Intrusive thoughts - Information for health professionals

What are intrusive thoughts?

Intrusive thoughts and/or images are key features of depression, anxiety, and obsessive-compulsive disorder (OCD), however they are also common in the general population, particularly in the postnatal period.  

Intrusive thoughts contain unwanted negative thoughts and images that frequently intrude over the top of other thoughts or activities and are difficult to dismiss. Even if they are able to be dismissed, they recur, often in a ruminating way.

Information for frontline health professionals about intrusive thoughts

These types of intrusive thoughts and images occurring the perinatal context have largely been researched with women, however they can and do occur with men and non-birthing mothers as well. While not all people experiencing intrusive thoughts meet the criteria for OCD, many report their debilitating impact and frequent occurrence. Some research has suggested postnatal OCD is as common as PND and Postnatal anxiety conditions. 

Many of these types of thoughts and images are associated with great distress and shame because the content is often very different to how the individual actually thinks and feels.  

In the Perinatal context the content of these unwanted thoughts often pertain to harm related to the infant.  Sometimes they are more focused on what if something bad accidentally happens to the baby, but they can also be thoughts of hurting one’s baby on purpose, even though the thought of this is disturbing to them.  

The British Journal of general practitioners identified specific content of intrusive thoughts of intentionally harming one’s infant:

• Shaking the baby
• Hitting the baby too hard during winding
• Throwing the baby to the ground or against a wall
• Puncturing the infant’s fontanelle
• Drowning the baby in the bath
• Smothering the baby, for example, with a baby’s milk bottle or pillow
• Releasing the baby in a pram from the top of a hill/into traffic

In terms of assessing for these intrusive types of thoughts, this should be conducted by a GP and/or mental health professional. However, front line HP can effectively screen and develop a trusting relationship. It is important to firstly build a positive rapport so that the individual feels safe to discuss their confronting inner world.  

Features to assess or screen for intrusive thoughts

Below are some questions that can be useful to guide the conversation 

• Is the mother indifferent to the intrusive thoughts? 

• Is the mother emotionally unaffected by the thoughts? 

• Does the mother try to trigger the thoughts? 

• Does the mother decline help to manage the thoughts? 

• Does the mother intend to act out the thoughts? 

• Has the mother ever intentionally harmed her baby? 

Negative answers to these questions are entirely consistent with a very low risk of a mother deliberately harming her infant. Conversely, an affirmative answer to the first four points does not necessarily indicate that a mother will harm her infant. Rather, the overall clinical picture from answers to all of these questions is the more informative indicator. However, if the mother acknowledges intention to act out the thoughts or has a history of previously harming her baby, the risk needs to be taken seriously.  

The content of intrusions is important only so far as secondary risks might arise. For example, if a mother fears smothering the baby using the baby’s milk bottle, she might refuse to feed the baby.

Unlike in puerperal psychosis, intrusive thoughts of intentional harm to the infant are ego-dystonic. That is, they are experienced as unacceptable and inconsistent with a person’s sense of self.

Reference: Lawrence PJ, Craske MG, Kempton C, Stewart A, Stein A. Intrusive thoughts and images of intentional harm to infants in the context of maternal postnatal depression, anxiety, and OCD. Br J Gen Pract. 2017

Tips for health professionals

You can help by:

• Normalising and building understanding of these types of thoughts and images
• Spending time building rapport so you can ask questions that will help the individual feel more comfortable to share with you
• Knowing your referral pathways

What do therapists need to know about intrusive thoughts? 

Much of what we have covered for front line health professionals relates in the therapeutic space as well. However, as we are generally providing longer term support and more in-depth assessment and treatment there are further considerations. 

What should therapists provide?  

Remind your client good mothers DO think bad thoughts when they are struggling with depression and anxiety. 

Educate your client about anxiety and OCD and also normal thought patterns. 

Explore strategies to cope and disengage the thoughts. 

Encourage sharing and open communication with others. 

Consider referral and find appropriate treatment pathways.