• Dr. Nicole Amoyal Pensak

Even as a Psychologist, I Still Couldn’t See My Diagnosis of Postpartum OCD

Published in Moms Don’t Have Time to Write, Feb. 15, 2022

Effective ways to treat the real mommy wars happening inside your brain

I paced the floor of my baby’s bedroom, my brain on fire with various childrearing problems that I could not solve. What if I never slept again? Did my baby get enough during his last feed? Was I stimulating him enough? Most terrifying of all, who would take care of my baby if we all got COVID?


As I poured myself a second cup of coffee to try and catch up, my husband snapped me out of my troubled thoughts. “I need you,” he said. Eight days later, with a diagnosis of postpartum obsessive-compulsive disorder (OCD) and a course of medication and therapy, I began to feel better.


I didn’t see my diagnosis coming even though I’m a psychologist. It didn’t matter that I was trained at Harvard and Yale, nor was it relevant that I specialized in the exact thing I would be diagnosed with. None of it mattered because I had never been a mother. Motherhood came with a postpartum OCD that revealed itself after both of my children were born — and with a vengeance the second time. If it happened to me, with my experience and many resources, what would happen to women without the same advantages?


Although I was prepared for motherhood as an expert in self-care and mental health, I wondered what I could have done better. In hindsight, I’ve realized that all the books about the prenatal period had been focused on the baby, and all the books about the postnatal period are focused on parenting the baby. There’s little to guide the psychological health and wellbeing of the mother, even though the transition to motherhood is beset with precarious mental and physical changes.


Recent research suggests that mothers undergo a transformation of neuroplasticity — the brain’s ability to change and reorganize itself — after giving birth which is both physiologically induced and experience-dependent. The maternal human brain sustains a structural and cellular remodeling that is unlike any other discrete period in human development and continues to reorganize itself and evolve based on mothers’ experiences with the infant.


But many of these biological and hormone-driven “neuroplastic” changes that are beneficial to the baby can be simultaneously deleterious to the mother. Turns out, there is good reason for that. Pregnant women have decreased immune functioning to provide greater immune responses to their baby’s fetal development. Hormonal changes that promote healthy fetal development can lead to increased psychopathology for the mother. Inflammatory markers necessary to protect from infection are associated with a range of physical and psychological health conditions for mothers, including postpartum depression and anxiety, which are estimated to impact between ten and twenty percent of women.


Changes to new mothers regarding reward and motivation are more sensitive to responding to their own babies, heightened fear reactivity, and decreases in memory functioning (e.g., “mommy brain”). In fact, MRI studies confirm that some of these processes are correlated with a more adaptive attachment with the baby. Furthermore, the new mother’s brain is more vulnerable to neuronal stress in the postnatal period. Recent studies have even identified significant differences in telomere length in new mothers, suggesting that childbirth can age the mother up to eleven years. To sum it up, the same brain changes that evolve to make you a good mom can work against your own mental health.


Mothers must know that it is no longer a choice between what’s best for the baby and what’s best for them. The good news is that new mothers might also surf this tidal wave of neuroplasticity.


When I spoke to Helena Rutherford Ph.D., Director of the Before and After Baby Lab at Yale University School of Medicine, I asked her what she would want every new mother to know about their brain.


“When we speak about development, the conversation usually ends at adulthood. However, what we know now is that the transition to motherhood is prolific in terms of neural development. This transformation serves as an opportunity for intervention where we can leverage plasticity to improve maternal mental health care.”


Here are three ways we can work with the neuroplastic changes that are occurring in the maternal brain, instead of fighting against them.


1. Establish care with a mental health specialist for therapy and a psychiatrist for medication management before you give birth. You do not have to determine if your worry, distress, or other symptoms are a “normal” part of motherhood. The professionals can do that, so let them do their jobs. Therapy is like building new roads in your brain and letting old highways dissipate. I tell my patients to avoid the old roads that reinforce maladaptive thought patterns and work with them to create new roads. This is especially important during motherhood when so many new neural networks are being formed. One of the most important ways I help my patients create new roads is by highlighting cognitive dissonance — i.e. “I love my baby and I need to take a break. I want my baby to have the best nutrition and breastfeeding is sacrificing my mental health. I want to tend to my baby’s every need and I would like to go back to work.” In the maternal brain, there is room to add in the “and” statement pertaining to your own needs in conjunction with the concern for your baby. By practicing this simultaneously, and early on, you will force the new neural networks to form and can potentially direct neural plasticity to work in your favor.


2. Lean into pleasure. As a new mom, your entire reward system will change. Research suggests that breastfeeding can be more gratifying than cocaine on the maternal brain. Your new mom brain is also wired to wait for the other shoe to drop. Drop that habit. Self-directed neuroplasticity would say to increase that pleasure as much as you can. For example, as you are rocking your baby, smell your baby’s skin, feel the softness of your baby’s head on your chest, play soothing music, envision your baby growing into a healthy adult and completing life’s milestones. Then think about yourself as a mother and what type of mother you hope to be. Perhaps this involves healing your own mother wound. Think about what you are grateful for in this moment with your baby. As you think these thoughts about yourself and simultaneously engage your senses with your baby, new neurons will fire together, and wire together, strengthening that pleasure, and ultimately buffer against the stresses of motherhood. Let negative thoughts come and go, without judgment, as if they are just passing through and then redirect back to pleasure. Allow yourself to spoil yourself in the pleasure of the moment, your neurons will thank you.


3. Allow yourself to approach motherhood with curiosity, flexibility, and empathy. As you make mistakes, be compassionate with yourself. Be curious about how that could go differently next time. As you complete each new task, integrate it within yourself. For example, “Wow, I figured out how to soothe my baby. That’s great problem-solving.” That way, you are giving yourself credit and incorporating value for yourself into what you are doing. By tending to your own needs, you are putting a placeholder in for your baby to tend to their own needs as they grow older, which is the optimal way to facilitate your baby’s development.


Dr. Nicole Amoyal Pensak is a Clinical Psychologist and Owner of Atlantic Coast Mind & Body in Little Silver, New Jersey. She specializes in treating adults with postpartum anxiety and depression. She received her PhD in Clinical Psychology from the University of Rhode Island and completed her predoctoral internship at Yale School of Medicine. She completed postdoctoral fellowships in Behavioral Medicine and Palliative Care at Massachusetts General Hospital/ Harvard Medical School and University of Colorado Anschutz Medical Campus.


She is the former Director of Psycho-Oncology at Jersey Shore Medical Center and Assistant Professor in Oncology at Georgetown University School of Medicine. She also held positions as Assistant Scientist at Hackensack Meridian Hospital and University of Colorado Anschutz Medical Campus. She has published over 25 scientific articles in peer-reviewed journals, presented at over 30 national conferences, and is the recipient of 15 grants and awards recognizing her scholarly research.

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