Postpartum OCD: Understanding Intrusive Thoughts and Finding Relief

You're carrying the baby down the stairs and an image flashes through your mind: dropping him. You grip the railing and your heart pounds. That night you can't stop seeing it. By the end of the week you won't carry him on the stairs at all, you've asked your partner three times whether you seem okay with the baby, and the thought is there every time you look at him.

Most new moms get a scary thought like that now and then. It jolts them and fades. With postpartum OCD, the thought doesn't fade. It sticks, it repeats, and you start doing things to make it go away, which is exactly what keeps it coming back. Here is what postpartum OCD is, why it gets stuck, and the treatment that works.

What postpartum OCD is

Postpartum OCD has two parts.

Obsessions are unwanted thoughts, images, or urges that keep coming back and cause real distress. After a baby, they are almost always about the baby getting hurt, often with you as the cause.

Compulsions are the things you do, out loud or in your head, to make the anxiety from those thoughts go down or to make sure the feared thing doesn't happen.

Studies estimate that a few in every hundred moms develop OCD in pregnancy or after birth, and the real number is probably higher, because so many moms are too frightened of their thoughts to tell anyone. It can start for the first time after a baby, or an earlier tendency toward OCD or anxiety can get much louder.

The thoughts

These are some of the most common. I'm listing them plainly, because secrecy is part of what gives them power, and many moms are sure they're the only one.

• Dropping the baby down the stairs or off a changing table
• Drowning the baby in the bath
• Smothering or shaking the baby
• Hurting the baby with a knife while cooking
• Unwanted sexual thoughts during diaper changes or baths
• Germs, chemicals, or something you touched making the baby sick
• The baby dying in their sleep
• Losing control and doing something you would never want to do

The thoughts horrify you because they go against everything you want. Moms with postpartum OCD are not more likely to harm their babies. If anything, they tend to be more careful, because they are so afraid of the thoughts.

The compulsions

Some compulsions you can see:

• Checking the baby's breathing over and over, all night
• Avoiding the stairs, the bath, or the kitchen knives
• Not wanting to be alone with the baby
• Washing or sanitizing again and again
• Asking your partner, a friend, or the internet for reassurance
• Hiding or removing things in the house that feel dangerous

And some happen only in your head:

• Replaying a moment to make sure nothing bad happened
• Arguing with the thought, or trying to push it out
• Saying a phrase, praying, or counting to cancel it
• Searching your feelings to prove you love the baby

Every compulsion brings a little relief, and that is the trap. The relief teaches your brain that the thought was dangerous and that the ritual kept everyone safe, so the next thought hits harder and the ritual grows.

Ordinary scary thoughts, OCD, and the emergency

Ordinary scary thoughts come, shock you, and pass. Almost every new mom has them. Here is more about those.

Postpartum OCD is when the thoughts keep coming back, take up a lot of your day, and you've started avoiding, checking, or seeking reassurance because of them. Here is how postpartum OCD differs from postpartum anxiety.

Postpartum psychosis is different, and it is an emergency. If the thoughts start to feel like they make sense or like something you should do, if you see or hear things other people don't, if you believe things that feel completely true but worry the people around you, if you go days without sleep and don't feel tired, or if you feel confused about what is real, call 911 or go to the nearest emergency room. It is rare, about 1 or 2 in every 1,000 births, and very treatable, but it needs care right away.

Treatment that works

Postpartum OCD is very treatable, and the right treatment is specific. General talk therapy or "just try to relax" often doesn't touch it, and some well-meaning approaches, like reassuring you every time, can make it worse.

Exposure and response prevention (ERP) is the best-studied therapy for OCD. With a therapist, you slowly face the situations and thoughts you've been avoiding, without doing the compulsion. That might mean carrying the baby down the stairs without counting the steps, giving a bath without checking the water five times, or writing the thought out and reading it without arguing with it. You never do anything that is actually unsafe. Over time your brain learns that the thought is just a thought, and the alarm quiets down.

Inference-based CBT (I-CBT) works on the doubt underneath the obsession. OCD often starts with a "what if" that your mind treats as real evidence: what if I lose control, what if I'm secretly dangerous. I-CBT helps you notice that the doubt comes from imagined possibilities, not from anything you actually see or know about yourself, so you can stop arguing with it.

I use both in my practice. Some moms do better with one, many use pieces of each.

Medication helps many moms too. Antidepressants are often used for OCD, and some are considered compatible with breastfeeding. That decision belongs with your OB or a prescriber who knows perinatal care. I wrote about the medication questions moms ask most.

What helps right now

• Notice the thought without answering it. "There's the stairs thought again." You don't have to argue with it, solve it, or prove it wrong.
• Try to put off the ritual. If you usually check right away, wait a few minutes. Then a few more next time. You're teaching your brain that you can handle the anxiety.
• Tell one person, out loud. Shame keeps these thoughts alive. Saying them to someone who understands takes away some of their power.
• Partners: support the mom, not the OCD. Instead of answering "are you sure I'm okay with her?" for the tenth time, try: "I can see that thought is scaring you. I'm right here." Then help her get care.

Finding the right therapist

Look for someone trained in OCD treatment specifically, and if possible in perinatal mental health. On the first call, ask, "Do you use exposure and response prevention?" A clear yes and an explanation of how they do it is a good sign. The International OCD Foundation and Postpartum Support International both have provider directories. You can reach PSI at 1-800-944-4773, and the National Maternal Mental Health Hotline is open 24/7 at 1-833-852-6262. You can call or text 988 any time.

Working with me

I'm a licensed clinical psychologist, a certified perinatal mental health specialist, and intrusive thoughts and postpartum OCD are a big part of my work. Many moms tell me I'm the first person they've said the thoughts to out loud, and nothing you say will shock me. I see moms in Austin or on video, and babies are always welcome in my office.

You don't have to be "bad enough" to benefit from support. Many of the moms I work with aren't clinically depressed at all. They're dealing with the everyday stress of becoming a mom, and therapy helps with that just as much as it helps with depression or anxiety.

The first step is a free 15-minute call. Tell me what has been going on, and I will tell you honestly what I think would help.

Book a free 15-minute call