lecture 6-Serious postnatal concerns Flashcards
what is maternal OCD?
What is Obsessive-Compulsive Disorder (OCD)?
DSM-5
A. Presence of obsessions, compulsions, or both:
Obsessions as defined by (1) and (2):
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 such thoughts, urges, or images, or to neutralise them with some other thought or action (i.e. by performing a compulsion)
DSM-5
Compulsions as defined by (1) and (2):
1. Repetitive behaviours (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) 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 either are not connected in a realistic way with what they are designed to neutralise or prevent, or are clearly excessive
How to get an OCD diagnosis
DSM-5
B. The obsessions or compulsions are time consuming (take more than 1 hour a day), or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
C. The disturbance is not due to the direct physiological effects of a substance or a general medical condition
D. The disturbance is not better explained by another mental disorder
Maternal OCD – intrusive thoughts and compulsions often focus on safety of child
facts about maternal OCD
Prevalence – 2.5-9% in perinatal period
Compare to 1% OCD generally
And yet, Maternal OCD often overlooked
Some ‘mums’ get OCD for 1st time
While, for others, symptoms worsen
Increased prevalence may be due to ‘safety’ behaviours
Or can be related to anxiety/uncertainty
Over-vigilance on safety/protection can trigger compulsions
Cleaning, rumination, excessive safety behaviours
It’s not the ‘thought’ of safety that’s the problem
The worry of having thought (and reaction to that) is overwhelming to mums, they cant overcome it.
what are common obsessions and compulsions for mothers with OCD?
Most people don’t give ‘fleeting thoughts’ much attention
Someone with maternal OCD will dwell on that intrusive thought
Common obsessions
Fear of contamination
Intrusive thoughts, images, doubts of harm
Perfectionism
Compulsions serve to counter anxiety from obsession
But make it worse
Common compulsions
Hypervigilance
Hiding anything sharp around the house
Constantly checking
Waking earlier/going to bed later
Constant reassurance-seeking
Over checking the environment-has to be the first person awake/last person asleep to make sure that the environment is safe for the child.
impact of Maternal OCD
Obsessions and compulsion take over Mother may act ‘strangely’ May not take part in everyday family life High risk of suicide VERY distressing for mother and family Risk of suicide is elevated
Treatments and therapies for maternal OCD
Medication
Conflicting evidence on safety – needs more studies
Some women offered talking therapy as alternative
But many must be medicated for own safety
Implications for breastfeeding
Therapy
CBT quite common (e.g. see – Challacombe et al. 2017)
Short term, structured, problem focused & goal directed
Focus on relationship of thought & behaviour
Exposure and Response Prevention
Break cycle of thought & catastrophic outcome
Frightening thoughts gradually tested in safe place
Relapse prevention
Self-taught tool kit
Postnatal Psychosis (PNP)
PNP needs same DSM-5 diagnosis as any psychotic disorder
Schizophrenia
Schizoaffective disorder
Brief psychotic disorder
Can also include manic stages of bipolar disorder
But PNP is not specifically mentioned in DSM-5
Other than ‘postpartum mood (MDD or manic) with psychotic features’
Not particularly helpful
Symptoms usually immediately within few weeks of birth
Some sources call this condition puerperal psychosis
What is the clinical threshold for schizophrenia?
DSM-5
Two or more of following (each present for a significant portion of time during a one-month period – or less is successfully treated). At least one must be 1, 2 or 3
Delusions
Hallucinations
Disorganised (incoherent) speech
Grossly disorganised or catatonic behaviour
Negative symptoms
e.g. no emotion, reduced activity, poverty of speech
what is the criteria for bipolar 1 and bipolar 2 disorder?
Bipolar I
A. Manic criteria for at least one manic episode
The manic episode MAY have preceded or be followed by hypomanic or depressive episodes
B. The occurrence of manic and major depressive episode(s) not better explained by schizoaffective disorder/schizophrenia (etc.)
Bipolar II
A. Hypomanic criteria for at least one hypomanic episode
AND there MUST be current/past MDD episode
B. There has NEVER been a manic episode
C. The occurrence of hypomanic and major depressive episode(s) not better explained by schizoaffective disorder
what are the initial key signs of PNP?
- Can start suddenly or a few weeks after birth
- Mum becomes very restless, or elated, and unable to sleep
- Becomes confused and disorientated
- May not recognise friends or family members (or baby)
- Odd/erratic speech
- May have delusions or hallucinations
- She may misconstrue events
- Mum may be manic or have wild mood swings
- Behaviour may become increasingly bizarre
- May lose touch with reality
what are the main features of PNP?
Very serious illness Potential risks for mother and baby Needs quick intervention, usually hospital High risk of suicide and infanticide Delusions may be directed at baby Often focus on religious aspects Son of God… Chosen one… Or devil child… Also called puerperal psychosis Prevalence 1 in 1000 mums may get post-natal psychosis (0.1%)
what are the causes of PNP?
Depletion of oestrogen immediately after birth
Hormone abnormalities more likely with PNP than with PND
Sleep disruptions (before and after birth)
Postpartum psychosis may be related to bipolar disorder
Psychotic episodes and mood swings may actually represent first bipolar episodes
Especially in new mothers
Previous bipolar disorder or schizophrenia is major risk factor
Or family history of one of these conditions
Previous history of PND or psychosis also a risk factor
impact of PNP on the child?
Serious illness with extremely serious implications for infant
High risk of suicide and infanticide
Potentially dangerous delusions
Paranoid symptoms may cause mum to hide symptoms
Attention and cognition also a problem
Both of those are important in caring for baby
Or care for herself
Mum may harm baby
She may not be able to focus properly
Or act quickly enough
May have impact on bonding and attachment
Enormous risk of suicide
Wouldn’t deliberately harm the child but erratic delusions may lead her to accidentally
May not be able to focus on the child well enough to be able to care for the child
More evidence
Postnatal psychosis (PP) presents dangers to mum and child
70-fold, increase in maternal suicide risk
Leading cause of maternal death in first year after birth
Homicidal behaviour is rare
But 28%–35% PP mums described delusions about infants
Only 9% had thoughts of harming the infant
And PNP women more likely to state homicidal thought than healthy mums
And than mothers with PND
Cognitive disorganisation in PNP may cause mum to neglect infant
See Sit, et al (2006) for review of postpartum psychosis
Other evidence of SMI in mums and effect on children
Developmental problems (Henriksson & McNeil, 2004)
Children of schizophrenic mums showed (compared to controls):
Significantly increased rates of delayed walking
Visual dysfunction
Language skill disorders
Enuresis (bed-wetting)
Disturbed behaviour
Poor social competence
Greater risk behaviours
Children of PND mums showed:
Significantly increased rates of delayed walking only
PNP treatment
Often mum needs to be admitted to hospital
Sometimes in mother and baby unit in psychiatric ward
Probably needs medication
Stabilising drugs (e.g. lithium)
Antipsychotic drugs: olanzapine, risperidone, or aripiprazole
Antidepressants
But medication needs to be carefully considered
Because of the breastfeeding implications (see Pearlstein, 2008)
CBT may also be used
But usually as ‘add-on’ to medication
Where meds not appropriate, ECT has been successful (Sit et al 2006)
