Download What is Obsessive-Compulsive Disorder

Maternal Mental Illness
Serious postnatal concerns
Dr Andrew Mayers
[email protected]
Maternal Mental Illness
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Overview
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Serious mental illness
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Maternal OCD
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Postpartum psychosis (including bipolar disorders)
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Maternal OCD
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What is Obsessive-Compulsive Disorder (OCD)?
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DSM-5
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A. Presence of obsessions, compulsions, or both:
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Obsessions as defined by (1) and (2):
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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)
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Obsessive-Compulsive Disorder (OCD)
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DSM-5
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Compulsions as defined by (1) and (2):
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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
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Obsessive-Compulsive Disorder (OCD)
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DSM-5
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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
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Maternal OCD
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Prevalence – 2.5-9% in perinatal period
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Compare to 1% OCD generally
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Some ‘mums’ get OCD for 1st time
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Or can be related to anxiety/uncertainty
Over-vigilance on safety/protection can trigger compulsions
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While, for others, symptoms worsen
Increased prevalence may be due to ‘safety’ behaviours
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And yet, Maternal OCD often overlooked
Cleaning, praying, rumination, avoidance…
It’s not the ‘thought’ of safety that’s the problem
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The worry of having thought (and reaction to that) IS
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See Fairbrother & Abramowitz 2007
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Maternal OCD
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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
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Maternal OCD - Impact
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Not ‘fashionable’ or ‘cool’
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No such thing as ‘a little bit OCD’
Significant impact on mother and family
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Obsessions and compulsion take over
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Mother may act ‘strangely’
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May not take part in everyday family life
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High risk of suicide
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VERY distressing for mother and family
Here’s a short video from my friends at MaternalOCD
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https://www.youtube.com/watch?v=VcghErjT5GQ
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Post-natal psychosis (PNP)
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PNP needs same DSM-5 diagnosis as any psychotic disorder
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Schizophrenia
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Schizoaffective disorder
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Brief psychotic disorder
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Can also include manic stages of Bipolar disorder
But PNP is not specifically mentioned in DSM-5
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Other than ‘postpartum mood (MDD or manic) with psychotic
features’
Not particularly helpful
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Symptoms usually immediately within few weeks of birth
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But psychotic episodes can also occur during pregnancy
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Schizophrenia
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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
1. Delusions
2. Hallucinations
3. Disorganised speech
 e.g. frequent derailment or incoherence
4. Grossly disorganised or catatonic behaviour
5. Negative symptoms
 e.g. diminished emotional expression flattening or avolition
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Bipolar disorders
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Bipolar I
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A. Manic criteria for at least one manic episode
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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
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A. Hypomanic criteria for at least one hypomanic episode
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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…
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PNP - features
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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
 “The child is not mine… it is evil incarnate… must be
terminated or he will kill me…”
 Also called puerperal psychosis
Prevalence
 1 in 1000 mums may get post-natal psychosis (0.1%)
 Contrast with baby blues and PND
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PNP - features
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First signs…
 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)
 May make bonding with baby difficult
 May have delusions or hallucinations
 She may misconstrue events
 Such as thinking the baby is about to be taken away
 When staff are taking it for a sleep or a feed
 Mum may be manic or have wild mood swings
 Behaviour may become increasingly bizarre
 May lose touch with reality
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PNP - Causes
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Depletion of oestrogen immediately after birth
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Hormone abnormalities more likely with PNP than with PND
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Sleep disruptions (before and after birth)
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Postpartum psychosis may be related to bipolar disorder
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Psychotic episodes and mood swings may actually represent first
bipolar episodes
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Previous bipolar disorder or schizophrenia is major risk factor
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Especially in new mothers
Or family history of one of these conditions
Previous history of PND or psychosis also a risk factor
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Postpartum psychosis
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I often use this video when training health profs on maternal MH
 From BBC Newsnight, August 2012
 Click this link and scroll to end “Watch Newsnight's film on
postpartum psychosis in full”
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Exercise
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How much more serious is postnatal psychosis than PND?
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What signs should we look out for?
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Should mother and baby be separated?
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What is the impact of stigma?
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What are the options?
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What are the consequences of PNP for mother and child?
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PNP and the child
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Serious illness with extremely serious implications for infant
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High risk of suicide and infanticide
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Potentially dangerous delusions
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Paranoid symptoms may cause mum to hide symptoms
Attention and cognition also a problem
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Both of those are important in caring for baby
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Or care for herself
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Mum may harm baby
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She may not be able to focus properly
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Or act quickly enough
May damage bonding and attachment
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PNP and the child
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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 puerperal psychosis
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What we have learned
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We have examined several aspects of maternal mental illness
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What is serious maternal mental illness?
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Postpartum psychosis
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Maternal OCD
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