Medicine, Faculty of
Obstetrics and Gynaecology, Department of
DSpace
UBCV
Stagg, Bryn
Master of Science - MSc
University of British Columbia
Background: Obsessive-compulsive disorder (OCD) is an anxiety-related mental health condition characterized by unwanted, intrusive thoughts (obsessions), and repetitive behaviours (compulsions). OCD is experienced by as many as 17% of postpartum gestational people, with obsessional content frequently involving distressing thoughts of harm related to oneâs newborn. OCD is associated with sleep disturbances in non-perinatal populations. Despite the common occurrence of poor perinatal sleep, there are no published studies of perinatal sleep predicting postpartum OC symptoms. The purpose of this research is to assess reduced perinatal sleep quality as a predictor of postpartum OCD. Methodology: This research utilizes data from a prospective cohort study of pregnant people in the province of British Columbia. Questionnaires and interviews were administered once during pregnancy (33 weeks) and twice postpartum (9 weeks and 20 weeks), and assessed sleep quality, symptoms, and diagnostic status of OCD. Linear regression and mixed-effects models explored the predictive ability of sleep on postpartum OC symptoms. Mann-Whitney U Tests were conducted to analyze differences in concurrent sleep quality based on OCD diagnosis and the experience of thoughts of intentional infant-related harm. Results: In final models, poor prenatal sleep quality remained a moderate predictor of more severe postpartum OC symptoms across regression (β = 0.12, 95% CI [0.03, 0.21], p =.01; β = 0.14, 95% CI [0.01, 0.27], p = .04) and mixed-effects models (β = 0.23, 95% CI [0.03, 0.43], p = .02). Birthing individuals meeting criteria for postpartum OCD experienced significantly poorer concurrent sleep quality at both postpartum timepoints (Z = -2.03, p = .04; Z = -2.09, p = .04), although only participants experiencing UITs of intentional harm in the later postpartum experienced worse concurrent sleep quality (Z = -4.21, p <.001). Discussion: Findings provide insight into the etiology and experience of postpartum OCD. Perinatal sleep quality should be monitored among all birthing people, especially those experiencing postpartum OCD and related symptoms, in order to alleviate unwanted symptoms and ensure the best postpartum experience.
THE ROLE OF POOR PERINATAL SLEEP QUALITY IN PREDICTING AND DESCRIBING POSTPARTUM OBSESSIVE-COMPULSIVE DISORDER by Bryn Stagg B.Sc., The University of Calgary, 2019 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Women+ and Childrenâs Health Sciences) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) October 2024 © Bryn Stagg, 2024 ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the thesis entitled: The role of poor perinatal sleep quality in predicting and describing postpartum obsessive-compulsive disorder submitted by Bryn Stagg in partial fulfilment of the requirements for the degree of Master of Science in Women+ and Childrenâs Health Sciences Examining Committee: Dr. Gillian Hanley, Associate Professor, Department of Obstetrics and Gynaecology, UBC Co-supervisor Dr. Nichole Fairbrother, Associate Professor, Department of Family Practice, UBC Co-supervisor Dr. Sheila Woody, Professor, Department of Psychology, UBC Additional Examiner Additional Supervisory Committee Members: Dr. Benicio Frey, Professor, Department of Psychiatry and Behavioural Neurosciences, McMaster University Supervisory Committee Member Dr. Lianne Tomfohr-Madsen, Associate Professor, Department of Educational and Counselling Psychology and Special Education, UBC Supervisory Committee Member iii Abstract Background: Obsessive-compulsive disorder (OCD) is an anxiety-related mental health condition characterized by unwanted, intrusive thoughts (obsessions), and repetitive behaviours (compulsions). OCD is experienced by as many as 17% of postpartum gestational people, with obsessional content frequently involving distressing thoughts of harm related to oneâs newborn. OCD is associated with sleep disturbances in non-perinatal populations. Despite the common occurrence of poor perinatal sleep, there are no published studies of perinatal sleep predicting postpartum OC symptoms. The purpose of this research is to assess reduced perinatal sleep quality as a predictor of postpartum OCD. Methodology: This research utilizes data from a prospective cohort study of pregnant people in the province of British Columbia. Questionnaires and interviews were administered once during pregnancy (33 weeks) and twice postpartum (9 weeks and 20 weeks), and assessed sleep quality, symptoms, and diagnostic status of OCD. Linear regression and mixed-effects models explored the predictive ability of sleep on postpartum OC symptoms. Mann-Whitney U Tests were conducted to analyze differences in concurrent sleep quality based on OCD diagnosis and the experience of thoughts of intentional infant-related harm. Results: In final models, poor prenatal sleep quality remained a moderate predictor of more severe postpartum OC symptoms across regression (β = 0.12, 95% CI [0.03, 0.21], p =.01; β = 0.14, 95% CI [0.01, 0.27], p = .04) and mixed-effects models (β = 0.23, 95% CI [0.03, 0.43], p = .02). Birthing individuals meeting criteria for postpartum OCD experienced significantly poorer concurrent sleep quality at both postpartum timepoints (Z = -2.03, p = .04; Z = -2.09, p = iv .04), although only participants experiencing UITs of intentional harm in the later postpartum experienced worse concurrent sleep quality (Z = -4.21, p <.001). Discussion: Findings provide insight into the etiology and experience of postpartum OCD. Perinatal sleep quality should be monitored among all birthing people, especially those experiencing postpartum OCD and related symptoms, in order to alleviate unwanted symptoms and ensure the best postpartum experience. v Lay Summary Obsessive-compulsive disorder (OCD) is an anxiety related condition that affects approximately 17% of people who have recently given birth. OCD is a distressing condition which can have a negative impact on pregnancy and birth, parenting, and family well-being. Poor sleep quality is common during pregnancy and the postpartum (perinatal period), and may impact mental health. This work aimed to evaluate the relationship between poor perinatal sleep quality and postpartum OCD. Perinatal people living in British Columbia completed a questionnaire and interview once during pregnancy, and twice in the postpartum. Reduced sleep quality during pregnancy modestly predicted more severe postpartum OCD. Parents suffering from postpartum OCD also experienced poorer postpartum sleep compared to those who were not experiencing OCD. This research adds to our understanding of postpartum OCD and provides insight into the common experience of poor sleep that occurs among parents who experience postpartum OCD. vi Preface This thesis is original work by myself, Bryn Stagg, under the supervision of Dr. Nichole Fairbrother. This thesis uses data collected from a previously completed prospective cohort study in which Dr. Nichole Fairbrother was the Principal Investigator. Study design, management, data collection and data cleaning were conducted by members of the study team. I generated the hypotheses, predictions, data analyses and interpretations of this work under the guidance of Dr. Fairbrother and my supervisory committee: Dr. Lianne Tomfohr-Madsen, Dr. Gillian Hanley, Dr. Benicio Frey. Additional consultation of data analysis was provided by Sabina Dobrer and Dr. Malcolm Fairbrother. A combination of chapter 1, chapter 2, chapter 3, and chapter 4 will be submitted for publication. Stagg, B., Fairbrother, N., Reduced perinatal sleep quality predicting postpartum OC symptom severity. Journal TBD. I conducted all the analyses and writing of the manuscript. Sabina Dobrer and Malcolm Fairbrother assisted with analysis. All co-authors will assist with revisions and approve the submitted manuscript. A combination of chapter 1 and chapter 2 and chapter 4 will be submitted for publication along with additional analyses. Fairbrother, N., Stagg, B., Title TBD. Journal TBD. I will assist with writing of the manuscript. Sabina Dobrer assisted with statistical analyses consultation. All co-authors will assist with revisions and approve the submitted manuscript. Ethics approval for the corresponding study was granted by the ethics boards of the University of British Columbia, the Vancouver Island Health Authority, the Vancouver Coastal Health, and the Fraser Health Authority (H11-03266). vii Table of Contents Abstract ......................................................................................................................................... iii Lay Summary .................................................................................................................................v Preface ........................................................................................................................................... vi Table of Contents ........................................................................................................................ vii List of Tables .............................................................................................................................. xiii List of Figures ...............................................................................................................................xv List of Abbreviations ................................................................................................................. xvi Acknowledgements ................................................................................................................... xvii Dedication ................................................................................................................................. xviii Chapter 1: Introduction ................................................................................................................1 1.1 Obsessive-Compulsive Disorder (OCD) ...................................................................... 3 1.1.1 Definition .................................................................................................................... 3 1.1.2 Prevalence ................................................................................................................... 3 1.1.3 Symptoms ................................................................................................................... 3 1.1.4 Assessment .................................................................................................................. 4 1.2 Perinatal OCD ............................................................................................................... 6 1.2.1 Overview of OCD in Pregnancy and the Postpartum ................................................. 6 1.2.2 Postpartum OCD ......................................................................................................... 6 1.2.2.1 Definition ............................................................................................................ 6 1.2.2.2 Prevalence ........................................................................................................... 6 1.2.2.3 Symptoms ........................................................................................................... 7 viii 1.2.2.4 Risk Factors ........................................................................................................ 8 1.2.2.5 Treatment of Postpartum OCD ........................................................................... 8 1.3 Unwanted, Intrusive Thoughts (UITs) ...................................................................... 10 1.3.1 Definition .................................................................................................................. 10 1.3.2 Prevalence ................................................................................................................. 10 1.3.3 UITs of Accidental and Intentional Infant-Related Harm ........................................ 11 1.3.4 UITs and Postpartum OCD ....................................................................................... 11 1.3.5 Cognitive Behavioural Conceptualization of Postpartum OCD ............................... 12 1.3.6 Postpartum OCD in Birthing and Non-Birthing Parents .......................................... 13 1.3.7 Impact of UITs and OCD in the Postpartum ............................................................ 14 1.4 Perinatal Sleep Quality .............................................................................................. 15 1.4.1 Prevanence of Poor Sleep Quality ............................................................................ 15 1.4.2 Associations of Poor Sleep ....................................................................................... 16 1.4.2.1 Sleep and Parental Functioning ........................................................................ 16 1.4.2.2 Sleep and Mental Health ................................................................................... 16 1.4.3 Sleep Interventions and Treatment ........................................................................... 17 1.4.4 Measuring Sleep Quality........................................................................................... 19 1.5 Sleep and OCD ............................................................................................................ 20 1.5.1 Sleep and OCD in Non-Perinatal Populations ......................................................... 20 1.5.2 Sleep and OCD in Perinatal Populations .................................................................. 20 1.6 Rationale ...................................................................................................................... 22 1.7 Research Questions ..................................................................................................... 23 1.8 Thesis Roadmap .......................................................................................................... 23 ix Chapter 2: Methods .....................................................................................................................25 2.1 Methods ........................................................................................................................ 25 2.1.1 Study Design ............................................................................................................. 25 2.1.2 Recruitment ............................................................................................................... 25 2.1.3 Participants ................................................................................................................ 26 2.1.4 Procedures ................................................................................................................. 26 2.2 Measures ...................................................................................................................... 28 2.2.1 Questionnaire Measures ............................................................................................ 28 2.2.1.1 PSQI .................................................................................................................. 28 2.2.1.2 DOCS ................................................................................................................ 32 2.2.2 Interview Measures ................................................................................................... 33 2.2.2.1 SCID-5 .............................................................................................................. 33 2.2.2.2 PPII ................................................................................................................... 33 2.3 Ethics ............................................................................................................................ 34 Chapter 3: Reduced perinatal sleep predicting postpartum OC symptoms ..........................36 3.1 Introduction ................................................................................................................. 36 3.2 Research Hypothesis and Predictions ....................................................................... 37 3.3 Study Methods Specific to this Chapter.................................................................... 37 3.4 Data Analysis ............................................................................................................... 38 3.4.1 Overview ................................................................................................................... 38 3.4.2 Missing Data ............................................................................................................. 38 3.4.3 Sample Characterstics ............................................................................................... 38 3.4.3.1 Sleep Quality ..................................................................................................... 38 x 3.4.3.2 OC Symptoms ................................................................................................... 39 3.4.4 Hypothesis Testing.................................................................................................... 39 3.5 Sample Characterstic Results .................................................................................... 40 3.5.1 Demographics ........................................................................................................... 40 3.5.2 Sleep Quality Characterstics ..................................................................................... 42 3.5.2.1 Total Sleep Quality Scores................................................................................ 42 3.5.2.2 Sleep Component Scores .................................................................................. 42 3.5.2.3 Sleep Quality Cut-Off Score ............................................................................. 44 3.5.3 OC Symptom Characterstics ..................................................................................... 45 3.4.3.1 OC Symptoms ................................................................................................... 45 3.4.3.2 OC Symptoms Cut-Off Score ........................................................................... 45 3.6 Linear Regression Modelling Analyses and Results ................................................ 45 3.6.1 Associations between Predictor and Outcome Variables ......................................... 46 3.6.2 Linear Regression Modelling Development ............................................................. 46 3.6.2.1 Identifcation and Selection of Covariates ......................................................... 47 3.6.2.2 Model Evaluation .............................................................................................. 47 3.6.3 Results of the Associations between Predictor and Outcome Variables .................. 48 3.6.4 Results of Linear Regression Modelling................................................................... 49 3.6.4.1 Identifcation and Selection of Covariates ......................................................... 49 3.6.4.2 Model Evaluation .............................................................................................. 52 3.7 Linear Mixed-Effects Modelling Analysis and Results ........................................... 56 3.7.1 Linear Mixed-Effects Modelling Development ........................................................ 56 3.7.2 Results of Linear Mixed-Effects Modelling ............................................................. 57 xi 3.8 Summary and Conclusion .......................................................................................... 60 Chapter 4: Exploring perinatal sleep among new parents expiencing postpartum OCD and harm thoughts .............................................................................................................................61 4.1 Introduction ................................................................................................................. 61 4.2 Reseach Hypotheses and Predictions ........................................................................ 62 4.3 Methods Specific to this Chapter............................................................................... 63 4.4 Data Analysis ............................................................................................................... 63 4.4.1 Overview ................................................................................................................... 63 4.4.2 Missing Data ............................................................................................................. 63 4.4.3 Outcome Variables.................................................................................................... 64 4.4.4 Exposure Variables ................................................................................................... 64 4.4.4.1 Hypothesis 2 - OCD Diagnostic Status ............................................................. 64 4.4.4.2 Hypothesis 3 - UITs of Intentional Harm ......................................................... 65 4.4.5 Specific Analyses ...................................................................................................... 65 4.4.5.1 Hypothesis 2 - OCD Diagnostic Status ............................................................. 65 4.4.5.2 Hypothesis 3 - UITs of Intentional Harm ......................................................... 66 4.5 Results .......................................................................................................................... 67 4.5.1 Sample Descriptives.................................................................................................. 67 4.5.2 Hypothesis 2 - OCD Diagnostic Status ..................................................................... 69 4.5.2.1 Hypothesis Testing............................................................................................ 69 4.5.2.2 Exploratory Analyses ........................................................................................ 71 4.5.3 Hypothesis 3 - UITs of Intentional Harm ................................................................. 72 4.5.3.1 Hypothesis Testing............................................................................................ 72 xii 4.5.3.2 Exploratory Analyses ........................................................................................ 73 4.6 Summary and Conclusion ......................................................................................... 74 Chapter 5: Conclusion ................................................................................................................76 5.1 Thesis Overview .......................................................................................................... 76 5.2 Study Findings ............................................................................................................. 76 5.2.1 Postpartum OC Symptoms ........................................................................................ 76 5.2.2 Perinatal Sleep across OCD Diagnostic Categories.................................................. 79 5.2.3 UITs of Intentional Harm.......................................................................................... 81 5.3 Contribution to the Literature ................................................................................... 82 5.4 Clinical Implications ................................................................................................... 85 5.5 Strengths ...................................................................................................................... 86 5.6 Limitations ................................................................................................................... 87 5.7 Future Research .......................................................................................................... 88 5.8 Conclusion ................................................................................................................... 90 References .....................................................................................................................................91 Appendices ..................................................................................................................................121 Appendix A ............................................................................................................................ 121 Appendix B ............................................................................................................................ 124 xiii List of Tables Table 1. PSQI Component Score Response Scale Meanings ....................................................... 31 Table 2. Demographic Information............................................................................................... 41 Table 3. Descriptive Statistics for Participant Sleep and OC Symptom Characterstics ............... 42 Table 4. Number of Participants with Clinically Significant Symptoms according to Measure Cut-Offs ........................................................................................................................................ 44 Table 5. Pearson Correlation between Perinatal Sleep Quality and OC Symptoms ..................... 48 Table 6. Clinically and Data-Driven Covariates Considered for Inclusion in Model of Perinatal Sleep Predicting Postpartum OC Symptoms ............................................................................... 51 Table 7. Linear Regression Results of Prenatal Sleep Predicting OC Symptoms in the Early Postpartum .................................................................................................................................... 53 Table 8. Final Linear Regression Model of OC Symptoms in the Early Posptartum ................... 53 Table 9. Linear Regression Results of Perinatal Sleep Predicting OC Symptoms in the Later Postpartum .................................................................................................................................... 55 Table 10. Final Linear Regression Model of OC Symptoms in the Later Posptartum ................. 55 Table 11. Fixed-Effect Estiamtes from Mixed-Effects Model: Results of Perinatal Sleep Predicting Postpartum OC Symptom Severity ............................................................................. 59 Table 12. Sample Demographics .................................................................................................. 68 Table 13. Descriptive Statistics for Study Outcome Variables..................................................... 69 Table 14. Mann-Whitney U Test Results of Differences in Concurrent Sleep Quality among Participants Experiencing Full or Sub-clinical OCD and Those Not ........................................... 70 xiv Table 15. Mann-Whitney U Test Exploratory Results of Sleep Component Differences among Birthing Parents Experiencing Full or Sub-clinical OCD and Those Not .................................... 71 Table 16. Mann-Whitney U Test Results of Differences in Concurrent Sleep Quality based on Reporting of UITs of Intentional Harm ........................................................................................ 72 Table 17. Mann-Whitney U Test Exploratory Results of Sleep Component Differences among New Birthing Parents Experiencing UITs of Intentional Infant-Related Harm and Those Not ... 74 xv List of Figures Figure 1. Overview of Study Timeline and Measures .................................................................. 28 Figure 2. Mean Sleep Component Scores Across All Perinatal Timepoints ................................ 43 Figure 3. Main Independent and Dependant Study Variables in Linear Mixed-Effects Model .. 57 xvi List of Abbreviations BC: British Columbia CI: Confidence Interval CB: : Cognitive Behavioural CBT: Cognitive Behavioural Therapy CBT-I: Cognitive Behavioural Therapy for Insomnia DOCS: Dimensional Obsessive-Compulsive Scale DSM-5: Diagnostic and Statistical Manual of Mental Disorders, fifth edition ERP: Exposure and Response Prevention M: Mean OC: Obsessive-Compulsive OCD: Obsessive-Compulsive Disorder PPII: Postpartum Intrusions Interview ppOCD: Postpartum Obsessive-Compulsive Disorder PSQI: Pittsburgh Sleep Quality Index SCID-5: Structured Clinical Interview for the DSM-5 SD: Standard Deviation UITs: Unwanted, Intrusive Thoughts VIF: Variance Inflation Factor xvii Acknowledgements This work is not complete without acknowledging my endless support systems that made this possible. I would like to thank my mentor and supervisor Nichole, for always pushing me and teaching me more about life and myself than I ever imagined possible in a Masters. The opportunities you have provided me during this time have guided my growth, not only in research and a career, but also in life and my future. Thank you to my âdream teamâ committee members, Dr. Gillian Hanley, Dr. Lianne Tomfohr-Madsen, Dr. Benicio Frey, and committee chair Dr. Lori Brotto whose experience, patience and guidance supported me through all aspects of this project. To my family and friends, new and old - thank you for being my constants, for your compassion, for sharing this experience with me, and for keeping me grounded through any and all geographical distances. I am forever grateful for every choice that led me to this program and allowed me meet the forever friends I did on this journey. To my brilliant, admirable sister and parents, thank you for sharing in all the ups and downs, for investing so much of you in me, for holding space in your hearts for me, and for always welcoming me home. Your drive and strength inspire me daily, and without your love and support I would not be where I am, or an ounce of who I am. And finally, though words will never be enough - to my partner Zenon, whose excitement and unwavering belief in me helps me to be brave. Your encouragement gave me the strength to not only follow this dream, but also continues to let me trust in all of them. Thank you for always being my light at the end of any tunnel. xviii Dedication This work is dedicated to the mothers and birthing parents who bravely shared their experiences with our research team, and to all new parents who have silently struggled with overwhelming, scary thoughts about their baby. May this work be one step closer to validating your experience, and creating a space where you do not have to be afraid of being heard.1 Chapter 1: Introduction While joyful and exciting, becoming a new parent is also extremely demanding and has been found to represent a risk factor for mental health difficulties, including obsessive-compulsive disorder (OCD) (Brandes et al., 2004; Fairbrother & Abramowitz, 2007). OCD is an anxiety-related condition characterized by two core symptoms: obsessions (persistent unwanted, intrusive, thoughts, images, and impulses) and compulsions (repeated behaviours) (American Psychiatric Association, 2022), and can cause significant distress and interference with daily functioning (Challacombe et al., 2016; Fairbrother & Woody, 2008). OCD is of particular significance for perinatal people (Fairbrother et al., 2021), as there is now strong evidence of an increased risk of onset, recurrence, and exacerbation during the perinatal period (i.e., pregnancy and postpartum) (Fairbrother & Abramowitz, 2007). Recent evidence indicates that OCD may be experienced by as many as 17% of postpartum people (Brandes et al., 2004; Fairbrother & Abramowitz, 2007; Fairbrother et al., 2021) - considerably higher than the 2% prevalence of OCD in general population samples (Russell et al., 2013). Unwanted intrusive thoughts, images, and impulses (UITs) of accidental harm coming to oneâs infant are reported by 100% of mothers while 50% of mothers report experiencing unwanted thoughts of intentionally harming their infant (Fairbrother et al., 2022). These UITs have the potential to develop into obsessions and lead to the development of OCD (Fairbrother et al., 2018) and are therefore fundamental to consider when studying postpartum OCD and related symptoms. It is not surprising that in perinatally occurring OCD, obsessions involving the infant, and in particular obsessions of harming oneâs infant, are also extremely common (Abramowitz et al., 2007; Brok et al., 2017; Fairbrother et al., 2022; McGuinness et al., 2011). 2 A well-known challenge for perinatal people is reduced sleep. New parents universally struggle to get enough sleep while caring for a newborn. Birthing people can also experience disordered sleep for various reasons (e.g., hormonal changes, bodily discomfort). While broad research on sleep and perinatal mental health conditions exists, very little published work has investigated the relationship between sleep and OCD specifically in birthing people (Fairbrother et al., 2018; Obeysekare et al., 2020; Osnes et al., 2020). This is despite the increased frequency of reduced sleep quality (Sedov et al., 2018; Yang et al., 2020) and sleep disorders (El-Sherbeeny et al., 2022; Moghadam et al., 2021) in this population, with over 54.2% of mothers reporting poor sleep (Yang et al., 2020). In non-perinatal samples, more severe OC symptoms have been associated with higher rates of insomnia and poor sleep quality (Cox & Olatunji, 2016; Timpano et al., 2014). Interestingly, reduced sleep quality in general populations has been positively associated with obsessions and UITs (Raines et al., 2015; Timpano et al., 2014). Improving our understanding of OCD, in particular the reasons for increased prevalence and incidence perinatally, is extremely important to ensure the health of the birthing person, their infant, and the family unit as whole. Given the ubiquity of UITs of infant-related harm among birthing people suffering from perinatal OCD in combination with the high prevalence of reduced sleep in the postpartum, research investigating sleep as predictors of postpartum OCD is important and has the potential to add significantly to our understanding of perinatally occurring OCD. The proposed work has the potential to lead to improved, targeted management and treatment of postpartum OCD in addition to improving etiology. 3 1.1 Obsessive-Compulsive Disorder 1.1.1 Definition Obsessive-compulsive disorder (OCD) is an anxiety-related condition under the disorder class of Obsessive-Compulsive and Related Disorders in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5). OCD is defined as presence of obsessions and/or compulsions (American Psychiatric Association, 2022). 1.1.2 Prevalence The best estimate of the prevalence of clinical OCD in adult populations comes from a comprehensive meta-analysis by Fawcett, Power, and Fawcett (2020). Authors reported a lifetime prevalence of 1.3% (Fawcett et al., 2020). Importantly, women are 1.6 times more likely to experience OCD and have a higher lifetime prevalence of 1.6% compared to 1.0% among men, representing a key demographic to focus intervention (Fawcett et al., 2020). 1.1.3 Symptoms Obsessions are repetitive, unwanted, intrusive thoughts, images or impulses that frequently cause anxiety or distress. Examples include worries of dirt, disease or germs, repetitive superstitious thoughts, or intrusive sexual urges or images. As a result of these sometimes alarming and distressing intrusions, guilt and shame are common accompanying symptoms of obsessions (Weingarden & Renshaw, 2015). Compulsions are behaviours or actions undertaken to suppress/neutralize distress or avoid an imagined consequence. These rituals are typically very repetitive, follow specific rules created by the individual, and are completed in response to obsessions. For example, repeated handwashing or cleaning of the body, or repeating a phrase or action. The repetitive nature of 4 both obsessions and compulsions are a key symptom that distinguishes OCD from other anxiety disorders (APA, 2022). Symptoms of OCD are heterogenous (Cervin et al., 2022) and thus have been categorized into structured categories for easier identification. Main categories commonly used in education, identification and research include symmetry (ordering, incompleteness, repeating and counting); cleaning and contamination; intrusive or unacceptable thoughts (aggression, sexual, religious), which are sometimes combined with responsibility for harm or mistakes (checking and reassurance seeking). While the media typically exhibits OCD symptoms as contamination (i.e., excessive handwashing and worry of germs) and symmetry (i.e., needing objectives to be symmetrically aligned and perfect), OCD presents more heterogeneously. Previously hoarding was included in these symptom categories of OCD, but in the DSM-5, hoarding was separated into its own diagnostic disorder under the umbrella of Obsessive-Compulsive and Related Disorders (APA, 2013). OCD has been associated with a poorer quality of life, especially in aspects of family, social-ness and work (Huppert, 2009). Additionally, people experiencing symptoms are more likely to utilize health care services (Bobes et al., 2001). 1.1.4 Assessment OCD is typically diagnosed through a clinical interview with a trained mental health care provider, such as a psychiatrist. In research settings, the most accurate and reliable diagnoses are obtained using a structured interview and the diagnostic criteria of the Diagnostic and Statistical Manual (APA, 2022), or a similar diagnostic interview tool. In the DSM-5, clinically significant OCD meeting full diagnostic criteria is defined as obsessions and compulsions that (a) cause 5 clinically meaningful distress, or significantly reduce functioning or are time-consuming (i.e., take an hour or more each day), and (b) are not otherwise explained by another mental condition. If criterion (a) above of obsessions or compulsions causing significant distress/impairment/being time-consuming is not met, the OCD is classified as sub-clinical. Despite not meeting clinical severity for a diagnosis of OCD, individuals with sub-clinical symptoms of OCD may still experience significant life burden and interference, and thus may still need additional resources and treatment (Bobes et al., 2001; Huppert, 2009). If symptoms subside and an individual experiences an extended period without symptoms (i.e., a symptom-free episode), this is categorized as in remission. Full remission, defined by the DSM-5, occurs when severity of symptoms has greatly reduced to below significant ratings for over 8 weeks, while partial remission is defined as symptoms reaching average/some severity over 8 consecutive weeks. These definitions have also been used in large-scale studies of other mental health disorders throughout the years (Ansell et al., 2011; Bruce et al., 2005; Eisen et al., 2013; Keller & Shapiro, 1982). Apart from semi-structured interviews, individuals may be screened for symptoms of OCD using self-report or clinician administered questionnaires. Although not diagnostic, questionnaires assess symptom severity and screen for potential disorders. Screening via self-report questionnaires can facilitate the triage of those with more severe symptoms to additional diagnostic assessments, resources and treatments that can greatly improve quality of life. Obsessions and compulsions present in OCD characteristically deter individuals from seeking support, as many fear the judgement and even criminal charges that may result from the disclosure of intrusive thoughts (Robinson et al., 2017). Resultingly, there is a delay from the onset or experience of symptoms to when an individual receives supports and treatment (Garcia-6 Soriano et al., 2014; Pampaloni et al., 2022). Even after seeking treatment, many OCD patients feel they did not receive adequate support for mental and emotional wellbeing (Osland et al., 2018). This highlights the importance of increasing knowledge of OCD and related risk factors so patients can receive support and treatment to manage symptoms and improve their functioning. This is especially true in the high-risk population of perinatal people. 1.2 Perinatal OCD 1.2.1 Overview of OCD in Pregnancy and the Postpartum Becoming a new parent may represent a risk factor developing obsessive-compulsive disorder (OCD) (Brandes et al., 2004; Fairbrother & Abramowitz, 2007), and as such is of particular significance for perinatal people (Fairbrother et al., 2021) because of the increased risk of onset, exacerbation and recurrence during the perinatal period (i.e., pregnancy and postpartum) (Fairbrother & Abramowitz, 2007). Perinatally occurring OCD is often referred to as perinatal OCD. Similarly to non-perinatally occurring, it can cause significant distress and interference with daily functioning (Challacombe et al., 2016; Fairbrother & Woody, 2008). 1.2.2 Postpartum OCD 1.2.2.1 Definition OCD that occurs postnatally is often referred to as postpartum OCD (ppOCD), and is characterized by a rapid onset or exacerbation following childbirth (Challacombe et al., 2016; Fairbrother & Abramowitz, 2014). 1.2.2.2 Prevalence The prevalence of OCD throughout pregnancy and the postpartum is higher compared to the general population of women >18 years (Russell et al., 2013), and appears to increase following childbirth, reaching a peak at approximately 8 weeks postpartum (Fairbrother et al., 7 2021). A previous meta-analysis (Russell et al., 2013) estimated OCD prevalence prenatally at 2.3%, during the postpartum at 1.7%, and overall, at 2.2%. These estimates are likely underestimates due to the methodological limitations of general OCD assessment tools and out of date diagnostic criteria (Fairbrother et al., 2021). More recently, higher perinatal prevalence has been found using gold-standard methodology of a DSM-5 diagnostic interview to confirm OCD diagnostic, in combination with perinatal specific questions in this assessment. This recent study provides the most up to date assessment of perinatal OCD prevalence, reporting a prenatal prevalence of approximately 8%, and a postpartum period prevalence just under 17% (Fairbrother et al., 2021). These findings highlight the under-reporting in previous published studies and the importance of assessing perinatal specific symptoms of OCD. 1.2.2.3 Symptoms Although the content of obsessions experienced during perinatally occurring OCD may be similar to those occurring in non-perinatal OCD, such as thoughts related to contamination, aggression, exactness and compulsions that involve constant cleaning and checking (Fairbrother & Abramowitz, 2014), they may also differ. Specifically, thoughts and obsessions in the content of perinatally occurring OCD predominantly revolve around the infant (Hudak & Wisner, 2012), such as excessive cleaning of the infant, bottles, and other newborn items. These may also include obsessions of harming ones infant by accident, or obsessions of harming ones infant on purpose (Fairbrother et al., 2018). Resultingly, many mothers employ neutralizing strategies such as repeatedly checking on their baby (Speisman et al., 2011) or avoiding their infant to suppress these thoughts (McGuinness et al., 2011). The focus of thoughts and behaviours around the new infant is a unique and fundamental aspect of postpartum OCD. 8 1.2.2.4 Risk factors for Postpartum OCD The unique circumstances of pregnancy and birth are thought to create a complex scenario for OCD presentation, and acts as a risk factor for the onset, recurrence, or exacerbation of previous OCD (Forray et al., 2010). Other proposed risk factors for postpartum OCD include history of mental health conditions (Guglielmi et al., 2014; Uguz et al., 2011), primiparity (Fairbrother & Abramowitz 2007; Uguz et al., 2007), pregnancy or birth complications (Maina et al., 1999), and delivering via caesarean section (House et al., 2016). While the perinatal period itself is a risk factor for the development of OCD (Russell et al., 2013), the etiology of OCD is still being studied, and remains largely unknown due to the limited research (Hudepohl et al., 2022). 1.2.2.5 Treatment of Postpartum OCD Effective treatment for perinatal or postpartum OCD is similar to general population recommendations and includes pharmacotherapy and/or behavioural treatments such as cognitive behavioural therapy (Hudepohl et al., 2022). Treatment type may differ based on mental health history, lifestyle, and severity (Foa et al., 2005). Unique to the experience of perinatal OCD, pregnant or breastfeeding parents are more cautious, and even resistant to taking medication during this time (Burton et al., 2022; Lynch et al., 2018). As such, psychotherapy alone (or later in combination with medication) is often the preferred approach by pregnant or breastfeeding individuals (Marchesi et al., 2016). Cognitive behavioural therapy (CBT), a type of psychotherapy, has consistently proven to be an effective first-line treatment for OCD (McKay et al., 2015; National Collaborating Centre for Mental Health (UK), 2006; Van Noppen et al., 2021), and is the recommended treatment for perinatal OCD (Christian & Storch, 2009). CBT has proven to be effective in 9 managing prenatal OCD symptoms (Chelmow & Halfin, 1997), treating postpartum OCD (Challacombe & Salkovskis, 2011; Christian & Storch, 2009), and may have more beneficial, long-term effects on OC symptoms than medication alone (Van Noppen et al., 2021). A randomized controlled trial looking at CBT and treatment as usual found CBT delivered from 6-9 months postpartum was successful in reducing symptoms of OCD (effect size d = 1.31 â 1.90) (Challacombe et al., 2017). Similar results have been found in individual case studies (Christian & Storch, 2009; Pirec & Grabowski, 2017). More recently, CBT including exposure and response prevention (ERP) has been effective in treating OCD in general populations (Skapinakis et al., 2016) and thus has been recommended as a first line treatment (Hezel & Simpson, 2019; Koran & Simpson, 2013). ERP involves exposing patients to the triggers of their obsessional thoughts during CBT sessions, where they can confront the distress brought upon by these thoughts and learn to challenge or tolerate the discomfort without engaging in compulsions (Foa et al., 2012; Hezel & Simpson, 2019; Law & Boisseau, 2019). CBT with ERP has been recommended in perinatal populations specifically (Hudepohl et al., 2022), although more research studying perinatal OCD treatment in general is needed to fully capture the nuanced features of this particular period. As mentioned, many perinatal people are hesitant toward pharmacotherapy while pregnant or breastfeeding due to the potential harm that may come to their infant (Challacombe et al., 2016; Challacombe & Wroe, 2013). This fear of harm is common, despite research finding that associations between medication use and harm to infant are small and within normal, acceptable ranges (Ross et al., 2013). Given ethical considerations and the unlikeliness that pregnant people would agree to randomization of these treatment decisions, it is not surprising there are little to no randomized placebo-controlled drug trials with placebo that study the 10 treatment of postpartum OCD. Regardless, antidepressants (e.g., SSRIs, TCAs) have been a commonly prescribed treatment for postpartum OCD (Abramowitz, Larsen, et al., 2006; Arnold, 1999; Hudak & Wisner, 2012; Sichel et al., 1993; Uguz et al., 2008). Additionally, antipsychotics (e.g., quetiapine), were effective in a small randomized controlled trial of antidepressant-resistant patients (Misri & Milis, 2004). It is common for family members to be involved in the obsessions and compulsions of perinatal OCD (e.g., reassurance seeking). As such, it is important to establish education and resources inclusive of partners, family members and support systems (Abramowitz et al., 2013; Brandes et al., 2004). 1.3 Unwanted, Intrusive Thoughts (UITs) 1.3.1 Definition Unwanted intrusive thoughts (UITs) are normally occurring unwanted intrusive thoughts, images, and impulses. UITs are different from obsessions in that they are less frequent or persistent, little distress is experienced and thus fewer attempts are made to ignore, suppress or neutralize these thoughts (Brok et al., 2017). 1.3.2 Prevalence of UITs Many people experience unwanted, fleeting thoughts that come to mind unprovoked. These unwanted intrusive thoughts (UITs) are common - 74% to 99% of the general population report experiencing these kinds of thoughts (Belloch et al., 2004; Radomsky et al., 2014; Salkovskis et al., 1998). UITs are proposed to be an evolutionary response to alert us to harm and potential danger (Salkovskis et al., 1998). As such, the content of UITs is composed of current everyday concerns and they are more common when anxious or stressed (Nassif & Wells, 2014). 11 1.3.3 UITs of Accidental and Intentional Infant-Related Harm UITs of harm coming to oneâs infant are a common occurrence among new parents (Fairbrother & Woody, 2008; McGuinness et al., 2011). According to the most recent review published, the prevalence of UITs of infant-related harm is 65%-100% in new parents (Brok et al., 2017). The contents of the UITs experienced by new parents can involve harm coming to the infant either accidentally (e.g., baby dying in sleep, baby rolling off change table) or intentionally (e.g., deliberately hurting the baby, throwing the baby). UITs of accidental harm are a universal experience among new mothers with a recent study reporting 100% of mothers had these thoughts. Conversely, almost 50% of mothers reported experiencing thoughts of harming their infant intentionally, or on purpose (Fairbrother et al., 2022). While less common, UITs of intentional harming oneâs infant are significantly more distressing due to the content and the perceived meaning that one may attribute to these thoughts (Fairbrother et al., 2019), and as such generate higher vulnerability in parents who experience these thoughts. 1.3.4 UITs and Postpartum OCD UITs are a normal human experience which have the potential to develop into OCD (Belloch et al., 2004; Fairbrother & Abramowitz, 2007; Rachman, 1997). They are therefore fundamental to consider when studying postpartum OCD and related symptoms. Normally occurring UITs differ from obsessions in the interpretation the person makes of the occurrence and content of the thought (Salkovskis, 1989). Normally occurring UITs can develop into obsessions and OCD if the person perceives the occurrence or the contents of the thoughts to have substantial meaning (typically resulting in significant distress), and interprets responsibility for harm that may come as a result of this thought (Rachman, 1997; Salkovskis, 1989; Salkovskis et al., 1998). It is not surprising that in perinatally occurring OCD, obsessions 12 involving the infant, and in particular obsessions of harming oneâs infant, are extremely common in the postpartum following the abrupt surge of responsibility that follows birth (Abramowitz et al., 2007; Brok et al., 2017; Fairbrother et al., 2022; Fairbrother & Abramowitz, 2007; McGuinness et al., 2011). 1.3.5 Cognitive Behavioural Conceptualization of Postpartum OCD Researchers have hypothesized explanations for the heightened prevalence of OCD during the perinatal period, taking inspiration from OCD models in the general population to further explain the increased prevalence. This includes both psychological (e.g., cognitive-behavioural) and biological (e.g., serotonin, oxytocin) models. In my thesis, I focus on the cognitive behavioural theory of OCD, which has been supported in the OCD literature in general populations (Abramowitz et al., 2018; Frost et al., 2002; Gagné et al., 2018; Salkovskis, 1999; Salkovskis & Millar, 2016), as well as the perinatal OCD literature (Abramowitz et al., 2006; Abramowitz, Nelson, Rygwall, & Khandker, 2007; Barrett, Wroe, & Challacombe, 2016; Fairbrother, Thordarson, Challacombe, & Sakaluk, 2018 Fairbrother & Abramowitz, 2007). The cognitive behavioural (CB) model of OCD was created by Paul Salkovskis and Jack Rachman (Rachman, 1997; Salkovskis, 1985, 1999; Salkovskis et al., 1998). This concept is based on the main idea that it is not the content or the occurrence of the thought that drives the development of OCD, but the individualâs interpretation of the thought as being meaningfully disturbing or awful (Rachman, 1997; Rachman & Shafran, 1998; Salkovskis, 1985; Salkovskis et al., 2000), and belief that they are, or could be, responsible for harm. Taking influence from this model and support in general populations, Abramowitz and Fairbrother extended this theory to conceptualize perinatal and postpartum OCD. Based on this derived explanation, researchers Abramowitz and Fairbrother propose the high prevalence of 13 postpartum OCD is likely due to the increased appraisal of responsibility parents have for their new infant (Fairbrother & Abramowitz, 2007). Becoming a parent brings intense changes to oneâs roles and obligations. Specifically, following childbirth there is a sharp increase in caregiving duties and responsibilities for parents. The dramatic increase in responsibility, paired with caring for a vulnerable infant, may lower the threshold for the presentation or exacerbation of OCD (Frost et al., 2002; Salkovskis, 1999; Salkovskis & Millar, 2016), evidenced by the high incidence of OCD postpartum (Fairbrother et al., 2022). Parents are more cognizant of risks in everyday situations and potential harm that may come to their infant. Fairbrother and Abramowitz (2007) proposed that those who experience perinatal OCD likely over-estimate these dangers and exaggerate the possibility of harm occurring. The intense awareness of these dangers, in combination with the sudden responsibility for keeping a fragile infant safe and away from harm, makes it highly likely that any previously normal thoughts will result in significant worry and distress, especially when it revolves around the new infant. As a result of these upsetting thoughts, new parents are more likely to give more meaning to these scary thoughts, feel solely responsible, and engage in behavioural responses (e.g., ignore, suppress, neutralize) that can then become OCD. 1.3.6 Postpartum OCD in Birthing versus Non-Birthing Parents Evidence supporting the CB conceptualization extending to perinatal OCD comes from the finding that perinatal OCD also occurs in fathers or partners (i.e., non-birthing individuals). Although perinatal OCD research has mainly focused on women and other birthing parents, when studies have included non-birthing parents, fathers report experiencing similar UITs of infant-related harm that were incredibly upsetting (Abramowitz, Schwartz, & Moore, 2003; Abramowitz, Khandker, et al., 2006). The prevalence of UITs reported by fathers has been found 14 to be comparable to those reported by mothers, (Abramowitz et al., 2007; Abramowitz, Khandker, et al., 2006; Abramowitz, Schwartz, & Moore, 2003), and fathers report engaging in similar neutralizing behaviours as mothers (Abramowitz, Khandker, et al., 2006; Leckman et al., 1999). Currently, the only differences between mothers and fathers in the experience of infant-related UITs pertain to frequency of the thoughts and the amount of distress reported in response to them. Specifically, mothers were found to report more frequent UITs, and to experience more distress compared to fathers (Abramowitz, Schwartz, & Moore, 2003; Walker et al., 2021). This may be partly explained by the domestic role habitually taken on by mothers/birthing parents. As the birth parent commonly spends more time with the new infant, they would therefore feel increased responsibility, and thus may be more at risk for experiencing these thoughts (Abramowitz, Schwartz, & Moore, 2003). 1.3.7 Impact of UITs and OCD in the Postpartum A birthing person may respond to unwanted harm thoughts through compulsions of avoiding the infant, excessively checking on the infant or being over-protective. In addition to exacerbation of OC symptoms, these behaviours can also negatively impact mother-infant bonding and infant development (Brok et al., 2017). OCD and related symptoms also negatively affect the parents and the family unit, in addition to having lasting impacts on the newborn. Obsessions and compulsions in the postpartum lead to decreased daily functioning, hindered relationship quality, and other negative impacts for the well-being of the family (Burton, 2021; House et al., 2016; Uguz et al., 2015). Despite the high proportion of postpartum people that report experiencing intrusions (Fairbrother et al., 2022), thoughts of intentional harm are frequently hidden from family, friends and providers (Burton, 2021; Wheaton et al., 2016). Parents fear the negative perceptions, 15 shame, and guilt that often occur with disclosure, and are terrified of the possibility of extreme consequences, such as child removal (Brandes et al., 2004; Burton, 2021). Many healthcare practitioners are unfamiliar with postpartum OCD (Brok et al., 2017) and incorrectly believe that mothers and birthing persons who report these thoughts are a danger to their infants (Burton, 2021; Challacombe & Wroe, 2013). Regardless of the multiple requests by researchers and practitioners to decrease fear and stigma associated with OC symptoms following birth, (Burton, 2021; McGuinness et al., 2011; Russell et al., 2013; Sharma, 2019), little has been done and OCD remains largely unnoticed in many individuals during the postpartum. Increased understanding, education, and acceptance of OCD and related symptoms in the postpartum is key for proper assessment and treatment in affected populations. Birthing persons should feel safe enough to disclose any thoughts, images, impulses, or behaviours that they are experiencing related to their baby, without judgement or punishment. 1.4 Perinatal Sleep Poor sleep (i.e., reduced sleep duration and quality) is a well-known challenge for perinatal people. New parents universally struggle to get enough sleep while caring for a newborn. Birthing people can also experience disordered sleep for various reasons (e.g., hormonal changes, bodily discomfort). 1.4.1 Prevalence of Poor Sleep Quality during the Perinatal Period Given the hormone changes that occur during the perinatal period, and the fact that newborns wake throughout the night, it is not surprising that the perinatal period is associated with reduced parental sleep quality and duration. Reduced sleep is an inevitable part of becoming a parent, and thus can commonly be overlooked by both parents and practitioners. Sleep quality 16 during pregnancy generally decreases from the second to third trimester (Sedov et al., 2018). A recent meta-analysis found that over two in every three birthing persons experience considerably poor sleep quality in the postpartum (Yang et al., 2020). Research during pregnancy and the postpartum has reported increased frequency of reduced sleep quality (Sedov et al., 2018; Yang et al., 2020) and sleep disorders (El-Sherbeeny et al., 2022; Moghadam et al., 2021) in this population, with over 54.2% of mothers reporting poor sleep (Yang et al., 2020). The high prevalence of poor sleep during the perinatal period is concerning given the strong negative association found between sleep and health. 1.4.2 Associations of Poor Sleep During the Perinatal Period 1.4.2.1 Sleep and Parental Functioning Poor sleep has been associated with many negative consequences, both psychological (e.g., cognitive performance, burnout, negative affectivity) and biological (e.g., hormone levels, immune response, high blood pressure) (Alhola & Polo-Kantola, 2007; Medic et al., 2017; Medina et al., 2009; Thompson et al., 2022). Poor sleep specifically during pregnancy and the postpartum has been found to be correlated with reduced self-efficacy, marital satisfaction (Medina et al., 2009), happiness and quality of life (Simard et al., 2021), and has also been found to lessen mothersâ enjoyment in spending time with their infant (Albanese et al., 2020). The combination of poor sleep and concurrent postpartum mental health disorders has been linked to poor mother-infant relationships, less confidence and coping skills, and more frequent anger towards the infant (Bhati & Richards, 2015). 1.4.2.2 Sleep and Mental Health Sleep difficulties have consistently been associated with poor mental health in general populations. Reduced sleep quality and insomnia are associated with poor mental health or the 17 presence of mental health conditions (Bhati & Richards, 2015; Osnes et al., 2019; Slyepchenko et al., 2022; Smith & Saleh, 2021; Tomfohr et al., 2015). Similarly, the literature pertaining to the relationship between sleep and mental health during the perinatal period is equally extensive (Dørheim et al., 2014; Fairbrother et al., 2018; Obeysekare et al., 2020; Polo-Kantola et al., 2017; Tomfohr et al., 2015). Key findings from this work reported reduced quality of sleep during pregnancy was associated with an increase in the occurrence of anxiety and depressive symptoms in the postpartum period (Tomfohr et al., 2015). Similarly, birthing people who experienced insomnia during pregnancy were also found to have higher levels of perinatal anxiety disorders and depression (Osnes et al., 2019, 2020, 2021), indicating similar and interchangeable associations between poor/reduced sleep quality and symptoms of insomnia. 1.4.3 Sleep Interventions and Treatment Interventions for poor sleep quality during the perinatal period are comprised of pharmacological and non-pharmacological approaches. Non-pharmacological intervention methods include education (practical information), lifestyle (exercise, acupuncture, massage, yoga, etc.), circadian rhythms (e.g., sleep timing), and psychological (e.g., CBT, mindfulness), all of which can lead to improvements in sleep hygiene and sleep behaviour (Choong et al., 2022; Ladyman et al., 2022). As with treating any disorder or condition during the perinatal period, many pregnant or breastfeeding parents prefer non-pharmacological treatment over the potential risks of medication (Sedov et al., 2017). There is growing evidence supporting CBT for Insomnia (CBT-I), as the most effective and recommended first line treatment for adults with insomnia or sleep disruptions (Kalmbach et al., 2022). Given this, evidence also supports this intervention as effective for use in perinatal populations, and is preferred based on extended long term outcomes over pharmacotherapy seen 18 in adult populations (Mitchell et al., 2012; Riemann & Perlis, 2009). A study of treatment preferences by Sedov, Goodman, and Tomfohr-Madsen (2017), found 51% of pregnant participants preferred CBT-I to pharmacotherapy and acupuncture. CBT-I administered during pregnancy has been seen to significantly improve sleep quality (Kalmbach et al., 2022; Manber et al., 2023; Tomfohr-Madsen et al., 2017; Zheng et al., 2023), and may even provide protection against sleep loss following childbirth in the early postpartum (Kalmbach et al., 2022; Manber et al., 2023). Similarly, CBT-I delivered across pregnancy and into the postpartum showed equally effective outcomes, with benefits of improved insomnia symptoms extending up to 2 years postpartum (Bei et al., 2023). A recent meta-analysis of RCTs studying the effectiveness of CBT-I in pregnancy reported a significant decrease in sleep quality after completing under 6 weeks of treatment compared to control groups who received education (Zheng et al., 2023), indicating significant improvements in sleep quality and insomnia symptoms. Interestingly, a common theme emerged that those receiving CBT-I during the perinatal period also reported improvements in anxiety and depressive symptoms (Zheng et al., 2023), which was also found in other small pilot studies (Swanson et al., 2013; Tomfohr-Madsen et al., 2017). Pharmacotherapy is a viable treatment option for sleep disruptions, poor sleep, and/or insomnia, although less preferred by perinatal populations (Sedov et al., 2017). Medication treatment is considered on a case-by-case basis after considering the risks of infant exposure to treatment via medication, versus exposure to not treating the condition (Miller et al., 2020; Sedov et al., 2017). Insomnia treatment via an antidepressant (trazodone) or antihistamine (diphenhydramine) during pregnancy has been shown to have significant improvements on postpartum sleep quality compared to placebo, as well as later postpartum depressive symptoms (Khazaie et al., 2013). Palagini et al. (2022) recommend pharmacological therapy for perinatal 19 people with severe insomnia who do not respond to non-pharmacological treatment (Palagini et al., 2022). In any case, the first course of treatment should consider all potential options, be decided by the patient and healthcare practitioner together, and include educational resources about disordered sleep and treatment specifically during pregnancy and postpartum (Miller et al., 2020). The timing of sleep interventions is also a crucial aspect of treatment that is especially unique to the perinatal period. Specifically, in the postpartum, sleep disruptions can be attributed to the infants sleep behaviour (i.e., infant waking and feeding during the night), and to the individualâs own sleep difficulties. While CBT-I administered during pregnancy has been found to be effective in reducing prenatal insomnia symptoms (Felder et al., 2020; Kalmbach et al., 2022; Manber et al., 2023; Tomfohr-Madsen et al., 2017), these improvements in sleep resulting from treatment may not continue into the postpartum, given that there is now a new infant that is also disrupting sleep and reducing sleep quality (Quin et al., 2022). As such, it is important to consider sleep treatments and preventative measure to continue into the postpartum for greatest effect (Bei et al., 2023; Tomfohr-Madsen et al., 2017). 1.4.4 Measuring Sleep Quality Sleep can be measured through subjective and objective measures, with objective measures of actigraphy and polysomnography commonly considered the gold standard in general populations (Kushida et al., 2005). In perinatal populations, postpartum mood is more strongly associated with perceptions of sleep quality (subjective) versus the actual experienced sleep quality (objective) (Bei et al., 2010; Hiscock & Wake, 2001), and this finding has been true in subsequent studies (Dørheim et al., 2009; Park et al., 2013). Authors Bei, Wiley, Allen and Trinder (2015) hypothesize the strong associations observed between mood and subjective sleep 20 during the perinatal period emphasize the impact of perception on a situation. In terms of clinically meaningful findings, perceived sleep quality may be more likely to benefit from and respond positively to treatment, versus treatments aimed at actively altering objective sleep and disruptions that are less controllable (Bei et al., 2015), especially in the context of pregnancy and postpartum when disruptions result from the infant. As such this thesis will focus on subjective sleep quality, given that this may be a feature of sleep that may respond better to clinical interventions. 1.5 Sleep and OCD 1.5.1 Sleep and OCD in Non-Perinatal Populations Among non-perinatal people, there is a well-established relationship between sleep difficulties and OCD (Cox & Olatunji, 2016; Segalà s et al., 2021). A systematic review looking at sleep levels in adults found that disturbed sleep was extremely common in adults with OCD (Paterson et al., 2013). In non-perinatal samples, more severe OC symptoms are associated with higher levels of insomnia and poor sleep (Cox & Olatunji, 2016; Timpano et al., 2014). Interestingly, reduced sleep quality and symptoms of insomnia in general adult populations have been positively associated with obsessions (Timpano et al., 2014), and even more specifically, the content of unacceptable thoughts (Raines et al., 2015). Timpano et al. (2014) found this association held true even after controlling for depressive symptoms. Identifying poor sleep as a risk factor for OCD would be of great significance for new parents who consistently lack sleep, but this association has not been adequately investigated in perinatal populations. 1.5.2 Sleep and OCD in Perinatal Populations Despite a broad literature linking sleep and mental health difficulties experienced by perinatal people and numerous studies of the relationship between sleep and OCD in non-21 perinatal populations (Díaz-Román et al., 2015; Nota et al., 2015), the relationship between sleep and OCD in perinatal people is largely unstudied (Sharma, 2019). To our knowledge, only three studies have reported on the relationship between sleep difficulties and OC symptoms among perinatal people. The most recent study (Osnes et al., 2020), is a prospective cohort study of pregnant Norwegian people (N = 530). The authors compared the proportion of participants reporting OC symptoms in pregnancy and the postpartum (at 17 weeks gestation and at 8 weeks postpartum), between people with and without sleep issues at 17 weeks gestation. Compared to those with normal sleep, participants who reported sleep issues at 17 weeks gestation also reported significantly higher levels of OC symptoms at 8 weeks postpartum, but not at 17 weeks gestation. The only published study to assess the relationship between postpartum OC symptoms and subjective sleep quality was conducted by members of our lab (Fairbrother et al., 2018). The study included a convenience sample of 100 primiparous pregnant people. Sleep and OC symptoms were assessed at 4 and 12 weeks postpartum. Investigators found a positive association between OC symptoms and concurrent sleep difficulties at 4 weeks postpartum, but not 12 weeks postpartum. The only other study to our knowledge to objectively assess sleep in relation to OC symptoms was conducted by Obeysekare et al., (2020). In this study, sleep was measured with respect to circadian rhythm. Participants who reported delayed sleep in regards to their circadian phase (i.e., went to sleep later than their optimal time) during pregnancy reported more postpartum OC symptoms. These authors hypothesized that ppOC symptoms may worsen during the night due to the slowing of the brain in preparation for sleep, which may result in increased 22 intrusive OC thoughts and impulses (Obeysekare et al., 2020). This high-risk sample of women was limited to perinatal people with a history of bipolar or major depressive disorder, and thus is not as informative for general samples such as our own. 1.6 Rationale Although findings from the studies outlined above (Fairbrother et al., 2018; Obeysekare et al., 2020; Osnes et al., 2020) provide preliminary evidence of a relationship between sleep and OCD among perinatal people, significant gaps remain. Specifically, studies to date have relied exclusively upon self-report measures of OCD (i.e., symptom measures rather than diagnostic measures). No studies involving diagnostic assessments of OCD and sleep have been published. Further, prospective evaluations of perinatal sleep as a predictor of postpartum OCD symptoms have not been published. In addition to filling these gaps, this work will also extend on the labâs own previous work looking at the association between poor perinatal sleep and OC symptoms using a larger, representative sample that will provide more accurate results and insight into correlations between concurrent sleep and OC symptoms, as well as previous sleep and later OC symptoms (Fairbrother et al., 2018). Improving our understanding of OCD, in particular the reasons for increased prevalence and incidence perinatally, is extremely important to ensure the health of the birthing person, their infant, and the family unit as whole. Given the ubiquity of UITs of infant-related harm among parents, the high prevalence of OCD in the postpartum in combination with the high prevalence of reduced sleep perinatally, research investigating early perinatal sleep as a predictor of postpartum OCD is important and has the potential to add significantly to our understanding of perinatally occurring OCD. The proposed work has the potential to lead to improved understanding, and targeted management of postpartum OCD in addition to improving etiology. 23 1.7 Research Questions Thus, the purpose of this thesis is to examine the relationship between perinatal sleep quality and postpartum OCD. This will be done through the assessment of three main research questions: 1. Does poorer perinatal sleep quality predict more severe postpartum OCD symptoms? 2. Is concurrent perinatal sleep quality poorer among participants who report symptoms meeting diagnostic criteria for OCD in the perinatal period? 3. Is concurrent sleep quality poorer among participants who report experiencing unwanted, intrusive thoughts of intentional infant-related harm in the postpartum? 1.8 Thesis Roadmap The following chapters of this thesis provide methods, data analyses, findings and discussion surrounding the assessment of a relationship between perinatal sleep and postpartum OCD. Specifically, chapter 2 is an overview of all study methods used in this thesis. I describe the study, recruitment processes, participant information, procedures of data collection and ethical considerations. I also provide descriptions and details on the questionnaire and interview measures utilized in this thesis to evaluate my hypotheses and predictions. Chapter 3 is the first chapter of hypotheses testing and results. In this chapter, I assess the first research question; the ability of earlier perinatal sleep quality to predict symptoms of postpartum OCD. This chapter assesses the following hypothesis: Hypothesis 1: Poorer earlier perinatal sleep quality predicts more severe postpartum OCD symptoms. This is true for both postpartum timepoints: poor prenatal sleep is predictive of more 24 severe early postpartum OC symptoms; poor prenatal sleep quality and poor early postpartum sleep quality is predictive of more severe OC symptoms in the later postpartum. Chapter 4 includes the analyses and findings used to assess the second and third research questions of this thesis. Specifically, I explore how sleep quality differs between groups with different experiences of perinatal and postpartum OCD. I look at differences between groups who a) reported experiencing symptoms meeting diagnostic criteria of OCD compared to those that did not, and b) reported experiencing UITs of intentional infant-related harm and those that did not. This chapter assesses the following two corresponding hypotheses: Hypothesis 2: Pregnant and postpartum people who report symptoms meeting diagnostic criteria (sub-clinical or full) for OCD in the perinatal period will report poorer concurrent sleep quality and increased sleep disruptions compared with those who do not report symptoms meeting diagnostic criteria for OCD. This is true at all timepoints. Hypothesis 3. Postpartum people who report experiencing unwanted, intrusive thoughts of intentional infant-related harm in the postpartum will report poorer concurrent sleep quality compared to those who do not. This is also true across both postpartum timepoints. In addition to testing the above hypotheses and predictions considering overall sleep quality, in chapter 4 I also explore specific characteristics of perinatal sleep that may differ between the groups studied. The final chapter, chapter 5, contains my discussion. In this section I report on the findings of each chapter and if my hypotheses and predictions were supported by my results. I also provide details on what these findings add to the literature, what these findings mean clinically, and what future research should consider based on my results. Additionally, I comment on the specific strengths and limitations of this thesis. 25 Chapter 2: Methods 2.1 Methods 2.1.1 Study Design This work is an analysis of previous collected data from a prospective cohort study conducted between 2014-2017 in the province of British Columbia (BC). The primary purpose of the larger study was to assess perinatal OCD prevalence, incidence, and associated factors. The full study protocol has been published (Collardeau et al., 2019). 2.1.2 Recruitment Recruitment was conducted from January 2014 through to September 2016 via direct and indirect methods, with the approach to recruitment designed to maximize the chances of obtaining a representative sample of birthing people in BC. Direct recruitment methods were used at select hospitals around the province that have more than 1,500 births annually (BC Perinatal Database Registry, April 2010). This included BC Children and Womenâs, Burnaby Hospital, St Paulâs Hospital, Surrey Memorial Hospital, Lionâs Gate Hospital, Victoria General, and Langley Hospital. At these hospitals, study team members directly approached birthing people regarding participation in the study. To maximize representativeness, hospital-based recruitment, responsible for procuring 85.3% of the total sample, was conducted proportionally based on the corresponding number of births at each specific hospital. Additional indirect community (13.3% of total sample) and rural (1.4% of total sample) recruitment was undertaken through the distribution of study posters and pamphlets to various midwives, physicians, obstetricians, community centers, clinics, perinatal events, and prenatal education classes throughout the province. 26 2.1.3 Participants Data was collected from February 2014 to February 2017. Anyone pregnant, living in the province of British Columbia during recruitment, aged 19 years or older, and English speaking was eligible to participate in this study. In total, 1,113 eligible women and/or birthing people expressed interest. Of these, 763 provided some data. This report of findings, described in following chapters, used data from a portion of that sample. For inclusion in chapter 3 of this thesis, participants were required to complete the prenatal questionnaire package and at least one of the two postpartum questionnaire packages. A total of n = 500 provided these data and are included in the analyses described in chapter 3. The analyses I conducted in chapter 4 was comprised of participants who completed the prenatal questionnaire package, at least one postpartum questionnaire package, and at least one of the two postpartum interviews that collected information on diagnostic status of OCD, and the experience of UITs of harm. A total of n = 375 provided this data and were included in the chapter 4 analyses. 2.1.4 Procedures Participants who provided consent and were eligible to participate in the study were administered a battery of self-report questionnaires and a diagnostic interview. At approximately 33 weeks gestation (T1), and 9 weeks (T2) and 20 weeks postpartum (T3), participants completed study assessments. In the first two assessments, questionnaires were completed prior to the diagnostic interviews. Because highly sensitive information was collected in the final questionnaire package (i.e., reports of aggression towards oneâs infant), in order for participants to feel safe reporting this information, it was important that their responses be anonymous. In order to ensure the anonymity of the responses to the final questionnaires, these questionnaires 27 were completed after the final interview. This allowed the study investigators to keep participant data linked throughout the study, while separating data from participantsâ identity (thus ensuring anonymity) once these final questionnaires had been completed. Prenatal questionnaires included questions pertaining to demographic and reproductive history, as well as self-report measures to assess symptoms of OCD and depressed mood, and other functioning (e.g., social support, sleep quality, parenting behaviours). The postpartum questionnaires included the same screening and functioning measures. Additional birthing information was collected in the 9 weeks postpartum questionnaire. Diagnostic interviews were conducted by trained members of the study team over the phone, and assessed participants for diagnoses of OCD and major depressive episode. Additional information on thoughts of harm related to the infant were also collected in interviews. This current work utilized sleep quality and OC symptom data from questionnaires in addition to diagnostic information collected during the postpartum interviews (Figure 1). 28 Figure 1 Overview of Study Timeline and Measures Note. Weeks pregnant and postpartum are approximate. PSQI = Pittsburgh Sleep Quality Index, DOCS = Dimensional Obsessive-Compulsive Scale, SCID-5 = Structured Clinical Interview for the DSM-5, PPII = Postpartum Intrusions Interview. 2.2 Measures The questionnaires and interview components used in this secondary analysis of data are described in detail below. Instruments not used for this report of findings are not included. An overview of all questionnaire measures, interview measures and timing of administration can be found in Figure 1. 2.2.1 Questionnaire Measures 2.2.1.1 Pittsburgh Sleep Quality Index Subjective perinatal sleep quality was measured via the Pittsburgh Sleep Quality Index (PSQI) (Buysse et al., 1989). The PSQI is a common measure of sleep composed of nineteen self-report items that measure sleep quality over the last month. The PSQI items assess seven 29 components of sleep that are commonly evaluated in clinical interviews of diagnosed sleep issues: subjective sleep quality, sleep duration, sleep latency (the time it takes to fall asleep), sleep efficiency (time spent sleeping/time spent in bed), sleep disturbance, sleep medication use and daytime dysfunction. Each component is scored on a scale of 0 (no symptoms) to 3 (severe symptoms). All seven components are added together produce a cumulative global score ranging from 0-21, with higher scores indicative of poorer quality sleep (Buysse et al., 1988). Information about the meaning of PSQI scores and severity is provided in Table 1. This measure has shown good internal consistency in clinical and community populations, with reported Cronbach alphaâs ranging from .6 to .8 based on findings of a meta-analysis reviewing the PSQI as a screening tool for sleep dysfunction (Mollayeva et al., 2016). The PSQI is the most common measure of sleep quality in research settings and has been used and validated as a reliable tool for research and health practitioners to assess sleep quality during pregnancy (Qiu et al., 2016; Skouteris et al., 2009) and the postpartum (Baattaiah et al., 2023, Okun et al., 2018). In perinatal populations, the PSQI has been shown to have high levels of construct validity, with total scores positively correlating with measure scores of depression symptoms, anxiety and stress (Qiu et al., 2016; Skouteris et al., 2009). Additionally, PSQI components scores of sleep efficiency, sleep quality, day and night disturbances have also positively correlated with depression scores (Qiu et al., 2016; Skouteris et al., 2009). In this sample, the PSQI items resulted in a Cronbach alpha of .8 prenatally, and a Cronbach alpha of .6 in the early postpartum. This value of internal consistency, although lower than optimal, is within the range for acceptable content validity (Janssens, 2008). The PSQI identifies âpoorâ sleepers via a cumulative cut-off score of five, with scores greater than 5 indicating relevant sleep disturbances (Mollayeva et al., 2016). While this cut-off 30 score has been used in general population and perinatal samples (Christian et al., 2019; Smyka et al., 2021; Wang et al., 2023; Yang et al., 2018), a higher cut-off score may be needed to properly distinguish pregnancy and postpartum populations needing additional support and treatment as poor sleep is so common during this time (Sedov et al., 2018). A meta-analysis by Sedov et al. (2018) assessing the quality of sleep experienced by birthing persons during pregnancy calculated a mean PSQI score of 6.07 (N = 6,796 pregnant individuals) across all 24 included studies. By this calculation, an average pregnant women/person would be considered to have significantly poor sleep quality. Therefore, using a cut-off score of 5 in perinatal populations may not be useful in clinical settings for the identification of individuals who require additional treatment and supports. This was the conclusion of the authors of this meta-analysis. Specifically, they argued that a cut-off score of 5 may not be appropriate to identify those in need of resources (Sedov et al., 2018), although to date there has not been a consensus on a more accurate score, nor has a new cut-off been tested in this population (Poeira et al., 2023). As such, I will be utilizing a cut-off score of 5 to in this work to identify the number of participants experiencing clinically meaningful poor sleep. Due to the arguments in the literature mentioned above, I will be performing sensitivity analyses to describe the frequency of my sample experiencing poor sleep with higher PSQI cut-off scores (>6, >7). 31 Table 1 PSQI Component Score Response Scale Meanings PSQI Component Component Item(s) Response Scale âDuring the past month . .â 0 1 2 3 1. Subjective quality How would you rate your sleep quality overall? Very good Fairly good Fairly bad Very bad 2. Sleep latency How long in minutes does it take you to fall asleep? â¤ 15 minutes 16-30 minutes 31-60 minutes >60 minutes How often have you had trouble sleeping because you cannot get to sleep within 30 minutes? Not during the past month Less than once a week Once or twice a week Three or more times a week 3. Sleep duration How many hours of actual sleep did you get at night? > 7 hours 6-7 hours 5-6 hours < 5 hours 4. Sleep efficiency # hours slept# hours spent in bed x 100% > 85% 75-84% 65-74% < 65 % 5. Sleep disturbance How often have you had trouble sleeping because you (e.g., had to use bathroom, felt hot, etc.) Not during the past month Less than once a week Once or twice a week Three or more times a week 6. Medication use How often have you taken medicine to help you sleep? Not during the past month Less than once a week Once or twice a week Three or more times a week 7. Daytime dysfunction How often have you had trouble staying awake while driving, eating meals, or engaging in social activity? Not during the past month Less than once a week Once or twice a week Three or more times a week How much of a problem has it been for you to keep up enthusiasm to get things done? No problem at all Only a very slight problem Somewhat a problem A very big problem Note. PSQI = Pittsburgh Sleep Quality Index 32 2.2.1.1 Dimensional Obsessive-Compulsive Scale Symptoms of OCD were measured via the Dimensional Obsessive-Compulsive Scale (DOCS) (Abramowitz et al., 2010). The DOCS is a self-report survey used to measure OC symptoms over the past month. This scale measures obsessions and compulsions across four common symptom dimensions (contamination, responsibility of harm or injury, unacceptable thoughts, symmetry/incompleteness). Each category is composed of 5 questions, scored on a Likert-type scale of 0 (no symptoms) to 4 (severe symptoms). Evidence supports the use of the DOCS as a measure of OC symptoms in research (Kuckertz et al., 2021) and clinical settings (Christian et al., 2019; Smyka et al., 2021; Wang et al., 2023; Yang et al., 2018). Both within- and between-person change reliability has been reported good to excellent (.8 and .9 â 1.0), indicating the DOCS is able to capture changes in symptoms over time, providing specific support in longitudinal research (Kuckertz et al., 2021). This measure has shown excellent internal consistency in adult populations, with alphas ranging from .8 to over .9 (Abramowitz et al., 2010; Kuckertz et al., 2021). DOCS total scores have also been shown to more accurately identify OCD than an alternate measure, OCI-R (Abramowitz et al., 2010). A cut-off score of 18 has been recommended to classify patients experiencing more severe OCD symptoms, needing additional assessment, from those not experiencing symptoms. Additionally, a cut-off score of 21 accurately identifies patients likely experiencing symptoms of OCD from those with other anxiety disorders, with a sensitivity and specificity of 70% (Abramowitz et al., 2010). In this sample, the DOCS Cronbach alpha was excellent across all timepoints (.9), representing excellent internal consistency. While this measure has been used in screening to identify individuals with severe OC symptoms that are more at risk for developing 33 or having clinical OCD, this self-report measure in itself is not a diagnostic instrument. Total sum scores are not indicative of clinically significant OCD, as is true with a diagnostic interview. 2.2.2 Interview Measures 2.2.2.1 Structured Clinical Interview for the DSM-5 The Structured Clinical Interview for the DSM-5 (SCID-5) (First et al., 2016), was used to identify participants meeting diagnostic criteria of OCD using DSM-5 criteria. Diagnostic interviews were conducted over the phone by trained members of the study team at each timepoint of study (Figure 1). In addition to assessing OCD diagnostic criteria, interviewers administered additional questions to probe for specific perinatal obsessions (i.e., obsessions of accidental or intentional infant-related harm). Following data collection, 100% of interviews resulting in a full criteria OCD diagnosis (and in which an audio recording was available), were checked by additional team members and experts for reliability, in addition to 5% of interviews from which no clinical diagnoses resulted. OCD diagnoses were categorized as one of the following based on symptom severity: absent, in full remission, in partial remission, sub-clinical or full criteria. Symptom severity was rated from 0 (no symptoms) to 8 (very severe/disabling symptoms). Based on symptom severity ratings, diagnoses were assigned as: 0 = absent or in full remission; 0.5-2.5 = in partial remission; 3-3.5 = sub-clinical, 4-8 = full criteria. 2.2.2.2 Postpartum Intrusions Interview The Postpartum Intrusions Interview (PPII) (Fairbrother & Woody, 2008) was used to evaluate the occurrence of UITs of accidental and intentional infant-related harm that participants experienced in the postpartum, including when the thoughts started, frequency and intensity. The PPII also collects information on behaviours done in response to any thoughts experienced (e.g., repetitive cleaning, avoiding the baby). During study interviews, interviewers 34 provided examples of commonly experienced thoughts of unwanted, intrusive thoughts of infant-related harm to encourage reporting. If applicable, they also provided examples from their own personal experience of these thoughts surrounding their own newborn. For this secondary analysis of data, I included data on the experience of unwanted, intrusive thoughts of intentional infant-related harm in the early postpartum. This variable was coded as: 1=yes, participant experienced UITs of intentional infant-related harm, and 0=No, did not experience UITs of intentional infant-related harm. 2.3 Ethics Ethics board approvals for this research was obtained via the ethics boards of the University of British Columbia, the Vancouver Island Health Authority, and the Vancouver Coastal Health and the Fraser Health Authority (H11-03266). Participants provided written consent prior to completing the prenatal questionnaire and again at the time of the first postpartum assessment. The reason that consent was sought prenatally and postpartum is because many of the postpartum questions were sensitive in nature (e.g., assessing infant-related harm thoughts) and the investigators thought that participants might view these questions differently once their infant was born, and consequently, fresh consent was merited. Further, due to the assessment of harm thoughts, additional information regarding duty to report child abuse and the limits of confidentiality in the research was also provided in the second consent form. The second consent form was also reviewed with participants at the time of the first postpartum interview. Verbal consent to record study interviews was obtained prior to each interview. To ensure participant safety and encourage honest reporting, participant identities were closely protected through assigned study codes and the anonymization of data. As there was the potential for serious topics to be brought to participantsâ attention, the study team was informed 35 and trained on safety precautions/procedures to employ based on participantsâ responses during the questionnaires and the study interviews. Any doubts or concerns were discussed during study interviews, where trained interviewers provided feedback and options for support. Participants were encouraged to reach out to the members of the team for additional resources and/or treatment options. Additionally, respondents were provided with resources and information to reference throughout their participation in addition to a debriefing form following the end of participation. 36 Chapter 3: The role of reduced perinatal sleep quality in predicting postpartum OC symptom severity 3.1 Introduction New parents universally struggle to get enough sleep while caring for a newborn. Birthing people can also experience disordered sleep for various reasons (e.g., hormonal changes, bodily discomfort). While broad research on sleep and perinatal mental health conditions exists, very little published work has investigated the relationship between sleep and OCD in birthing people, despite the increased frequency of reduced sleep quality and sleep disorders in this population (El-Sherbeeny et al., 2022; Moghadam et al., 2021; Sedov et al., 2018; Yang et al., 2020) and the literature studying this in general populations. In non-perinatal samples, more severe OC symptoms have been associated with higher rates of insomnia and poor sleep quality (Cox & Olatunji, 2016; Timpano et al., 2014). A preliminary study looking at the predictive ability of poor sleep on OCD symptoms reported that delayed sleep timing predicted an increase in obsessive and compulsive symptoms of individuals with OCD (Schubert et al., 2020). Despite the abundance of primary literature, systematic reviews and meta-analyses in adult populations linking poor sleep quality and OCD (Díaz-Román et al., 2015; Nota et al., 2015; Paterson et al., 2013; Raines et al., 2015; Segalà s et al., 2021; Timpano et al., 2014), few studies to date have considered this connection in the perinatal period (Fairbrother et al., 2018; Obeysekare et al., 2020; Osnes et al., 2020), and none have considered poor perinatal sleep as a predictor of more severe OCD symptoms in the postpartum. 37 The following chapter addresses this literature gap and assesses perinatal sleep as a predictor of postpartum OC symptoms, thus adding to our knowledge and understanding of postpartum OCD etiology. 3.2 Research Hypothesis and Predictions The purpose of this chapter is to evaluate the first research question of this thesis, through the following primary study hypothesis: Hypothesis 1: Poorer earlier perinatal sleep quality predicts more severe postpartum OCD symptoms. From this hypothesis I have made the following predictions: Prediction 1: Poor prenatal sleep (i.e., higher PSQI total scores at approximately 33 weeks gestation) is predictive of more severe early postpartum OC symptoms (i.e., higher DOCS total scores at approximately 9 weeks postpartum). Prediction 2: Poor prenatal sleep quality (i.e., higher PSQI scores at approximately 33 weeks gestation) and poor early postpartum sleep quality (i.e., higher PSQI scores at approximately 9 weeks postpartum) is predictive of more severe OC symptoms in the later postpartum (i.e., higher DOCS total scores at approximately 20 weeks postpartum). 3.3 Study Methods Specific to this Chapter Detailed study methods are provided in chapter 2. A total of 500 out of the 763 participants provided data for this portion of the thesis. These 500 participants met my study inclusion criteria (i.e., they completed the prenatal questionnaire package and at least one postpartum questionnaire package), and were therefore included in the analyses for both predictions of Hypothesis 1. Sleep quality and OC symptom severity were assessed using the 38 PSQI and the DOCS. Additional demographic and reproductive information collected in the study questionnaires were considered for inclusion as covariates. 3.4 Data Analysis 3.4.1 Overview Data was analyzed using IBM SPSS Statistics (Version 28). A p value of less than or equal to .05 was considered statistically significant for all statistical tests. 3.4.2 Missing Data Missing data were included using person missing substitution (PMS). This imputation was utilized to replace single missing items within measure subscales (i.e., 20% or less of subscale data missing). This simple replacement method has been shown to be an acceptable imputation to account for missing data in self-report scales (Shrive et al., 2006), while still representing the original data (Downey & King, 1998). 3.4.3 Sample Characteristics Descriptive statistics are presented as means and standard deviations (M (SD)), medians and mode, or as frequencies and percentages (n (%)). 3.4.3.1 Sleep Quality Mean total PSQI scores will be used to characterize overall sleep quality in the study population across timepoints of data collection. Throughout the PSQI, high scores indicate more severe symptoms. Mean scores of the seven PSQI components will also be provided separately across each timepoint to show symptom severity of specific sleep features the PSQI reports on (e.g., sleep duration, sleep efficiency, sleep latency). Lastly, to further establish the severity of poor sleep symptoms experienced by this sample, I will use the PSQI cut-off score (>5) to identify the number of participants experiencing clinically meaningful poor sleep. However, as it 39 has been proposed that a higher cut-off score may be needed for perinatal populations (Sedov et al., 2018), I will also report additional frequencies using higher cut-off scores of >6 and >7. 3.4.3.2 OC Symptoms OC symptom severity of this sample will be measured using mean DOCS total score at each timepoint, with higher scores indicating more severe OC symptoms. The frequencies of participants reporting DOCS scores over cut-off values will also be included to interpret the severity of OC symptoms in terms of an OCD diagnosis from this screening tool. DOCS total scores â¥ 18 identify participants more likely to suffer from OCD who may need further assessment and treatment (i.e., clinically significant OC symptoms), while DOCS â¥ 21 distinguishes participants who are likely suffering from OCD versus from another anxiety-related disorder (Abramowitz et al., 2010). 3.4.4 Hypothesis Testing The present chapter involves data from multiple timepoints (i.e., three in total) across the perinatal period, with various measures administered across all three assessments (e.g., OC symptoms). Because of this, the predictions arising from study Hypothesis 1 were tested in two ways: via linear regression and linear mixed-effects modelling. In addition to linear regression, mixed-effects modelling was also employed because, unlike linear regression, it accounts for within subject correlations among predictors and outcomes across time. The addition of random effects in this multi-level model also considers that OC symptom severity (i.e., DOCS total scores) differs between individuals. Although linear mixed-effects modelling is the analysis of choice for repeated measures data (i.e., the same variable measured the same way over time), in these analyses, there were only two timepoints of repeated measure (early and later postpartum OC symptoms as measured by the DOCS). Therefore, when the repeated measure correlation 40 was taken into account in a longitudinal model, the differences in outcomes were trivial. Therefore, in order to collect comprehensive information such as R2 to better describe model fit, linear regression was conducted first, then findings were further supported with linear mixed-effects modelling in order to confirm my results were valid after considering the correlated nature of repeated measure outcomes. The detailed analysis steps and findings for the linear regression models are described in section 3.6. The details of the linear mixed-effect modelling and analysis findings are described in section 3.7. 3.5 Sample Characteristic Results 3.5.1 Demographics A total of 500 participants were included in these analyses. This sample had a mean age of 32.6 ± 4.9, majority of whom were of European heritage (55.7%), married or cohabiting (94.3%), employed full time (59.3%), and expecting their first child (53.3%). For the pregnancy/birth that occurred during participation, 35% experienced pregnancy complications, 34% experienced delivery complications and approximately 24% reported a traumatic birthing experience. Majority of the study population gave birth vaginally (n = 300, 60.7%) and reported exclusively breastfeeding their infant (n = 325, 65.9%). Sample demographics and reproductive information are provided in Table 2, stratified based on prenatal sleep quality. 41 Table 2 Demographic information Characteristic Frequency (%) Poor Prenatal Sleep (PSQI >5) (n = 266) Good Prenatal Sleep (PSQI â¤ 5) (n = 137) Agea 32.5 (5.2) a 31.9 (4.3) a Relationship Status Single 11 (4.1) 6 (4.4) Married/Partnered/Cohabiting 253 (95.1) 128 (93.5) Separated/Divorced 2 (0.8) 3 (2.2) Employment Full-time 152 (57.4) 84 (61.8) Part-time 44 (16.6) 16 (11.8) Full-time home 27 (10.2) 12 (8.8) Unemployed 28 (10.5) 16 (11.7) Disabled 5 (1.9) 2 (1.5) Student 9 (3.4) 6 (4.4) Education Did not complete high school 6 (2.3) 2 (1.5) Completed high school 21 (7.9) 7 (5.1) Undergraduate/college education 139 (52.5) 67 (48.9) Graduate education 99 (37.3) 61 (44.5) Heritage European 156 (59.3) 69 (50.4) East Asian 22 (8.4) 22 (16.1) South Asian 22 (8.4) 5 (3.6) Southeast Asian 13 (4.9) 12 (8.8) Indigenous 7 (2.7) 5 (2.6) Latin, Central, South America 5 (1.9) 3 (2.2) Middle Eastern 7 (2.7) 3 (2.2) Mixed 22 (8.4) 14 (10.2) Other 9 (3.4) 4 (2.9) Household Income < $70 000 52 (25.1) 30 (28.8) $70 000 â $140 000 124 (59.9) 53 (51.0) > $140 000 31 (15.0) 21 (20.2) Reproductive History and Birthb Primiparous (first delivery) 145 (54.7) 87 (64.0) Multiparous 120 (45.3) 49 (36.0) Pregnancy complications 101 (38.5) 35 (25.9) Vaginal delivery 160 (61.1) 87 (64.4) Cesarian delivery 102 (38.9) 48 (35.6) Delivery complications 89 (34.0) 42 (31.3) Traumatic birth 70 (26.7) 19 (14.2) Infant Feedingb Breastfeeding exclusive 164 (62.6) 101 (75.4) Formula exclusive 22 (8.4) 3 (2.2) Combination 76 (29.0) 30 (22.4) Note. aMean (SD). bAll collected in T1 questionnaire except for pregnancy complications, mode of delivery, delivery complications, traumatic birth, and infant feeding. 42 3.5.2 Sleep Quality Characteristics 3.5.2.1 Total Sleep Quality Scores Sleep quality of the sample across perinatal timepoints is given in Table 3. Sleep quality scores ranged from 0-19, with a mean sleep quality of 7.5 SD ± 3.7 in the prenatal period, and 8.0 ± 3.1 in the early postpartum. The best quality sleep, indicated by the lowest mean total score on the PSQI, occurred in the later postpartum (M = 6.9 ± 3.2). 3.5.2.2 Sleep Component Scores Mean sleep component scores by timepoint are shown in Figure 2. Mean scores for the components of subjective sleep (component 1), sleep efficiency (component 4), and sleep disturbance (component 5) were all greater than 1 at each timepoint, indicating the presence of some difficulty and mild symptom severity (Figure 2). Prenatally, participants reported the high Table 3 Descriptive Statistics for Participant Sleep and OC Symptom Characteristics Mean (SD) Median Mode Range Cronbachâs α Prenatal PSQI 7.5 (3.7) 7.0 6.0 1-19 .8 DOCS 9.4 (9.1) 7.0 0.0 0-57 .9 Early Postpartum PSQI 8.0 (3.1) 8.0 7.0 1-17 .6 DOCS 9.3 (9.5) 7.0 0.0 0-58 .9 Later Postpartum PSQI 6.9 (3.2) 6.0 6.0 0-18 .7 DOCS 7.1 (7.8) 5.0 0.0 0-44 .9 Note. PSQI = Pittsburgh Sleep Quality Index measuring sleep quality, DOCS = Dimensional Obsessive-Compulsive Scale measuring OC symptom severity, α = alpha. 43 levels of sleep disturbance symptoms (component 5; M = 1.8). Participants in the early postpartum reported short time asleep (component 3; M = 1.5) and the poor sleep efficiency (component 4; M = 1.9). Sleep medication use over the last week was low across all timepoints, as is common among this population (Dørheim et al., 2014; Yang et al., 2020). Figure 2 Mean Sleep Component Scores Across All Perinatal Timepoints. Note. PSQI = Pittsburgh Sleep Quality Index. PSQI component 1 = subjective sleep; 2 = sleep latency; 3 = sleep duration; 4 = sleep efficiency; 5 = sleep disturbance; 6 = sleep medication use; 7 = daytime dysfunction. Components are scored from 0-3. Higher scores are indicative of more severe symptoms. All seven of the above component scores are summed to give total global score that represents overall sleep quality. Error bars represent mean standard error. 00.511.522.51 2 3 4 5 6 7Mean PSQI ScorePSQI ComponentPrenatalEarly postpartumLater postpartum 44 3.5.2.3 Sleep Quality Cut-off Score The number of participants experiencing significantly poor sleep according to the PSQI is given in Table 4. As per the validated cut-off score of 5 for the PSQI (Buysse et al., 1988), the majority of participants (61.9% - 77.5%) met the cut-off for clinically significantly poor sleep at all points of data collection, as all mean scores fell well above this value (Table 4). Regardless of the cut-off score used, over half of this sample still experienced significantly poor sleep quality during the early postpartum. Table 4 Number of Participants with Clinically Significant Symptoms according to Measure Cut-offs Frequency (%) Prenatal Early Postpartum Later Postpartum Significantly poor sleep (PSQI >5)a 266 (66.0) 354 (77.5) 206 (61.9) Significantly poor sleep (PSQI >6)b 207 (51.4) 311 (68.1) 165 (49.5) Significantly poor sleep (PSQI >7)b 178 (44.2) 248 (54.3) 124 (37.2) OCD or other anxiety disorder (DOCS â¥ 18)c 75 (15.6) 71 (15.5) 20 (8.7) OCD (DOCS â¥ 21)d 45 (9.4) 44 (9.6) 16 (4.8) Note. PSQI = Pittsburgh Sleep Quality Index, OCD = Obsessive-compulsive disorder, DOCS = Dimensional Obsessive-Compulsive Scale. aValidated cut-off score of 5 accepted in general population literature and previously used in perinatal research. b Cut-off scores of 6 and 7 were included for completion as recent literature has suggested that perinatal populations may require a higher cut-off score to correctly identify populations needing more support. c Scores greater than or equal to 18 distinguishes participants likely to be suffering from more severe OCD, from those not experiencing symptoms. d Scores greater or equal to 21 distinguishes participants likely experiencing OCD from those with other anxiety-related disorders. 45 3.5.3 OC Symptom Characteristics 3.5.3.1 OC Symptoms Mean OC symptom scores are given in Table 3. OC symptoms scores ranged from 0-58 across the three timepoints in the perinatal period, from a possible range of 0-80 (Abramowitz et al., 2010). Mean total DOCS scores were high in the prenatal period (9.4 ± 9.1) and early postpartum period (9.3 ± 9.5), indicating more severe OC symptoms. Higher standard deviations indicate that OC symptoms varied considerably from participant to participant (Andrade, 2020), resultingly, median and mode of each measure of interest were also reported (Table 3). 3.5.3.2 OC Symptoms Cut-off Scores Number of participants with clinically significant symptoms of OCD based on DOCS cut-off scores are provided in Table 4. The largest proportion of clinically significant OC symptoms were reported in the prenatal period (15.6%). The least number of people experienced clinically significant OC symptoms in the later postpartum (8.7%). 3.6 Linear Regression Modelling Analyses and Results Linear regression modelling was used to examine my two predictions for hypothesis 1 (perinatal sleep difficulties predict more severe postpartum OCD symptoms): Prediction 1 - Poor prenatal sleep (i.e., higher PSQI total scores at approximately 33 weeks gestation) is predictive of more severe early postpartum OC symptoms (i.e., higher DOCS total scores at approximately 9 weeks postpartum), and Prediction 2 - Poor prenatal sleep quality (i.e., higher PSQI scores at approximately 33 weeks gestation) and poor early postpartum sleep quality (i.e., higher PSQI scores at approximately 9 weeks postpartum) is predictive of more severe OC symptoms in the later postpartum (i.e., higher DOCS total scores at approximately 20 weeks postpartum). 46 3.6.1 Associations between Predictor and Outcome Variables As a preliminary step to conducting the linear regressions, Pearson correlation was used to assess the association between perinatal sleep (i.e., PSQI total scores) and perinatal OC symptom severity (i.e., DOCS total scores). Direction and magnitude of association was tested concurrently and with each later time (i.e., prenatal sleep with early and later postpartum OC symptoms; early postpartum sleep with later postpartum OC symptoms). 3.6.2 Linear Regression Model Development Linear regression models were created and run in a step-wise manner to determine the predictive ability of perinatal sleep on postpartum OCD symptoms. Across two regression analyses, perinatal sleep was assessed as a predictor of postpartum OC symptom severity at each timepoint (one regression for each prediction). The data analytic approach was the same for predictions 1 and 2 and consequently is presented once for both predictions. Preliminary analyses were conducted between main predictors of sleep and outcome of DOCS to ensure all assumptions for linear regression were met. For the first of these analyses, prenatal sleep (i.e., PSQI total score at approximately 33 weeks gestation) was assessed as a predictor of early postpartum OC symptom severity (i.e., DOCS total score at approximately 9 weeks postpartum). In the second regression analysis, testing my second prediction, prenatal and early postpartum sleep were assessed as predictors of later postpartum OC symptom severity (i.e., DOCS total score at approximately 20 weeks postpartum). To arrive at a final regression model for the outcome of each prediction (i.e., early and later postpartum OC symptom severity) the following steps were taken based on model development guidelines described by Shipe et al. (2019). 47 3.6.2.1 Identification and Selection of Covariates In both of my linear regression analyses, potential covariates were identified using both data-driven (based on significant association with our outcome of OC symptoms) and clinically-driven (significance found in previous literature) approaches. Clinically-Driven: A literature review was conducted on the outcome of interest, postpartum OCD/OC symptoms to account for risk factors of OCD established in the literature. In order to consider all potential covariates relevant in the literature, other social and demographic variables were also considered for inclusion. This resulted in the consideration of two types of clinically-driven covariates (i.e., one of predictors specific to postpartum OCD, one of general demographic variables). Data-Driven: Correlations were run between available reproductive and demographic variables (including any Clinically-Driven variables from above) and the study outcome (i.e., OC symptoms measured as mean DOCS total scores at T2 and T3). Only variables that correlated significantly with OC symptoms at both postpartum timepoints were considered for inclusion in both final regression models. Covariates were retained in the two final models based on (1) significant support in the literature; or (2) selection from data-driven covariates. Variance inflation factor (VIF), a widely used tool to measure the degree of multicollinearity (Marcoulides & Raykov, 2019), was used to ensure no two independent variables added into the final model were too highly correlated to be included. 3.6.2.2 Model Evaluation Regression models were assessed based on goodness of fit using the adjusted coefficient of determination (Adjusted R2), with higher values indicating more variability of OC symptoms 48 explained through the addition of independent variables. The addition of main exploratory variable(s) (i.e., prenatal and early postpartum sleep) were added in a step-wise manner in order to assess if the addition significantly impacted the final model. The change in R2 was used to determine the additional variability accounted for by the addition of the exploratory variable(s). The final tested model presented in this thesis includes the main predictor(s) sleep, as well as selected covariates and prenatal OC symptoms. Results of these analyses are provided in the followings section. 3.6.3 Results of the Associations between Predictor and Outcome Variables Concurrent perinatal sleep quality and OC symptoms were significantly positively correlated at all 3 timepoints (Table 5). Additionally, prenatal sleep was significantly correlated with both early (r = .30 p < .001), and later postpartum OC symptoms (r = .32 p < .001). Early postpartum sleep was positively correlated with later postpartum OC symptoms (r = .28, p <.001). Table 5 Pearson Correlation between Perinatal Sleep Quality and Obsessive-Compulsive Symptoms Prenatal sleep Early postpartum sleep Later postpartum sleep Prenatal OC symptoms .31* Early postpartum OC symptoms .30* .31* Later postpartum OC symptoms .32* .28* .26* Note. OC = Obsessive-compulsive. *p value significant at p < .05 49 3.6.4 Results of Linear Regression Modelling Results describing the identification and selection of my covariates are presented together for both predictions 1 and 2. Model performance is evaluated separately for each model corresponding to my two predictions. 3.6.4.1 Identification and Selection of Covariates Clinically-Driven: Based on literature searches, covariates considered for inclusion were pregnancy and birthing complications, primiparity, giving birth via a cesarean section. A variety of demographic, reproductive and birthing characteristics were also considered for inclusion as covariates to replicate what has been done in previous research in this area (Osnes et al., 2019; Osnes et al., 2021; Tomfohr-Madsen et al., 2022). Based on the above, only general demographic covariates were included in the final linear regression models for both prediction 1 and 2. Although not all of these variables were seen to significantly predict early and later postpartum OC symptoms (i.e., age, marital status and education), given the abundance of literature in the field that controls for these covariates in analyses, they were nevertheless retained in my final models for both predictions (see Table 6). Data-Driven: Pearson correlations between demographic, reproductive and birthing variables and the study outcome were significant for the following variables: household income (r = -.20 and -.24, p < .001), family heritage (r = .16 and .12, p < .03), traumatic birth (r = .14 and .14, p < .01), and delivery complications (r = .10 and .12, p = .03). Each of these correlated significantly with OC symptoms at both postpartum timepoints, and consequently were considered for inclusion for both prediction 1 and prediction 2. Upon further assessment, despite being associated with OC symptoms at both postpartum timepoints, delivery complications did not significantly predict postpartum OC symptom severity at either timepoint, and thus was not 50 included in the final model (Table 6). Alternatively, household income, family heritage and traumatic birth all remained significant in the data-driven predictive model of postpartum OC symptoms, and were retained as data-driven covariates in the final model. The final selected covariates for the linear regression models assessing my two predictions included: age, household income, heritage, education, marital status, traumatic birth, and prenatal OC symptoms. Covariates were the same for both regression models of prediction 1 and prediction 2. Data on the predictive ability of the prospective and final selected covariates is provided in Table 6. Covariate VIF values were well below 5, ranging from 1.0-1.5. Consequently, no covariates needed to be removed from the final models due to concerns related to multicollinearity (Daoud 2017; Kim 2019). 51 Table 6 Clinically and Data-Driven Covariates Considered for Inclusion in Model of Perinatal Sleep Predicting Postpartum OC Symptoms Linear Regression Variables predicting OC Symptoms Early Postpartum Later Postpartum F R2 AdjR2 p F R2 AdjR2 p Covariates Considered for Inclusion Clinically-Driven OCD specific: Parity, pregnancy complications, caesarean delivery, delivery complications 1.33 .01 .00 .26 1.41 .02 .01 .23 General demographics: Age, household income, heritage, marital status, education 5.88 .08 .07 <.001 3.12 .06 .04 .01 Data-Driven Household income, heritage, delivery complications, traumatic birth 7.94 .09 .08 <.001 5.67 .08 .07 <.001 OC Symptoms Prenatal OC symptoms 431.52 .50 .49 <.001 173.17 .35 .35 <.001 Final Included Covariates Household income, heritage, marital statusa, age, education, traumatic birth, prenatal OC symptoms 44.74 .49 .48 <.001 21.47 .38 .37 <.001 Note. Bold represents variables that were statistically significant in model and contributed to Adjusted R2. aMarital status was significant predictor of OC symptoms in early postpartum but not later postpartum. 52 3.6.4.2 Model Evaluation The following section includes the results of my linear regression analyses. The regression model corresponding to each prediction was evaluated separately. Prediction 1 â Predicting early postpartum OC symptoms: The linear regression model created to assess my first prediction that poorer prenatal sleep predicts more severe OC symptoms in the early postpartum, is shown in Table 7. A more detailed summary of the final adjusted model is presented in Table 8. Table 7 shows the unadjusted model of prenatal sleep predicting early postpartum OC symptoms accounted for 9% variance in early postpartum OC symptoms, F (1, 367) = 35.35, p <0.001. In the final model after adjusting for covariates, significant variables accounted for 49% of the variance in early postpartum OC symptoms, F (8, 267) = 34.19, p <0.001. The addition of prenatal sleep significantly improved the model, and explained an additional 1% of the variance in early postpartum OC symptoms. In this final model, household income, marital status, prenatal OC symptoms, traumatic birth and prenatal sleep significantly predicted early postpartum OC symptoms (Table 8). 53 Table 7 Linear Regression Results of Prenatal Sleep Predicting OC Symptom in the Early Postpartum Model Included Variables F R2 Adjusted R2 p Unadjusted Prenatal sleep 35.35 .09 .09 <.001 Covariates Household income, heritage, marital status, age, education, traumatic birth, prenatal OC symptoms 44.74 .49 .48 <.001 Adjusted - Final Model Household income, heritage, marital status, age, education, traumatic birth, prenatal OC symptoms, prenatal sleep 34.19 .51 .49 <.001 R2 change = .01 .01 Note. OC = Obsessive-compulsive. Bold represents variables significant in model that contribute to Adjusted R2.. Table 8 Final Linear Regression Model of OC Symptoms in the Early Postpartum Variables B β β 95 % CI p Household income -2.15 E-5 -0.11 [-0.20, -0.004] .04 Heritage 0.20 0.08 [-0.01, 0.16] .07 Marital status 0.63 0.10 [0.003, 0.18] .04 Participant age 0.00 0.00 [-0.09, 0.09] .99 Education 0.56 0.06 [-0.04, 0.15] .23 Traumatic birth 2.89 0.14 [0.05, 0.21] .001 Prenatal OC symptoms 0.59 0.61 [0.48, 0.66] <.001 Prenatal sleep 0.29 0.12 [0.03, 0.20] .01 Note. OC = Obsessive-compulsive. 54 Prediction 2 â Predicting later postpartum OC symptoms: The results of my linear regression model created to assess prediction 2 (poor prenatal and early postpartum sleep predict more severe later postpartum OC symptoms), are presented in Table 9. A more detailed summary of the regression coefficients and confidence intervals (CI) for all variables and covariates included in the final adjusted model is presented in Table 10. Both prenatal sleep and early postpartum sleep were included as main independent variables as they were not too highly correlated (r = .460, p < .001) and met the assumption that multicollinearity was not a concern, PSQI T1: Tolerance = .70, VIF = 1.42; PSQI T2: Tolerance = .80, VIF = 1.25. In the unadjusted model, sleep during pregnancy and the early postpartum accounted for approximately 12% of the variance in later postpartum OC symptoms, F (2, 243) = 17.49, p <0.001. After adjusting for covariates, the final model accounted for 41% of the variance in later postpartum OC symptoms (Table 9). The addition of the independent variables, prenatal and early postpartum sleep, to the covariates significantly improved the model (Table 9), and explained an additional 3% of the variance of later postpartum OC symptoms, change in R2 = .03, p = .01. In the adjusted model, prenatal sleep, but not early postpartum sleep, significantly predicted later postpartum OC symptoms, β = 0.14, t (179) = 2.11, p = .04 (Table 10). Of note, covariates found to significantly predict later postpartum OC symptom severity included prenatal OC symptoms and traumatic birth (Table 10). 55 Table 10 Final Linear Regression Model of OC Symptoms in the Later Postpartum Variable B β β 95 % CI p Household income -1.37 E-5 -0.08 [-0.21, 0.05] .24 Heritage 0.10 0.05 [-0.05, 0.15] .35 Marital status 0.56 0.10 [-0.02, 0.21] .11 Participant age 0.04 0.02 [-0.10, 0.15] .73 Education -0.31 -0.04 [-0.15, 0.07] .51 Traumatic birth 2.30 0.14 [0.03, 0.23] .01 Prenatal OC symptoms 0.45 0.54 [0.41, 0.65] <.001 Prenatal sleep 0.26 0.14 [0.01, 0.24] .04 Early postpartum sleep 0.18 0.08 [-0.04, 0.18] .19 Note. OC = Obsessive-compulsive. Table 9 Linear Regression Results of Perinatal Sleep Predicting OC Symptoms in the Later Postpartum Model Included Variables F R2 Adjusted R2 p Unadjusted Prenatal sleep, early postpartum sleep 17.49 .13 .12 <.001 Covariates Household income, heritage, marital status, age, education, traumatic birth, prenatal OC symptoms 21.47 .38 .37 <.001 Adjusted â Final Model Household income, heritage, marital status, age, education, traumatic birth, prenatal OC symptoms, prenatal sleep, early postpartum sleep 15.67 .44 .41 <.001 R2 change = .03 .01 Note. OC = Obsessive-compulsive. Bold represents statistically significant variables that contribute to Adjusted R2.. 56 3.7 Linear Mixed-Effects Model Analysis and Results As noted above, because of the correlated nature of participantsâ data of our outcome, OC symptoms, linear mixed-effects repeated measure modelling was used to test my predictions for hypothesis 1 (perinatal sleep difficulties predict more severe postpartum OCD symptoms). As this repeated measure model includes OC symptom severity at both postpartum timepoints as the outcome, both prediction 1 and prediction 2 were tested using one multi-level model. 3.7.1 Linear Mixed-Effects Model Development To test my hypothesis that reduced perinatal sleep quality predicts more severe postpartum OC symptoms, a linear mixed-effect random intercept model was used. Early (i.e., 9 weeks) and late (i.e., 20 weeks) postpartum OC symptoms were included as repeated measure dependent variables. Prenatal (PSQI total sleep scores at 33 weeks gestation) and early postpartum sleep (PSQI total sleep scores at 9 weeks postpartum) were added as independent fixed variables to examine the contribution of both prenatal and early postpartum sleep. The main variables of study in this model are shown in Figure 3. Covariance structure for this model was selected based on Akaike Information Criterion, and first order autoregressive covariance structure was used to account for repeated measures correlation within the outcome (OC symptoms). Employing the same approach to covariate selection as in the linear mixed model regression resulted in the same covariates being included in the final model. The final model adjusted for: participant age, post-secondary education, heritage, marital status, household income, traumatic birth, and prenatal OC symptoms. For this mixed-effect model, education was recoded to characterize the completion of postsecondary education. These covariates were added as fixed effects as they do not vary across time. The categorical variable of time (i.e., early postpartum/T2 and later postpartum/T3) was also added as a fixed-effect as this was the repeated 57 measure across which the outcome was measured, and likely explains some of the variability in the outcome of OC symptoms. Each individual subject, as represented by subject ID, was added as a random intercept to account for intra-person variability, as individuals were expected to have varying levels of OC symptom severity. Figure 3 Main Independent and Dependent Study Variables in Linear Mixed-Effects Model Note. Grey shaded boxes represent dependent repeated measure variable of DOCS (i.e., OC symptoms) in the early (T2) and later (T3) postpartum. DOCS = Dimensional Obsessive-Compulsive Scale, PSQI = Pittsburgh Sleep Quality Index. T1: approximately 33 weeks gestation; T2: approximately 9 weeks postpartum; T3: approximately 20 weeks postpartum. 3.7.2 Results of Linear Mixed-Effects Model Results Fixed-effect results from my linear mixed-effects model are shown in Table 11. In the unadjusted model in which perinatal sleep were the only predictors, both prenatal (β = 0.56, 95% CI [0.31, 0.82], p < .001) and early postpartum (β = 0.35, 95% CI [0.05, 0.65], p = .02) sleep quality were significant predictors of postpartum OC symptom severity. After adjusting for 58 covariates, both prenatal and early postpartum sleep remained significant predictors of postpartum OC symptom severity, β = 0.23, 95% CI [0.03, 0.43], p = .02; β = 0.33, 95% CI [0.11, 0.54], p = .003, respectively. These results demonstrate both reduced prenatal and early postpartum sleep were longitudinally associated with more severe postpartum OC symptoms, after considering the correlated nature of the repeated measure DOCS and the variation in OC symptoms among individuals. In addition, similarly to what was found in the previously conducted linear regression models, prenatal OC symptom severity was also a significant predictor of more severe OC symptoms in the postpartum, β = 0.56, 95% CI [0.48, 0.64], p < .001. Furthermore, not experiencing a traumatic birth was also significantly predictive of less severe OC symptoms in the postpartum, β = -2.46, 95% CI [-3.89, -1.04], p < .001. 59 Table 11 Fixed Effect Estimates from Mixed-Effects Model: Results of Perinatal Sleep Predicting Postpartum OC Symptom Severity OC symptoms Variables β Coefficient Estimate β 95% CI p Unadjusted Intercept 0.44 [-1.97, 2.85] .72 Prenatal sleep 0.56 [0.31, 0.82] < .001 Early postpartum sleep 0.35 [0.05, 0.65] .02 Adjusteda Intercept -0.97 [-6.60, 4.67] .74 Timepointb 1.82 [1.04, 2.61] < .001 Prenatal sleep 0.23 [0.03, 0.43] .02 Early postpartum sleep 0.33 [0.11, 0.54] .003 Prenatal OC symptomsb 0.56 [0.48, 0.64] < .001 No traumatic birthb -2.46 [-3.89, -1.04] < .001 Note. OC = Obsessive-compulsive. aModel adjusted for participant age, household income, marital status, heritage, education, traumatic birth, and prenatal OC symptoms. bTimepoint, traumatic birth and prenatal OC symptoms were the only covariates significantly associated with postpartum OC symptom severity. 60 3.8 Chapter Summary and Conclusion To summarize the findings of this chapter, perinatal sleep in the last trimester of pregnancy was found to be a significant predictor of postpartum OC symptom severity. These results supported my first prediction as poorer sleep quality in pregnancy was found to predict more severe early postpartum OC symptoms at approximately 9 weeks postpartum. My second prediction, that reduced prenatal and early postpartum sleep quality predict more severe later postpartum OC symptom severity, was partly supported by linear regression analyses, as prenatal sleep quality emerged as a small, but still a significant predictor. After considering the repeated measure of the DOCS, the linear mixed-effects model supported these results, as prenatal sleep remained a small but significant predictor of postpartum OC symptom severity. Moreover, prenatal OC symptom severity remained a significant predictor throughout linear regression and mixed-effects model analyses, accounting for the majority of variance in my model of postpartum OC symptoms. Overall, these findings suggest that while poor earlier perinatal sleep, specifically reduced prenatal sleep, predicts more severe postpartum OC symptoms, OC symptoms during pregnancy are the most significant predictor of more severe postpartum OC symptoms. 61 Chapter 4: Exploring perinatal sleep quality among birthing parents experiencing postpartum OCD and harm thoughts 4.1 Introduction The relationship between sleep quality and OCD has been widely studied in the general population, with findings in agreement that poor sleep and higher levels of insomnia are associated with more severe OC symptoms (Cox & Olatunji, 2016; Timpano et al., 2014). In patients diagnosed with OCD, reports of disturbed sleep are extremely common (Paterson et al., 2013). Despite this, we do not currently know if the same relationship exists in the perinatal period, when the prevalence of OCD is much greater, and the risks of detrimental harm much higher for both parent and baby (Challacombe & Wroe, 2013; Fernández de la Cruz et al., 2023) When considering the unique etiology of postpartum occurring OCD, understanding how perinatal sleep quality differs among birthing people experiencing varying severities of OCD can assist in identifying individuals who are most at risk for emotional distress or mental health problems, in particular OCD, in the postpartum period. To date, few studies have assessed the relationship between perinatal sleep and symptoms of obsessive-compulsive disorder, and none to our knowledge have assessed the relationship between sleep and perinatal OCD diagnoses. Ours will be the first to assess the relationship between sleep and OCD diagnostic status, in addition to sleep and postpartum thoughts of intentional infant-related harm. Given the ubiquity of UITs of infant-related harm among birthing persons in the perinatal period, in combination with the heightened prevalence of perinatal OCD and reduced sleep during this time, research investigating the relationship between sleep and harming ideation as 62 well as sleep and OCD diagnostic status is important and has the potential to add significantly to our understanding of OCD occurring in the postpartum, allowing for more effective identification and interventions towards at-risk populations that would benefit most from such support. 4.2 Research Hypotheses and Predictions In the following chapter, I present findings from the evaluation of the following hypotheses and predictions that were used to answer the second and third research questions of this thesis: Hypothesis 2: Pregnant and postpartum people who report symptoms meeting diagnostic criteria for OCD in the perinatal period will report poorer concurrent sleep quality and increased sleep disruptions compared with those who do not report symptoms meeting diagnostic criteria for OCD. Predictions: Prenatal and postpartum sleep quality (PSQI total scores) is poorer among pregnant and birthing people who, concurrently report symptoms meeting criteria for OCD (sub-clinical or full), compared to those who do not. This is true across all timepoints: Prediction 1: Prenatally at approximately 33 weeks gestation; Prediction 2: In the early postpartum at approximately 9 weeks postpartum; Prediction 3: In the late postpartum at approximately 20 weeks postpartum. Hypothesis 3: Postpartum sleep quality (PSQI total scores) is poorer among new parents who concurrently report unwanted, intrusive thoughts of intentional infant-related harm in the postpartum compared to those who do not. This is also true across both postpartum timepoints: Prediction 1: In the early postpartum at approximately 9 weeks postpartum; 63 Prediction 2: In the later postpartum at approximately 20 weeks postpartum. In addition to testing the above two hypotheses and predictions with PSQI total score data, I also explored specific areas of sleep that may differ throughout the perinatal period using PSQI component scores. These analyses were done in an exploratory manner to guide future areas of research. 4.3 Methods Specific to this Chapter Only participants who completed the prenatal questionnaire, at least one postpartum questionnaire, and at least one postpartum interview were included in this portion of the research. A total of 375 out of a possible 763 participants fit these criteria and thus were included in the analyses for this chapter. This chapter uses data collected from questionnaire packages and interviews. Sleep quality was measured via the PSQI. OCD diagnostic status and experiences of UITs of intentional, infant-related harm were assessed via the SCID-5 and the PPII interviews. Details regarding study design, recruitment, participants, procedures, and details related to measures of sleep and OCD are described in chapter 2. 4.4 Data Analysis 4.4.1 Overview Data was analyzed using IBM SPSS Statistics (Version 28). A p value of less than or equal to .05 was considered statistically significant for all statistical hypotheses testing analyses. Descriptive statistics are reported in the form of means, standard deviations, frequencies, and percentages. 4.4.2 Missing Data Missing data for self-report questionnaires collecting information on sleep quality was included using person missing substitution (PMS) to replace single missing items within 64 subscales. PMS has been previously shown to be an acceptable imputation to account for missing data in self-report scales (Shrive et al., 2006), while still representing the original data (Downey & King 1996). 4.4.3 Outcome Variables Hypothesis Testing: In the following sections testing hypotheses 2 and 3, the main outcome was overall sleep quality (i.e., mean PSQI total scores) at each of the three perinatal timepoints assessed. Exploratory Analyses: In addition to hypotheses testing, differences in individual PSQI component scores were also assessed between groups in an exploratory fashion to identify specific features of sleep quality at each timepoint that may differ between groups studied. For these analyses, mean scores of each component of the PSQI measure (i.e., subjective sleep, sleep latency, sleep duration, sleep efficiency, sleep disturbance, medication use, daytime dysfunction) were the outcome. Given that these additional analyses were exploratory in nature and added to enhance the direction of further investigation in this area, significance corrections (e.g., Bonferroni corrections) were not utilized as is recommended with such intention (Armstrong 2014; Streiner & Norman 2011). 4.4.4 Exposure Variables 4.4.4.1 Hypothesis 2 â OCD Diagnostic Status To investigate the second hypothesis of this thesis, differences in concurrent sleep quality among those who experienced perinatal OCD were assessed. For these analyses OCD diagnostic status was the exposure variable. OCD diagnostic status collected via interviews was 65 dichotomized into either meeting sub or full clinical diagnostic status (1), or not meeting criteria (0) at each timepoint. The decision was made to include both full and sub-clinical diagnostic criteria together as âan OCD diagnosisâ for two reasons: 1) the sample of perinatal people throughout the study who experienced symptoms meeting full and sub-clinical criteria were insufficiently powered on their own, and 2) those experiencing symptoms meeting criteria for sub-clinical OCD also experience distress, utilize healthcare systems, and require additional treatment or resources (Ruscio et al., 2010). As such, these diagnostic categories were considered together in data analyses. 4.4.4.2 Hypothesis 3 â UITs of Intentional Harm For the analyses used to investigate the third hypothesis of this thesis, the exposure variable was the experience of UITs of intentional harm, which was collected during study interviews. The variable of UITs was also dichotomized to represent: (1) participants who reported UITs of intentional infant-related harm in the early or late postpartum, and (0) those who did not. 4.4.5 Specific Analyses After performing a Shapiro-Wilk test of normality on our main outcome, the distributions of sleep scores were all non-normal for the dependent variables of prenatal sleep (W = .95, p < .001), early postpartum sleep (W = .98, p = .001), and later postpartum sleep (W = .96, p < .001). Therefore, non-parametric Mann-Whitney U tests were conducted. Specifics based on hypothesis/exposure variable are described below. 4.4.5.1 Hypothesis 2 â OCD Diagnostic Status To determine if concurrent sleep quality differed between those who experienced symptoms meeting diagnostic criteria for OCD across the perinatal period, a Mann-Whitney U 66 test was conducted. At each timepoint, the study sample was stratified into those who met full or sub-clinical criteria for OCD and those that did not. Sleep quality (i.e., PSQI total scores) differences were assessed between participants who concurrently reported symptoms meeting criteria for OCD (i.e., full or sub-clinical OCD) and those who did not, were assessed. Specifically, sleep quality among participants reporting concurrent symptoms meeting criteria for OCD and those who did not was compared prenatally (at approximately 33 weeks gestation), in the early postpartum (at approximately 9 weeks postpartum), and the late postpartum (at approximately 20 weeks postpartum). As mentioned, additional exploratory analyses were run among PSQI component scores to investigate specific aspects of concurrent sleep quality that differed between those experiencing perinatal OCD (i.e., full/sub-clinical OCD diagnostic status) and those who did not, at each timepoint. 4.4.5.2 Hypothesis 3 â UITs of Intentional Harm In order to determine if concurrent postpartum sleep (at approximately 9 weeks postpartum) and later postpartum sleep (at approximately 20 weeks postpartum) differs among participants who did and did not report concurrent UITs of intentional infant-related harm, non-parametric Mann-Whitney U tests were conducted. At each timepoint, the study sample was stratified into those who concurrently reported experiencing UITs of intentional infant-related harm and those that did not, and differences between overall sleep quality (i.e., PSQI total scores) was assessed. Additionally, exploratory analyses were run among component scores of the PSQI to further study specific features of sleep quality that may differ between new birthing parents who 67 reported UITs of intentional harm related to their infant compared to those that did not report these thoughts. 4.5 Results 4.5.1 Sample Descriptives As noted above, a total of 375 participants provided data for this portion of the research. Demographic and reproductive information is provided in Table 12, stratified based on experience of prenatal sleep quality. Participants were primarily of European heritage (57.9%), had a mean age of 32.6 years, and were married/partnered or cohabiting (95.9%). Over 75% (n = 224) reported a household income over the median income (approximately $70,000) during the time of data collection (Statistics Canada, 2017). Descriptive statistics for sleep quality, OCD diagnostic status and UITs of intentional harm are summarized in Table 13. Participants reported poor sleep quality in the early postpartum, and better overall sleep quality (as represented by a lower PSQI total score) in the later postpartum (Table 13). The frequency of OCD diagnoses (either full or sub-clinical) was greatest in the early postpartum (14%, n = 47), followed by the later postpartum (8.3%, n = 28), and was lowest prenatally (Table 13). In the early postpartum, 41.7% of new parents reported experiencing unwanted, intrusive thoughts of intentional infant-related harm. This decreased slightly to 34.3% in the later postpartum. 68 Table 12 Sample Demographics Characteristic Frequency (%) Poor Prenatal Sleep (PSQI > 5) (n = 199) Good Prenatal Sleep (PSQI â¤ 5) (n = 109) Agea 32.7 (5.1)a 31.7 (4.3)a Relationship Status Single 6 (3.0) 5 (4.6) Married/partnered/cohabiting 193 (97.0) 103 (94.5) Separated/divorced 0 1 (0.9) Education Did not complete high school 3 (1.5) 1 (0.9) Completed high school 18 (9.1) 5 (4.6) Undergraduate/college education 102 (51.5) 51 (46.8) Graduate education 75 (37.8) 52 (47.7) Household Income < $70 000 36 (23.1) 21 (24.7) $70 000 â $140 000 97 (62.2) 44 (51.8) > $140 000 23 (14.7) 20 (23.5) Heritage European 121 (61.4) 59 (54.1) East Asian 18 (9.1) 16 (14.7) South Asian 17 (8.6) 3 (2.8) Southeast Asian 10 (5.1) 10 (9.2) Indigenous 3 (1.5) 3 (2.8) Latin, Central, South America 4 (2.0) 3 (2.8) Other 8 (4.0) 5 (4.6) Mixed 16 (8.1) 10 (9.2) Reproductive History and Birthb Primiparous (first delivery) 102 (51.5) 67 (61.5) Multiparous 96 (48.5) 42 (38.5) Pregnancy complications 76 (38.6) 28 ( 25.9) Vaginal delivery 125 (63.5) 69 (63.9) Cesarian delivery 72 (36.5) 39 (36.1) Delivery complications 62 (31.5) 34 (31.8) Traumatic birth 51 (25.9) 16 (15.0) Infant Feedingb Breastfeeding exclusive 127 (64.5) 84 (78.5) Formula exclusive 17 (8.6) 2 (1.9) Combination 53 (26.9) 21 (19.6) Note. PSQI = Pittsburgh Sleep Quality Index. aMean (SD). bAll variables were collected in the prenatal questionnaire except for birthing variables of pregnancy complications, mode of delivery, delivery complications, traumatic birth and infant feeding which were collected following birth. 69 4.5.2 Hypothesis 2 - OCD Diagnostic Status The following section describes the results of the analyses I conducted to test my hypothesis that birthing persons experiencing symptoms meeting sub-clinical or full diagnostic criteria for OCD in the perinatal period also experienced poorer concurrent sleep quality. 4.5.2.1 Hypothesis Testing Concurrent sleep quality between OCD diagnostic groups differed significantly at both the early (Z = -2.03, p = .04), and later postpartum (Z = -2.09, p = .04), with sleep being significantly poorer among participants reporting symptoms meeting criteria for OCD (Table Table 13 Descriptive Statistics for Study Outcome Variables Mean (SD) or Frequency (%) Characteristic Prenatal Early Postpartum Later Postpartum Sleep qualitya 7.4 (3.7) 8.0 (3.1) 6.7 (3.1) OCD diagnoses (full or sub-clinical) 12 (5.4) 47 (14.1) 28 (8.3) Full criteria 8 (3.6) 36 (10.8) 22 (6.5) Sub-clinical 4 (1.8) 11 (3.3) 6 (1.8) No OCD diagnoses 211 (94.6) 286 (85.9) 309 (91.7) Absent 207 (92.8) 280 (84.1) 265 (78.6) Partial remission 4 (1.8) 5 (1.5) 24 (7.1) Full remission 0 (0) 1 (0.3) 20 (5.9) Reported UITs of intentional infant-related harm - 129 (41.7) 113 (34.3) Note. OCD = Obsessive-compulsive disorder, UITs = Unwanted, intrusive thoughts. aSleep quality measured via mean total global score on PSQI. 70 14). Although poorer overall sleep was also reported among participants who reported prenatal OCD (Table 14), this difference was not statistically significantly (Z = -1.82, p =.07). Table 14 Mann-Whitney U Test Results of Differences in Concurrent Sleep Quality among Participants Experiencing Full or Sub-Clinical Obsessive-Compulsive Disorder and Those Not Concurrent Sleep Qualitya No OCD OCD Timepoint n M SD n M SD p Prenatal 191 6.8 3.5 11 9.1 4.0 .07 Early postpartum 268 7.6 3.0 47 9.9 2.6 .04 Late Postpartum 261 6.6 3.0 19 8.7 4.1 .04 Note. SD = Standard deviation, OCD = Obsessive-compulsive disorder, PSQI = Pittsburgh Sleep Quality Index. aPSQI total global score; sum of all components. 4.5.2.2 Exploratory Analyses Following the testing of my predictions, further exploratory analyses showed concurrent subjective sleep differed significantly between groups across all three perinatal timepoints (Table 15). In both the early and later postpartum timepoints, participants with OCD reported higher symptom severity of sleep latency (Z = -2.45, p = .01; Z = -1.98, p = .05), sleep disturbance (Z = -4.27, p< .001; Z = -2.41, p = .02) and daytime dysfunction (Z = -3.46, p< .001; Z = -2.10, p = .04). Lastly, participants with OCD in the early postpartum reported reduced concurrent sleep duration (Table 15). 71 Table 15 Mann-Whitney U Test Exploratory Results of Sleep Component Differences Among Birthing Parents Experiencing Full or Sub-Clinical Obsessive-Compulsive Disorder (OCD) and Those Not Concurrent Sleep Qualitya Mean (SD) Prenatal Early Postpartum Later Postpartum PSQI Components No OCD (n = 191) OCDb (n = 11) p No OCD (n = 268) OCDb (n = 47) p No OCD (n = 261) OCDb (n = 19) p 1. Subjective sleep 1.3 (0.7) 1.7 (0.5) .02 1.4 (0.7) 1.8 (0.8) .002 1.3 (0.7) 1.6 (0.8) .05 2. Sleep latency 1.2 (1.0) 1.6 (1.0) .14 0.6 (0.8) 1.1 (1.1) .01 1.0 (0.9) 1.4 (1.0) .05 3. Sleep duration 0.7 (1.0) 0.7 (0.8) .52 1.4 (1.0) 2.0 (0.9) <.001 0.8 (0.9) 1.1 (1.2) .39 4. Sleep efficiency 1.0 (1.1) 1.5 (1.2) .14 1.9 (1.1) 1.9 (1.2) .85 1.4 (1.1) 1.6 (1.3) .53 5. Sleep disturbance 1.7 (0.6) 1.9 (0.7) .35 1.2 (0.6) 1.6 (0.6) <.001 1.3 (0.5) 1.8 (0.6) .02 6. Medication use 0.0 (0.2) 0.3 (0.9) .43 0.0 (0.3) 0.1 (0.6) .07 0.1 (0.4) 0.2 (0.7) .87 7. Daytime dysfunction 1.0 (0.7) 1.4 (0.7) .04 1.0 (0.8) 1.5 (0.7) <.001 0.8 (0.7) 1.2 (0.8) .04 Note. SD = Standard deviation, OCD = Obsessive-compulsive disorder, PSQI = Pittsburgh Sleep Quality Index. aMean PSQI component scores. bParticipant reported symptoms meeting diagnostic criteria for either full or sub-clinical OCD. 72 4.5.3 Hypothesis 3 - UITs of Intentional Harm In this section I report findings from my hypothesis that postpartum sleep quality was poorer among new parents who concurrently reported unwanted, intrusive thoughts of intentional infant-related harm compared to those who did not. 4.5.3.1 Hypothesis Testing Results from Mann-Whitney U tests show concurrent mean sleep quality did not differ significantly between those who did and did not report experiencing UITs of intentional infant-related harm in the early postpartum (Table 16). Alternatively, concurrent later postpartum sleep quality differed significantly between individuals based on the reporting of UITs in the later postpartum, with poorer quality sleep experienced among participants who reported experiencing UITs of intentional harm, Z = -4.21, p <.001. Table 16 Mann-Whitney U Test Results of Differences in Concurrent Sleep Quality based on Reporting of UITs of Intentional Harm Concurrent Mean Sleep Qualitya No UITs of Intentional Harm UITs of Intentional Harm Timepoint n M SD n M SD p Early Postpartum 176 7.9 3.1 123 7.8 2.9 .89 Later Postpartum 182 6.2 2.9 92 7.9 3.0 <.001 Note. M = Mean, SD = Standard deviations, PSQI = Pittsburgh Sleep Quality Index, UITs = Unwanted, intrusive thoughts. aMean overall sleep quality as measured by PSQI; sum of all components. 73 4.5.3.2 Exploratory Analyses When exploring early postpartum sleep characteristic scores, none of the seven measured aspects of concurrent sleep differed between groups who did and did not report early postpartum UITs of intentional harm (Table 17). Alternatively in the later postpartum, sleep latency (i.e., the time it takes to fall asleep) and daytime dysfunction both appeared to differ between new birthing parents who did and did not report UITs of intentional infant-related harm (Z = -3.96, p < .001; Z = -3.62, p < .001), with increased sleep latency and more daytime disruptions experienced by participants who reported experiencing UITs of intentional harm. Additional characteristics of subjective sleep and sleep disturbance also appear to differ between groups, although these differences may be clinically meaningful (Table 17). 74 Table 17 Mann-Whitney U Test Exploratory Results of Sleep Component Differences among New Birthing Parents Experiencing UITs of Intentional Infant-Related Harm and Those Not Concurrent Sleep Qualitya Mean (SD) Early Postpartum Later Postpartum PSQI Components No UITs of Intentional Harm (n = 176) UITs of Intentional Harm (n = 123) p No UITs of Intentional Harm (n = 182) UITs of Intentional Harm (n = 92) p 1. Subjective sleep 1.5 (0.7) 1.4 (0.7) .48 1.2 (0.7) 1.5 (0.7) .003 2. Sleep latency 0.6 (0.8) 0.7 (0.9) .19 0.9 (0.8) 1.3 (0.9) <.001 3. Sleep duration 1.5 (1.0) 1.4 (1.0) .63 0.8 (0.9) 1.0 (1.0) .08 4. Sleep efficiency 1.9 (1.1) 1.9 (1.1) .37 1.3 (1.1) 1.5 (1.1) .21 5. Sleep disturbance 1.3 (0.6) 1.2 (0.6) .17 1.2 (0.5) 1.4 (0.5) .002 6. Medication use 0.04 (0.3) 0.06 (0.4) .21 0.06 (0.4) 0.09 (0.4) .14 7. Daytime dysfunction 1.1 (0.8) 1.2 (0.8) .27 0.7 (0.6) 1.0 (0.7) <.001 Note. SD = Standard deviation, PSQI = Pittsburgh Sleep Quality Index. UITs = Unwanted, intrusive thoughts. aMean PSQI component scores. 4.6 Chapter Summary and Conclusion In this chapter, I explored how concurrent perinatal sleep differed among perinatal birthing people experiencing OCD, as well as the differences in concurrent perinatal sleep of new parents who experience UITs of intentional infant-related harm in the postpartum. 75 Consistent with my hypothesis, concurrent perinatal sleep quality was significantly worse in birthing parents who reported experiencing OCD symptoms meeting full or sub-clinical criteria in both postpartum timepoints. While minor differences were seen in concurrent sleep quality between prenatal participants with and without OCD, these differences were not extreme enough to merit statistical significance, although the sample size of pregnant people who reported experiencing OCD prenatally was quite small (n=12). Contrary to my first prediction regarding my second hypothesis, early postpartum sleep quality did not meaningfully differ among new mothers/birthing parents who reported experiencing concurrent UITs of intentional infant-related harm. Alternatively, consistent with my second prediction, later postpartum sleep quality was significantly poorer among new birthing parents who reported experiencing concurrent UITs of intentional harm. The findings from these analyses provide insight into how differing severities of perinatal OCD experience sleep quality. Concurrent sleep quality is clearly an important aspect of postpartum OCD among those experiencing symptoms meeting full or sub-clinical criteria and should be considered in OCD screening and treatment for the healthiest postpartum experience for both the parent and their infant. 76 Chapter 5: Conclusion 5.1 Thesis Overview The purpose of this thesis research was to assess: (a) prenatal and early postpartum sleep quality as predictors of early and late postpartum OC symptoms, respectively, (b) differences in concurrent perinatal sleep quality between people with and without a diagnosis of OCD at three timepoints in the perinatal period, and (c) differences in postpartum sleep quality among participants who do and do not report concurrent postpartum UITs of infant-related intentional harm. Three hypotheses regarding perinatal sleep and postpartum OCD were constructed from the research questions and tested in this work: 1. Poor early perinatal sleep quality predicts more severe OC symptoms later in the perinatal period; 2. Perinatal sleep quality is worse among pregnant and postpartum people who concurrently report symptoms meeting full or sub-clinical diagnostic criteria for OCD; 3. Postpartum sleep quality is worse among postpartum birthing parents who concurrently report UITs of intentional infant-related harm. 5.2 Study Findings 5.2.1 Postpartum OC Symptoms To my knowledge, this represents the first prospective assessment of perinatal sleep as a predictor of postpartum OC symptom severity. Overall, it was found that poorer earlier sleep quality was a modest predictor of more severe postpartum OC symptoms. The results of linear regression analyses indicated that poor prenatal sleep was a significant predictor of both early 77 and later postpartum OC symptoms, even after controlling for various demographic and reproductive variables and prenatal OC symptom severity. While no previous work has examined the predictive ability of sleep quality on postpartum OCD symptoms, these results are consistent with findings examining the role of sleep predicting postpartum depression. Previous research has reported that poorer sleep quality during the second trimester of pregnancy was associated with increased risk for postpartum depression among birthing people over 30 years old (Gao et al., 2019). Similarly, Tomfohr et al. (2015), found that pregnant women who reported poor subjective sleep quality throughout pregnancy were more likely to experience more severe symptoms of depression in the postpartum. In the final linear regression model predicting later postpartum OC symptoms, early postpartum sleep was not a significant predictor. However, when employing multi-level mixed-effects modelling which considers the intercorrelated nature of OC symptom assessments over time, early postpartum sleep then emerged as a significant predictor of postpartum OC symptoms. This is likely due to the strong association of concurrent sleep (i.e., PSQI T2) with early postpartum OC symptoms (i.e., DOCS T2) (r = .31 p < .001). The use of repeated measures modelling to predict postpartum OC symptoms (i.e., DOCS T2 and T3) in the linear mixed-effects model considers the concurrent association between early postpartum sleep and concurrently experienced OC symptoms (Figure 2), as this finding was not seen in the linear regression model of prenatal and early postpartum sleep predicting later postpartum OC symptoms. Regardless, these findings are similar to findings in other postpartum mental health literature in which poor sleep quality in the early postpartum has been found to significantly predict later postpartum depressive symptoms (McEvoy et al., 2019). Additionally, Baattaiah et 78 al. (2023), found that poor sleep quality in the postpartum was a significant factor in predicting concurrent postpartum depressive symptoms. While it is true that earlier perinatal sleep can be considered a predictor of postpartum OC symptom severity, the analyses show that effects were small to moderate. When added into the model predicting early postpartum OC symptoms, prenatal sleep quality predicted an added 1% of OC symptoms on top of the covariates (Change in R2 = .01), while prenatal and early postpartum sleep explained an additional 3% variance in later postpartum OC symptom severity (Change in R2 = .03). Unsurprisingly, the strongest predictor of postpartum OC symptom severity was prenatal OC symptom severity, indicating that while sleep contributes to postpartum OC symptom severity, managing oneâs pre-existing symptoms of OCD in pregnancy may be more impactful in protecting against the development of more severe OC symptoms postpartum. Similar conclusions have been made in with respect to perinatal depression - prenatal depression has consistently been found to predict postpartum depression (Beck, 1996, 2001; Yim et al., 2015). Interestingly, a self-reported traumatic birth experience was found to predict postpartum OC symptoms to a similar degree as sleep. In both linear regression final models, prenatal sleep and traumatic birth each contributed similarly to predicting both early (Traumatic birth β=0.14, p = .001; Prenatal sleep β=0.12, p = .01), and later (Traumatic birth β=0.14, p = .01; Prenatal sleep β=0.14, p = .04) postpartum OC symptom severity. Multilevel modelling showed that those who experienced their birth as traumatic were significantly more likely to report severe postpartum OC symptoms. Previous research has found that a traumatic childbirth experience can cause psychological distress (Skari et al., 2002), and increases the risk of anxiety, depression and psychosis in the postpartum (Dunkel Schetter & Tanner, 2012; Rodríguez-Almagro et al., 2019). 79 It may be that participants who reported experiencing their recent childbirth as traumatic may have, at the time of the study assessments, also been suffering from symptoms of posttraumatic stress disorder (e.g., distressing dreams, memories, avoidance of reminders of the birth) (DSM-5-TR). It is possible that oneâs experience of birth trauma may lead to an increase in OC symptom severity. Evidence of this has recently been found in a community sample (Drake et al., 2023), in which symptoms of posttraumatic stress disorder were strongly associated with postpartum OC symptoms. Regardless, this predictor should possibly be considered in future research and studied further. Overall, findings from this thesis suggest prenatal and early postpartum sleep are predictors of more severe postpartum OC symptoms, although more variation in OCD symptoms was explained by prenatal OC symptom severity. 5.2.2 Perinatal Sleep Across OCD Diagnostic Categories In this thesis, I also sought to examine differences in concurrent sleep quality reported by birthing people meeting criteria for OCD (i.e., reported symptoms meeting criteria for full or sub-clinical OCD) compared to those who did not across the perinatal period. To my knowledge, this is the first study to assess the relationship between sleep quality and OCD during the perinatal period, in which OCD is assessed via diagnostic interview and not questionnaires only. As such, this research provides novel insight regarding the relationship between perinatal sleep and OCD among people for whom their symptoms meet full or sub-clinical criteria for OCD. Contrary to what was predicted, concurrent prenatal sleep quality at approximately 33 weeks gestation did not differ significantly between participants who reported symptoms meeting sub-clinical or full criteria for OCD and those who did not. Given that the number of participants who reported symptoms meeting sub-clinical or full criteria for OCD was 80 small (n = 12), it is likely the study was underpowered to detect a significant difference in sleep quality. In contrast, concurrent sleep quality at both postpartum timepoints was significantly poorer among new birthing parents who reported experiencing symptoms that met diagnostic criteria for either a sub-clinical or full postpartum OCD, as was predicted. The dissimilar findings of sleep quality differences among OCD diagnostic categories in prenatal versus both postpartum timepoints may be a function of the following: a) OCD is more common in the postpartum period; and b) postpartum sleep is qualitatively different from sleep during pregnancy. Specifically, sleep disruptions that occur during pregnancy are not the same as sleep disruptions that occur during the postpartum â primarily due to hormone changes, the new infant waking through the night, and feeding schedules (Dennis & Ross, 2005). These disruptions result in less time asleep (i.e., lower sleep duration), and more fragmented sleep (Parsons et al., 2023). It is likely that in the postpartum, sleep quality is significantly worse, and poor sleep significantly more common among birthing parents who are concurrently experiencing symptoms of full or sub-clinical OCD as a result of birth and raising an infant. Although this work is unique in that it is the first study to assess OCD diagnostically and not only via questionnaire measures of OC symptoms, some comparisons to previous literature can be made. Similar to my prenatal results, a previous study looking at insomnia and OC symptoms during the perinatal period found no difference in the number of pregnant women reporting symptoms of prenatal OCD symptoms between those with and without insomnia mid pregnancy (17 weeks gestation). This same study reported substantially more individuals who experienced mid-pregnancy insomnia also experienced postpartum OC symptoms, indicating that the relationship between prenatal sleep and postpartum OCD symptoms may be stronger and 81 more apparent than the relationship between concurrent sleep and prenatal OCD (Osnes et al., 2020). 5.2.3 UITs of Intentional Harm Lastly, in this thesis I examined how sleep during the perinatal period differed depending on participantsâ experiences of UITs of intentional harm. Given that UITs of intentional infant-related harm are associated with extreme distress (Lawrence et al., 2017), I predicted that concurrent sleep quality (in both the early and later postpartum), would be significantly reduced among those who reported postpartum UITs of intentional harm. Though this prediction was in line with othersâ expectations (Hudepohl et al., 2022; Sharma, 2019), in my sample, this prediction was only supported during the later postpartum. Early postpartum sleep quality was not poorer among parents who reported experiencing concurrent UITs of intentional harm thoughts. This suggests that the overall reduction of sleep quality seen in the early postpartum may not be associated with the occurrence of UITs of intentional infant-related harm. Similar results have been found in other work where concurrent sleep quality and intentional harm thought characteristics were not associated at both 4 and 12 weeksâ postpartum (Fairbrother et al., 2018). As predicted, later postpartum sleep quality was significantly poorer among postpartum birthing persons who reported concurrently experiencing UITs of intentional, infant-related harm. Further exploratory analyses of the components of sleep assessed showed participants who reported UITs of intentional harm differed among certain characteristics that compose sleep quality. Specifically, participants who reported UITs of intentional harm thoughts had a harder time getting to sleep, more disturbances during their sleep, poorer daytime coping due to their sleep, and overall thought their sleep was poor compared to those who did not experience UITs 82 of intentional harm. A study conducted in 2020 found that sleep-deprived adults experienced significantly more intrusive thoughts compared to normal-sleeping adults and concluded that sleep deprivation reduces oneâs ability to prevent unwanted intrusions from entering the mind (Harrington et al., 2021). Given that our findings show more severe sleep difficulties among participants who reported UITs of intentional harm in the later postpartum, but not the early postpartum, it may be that oneâs experience of these thoughtsâ changes from the early to later postpartum. Although UITs of intentional, infant-related harm are more prevalent in the early postpartum, birthing parents may be more focused on their infant, adjusting to parenting and therefore have poor sleep regardless of their thoughts as they are now waking throughout the night with a new infant. It may be that the potential relationship between UITs and sleep quality may not be discerned until later in the postpartum, when parents are more adjusted to the abrupt changes of raising an infant â making sleep difficulties more noticeable. In some cases, experiencing intentional harm thoughts that continue from the early to the later postpartum period may be more upsetting because they have persisted, and therefore are more worrying to the new parent, likely resulting in increased concern that can be associated with difficulty falling asleep, staying asleep and therefore poorer concurrent sleep quality. 5.3 Contribution to the Literature The majority of perinatal OCD literature has focused on etiology and prevalence. As mentioned, only three other studies have specifically assessed the relationship between OCD and sleep among perinatal people (Fairbrother et al., 2018; Obeysekare et al., 2020; Osnes et al., 2020). Although, none of the mentioned studies included a prospective evaluation of perinatal sleep as a predictor of postpartum OCD symptoms, nor did any include diagnostic assessments 83 of OCD. As such, this thesis is the first to model predictors of more severe postpartum OC symptoms and include earlier perinatal sleep as a predictor. This current work also provides additional insight into the relationship between perinatal sleep quality and postpartum OC symptoms and extends upon previous work (Fairbrother et al., 2018), which, similar to our findings, found that OC symptoms and concurrent sleep difficulties were positively correlated in the early postpartum (i.e., 4 weeks postpartum). Although, alternatively to the findings of this current thesis, authors Fairbrother et al. did not find the same positive correlation between OC symptoms and concurrent sleep in the later postpartum (i.e., approximately 12 weeks postpartum) (Fairbrother et al., 2018). Given that the study by Fairbrother et al. involved a small sample (N =100), the current thesis extends that work and likely provides more accurate findings of the positive association that exists between postpartum OC symptoms and concurrent sleep quality at both postpartum timepoints. Osnes et al. (2020) also assessed differences in concurrent prenatal and later postpartum OC symptoms experienced among pregnant people with insomnia, through chi-squared analyses. Similar to this thesis and Fairbrother et al., (2018) they reported a relationship between sleep and OC symptoms. Specifically, Osnes et al. found higher levels of postpartum OC symptoms among participants who reported sleep issues and insomnia during pregnancy (Osnes et al., 2020). Interestingly, Osnes et al. did not find the same was true among concurrent sleep and OC symptoms, as those experiencing concurrent insomnia during pregnancy did not experience high levels of OC symptoms. These results are similar to what was found in chapter 4 of this current thesis, although this thesis considered OCD diagnostic status via gold standard methodology of a diagnostic interview, versus only a questionnaire. While my thesis found concurrent postpartum sleep was significantly worse among birthing parents experiencing postpartum OCD, I also 84 found, similar to Osnes et al., this was not true among prenatal OCD diagnostic status and concurrent sleep quality. The only study to my knowledge to assess the relationship between UITs of intentional harm thoughts and perinatal sleep quality was that of Fairbrother et al. (2018). These authors reported no positive associations between concurrent sleep quality and characteristics of UITs of intentional harm thoughts at either 4 or 12 weeks postpartum (Fairbrother et al. 2018). As previously mentioned, this study was much smaller than the current investigation, and specifically noted that the sample size of those providing data on UITs of intentional harm thoughts was likely too small to provide conclusive estimates (Fairbrother et al., 2018). As such, this thesis likely provides more accurate data on the relationship between UITs of intentional harm and concurrent sleep quality that extends further into the postpartum period (i.e., 20 weeks postpartum). Lastly, additional exploratory analyses were run within this thesis in an attempt to probe for specific aspects (i.e., PSQI components) of sleep quality that differ among OCD diagnostic groups and those who did and did not experience UITs of intentional infant-related harm. One of the few sleep characteristics that was repeatedly found to differ between postpartum OCD diagnostic groups was sleep latency (i.e., the time it takes to fall asleep). Interestingly, the only objective study of perinatal sleep and postpartum OC symptoms found no relationship between sleep onset clock time in the third trimester and the experience of later postpartum OC symptoms (Obeysekare et al., 2020), although it is important to note that this study team conducted their work in a sample of individuals with a history of bipolar or MDD. The authors found that it was not basic sleep onset, but sleep onset relative to oneâs own internal circadian rhythm (i.e., longer phase angle) that was associated with an increase in postpartum OC symptoms at 6 weeks 85 postpartum (Obeysekare et al., 2020). Given that this current thesis relied on subjective measures, I instead focused on concurrent sleep quality and sleep latency, providing different, additional information on how sleep quality is among birthing people experiencing OCD. Overall, this work adds to the literature studying the negative impacts of reduced perinatal sleep quality. Given that poor prenatal sleep quality has previously been associated with perinatal depression and anxiety, (Osnes et al., 2019, 2020, 2021; Tomfohr et al., 2015), in addition to adverse pregnancy and fetal outcomes (Pauley et al., 2020; Sedov et al., 2019), poor sleep quality, especially during pregnancy should be assessed and managed to improve well-being of parents and infants. Extending on previous work, this thesis provides basic evidence that sleep quality, although not the strongest predictor of postpartum OC symptoms, is significantly poorer among participants concurrently experiencing OCD in the postpartum, and thus deserves clinical consideration among birthing individuals experiencing postpartum OC symptoms and OCD to enhance overall well-being. 5.4 Clinical Implications The identification of poor prenatal and early postpartum sleep as a modest predictor for increased symptoms of postpartum OCD adds to our understanding of postpartum OCD. As a practitioner, it is first and foremost crucial for healthcare providers to ask their patients about UITs and perinatal OCD. Stigma is a large barrier to parentsâ willingness to disclose mental health difficulties during the perinatal period (Bilszta et al., 2020). Due to the lack of education regarding symptoms of OCD during the perinatal period, many women and birthing people feel shame and believe that experiencing these symptoms make them âunfitâ or a âbad parent/motherâ (Moore et al., 2016; Sharma & Sommerdyk, 2015). Resultingly, mothers 86 and birthing parents frequently conceal their mental health challenges from healthcare providers and thus do not seek or receive diagnoses or treatment for OCD (Burton et al., 2022). This conversation is especially important to have with perinatal patients who have a history of mental health conditions (Sharma & Sommerdyk, 2015). Although early perinatal sleep weakly predicts postpartum OC symptom severity, it was nevertheless the case that among those experiencing full or sub-clinical postpartum OCD, it may be helpful to look at individuals concurrent sleep, and to ask perinatal people with OCD about their sleep, as improvements in sleep among birthing persons with OCD could alleviate symptoms. While sleep was not identified as a major contributor to postpartum OC symptom severity, it is nevertheless important to assess perinatal sleep and ensure parents are getting access to enough sleep given the implications of all perinatal mental health conditions, including OCD. This work provides information on how we think about sleep in relation to postpartum OCD, and can provide reassurance to parents that sleep is unlikely a significant contributor to their experience of OCD symptoms. 5.5 Strengths The strengths of this thesis work include the large sample size (n = 500; n = 375), the careful protection of participantsâ identities, and the focus throughout data collection in ensuring participants felt safe and validated during the sharing of their experiences. This allowed for maximum accuracy of data on OC symptoms and the experience of unwanted, intrusive thoughts of intentional infant-related harm â symptoms that new parents may be more hesitant to share with others (Burton et al., 2022). These UITs were carefully assessed throughout data collection. The longitudinal method of data collection allowed for the consideration of specific timepoints, variables and repeated measures over time. In addition to this method of data collection, study 87 interviews assessing OCD diagnostic status included specific questions to probe and assess perinatal and postpartum specific OCD (i.e., including specific examples of infant harm thoughts). The administration of the PSQI to assess sleep quality allowed for exploratory analyses of specific sleep characteristics that compose overall sleep quality using a commonly used and validated measure. This provided additional information that may be of interest to practitioners and researchers when considering the timing of both screening and treatment interventions for postpartum OCD. This research is the first to consider perinatal sleep as a predictor of postpartum OC symptoms â and as such fills an important gap in the literature of postpartum OCD. 5.6 Limitations This thesis has several limitations that should be considered with interpretation of study results. While this work focused on proportional hospital-based recruitment, the sample was limited to only English-speaking populations within one province, of whom the majority were high income and had a high level of post-secondary education. Additionally, substantially fewer individuals reported experiencing symptoms meeting full or sub-clinical diagnostic criteria for OCD in the prenatal period (n = 12), potentially underpowering the differences in sleep quality that could be discerned between groups in chapter 3. While this homogenous sample and smaller sample size is important, this study was a primary study conducted specifically looking at perinatal OCD and thoughts of infant-related harm, and the only study to consider perinatal sleep as a predictor of postpartum OC symptoms, and as such only represents a starting point for content in this field. This lack of diversity and power is nonetheless important to consider in the generalizability of findings for larger, country-wide populations. 88 Lastly, given that this work utilized data from a study that was previously conducted, I did not have access to information on previous/history of mental health conditions which are known predictors of postpartum OCD and have been reported in higher frequency among mothers with OCD (Challacombe et al., 2016). Although this may have reduced the predictive ability of my linear regression models, the R2 and Adjusted R2 values were similar to previous perinatal mental health literature (Baattaiah et al., 2023; Rudzik et al., 2023), and any significant findings were supported through the addition of the multi-level model. Although the analyses assessing concurrent sleep quality among different experiences of postpartum OCD were prospective in nature and no causality can be inferred, the association of significantly worse sleep occurring among postpartum birthing people simultaneously experiencing OCD provides evidence of a potential relationship that can be studied further, adding to our knowledge of postpartum OCD. 5.7 Future Research This work creates foundational components that can be built upon through future research studying OCD in the context of the postpartum. Future research can expand on this work, specifically the exploratory findings. Throughout the analyses, sleep components of sleep latency, subjective sleep, sleep disturbance and daytime dysfunction were the primary aspects of sleep that differed between participant groups. Similar to previous work, sleep medication use was the lowest across all perinatal points, reflecting the hesitation of perinatal people to use medication during pregnancy/breastfeeding (Yang et al., 2020). Future studies can focus on specific aspects of sleep quality (e.g., sleep disturbance, sleep latency) that are consistently poorer in the perinatal period (El-Sherbeeny et al., 2022), and may be uniquely linked to perinatal mental health or OCD. 89 Only one study to date has assessed perinatal sleep objectively (i.e., using actigraphy or wrist tracking) in the relationship between sleep and OCD (Obeysekare et al., 2020). Although it has been shown that subjective measures of sleep are more strongly correlated with mental health in the postpartum (Bei et al., 2010, 2015), and an important feature of OCD specifically (Simor et al., 2018), it is important to also consider objective assessments specifically for measurable elements such as sleep duration and sleep latency that have previously been more common in OCD patients (Donse et al., 2017; Paterson et al., 2013; Segalà s et al., 2021). Objective measures of perinatal sleep may provide a more accurate, unbiased account of actual sleep quality in these cases. These findings also provide insight into another prospective predictor that may be a risk factor for postpartum OC symptoms â experiencing a traumatic birth. Experiencing a traumatic birth was associated with an increased likelihood of developing more severe postpartum obsessive-compulsive symptoms. In the current research, information on traumatic birth was assessed using one single item. Future work should consider the addition of a validated screening measure created to capture data on the entirety of a traumatic birth experience (e.g., The City Birth Trauma Scale) (Ayers et al., 2018). This potential predictor can be further studied along with other obstetrical factors or experiences (e.g., fear of birth), that may also play into oneâs experience of pregnancy, birth and being a new parent. Most importantly, there remains a need for perinatal mental health research to be targeted towards more diverse populations - specifically unpartnered, lower education, lower income, minority communities, as these have repeatedly been found to be at a higher risk of poor perinatal mental health (Liu et al., 2016). Non-diverse samples are a common limitation in perinatal mental health studies, specifically among the few assessing sleep and postpartum OCD 90 (Fairbrother et al., 2018; Osnes et al., 2020), and thus should be improved upon in future work in order to enhance the generalizability of findings. 5.8 Conclusion Findings from this work show that earlier experienced perinatal sleep quality is weakly predictive of more severe postpartum OCD symptoms, with significantly worse sleep being reported by participants who concurrently report symptoms meeting full or sub-clinical criteria for postpartum OCD. Poor sleep quality, although a common experience during pregnancy and the postpartum, should not be disregarded as a modest symptom of pregnancy and raising a newborn, but instead should be assessed among birthing parents experiencing OCD symptoms in the postpartum in order to potentially alleviate symptoms, and improve postpartum health. 91 References Abramowitz, J. S., Baucom, D. 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Thesis/Dissertation
eng
Women+ and Childrenâs Health Sciences
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Hanley, Gillian E.
Fairbrother, Nichole
The role of poor perinatal sleep quality in predicting and describing postpartum obsessive-compulsive disorder
Text