Postpartum OCD & Postpartum Psychosis

Andrea, a PPD survivor, will chat about the cluster of symptoms under the umbrella of postpartum depression as well as dissect the difference between Postpartum OCD and Postpartum Psychosis and what to do if you or someone you love might be experiencing these symptoms. It is important for women who think they might have PPD or another related condition to not self-diagnose. Andrea will discuss the importance of getting an assessment and treatment with a specialist in perinatal mood/anxiety disorders.

Andrea brings a wealth of experience as a licensed psychotherapist specializing in women's reproductive mental health in Glendora, CA. She works with women and their families from pregnancy through postpartum, in addition to helping women who are challenged with infertility and perinatal loss. Andrea supports women navigating the challenging waters of perimenopause and menopause. In addition, Andrea is a volunteer Co-Coordinator for Postpartum Support International, www.postpartum.net.

Welcome Andrea!!!

Andrea Schneider, LCSW: I am so honored to be here. Welcome everyone! Tiffani, this is such a wonderful service for so many mamas and professionals who are struggling with perinatal mood and anxiety disorders. So thank you for the great work you do!

Tiffani Lawton: Thank you, Andrea

Andrea Schneider, LCSW: I would like to say that as a survivor of PPD and a therapist who specializes in this area, I am thrilled to see you all here today. I would like to start with discussing the difference between Postpartum Obsessive Compulsive Disorder (PPOCD) and Postpartum Psychosis (PPP) if that works for you all.

Andrea Schneider, LCSW: 3 to 5 percent of all new Moms with develop Postpartum OCD. Postpartum Psychosis is much rarer, occurring in one to two per thousand new moms. We hear a lot of media discussion about postpartum psychosis and people presume that we are talking about Postpartum Depression. Postpartum Depression is actually a cluster of symptoms, which I will discuss, which includes anxiety and depressive symptoms. It can occur in 15-20 percent of new moms, perhaps a higher percentage. With Postpartum OCD, a woman will experience intrusive, repetitive, and persistent thoughts or mental pictures, often of harm befalling her baby. In some of those thoughts she has, and she may be the individual harming the baby. However, what is REALLY IMPORTANT is that in Postpartum OCD, a woman is grounded in reality and would likely NOT act on those thoughts. In fact, she is typically repulsed at those intrusive thoughts and feels incredibly guilty for having them. Her intrusive thoughts are typically accompanied by behaviors to reduce anxiety (like hiding anything that might harm her baby). She may have counting, checking, or other repetitive behaviors that interfere with her functioning.

Tiffani Lawton: Can it also include excessive worrying? For example, constantly on vigil watching the baby breathe because of the anxiety or thought that the baby might stop breathing?

Andrea Schneider, LCSW: Absolutely! Excessive anxiety and worrying often accompany the above symptoms and sometimes women will also have the postpartum depression component. The woman is driven to make sure her baby is OK because the intrusive thought is driving her behavior. Key is that the woman is grounded in reality and NOT hallucinating. These are intrusive thoughts that can be treated with antidepressants. I have seen so many women do so well on SSRIs with this particular issue.

Celine Land:How can we tell if she is grounded and not hallucinating?

Andrea Schneider, LCSW: A woman with postpartum psychosis or postpartum biploar disorder with psychotic features will have visual or auditory hallucinations. She will have delusional thinking. She will also have delirium or possibly mania. The onset for postpartum psychosis is typically 2-3 days postpartum.

Tiffani Lawton: Can you give some examples?

Andrea Schneider, LCSW: Yes, a woman who has PPP might be "spaced out", mumbling to herself, seeing things that people in the room don't see or hear. A woman is at high risk for PPP if she has a family history of psychosis or bipolar disorder or a previous episode of either herself. You would typically see drastic behavioral change in a woman with PPP 2-3 days postpartum and this is considered A MEDICAL EMERGENCY. Don't diagnose her or self-diagnose. Postpartum Psychosis requires swift intervention with perinatal clinicians/doctors.

Lauren Hale: Schizophrenic history is a risk as well too, correct?

Andrea Schneider, LCSW: Yes, schizophrenic history puts a woman at high risk.

Andrea Schneider, LCSW: Postpartum OCD onset can occur any time in the first year postpartum, and even beyond if it is not treated. A woman with Postpartum OCD will likely be highly anxious and possibly verbalizing that she is concerned about her baby's health for some reason. But she may be afraid to disclose her intrusive images because she is afraid of judgment or afraid that CPS would remove her children, because people might think she has psychosis. Both Postpartum OCD and Postpartum Psychosis are very treatable.

Tiffani Lawton: Are there any social factors that are contributors?

Andrea Schneider, LCSW: Aside from biochemistry and hormones, stressors of any kind can trigger a postpartum depression, postpartum anxiety, postpartum OCD, PPP and postpartum bipolar disorder. Postpartum Psychosis typically pops up 2-3 days postpartum, thus the need for medical assessment in our hospitals for all postpartum women. It is very rare, however the consequences can be devastating for mom and baby with an approximate 5 percent suicide rate and 4 percent infanticide rate.

Michelle-Nicholle Calareso: What types of stresses?

Andrea Schneider, LCSW: Michelle,...stresses can be financial, relational, if a geographic move has taken place, adjustment to motherhood, sometimes returning to work, traumas or losses -- any of those things can trigger an episode in a woman who is already vulnerable.

Lauren Hale: I have a question about the medical assessment in hospitals for postpartum women. I have a friend who was screened at just 24 hours postpartum by a nurse who had no clue what she was doing. She admitted she lied to the screener because she was afraid of the nurse. How useful would the screening really be if that sort of situation is faced?

Andrea Schneider, LCSW: Yes, women need to be monitored more closely and regularly after delivery and throughout the first year postpartum. The medical staff need to be trained in perinatal issues. If they don't have the training, they can cause more harm than good.

Tiffani Lawton: I second that!

Lauren Hale: I completely agree

Andrea Schneider, LCSW: Some misdiagnose the OCD as Psychosis, which can have devastating consequences. PSI, Postpartum Support International is the leading non profit who trains perinatal professionals. There is a conference in L.A. this summer. I highly recommend any clinician or medical practitioner in the field who wants to be trained, attend a training with PSI.

Emily:I had PPD OCD with my first son and am now 31 weeks pregnant and starting to feel all the same anxiety and fears even though I went through it before. I feel shocked by how much it is affecting me now.

Andrea Schneider, LCSW: Hi Emily. It is very likely for a second episode to occur if you've had a prior episode. But it is NOT your fault. We will help you to get swift treatment so you can feel better.

Tiffani Lawton: In your opinion, do you think the in-hospital screening should look at personal and familial history as well as the social factors? As opposed to screening for psychosis or depression since they are only reading a questionnaire?

Andrea Schneider, LCSW: Tiffani--YES! A comprehensive pre-delivery (3rd trimester) and postpartum assessment should take place, after delivery and again at two weeks and then every trimester (or more) after the baby arrives. The evaluator must have perinatal training to discriminate what he/she is looking at.

Denise Hibben: I also wonder if it might be a better idea if instead of ending a woman's care after her baby's birth at 6 weeks, if she shouldn't still be seen a few more times by her care provider, say ending her care at 6 months after the birth.

Tiffani Lawton: France does this up to one year postpartum...free...

Andrea Schneider, LCSW: France is right on! I believe every woman should be screened before conception and at each trimester, and again at several points in the first year postpartum.

Emily: I agree!

Michelle-Nicholle Calareso: I had a client who with had PP BPD with her first and started treatment before her second and the Dr and LCSW were helpful with pointing out symptoms and catching it before it got really bad.

Andrea Schneider, LCSW: That's wonderful, Michelle. Every woman deserves to have treatment and specialists who can help her. There is legislation pending in Congress now (The Mother's Act) that will require medical professionals to have training in this field and also to screen women at regular intervals for these diagnoses. See Postpartum Support International www.postpartum.net for more information about legislation, training, and support for women all over the globe. PSI is wonderful because each state has at least one volunteer coordinator who has resources and referrals available for women who need to see a perinatal specialist like a perinatal psychotherapist, psychiatrist, postpartum doula, lactation consultant, etc.

Celine Land: Do you know if PSI also has resources for Canada?

Andrea Schneider, LCSW: Yes, PSI has resources all over the globe. Go to the resource section on the website and click under the country you are looking for assistance in.

Michelle-Nicholle Calareso: Does PSI do trainings for lay people like doulas?

Andrea Schneider, LCSW: Yes. Doulas can attend workshops. However, only licensed psychotherapists and psychiatrists can diagnose, assess and treat these conditions. That's REALLY important. It's great for doulas to be on the look out for such symptoms so you can refer to a specialist immediately. Doulas are SO IMPORTANT. In fact, studies show that there is less likelihood of postpartum depression if a woman has a postpartum doula.

Michelle-Nicholle Calareso: I was thinking since we have a close relationship that we may be able to see the changes.

Tiffani Lawton: I would love to see doula care become part of the Mothers Act...so insurance companies will cover them.

Andrea Schneider, LCSW: Doulas are wonderful as part of the self-care program I recommend to my clients.

Denise Hibben: I have noticed that a lot of what causes PPD seems to be lack of support as well. Do you find that to be true?

Andrea Schneider, LCSW: No woman is at fault if she has a postpartum depression or anxiety. Lack of support can certainly contribute to her stress and amplify feelings of isolation, thus worsening symptoms. Part of recovery is generating social supports.

Tiffani Lawton: If someone had PPP with their first child, was able to cope the second child, it returned with the third child...is this possible? And is it always within 2-3 day PP or can it be later?

Andrea Schneider, LCSW: Yes, it's absolutely possible. Every woman is different, her body is different, and her biochemistry is different. Sometimes it can surface beyond on the 2-3 day window, especially if it is part of a postpartum bipolar disorder with psychotic features, it referring to PPP.

Denise Hibben: Has there been any studies done that you know of that show the difference in occurrence of PPOCD in women who are under the care of an OB and women under the care of midwives?

Andrea Schneider, LCSW: I don't have specific figures but there are studies that indicate that if a woman is has good prenatal care and those individuals are training in looking for the signs of postpartum mood and anxiety disorders, than likely if she develops a postpartum OCD or Postpartum Psychosis, she will get treatment faster, and thus recover faster. Assessment, Diagnosis and swift treatment is essential.

Tiffani Lawton: So in your opinion, can we as a society prevent infanticide related to PPP?

Andrea Schneider, LCSW: I think so...so long as medical folks are trained to do screenings at the appropriate intervals and if the woman in question can get treatment immediately.

Andrea Schneider, LCSW: Yes, a licensed psychiatric nurse can diagnose if she specializes in this area. OB/GYNs can diagnose, but likely feel more comfortable referring to psychiatrists or licensed psychotherapists who specialize in perinatal mood/anxiety disorders. OBs and Pediatricians are essential in being a part of the treatment team. Treatment means psychotherapy, medication management in the case of PPP or postpartum biploar disorder and highly recommended in postpartum OCD, and increased social supports and self care.

Tiffani Lawton: What do you recommend to your clients with regard to increased social supports and self care?

Andrea Schneider, LCSW: As relates to increased self care and social supports, exercise, good nutrition, good sleep hygiene, medical supervision if she is taking medications, joining a postpartum support group when she is ready (not a mommy and me group)

Tiffani Lawton: Are all cases of infanticide tied to PPP?

Andrea Schneider, LCSW: I will need to find that info for you. I know in the case of Andrea Yates she likely had an untreated biploar disorder with psychotic features.

Lauren Hale: Dr. Arlene Huysman has a wonderful book out, The Postpartum Effect, that examines infanticide and filicide if any of you feel up to reading more about it.

Andrea Schneider, LCSW: It is truly a medical emergency with psychosis of any kind because the woman is not grounded in reality and can either harm herself or her baby. Therefore, if you suspect PPP or psychosis, get her to an emergency room to be evaluated immediately and don't leave her alone.

Denise Hibben: I have come to the understanding that PPP can show up at anytime in the first year after birth. Is this True?

Andrea Schneider, LCSW: PPP can show up at any time, but it is commonly present rather quickly after delivery (2-3 days postpartum). However, if a woman has bipolar disorder; psychotic features can surface at any time. Thus the need for evaluation, I believe, throughout the first year postpartum and beyond

Denise Hibben: I know it can be a loss when you stop care with a well loved provider. I wonder if that has any relation. It is like losing a really great friend.

Andrea Schneider, LCSW: Any loss or trauma can trigger depressive symptoms or a postpartum mood disorder episode in any vulnerable woman. By vulnerable I mean her biochemistry makes her vulnerable due to prior episodes, family history and hormones

Emily: Does this include during pregnancy?

Andrea Schneider, LCSW: Yes, thank you Emily. It does include when a woman is pregnant, thus the term "perinatal"

Denise Hibben: Does socioeconomic status have any relation to incidence of postpartum mood disorders?

Andrea Schneider, LCSW: Postpartum disorders can affect any woman of any ethnic background or financial means. However, financial stressors can magnify and make it worse.

Tiffani Lawton: Does bipolar disorder often fly under the radar, so to speak until psychotic features emerge?

Andrea Schneider, LCSW: Tiffani...yes postpartum bipolar disorder can fly under the radar, especially if a woman does not have the psychotic features. She may have mania or depression or anxiety. That's why the differential diagnosis is so intricate and requires a perinatal specialist.

Teresa Twomey: Can you say a little more about the difference between PPP and PP Bipolar Disorder?

Andrea Schneider, LCSW: PPP is speaking purely to psychotic features such as visual or auditory hallucinations, delusional thinking, and/or delirium or mania. The woman is disoriented and not in touch with reality. Postpartum Bipolar Disorder is more complicated because it can include symptoms of depression, anxiety, and/or psychosis. It presents differently with each woman whether pregnant, postpartum, or even during times with not pregnant or postpartum.

Teresa Twomey: When a woman with PP Bipolar Disorder is having a psychotic episode, would you call that PPP?

Andrea Schneider, LCSW: It's more complicated than that, but both are considered medical emergencies. No, I would call it Postpartum Bipolar Disorder with Psychotic Features, if she is truly in a bipolar episode

Denise Hibben: I have a client that is bipolar, as a doula, what should I be looking out for to catch it before it really starts and help her get the help she needs before the fact? She had a really bad case of PPD with her previous baby. She is aware that she may have another recurrence, and is worried about it.

Andrea Schneider, LCSW: Denise....if you suspect your client needs an evaluation for any reason, insist that she get an evaluation.

Teresa Twomey: Denise: from what I understand, she should see a well-trained professional who can develop a plan with her for the prevention of an episode.

Tiffani Lawton: To revisit Teresa's question....what if the client is not diagnosed officially with bipolar disorder and is seen the first time with psychotic features...how will that be seen?

Teresa Twomey: Yes, because I thought the rule of thumb was to consider a woman w/ PPP to be bipolar unless otherwise indicated. Is that an "old" belief now?

Andrea Schneider, LCSW: With Bipolar Disorder, some women have depressive symptoms, some are manic, some are anxious, and some have a few of those symptoms or more in addition to psychosis. It's a very intricate diagnosis. Bipolar Disorder is a mood disorder than can include depression, anxiety, mania, and/or psychosis. Again, it looks different with each woman who has it. That's why an assessment by a trained perinatal professional is KEY.

Nadia Delshad PsyD: Pregnant women or new mothers with bipolar disorder have a sevenfold higher risk of hospital admission and a twofold higher risk for a recurrent episode, compared with those who have not recently delivered a child or are not pregnant.

Andrea Schneider, LCSW: My understanding is that people differ in opinion on that, Teresa. Some feel that psychosis is its own category because other symptoms are absent which would make it hard to diagnose bipolar disorder. However, Postpartum Bipolar Disorder is probably UNDER diagnosed.

Andrea Schneider, LCSW: Thanks for everyone's wonderful input.

Tiffani Lawton: I think a discussion about PP Bipolar Disorder would be a good one, huh?

Andrea Schneider, LCSW: YES! It's cutting edge research.

Tiffani Lawton: Let's set one up then!

Teresa Twomey: Thanks Tiffany: How about one on "When is PPP not bipolar and how that determines course of treatment. Because I had been putting Bipolar UNDER PPP (i.e.: as a type of...)

Nadia Delshad PsyD: Thank you.

Tiffani Lawton: Thank you Andrea...this was very informative

Denise Hibben: Thank you Andrea!!! Thank you, Tiffani for setting this up!

Michelle-Nicholle Calareso: Thanks. This was wonderful

Andrea Schneider, LCSW: Thank you for having me!