Are My Intrusive Thoughts a Sign of Postpartum Psychosis?

If you've had a thought about your baby being hurt that made your stomach drop, and you have not told a single person about it, this post is for you.

I've been thinking about this a lot the past few weeks. A murder trial in Massachusetts involving a mother and postpartum psychosis has been in the news constantly, and it ended in a mistrial earlier this month. I'm not going to weigh in on that case. What I want to talk about is what all that coverage is doing to a very different group of people.

Because I've heard from more than one person recently that the coverage has been hard to be around. I've had conversations about it with people in my own life. Mikayla, one of our clinicians who knows this area well, and I were talking about how the trial is raising real awareness about new mothers' mental health, and also about maternal anxiety and what gets missed. And I attended a perinatal mental health training through Postpartum Support International this week, where the presenter spent a good amount of time on exactly this distinction.

So here's the thing I want to say clearly:

The thoughts that terrify you are most likely not psychosis. In fact, the fact that they terrify you is one clue.

What are intrusive thoughts, really?

An intrusive thought is an unwanted thought, image, or urge that shows up in your head uninvited. It doesn't match what you believe or want. It just arrives.

In new parents, these thoughts very often involve the baby being harmed. Dropping them down the stairs. Something happening in the bath. Sometimes the thought involves you harming them on purpose, which is the version almost nobody says out loud.

In fact, studies estimate that somewhere between 70 and 100 percent of new mothers have unwanted intrusive thoughts about harm coming to their infant. As many as half report thoughts of harming the baby intentionally. Fathers have them too.

That is not a fringe experience. That is most parents.

If I'm having these thoughts, does that mean I might act on them?

A large prospective study followed new mothers and specifically looked at whether unwanted intrusive thoughts of intentionally harming the infant were connected to actual harm. They weren't. Having the thought was not associated with an increased risk of aggression toward the baby.

Think about what your reaction to the thought tells you. You were horrified. You may have handed the baby to someone else, or stopped bathing them alone, or avoided the stairs, or stayed up watching them breathe. That's not the behavior of someone moving toward harm. That's the behavior of someone desperately trying to prevent it.

The distress is the evidence. It runs opposite to what you're afraid of.

What's the difference between intrusive thoughts and postpartum psychosis?

They get lumped together in news coverage, and they are not the same thing at all.

Intrusive thoughts are unwanted. You know they're your own thoughts, you know they don't fit who you are, and you find them disturbing. You want them gone. You're not confused about what's real.

Postpartum psychosis is a psychiatric emergency and it's rare, affecting roughly one or two out of every thousand births. It involves a loss of contact with reality. Thoughts tend to be odd or disorganized rather than simply upsetting. There may be delusions, or seeing, hearing, feeling, or smelling things that aren't there. A person can be distressed by these experiences. But here's the crucial difference. Psychosis can carry a real risk of acting, because the thinking has stopped being anchored to reality. It can also come on fast. And it can happen to someone with no mental health history at all.

Those are two different things, and they need two different responses. One needs treatment. The other needs emergency care today.

When do intrusive thoughts become postpartum OCD?

Most parents have the thought, feel awful, and move on. For some people, the thought sticks.

You start checking. You start avoiding. You start asking others for excessive reassurance. You arrange your day around never being alone with the baby. You mentally review what you did in the nursery, over and over, trying to be certain nothing happened. You seek reassurance, and the relief lasts about ten minutes before the doubt comes back.

That cycle is what turns a common thought into OCD. Research puts postpartum OCD somewhere around two to nine percent of new mothers. New fathers get it too. It gets missed a lot, partly because people are too frightened of their own thoughts to say them out loud.

I want to name something here. At Aspire, we've worked with a lot of people whose OCD attached itself to the most unbearable content their brain could find. People terrified they would harm someone. People terrified they would abuse or molest a child. These are recognized OCD themes, and we have seen them more than once. In every single case, we were sitting with someone who was frantic about preventing the thing they were afraid of.

If that's where your brain has gone, you are not the first person to walk in with it. You will not shock your therapist.

What actually treats this?

Exposure and Response Prevention, usually called ERP. It's the gold standard treatment for OCD, and it's what's recommended for postpartum OCD too.

ERP works differently than most people expect. We are not going to spend your sessions convincing you that you won't hurt your baby. That's reassurance, and reassurance is part of what keeps the cycle running. Your brain gets a little relief, then needs more.

Instead, we slowly help you stop the checking, the avoiding, and the mental reviewing. Your brain gets to learn something new: you can have a horrible thought, do nothing about it, and nothing happens. The thought loses its grip. Not because you disproved it, but because you stopped treating it like a threat.

It's uncomfortable work. It's also very effective, and it tends not to take years.

One important note. ERP should be done with a therapist trained in it. Trying it alone, or with a well-meaning therapist who isn't trained in ERP, often turns into accidental reassurance. Or exposure done in a way that makes things worse. Ask any therapist you're considering whether they're specifically trained in ERP.

When you need help right now, not next week

Please take this part seriously.

Call 911 or go to an emergency room if you or someone you love is experiencing confusion, seeing or hearing things others don't, saying things that don't make sense, going without sleep for days, or seems to have lost touch with what's real. Postpartum psychosis is a medical emergency and it can escalate quickly.

If you're having thoughts of ending your life, call or text 988 for the Suicide and Crisis Lifeline.

For around the clock support specific to pregnancy and new parenthood, the National Maternal Mental Health Hotline is 1-833-TLC-MAMA (1-833-852-6262), available 24/7 in English and Spanish.

Postpartum Support International is also an excellent resource. Their helpline is 1-800-944-4773, and you can call or text. They run more than fifty free online support groups, including groups for parents whose babies spent time in the NICU and for people who have experienced postpartum psychosis. Their helpline is for support and resources rather than emergencies, so use 988 or 911 in a crisis.

Get Help for Postpartum OCD in Missouri

I'll be straightforward about what we do and don't do.

We are not a perinatal mental health clinic, and if you're in an acute psychiatric emergency you need a hospital, not an outpatient therapy office. What we are is a practice with clinicians who are genuinely trained in ERP for OCD, including OCD that shows up after a baby arrives.

If you've been sitting on thoughts you're too ashamed to say out loud, that's the thing we can actually help with.

We see clients in Columbia and Lee's Summit, and throughout Missouri with online therapy, which many new parents find far more workable than getting out the door with an infant. Call 573-328-2288 for Columbia or (816) 287-1116 for Lee's Summit and our client care team will help you find the right fit.

You can say the thought out loud here. That's usually where this starts getting better.

About the Author

Jessica Oliver, MSW, LCSW is the founder and clinical director of Aspire Counseling.

She has spent most of her career treating anxiety and OCD, and Exposure and Response Prevention is one of the treatments she knows best. A good portion of that work has been with people whose obsessions latched onto the most disturbing content their brain could produce, the kind of thoughts people are terrified to say out loud. She has yet to meet one of those clients who turned out to be dangerous. She has met a lot who were exhausted from trying to carry it alone.

She recently completed a perinatal mental health training through Postpartum Support International, which is part of what prompted this post.

Sources worth reading:

• Collardeau et al., prevalence of unwanted intrusive thoughts of infant-related harm: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6429780/

• MGH Center for Women's Mental Health summary of the Fairbrother research on intrusive thoughts and infant safety: https://womensmentalhealth.org/posts/understanding-postpartum-ocd-and-intrusive-thoughts/