Dear Brain: Could You Stop Trying to Kill My Baby?

I know. That title made you uncomfortable.

Good.

Because we need to talk about this.

Postpartum OCD is one of those conditions nobody talks about until you're sitting in my office, usually crying, absolutely terrified that I'm going to take your baby away because you finally told someone what has been happening inside your head.

Almost every woman says some version of the same thing: "I'm scared to tell you what I'm thinking."

So sometimes I'll tell her first.

"Are you having thoughts about something terrible happening to the baby?"

She nods.

"Are you having thoughts that you might be the one who does it?"

And then the floodgates open.

Because someone finally said the unsayable thing.

Welcome to Intrusive Thoughts

Maybe you're standing at the top of the stairs holding your baby when your brain suddenly produces an image of dropping her. Maybe you're giving your baby a bath and think, What if I drowned him? Maybe you're chopping vegetables and suddenly imagine stabbing your baby.

Or maybe you have an unwanted sexual thought involving your baby—and that one horrifies you so profoundly that you spend the next three days wondering what kind of monster even thinks something like that.

Sometimes the thoughts are less graphic but just as relentless. What if she stops breathing? What if he chokes? What if I accidentally leave her in the car? What if someone kidnaps him? What if I fall asleep holding her? What if I lose control?

And eventually comes the question that makes postpartum OCD so unbelievably cruel:

What if having this thought means some part of me actually wants to do it?

That's where OCD gets you. The thought itself isn't necessarily the problem. It's the meaning your brain attaches to having the thought.

Your Brain Produces Weird Crap All Day Long

Brains are weird. Everyone has intrusive thoughts.

Have you ever been driving down the highway and suddenly thought, I could just turn the steering wheel right now? You don't want to. You're not going to. Your brain just noticed that technically...you could.

Most people think, Well, that was weird, and continue driving.

OCD says:

EXCUSE ME. WHY DID WE THINK THAT?

And now we're off to the races.

Why did I think it? What kind of person thinks that? Would a good mother think that? What if thinking it means I secretly want it? What if I snap? What if I lose control? What if this is the first sign that I'm becoming psychotic? What if I tell someone and they take my baby away? The brain desperately wants certainty. Unfortunately, OCD has approximately the same relationship with certainty that my children have with asking, "But why?" There is no answer that will ever be quite enough.

So You Start Trying to Make Yourself Feel Safe

This is where the compulsive part of obsessive-compulsive disorder comes in, and compulsions don't always look like washing your hands or checking whether the stove is off.

Maybe you hide the knives. You won't bathe the baby alone. You refuse to carry her near the stairs. You check his breathing 37 times every night. You repeatedly ask your partner, "You don't think I would ever hurt the baby, right?" Or maybe your compulsions happen entirely inside your head. You replay the thought over and over, trying to determine exactly what you felt when you had it. You test yourself to see whether the thought still disgusts you. You pray. You mentally review every interaction you've ever had with your baby looking for evidence that you're a good mother.

And, of course, you Google.

"Does having intrusive thoughts mean I want to hurt my baby?"

You read six articles. You feel better for eleven minutes. Then your brain says, Okay, but what if MY case is different?

Back to Google.

That's the OCD cycle: an intrusive thought creates anxiety, so you do something to neutralize the thought or make yourself feel safe. It works—briefly. But that relief accidentally teaches your brain that the thought really was dangerous and the compulsion was what kept everyone safe. So the next time the thought appears, the alarm gets louder.

Here's the Most Important Part

An intrusive thought is not an intention.

Having the thought "What if I throw my baby down the stairs?" is not the same thing as wanting to throw your baby down the stairs. In postpartum OCD, these thoughts are typically ego-dystonic, which is clinician language for saying the thought feels completely inconsistent with who you are, what you believe, and what you want. That's why you're horrified by it. That's why you're avoiding the stairs. That's why you've been awake for three hours crying because you're terrified that having the thought means something about you. You don't want the thought. You don't like the thought. You're desperately trying to make sure the thought never becomes reality.

That distinction matters enormously.

Postpartum OCD Is Not Postpartum Psychosis

This is one of the most important distinctions I make clinically because women with postpartum OCD are often terrified they're "going crazy."

Postpartum OCD and postpartum psychosis are not the same illness.

With OCD, insight is generally preserved. You recognize that the thought came from your own mind. It feels unwanted, frightening, unreasonable, or inconsistent with what you actually want—even though OCD can make you question that over and over again. Psychosis involves impaired reality testing. Someone may experience hallucinations, delusions, severe confusion, paranoia, mania, or beliefs that feel completely real to them. For example, there is a very meaningful clinical difference between a mother saying, "I'm terrified I might hurt my baby even though I don't want to," and a mother saying, "God told me I have to hurt my baby to save him." Both statements involve frightening content. Psychiatrically, they are not remotely the same thing.

Postpartum psychosis is rare, but it is a psychiatric emergency and requires immediate medical evaluation. Postpartum OCD is also serious and deserves treatment, but the presence of an unwanted intrusive thought does not, by itself, mean a mother wants to harm her baby.

Here's Where Healthcare Sometimes Makes This Worse

A terrified mom finally works up the courage to tell someone, "I keep seeing an image of myself dropping the baby." If the person hearing that doesn't understand OCD, they may immediately respond as though she just disclosed homicidal intent.

Guess what she learns?

Never tell anyone again.

And now we've taken a very treatable psychiatric condition and wrapped it in shame.

This is why, clinically, I need more information than simply asking, "Are you having thoughts of harming your baby?" I want to know whether the thought is wanted or unwanted. Does it frighten you? Do you have any desire or intention to act on it? Do you believe the thought is true? Are you changing your behavior because of it? Are you checking, avoiding, seeking reassurance, or performing rituals? Are there hallucinations, delusions, mania, severe confusion, or a loss of reality testing?

The content of a thought matters, but the relationship someone has with that thought matters enormously.

And Yes, We Can Treat This

Postpartum OCD is treatable.

One of the primary evidence-based treatments for OCD is cognitive behavioral therapy with exposure and response prevention, usually called ERP. ERP helps someone gradually learn that she can experience an intrusive thought, image, sensation, or uncertainty without performing the compulsions OCD demands in response.

And because somebody somewhere is going to misunderstand that sentence: ERP does not mean exposing a baby to danger.

Let me repeat that for everyone in the back.

WE DO NOT EXPOSE BABIES TO DANGER.

Medication, particularly serotonergic antidepressants, may also be part of treatment depending on symptom severity, individual history, pregnancy or breastfeeding considerations, and patient preference. But sometimes the first therapeutic intervention is simply education. Because watching a woman's face change when I tell her, "Oh. This has a name. I know exactly what you're describing. I've treated this before," is one of my favorite moments in this job.

The OCD doesn't disappear in that moment.

But sometimes the shame does.

So, Dear Brain...

Thank you for trying to protect the baby. Truly. I appreciate the enthusiasm. But suggesting that I might fling my infant off the balcony and then requiring me to avoid balconies for six months was perhaps...

A bit much.

We're going to teach you a different way to handle uncertainty.

Because the goal of OCD treatment isn't to guarantee that you'll never have another bizarre, disturbing, completely inappropriate thought. You will. You're a human being with a human brain. Human brains generate all kinds of nonsense. The goal is to get to the point where your brain says, "What if you dropped the baby?" and instead of launching a six-hour internal investigation into whether you're secretly a murderer, you can think:

Wow. That was weird. And move on.

Because thoughts are not actions. Thoughts are not intentions. Thoughts are not character. And having a terrifying thought about the person you love most in the world does not make you dangerous. Sometimes it means your brain figured out exactly what would scare you the most...

and OCD grabbed a megaphone.