Psychosomatics 42:429-431, October 2001
© 2001 The Academy of Psychosomatic Medicine
Acute Onset of Obsessive-Compulsive Disorder in Males Following Childbirth
Jonathan Abramowitz, Ph.D.,
Katherine Moore, M.D.,
Cheryl Carmin, Ph.D.,
Pamela S. Wiegartz, Ph.D., and
Christine Purdon, Ph.D.
Received May 9, 2001; accepted May 16, 2001. From the Department of Psychiatry, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905. Address correspondence and reprint requests to Dr. Abramowitz; E-mail: abramowitz.jonathan{at}mayo.edu
ABSTRACT
Research on postpartum onset obsessive-compulsive disorder (OCD) has focused exclusively on females. However, the authors present four cases of males with OCD onset that coincide with a spouse's pregnancy or delivery. The rapid onset and content of obsessions and compulsions are remarkably similar to those reported in previous studies of postpartum OCD in females. Each patient also responded to cognitive-behavioral therapy using exposure procedures. The implications of these cases for etiological models of postpartum OCD and future research directions are discussed.
Key Words: Other Mood Disorder • Disorders
Retrospective studies conclude that some women experience an acute onset of obsessive-compulsive disorder (OCD) during pregnancy, or within the first few weeks after giving birth.1–3 The most common features in "postpartum OCD" are intrusive, ego-dystonic, anxiety-evoking obsessional thoughts about harming the newborn infant and avoidance of situations that evoke these kinds of cognitions. Often, the associated distress and avoidance lead to impairment in family functioning.1–3 Treatment with serotonergic medication and/or cognitive-behavioral therapy (CBT) by exposure and response prevention (E/ RP) appears to be successful in alleviating these symptoms and improving the mother-infant relationship.1–3
Unfortunately, little attention has been paid to the relationship between childbirth and OCD symptoms in other family members, for example, fathers. Many authors report that postpartum OCD is a biological condition triggered by fluctuations in gonadal hormones at the termination of pregnancy.1–3 This may account for the exclusive focus on childbearing women. In the present case series, however, we describe four males who presented with rapid-onset OCD symptoms associated with their spouse's pregnancy or the birth of a child. To our knowledge, this is the first report describing postpartum OCD in new fathers. We also discuss implications for etiological models and treatment strategies.
Case Reports
Case 1. Mr. R. (28 years old) was evaluated 5 months after the birth of his first child (a boy). Mr. R.'s wife had had an uncomplicated pregnancy and their son was healthy. However, 2 days after the birth, Mr. R. reported the emergence of disturbing intrusive thoughts and images of him shaking the baby to death. Attempts to suppress these cognitions failed, and he began to fear that he might lose control and harm his child, resulting in his overwhelming distress and avoidance of handling or being alone with the infant. Ashamed, he concealed these thoughts until his physician inquired about stress related to being a new parent. He was subsequently referred to our CBT program.
Treatment began with education about OCD, emphasizing that upsetting, yet otherwise normal, thoughts can sometimes seem threatening and lead to high levels of anxiety and avoidance. Mr. R. was also taught that trying to suppress unwanted thoughts had the paradoxical effect of increasing attention to them and increasing their frequency. A hierarchy of anxiety-evoking thoughts (e.g., of shaking the baby) and situations (e.g., holding the baby while alone) was constructed for systematic exposure, and Mr. R. practiced entering these situations both in sessions and for homework. Distressing thoughts were confronted via tape recordings of descriptions of these cognitions. Following 7 weeks of therapy (2 sessions per week), Mr. R. reported a substantial decrease in his obsessional symptoms. He had stopped the avoidance behavior and was able to handle his child without distress. At his 3 months follow-up, Mr. R. reported only occasional intrusive thoughts without high levels of distress.
Case 2. Mr. W. (38 years old) began experiencing distressing, intrusive thoughts shortly after the birth of his third son. Initially, he made attempts to ignore or distract himself from dwelling on these thoughts. However, by the time he sought treatment, he was experiencing almost incessant thoughts of harming not only his newborn son, but his other two children as well. Specifically, his obsessions concerned the possibility that, while handling sharp objects, he might lose control and impulsively stab one of the children. As a result, for example, he avoided entering the children's bedrooms if he was holding a pair of scissors.
Treatment began with an educational component emphasizing that intrusive thoughts are normal. However, Mr. W.'s anxious response and excessive attention to such thoughts was serving to reinforce their credibility. The rudiments of E/RP procedures were reviewed as were instructions for the use of anxiety management skills (i.e., paced, diaphragmatic breathing). Mr. W. developed an exposure hierarchy of situations evoking low (e.g., sitting alone with a pair of scissors), moderate (e.g., using a paring knife to cut vegetables with his wife and children present), and high levels of anxiety (e.g., holding a sharp butcher's knife while sitting next to sleeping children). Within several weeks, he was able to confront the items on his hierarchy without needing to avoid or distract himself. Likewise, he was able to tolerate the anxiety his obsessions generated. By 12 weeks, Mr. W. reported that his anxious response to the intrusive, harm-related thoughts had significantly abated. At his 1 year follow-up, he indicated that he was essentially free from obsessive symptoms.
Case 3. Mr. Q. (35 years old) was self-referred to our clinic for treatment of intrusive, aggressive thoughts and impulses. Symptom onset coincided with the conception of his first child, 5 months prior to presentation for treatment. At that time, he began to experience ego-dystonic, aggressive impulses and obsessions about harming others, particularly his wife, as well as recurrent violent or morbid images and thoughts. Intrusive mental repetition of profanity and/or other "bad" words was also present, as were concurrent sexual obsessions about children. Mr. Q. ruminated about the meaning and significance of these thoughts and developed doubts about his mental health and about his intentions to act on these intrusions. He sought reassurance from friends, family, and doctors that he was "all right" and a "good person" and performed mental rituals such as debating his intentions or "undoing" his obsessions with "good thoughts."
Treatment for Mr. Q consisted of education, cognitive restructuring, and E/RP. Initially, Mr. Q received education about the normality of intrusive thoughts and the role of avoidance and misinterpretation in prolonging and/or exacerbating obsessions. Mr. Q's misinterpretations about the significance of these intrusions (e.g., "Having these thoughts means I'm a bad person", "I should always have control over my thoughts") were targeted with cognitive therapy techniques. Through exposure and the challenging of cognitive appraisals, Mr. Q gained some insight into the benign nature of his thoughts and consented to begin E/RP. A hierarchy of intrusive thoughts was developed and, based on this hierarchy, loop tapes of his obsessional thoughts were created. With therapist guidance, Mr. Q was able to listen to these tapes in session without performing associated cognitive rituals. He was next asked to repeat these exposures at home, in the presence of his wife, until they no longer evoked anxiety. Concurrently, Mr. Q was asked to refrain from reassurance-seeking rituals such as researching OCD and asking questions of others. After five weekly treatment sessions, he reported a decrease in the frequency of his obsessions, as well as decreased anxiety and distress in response to the intrusions. As a consequence, his mood improved and he noted no avoidance and minimal interference in functioning.
Case 4. Mr. S. (40 years old) reported that immediately following the birth of his first son he felt a profound sense of responsibility for protecting his child from harm. This manifested itself in frequent time-consuming checking rituals to ensure that appliances were off, electrical cords weren't frayed, light fixtures were intact, and so on. He engaged in elaborate rituals at work as well, such as spending several hours repeatedly checking every letter and number on checks he wrote for his company before he was able to sign them. Gradually, he began to doubt most of his actions at work, and he would have to conjure up a "perfect" mental image of having completed a task "correctly" before he could move on to the next task. He also began to avoid leaving the office last so that he did not to have to be responsible for locking up. Mr. S.'s checking rituals escalated after the birth of his second child. He once spent several hours frantically searching the floor for a fallen thumbtack out of concern that one of his children might step on it. He also avoided being the last person to leave the house on outings. Mr. S. had an extramarital affair and left the home for about 1 year, during which time his checking rituals remitted drastically. However, upon reconciliation with his wife and returning home, his rituals resumed their previous intensity. Mr. S. presented for psychotherapy after an unsatisfactory response to several selective serotonin reuptake inhibitor medications (SSRIs). Treatment using exposure with response prevention proved highly effective in reducing Mr. S.'s rituals both at home and at work.
Discussion
The four male patients described above were assessed at different clinics in different geographical regions, yet each experienced significant anxiety and ego-dystonic thoughts about responsibility for harm coming to a newborn child or pregnant wife. All met DSM-IV criteria for OCD and none had past psychiatric histories. The remarkable similarity in presentation between these cases and those described in previous research on OCD in childbearing women,1–3 suggests that pregnancy and the postpartum are also vulnerable periods for the development of OCD in expecting fathers.
Guided by the well-known "serotonin hypothesis" of OCD,4 some authors have suggested that an acute onset of symptoms during pregnancy or the puerperium is the result of interactions between rapidly changing levels of reproductive hormones (i.e., estrogen and progesterone), which in turn influence serotonin levels.3 To date, however, precise neurobiological mechanisms of OCD have not been well elucidated and research does not consistently support the hypothesis that OCD is caused by a dysfunctional serotonin system.5 The occurrence of OCD symptoms in males following conception and childbirth, as noted here, further highlights the need to look beyond neurobiological models to adequately account for the onset of OCD symptoms during this period and perhaps in general.
The cognitive-behavioral model of OCD is based on an empirically consistent understanding of the symptoms of OCD6 and provides a parsimonious and well-articulated explanation for the presence of obsessional phenomena in postpartum women, as well as in their partners. This model begins with an understanding that most adults normally experience intrusive, upsetting (ego-dystonic) thoughts.7 However, when individuals misappraise these benign thoughts as threatening (e.g., "I may act on them," "thinking about it is the same as doing it"), the result is increased preoccupation with and difficulty controlling the thought, increased thought frequency, and negative mood.6 Individuals with obsessional problems are thus highly motivated to neutralize their obsessional thoughts (via compulsive rituals) or keep them from entering consciousness (via avoidance) in order to forestall the associated sense of responsibility, and avert potential catastrophes represented by the thought. Inevitable failures to successfully control such thoughts are then misperceived as further evidence that the thoughts are significant (i.e., they represent a desire to act violently) and must therefore be controlled.
From the cognitive-behavioral perspective, pregnancy and the postpartum period are fertile grounds for the development of obsessional problems in both males and females because of the responsibility of maintaining the (helpless) infant's well-being. Ego-dystonic thoughts about harm, which occur normally in most people, by definition do not reflect violent intentions. However, the more responsible one feels in a given situation, the worse it will seem to have related violent or otherwise negative thoughts, especially among individuals with a delicate conscience or the tendency to appraise unwanted thoughts as highly significant. When this occurs in new parents, it is easy to understand urges to neutralize or suppress such thoughts. However, these responses backfire, resulting in increased preoccupation, distress, and avoidance. Whereas this model can account for the development of OCD symptoms in those who have not actually been pregnant (i.e., fathers), it predicts that the newborn's primary caretaker (often the mother) will be most vulnerable to postpartum OCD.
CBT based on the model described above has as its goal the modification of erroneous appraisals of ego-dystonic thoughts.8 When patients fully believe that such thoughts are completely normal, meaningless, and nonthreatening, the result is a reduction in associated anxiety and urges to avoid or ritualize. Effective cognitive-behavioral procedures, such as psychoeducation, E/RP, and cognitive restructuring, also lend themselves to the development of programs that can help to prevent postpartum obsessional problems. Childbirth classes, for instance, can include educational material explaining that the negative thoughts sometimes associated with having a new baby are normal. Effective strategies for coping with such intrusions can also be described. Research on factors that predict the onset of OCD in pregnancy or the postpartum is also necessary to help aid early recognition and treatment of this problem in childbearing women and their partners.
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