OCD, Perinatal OCD, Parental Preoccupation and Parenting By Miri Keren, MD, Israel From normal Primary Parental Preoccupation to Obsessive Introduction Compulsive Disorder Perinatal depression and postpartum Winnicott (1956) described the perinatal psychosis are nowadays well detected, period as a unique state of heightened and numerous studies have shown their sensitivity, that is like a dissociative detrimental impact on the mother- state; the aim of which is to enhance the child relationship and on the offsprings’ mother’s ability to anticipate the infant’s socio-emotional development (Murray needs and to learn its unique signals. He et al., 2019). In contrast, the impact of called it: "almost an illness that a mother perinatal maternal or paternal obsessive- must experience and recover from, in order compulsive disorder (OCD) on the parent- to create and sustain an environment that infant relationship and on the offsprings’ can meet the physical and psychological outcome, has been scarcely studied. This, needs of the infant". Winnicott emphasized in spite of the study published already in the crucial importance of such a stage 2007 (Fairbrother et al., 2007) that showed for the infant’s self-development (even new parenthood as a risk factor for the before what we know today about the development of obsessional problems. impact of early interactive experiences Even in the last edition of the Handbook of on the brain development), and the Infant Mental Health (Zeanah, 2018), the detrimental developmental consequences topic has not been mentioned. for infants when mothers are unable to Several cases we have had at our tolerate such a level of intense sensitivity. community-based infant mental health Postpartum depression may actually be clinic have prompted us to look deeper at conceptualized as the inability to enter this the phenomenon, and we wish to share special state of sensitivity, while perinatal this clinical experience of ours with WAIMH obsessive-compulsive disorder could be members. First to note, is the fact that the viewed as a hyper primary preoccupation interactions with the offspring relate reason for referral was not the parental and postpartum psychosis as a distorted to complex structural and functional OCD but rather non-specific symptoms primary preoccupation. changes in the various areas implicated in maternal caregiving: areas of reward/ in the young child. Such as: separation From maternal to paternal primary anxiety and aggressive temper tantrums in motivation, salience/threat detection, preoccupation: A prospective longitudinal emotion regulation, and social cognition/ a 3 year old boy whose father turned out to study of 82 parents (Leckman et al., 1999) have OCD; overeating disorder in a 2 years empathy (Barbara-Muller et al., 2019). Thus, on the course and content of the parental the pregnant and postpartum mother’s and 10 months old girl and maternal OCD; preoccupation showed that it starts strong refusal to stay with mother in a 2 brain evolves in ways that promote towards end of pregnancy and peaks mother-infant bonding and sensitive and half year old, and maternal OCD; and around the time of delivery. Fathers and autistic-like symptoms in a 3 and half year caregiving. At the same time, this brain mothers displayed a similar time course, plasticity predisposes the mother-to-be, to old and maternal OCD. The youngest and though the intensity of preoccupation was most recent case, which will be described peripartum disorders. Sensitive maternal less in fathers (this maybe well fitted to care lies on a U-shaped curve, where both later in detail, was a 5-month-old baby boy, the fact they need to go back to work and of a mother with OCD, who was referred hypo-reactivity (such as in postpartum to invest in the external world). Leckman depression) and hyper-reactivity (such as because of concerning passivity and slow and Mayes (1999) made an interesting motor development. in postpartum anxiety) to infant cues in the link between parental and romantic love amygdala, are problematic (Young et al., In this paper, we will first review the with the obsessive- compulsive condition. 2017). literature on maternal and paternal OCD, Furthermore, on the biological level, a while noting a theoretical continuum from link between parental preoccupation and Is Perinatal OCD a subtype normal parental primary preoccupation to oxytocin secretion has been demonstrated perinatal obsessive-compulsive disorder in mothers as well as in fathers (Leckman et of Obsessive-Compulsive and raising the question whether perinatal al., 2004). Disorder? OCD is different from OCD in other periods Postpartum period and brain plasticity: Perinatal OCD is defined as an obsessive- of life. We will end with suggested clinical The altered mental states associated with implications, including the importance compulsive disorder that occurs during this normal hypersensitive period is also pregnancy or postnatally, with either to think of, and detect, paternal perinatal a risky time. While many animal studies OCD. new or exacerbated existing OCD. The have shown a distinct neural plasticity clinical presentation is characterized by of the female brain during pregnancy symptoms that orientate around baby and postpartum period, an emerging and caregiving, but interestingly, the body of research reveals the existence of content of the obsessions differs by time reproduction-related brain plasticity in of onset. Pregnancy-onset OCD has been human mothers. Hormones and sensory more associated with fears of accidentally

24 PERSPECTIVES IN INFANT MENTAL HEALTH SPRING/SUMMER 2020 harming the baby by contamination and Postpartum Paternal for maternal depression) (Hanington et al., related compulsions, while the postnatal- 2012; Ramchandani et al., 2005, 2008, 2011; onset OCD has been more associated with Psychopathology Connell et al., 2002). Although depression fears of deliberately harming the baby Paternal mental health is still a neglected and anxiety are highly comorbid, few with avoidance of caregiving tasks and topic in the child development research studies have examined the impact of mental rituals (Abramovitz et al., 2003). and clinical literature in spite of the paternal anxiety compared to paternal The prevalence of OCD in the general increasing involvement of fathers into the depression. Fathers are at the same risk population is 1.2%, in contrast with OCD parenting roles (due to several societal (21%) as mothers (24%) to experience 4-9% for prenatal and postpartum OCD changing phenomenon such as women’s depression and anxiety during pregnancy, (Uguz et al., 2007 a, b, c; McGuinness et al., increasing role in the work force, single post-partum, and after (Luoma et al., 2013) 2011). gender families, and more) and in spite and both maternal and paternal factors predict high paternal symptoms; infant Similarly, Miller and colleagues (2013) of what we know about the unique role of fathers in child development. Such as, factors do not. Low social support and studied 461 pregnant women and found poor marital quality are risk factors for both that 11% of women screened positive for father involvement and secure attachment has been linked with positive mental and fathers and mothers, more than the direct OCD at 2 weeks postpartum (in contrast to stress linked with the infant’s condition 2-3% in general population). At 6 months, physical health outcomes that persist into adulthood (Cabrera et al., 2000; Flouri et (Zelkowitz et al., 2007). The inclusion of half of them still had persistent symptoms anxiety disorders in diagnostic interviews and 5.4% had developed new symptoms. al., 2003; Wilson et al., 2010; Martin et al., 2007). Just in a mother’s case, a father’s have substantially increased the rate of Depression was the most frequent detected paternal postpartum mental co-morbid diagnosis. The limitation mental health problem can be present before or at entry into parenthood. illness (Matthey et al., 2003). Paternal of the study was the lack of antenatal anxiety is associated with overinvolvement assessment. It is interesting to note that Entry into parenthood is a challenging developmental task as it involves multi- and overcontrolling behaviors and these the experience of intrusive thoughts of have been linked with both internalizing deliberate or accidental harm occurs in level changes (personal, marital, social and financial) with a risk of mental health and externalizing child symptoms (Cimino 80% of the general population of parents et al., 2015; Breaux et al., 2014). and even more commonly in new parents problems in men as well as in women (Fairbrother et al., 2008). These thoughts (Wonch et al., 2016). Although father Paternal obsessive-compulsive disorder are usually easily dismissed, in contrast mental health has been rarely examined (OCD) is the most under-researched of with parents with OCD who do not get rid in comparison to mothers, most studies the paternal mental health disorders of them and become highly preoccupied have been on postpartum and subsequent (Fisher, 2017; Misri, 2018). Abramowitz et and distressed. All this data may suggest paternal depression. It occurs in 10% of al. (2001) was the first to report four cases that the Primary Parental Preoccupation men (as compared to 5% rate of depression of paternal postpartum OCD, and found it that is inherent to the transition to among men in general) during the first very similar to maternal postpartum OCD, parenthood, increases the risk for the postpartum year, the peak being between even though men do not experience the development of OCD. 3 to 6 months (The 1:2 male to female ratio same postpartum hormonal fluctuations is kept as some 22% of mothers have post- as female. Coelho et al. (2014) conducted Several retrospective studies have reported partum depression (PPD)). a follow-up study to describe prevalence a significant rate of perinatal onset of rates and correlates of OCD in fathers in OCD between 15 and 30 % (Forray et al., Several key factors have been identified that contribute to paternal depression, the third trimester of pregnancy and in the 2010; Neziroglu et al., 2010), raising the first 2 months postpartum. The prevalence possibility of a “hormone related” subtype including: maternal PPD (Paulson et al., 2010), past history of depression, and the of OCD was 3.4% in the third trimester of of OCD. Women with pregnancy-onset pregnancy and 1.8% in the postpartum OCD or perinatal worsening of preexisting difficulty to express their depression and to ask for help, with a tendency to engage period. Most postpartum cases were of OCD are more likely to experience new onset (92.3%). premenstrual exacerbation of their OCD in avoidant, escape, or numbing behaviors symptoms as compared to those women (aggression, addiction, suicide). Although Of interest, OCD in fathers was significantly with symptoms that are unaffected by many men experience psychological associated with OCD in mothers, both pregnancy. This link would be similar to distress in the perinatal period, they during pregnancy and in the postpartum the one found between premenstrual may question the legitimacy of their period (Coelho et al., 2014). These figures depressive disorder and increased risk experiences, foregrounding their partner’s definitely show the need to actively look for postpartum depression (Bloch et al., needs. There is a lack of resources that are for perinatal disorders among fathers, and 2005). A prospective longitudinal study tailored specifically to men’s information not only among mothers, as fathers tend to (Chaudron et al., 2010) of 44 women and preparing to become fathers. Fathers restrain from disclosing their distress and recruited at a gynecological clinic found tend to manage stress through distraction, to look for help (O’Brien et al., 2016). that the majority of women diagnosed denial, and release (Brownhill et al., 2005). with OCD in pregnancy (29%) had: long- With similar effect sizes to the impact The impact of perinatal OCD standing symptoms since childhood; and of maternal depression, paternal on parent and child their symptoms increased in intensity depression (Wilson et al., 2010) has been postpartum, though did not change in associated with maladaptive parenting Untreated perinatal OCD has been character. An interaction between gonadal behaviors toward children, including: associated (Gezginc et al., 2008) with poor steroids, serotonin, and oxytocin has been increased negative parenting (control, quality of life, impaired physical health, hypothesized by the authors. hostility, intrusiveness), decreased impaired social, marital, and parent-child positive parenting behaviors (affection, relationships. The impact of parental positive involvement, supportiveness), anxiety, depression, bipolar disorders, and negative child outcomes, such as eating disorders, and schizophrenia on internalizing and externalizing problematic the infant have been studied, but parental behaviors at 3 and 7 years (after controlling OCD has received much less clinical and

25 WORLD ASSOCIATION FOR INFANT MENTAL HEALTH SPRING/SUMMER 2020 research attention (House et al., 2016). with ADHD and overeating. The Y.,2 years and 8 months, was Weinberg and Tronick (1998) studied observation of her interaction referred to our IMH clinic for infants of parents with OCD, depression, with O. reveals an extremely aggressive behaviors at home and or panic disorder, and found compromised mother-infant interactions in all the three intrusive pattern of over at kindergarten, together with groups. To our best knowledge, there are stimulation and hypervigilance, separation anxiety. Mother had no other studies among infants of parents as if danger is all around. She just delivered her third child. Y. is with OCD. In contrast, among children argues endlessly about the room the second one. His aggressive and adolescents, Griffiths et al. (2012) conducted semi-structured interviews of temperature being either too behavior was first interpreted ten 13-19 years old who had one parent high or too low for O. Even when by us as being an adjustment with OCD and found recurrent themes. the baby drinks from the bottle, reaction to the birth of his Having a parent with OCD meant living in she feels an urge to show him baby brother. Father was very a highly controlled home environment, with frequent arguments, social isolation, toys “so he does not get bored”. reluctant to come to the clinic a negative impact on schooling, assuming O. is a very quiet baby, stays still as he explained: “my wife is the aspects of the parenting role, and on the carpet, but is attentive one who deals with the kids, I am participating in their parent’s rituals. and makes good eye contact. at work most of the day”. Hence, Clinical vignettes Baby does not try to reach toys the treatment started as a dyadic but grasps them when handled. interactional guidance and was A 5-month-old baby was referred The treatment plan includes CBT aimed at increasing the mother’s to our community-based infant and psychiatric follow up for the reflective functioning. During one mental health clinic by the mother, and triadic interactive of the sessions, Mother revealed mother’s psychiatrist who treats guidance at our clinic. Parents that her husband has often severe her for a severe OCD. The main are well aware of the changes anger outbursts at her not being concern regarding the infant that need to be done, but by the “efficient enough” at doing all was, on one hand, an extreme first 6 months of treatment, no the home and caregiving chores. passivity and slow motor changes are achieved, O. starts As it became obvious that part development, and on the other to show signs of motor delay and of the problem was around the hand, the mother’s compulsive mother finally says “I am not sure parents’ co-parenting alliance, need to stimulate him from fear I really want to get rid of my OCD, we persisted in trying to reach that he would “get bored”. O. it often helps me to get things out the father. He finally agreed is the only child of his mother, the way I want them to be”. Under to come, as the marital tension 35 years old, and his father, 27 the threat of involving the Child raised, and mother started to years old. Mother’s OCD started Protection Services, the mother threaten she would divorce him. in her twenties but significantly agrees to have O. start day care Only then, the father’s severe, worsened during pregnancy. She (a move the father wanted very chronic and untreated OCD is also diagnosed with borderline much), but they stopped coming with periods of depression was personality traits and eating to the Unit and mother did not disclosed. Entry to parenthood disorder (mixed periods of binge comply with her CBT treatment. had exacerbated his OCD as he eating and fasting). She is also Four months later, mother described “my wife and kids make described as having a tendency calls and asks for renewing the mess all the time, I come back to use her OCD symptoms as an treatment process, as she and from work tired and I cannot excuse for problematic behaviors her husband are having a hard stand the mess, I am angry most at work and at home. Since O’s time to say “no” to O. (now a year of the time, especially at Y.’s birth, she does not let the father and half old), and to give him behavior”. He confessed he would get involved in the baby’s care autonomy in eating. often lose his temper and become because “only mothers know This case illustrates the potentially very aggressive…. like Y. Treatment how to do it”, and the marital detrimental impact of perinatal OCD became triadic, father agreed relationship has become very on parenting. The mother’s chronic to have a CBT treatment for tense. Mother’s own mother was OCD changed its nature with entry into himself, and Y’s symptoms almost motherhood: it became a “relational” intrusive and forced her to eat. disappeared. OCD. Its ego-syntonic quality makes it O’s father is withdrawn, sad and very challenging to treat and requires As this second case illustrates, the helpless, does not contradict his close collaboration between the adult impact of paternal OCD on the child is as wife so as to avoid stormy fights. psychiatrist and the child psychiatrist, each significant as the impact of maternal OCD. His wife’s obsessive-compulsive with his/her own lens. disorders, reminds him of his father’s; he himself is diagnosed

26 PERSPECTIVES IN INFANT MENTAL HEALTH SPRING/SUMMER 2020 Conclusion Cimino, S., Cerniglia, L., & Paciello, M. Leckman, J. F. & Mayes, L. C. (1999). (2015). Mothers with depression, Preoccupations and behaviors Perinatal OCD is still a hidden problem with anxiety, or eating disorders; outcomes associated with romantic and parental long term consequences on parenting. on their children and the role of love. Perspectives on the origin of Challacombe & Wroe (2013) have described paternal psychological profiles. Child obsessive-compulsive disorder. Child how perinatal OCD is often misdiagnosed Psychiatr Hum Dev, 46, 228-236. Adol Psych Cl, 8, 635–65. due to several barriers to detection, Coelho, F. M., Silva, R. A. D., Quevedo, Leckman, J. F., Mayes, L. C., Feldman, R., including: the shame of disclosing the L. D. Á., Souza, L. D., Pinheiro, K. A., Evans, D. W., King, R.A. & Cohen, D. J. intrusive thoughts and compulsions; and & Pinheiro, R. T. (2014). Obsessive- (1999). 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