Treatment for Perinatal or Postpartum OCD
Perinatal Obsessive-Compulsive Disorder (PP-PCD) which can also be referred to as Perinatal OCD or Postpartum OCD is gaining more attention in the field of maternal mental health, but it is still highly under-recognized, mis-diagnosed and often misunderstood. Perinatal OCD can come in many forms as outlined in my previous blog here. Once there is a diagnosis of Perinatal / Postpartum OCD, it is so important to pursue the right type of treatment.
The gold standard treatment for OCD is Exposure and Response Prevention (ERP). ERP is an evidence-based treatment that involves gradually exposing ourselves to anxiety provoking situations/fears in a safe and empathic environment. The patient learns to approach these situations while resisting compulsions, rituals, and safety behaviors. With the guidance of the therapist, this process allows the person to learn new, more helpful responses rather than continuing to reinforce the vicious cycle of OCD, fears, and ruminations. It is an active treatment, in which the patient gains corrective experiences by “doing”, not just talking.
What to expect when doing ERP
Together, we’ll create a comprehensive list of the main things that you’re distressed about, anxious over, or avoiding. This list is value-based, meaning we will collaborative choose to face the situations that you have been avoiding but are actually very important and meaningful to you (and very likely impacting your ability to bond with your baby). Then, we’ll start to address those barriers in a gradual way.
ERP includes guidance through either the actual situation (In Vivo) or through the use of your imagination (Imaginal) to make yourself vulnerable to distress without resorting to protective behaviors.
You’re in the driver’s seat the entire time. We don’t flood or overwhelm you to the point that you would want to leave your session or avoid coming back to treatment.
This teaches you how to tolerate the distress you experience, work through it, and ultimately lower your distress when you encounter an activating situation in daily life. One of the main goals is for a person to realize that the distress they experience is tolerable, manageable, temporary, and does not need to inhibit them. When this type of new learning occurs, a person can make the choices in their lives that they normally would have avoided.
Engaging in ERP is considered safe during pregnancy. Typically, the distress caused by the OCD itself is more upsetting for an expecting parent than the anxiety induced during exposure work. When it comes to exposures during pregnancy and postpartum, a trained professional would work with the client and family to agree to a ‘safe enough’ exposure. For example, for contamination OCD, we would never put the infant at risk by not washing a bottle ever. We would have the client commit to washing the bottle once, which is reasonable and generally acceptable, and then commit to tolerating the anxiety that comes up when thoughts arise of the bottle not being clean enough.
A crucial part of treatment is family sessions to address the role of family accommodation. In the case of OCD, it is common to see family members responding to the symptoms of OCD in a way that actually makes the OCD bigger. Of course, when we see a family member in distress, we want to jump in and take the pain away. Accommodations temporarily relieve the distress, but they strengthen the OCD cycle in the long run. If a family member or partner participates in or completes compulsions for their loved one, for instance, they take over bath time or bedtime routines or start participating in checking behaviors and other rituals, it actually makes things worse. Over the course of treatment, family sessions are crucial so the family can learn about and ultimately reduce/resist accommodations to better support their family recovery.
Acceptance & Commitment Therapy (ACT) as an adjunct to treatment
Sometimes, clients may benefit from integrating Acceptance & Commitment Therapy (ACT) into their treatment. ACT is a “Third Wave” form of CBT that involves cognitive, behavioral and mindfulness practices.
In ACT, the main focus of the work is helping people to utilize certain psychological processes: Acceptance, Defusion, developing a Self as Context, Committed Action, Value driven behavior, and Contact with the Present Moment in order to achieve Psychological Flexibility. To learn more about how ACT can be helpful in motherhood, click here.
What about medication?
The research indicates that there are options that are considered safe during pregnancy and breastfeeding. For instance, Selective Serotonin Reuptake Inhibitors (SSRIs) like sertraline have been considered safe. Some medication prescribers may not be up to date on this information and it may be best to consult with a reproductive psychiatrist who specializes in this area. Other options may be to seek a psychiatrist or psychiatric nurse practitioners that are trained in Perinatal Mood and Anxiety Disorders (PMADs) through Postpartum Support International.
Many expecting and new moms or their families may have a hard time deciding if medication is right for them. With a trusted mental health professional, it can be helpful to weigh the risk of having perinatal OCD go untreated versus any potential risk of medication. Research does indicate that untreated perinatal mood and anxiety disorders can persist for years if left untreated, and there are long term mental health and developmental impacts for the child.