Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2021 Jul 1.
Published in final edited form as: J Reprod Infant Psychol. 2019 Aug 20;38(3):226–242. doi: 10.1080/02646838.2019.1652255

Obsessive-Compulsive Symptoms, Intrusive Thoughts, and Depressive Symptoms: A Longitudinal Study Examining Relation to Maternal Responsiveness

Michelle L Miller a, Michael W O’Hara a
PMCID: PMC7031018  NIHMSID: NIHMS1536957  PMID: 31431052

Abstract

Background:

The postpartum period is a vulnerable time for the development of depression. While perinatal depression has been well-studied, intrusive thoughts related to the infant and classic obsessive-compulsive (OC) symptoms (e.g. checking, ordering, and cleaning) are also common in the postpartum and less well-understood.

Objective:

The present study investigated the associations among depressive symptoms, intrusive thoughts, and OC symptoms and their relation to the quality of the mother-infant relationship, particularly in the realm of maternal responsiveness.

Methods:

Participants (N=228) were recruited after delivery from a large Midwestern academic medical center. At two and twelve weeks postpartum, participants completed self-report questionnaires that assessed demographics, depressive and OC symptoms, postpartum-specific intrusive thoughts and accompanying neutralizing strategies, and maternal responsiveness.

Results:

At twelve weeks postpartum, maternal responsiveness was significantly lower for participants that endorsed intrusive thoughts, neutralizing strategies or OC symptoms of clinical significance. More severe intrusive thoughts and neutralizing strategies were associated with maternal responsiveness but not predictive after accounting for depressive symptoms; depressive symptoms were associated with lower levels of maternal responsiveness across the postpartum.

Conclusions:

A sizable number of postpartum women experience clinically significant postpartum-specific intrusive thoughts and utilize neutralizing strategies, especially in the context of postpartum depressive symptoms. Depressive symptoms have the most influence on maternal responsiveness but it is also important to target intrusive thoughts and OC symptoms in the context of postpartum depression to promote the welfare of new mothers and their offspring.

Keywords: postpartum depression, obsessive-compulsive symptoms, intrusive thoughts, postpartum anxiety, women’s mental health

1. Introduction

The development or exacerbation of depressive symptoms associated with the perinatal period has been well-established, affecting about 13% to 19% of all women (Gavin et al., 2005; Jairaj et al., 2018; O’Hara & McCabe, 2013). Although much of the literature has focused on perinatal depression, perinatal anxiety is increasingly recognized as prevalent (Fairbrother et al., 2016; Uguz et al., 2019) and detrimental to women and their children (Bauer et al., 2016). One of the most common and impairing anxiety disorders in the perinatal period is obsessive–compulsive disorder (Collardeau et al., 2019; Frias et al., 2015; Maina et al., 1999; Challacombe et al., 2016).

Obsessive-compulsive disorder (OCD) is characterized by the presence of obsessions (recurrent thoughts, urges, or images that are intrusive and unwanted) and/or compulsions (repetitive behaviors or mental acts performed to prevent or reduce anxiety); OCD is now classified with Obsessive-Compulsive and Related Disorders in the DSM-5 (American Psychiatric Association, 2013). OCD experienced during the postpartum period is notable because of a) higher than expected incidence, b) swift onset, c) content of symptoms, and d) potential pathophysiology. OCD occurs at rates of 3–10% in the postpartum period (Fairbrother, Janssen, Antony, Tucker, & Young, 2016; Kitamura et al., 2006; Labad et al, 2010; Wenzel et al., 2005), with onset often within two to four weeks postpartum (Abramowitz & Fairbrother, 2008; Arnold, 1999). Additionally, entering the perinatal period is the only specific life event continuously associated with OCD onset and exacerbation across studies (Abramowitz, Schwartz, Moore, & Luenzmann, 2003; Fairbrother & Abramowitz, 2007; Maina, Albert, Bogetto, Vaschetto, & Ravizza, 1999).

One notable difference between obsessive-compulsive (OC) symptoms in the postpartum compared to other life periods is symptom content. The theme of postpartum OC symptoms are often about the newborn, such as obsessions around harm occurring to the newborn, rather than more classic OC symptom presentation (e.g. checking, ordering, and cleaning; Abramowitz et al., 2003). Lastly, the etiology of postpartum OC symptoms may be in part due to change in hormones around delivery, including estradiol and progesterone, which may subsequently alter serotonin and dopamine levels in the postpartum period (Vulink et al., 2006, Labad et al., 2005; Williams & Koran, 1997).

There are important distinctions between normal postpartum adjustment and clinical psychopathology. Intrusive thoughts of accidentally or intentionally harming one’s infant (e.g., dropping or throwing the baby) are experienced by most mothers and fathers in the postpartum period (Abramowitz et al., 2010; Fairbrother & Abramowitz, 2008). However, clinically significant OC symptoms and more severe intrusive thoughts differ from harmless intrusive thoughts in the following ways: increased duration and/or frequency of thoughts, increased level of distress/amount of impairment associated with occurrence of thoughts, use of neutralizing behavior to reduce intrusive thoughts, and appraising the intrusive thoughts as significant rather than irrational mental imagery (Barrett, Wroe, & Challacombe, 2016; Fairbrother & Abramowitz, 2007; Fairbrother, Thordarson, Challacombe, & Sakaluk, 2018; Wroe, Salkovskis, & Richards, 2000). Further, women experiencing clinically significant OC symptoms often experience comorbid depression, with more severe unwanted maternal postpartum intrusive thoughts associated with more severe depressive symptoms (Abramowitz, Schwartz, & Moore, 2003; Wisner Peindl, Gigliotti, & Hanusa, 1999).

Intrusive postpartum-specific thoughts can create significant distress for mothers if they interpret these intrusive thoughts as true (Kleiman & Wenzel, 2011). According to cognitive-behavioral theory, intrusive thoughts have the potential to develop into clinically significant obsessions if the intrusive thoughts are interpreted as predictive of behavior and behavioral strategies are used to reduce the distress and perceived risk (Fairbrother & Abramowitz, 2007; Rachman, 1997; Salkovskis, 1985). Although intrusive thoughts are common in the postpartum period, less is known about the more severe intrusive thoughts and accompanying behavioral strategies (e.g. when there a significant amount of distress or interference in role functioning). The extremely limited literature has demonstrated that increased behavioral response to intrusive thoughts in the early postpartum period predicted a) increased frequency and time occupied of thoughts of accidental harm and b) interference in parenting by intentional harm thoughts (Fairbrother, Thordarson, Challacombe, & Sakaluk, 2018). Severe intrusive postpartum thoughts and accompanying neutralizing behaviors may be significantly related to parenting or mental health outcomes but are not yet well understood.

It is important to understand intrusive thoughts in the context of postpartum anxiety because women experiencing postpartum anxiety relative to women not experiencing postpartum anxiety are less likely to engage with their infant, breastfeed, or quickly respond to their infant’s signals (Challacombe et al., 2016; Nicol-Harper et al., 2007; Weinberg & Tronick, 1998). This avoidance is problematic because maternal responsiveness, the timely and appropriate behavior of the mother in response to an infant’s signals or behaviors (Beckwith & Cohen, 1989), is particularly important to infant development (Richter, 2004). Higher levels of maternal responsiveness are associated with positive child outcomes, such as increasing the child’s sense of security and willingness to explore its environment, as well as strengthening the bond between mother and infant (Bigelow et al., 2010; Bornstein & Tamis-LeMonda, 1989; McElwain & Booth-Laforce, 2006; Pridham et al., 2000). Maternal responsiveness to infant signals may affect infants’ internal working models of their mothers. A recent review demonstrated the lasting implications of early secure parent-child relationships and their importance to shaping future prosocial behavior such as socialization, ability to follow rules, and empathy (Kochanska, Boldt, & Goffin, 2019). Yet, for children with low expectations of responsiveness and trust in the parental bond, there is a higher risk of rejection of parents’ messages on discipline and socialization and subsequent problems with disorderly behavior (Carlson et al., 2004; Dykas & Cassidy, 2011). While exploring all maternal characteristics that can affect how mothers and infants respond to each other is beyond the scope of this article (for review see McMahon & Bernier, 2017), maternal responsiveness may be particularly important to explore in the early postpartum.

To better understand what variables lead to reduced maternal responsiveness, the literature has focused on perinatal depression. A robust association has been found between current or recent history of maternal depression and reduced maternal responsiveness (Field, 2010; Pearson et al., 2012). Given the importance of maternal responsiveness and that women experiencing OC symptoms or high levels of impairment related to intrusive thoughts may be likely to avoid their infants to reduce their distress (Sichel et al., 1993; Larsen, et al., 2006), it is important to determine if there also exists an association between OC symptoms, intrusive thoughts, and maternal responsiveness.

While intrusive thoughts in the postpartum do not cause impairment for all women, much less is known about how more severe postpartum-specific intrusive thoughts and accompanying behaviors to neutralize them affect maternal-child interactions when also measuring concurrent depressive and OC symptoms. The current longitudinal study tested the hypothesis that women who experienced more severe intrusive thoughts and/or neutralizing strategies as well as clinically significant OC symptoms would demonstrate significantly lower levels of maternal responsiveness at both two and twelve weeks postpartum compared to women who did not endorse severe intrusive thoughts, neutralizing strategies or clinically significant OC symptoms (H1). Given that depressive symptoms are a risk factor for low maternal responsiveness, our second hypothesis (H2) was that clinically significant OC symptoms, more severe intrusive thoughts, and neutralizing strategies would continue to predict lower levels of maternal responsiveness even after controlling for depressive symptoms at both two and twelve weeks postpartum.

2. Methods

2.1. Participants and procedures

The current study (N = 228) was part of a longitudinal study that examined postpartum internalizing psychopathology, OC symptoms, and intrusive thoughts. Women who had recently delivered were approached in the Mother-Baby unit of a large Midwestern academic medical center. Recruitment occurred from February 2013 to October 2014. Participants were excluded from recruitment if they were less than 18 years of age, unable to read and speak English, or on leave from incarceration. All procedures were approved by the University Institutional Review Board.

After a woman consented to participate, she completed a baseline assessment of depression while still on the Mother-Baby unit, within approximately 0–3 days postpartum. Participants were then sent questionnaire packets early in the postpartum (two weeks postpartum) and again later in the postpartum (twelve weeks postpartum; Figure 1 for study flow). Online study data were collected by REDCap (Research Electronic Data Capture) electronic data capture tools, which is a secure, web-based application designed for research and hosted by the University (Harris et al., 2009).

Figure 1. Flow diagram of participants.

Figure 1

Open in a new tab

Note. IDAS = Inventory of Depression and Anxiety Symptoms; IDAS-II = Inventory of Depression and Anxiety Symptoms, Second Edition; PRAMS = Pregnancy Risk Assessment Monitoring System; PTBC = Parental Thoughts and Behaviors Checklist; MIRI = Maternal Infant Responsiveness Instrument.

2.2. Measures

2.2.1. Demographics

The Pregnancy Risk Assessment Monitoring System (PRAMS; Centers for Disease Control and Prevention, 2009) was used to assess demographic variables. This measure is used by state health departments to obtain information on a wide range of experiences and behaviors that occurred during women’s pregnancy and in the 12 months prior to pregnancy. The PRAMS measure was found to be valid across multiple maternal and infant health indicators using two representative samples of mothers at four months post-delivery (Dietz et al., 2014).

2.2.2. Maternal responsiveness

The Maternal Infant Responsiveness Instrument (MIRI) was used to assess maternal responsiveness at two weeks and again at twelve weeks postpartum (Amankwaa et al., 2002; Amankwaa et al., 2007; Drake et al., 2007). The MIRI is a 22-item scale designed to measure a mother’s feelings about her infant using a 5-point Likert-type scale (1= ‘strongly agree’ to 5= ‘strongly disagree’). Experts in maternal child health established the face and content validity of the measure, with the final measure’s internal consistency at α = .83 (Amankwaa et al., 2007). Higher scores indicate less maternal responsiveness. Internal reliability for this study was satisfactory across time points (mean Cronbach’s α = .86).

2.2.3. Internalizing psychopathology

The Inventory of Depression and Anxiety Symptoms (IDAS and IDAS-II; Watson et. al., 2007; Watson et al., 2012) was used to assess internalizing psychopathology. The IDAS (64 items) and IDAS-II (100 items) both assess depressive and anxiety symptoms experienced over the last two weeks on a 5-point Likert-type scale (1 = “not at all” to 5 = “extremely”). The shorter IDAS was utilized at baseline to reduce participant burden. All anxiety and depressive symptom scores are continuous total scores, with higher scores indicating more severe symptoms. Strong evidence of convergent and discriminant validity was reported for the depression and OC subscales (Watson et al., 2007, 2012). In the current study, the IDAS Depression scale demonstrated good internal consistency (Cronbach’s α = .89) while the internal consistencies for the IDAS-II anxiety subscales were acceptable to good across time points (Depression [mean α =.90], Checking [mean α = .73], Ordering [mean α =.76], and Cleaning [mean α =.78]).

2.2.4. Postpartum-specific intrusive thoughts

The Parental Thoughts and Behaviors Checklist (PTBC; Abramowitz et al., 2006) is a self-report measure used to evaluate postpartum intrusive thoughts and neutralizing strategies. A brief introductory paragraph is included to explain and normalize the occurrence of intrusive thoughts and neutralizing behaviors. Participants were then asked to indicate if they experienced any of 33 postpartum-specific thoughts, divided into seven categories: accidents, contamination, illness, intentional harm, losing the baby, sexual, and suffocation/Sudden Infant Death Syndrome (SIDS). After completing the section on content of thoughts, a 5-point Likert scale (0 = None to 4 = Extreme) was used to rate severity. Participants were also asked to indicate if they used any behavioral and mental neutralizing strategies, including avoidance, behavioral distraction, checking, cognitive distraction, religious, seeking social support, and self-reassurance. After reporting if any of those strategies were utilized, participants again used a 5-point Likert scale to rate severity using the same indicators as intrusive thoughts.

To determine the severity of a participant’s postpartum-specific intrusive thoughts/neutralizing strategies, two continuous variables, 1) severity of intrusive thoughts total score and 2) a severity of neutralizing strategies total score, were constructed by study authors. The severity of intrusive thoughts total score was computed by summing the three questions: 1) amount of time preoccupied with intrusive thoughts, 2) amount of interference with family or social or work functioning, and 3) distress caused by intrusive thoughts. Each question score ranged from 0–4, for a total severity of intrusive thoughts total score ranging from 0–12. The severity of neutralizing strategies total score was computed in the exact same manner, utilizing the questions that assessed severity of neutralizing strategies. Increased scores in amount of time preoccupied, role interference, and level of distress indicated more severe intrusive thoughts and more use of neutralizing strategies.

If a participant endorsed clinically significant levels of OC symptoms, intrusive thoughts, or neutralizing strategies, she was considered to meet criteria for clinical significance of her symptoms and included in the clinical group; all other participants were included in the non-clinical group. Participants were given clinical or non-clinical designations for the purposes of this study alone; participants were not grouped according to any other pre-existing clinical variable (e.g. history of psychiatric illness, psychotropic medication status). Clinically significant OC symptoms were defined as being one standard deviation or higher above the community norm mean score for each individual subscale; this placed clinically significant scores within the range of outpatient sample means (Watson et al., 2012; Watson & O’Hara, 2017, pg. 58). For classification in the clinical group based on severity of intrusive thoughts or neutralizing strategies, a participant’s total score needed to indicate at least moderate severity in one or more domains on any of the questions related to amount of distress, time spent preoccupied, or role interference.

2.3. Statistical analyses

Statistical analyses were performed using SPSS version 23.0 with listwise deletion utilized for missing data. The percentages of participants who endorsed intrusive thoughts and/or neutralizing responses, as well as the mean score across categories of thoughts endorsed, were tallied for each time point. Independent sample t-tests were conducted to compare the clinical and non-clinical groups on level of maternal responsiveness. Bivariate correlations and hierarchical multiple regression analyses were utilized, with maternal responsiveness as the outcome variable for regression models. Baseline depressive symptom level (assessed immediately postpartum) was included as a covariate in Step 1, co-occurring depressive symptom level in Step 2, and OC symptom subscales, intrusive thoughts and neutralizing strategies total scores were included in Step 3.

3. Results

A univariate independent t-test was used to compare depressive symptom scores of participants that only completed baseline assessments compared to participants that completed two weeks and/or twelve weeks postpartum assessments. Comparisons indicated that participants that completed two weeks and/or twelve weeks assessments did not differ significantly in mean baseline depressive symptom scores from participants that only completed baseline assessments (t = 1.64, p >.05).

3.1. Participant characteristics

Participants were primarily white (87%), in a committed relationship (85%), and had completed at least a Bachelor’s degree (61%). A little more than half of participants (55%) had previously given birth (Table 1). At two weeks postpartum, about 30% (n = 65) of participants met criteria for clinically significant levels of OC symptoms, intrusive thoughts or neutralizing strategies. Approximately 11% (n = 23) of participants were at or above the clinical threshold for depressive symptoms (Table 2). At twelve weeks postpartum, there were fewer participants at or above the clinical threshold for OC symptoms, intrusive thoughts, or severity of neutralizing strategies (23%, n = 42), as well as at or above the clinical threshold for depressive symptoms (6%, n = 11). A majority of individuals with clinically significant levels of OC symptoms, intrusive thoughts or neutralizing strategies were also above the clinical threshold for depressive symptoms at 2 weeks postpartum (n =14, 60.9%) and 12 weeks postpartum (n =7, 63.6%). Prevalence of intrusive thoughts for all participants can be found in Table 3.

Table 1.

Characteristics of All Participants

Demographic
M (SD)
Age 30.7(5.0)
N (%)
White 199(87.3)
Latina 8(3.5)
Education Level
High School Degree or Less 28(12.3)
Associates Degree/Some College 53(23.2)
Bachelor’s Degree 75(32.9)
Masters or Doctoral/Professional Degree 64(28.1)
Income Level
< $30,000 41(18.0)
$30–70,000 80(35.1)
> $70,000 89(39.0)
Committed Relationship 193(84.6)
Multiparous 127(55.7)
NICU Infant 52(22.8)
History of Pregnancy Complications
0 91(39.9)
1 68(29.8)
2+ 37(16.2)
Open in a new tab

Note. M = mean; SD = standard deviation; N = 196–220.

Table 2.

Measure Descriptives and Clinically Significant Scores

Subscale 2 Weeks Postpartum 12 Weeks Postpartum
(N =228) (N =180)
M (SD) Range Above Clinical Threshold M (SD) Range Above Clinical Threshold Δ between 2 and 12 Weeks
N(%) N(%) t(df)
Depression 37.76(10.29) 20–71 23(10.5) 33.58(9.36) 19–68 11(6.1) t = 5.46(146)***
Checking 4.69(1.90) 3–13 31(14.1) 4.31(1.67) 3–12 18(10.1) t = 1.74(164)
Ordering 7.28(2.75) 5–22 18(8.2) 6.66(2.35 5–18 8(4.5) t =2.92 (163)**
Cleaning 9.71(3.31) 7–27 29(13.2) 8.68(2.91) 7–22 22(12.3) t = 3.05(157)**
Intrusive* 1.63(1.28) 0–9 10(4.5) 1.27(1.48) 0–6 11(6.1) t = 3.78(144)***
Neutralizing* 1.49(1.34) 0–7 15(6.8) 1.05(1.19) 0–5 8(4.5) t = 3.67(141)***
Responsiveness 35.10(9.54) 22–74 − 29.70(6.56) 22–58 N/A t = 10.31(136)***
Baseline Dep 39.46(11.18) 21–73 − − − − −
Open in a new tab

Note. Skew was within the normal range for nearly all measure subscales, although many scales were highly concentrated around the mean. *= severity of intrusive thoughts total score, severity of neutralizing strategies total score; Baseline Dep = depressive symptoms assessed on Mother Baby Unit; N/A= norms not available for this measure/subscale; - = not calculated; M = mean; SD = standard deviation; Δ = change;

*

p <.05;

**

p <.01;

***

p <.001.

Table 3.

Intrusive Thoughts and Neutralizing Responses at Two and Twelve Weeks Postpartum

2 Weeks Postpartum 12 Weeks Postpartum
(N/%) M (SD) (N/%) M (SD)
Intrusive Thoughts
Accidents 146(66.7) 2.31(2.22) 98(54.4) 1.67(2.04)
Contamination 89(40.6) 0.87(1.21) 62(34.4) 0.65(1.08)
Illness 38(17.4) 0.18(0.39) 19(10.6) 0.11(0.31)
Intentional harm 31(14.2) 0.21(0.56) 20(11.1) 0.14(0.43)
Losing the baby 124(56.6) 1.04(1.05) 102(56.7) 0.93(1.01)
Sexual 18(8.2) 0.09(0.28) 11(6.1) 0.06(0.24)
Suffocation/SIDS 176(80.4) 2.52(1.37) 119(66.1) 1.83(1.53)
Total 187(85) 7.35(5.22) 143(79.4) 5.55(4.97)
Neutralizing Strategies
Avoidance 53(24.2) 0.27(0.44) 23(12.8) 0.14(0.37)
Behavioral distraction 57(26) 0.29(0.45) 50(27.8) 0.3(0.46)
Checking 150(68.5) 0.76(0.43) 106(58.9) 0.64(0.48)
Cognitive distraction 140(63.9) 1.17(0.84) 90(50) 0.89(0.90)
Religious 28(12.8) 0.14(0.35) 39(21.7) 0.23(0.42)
Seek social support 117(53.4) 1.11(1.13) 69(38.3) 0.82(1.12)
Self-reassurance 173(79) 1.26(0.66) 129(71.7) 1.07(0.73)
Total 185(84.1) 5.09(2.76) 157(87.2) 4.18(3.15)
Open in a new tab

Note. Total = number of participants that endorsed any type of intrusive thought, in at least one category; M = mean; SD = standard deviation.

3.3. Difference in maternal responsiveness between clinical and non-clinical groups

There was no statistically significant difference in maternal responsiveness between clinical and non-clinical groups at two weeks postpartum, t(189) = −1.96, p >.05, yet there was a statistically significant difference in maternal responsiveness at twelve weeks postpartum (clinical, M = 32.31, SD = 8.38; control, M = 28.96, SD = 5.77, t(44.84) = −2.249, p <.05). Maternal responsiveness was significantly lower for participants in the clinical group than for non-clinical group at twelve weeks postpartum.

3.4. Hierarchical regression models predicting maternal responsiveness

Bivariate correlational analyses can be found in Table 4. In the context of a hierarchical regression model at two weeks postpartum, there was a significant effect for baseline depressive symptoms (β = .17, p < .05; Table 5). After controlling for baseline depressive symptoms, co-occurring depressive symptoms were significant (β = .33, p <.001), accounting for 8% of the variance; no other variables were significant (β = −.15−.05, p >.05). At twelve weeks postpartum, there was only a significant effect for co-occurring depressive symptoms (β = .36, p <.001), accounting for 9.5% of the variance for maternal responsiveness. Higher levels of depressive symptoms were significant predictors of lower levels of maternal responsiveness at both time points.

Table 4.

Intercorrelations among Internalizing Psychopathology, Intrusive Thoughts Severity, and Neutralizing Strategies Severity at Two Weeks and Twelve Weeks Postpartum

1 2 3 4 5 6 7 8
1. Maternal Responsive .12 .31** .07 −.01 .15 .21** .18*
2. Baseline Depression .17* .47** .25** .20* .26** .15 .20*
3. Depression .33** .53** .46** .38** .28** .34** .40**
4. Checking .05 .32** .45** .59** .39** .20* .24**
5. Ordering −.03 .31** .23** .50** .52** .17* .15
6. Cleaning .02 .23** .27** .34** .45** .30** .18*
7. Sev Intrusive Thought .18* .27** .34** .22** .17* .22** .73**
8. Sev Neutralizing .16* .31** .42** .24** .13 .23** .59**
Open in a new tab

Note. Two weeks correlations bottom left, twelve weeks correlations top right. Sev= severity; intrusive thoughts and neutralizing strategies refer to severity of intrusive thoughts/neutralizing strategies total score;

*

p < .05;

**

p < .01;

***

p < .001; N =176–220.

Table 5.

Hierarchical Multiple Regression Analyses of Depressive Symptoms, Postpartum-Specific Intrusive Thoughts, and Neutralizing Strategies on Maternal Responsiveness

Step 1 Step 2 Step 3
Predictor B SE B β B SE B β B SE B β
Maternal Responsiveness at 2 Weeks
Baseline Depressive 0.14 0.06 .17* −0.01 0.075 −.02 −0.04 0.09 −.05
Co-occurring Depressive 0.31 0.083 .33*** 0.42 0.10 .44***
Checking −0.81 0.54 −.15
Ordering −0.38 0.38 −.10
Cleaning 0.04 0.30 .01
Sev Intrusive Thoughts 0.43 0.83 .05
Sev Neutralizing Strategies 0.29 0.84 .04
R2 .03 .11 .17
ΔR2 .08 .04
F for change in ΔR2 4.76* 14.11*** 1.31
Maternal Responsiveness at 12 Weeks
Baseline Depressive 0.07 0.05 .12 −0.03 0.06 −.05 −0.05 0.07 −.07
Co-occurring Depressive 0.26 0.07 .36*** 0.27 0.09 .38**
Checking −0.47 0.52 −.11
Ordering −0.67 0.38 −.22
Cleaning 0.39 0.25 .17
Sev Intrusive Thoughts 0.25 0.60 .05
Sev Neutralizing Strategies 0.40 0.77 .07
R2 .01 .12 .17
ΔR2 .10 .07
F for change in ΔR2 2.00 14.83*** 1.85
Open in a new tab

Note. B = unstandardized beta; SE B = standard error of unstandardized beta; β = standardized beta; Sev = severity;

*

p < .05;

**

p < .01;

***

p < .001;

N at 2 weeks=143; N at 12 weeks=112.

4. Discussion

In this study, confirming our first hypothesis, participants who endorsed intrusive thoughts, neutralizing strategies, or OC symptoms of clinical significance were more likely to endorse responses indicative of low levels of maternal responsiveness at twelve weeks postpartum but not at two weeks postpartum. Contrary to our second hypothesis, more severe OC symptoms, intrusive thoughts, or neutralizing strategies did not predict maternal responsiveness when controlling for depressive symptoms. Depressive symptoms were the strongest predictor at two and twelve weeks postpartum.

There were significant differences in maternal responsiveness later in the postpartum between individuals who endorsed clinically significant symptoms compared to those individuals who did not endorse clinical symptoms. This is consistent with the literature demonstrating that women with internalizing psychopathology symptoms exhibit lower levels of maternal responsiveness (Dubber et al., 2015; Challacombe et al., 2016), especially later in the postpartum (Milgrom et al., 2004). One reason for this may be that women experiencing anxiety and depression are particularly preoccupied with negative maternal cognitions and intrusive negative thoughts. For example, Stein et al. (2012) found that when mothers with postpartum generalized anxiety disorder (GAD) and major depressive disorder were primed with worry and rumination cognitions, they displayed lower levels maternal responsiveness at 10 months postpartum, with a stronger effect for mothers with GAD. Future research should continue to explore the role that recurrent, maladaptive cognitions have in potentially altering maternal responsiveness across the postpartum period.

Elevated depressive symptoms were the strongest predictors of lower levels of self-reported maternal responsiveness both early and later in the postpartum. This is consistent with the literature demonstrating a strong link between maternal responsiveness and postpartum depression (Milgrom et al., 2004), with significant implications for the infant’s future behavior (Goodman et al., 2011; Kim-Cohen et al., 2005). Additionally, higher levels of depression were associated with more severe postpartum-specific intrusive thoughts, neutralizing strategies, and OC symptoms across the postpartum. Other studies have reliably demonstrated that the presentation of postpartum depression often includes higher rates of postpartum obsessions and compulsions (Wisner et al., 1999) or unwanted postpartum-specific intrusive thoughts (Abramowitz et al., 2003). While depressive symptoms have the most impact on maternal responsiveness, it is important to understand that postpartum-specific intrusive thoughts and OC symptoms often co-occur with postpartum depression and cause significant distress. Future research should continue to explore the relation between depressive symptoms, postpartum-specific intrusive thoughts, and OC symptoms to understand all facets of depression across the postpartum period.

4.1. Clinical implications

The presence of OC symptoms, intrusive thoughts, and neutralizing strategies is an important clinical target for both new mothers and mental health providers. About one out of three mothers were experiencing clinically significant levels of OC symptoms, intrusive thoughts or neutralizing strategies, demonstrating how ubiquitous this is in the very early postpartum. Further, depression, OC symptoms, and severity of intrusive thoughts or neutralizing strategies were strongly associated, consistent with the literature (Abramowitz, Storch, Keeley, & Cordell, 2007).

Mental health providers need to be aware that intrusive thoughts are common in the postpartum period and that it is important to normalize intrusive thoughts in all postpartum patients. Routinely screening for postpartum depression is highly recommended and an increasingly common occurrence (Earls & Committee on Psychosocial Aspects of Child and Family Health, American Academy of Pediatrics, 2010; O’Connor, Rossom, Henninger, Groom, & Burda, 2016; Puryear, Nong, Correa, Cox, & Greeley, 2019). Due to the strong overlap, it may be ideal to also assess for OC symptoms/severe intrusive thoughts when assessing perinatal depressive symptoms. OC and depressive symptoms often complicate the course of each other (Miller, Hoxha, Wisner, & Gossett, 2015) and targeting both during the perinatal time period with behavioral interventions such as Cognitive Behavioral Therapy (Hofmann et al., 2012) could greatly reduce suffering. Also, it is likely that a postpartum woman has not openly shared her intrusive thoughts because of shame and guilt about obsessive thoughts (Hennig-Fast et al., 2015). If a woman is experiencing OC symptoms or significant distress surrounding her intrusive thoughts, especially neutralizing strategies, empirically-supported treatments such as Exposure and Response Prevention (ERP; Abramowitz, 1997) are effective in reducing symptoms.

4.2. Strengths & limitations

This study had several strengths. It had a sizable sample and participants were recruited immediately after delivery, allowing for the capture of psychopathology symptoms from the beginning of the postpartum period. Further, this study is one of few to report on the prevalence of intrusive thoughts in the postpartum, a common but stigmatized phenomenon that needs more research. Additionally, this study examined how severity of postpartum-specific intrusive thoughts, in addition to classic OC symptoms, might affect maternal outcomes. There is a lack of information on OC symptomology and more severe postpartum-specific intrusive thoughts affect and this study is an important step.

There were also some limitations to this study. First, there was attrition across time points, resulting in smaller sample sizes. Secondly, this was a homogenous sample composed mostly of married, white women with high levels of education. It is unclear how much these findings generalize to other populations. More research needs to be conducted on postpartum OC symptoms in samples of underserved women (i.e. low-income, urban women of color) that often experience higher prevalence of perinatal psychiatric symptoms (Seng, Kohn-Wood, McPherson, & Sperlich, 2011). Moreover, data was not collected on participants’ current stress level, social support, quality of relationship with partner, or if they were currently receiving mental health care, which are all factors that could contribute to the exacerbation or reduction of their internalizing symptoms. Another limitation is that this study did not evaluate infant characteristics. Infant temperament has the potential to interact with maternal psychopathology (Sacchi et al., 2018), yet was not examined in this sample. The relation between infant characteristics and severity of distress associated with postpartum intrusive thoughts has yet to be studied and would be an important area for future research.

Lastly, all data was self-report and did not include direct observation of maternal-infant dyad behavior. Participants may have endorsed more socially desirable answers, such as fewer intrusive thoughts (especially sexual or aggressive thoughts) for several reasons. There is a strong societal stigma associated with women who harm their children, so much so that some individuals may fear that endorsing intrusive thoughts could lead to removal of children from the home (Porter & Gavin, 2010). Women may feel significant shame endorsing these intrusive thoughts, feeling that it reflects poorly on them and their parenting skills, and subsequently underreport their symptoms (Collardeau et al., 2018). Future research needs to continue to normalize postpartum intrusive thoughts while also collecting clinical assessments of depressive, anxiety, and OC symptoms according to DSM-5 criteria in order to obtain the most accurate data. Ideally, a mixed methods study should be conducted that collects clinical assessments on maternal depressive symptoms, OC symptoms, and feelings about parenting, paired with observational data on maternal responsiveness and general care of their infants to provide the most comprehensive understanding of maternal psychopathology and maternal responsiveness.

4.3. Conclusions

Although depressive symptoms appear to be the strongest driver of poor maternal responsiveness, intrusive thoughts are common for postpartum mothers. A considerable number of women are experience intrusive thoughts at a high level and use neutralizing strategies that diminish their responsiveness to their infant. Postpartum intrusive thoughts, neutralizing strategies, and OC symptoms should continue to be a target for clinical research, especially in the context of postpartum depression, to better understand how maternal and child outcomes may be affected.

Funding:

Research reported in this publication was supported by the National Center For Advancing Translational Sciences of the National Institutes of Health under Award Number U54TR001356. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

Disclosure of Interest: The authors report no conflict of interest.

References:

  1. Abramowitz JS (1997). Effectiveness of psychological and pharmacological treatments for obsessive-compulsive disorder: A quantitative review. Journal of Consulting and Clinical Psychology, 65(1), 44–52. [DOI] [PubMed] [Google Scholar]
  2. Abramowitz JS, Schwartz SA, & Moore KM (2003). Obsessional thoughts in postpartum females and their partners: Content, severity and relationship with depression. Journal of Clinical Psychology in Medical Settings, 10, 157–164. [Google Scholar]
  3. Abramowitz JS, Storch EA, Keeley M, & Cordell E (2007). Obsessive-compulsive disorder with comorbid major depression: what is the role of cognitive factors?. Behaviour Research and Therapy, 45(10), 2257–2267. [DOI] [PubMed] [Google Scholar]
  4. Abramowitz JS, Schwartz SA, Moore KM, & Luenzmann KR (2003). Obsessive-compulsive symptoms in pregnancy and the puerperium: A review of the literature. Journal of Anxiety Disorders, 17(4), 461–478. [DOI] [PubMed] [Google Scholar]
  5. Abramowitz JS, Khandker M, Nelson CA, Deacon BJ, & Rygwall R (2006). The role of cognitive factors in the pathogenesis of obsessive-compulsive symptoms: A prospective study. Behaviour Research and Therapy, 44(9), 1361–1374. [DOI] [PubMed] [Google Scholar]
  6. Abramowitz JS & Fairbrother N (2008). Postpartum obsessive-compulsive disorder In Abramowitz JS, McKay D, & Taylor S (Eds.), Clinical handbook of obsessive-compulsive disorder and related problems (139–155). Baltimore, MD, US: Johns Hopkins University Press. [Google Scholar]
  7. Abramowitz JS, Meltzer-Brody S, Leserman J, Killenberg S, Rinaldi K, Mahaffey BL & Pedersen C (2010). Obsessional thoughts and compulsive behaviors in a sample of women with postpartum mood symptoms. Archives of Women’s Mental Health, 13, 523–530. [DOI] [PubMed] [Google Scholar]
  8. Amankwaa LC, Younger J, Best A, & Pickler R (2002). Psychometric properties of the MIRI. Unpublished manuscript.
  9. Amankwaa LC, Pickler RH, & Boonmee J (2007). Maternal responsiveness in mothers of preterm infants. Newborn and Infant Nursing Reviews, 7(1), 25–30. [Google Scholar]
  10. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. [Google Scholar]
  11. Arnold LM (1999). A case series of women with postpartum-onset obsessive-compulsive disorder. Primary Care Companion, Journal of Clinical Psychiatry, 1(4), 103–108. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Barrett R, Wroe AL, & Challacombe FL (2016). Context is everything: an investigation of responsibility beliefs and interpretations and the relationship with obsessive-compulsive symptomatology across the perinatal period. Behavioural and cognitive psychotherapy, 44(3), 318–330. [DOI] [PubMed] [Google Scholar]
  13. Bauer A, Knapp M, & Parsonage M (2016).Lifetime costs of perinatal anxiety and depression. Journal of Affective Disorders, 192, 83–90. [DOI] [PubMed] [Google Scholar]
  14. Beckwith L, & Cohen SE (1989). Maternal responsiveness with preterm infants and later competency In Bornstein M (Ed.), Maternal responsiveness: Characteristics and consequences. (p. 75–87). San Francisco: Jossey-Bass Inc. [DOI] [PubMed] [Google Scholar]
  15. Bigelow AE, Maclean K, Proctor J, Myatt T, Gillis R, & Power M (2010). Maternal sensitivity throughout infancy: Continuity and relation to attachment security. Infant Behavior and Development, 33, 50–60. [DOI] [PubMed] [Google Scholar]
  16. Bornstein MH, & Tamis-LeMonda CS (1989). Maternal responsiveness and cognitive development In Bornstein MH (Ed.), Maternal responsiveness: Characteristics and consequences. (p. 49–61). San Francisco: Jossey-Bass Inc. [DOI] [PubMed] [Google Scholar]
  17. Brockington IF, Oates J, George S, Turner D, Vostanis P, Sullivan M, … & Murdoch C (2001). A screening questionnaire for mother-infant bonding disorders. Archives of Women’s Mental Health, 3(4), 133–140. [Google Scholar]
  18. Carlson EA, Sroufe LA, & Egeland B (2004). The construction of experience: A longitudinal study of representation and behavior. Child Development, 75, 66–83. [DOI] [PubMed] [Google Scholar]
  19. Centers for Disease Control (2009) Pregnancy Risk Assessment Monitoring System (PRAMS): Questionnaire. Phase 6 core questions. Available at http://www.cdc.gov/PRAMS/Questionnaire.htm.
  20. Challacombe FL, Salkovskis PM, Woolgar M, Wilkinson EL, Read J, & Acheson R (2016). Parenting and mother-infant interactions in the context of maternal postpartum obsessive-compulsive disorder: Effects of obsessional symptoms and mood. Infant Behavior and Development, 44, 11–20. [DOI] [PubMed] [Google Scholar]
  21. Collardeau F, Corbyn B, Abramowitz J, Janssen PA, Woody S, & Fairbrother N (2019). Maternal unwanted and intrusive thoughts of infant-related harm, obsessive-compulsive disorder and depression in the perinatal period: study protocol. BMC Psychiatry, 19(1), 94. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Dietz P, Bombard J, Mulready-Ward C, Gauthier J, Sackoff J, Brozicevic P, … & Taylor A (2014). Validation of self-reported maternal and infant health indicators in the Pregnancy Risk Assessment Monitoring System. Maternal and Child Health Journal, 18(10), 2489–2498. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Drake E, Humenick S, Amankwaa L, Younger J & Roux G (2007). Predictors of Maternal Responsiveness. Journal of Nursing Scholarship, 39(2), 119–125. [DOI] [PubMed] [Google Scholar]
  24. Dykas MJ, & Cassidy J (2011). Attachment and the processing of social information across the life span: Theory and evidence. Psychological Bulletin, 137, 19–46. [DOI] [PubMed] [Google Scholar]
  25. Earls MF, & Committee on Psychosocial Aspects of Child and Family Health, American Academy of Pediatrics. (2010). Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics, 126(5), 1032–1039. [DOI] [PubMed] [Google Scholar]
  26. Fairbrother N, & Woody SR (2008). New mothers’ thoughts of harm related to the newborn. Archives of Women’s Mental Health, 11(3), 221–229. [DOI] [PubMed] [Google Scholar]
  27. Fairbrother N, Janssen P, Antony MM, Tucker E, & Young AH (2016). Perinatal anxiety disorder prevalence and incidence. Journal of Affective Disorders, 200, 148–155. [DOI] [PubMed] [Google Scholar]
  28. Field T (2010). Postpartum depression effects on early interactions, parenting, and safety practices: A review. Infant Behavior and Development, 33, 1–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Fairbrother N, Thordarson DS, Challacombe FL, & Sakaluk JK (2018). Correlates and predictors of new mothers’ responses to postpartum thoughts of accidental and intentional harm and obsessive compulsive symptoms. Behavioural and Cognitive Psychotherapy, 46(4), 437–453. [DOI] [PubMed] [Google Scholar]
  30. Frías Á, Palma C, Barón F, Varela P, Álvarez A, & Salvador A (2015). Obsessive-compulsive disorder in the perinatal period: Epidemiology, phenomenology, pathogenesis, and treatment. Anales De Psicología/Annals of Psychology, 31(1), 1–7. [Google Scholar]
  31. Gavin NI, Gaynes BN, Lohr KN, Meltzer-Brody S, Gartlehner G, & Swinson T (2005). Perinatal depression: a systematic review of prevalence and incidence. Obstetrics & Gynecology, 106(5), 1071–1083. [DOI] [PubMed] [Google Scholar]
  32. Ginsburg GS, Grover RL, Cord JJ, & Ialongo N (2006). Observational measures of parenting in anxious and nonanxious mothers: Does type of task matter? Journal of Clinical Child and Adolescent Psychology, 35, 323–328. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Goodman SH, Rouse MH, Connell AM, Broth MR, Hall CM, & Heyward D (2011). Maternal depression and child psychopathology: A meta-analytic review. Clinical Child and Family Psychology Review, 14(1), 1–27. [DOI] [PubMed] [Google Scholar]
  34. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, & Conde JG (2009). Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42(2), 377–381. [DOI] [PMC free article] [PubMed] [Google Scholar]
  35. Hennig-Fast K, Michl P, Müller J, Niedermeier N, Coates U, Müller N, … & Meindl T(2015). Obsessive-compulsive disorder-A question of conscience? An fMRI study of behavioural and neurofunctional correlates of shame and guilt. Journal of Psychiatric Research, 68, 354–362. [DOI] [PubMed] [Google Scholar]
  36. Hofmann SG, Asnaani A, Vonk IJ, Sawyer AT, & Fang A (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36(5), 427–440. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Jairaj C, Fitzsimons CM, McAuliffe FM, O’Leary N, Joyce N, McCarthy A, … O’Keane V (2018). A population survey of prevalence rates of antenatal depression in the Irish obstetric services using the Edinburgh postnatal depression scale (EPDS). Archives of Women’s Mental Health. Advance online publication. [DOI] [PubMed] [Google Scholar]
  38. Kim-Cohen J, Moffitt TE, Taylor A, Pawlby SJ, & Caspi A (2005). Maternal depression and children’s antisocial behavior: Nature and nurture effects. Archives of General Psychiatry, 62(2), 173–181. [DOI] [PubMed] [Google Scholar]
  39. Kitamura T, Yoshida K, Okano T, Kinoshita K, Hayashi M, Toyoda N, Ito M, Kudo N, Tada K, Kanazawa K, Sakumoto K, Satoh S, Furukawa T, & Nakano H (2006). Multicentre prospective study of perinatal depression in Japan: incidence and correlates of antenatal and postnatal depression. Archives of Women’s Mental Health, 9(3), 121–130. [DOI] [PubMed] [Google Scholar]
  40. Kleiman K, & Wenzel A (2011). Dropping the baby and other scary thoughts: Breaking the cycle of unwanted thoughts in motherhood. Routledge. [Google Scholar]
  41. Kochanska G, Boldt LJ, & Goffin KC (2019). Early Relational Experience: A foundation for the unfolding dynamics of parent–child socialization. Child Development Perspectives, 13(1), 41–47. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Labad J, Alonso P, Segalas C, Real E, Jimenez S, Bueno B, Vallejo J, & Menchon JM (2010). Distinct correlates of hoarding and cleaning symptom dimensions in relation to onset of obsessive-compulsive disorder at menarche or the perinatal period. Archives of Women’s Mental Health, 13(1), 75–81. [DOI] [PubMed] [Google Scholar]
  43. Larsen KE, Schwartz SA, Whiteside SP, & Khandker M (2006). Thought control strategies used by parents reporting postpartum obsessions. Journal of Cognitive Psychotherapy, 20(4), 435–445. [Google Scholar]
  44. Maina G, Albert U, Bogetto F, Vaschetto P, & Ravizza L (1999). Recent life events and obsessive–compulsive disorder (OCD): The role of pregnancy/delivery. Psychiatry Research, 89(1), 49–58. [DOI] [PubMed] [Google Scholar]
  45. McMahon CA, & Bernier A (2017). Twenty years of research on parental mind-mindedness: Empirical findings, theoretical and methodological challenges, and new directions. Developmental Review, 46, 54–80. [Google Scholar]
  46. McElwain NL, & Booth-Laforce C (2006). Maternal sensitivity to infant distress and nondistress as predictors of infant–mother attachment security. Journal of Family Psychology,20, 247–255. [DOI] [PubMed] [Google Scholar]
  47. Milgrom J, Westley DT, & Gemmill AW (2004). The mediating role of maternal responsiveness in some longer term effects of postnatal depression on infant development. Infant Behavior and Development, 27(4), 443–454. [Google Scholar]
  48. Miller ES, Hoxha D, Wisner KL, & Gossett DR (2015). The impact of perinatal depression on the evolution of anxiety and obsessive-compulsive symptoms. Archives of Women’s Mental Health, 18(3), 457–461. [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Nicol-Harper R, Harvey AG, & Stein A (2007). Interactions between mothers and infants: Impact of maternal anxiety. Infant Behavior and Development, 30(1), 161–167. [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. O’Connor E, Rossom RC, Henninger M, Groom HC, & Burda BU (2016). Primary care screening for and treatment of depression in pregnant and postpartum women: Evidence report and systematic review for the US Preventive Services Task Force. JAMA, 315(4), 388–406 [DOI] [PubMed] [Google Scholar]
  51. O’Hara MW, & McCabe JE (2013). Postpartum depression: Current status and future directions. Annual Review of Clinical Psychology, 9, 379–407. [DOI] [PubMed] [Google Scholar]
  52. Puryear LJ, Nong YH, Correa NP, Cox K, & Greeley CS (2019). Outcomes of implementing routine screening and referrals for perinatal mood disorders in an integrated multi-site pediatric and obstetric setting. Maternal and Child Health Journal. Advance online publication. [DOI] [PubMed] [Google Scholar]
  53. Porter T, & Gavin H (2010). Infanticide and neonaticide: A review of 40 years of research literature on incidence and causes. Trauma, Violence, & Abuse, 11(3), 99–112. [DOI] [PubMed] [Google Scholar]
  54. Pridham KF, Becker P, & Brown R (2000). Effects of infant and caregiving conditions on an infant’s focused exploration of toys. Journal of Advanced Nursing, 31(6), 1439–1448. [DOI] [PubMed] [Google Scholar]
  55. Rachman S (1997). A cognitive theory of obsessions. Behaviour Research and Therapy, 35(9), 793–802. [DOI] [PubMed] [Google Scholar]
  56. Richter L (2004). The importance of caregiver-child interactions for the survival and healthy development of young children: A review. (Department of Child and Adolescent Health and Development, World Health Organization; ). [Google Scholar]
  57. Sacchi C, De Carli P, Vieno A, Piallini G, Zoia S, & Simonelli A (2018). Does infant negative emotionality moderate the effect of maternal depression on motor development?. Early Human Development, 119, 56–61. [DOI] [PubMed] [Google Scholar]
  58. Salkovskis PM (1985). Obsessional-compulsive problems: A cognitive-behavioural analysis. Behaviour Research and Therapy, 23(5), 571–583. [DOI] [PubMed] [Google Scholar]
  59. Seng JS, Kohn-Wood LP, McPherson MD, & Sperlich M (2011). Disparity in posttraumatic stress disorder diagnosis among African American pregnant women. Archives of Women’s Mental Health, 14(4), 295–306. [DOI] [PMC free article] [PubMed] [Google Scholar]
  60. Sichel DA, Cohen LS, Dimmock JA, & Rosenbaum JF (1993). Postpartum obsessive compulsive disorder: A case series. Journal of Clinical Psychiatry, 54, 156–159. [PubMed] [Google Scholar]
  61. Stein A, Craske MG, Lehtonen A, Harvey A, Savage-McGlynn E, Davies B, … & Counsell N (2012). Maternal cognitions and mother–infant interaction in postnatal depression and generalized anxiety disorder. Journal of Abnormal Psychology, 121(4), 795. [DOI] [PMC free article] [PubMed] [Google Scholar]
  62. Uguz F, Yakut E, Aydogan S, Bayman MG, & Gezginc K (2019). Prevalence of mood and anxiety disorders during pregnancy: A case-control study with a large sample size. Psychiatry Research, 272, 316–318. [DOI] [PubMed] [Google Scholar]
  63. Watson D, O’Hara MW, Simms LJ, Kotov R, Chmielewski M, McDade-Montez EA, … & Stuart S (2007). Development and validation of the Inventory of Depression and Anxiety Symptoms (IDAS). Psychological Assessment, 19(3), 253. [DOI] [PubMed] [Google Scholar]
  64. Watson D, O’Hara MW, Naragon-Gainey K, Koffel E, Chmielewski M, Kotov R, Stasik SM, & Ruggero CJ (2012). Development and Validation of New Anxiety and Bipolar Symptom Scales for an Expanded Version of the IDAS (the IDAS-II). Assessment, 19, 399–420. [DOI] [PubMed] [Google Scholar]
  65. Watson D, & O’Hara MW (2017). Understanding the Emotional Disorders: A Symptom-Level Approach Based on the IDAS-II. Oxford University Press. [Google Scholar]
  66. Weinberg MK, & Tronick EZ (1998). The impact of maternal psychiatric illness on infant development. The Journal of Clinical Psychiatry, 59(Suppl 2), 53–61. [PubMed] [Google Scholar]
  67. Wenzel A, Haugen EN, Jackson LC, & Brendle JR (2005). Anxiety symptoms and disorders at eight weeks postpartum. Journal of Anxiety Disorders, 19(3), 295–311. [DOI] [PubMed] [Google Scholar]
  68. Wisner KL, Peindl KS, Gigliotti T, & Hanusa BH (1999). Obsessions and compulsions in women with postpartum depression. The Journal of Clinical Psychiatry, 60(3), 176–180. [DOI] [PubMed] [Google Scholar]
  69. Wroe AL, Salkovskis PM, & Richards HC (2000). “Now I know it could happen, I have to prevent it”: A clinical study of the specificity of intrusive thoughts and the decision to prevent harm. Behavioural and Cognitive Psychotherapy, 28(1), 63–70. [Google Scholar]

RESOURCES