Understanding Postpartum OCD: What Intrusive Thoughts Are and How Therapy Can Help

Written By Jess Coleman, Ph.D.

Table of contents

1. What is postpartum OCD?

98% of parents experience intrusive thoughts. After a baby is born, parents’ brains “rewire” to be more alert to danger, so they can protect their baby from possible harm. It makes sense for parents to be on higher alert when caring for a baby that relies on adults to stay alive. However, constantly being on high alert can be a risk factor for developing an anxiety disorder or Obsessive Compulsive Disorder (OCD).

Obsessive Compulsive Disorder, or OCD, involves experiencing intrusive, unwanted thoughts or images and engaging in repetitive behaviors or mental rituals to try to reduce distress. Most people are accustomed to listening to their brain and body’s cues for danger and can usually tell when those signals are accurate and helpful, or less helpful. OCD makes this distinction extremely difficult.

When someone has OCD, intrusive thoughts and images can feel so vivid and frightening that it becomes hard to determine which thoughts require action and which are simply false alarms. As a result, people with OCD may feel an intense sense of dread or urgency, as though something terrible is about to happen, even when no real danger exists. In this state of distress, people with OCD can get caught in a cycle of experiencing intrusive thoughts and engaging in compulsive behaviors to try to reduce distress and feel in control.

Intrusive thoughts in the postpartum period often focus on harm coming to the baby, which can make them feel especially alarming. I conceptualize new onset or worsening OCD during pregnancy and postpartum as occurring, in part, because the brain and nervous system are overwhelmed and working overtime to adapt and protect both the parent and the baby. It can feel like the brain is constantly scanning for potential danger and sounding an internal “alarm”, even when no immediate threat is present.

Signs that a person would benefit from treatment are that intrusive thoughts and compulsive behaviors are on overdrive and feel constant and overwhelming, get in the way of parents’ sleeping when the baby sleeps, and result in parents taking extra precautions above and beyond what most parents might think is necessary.

For example, parents commonly experience intrusive thoughts about accidentally falling down the stairs with their baby in their arms. Just because someone has those thoughts doesn’t mean they pose a risk of falling and hurting their baby. Avoiding walking down the stairs while holding their baby is an example of anxiety going on overdrive and beginning to impact someone’s life and routine.

Having intrusive thoughts does not mean that a caregiver intends harm or is a danger to others. On the contrary, intrusive thoughts are unwanted and extremely upsetting because the person would never want those thoughts to actually happen. They are symptoms of anxiety and do not reflect someone’s character or ability as a parent.

2. How to recognize intrusive thoughts and compulsive behaviors

OCD can begin during pregnancy or after birth. It can affect people who have never experienced OCD before, as well as those with a prior history of anxiety, trauma, or OCD.

People experience intrusive thoughts as thoughts or images that feel disturbing, scary, or out of character. They can appear as:

  • Thoughts about something bad happening to the baby (shaking the baby, injuring the baby with a kitchen knife)
  • Thoughts about accidentally harming the baby (dropping the baby down the stairs, the baby falling off the changing table, not being strapped into their car seat correctly)
  • Thoughts about the baby dying from SIDS, suffocating, or drowning
  • Thoughts about contamination, illness, or germs
  • Thoughts about you or others thinking about the baby in a sexual manner, when changing diapers or bathing them
  • Thoughts about feeling like you must do everything perfectly in order to prevent harm
  • Fears about losing control and hurting the baby

People with postpartum OCD often respond with compulsive behaviors, such as:

  • Constantly checking if the baby is breathing, if bottles are sterilized, if they are buckled correctly, or doors are locked
  • Avoiding certain rooms, stairs, objects, or caregiving tasks
  • Asking for frequent reassurance from partners or providers that things are safe, or asking them to “double check”
  • Mentally reviewing memories to “make sure” nothing bad happened
  • Replaying what they have done recently and where they may have caused harm
  • Doing research online to try to understand more about potential risks and preventive strategies

Feeling like something needs to be done in response to intrusive thoughts or something bad will happen can be exhausting. It can leave people feeling like they can’t trust themselves, terrified of their own mind, and disconnected from parenthood. It can consume so much time and energy that people can lose sight of their sense of self, what matters to them, and things that they enjoy.

I use therapeutic approaches that help my clients understand intrusive thoughts and build a toolkit of coping strategies to respond without unnecessary safety measures. With practice, this takes power away from the unhelpful thoughts and gives power back to my clients so they can live with greater agency and stability.

3. Why OCD is often misunderstood

Postpartum OCD is frequently missed or misdiagnosed. Many parents are afraid to speak their thoughts out loud to loved ones or providers, worried they might be judged or misunderstood. High profile stories about postpartum mental health conditions can make people afraid to share their struggle with OCD symptoms because they do not know if others will understand that they are not a danger to their baby and do not want to act on these thoughts.

Evidence indicates that intrusive thoughts in postpartum OCD do not make someone more likely to act on them, although they feel frightening.

Sometimes people confuse postpartum OCD and postpartum psychosis, which are very different conditions. In postpartum OCD, the intrusive thoughts are unwanted and distressing. People who have OCD recognize that these thoughts do not match their values and they feel strongly that they would do anything they could do to prevent the feared events from happening.

In postpartum psychosis, people can lose touch with reality and can see or hear things that aren’t there. This can sometimes manifest as having paranoid delusions about harm coming to the baby, or urges to harm the baby either because they don’t recognize it as a baby or because they think they are protecting the baby from other harm.

Knowing the difference between these conditions is critical for accurate diagnosis and appropriate support. OCD can be treated with therapy, or a combination of therapy and medications. When someone shows signs of postpartum psychosis, an immediate trip to the Emergency Room is needed for thorough assessment and inpatient treatment with medications.

4. How ERP therapy can treat OCD

Exposure and Response Prevention, or ERP, is the gold standard treatment for OCD. It is a form of cognitive behavioral therapy that helps change how people respond to intrusive thoughts, instead of trying to control them, eliminate them, or prevent the unwanted events from occurring.

In ERP for OCD during pregnancy or postpartum, I work with my clients to:

  • Map out the specific intrusive thoughts, images, and urges they experience and how they are negatively impacting the client’s life
  • Notice the compulsive behaviors that they do to try to keep themselves and others safe that can fuel distress
  • Gradually face feared situations in a planned, supported way
  • Practice new ways of coping rather than checking, reassurance seeking, or avoiding when they have intrusive thoughts
  • Build skills to tolerate anxiety and uncertainty without engaging in behaviors that they do to try to feel in control
  • Practice doing what matters to them in their day to day life, despite challenging emotions that may come up

I work closely with my clients to create a treatment plan they feel comfortable with. Many people feel nervous about sharing the frightening and intrusive thoughts they experience. I am comfortable discussing all types of disturbing intrusive thoughts as part of OCD assessment and treatment. We move at a pace that feels appropriately challenging but not overwhelming, and I never suggest that clients do anything unsafe as part of the ERP process.

5. What therapy for OCD looks like online

Online therapy for OCD during pregnancy or postpartum can be especially helpful when leaving home feels overwhelming or childcare is limited. Sessions are held through a secure, HIPAA-compliant telehealth platform and focus on working with intrusive thoughts in the client’s real-life environment.

In ERP, clients learn to identify intrusive thoughts and compulsive behaviors and use specific behavioral approaches to respond differently to them. The goal is to reduce the impact of intrusive thoughts so time and energy can be directed back toward daily life and recovery.

Telehealth allows me to provide greater access to specialized, high quality pregnancy and postpartum OCD care for clients in North Carolina, California, and many PSYPACT states.

6. When to reach out to a therapist specializing in OCD during pregnancy and postpartum

It may be time to seek therapy for OCD if you notice that:

  • Intrusive thoughts are frequent, distressing, or feel out of control
  • You are spending a lot of time checking, avoiding situations, trying to get things exactly right, preventing harming yourself or someone else, or asking others for reassurance
  • Anxiety or behaviors you feel you must do to manage the intrusive thoughts are interfering with sleep or daily tasks
  • You feel afraid to be alone with your baby, even though you have never harmed anyone
  • You feel ashamed, isolated, or misunderstood

Reaching out for support is not a sign that you are failing as a parent or as a person. It is a sign that you are taking your mental health and your family’s well-being seriously.

7. Frequently asked questions about OCD during pregnancy or postpartum

Is OCD during pregnancy and postpartum common?

OCD is more common during the perinatal period than many people realize. Research suggests that 8% of people during pregnancy and 17% of people during the postpartum period have OCD, compared to 2 to 3% of the adult general population.

Does having postpartum intrusive thoughts mean I am a danger to my baby?

Intrusive thoughts are unwanted and distressing. They are a sign of anxiety, not intent to harm. There is no evidence that parents with OCD are more likely to act on these thoughts than parents who do not have OCD.

Does postpartum OCD go away on its own?

Some symptoms can lessen over time, but often people continue to feel distressed without support. ERP is the gold standard evidence-based therapy to treat OCD. I offer ERP through the lens of my reproductive mental health and trauma-informed care expertise, which can help to tailor treatment and optimize effectiveness.

8. Further reading

Jess Coleman, Ph.D.
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