During the weeks before she killed her children, as she tried one psychiatric drug regimen after another, Lindsay Clancy kept a careful record of the symptoms that troubled her.
“Intrusive thoughts,” she wrote in her diary on Dec. 8, 2022. The next day, “horrible intrusive thoughts.” On the 11th, 12th and 13th, she recorded more “horrible thoughts.” By the 14th something had changed; the intensity. “HORRIBLE thoughts,” she wrote, underlining both words.
Three and a half years later, Ms. Clancy’s case has put the psychiatric changes women experience in the aftermath of childbirth at the center of a national debate. At her murder trial, which ended in a hung jury, her defense argued that she was psychotic, and could not be held legally responsible for killing her three children; prosecutors argued that she was depressed, but rational.
That she was tormented by intrusive thoughts — distressing ideas or images that pop unbidden into a person’s mind — is clear to both sides. Even the state police seemed to understand their importance; one piece of evidence they collected was a book Ms. Clancy had in her kitchen, called “Good Moms Have Scary Thoughts: A Healing Guide to the Secret Fears of New Mothers.”
The trial’s focus on intrusive thoughts, a classic symptom of anxiety disorders, has unsettled a consensus in psychiatry and underlined how little is understood about the postpartum brain.
Research has emerged in recent years showing that, as the brain prepares for the marathon task of protecting a newborn, nearly every new parent experiences unwanted thoughts of harm to their baby. Experts reassure postpartum women that this does not indicate a risk of violence; indeed, frightening thoughts may produce a protective response, much as a fear of heights may cause someone to reflexively edge back from a cliff.
But Ms. Clancy’s defense has argued that her “horrible thoughts” were something rarer and more alarming: delusions or hallucinations that signaled a spiral into postpartum psychosis. This unusual case, with its tragic outcome, has sent ripples through networks of perinatal specialists, leading some to revisit how to distinguish harmless intrusive thoughts from dangerous ones.
“I had a lot of certainty before this case,” said Karen Kleiman, the author of “Good Moms Have Scary Thoughts.” Ms. Kleiman has made it a mission to reassure new parents that intrusive thoughts are normal. She has long recommended a simple test to determine whether such thoughts might signal psychosis: If the patient found the thoughts repellent or horrifying, “we say, ‘OK, good, you’re not psychotic.’ ”
“Well, we can’t do that anymore, from this day forward,” she said. Now, she says, she would recommend that clinicians dive deeper, checking for other symptoms like mania, confusion or paranoia. She hasreached out to her publishers to consider making changes to some of the book’s illustrations and text.
“What we’re really learning is how much we don’t know,” she said. “How much the experts don’t know.”
Scary visions
In 2017, when Ms. Kleiman began soliciting women’s accounts of intrusive thoughts on the website for the Postpartum Stress Center, the treatment center she heads outside Philadelphia, the stories flooded in.
“I’m scared I’ll trip and fall while holding my baby.” “I have visions of my child running into traffic, escaping from a train, or falling into water.” “I saw their death so many times in my vision and it scared me.”
Researchers have found that thoughts like these are nearly universal in the first weeks after childbirth, for fathers as well as mothers. One possible explanation is that the brain is preparing the new parent for vigilance by directing high levels of reproductive hormones to areas that produce vivid images.
A 2022 study by Nichole Fairbrother that tracked 763 Canadian women for six months after childbirth found that 96 percent reported thoughts of accidentally harming their infant, mostly by suffocation or crib death, and 54 percent reported thoughts of intentionally harming the baby, often by shaking it or screaming at it.
Those fears were at their most intense for the first two months postpartum, then began to decline, and were largely resolved within six months.
Intrusive thoughts are classically associated with obsessive-compulsive disorder, which is more common in postpartum women, affecting around 6 to 8 percent, than in the general population, where the prevalence is around 1 to 3 percent. O.C.D. is generally treated with exposure therapy, and, if necessary, a high-dose antidepressant.
In isolation, these thoughtscan actually serve a protective function, said Dr. Julia Riddle, the director of outpatient psychiatry at the Women’s Mood Disorders Center at the University of North Carolina at Chapel Hill.
A common example, she said, is “you’re driving and you have this image of yourself blowing a stop sign and getting hit by a car. It’s probably just your brain’s way of saying, remember, stop signs are important.”
Crucially, researchers have found no association between these thoughts and abuse.
In a 2008 paper in the Archives of Women’s Mental Health, Dr. Fairbrother and Sheila Woody found that parents who had thoughts of intentionally harming their baby were, in fact, unusually vigilant. They tended to frequently check on the baby and avoid situations they saw as dangerous.
“Good Moms Have Scary Thoughts,” Ms. Kleiman’s 2019 book, was designed to deliver this reassuring message. The book was so accessible that some hospitals distributed it to new moms. Ms. Kleiman sees it as her greatest professional accomplishment, because it prompted so many women to open up about their symptoms.
When a woman confides in a professional, she said, “it is my experience that her anxiety will go from a 10 to a five,” she said. “Because someone who knows what they’re talking about is telling me I’m OK.”
Losing insight
While many new mothers experience mental changes postpartum, testimony at Ms. Clancy’s trial suggested her illness followed an atypical path.
She began feeling much worse in September 2022, when her third child, Callan, was nearly four months old and she was weaning him. She made an appointment with a psychiatrist, describing “anxiety attacks, decreased appetite, depressed mood, easily distracted, excessive worry, guilt, unable to feel pleasure, unable to fall asleep, and racing thoughts.”
Over the next months, a series of clinicians tried to identify an underlying disorder, diagnosing her, at different points, with General Anxiety Disorder, Bipolar Disorder and Major Depressive Disorder. They initiated trials of 13 different psychotropic medications, among them antidepressants, benzodiapines, antipsychotics and mood stabilizers.
But Ms. Clancy responded badly to many of the medications, which she said caused insomnia and emotional numbing. She kept trying new treatments, and kept getting worse.
In late November, Ms. Clancy first mentioned intrusive thoughts to her psychiatrist, Dr. Jennifer Tufts. At that point, it seems, the thoughts were mainly suicidal.
“Horribly intrusive thoughts, wanted it to be all over,” she messaged a nurse practitioner, Rebecca Jollotta, on Dec. 2, according to court testimony.
“I want to reassure you that it’s not uncommon, and means nothing about who you are as a mother,” Ms. Jollotta wrote back. She suggested that Ms. Clancy pick up Ms. Kleiman’s book.
In mid-December, Ms. Clancy’s thoughts seemed to become more disturbing. Her mother, Paula Musgrove, testified that Ms. Clancy approached her and Lindsay’s husband, Patrick, in the kitchen. “I remember her being very nervous,” Ms. Musgrove said. “I remember her saying, ‘I have to tell you guys something.’ And then she told us that she had thoughts of harming the children.”
Ms. Clancy has said that on January 23, 2023, her symptoms escalated, and that she experienced a command hallucination — a male voice that told her to kill her children. This, her defense argued, was postpartum psychosis, which affects between 1 and 2 of every 1,000 new mothers. Though it is treatable with mood stabilizers, postpartum psychosis is considered a clear psychiatric emergency, usually dictating hospitalization.
New questions for experts
Experts on postpartum anxiety say there is a clear distinction between anxious, intrusive thoughts, which are common and generally pose no danger, and psychotic thoughts. The important question, they said, is whether the patient finds the thought repellent or uncomfortable.
“My reading of the literature is pretty clear that when folks have O.C.D., they generally have a fear response to those thoughts,” said Jonathan Abramowitz, a professor of psychology and neuroscience at U.N.C. Chapel Hill.
In psychosis, in contrast, a person generally finds their thoughts to be believable and justified. They “wrap their reality around the thoughts.” The two experiences, he said, are “qualitatively different.” He said he had never treated or evaluated a patient with O.C.D. whose frightening thoughts had became delusions.
If that happened, he said, he would reassess the diagnosis, and consider the possibility of a psychotic disorder.
Dr. Fairbrother, the director of the Perinatal Anxiety Research Lab at the University of British Columbia, also said she had never treated a patient whose anxious, intrusive thoughts had developed into psychotic symptoms, such as hearing voices.
“That is not on the table as an option,” she said. “It would be because a new, separate, parallel disease was happening.”
A patient in psychosis typically displays other symptoms, like confusion or paranoia. With O.C.D., intrusive thoughts tend to come in the form of images, words or urges, she said; a hallucination, which occurs in psychosis, is more likely to be experienced as a voice.
This distinction is important, she said, because generations of women have been afraid to disclose severe intrusive thoughts to clinicians, fearing that their children will be taken away. It’s a reasonable fear, she added. “The chances they are met with a child-abuse related response is still very high,” she said.
But some clinicians said the boundary can be blurry.
Dr. Uruj Kamal Haider, an assistant professor of psychiatry and obstetrics and gynecology at UMass Chan Medical School, recalled a patient who was in treatment for severe intrusive thoughts, clearly understood that they were not real. But then her baby stopped sleeping well, and, after three nights without sleep, the patient hallucinated a commanding voice, which ordered her to feed a fatal dose of Ativan to her barking dog.
“What was clear is that she developed this sudden loss of insight,” Dr. Haider said. (In psychiatry, “insight” is an awareness that one’s experiences are the result of mental illness.) At that point, she treated the patient — successfully — for postpartum psychosis.
Dr. Riddle, who works on the perinatal psychiatry inpatient unit at U.N.C. Chapel Hill, said she had seen a handful of especially challenging cases in which patients in treatment for postpartum O.C.D. lost their insight, and became delusional.
She described, as an example, a patient who is afraid to take her baby outside; early on, she may understand that her fear is a symptom, and gather herself to go outside. But if she loses insight, she may come to believe, “as a concrete fact,” that the world is unsafe for her child.
“You do sort of tip into psychotic thoughts,” Dr. Riddle said. “It becomes a delusion.”
It can be difficult to discern when this is happening to a patient, she said; the best approach is to interview the other people in their lives, who may recognize emerging paranoia or changes in their behavior.
A broader challenge, as the nation considers the Clancy case, is to remind women suffering from postpartum disorders that they are “not villains or bad mothers,” so that they can feel comfortable seeking treatment, Dr. Riddle said.
“I’m excited for when it’s over, because it’s so gruesome, and it’s scaring our patients,” she said, speaking of the furor around the Clancy trial. “That’s an awful thing. And the greatest fear is, when it’s over, it all goes back into the ether, and people don’t care about women’s health again.”
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