What I wish every parent knew about intrusive thoughts (and what doesn't work to manage them)
Intrusive and unwanted thoughts and images are super common, with up to 90% of new parents having these at times.
It’s normal, in other words, to have worrisome images or thoughts pop into your mind about harm coming to you or your baby.
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It’s like your brain is doing it’s job, scanning the environment for danger, and trying to be protective. When the thoughts persist on a loop, or when you feel like you have to avoid situations, or do something to make sure the bad thing doesn’t happen, then it can become more difficult to manage.
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Actual Perinatal-onset OCD occurs in about 5% of new parents, and perinatal women are up to 2x more likely to get OCD than the general public.
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If you’re experiencing OCD symptoms, and struggling with worry from your thoughts, you’re not alone and deserve support. OCD responds really well to medication and Exposure and Response Prevention (ERP), a type of therapy used to treat obsessive thoughts and compulsive behaviors.
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What OCD is:
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▫️Unwanted and persistent thoughts that are repetitive
▫️Thoughts or images that are “sticky” and difficult to get out of your head
▫️Sometimes coupled with a strong desire to avoid the thoughts
▫️Complete avoidance of a situation (such as not going up the stairs while holding the baby)
▫️Use of mental rituals (counting, praying, seeking reassurance, saying something over and over)
▫️Use of compensatory behavior to manage the distress (frequent checking, washing, rituals)
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What OCD isn’t:
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▫️That you’re controlling or organized
▫️The same as getting a random thought that pops into your head and goes away
▫️The same thing as having intention (seeing yourself doing something awful does NOT mean you want to do it, or are capable of doing it)
▫️The same as psychosis (intrusive images and thoughts, while super distressing, are NOT hallucinations or delusions)
▫️Warranting of Child Services or the authorities involvement
Why is it that new parents often have intrusive, unwanted thoughts around harm coming to their baby? And, do their thoughts mean that they’re capable of acting on these thoughts?
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And, how to do we know that thoughts DON’T equal intention?
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Thought action fusion is an important concept, where folks with anxiety and OCD will frequently confuse having an intrusive, unwanted thought with being the same thing as it coming true. Meaning:
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“If I’ve had this thought, then it must be real”. “If I’ve seen this awful thing happening, then it must mean it will happen in the future”. “If I’ve seen an image of myself doing this god-awful thing, then it must mean I’m capable of doing it”.
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OCD is a beast of a liar and will tell you that you are capable of doing the thing that you just thought (or saw). But here’s the thing, thoughts don’t equal action.
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If they did, I would magically think up a taco right now (hey, I’m hungry), and can certainly picture a lot of cool stuff I’d like to be doing but am not (hellooooo trip to Antarctica!). This is an important concept that we teach people as they’re being treated with OCD.
And did you know these thoughts can even start during conception?
I’ve had a number of clients have unwanted images and thoughts about their baby start while going through infertility treatments, and during their pregnancies!
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These thoughts can center around harm coming to the baby, with the parent seeing themselves as the one causing the harm. It can be really distressing.
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These intrusive / unwanted thoughts can look like:
▫️What if I just touched something contagious and then passed it to the baby?
▫️What if I lose control and shake my baby?
▫️What if I drop my baby while going up the stairs (or if I do it on purpose?)
▫️If I pictured my baby dying, does that mean it's going to happen?
▫️If I pictured myself hurting my baby, does that mean I'm capable of doing it?
▫️Am I capable of drowning my baby?
▫️What if I act out sexually against my baby?
I gave you only a few examples above, but the thoughts and images can get SO awful and visceral and vivid. Needless to say, if you’ve thought it, as perinatal therapists who treat OCD, we’ve heard it, and it doesn’t rattle us.
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And yet here’s the thing. As we’ve been talking about, thoughts do not equal action. It can be so awful to see these images or think these thoughts.
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Sometimes these thoughts just pop up, and then fade away. But when these thoughts stay on a loop or when parents start doing anything within their control to avoid the situation, pervasive and chronic thoughts can become a pattern of OCD including compulsive behaviors (more on this later).
And this tidbit always blows my mind, and gets me so fired up and inspired to continue to spread awareness: did you know it can take people an average of 14-17 years to finally be accurately diagnosed with OCD!?
⠀⠀⠀⠀⠀⠀⠀⠀ Misdiagnosis along the way is really common, with upwards of half of non-psychiatrist MDs misidentifying OCD, and up to 80% of these docs misidentifying harm obsessions.
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And in the perinatal population, around 70% of perinatal health practitioners did not accurately identify obsessions around harming the infant and 30% of them misidentified these thoughts as psychotic. 30%! That is such a big deal because of course this informs how the person is being treated (usually with medications) and how the person is learning to view themselves.
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I think there’s a few reasons why this may be the case:
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There are not enough providers trained in screening for, and treatment of OCD, we have to keep doing better. How many of you new parents were asked beyond basic questions around depression, and asked about obsessive thoughts and compulsive behaviors?
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I also think people are often ashamed and afraid, and without information and education, not likely to share the information to their providers themselves. Their families may also be helping “cover for them” inadvertently, by providing reassurance, or participating in their compulsions such as helping them actively avoiding distressing situations, or taking over when they’re too distressed.
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And lastly, I suspect a lot of this misdiagnosis has to do with compulsions not always being external (more on this later). Many compulsions are mental, with mental checking, praying, avoiding, etc., that cannot be overtly seen unless we ask.
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So, what CAN compulsions look like in new parents?
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Common compulsions in new parents are sometimes more obvious repetitive compensatory behaviors. People use these to manage and decrease the distress of the obsessive thoughts (but unfortunately don’t) such as:
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▫️frequent checking (baby’s breathing throughout the night, baby’s temp throughout the day, amount baby is eating, etc.)
▫️frequent washing, (hands, bottles, clothes, etc.)
▫️repetitive rituals like touching or doing things in certain order, etc.
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Compulsions can also be mental, however, and as such, are more “hidden” from others, and internal. These can look like:
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▫️Avoidance of the subject of the thoughts (such as not going up the stairs while holding the baby, getting rid of the knives, not turning on the stove, etc.)
▫️Use of mental rituals (counting, praying, seeking reassurance, saying something over and over, etc.)
▫️Mental checking (going over and over in your mind to double check something bad didn’t actually happen…think of it like feeding the Doubt Monster)
▫️Seeking reassurance from others - btw this isn’t the same as being worried about your baby and calling the pediatrician. Literally everyone does that. This is when calls to the doc don’t provide relief so you call again and again, or end up asking provider after provider, or keep doing more and more “research”, never feeling better.
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Compulsions are intended to reduce distress of the intrusive unwanted thoughts and images, and may work temporarily. Unfortunately they can become more and more excessive because they never fully provide relief. If this has resonated with you, or someone you love, you deserve support and treatment to overcome that which was previously controlling you.
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Please remember, Perinatal Mood and Anxiety Disorders (including OCD) are THE most common complications of pregnancy. They are treatable and you do not have to suffer alone and in silence. Thanks to IOCDF & PSI recently teaming up, there are now some great resources for perinatal OCD here. We also have an entire chapter devoted to these thoughts in our Pregnancy and Postpartum Mood Workbook.
Info is power and can take the "scaries" out of the unknown.
Fellow research nerds: Ruscio, Stein, Chiu, & Kessler (2008); Glazier, Swing, & McGinn, 2015; Mulchahy et al., 2020.