioning in important life areas.

Common Obsessions in Perinatal/Postpartum OCD

Common obsessions include (but are not limited to):

• Worries about dropping the baby
• Worries about drowning the baby
• Worries about shaking or suffocating the baby
• Worries that the baby will stop breathing while asleep
• Worries that the baby will become ill or develop a disease
• Experiencing unwanted sexual thoughts about the baby
• Worries about inappropriately touching the baby while changing diapers, bathing, and/or dressing the baby
• Worries about not properly sterilizing the baby’s bottles or other items that the baby may come into contact with
• Fears that baby equipment (cribs, playpens, car seats, strollers, etc.) may be faulty and the baby will get hurt
• Concerns that the family pet will contaminate the baby, bring diseases into the house, and/or become aggressive towards the baby
• Concerns about the security of the house, particularly the windows in the nursery
• Worries that food and/or drinks consumed as well as inoculations and medications taken during pregnancy will harm the baby
• Worries that the baby is unsafe with others
• Worries about being a bad parent, making bad parenting choices, negatively impacting the course of the baby’s life, etc.
• Worries about the baby’s exposure to medications, cleaning products, germs, environmental toxins, etc.
• Worries about losing control, “snapping,” and harming the baby
• Feeling anxious about news stories about parents who have harmed their babies and fearing that they are like/could become like the parents in the news

Common Compulsions in Perinatal/Postpartum OCD

Common compulsions/rituals/safety behaviors include (but are not limited to):

• Avoiding holding the baby, especially when walking and/or only holding the baby while seated
• Avoiding walking near stairs, balconies, crosswalks, etc. with the baby
• Avoiding changing diapers, bathing, and/or changing the baby and/or only doing these caregiving activities if another person is present
• Refraining from using potentially dangerous household items, such as scissors, knives, tweezers, nail clippers, plastic bags, insect repellent, tools, etc.
• Attempting to neutralize or cancel out intrusive thoughts (e.g. saying a certain word/phrase/mantra repeatedly, saying a prayer, providing oneself with reassurance)
• Excessively checking on the baby during naptime and/or overnight to make sure that he/she is still breathing
• Engaging in excessive cleaning, washing, and sterilizing behaviors of self, baby, and/or items that the baby will come into contact with (bottles, clothing, bedding, etc.)
• Requiring that others are “clean” (to an excessive degree) before allowing them to interact with the baby
• Avoiding breastfeeding due to concerns about the quality of breast milk and possibly contaminating or making the baby ill. Breastfeeding may also be avoided if the person if experiencing sexual intrusive thoughts about the baby
• Excessively testing baby equipment (cribs, car seat, stroller, etc.) to “make sure” that the furniture will not tip over, collapse, or harm the baby in some other way
• Not allowing the family pets to be around or interact with the baby
• Excessively checking the windows, locks, security system in the house, car, etc.
• Eliminating foods that have been recalled after it is deemed medically safe to be able to consume them again
• Refraining from taking medications that have been approved by a medical professional and are needed during pregnancy and/or that have been prescribed for the baby
• Not allowing the baby to be left alone with trusted others
• Seeking reassurance from one’s spouse, other family members, pediatricians, etc.
• Reassuring oneself (e.g. “You’re a good mom/dad,” “You did the right thing,” “The baby is completely safe”)
• Repeating caregiving activities until they are done “right”
• Engaging in excessive online research about the “best” parenting practices
• Confessing intrusive thoughts about harming the baby
• Relying on another person to complete caregiving activities for the baby

Special Considerations for Perinatal/Postpartum OCD

• Many mothers (regardless of whether or not they have OCD) experience mild mood changes after having a baby. These mood changes are more common than generally thought or discussed and experiencing mood swings and a variety of emotions is not uncommon post-delivery. Becoming a parent is a stressful time that comes with high-stakes responsibilities of caring for a newborn. Bringing a new baby home is associated with emotional highs and lows, which generally tend to be exacerbated by sleep deficits associated with adjusting to a newborn’s fragmented sleep schedule. Therefore, experiencing anxiety and/or low-mood is not automatically a cause for concern. OCD is distinguished from “normal” anxiety by its persistence, the presence of obsessions and compulsions, and high levels of distress and/or functional impairments in important life areas.

• Perinatal/Postpartum OCD is most commonly associated with mothers who give birth to the baby, but this type of OCD impacts mothers, fathers, foster/adoptive parents, and other people who care for the baby. It is typical for new parents to experience a wide range of emotions about becoming parents. While welcoming a new baby into one’s home is something to celebrate, it can also be an incredibly stressful time as an infant is completely reliant on his/her caregivers. Therefore, it is not uncommon for parents to have worries about the baby’s health and safety. Newborns are quite vulnerable and the high degree of medical overseeing that was present during the pregnancy notably decreases once the baby arrives at home. Parenting/caregiving comes with a lot of pressures, and it is normal for parents to experience anxiety and worries about their abilities to effectively bond with and take care of their baby. The tremendous responsibility associated with being a parent/caregiver to a newborn is prime territory for OCD. OCD is known to become linked to things that the person finds to be most important/valuable, and for a person who is feeling overwhelmed and exhausted with new parenting/caregiving duties, OCD can easily take root.

• The obsessions present in OCD are not only distressing because they are targeting something/someone that the individual highly values, but also because they are ego-dystonic, which means that the person deems the thoughts, impulses, sensations, urges, and/or mental pictures to be unacceptable and abhorrent. Thus, the obsessions are viewed as being incongruent with the person’s self-perception and his/her respective values. The mismatch is generally viewed as alarming and threatening to the individual. The person may consequently experience feelings of fear, shame, guilt, etc. These obsessions are often isolating as parents/caregivers are ashamed and reluctant to share their symptoms with others for fear of being seen as dangerous and worry that others will believe that they are a threat to the baby. OCD is a condition of over-control, not under-control. Impulsive and aggressive behaviors are not associated with the symptom profile of OCD. Feeling anxious and uncertain does not necessarily signal that there will be danger or that someone is dangerous

• In this subtype of OCD, individuals may become anxious about their decreased anxiety to content encountered during treatment and/or in their lives that is related to their obsessions. In other words, they may have anxiety about no longer feeling anxious when encountering previously triggering stimuli. They may believe that this reduction in anxiety is a sign that they may be “okay” with not doing everything in their power to ensure the utmost level of safety and well-being for their child. Remember, the experience of anxiety is not necessarily credible proof that something is true or false. It is an emotion stemming from your thoughts and from your interpretation of events. Sometimes thoughts are just simply thoughts. The bottom line is that everyone experiences intrusive thoughts. Intrusive thoughts are not welcomed or liked, hence the label “intrusive.” Fixating on and interpretating the intrusive thoughts as threats leads them to develop into obsessions and to present in a recurrent and persistent manner. Overresponding to the intrusive thoughts through attempts to suppress, neutralize, or undo them are all compulsive efforts, which act as maintenance factors that fuel the obsessions.

Treatment of Perinatal/Postpartum OCD

The gold-standard treatment for Real-Event OCD is Exposure and Response Prevention (ERP). ERP is an evidence-based treatment, which means that there is a significant amount of research, empirical studies, and data that consistently demonstrate the efficacy of employing an ERP treatment protocol to successfully ameliorate the symptoms of OCD. In the context of Perinatal/Postpartum OCD, the goals of treatment are to both reduce distress associated with triggering stimuli and situations and to decrease functional impairments in daily living and significant areas of life. Through ERP, individuals engage in exposure to their fears in order to help them to learn to become less reactive to their triggers and better able to disengage from their obsessions in constructive ways. ERP facilitates opportunities to challenge worries and to differentiate between anxious predictions and the actual outcomes of encountering feared stimuli and situations. Another goal of ERP is to increase the individual’s ability to tolerate the uncertainty, discomfort, and doubt that their OCD creates. Please see our previous blog entry — What is Exposure and Response Prevention (ERP) – for more information about this treatment.

Exposures can include anything that provokes anxiety and/or uncertainty related to the real event concerns. Examples of exposures that may be conducted in the context of ERP treatment for Perinatal/Postpartum OCD include:

• Interacting with the baby, even while experiencing intrusive thoughts
• Holding the baby for longer periods of time, in different positions, and in different places (gradually moving from having others in the same room, to having others in different rooms of the house, to being home alone with the baby)
• Changing the baby’s diapers or clothing (gradually reducing the level of monitoring and/or assistance from another adult)
• Bathing the baby (gradually reducing the amount of monitoring and assistance offered by others until this task can be completed alone)
• Following the pediatrician’s directives regarding the sterilization of bottles and other items and surfaces that may come into contact with the baby
• Reading articles and/or watching news stories about parents who have harmed their children
• Walking while holding the baby, walking in hallways, walking outdoors, etc.
• Using household items that were previously avoided (e.g. scissors, knives, tweezers, nail clippers, plastic bags, insect repellent, tools, etc.) and working up to using these items while the baby is in the same room
• Breastfeeding the baby as directed by the pediatrician/gynecologist
• Allowing others to watch or take care of the baby
• Splitting childcare responsibilities equally between parents/caregivers

In addition to participating in exposure work with triggering stimuli, treatment must also include Response Prevention, which involves eliminating compulsions and deconstructing rituals. Examples of Response Prevention in the context of treatment for Perinatal/Postpartum OCD include:

• Reducing the number of checks made on the baby during naptime and/or throughout the night
• Refraining from engaging in online researching about infant illnesses, SIDS etc.
• Refraining from rewashing items that are already sufficiently clean/sterilized
• Refraining from excessively checking baby equipment and furniture to ensure that they won’t malfunction, tip over, or break when in use or when the baby is nearby
• Refraining from asking family members about symptoms of illness, asking them to wash their hands, etc. before allowing them to come into contact with the baby
• Refraining from restricting a pet’s ability to move throughout the house
• Refraining from excessively (i.e. more than once) checking doors, windows, etc.
• Only refraining from foods, drinks, and medications as directed by one’s gynecologist
• Refraining from seeking reassurance from others and/or giving reassurance to oneself
• Refraining from confessing intrusive thoughts

Engaging in ERP treatment helps individuals to learn new ways to respond to stressful situations (in the past, present, and/or future) and, after engaging in repetitious practice, they will likely experience a reduction in anxiety and/or learn that they are able to tolerate the stress and uncertainty while still engaging in enjoyable and meaningful activities.

Although ERP is the first-line treatment for Perinatal/Postpartum OCD, Acceptance and Commitment Therapy (ACT) can serve as a beneficial adjunct. Within ACT, individuals are introduced to the concepts of mindfulness and acceptance, which aid them in being present with their anxious thoughts without trying to change them or engage in compulsions. Interventions focusing on increasing acceptance of uncertainty and doubt are necessary to supplement ERP work in the treatment of Perinatal/Postpartum OCD. In the context of ACT, acceptance is making space for the thoughts and worries to be present without feeling the need to react or respond to them. Struggling against anxious or worrisome thoughts is likely to exacerbate anxious feelings and create more emotional suffering. Using ACT-based strategies, individuals are better able to differentiate their thoughts and values from their OCD and identify if the behaviors they are engaging in provide them joy and pleasure (which is the goal), or if they are behaving in response to anxiety and uncertainty stemming from their OCD. They are able to learn to be aware of their thoughts and fears, while not paying undue attention to and/or over-engaging with them. The goal is to learn to live life and participate in activities that are important, even if the thoughts are present. Thus, ACT is employed to increase psychological flexibility and reduce the cognitive rigidity seen in OCD. ACT aims to help people to defuse from their obsessive/intrusive thoughts and maintain a present-focused awareness. This awareness will enable them to engage in the activities taking place in the moment, rather than retreating into obsessive worries.

Interventions targeting the area of self-compassion may also be added to treatment for Perinatal/Postpartum OCD. Incorporating such interventions in treatment will help the individual develop skills that promote self-compassion and decrease self-criticism and recrimination. Acquiring greater levels of self-compassion can help to remedy the distress caused by the intense emotions of guilt and shame that often accompany Perinatal/Postpartum OCD. Interventions that are focused on facilitating self-compassion may include learning strategies to increase the person’s abilities to engage in self-care, to attend appropriately and compassionately to their own emotions and needs, and to direct kindness, understanding, and acceptance towards themselves. Outside of therapy, individuals with Perinatal/Postpartum OCD may also benefit from medication. While it is always important to work with your doctor to evaluate the benefits and risks of taking medications, careful assessment is particularly important for women who are pregnant or breastfeeding. Consulting and working closely with a prescribing provider is necessary to determine each individual’s respective advantages and disadvantages of taking medications for Perinatal/Postpartum OCD.

Need help or support?

If you or a loved one are struggling with OCD or any other mental health concerns, know that you are not alone. If you are a parent or a caregiver and are seeking additional information about these diagnoses and how you can best support your child, our office provides parent training with the SPACE program. Please see previous blog entry – SPACE- Supporting Parenting for Anxious Childhood Emotions — for more information on SPACE.

To seek help for these or any other mental health concerns, please contact The OCD and Anxiety Center at (630) 522-3124 or info@theocdandanxietycenter.com. We have offices in Oak Brook and Orland Park, Illinois and in Marietta, Georgia that specialize in helping individuals overcome anxiety disorders, Obsessive-Compulsive Disorder, and other co-occurring mental health conditions. We provide telehealth services that are available in Illinois, Indiana, Iowa, and Georgia.

At The OCD and Anxiety Center, we can provide treatment both in the office and at off-site locations (your home, mall, school, etc.). We will work closely with you to create an individualized treatment plan and discuss the appropriate frequency of appointments (once a week or more, if needed). We look forward to working with you!

Dr. Ashley Butterfield is a licensed psychologist at The OCD & Anxiety Center in Oak Brook, IL.  She specializes in Cognitive Behavioral Therapy and Exposure and Response Prevention Therapy for anxiety, OCD, and anxiety-related disorders. She is comfortable working with children and adults and is able to provide treatment both in the office and outside of the office, wherever anxiety happens.