I wanted to have a baby. The time was right, my fourth book finished, the debt on my house paid down, my middle age approaching. Thirty-three, thirty-four, still young enough to touch the toes, but not so young that the future is forever, the way an adolescent sees it, time stretching out, blue and hazy as any horizon.
So one night my husband and I lobbed my diaphragm out the bedroom window, where it sailed through the air, shaped like a small spaceship. I remember that night, early spring, the air frosty in a bracing sort of way. The diaphragm landed there, in the garden, a brittle thorn hooking its underside.
Was that an omen? I didn't believe in omens, frankly still don't, but there was that thorn right in the gut of the rubber flesh. Three months later, I missed my period. I stood in a dawn-dark bathroom and peed in a pleated cup, watched the test window turn inky and blue, watched the first line appear, the second line then, straight and unambivalent: a definite yes.
I have a mental health history, but by the time I got pregnant, by the time I stood on the wood floor that morning, clutching the plastic stick, it was behind me, years ago. Of course I thought it would stay that way. And for a while it did. The first few weeks of the pregnancy were good. I was good. No, amend that. I was great. I was elated, my belly light and bright as a balloon, or so it seemed, holding me aloft. I floated.
Then, at week eight of the pregnancy, I found a little brown spot of blood on my underwear. It was such a strange spot, so precise, like a punctuation point: the end. "It's probably fine," my obstetrician said to me. "Fifty percent of women bleed in their first trimesters, and the blood isn't red, it's brown blood, old blood. I'm sure you're fine." But I wasn't fine. I was scared, on the edge, surreptitiously slipping my fingers beneath the elastic rim of my underwear, checking to see if they came back smeared. Again and again I did this. I got an ultrasound and saw the heartbeat, fast, the little baby curled like a cashew, all there. It didn't comfort me. It comforted me for maybe five seconds, and then anxiety set in again. The blood stopped, but the anxiety didn't. There were a million ways for a fetus to die; the slippage of a single cell, kaput. Was my progesterone stable? Was my HCG on the upswing? I went back to see the doctor again and again, demanding tests, ultrasounds, measurements, means. Though I was perfectly healthy, by the end of the first trimester, my pregnancy had turned into a techno-numerical nightmare. I was weeping, lying in bed with a calculator in hand, computing the complex rise of my HCG, my progesterone, and God knows what other chemicals I was insisting that my doctor measure daily.
I had, it turns out, what clinicians call gestational OCD. Obsessive-compulsive disorder. I needed to check and count and tap, whereas before getting pregnant, I'd been normal. There has been a lot of discussion about gestational and postpartum depression, the disease that caused Marie Osmond to leave her kids with the nanny and just drive away. Everyone knows, it seems, that depression is part and parcel of the pregnant and postpartum state; fewer people know that the anxiety constellation of OCD is also a frequent uninvited guest during this period.
Characterizations of OCD
OCD is characterized by repetitive thoughts that seem absurd but nevertheless fill you with fear, and then repetitive behaviors, like washing one's hands, or checking the sleeping child, designed to alleviate the anxiety. Usually the behavior, called the compulsion in clinical parlance, does relieve the anxiety (oh, thank God, my kid is breathing), but only for a moment, after which it returns in full force, oftentimes worse than before. Around and around you go, bound up by your own clacking brain.
Mental health professionals diagnose OCD when the worries are unrealistic and take up at least one hour of a person's day. They diagnose gestational or postpartum OCD if the disorder either occurs during pregnancy or within one year following a child's birth.
According to current estimates, OCD affects about 2 to 3 percent of the population. There are no current estimates as to how many women it affects in or after pregnancy, but some experts guess that about 1 in 200 will suffer from it in the prenatal or postpartum period. What makes OCD more difficult to diagnose in pregnancy and postpartum is the fact that both these states are characterized by heightened emotionality; how does one tell when feelings become pathological? Here's how. If, every once in a while, you need to check the oven before bed, or if you do it even every night, three times, and then sweetly drop off to sleep, you don't have OCD. If, in the postpartum period, you occasionally find yourself picturing some horrendous act of violence happening to your child (new mothers seem to torture themselves with such images as a matter of course), but can then shudder and shrug it off, and get on with your day, then you don't have this condition. OCD is at the far, far end of anxiety, in a place where worry turns monstrous, and the actions to temporarily dispel it, like checking or washing, are more time-consuming than several loads of laundry.
Prenatal or postpartum OCD differs from the everyday variety in that, often (although not always) the obsessions and compulsions revolve around the little creature you're carrying. You may worry that you'll hurt him. A passing thought, except it won't quite pass, it's killing you, and pretty soon, you're avoiding every window or tapping the stove three times for a talisman. In my own gestational OCD, I read a story in the newspaper about a woman who killed a chocolate Lab puppy by injecting him with insulin. The story stuck to the tortured Velcro that was my mind; I kept going over it and over it and then I got the idea that I would do that to my baby, as soon as she was born, although I don't own any insulin, and I've never mainlined a thing. Still, I developed a fear of pharmacies, because syringes were there, and in order to detoxify this terrible thought, I needed to blink my eyes six times when it emerged. I also got very worried about my breath. I felt the baby was using up my oxygen. I became highly conscious of every breath, the sucking in of air, the lungs expanding, and the more I thought about the process, the less I felt I could breathe, and then I panicked. "If I don't stop thinking about breathing," I thought, "I'll become so self-conscious I won't be able to breathe." Such is the logic of OCD.
I went on medication. If you're diagnosed with OCD during pregnancy, this is a complicated issue, although the data so far point to the relative safety of selective serotonin reuptake inhibitors (SSRIs), the class of drug usually used to treat the disorder. If OCD occurs in the postpartum period, you don't have your in-utero traveler to think about; trace amounts of SSRIs are found in breast milk, but there's no evidence these amounts hurt an infant. Because most OCD sufferers find relief using medication, it is often the treatment of choice. In less serious cases of the condition, some doctors and patients prefer to take a cognitive-behavioral therapy approach.
Why would a woman be vulnerable to OCD during and directly after pregnancy? Why wouldn't our bodies be set up, in some sort of genetic, evolutionary sense, to produce the kind of liquid calm that best allows for bonding with a baby and thus survival of the species? It may be, actually, that gestational OCD is a kind of maternal survival mechanism gone a little haywire. Some experts hypothesize that OCD is really a manifestation of ancient grooming and guarding behaviors -- two things a mother needs to do -- that have slipped their chemical loopholes and are acting in an overamplified fashion. The irony of maternal OCD is that it might be tied to the very mechanisms of mothering, but that tie gets twisted.
There has been, of late, a lot of research into the biochemical basis of gestational psychiatric disorders. The fact is that women with a prior psychiatric history (like me), or who have mental illness in their families, are at a much higher risk for experiencing conditions like OCD or depression during pregnancy or postpartum. "Some women appear to have a specific sensitivity to any kind of hormonal change in their brain," says Andrew G. Herzog, M.D., associate professor of neurology at Harvard Medical School and director of the Neuroendocrine Unit at Beth Israel Deaconess Medical Center in Boston. "Pregnancy results in a flood of hormones, and the postpartum period results in a sudden, rapid withdrawal. Either the sudden onslaught, or the sudden disappearance, can activate the emotional pathways in a woman's brain."
Turning The Corner
As for myself, by week 28 of my pregnancy I started to feel sane again, either because the meds were kicking in, or my brain had adjusted to its high-powered combo of estrogen and progesterone. The sky seemed sweet again, the clouds with a lambswool texture. I was relieved, but somber, newly appreciative of the power hormones can have in a woman's mental state. I joined a group for women suffering from gestational or postpartum OCD. In that group I met Grace, who had a beautiful, uneventful pregnancy, but two weeks after the birth couldn't stop thinking about putting her son in the oven. I met Irene, who in the last trimester of her pregnancy spent over $4,000 on "air washing" systems for her baby daughter's room, but still the pollutants were getting in. I met Josie, who, since the birth of her baby, had become so hypersensitive to sound that every screech and burp and rattle was an auditory assault, until all she could think about was sound and the accompanying, elusive search for silence. These women, plus me, were the face of gestational OCD, that cousin to the much discussed postpartum depression. OCD is just as toxic as depression is, far more jittery, and definitely devastating.
Women who experience any kind of psychiatric disorder in pregnancy are at a very high risk for recurrence in the postpartum period. My doctors pretty much guaranteed me that, even though stable at week 28, I'd go nose-diving down again after birth, my outraged brain saying, Bring back those hormones. That, of course, terrified me. A bit of bracketed peace, to be broken by the breaking of my waters. Given the severity of the OCD in my first and second trimesters, I was set up with a visiting nurse and a visiting shrink for the postpartum period.
On June 10, I gave birth to a baby girl. On June 14, I brought her home with me, and my husband and I waited for the OCD to flare up again. It didn't. My postpartum period was remarkably serene, my worries proportional, my drugs potent, my husband and nurses and shrink forming a wall of caring around me. I got well and stayed well. I have been well since. Just the other day, my newborn baby turned 3 years old.
Her name is Eva. I worry, sometimes, that she, too, will get OCD, either in adolescence, when hormones flood the body, or in the reproductive period of her life. She has, after all, a family history. And then she spent months in the womb, washed over with my worries, steeped in them. So far, Eva seems fine. She has dark curly hair with zigzag streaks of red, and defiance -- I like that in a daughter. She likes dinosaurs, Lincoln Logs, and singing about the old lady who swallowed a fly, I think she'll die.
She doesn't like bedtime, insists that the light stay on, and says, every time, "How long will it take, Mama, how long will it take?"
"Until what?" I say.
"Morning," she says, "it takes a long time to get here," she cries, "it takes a long time."
"It does," I say, for in the end, there's only this, the truth. "Morning takes a long time to arrive."
"I can do it," she says.
And then she does.
Lauren Slater is the author of Love Works Like This (Random House), a memoir of pregnancy and childbirth.
Coping with OCD
Everyone has heard of postpartum depression -- commonly known as the "baby blues," and few women are surprised when the hormonal chaos of pregnancy turns those nine months into an emotional rollercoaster. But women who suffer from gestational or postpartum obsessive compulsive disorder (OCD) are often taken by surprise, and have a hard time naming or even talking about their symptoms. While no one has tabulated exactly how many women suffer from OCD during pregnancy or the postpartum months, researchers agree that childbearing women are at particular risk for the anxiety disorder, which affects two to three percent of the general population.
Like depression, OCD results from an imbalance in the brain chemical serotonin. It's not clear why pregnant and postpartum women are vulnerable, though it's likely that the hormonal changes associated with those periods affect the serotonin system. Anxiety disorders, including OCD, "typically emerge during times of stress," adds Ruta Nonacs, M.D., Ph.D., a perinatal psychiatrist at Massachusetts General Hospital in Boston, so the strain of expecting or caring for a baby may also be a trigger.
Classic signs of OCD include persistent, anxiety-inducing thoughts or impulses, and repetitive rituals such as hand-washing or counting. In pregnant women, obsessions often revolve around the health or safety of the baby. Women who suffer from postpartum OCD may be haunted by recurrent images of harming the baby -- fantasies that horrify them but which they are very unlikely to act on.
Doctors generally diagnose OCD when obsessions and compulsions are so persistent that they interfere with a person's ability to function -- rituals become so numerous that it's hard to get out of the house, or a mother is so afraid of harming her baby that she avoids being left alone with him.
Non-pharmaceutical treatments for OCD include relaxation techniques and behavioral therapy, in which a patient is exposed in a controlled environment to the things that trigger anxiety. If these techniques do not work, many OCD sufferers respond well to the class of antidepressants known as selective serotonin reuptake inhibitors, such as Prozac, which is considered safe for use during pregnancy and breastfeeding.
While there is no surefire way to ward off gestational or postpartum OCD, Dr. Nonacs says simply raising awareness of the disorder could make a big difference. "The obsessive thoughts are often so disturbing," she notes, that women "sit at home not willing to tell anybody, even their doctors. If they knew this could happen, and that it was just an anxiety disorder, that would be very helpful."
For more information contact the Anxiety Disorders Association of America (240-485-1001; www.adaa.org), the Obsessive-Compulsive Foundation (203-315-2190; www.ocfoundation.org), or the Obsessive Compulsive Information Center (608-827-2470; www.miminc.org/aboutocic.html). The book Women's Moods: What Every Woman Must Know About Hormones, The Brain, and Emotional Health, by Deborah Sichel M.D., and Jeanne Watson Driscoll, R.N., offers detailed information about pregnancy and postpartum OCD, and co-author Driscoll's account of her own postpartum struggle.