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Perinatal OCD Harm Thoughts Safety — MRCPsych Paper B MCQ

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HardAnxiety & Stress-Related DisordersPerinatal OCD Harm Thoughts SafetyMRCPsych Paper B

A 31-year-old primiparous woman is assessed 4 weeks after an uncomplicated delivery. For 10 days she has experienced recurrent images of pressing a pillow over her baby's face. She describes the images as abhorrent and frightening, has never wanted to harm the baby, and repeatedly asks her partner for reassurance that she is not dangerous. She avoids settling the baby alone because this triggers the images. She denies any intention or plan to cause harm. There are no hallucinations, delusions, thought interference, severe depressive symptoms or substance misuse. She recognises that the images may be symptoms of an illness, and her observed care of the baby is warm and appropriate. Which is the most accurate risk formulation?

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Correct answer: A — The obsessions do not themselves confer increased risk of acting; additional risk factors should be assessed separately.

These are ego-dystonic harm obsessions characteristic of perinatal OCD: they are unwanted, abhorrent, resisted, associated with reassurance-seeking and avoidance, and accompanied by preserved insight. Such obsessions do not in themselves increase the likelihood of deliberate infant harm. A full individualised assessment remains necessary to identify separate risks such as intent, planning, psychosis, severe depression, substance misuse or impaired caregiving. Violent thought content alone therefore does not justify continuous supervision, automatic safeguarding referral or mother–baby separation. Postpartum psychosis would be suggested by features such as delusions, hallucinations, severe mood disturbance, disorganisation or impaired reality testing, none of which is present here.

Reference: Royal College of Psychiatrists. Perinatal OCD, sections 'Obsessions', 'Recognising Perinatal OCD' and 'Postpartum Psychosis'. 2021. https://www.rcpsych.ac.uk/mental-health/mental-illnesses-and-mental-health-problems/perinatal-ocd