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Archive for the ‘Anxiety’ Category

Intrusive Thoughts and Postpartum OCD

Don’t feel bad if you’re a mom, medical professional, or mental health therapist and you’ve never heard of Postpartum OCD. Most people haven’t. Thing is, it’s more common than you may think, and it’s important for most everyone to be aware of it. If  more people know about it, then chances are, women and their families will have a better chance at getting correctly diagnosed and treated. Hopefully, they’ll also avoid the uninformed judgements of others. I consider it my mission to spread the word because the women who have it typically suffer in silence and do so needlessly. I assure you, with help, relief is within reach.

Index of topics:

What it is
What it isn’t
Risks for developing it and prevalence rates
Why mothers stay silent
When to get help
A message to moms
What friends and family can do
Bibliography

What it is

There are some women who, after they give birth, experience a typical variety of OCD. They likely had OCD prior to becoming pregnant and, if they had been symptom-free previously, they may find that their symptoms re-emerge with the stresses that commonly accompany the transition to parenthood. Although their obsessions and compulsions can take many forms, one of the most well-known are obsessions centered around germs and cleanliness; they wash their hands until they bleed and fret over the idea that they and/or their children may get sick with something horrible. It is distressing, time consuming, and tiring.

What I’ve described above is what I learned about in graduate school and it is the kind of OCD that I had treated prior to my work as a volunteer with Baby Blues Connection (BBC), my local perinatal support organization. While facilitating support groups with BBC, I learned about a variation of OCD of which I had previously been unaware. Many of the moms I saw reported having scary, intrusive, and sometime violent, thoughts about harm coming to their babies. As Karen Kleiman and Amy Wenzel wrote in their 2011 book, Dropping the Baby and Other Scary Thoughts, these thoughts of harm fall into the following categories that frequently overlap with one another:

  • Threats to the baby’s physical well-being
  • Thoughts of an accident
  • Thoughts of intentional harm inflicted by the mother
  • Thoughts of intentional harm inflicted by another person
  • Disturbing sexual thoughts

Many times these thoughts are highly visual in nature and  some say that it’s as if they see a little movie play out in their heads. Women are horrified of these thoughts or impulses, especially when they see themselves causing the harm. They do not want to do these acts and often go to great lengths to ensure their babies’ safety. They may avoid certain places or activities and install safety devices. They may hire someone else to care for their baby. They may believe that they should not be a parent. Then they worry. And worry. Then worry some more. When they’re finally so exhausted that they fall asleep, they have nightmares about what they’ve spent their day trying not to think about. In pushing the thoughts away, they inevitably make it worse.

What it isn’t

Most all of us, at some point, have had intrusive, horrible thoughts. We imagine something gruesome or perverted, because…well…we’re human and that’s what the human brain will do. Typically, we dismiss that thought and if it does pop up again, we are able to continue with our daily lives without disruption. This is not OCD. It does not cause us undue distress and we can function normally.

This is also not psychosis. We have all heard the tragic stories on the news of mothers taking the lives of their children. The women in these stories almost certainly suffer from psychosis or other serious mental health disorder and typically have a long history of problems. When they think of harming their children, they are typically under the delusion that doing so would be a good thing. Hearing these stories, unfortunately, fuels the fears of postpartum women. In contrast, those with OCD are horrified by the intrusive thoughts and may go to great lengths to protect their children; the thoughts are extremely anxiety provoking. I have never heard of a woman with postpartum OCD killing her child.

Risks for developing it and prevalence rates

For some women, their symptoms of OCD seem to come out of nowhere. Researchers have found that all women are at higher risk for OCD following the birth of a child. Typically, however, women have had a history of OCD or other psychiatric disorder (such as depression or anxiety) or had complications during pregnancy or birth (Zambaldia, Cantillinoa, Montenegroa, et al., 2009). One’s thinking style, such as perfectionism, can also predispose a person to develop it (Timpano, KR, Abramowitz, JS, Mahaffey, BL, Mitchell, M, & Schmidt, N, 2011). Zambaldia et al. found that 9% of the 400 women they test met the criteria for OCD, but others (including me) believe that number is much higher; one small study found that 29% of the women in their study, who were in their third trimester of pregnancy, met the criteria for OCD, and that number went up in the one month after giving birth (Chaudron & Nirodi, 2011).

Why mothers stay silent

Mothers who have intrusive thoughts often avoid telling anyone of their scary thoughts because they are afraid others may think they are crazy. Sadly, they may themselves question their sanity. Those who have thoughts of themselves harming their babies are even less likely to disclose this information because they fear that their babies will be taken from them and that they may be locked up. They often feel intense shame. They may desperately want to tell someone to relieve the burden of their secret, but unless they are adequately informed about postpartum OCD and unless they can find someone in whom they can trust about the nature of their problem, they will likely stay silent. This is why I am so adamant about educating people about the nature of intrusive thoughts and OCD; if the reality of intrusive thoughts was common knowledge, women would be able to reach out and learn how to find relief.

When to get help

Most new parents will have intrusive, scary thoughts at some point following the birth of a child. It’s when those thoughts increase a person’s anxiety, stop them from enjoying time with their baby, impact the choices they make, and make it difficult to enjoy life, that she would benefit from professional help. Depression often accompanies Postpartum OCD, so having a depressed mood nearly every day for most of the day is another symptom to play close attention to.

It goes without saying that anyone who wants to harm his or her baby, doesn’t think it’s a really bad idea to act on these thoughts, and/or has a plan or intention to hurt her baby, needs to seek help immediately.

A message to moms

If you are a mother who is experiencing intrusive, scary thoughts, you are not alone. You are not crazy. Just because you have horrible thoughts, it does not mean that you’re going to act on them; no matter how awful they are, your thoughts do not make you a bad person. Also, Postpartum OCD and psychosis are two different things; one does not turn into the other. I also want to repeat what I said earlier — I’ve never heard of a mom with postpartum OCD killing her child. The best news is, help is readily available.

You can seek out the help of a therapist who specializes in postpartum issues (see my previous post about how to find a therapist). If you’re lucky enough to live in the Portland, Oregon area, you can contact Baby Blues Connection (BBC) and talk with someone over the phone at no charge who has suffered through — and come out the other side — of postpartum OCD. They can also tell you if there are free support groups in your area. If you do not have an organization such as BBC near you, call Postpartum Support International (PSI). They get it. If you’re still unsure whether or not you can trust such an organization, you can always call and ask what they know about intrusive thoughts. Doing so may allay your fears.

If group or individual therapy is not an option for you, call PSI for support, learn diaphragmatic breathing and practice it daily, eat healthy food, exercise, DO NOT isolate, and get Karen Kleiman’s book (listed in bibliography). You don’t have to feel this way forever. Be good to yourself; both you and your baby deserve it.

What friends and family can do

If you are lucky enough that a mom confides in your about having intrusive thoughts, listen without judgement. Know that she is not exaggerating the depths of her distress and anxiety, or how real and vivid the thoughts can be. Don’t minimize her feelings or tell her that she’ll be fine. Let her know that she can get help. If she wants information, point her to Postpartum Support International or this blog post. Discourage her from searching the internet about her symptoms. Unfortunately, there is a lot of inaccurate  information that could exacerbate her fears. If she says things such as, it would be better if I weren’t around, or otherwise indicates that she would be better off dead, seek professional help immediately.

Keep in mind that no one decides they want to get Postpartum OCD. They’ve done nothing to deserve it and they have not brought in on themselves. It is important to avoid blame, because adding that onto the guilt and shame they already feel will only make things worse.

And please…spread the word…okay? You may just save a life by doing so.

Bibliography

Chaudron, LH, Nirodi, N. (2010). The obsessive-compulsive spectrum in the perinatal period: A prospective pilot study. Archives of Women’s Mental Health, 13, 403-10.

Kleiman, K, Wenzel, A. (2011). Dropping the Baby and Other Scary Thoughts. New York, NY: Taylor and Francis Group.

Timpano, KR, Abramowitz, JS, Mahaffey, BL, Mitchell, M, Schmidt, N. (2011). Efficacy of a prevention program for postpartum obsessive-compulsive symptoms. Journal of Psychitaric Research, 45, 1511-7.

Zambaldia, CF, Cantilinoa, A, Montenegroa, AC, Paesb, JA, de Albuquerqueb, TLC, Sougeya, EB. (2009). Postpartum obsessive-compulsive disorder. Prevalence and clinical characteristics. Comprehensive Psychiatry, 5, 503-9.

Panic and Exposure Therapy

First, the good news: Panic Disorder is very treatable. And the bad news isn’t so bad, really. It’s just that you have to be committed to the process of getting better and you will need to work hard. In this post I’ll explain what Panic Disorder is, describe an effective treatment approach, and explain why commonly used methods for relieving anxiety may actually exacerbate it.

What is Panic Disorder?
Agorophobia and other risks of Panic Disorder
How does one develop Panic Disorder?
The tenacity of the four Fs
Treatment overview
Don’t make it worse
My next post

What is Panic Disorder?

Those with Panic Disorder (PD) have a number of intense physical symptoms that typically last for 10 minutes or less, but attacks can continue for much longer if one rolls into another. They are extremely frightening and uncomfortable, especially if the person believes there may be something physically wrong with him or her. Physical symptoms may include rapid heart beat, shortness of breath, tingling of the extremities, dizziness, feeling of choking, trembling or shaking, stomach upset, chest pain, chills or hot flashes and the person may feel oddly unreal or detached from themselves. Not fun. People who have these attacks may think they are having a heart attack or stroke, that they are going crazy or may lose control, or feel very embarrassed and self-conscious. Attacks may be brought on by seeing something that frightens you, such as snakes, or they can be triggered by certain situations, such as being in a crowded place. Most attacks, however, seem to come out of the blue (although recent research has shown that physiological changes actually precede “sudden” attacks), which is a hallmark of Panic Disorder. Recent research has shown that stressful life events may exacerbate the severity of a person’s panic attacks. This may explain why new moms often experience Panic Disorder for the first time.

The person with panic often feels a desperate need to escape and will do anything to avoid experiencing another attack. Left untreated, the anxiety typically gets worse.

Many people with Panic Disorder end up going to the Emergency Room or their doctor’s office at some point because they think there must be something physically wrong with them. If you’re like many people, you may not believe the doctor when she says you had a panic attack. You may also feel embarrassed because you were so sure that you were having a heart attack. This is a normal response but it’s important not to let your feelings of embarrassment stop you from getting treated. In fact, it’s a good thing that you went to the doctor because we know that you’re in good physical health. We can now move on to treating the anxiety.

Agorophobia and other risks of Panic Disorder

Agoraphobia sometimes develops as a side-effect of Panic Disorder and is, generally, a fear of public or open spaces. It develops because the person has had panic attacks that have scared the person so much that he avoids the places and activities he has associated with the attacks; he has been conditioned to believe he will panic in such places and will be unable to escape. At this point his symptoms have a big impact on his life and may seriously affect his relationships, employment, activity level, sense of freedom, and likely even his sense of self. According to the American Psychological Assocation (APA), those with Panic Disorder are also at risk for developing:

  • debilitating phobias
  • depression and suicidality
  • alcohol and drug abuse
  • feeling less emotionally and physically healthy
  • fear of leaving home

Again, it doesn’t have to rule your life and the treatment is effective for the vast majority of people who seek it.

How does one develop Panic Disorder?

It is difficult to pinpoint the exact cause of PD. Most of those who have it have had some problems with anxiety for most of their lives. The latest data point to a genetic component. Drug use may lead to an initial attack and so can mounting stress and responsibilities; panic attacks often first surface in times of transition. Smoking cigarettes may exacerbate the problem and those who smoke have have poorer treatment outcomes. Sometimes the death of someone close to us can be a trigger. At other times, no likely cause can be identified. They typically begin before the age of 30.

The tenacity of the four Fs

Panic is adaptive in some situations. If we are hiking in the northern hills, round a corner and suddenly find ourselves face-to-face with a bear, then it’s a good thing our bodies act the way they do. This is when our sympathetic nervous system kicks in, and it’s a good thing. In those cases, we are likely to do one of four Fs, all of which may save us: 1. Freeze. Some animals sense movement, so if we don’t move, they may not be able to see us or think we’re a threat and leave us alone. 2. Faint. If the animal thinks we’re dead, then they’re likely to move on or just play with us a bit. 3. Flight. If you run, they may not give chase and perhaps you can escape. 4. Fight. As a last resort, fighting may work against smaller, weaker predators, especially if you have some sort of weapon.

What’s interesting is that the physical symptoms during a panic attack are all things that can help us in that rare, dangerous situation described above. When our heart rate increases, blood is pumped toward our major muscle groups, such as our quadriceps, so that we can run. Sweating not only cools the body, but it makes us more slippery so that a predator has a harder time grabbing us. Tingling or numbness in the fingers and toes helps to draw blood toward the major muscle groups but also makes it less likely that we will not bleed to death if our hands gets injured in a fight. Do you tend to get dizzy? That is often a result of hyperventilation; fainting would be F #2, playing dead (but it is very rare that people actually faint during panic attacks).

While panic used to serve the purpose of ensuring our survival in times of danger, our environment has changed. Apart from the occasional mugger, rarely do we encounter situations in which we need the four Fs. Rather, we may have arguments with loved ones or co-workers, need to make a speech, or have tight deadlines we need to meet. Still, on occasion, our bodies continue to rely on their old tricks. When that happens, we can re-train our bodies and brains to respond more appropriately.

Treatment overview

Organizations such as the National Institute of Mental Health (NIMH) and the American Psychological Association (APA), and the American Psychiatric Association recommend CBT as the treatment of choice for PD. Although medications are also endorsed, below I explain why I think they are typically unnecessary in treating PD and can actually complicate it. If you have true PD, then the treatment is fairly straightforward. I follow the recommendations of Barlow and Craske,who have created a treatment model that combines educational, relaxation, cognitive, and behavioral components. Technically, it is a branch of CBT called “exposure therapy.” In my opinion, it is far and away the best approach and takes, on average, 10-16 sessions, depending on the individual’s specific needs.

It is certainly easier to take a pill than it is to go to a therapist and follow through on treatment recommendations, but psychotherapy is a better way to go. For most people with Panic Disorder, medication is unnecessary and only complicate treatment (but treatment is still fairly straight-forward). One problem with taking medications alone is that you will likely have to continue taking them indefinitely if you do not want to re-experience panic attacks. Also, anti-anxiety medications are potentially addicting, and anti-depressants are both less effective for panic and can lead to rebound effects when stopped. However, in some cases, especially if a person is also very depressed or suicidal, medications are an important part of treatment for PD. Never stop medications on your own; there can be serious effects from doing so. Please follow the recommendations of your doctor.

Don’t make it worse

One of the biggest components of treatment include helping you to recognize when you’re using avoidance. For those with anxiety, avoidance is a key component in maintaining and exacerbating your symptoms. When you avoid something that you associate with symptoms of panic, you actually increase both your anxiety and the likelihood that you will panic. For example, if you avoid driving over bridges because you think you may panic while driving over one (and perhaps you have in the past), then you will teach your body and brain that it is, in fact, too dangerous to do so. Your avoidance and fear of bridges will likely increase and you could develop a severe phobia of bridges. Your risk of having a panic attack on a bridge also increases.

Avoidance also applies to panic attacks themselves. As scary and uncomfortable as a panic attack is, it is not dangerous. If you find yourself panicking, remind yourself that while it is very uncomfortable, it will not kill you. You do not need to try to escape it. Each time you try to escape it, you are turning up the volume on future attacks and you may lengthen the duration of the attack. Again, by using avoidance strategies, you are teaching your body that panic attacks are too dangerous and must be avoided at all costs. When your body learns this, it reacts by going into panic mode more easily. You brain learns that it needs to be on high alert and may interpret harmless bodily sensations (such as an increased heart rate during exercise) as dangerous — once again, sending your body into panic mode.

A good therapist can help you identify your avoidance behaviors and give you tools and information to help you manage any attacks you may have. You will be given activities to practice at home, which are a vital part of your healing process.

Often people with PD spend a lot of time on the internet, trying to find a medical reason for their symptoms. This will only make things worse. It’s likely that you’re looking to confirm that you are seriously ill, and you won’t stop until you find something truly frightening. Chances are, you’re young, in good health, and have been told so by your doctor. There is no good reason to doubt her. There is, however, good information on the internet about Panic Disorder. Still, be a skeptical consumer; just because it’s on the internet, does not make it true.

I love working with clients who have Panic Disorder. Those I have seen who have been motivated to follow through with treatment see dramatic results. Best of all, they rediscover how to enjoy life. What could be better than that?

My next post

For my next post, I will talk about how you can stop smoking. I’ll include a description of different treatment options and your chances for success.

Bibliography:

Meuret, A; Rosenfield, D; Wilhelm, F; Zhou, E; Conrad, A; Ritz, T; Walton, T (2011). Do unexpected panic attacks occur spontaneously? Biological Psychiatry, 20, 985-91.

Moitra, E; Ingrid, D; Courtney, B; Bjornsson, A; Sibrava, N; Weisberg, R; Keller, M. (2011). Impact of stressful life events of the course of panic disorder. Journal of Affective Disorder, 134, 373-6.

Rosqvist, J (2005). Exposure Treatments for Anxiety Disorders: A Practitioner’s Guide to Concepts, Methods, and Evidence-Based Practice. New York: Taylor and Francis Group.