Instrusive Thoughts Diagnostic Distress Differential

Perinatal specialists wrestle with overlapping clinical presentations and key markers for differentiation. It seems that levels of distress can provide distinct diagnostic characteristics that can shape the course of intervention and treatment. This is particularly true when it comes to postpartum anxiety that manifests as intrusive thoughts.

While these are not mutually exclusive and diagnostic lines are often blurred, we have listed some of the common presentations with an associated distress index. Due to the nature of any mental health issue, these categories are not discreet and may manifest with unique inconsistencies in any one individual.

Non-postpartum OCD HIGH DISTRESS
A diagnosis of obsessive compulsive disorder involves a cycle of obsessions and compulsions so extreme that it consumes much of the day and significantly interferes in one’s ability to function. Obsessions often involve contamination, order, extreme neatness, perfectionism, symmetry, and hoarding. Compulsions involve ritualistic behaviors designed to reduce obsessions or distress associated with them.

Postpartum OCD usually emerges rapidly, sometimes immediately after giving birth and typically involves scary obsessional thoughts of harm coming to the newborn, either by accident or intent. Postpartum OCD thoughts are characterized by intrusive and sometimes violent thoughts, causing high levels of distress and attempts to resist the scary thoughts.

Postpartum Obsessive Thinking Style / Subclinical Obsessions and Compulsions (Non-OCD) LOW or HIGH DISTRESS
Some obsessions and compulsions, which arise during the postpartum period and look like OCD, such as intense concern about the baby’s safety, constant hand washing, excessive worry about being a good mother or making a mistake, may actually feel adaptive and not disrupt the mother’s life at all.  These women are at risk for postpartum depression and anxiety. Depending on many factors, e.g. her psychiatric history, genetics, personality, environmental stressors, she may or may not experience her thoughts/behavior as stressful. She may be able to dismiss her scary thoughts for what they are, or, she may suffer significantly as a result of her intense anxiety.

Obsessive-Compulsive Personality Disorder (OCPD) or traits LOW DISTRESS
While women with OCD have insight into the intrusive nature of their unwanted thoughts, individuals with OCPD think their way of thinking make total sense and typically feel at home with their thoughts and the rigid set of rules they impose on themselves. Pre-existed current episode.

Psychotic-Like Experiences (PLEs) LOW or HIGH DISTRESS
Some studies support the continuum model of psychosis, with Psychotic-Like Experiences (PLEs) defined as subtle, subclinical hallucinations and delusions which are common in the general population and may manifest frequently in perinatal individuals without a diagnosis of severe mental illness. Experiences such as perceptual illusions and superstitious beliefs are relatively common and clinically harmless for many individuals, yet highly distressing and/or could be indicative of psychosis risk for others.

Postpartum Mood or Anxiety Illness with Psychotic Symptoms LOW or HIGH DISTRESS
Women with severe depression, anxiety or bipolar illness can experience psychotic symptoms. When these severe symptoms emerge, they can be accompanied by an awareness that something is terribly wrong and associated with significant distress.

Postpartum Psychotic Illness LOW DISTRESS
Women with postpartum psychotic illness tend to experience their distorted thoughts as ego-syntonic, or, consistent with their world view. Typically, these thoughts are usually part of a primary psychotic episode, manifesting in delusions, or a bizarre belief system.

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