Hi everyone

Apologies for the radio (web) silence for some time. I took a little break from the online realm to focus on the real world – both professionally and personally, but you were never far from my mind I can assure you. I hope you are all well and enjoying 2019 so far.

I wanted to bring our focus and attention to a topic very close to my heart – the condition that is Obsessive Compulsive Disorder (OCD) and particularly OCD that presents in the perinatal period, often described as “Perinatal OCD” or “Maternal OCD”

Some of you may know that I have done some work and research on Maternal OCD – I founded the (hashtag) OCDBFING movement on Twitter and collaborated with charities Maternal OCD and OCD Action in doing a live twitter Q&A a few years ago. I am also work voluntarily as a scientific advisor for the Maternal OCD charity, and my specialism looks at diagnosing and treating OCD in the perinatal period, particularly looking at the effects of medication use in pregnancy and breastfeeding (something I know is a worry for many).

A question I get often about Maternal OCD, and OCD in general, is that isn’t it “normal” to be “a bit OCD anyway” ?

Its something we hear often people speak of in jest – though for me I find it personally as offensive as when people refer to (- minimise – ) individuals suffering with mental illness as “nuts, crackers, mad, or crazy” – words that are neither accurate nor helpful. OCD isn’t just about cleaning or liking a tidy decluttered home that “sparks joy” (don’t we all…)

Obsessive Compulsive Disorder falls under the umbrella of anxiety spectrum disorder; it is cousins with other conditions such as panic attacks, phobias, and health anxiety. It can be quite difficult to diagnose, particularly in the perinatal period – a time in a womans life where she faces the most change she is likely to ever encounter  (biological, emotional and relational). Should a woman present to health services seeking help (often something very difficult to do) it is often confused with post natal anxiety, depression, or even Psychosis in extreme cases. It is characterised by two phases, an “Obsessional phase” – thoughts, fears or beliefs that increase ones anxiety, followed by a “Compulsive phase” routines, rituals, or behaviours with the aim to reduce the feelings of anxiety – even (and commonly) temporarily.

In the perinatal period – we are faced with a different challenge. At the end of the pregnancy,  there is a new beginning – a tiny new life one is now responsible for 24 hours of the day, 7 days a week (and these intesne, almost obsessive feelings of care and responsibility doesn’t magically “disappear” when they leave home later in life).

With the influx of oxytocin (the “falling in love” hormone) as well as other biological changes in the blood and brain, mothers will often develop this “maternal instinct” – this feeling of the need to protect their child at all costs. This is why I tell my mothers in clinic that a “little bit of maternal anxiety is normal and natural” – it would be strange for a mother to not care about their childs safety – whether it be ensuring the hot cup of tea is a safe distance away from the table edge, or making sure the car seat is clicked in securely before a road trip.

So, if this protective “mama bear” instinct is normal and natural, where does OCD – a condition rooted in anxiety (often presenting in clinical practice as fear of harm occurring to the child) fit ?

From our clinical experience, the important factor is to consider how much these worries (natural or otherwise) are affecting your quality of life, your relationship with your child, your family and wider social circle. There is a massive difference in someone whom is worried about their child catching the seasonal cough of cold in the playground, to someone that will avoid interactions with others at all costs – housebound with their child as a result, afraid to send their child to school all term or have anyone (even their partner) hold their child without disinfecting themselves head to toe. It also may start to interfere with the mothers own well being – from the way she thinks about herself, to her mood and her sleep (which is often disturbed by “googling online until the early hours of the morning”…)

Often, with Perinatal OCD – no amount of “cleaning” or “checking” or “avoiding” the fear will make it go away – in fact, it serves the opposite purpose by reinforcing the inner fear, which will grow and require constant thought and attention – thus becoming an “obsessive rumination”.

Maternal OCD can present in a number of ways, from obsessive thoughts about fear of illness, harm or contamination (cue constant disinfecting of babys bottles and laundry on loop) to other examples of constant obsessive worrying (for example unwanted sexual thoughts – particularly problematic in breastfeeding). Uniquely, women may often experience disturbing visual images along with the anxious thoughts, sometimes numerous times a day – something which does not present typically postnatal depression.

Often partners and family members (and even professionals) can get caught in the vicious cycle of reassurance  – they may be asked to check/double and triple check that everything is “safe” – whether it be the doors are locked, the hob is turned off, or constantly stating that they are not a “Terrible mother”.  The important thing to realise is that however horrific the thoughts are – OCD is egodystonic – aka the thoughts are “alien to them” they are aknowledged as conflicting, incorrect, illogical, repulsive and distressing to the mothers sense of self or beliefs system, and there is no actual real harm or intent of harm o the child, ever.

So what happens next? firstly – if any of this is ringing any bells (for you or someone else you might know) please do not hesitate to ask for help. Speak to your GP,  midwife or health visitor and ask for a referral to your local Perinatal Mental Health specialist, because of all the conditions we come across – Perinatal OCD is one of the most treatable conditions once it is correctly diagnosed. Treatment comes in all shapes and sizes, often utilising talking therapy combined with “practical” therapy of putting those fears to the test (in baby steps). In some cases, medication can also be extremely helpful – and it is important to note that the medication needed to treat OCD is often at a higher dosage to that prescribed in postnatal depression and anxiety (thus I have seen many women on medication stuck “half cured”).

If you want to learn more about this condition – including some phenomenal success stories spoken by the mothers whom have been through it all and come out the other side stronger than ever – please check out the Maternal OCD charity website http://www.maternalocd.org

I also did a podcast with Maternal OCD summarising Perinatal OCD and the use of medication specifically in breastfeeding – which is still available online via the website or on youtube here.

[Side note: Podcasts have become my new favourite thing – and actually (spoiler alert) I’m planning on adding a few more here on the blog, so please let me know if this is something you are interested in and if so what you would like me to discuss!]

with love

Dr Chrissy Jayarajah

Hitchcock and the shell of a blonde bomb 

“Marnie” 1964 Alfred Hitchcock film psychoanalysis 

As a devoted Hitchcock fan, I was somewhat stunned into submission at the cognitive plot of Marnie; a “suspenseful sex mystery” (their words, not mine) released in 1964, starring Tippi Hendren and Sean Connery. It is a slow film in amidst the fast pace of the space race, civil rights, James Bond and birth control (not necessarily in that order…). Ms Hendren plays Margot “Marnie” Edgar, her follow-up to her silver screen debut with Hitchcock’s’ hit “The Birds” the year prior. The plot is unusual from the start – a wealthy handsome man Mark Rutland (Connery) falls in love and/or blackmail a young blonde with a bad habit and equally bad relationship with her mother. Against all the odds, and the painful truths she slowly reveals, he continues to stay with her and support her overcome her psychological difficulties.

I have found myself thinking of Marnie quite a bit since watching the film. She is a beautiful woman whom finds herself in a double bind of recoiling from the touch of man, but seeking her thrills elsewhere in the form of thievery and deception. She, and we, understand that what she is doing is wrong, but for some reason never comes across as the “villain” – you feel sorry for her, and you sense that there is something about her past which may explain her present behaviours. In many respects, she is lost, so lost in fact we do not question the motive of the security that Connery is willing to provide (though maybe we should).

What I find fascinating about Marnie, via the watchful eyes of Hitchcock, is that visually she is the epitome of the “blonde bombshell” he became known for casting with her ice cold allure and stunning mystique. However, her physical appearance is merely a façade, a hard “shell” like that in which a bomb is encased, ready to be detonated when the right (or wrong) buttons are pushed –as we glimpse in her moments of “Red haze” and graphically in the final scenes. Like for so many women even in our comparatively progressive times – the almost obsessive importance placed on beauty and outward appearance is paramount. Her immaculate sixties bouffant and mod tailoring with matching gloves provides ample distraction and gives the impression of a woman whom is “put together”, even though we all know she is falling apart, scene by scene. As in Hitchcock’s masterpiece “Vertigo”, the storyline dances around the male gaze of the female specimen, or as Marnie describes herself being “his possession in marriage”. Even in my clinical practice this is something I see women doing so very often; make up becomes the “war paint” and protective barrier against the attack of the outer (or inner) world. Sex, drugs and technology provides distraction and is “safer” than raw vulnerability and connection, with ourselves let alone with others.

As a Psychiatrist working predominantly with women, many of whom are vulnerable and going through the biggest emotional transition of them all (motherhood), I was struck by Tippi Hendrens’ performance and her incredible depiction of an “emotionally unstable woman”, a phrase I am aware has negative connotation in our society which shames one being in touch with ones feelings. An emotional unstable woman is seen to be as weak, unreliable, and unprofessional – and at extreme even a disorder, yet, many (as Mr Rutland) can find their impulsiveness and sense of danger equally exciting to be around. Despite all her flaws and learned helplessness, Marnie has a unique strength of character to weather all the storms that she faces, even though, like a little girl, she is afraid of thunder and lightning. This complex strength in feminine fragility in the shadow of domineering men is seen in other works of Hitchcock, most noticeably Rebecca.

Her raw emotion when her repressed memories came to surface is uncomfortable to watch, yet feels somewhat cathartic for both the viewer and the one being viewed. The now coined “rape scene” in which Sean Connery states firmly that he does want “to go to bed”, and, apologetically, yet non consensually undresses her as she lies motionless like a porcelain doll is disturbing to say the least. It is especially haunting in the wake of the hashtag “me too” movement and revelations of historical sexual harassment in Hollywood, and in the knowledge about the difficult off-screen relationship Hendren had with Hitchcock which climaxed in her refusing to work with him ever again. It undoubtedly weaves an unspoken tension throughout the whole film, but, sadly, there is no doubt it adds something to the realness of the on-screen performance. The overall plot of the movie arguably (and worryingly) even follows that of the stages of imitate relationship abuse; the period of tension building, the acting out period, the honeymoon period (in this case, quite literally), and the calm period *. We find ourselves believing in the closing credits that Sean Connery has “saved her”; the rape scene is forgotten and we imagine they live happily ever after she has some urgent psychotherapy.

We come to understand that our protagonist Marnie is a victim; and the power dynamics within her life (with her mother, with the nameless childhood stranger, with her career and her new husband) define her – she is powerless and childlike; even stealing all the money in the vault & changing her identity in every town does not provide the escape she craves. It is at the point where she truly regresses into a child like state, where she is freed (at least we hope, we never actually find out), of the demonic trappings of her childhood trauma.

There are moments in the movie that are flat, and moments that are so melodic and characteristically Hitchcock it makes my spine tingle (the heel dangling from her pocket might be one of my favourite examples of classic Hitchcock movie suspense), and more recognition in my opinion should be given to Bernard Herrmann, the mastermind behind the score of many of Alfred Hitchcock movies which sets the mood spectacularly.

I am still surprised that this was released in the cinema and would be a film you would go to see with friends or on a date. Many have slated Hitchcock and his use of “pop psychology” in his films and obvious interest in the works of Freud (most noticeably in Psycho and Spellbound, the latter possibly my favourite Hitchcock film) however Hitchcock continues to shock and awe, not with the use of special effects or computer technology but with the use of lights, camera and “action” (aka. the understanding of the human psyche – the most exciting prop of all). There are many obvious references to psychoanalysis, such as the defence mechanisms of dissociation, repression and regression; but also the more subtle references – for example the keys to the vault as a visual representation of her mind – and the anguish in her face when she has the keys in her hand and stacks of money within her reach yet there is a psycho-somatic “block” and ironic pending danger that is preventing her delving deeper into the (literal) “safe” – her unconscious (id).

The Golden Era of Hollywood in the 1950s and 60s mirrored that of Psychiatry, with the field exploding in various degrees, from the sharp development of psychotropic medications and psychoanalytical theory allowing a shift from institutionalism to the novel concept of having “outpatients”. Psychiatry, however, as all fields of medicine, remained caged within its paternalistic and misogynistic paradigm. Hitchcock was acutely aware of these prevailing mid-century cultural tensions and introduced the concept into his films with equal measures of humour and honesty, the quote below from “Marnie” illustrates this beautifully;

Mark Rutland: What you do need, I suspect, is a Psychiatrist.

Marnie Edgar: Oh, men! You say “no thanks” to one of them and BINGO! You’re a candidate for the funny farm.

Marnie is a film ahead of its time that also stands the test of time. Despite its mid 20^th century modern lightness and analytical heaviness, it’s a film that continues to resonate generation after generation. It is a study of the female sexuality, the pain and manifestations of unspoken trauma, and complexity of intimate relationships and abuser-victim dynamic that defies all logic. I don’t think this film could be recreated even if you tried; much like Marnies’ memories it feels trapped in a time, and something we can watch (and watch again) from a distance without ever truly understanding it. It is a truly unique film – and the beauty of cinema is that it is an art form that can open the door to discussions and difficult conversations. Marnie is a wonderful example of how a popular culture film can be entertaining on the surface, and/or used to debunk the myths and mystery surrounding psychiatry to create a dialogue about mental health, trauma and sexuality, should you wish to go deeper.