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OCD, Perinatal OCD, Parental Preoccupation and Parenting

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OCD, Perinatal OCD, Parental Preoccupation and Parenting 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.
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