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Obsessive-compulsive disorder in pregnant and postpartum women

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Obsessive-compulsive disorder in pregnant and postpartum women Authors Shaila Misri, MD, FRCPC Shari I Lusskin, MD, FAPA Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Oct 2013. | This topic last updated: Out 29, 2013. INTRODUCTION While the significance of depression and psychosis during pregnancy or postpartum have been widely recognized, obsessive-compulsive disorder (OCD) has not received as much attention. OCD may also occur during these periods and poses unique clinical challenges. Rigorous epidemiologic studies are not available, but women may be at an increased risk for OCD during or following pregnancy, including new-onset OCD, recurrence, or exacerbation of a chronic disorder illness. The mother's obsessional thoughts often focus on the baby, and the associated compulsive behaviors may suggest the potential for harm to the mother or child. Though relatively rare, the risk for harm should be carefully monitored. In some cases, intervention (eg hospitalization) may be required to ensure safety. OCD is an often-disabling illness that is frequently difficult to treat. Partial responses to treatment are common as are subsequent relapses [1]. Presentations during pregnancy and postpartum frequently go undetected and untreated. This topic reviews OCD during pregnancy and postpartum. The presentation, assessment, and treatment of OCD in the general population are discussed elsewhere. (See "Obsessive-compulsive disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis".) EPIDEMIOLOGY A meta-analysis of 19 retrospective studies with 6922 participants in 12 countries compared the prevalence of obsessive-compulsive disorder (OCD) among pregnant (12 studies) or postpartum women (7 studies) with the prevalence of OCD in 10 regionally matched studies of 17,955 women drawn from the general population of eight countries [2]. Estimates of the prevalence of OCD in pregnant and postpartum women were found to be greater than the estimated prevalence in the general population (2.07 and 2.43 versus 1.08 percent). Further research is needed to determine the significance of the difference in rates observed in pregnancy and postpartum, and on whether OCD prevalence differs by trimester. Several earlier, retrospective studies [3-5] suggest that OCD may be more common among pregnant and postpartum women than in the general United States population, where the estimated one-year prevalence is between 0.5 to 2.1 percent [6,7]. The only prospective study of OCD in pregnancy found a prevalence of 1.2 percent among 497 women in their third trimester, which is comparable to the general population [8]. Our clinical experience suggests that OCD is more common postpartum than during pregnancy, though research findings vary on this point [3,4,9-11]. The largest of these studies found a prevalence of 4 percent among 302 postpartum women, but this study was limited by a high rate of nonparticipation (38 percent) among the randomly selected sample [11]. Studies suggest that OCD may occur at a higher rate in the presence of postpartum depression [12,13]. Although the overwhelming majority of reported cases of postpartum OCD are women, men have been reported to develop OCD after the birth of a child [14]. Differences between women and men in age of onset of OCD have been observed. Onset in women peaks between 20 to 29 years of age, and is most common during the childbearing years, while onset in men is highest in mid-adolescence [6]. (See "Obsessive-compulsive disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis", section on 'Epidemiology'.) Section Editor Murray B Stein, MD, MPH Deputy Editor Richard Hermann, MD

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Obsessive-compulsive disorder in pregnant and postpartum women

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ETIOLOGY Obsessive-compulsive disorder (OCD) is a brain-based neurobiological disorder, but more specific knowledge about its etiology is limited (see "Obsessive-compulsive disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis"). One theory expands on the "serotonin hypothesis" of OCD, proposing that fluctuations in estrogen and progesterone during pregnancy and postpartum affect serotonin levels in the brain, leading to OCD symptoms [5,15]. Preliminary evidence suggests that onset or worsening of OCD symptoms may be associated with fluctuations of these hormones at specific points of the female reproductive cycle [16,17]. Oxytocin, a hormone that is elevated in postpartum women, also functions as a neurotransmitter; however, a relationship between postpartum oxytocin levels and OCD symptoms has not been demonstrated [18]. (See "Obsessive-compulsive disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis", section on 'Pathogenesis'.) One hypothesis derived from cognitive-behavioral theory describes a possible path for the development of postpartum obsessions and compulsions [5,19]. Many new parents may experience fleeting thoughts of harming their child. An example is the thought or mental image of shaking the baby. In people with OCD these unwanted, intrusive thoughts may be assigned a heightened level of meaning and responsibility. In order to neutralize the thought, the parent engages in compulsive rituals that produce emotional relief. This conceptualization suggests that treatment with cognitive-behavioral therapy should focus on helping the patient to understand and address maladaptive beliefs they have assigned to the intrusive thoughts. CLINICAL MANIFESTATIONS Presenting features The obsessional thinking and compulsive behaviors of obsessive-compulsive disorder (OCD) often focus on the pregnancy or baby. During pregnancy, obsessions are often about fears of fetal death or contamination [20,21]. An example of contamination is a mother's belief that she is infected and if she holds her baby the infection will spread to the baby as well. Postpartum, obsessive thoughts, or mental images of harming the baby are common, as are fears of contamination of the baby. Examples of aggressive thoughts or mental images include dropping the baby onto the floor, drowning the baby in the bathtub, throwing the baby out the window, crushing the baby's skull, or microwaving the baby [5,12,21-23]. Compulsive behaviors may include the mother's repeated requests for ultrasounds to check fetal wellbeing prior to birth, or subsequent avoidance of touching the baby, or subjecting the baby to repeated washing or changing. Other examples of obsessions and compulsions are listed in the table (table 1) [4,11,12,16,20-22,24-26]. The rate at which aggressive obsessions toward the baby lead to harmful behaviors is not known, but such acts are believed to be relatively rare. (See "Obsessive-compulsive disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis", section on 'Clinical manifestations'.) Patients with OCD often have insight into their obsessions, recognizing them as intrusive and inappropriate, though their degree of insight can vary. When severe obsessive thoughts persist over a long period of time, they can resemble fixed delusional thinking. On very rare occasions, these thoughts can progress to psychosis, where the patient believes the ideas/thoughts are real. (See "Postpartum psychosis: Epidemiology, clinical manifestations, and assessment" and "Treatment of postpartum psychosis".) Risk of harm There is a lack of research data on patient characteristics in this population that predict harmful acts, but clinical experience suggests that risk factors include the stated intent to cause harm, psychotic thoughts, poor insight, poor impulse control, accompanying severe depression, low levels of family support, or a baby with more than usual needs. Avoidance of the baby carries a risk for neglect, with the potential for severe harm or even death. Course The course of OCD during pregnancy and postpartum has not been well studied. Studies have had small samples and found mixed outcomes, with varying proportions of patients improving, worsening, and/or staying the same [9,10,20,27]. Clinically, we have observed that women often present for the first time with obsessional thoughts during pregnancy and postpartum, and these obsessions can occur with or without associated compulsions. Women who have new onset of OCD in the perinatal period tend to have a milder course. In our experience, among women with preexisting OCD, earlier onset and greater severity tends to be associated with a more severe course during pregnancy or postpartum. These patients typically experience their usual obsessions and compulsions with the addition of those that are baby-centered.

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Obsessive-compulsive disorder in pregnant and postpartum women

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SCREENING AND ASSESSMENT Screening Although screening for obsessive-compulsive disorder (OCD) among pregnant and postpartum women has not been rigorously studied, based on our experience we suggest that obstetricians or primary care clinicians administer a one-question screening in the course of prenatal and postpartum care. We suggest that clinicians caring for the mother or baby similarly screen the mother for the disorder periodically during the first six months after childbirth, beginning between week two and week four. Patients with a history of OCD should be assessed more frequently. Two illustrative screening questions include: "It's not uncommon for new mothers to experience intrusive, unwanted thoughts that they might harm their baby. Have any such thoughts occurred to you?" [28]. "Have you had any scary thoughts, for example, that you might accidentally harm the baby? Many women experience such thoughts, but are afraid to mention them." Assessment Patients who screen positive should receive a thorough psychiatric assessment that includes a diagnostic evaluation based on DSM-5 criteria for OCD [29]and considers possible alternative diagnoses. (See "Obsessive-compulsive disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis", section on 'Assessment and diagnosis'.) In evaluating the patients mental status, it is important to distinguish the obsessional thoughts of OCD from psychotic thoughts or ideas. The interviewer should explore whether the patient has insight into the false ideas and related behaviors (obsessions and compulsions) or if she believes they are real (psychosis). Particularly when the patient lacks insight into his or her illness, assessment should rule out the presence of accompanying psychotic symptoms (eg, hallucinations) that are characteristic of a psychotic disorder rather than OCD. Patients should be asked if they have intent or desire to harm the baby, others, or themselves. Patients should be evaluated for comorbid disorders, including depression and generalized anxiety disorder. Whenever possible, assessment for OCD should include secondary sources of information, such as the patient's partner or a close family member. Women with OCD are often secretive about their symptoms and may be reluctant to disclose them to a clinician due to stigma, shame, or fear that disclosure would lead to the baby being taken away. We have observed that the symptoms may come to clinical attention only when the partner or other family caregiver has to return to work and is concerned about the mother's ability to care for the child on her own. (See "Obsessive-compulsive disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis", section on 'Clinical manifestations'.) TREATMENT General principles Obsessive-compulsive disorder (OCD) is a challenging disorder to treat; only 20 percent of patients are estimated to achieve a full remission [1]. Treatment of the illness in pregnant and postpartum women can be more complex, with additional risk factors to consider and little data available to inform treatment. Some general principles to guide treatment are as follows: When the patient's illness is accompanied by factors suggesting a risk of harm to mother or baby (see 'Risk of harm' above), safety should be the foremost consideration. Interventions should be based on the likelihood of harm. In lower-risk situations, outpatient interventions may be sufficient, such as a partner or family members who will provide support, child care, and ensure the patient is not alone with the baby. In higher-risk circumstances, the mother may require hospitalization and intervention by the state department of child protective services may be required for the baby. (See "Child abuse: Social and medicolegal issues".) When multiple clinicians are treating a pregnant or postpartum woman with OCD (eg, an obstetrician or primary care clinician and a mental health specialist), communication among providers is important. Patients can be selective in revealing information related to safety, treatment compliance, or changes in severity of illness. Medication Medications shown to be effective for treatment of OCD in the general population include the serotonergic antidepressants and, for refractory cases, augmentation with atypical antipsychotic medication. (See "Pharmacotherapy for obsessive-compulsive disorder".) Deciding whether or not to prescribe one of these medications for a pregnant or nursing woman should be based,

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Obsessive-compulsive disorder in pregnant and postpartum women

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as it is for all patients, on a careful weighing of the benefits and risks of treatment, including: The severity and chronicity of the obsessions and compulsions, and the degree to which they impair patient and family functioning The risks that untreated illness present to the mother and baby (eg, avoidance, neglect, suicidality, or homicidality) The risks the medications present to the baby through exposure either in utero or during breast feeding (see "Use of psychotropic medications in breastfeeding women" and "Depression in pregnant women: Management") Decision-making is made more difficult by the paucity of research on the efficacy and adverse effects of medications. Thus, the physician may want to emphasize educating the patient and partner about risks and benefits and helping them come to an informed decision. Patient preferences can vary widely and similar patients may make very different decisions. The efficacy of medications for OCD in pregnant or postpartum women has not been tested in randomized trials. There are no published studies of any type for the serotonergic antidepressants in this population. A single uncontrolled study examined quetiapine augmentation following an inadequate response to an SSRI in 17 postpartum women with OCD. After 12 weeks of treatment, 11 of the 17 women experienced a 50 percent or greater reduction in symptoms [30]. When comorbid postpartum depression and OCD are treated with medication, first-line treatment is a serotonergic antidepressant, which can be effective for both disorders. Treatment should aimed at remission of both OCD and depression. At the start of treatment with these medications, a benzodiazepine such as lorazepam or clonazepam can be used to treat the anxiety and insomnia that may accompany the disorder or develop secondary to the medication. (See "Use of psychotropic medications in breastfeeding women" and "Depression in pregnant women: Management".). Psychotherapy Psychotherapies used to treat OCD are described elsewhere (see "Obsessive-compulsive disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis"). No placebocontrolled trials have been reported on the efficacy of psychotherapy for pregnant or postpartum women with OCD. One trial compared cognitive-behavioral therapy (CBT) and paroxetine with paroxetine alone in 35 postpartum women with comorbid depression and anxiety disorders [13]. No differences were seen between the groups receiving and not receiving CBT. Results were not reported separately for the 13 patients with OCD. Clinical experts have suggested the use of filial therapy or infant massage as adjunctive treatment when OCD interferes with attachment and bonding between the mother and child [31,32]. Filial therapy trains the mother through instruction, demonstration play, and supervision to create positive interactions with the baby, recognizing and responding to his or her emotions in an accepting environment. Symptoms suggesting the possible utility of this approach include the mother avoiding the infant, being intrusive, or being excessively clingy. Although evaluated for numerous populations, filial therapy has not been studied specifically for OCD. SUMMARY AND RECOMMENDATIONS Estimates of the prevalence of obsessive-compulsive disorder (OCD) in pregnant and postpartum women appears to be approximately two times estimates of OCD prevalence in women in the general population. (See 'Epidemiology' above.) Obsessional thoughts and compulsive behaviors in OCD during pregnancy or postpartum often concern the baby. Thoughts about contaminating or harming the baby are a common theme. Harmful behaviors are relatively rare but warrant careful assessment and intervention as needed to ensure safety. (See 'Clinical manifestations' above.) OCD may go undetected during prenatal or postpartum care. Obstetricians and primary care clinicians should consider routine screening during pregnancy and for several months post-delivery. (See 'Screening and assessment' above.) For mild OCD without immediate risks to the mother or child, we suggest treatment with cognitive-behavioral

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Obsessive-compulsive disorder in pregnant and postpartum women

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therapy (CBT) (Grade 2C). Adjunctive attachment therapy may be useful if an attachment or bonding issue is present. (See 'Psychotherapy' above.) Treatment with a serotonergic antidepressant is usually necessary for women with moderate to severe OCD. The decision to use psychotropic medication while pregnant or nursing requires informed consent via a careful discussion among the physician, the patient, and her partner of the potential risks of the medication versus the potential risks of the untreated illness. (See 'Medication' above.) When moderate-to-severe OCD is refractory to first-line treatment (serotonergic antidepressant), we suggest the patient and physician weigh the benefits and risks of the following options: augmentation with CBT, switching to a different class of serotonergic antidepressant, or augmentation with an atypical antipsychotic. (See 'Medication' above and 'Psychotherapy' above.) Attachment therapies may be useful in treating problems with attachment or bonding between mother and baby, although their use has not been studied for OCD. (See 'Psychotherapy' above.) Use of UpToDate is subject to the Subscription and License Agreement. Topic 504 Version 14.0

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Obsessive-compulsive disorder in pregnant and postpartum women

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GRAPHICS Obsessions and compulsions in pregnancy or postpartum


Obsessions
Pregnancy Fear of fetal death Fear of contaminating the fetus by toxic agents Aggressive obsessions towards fetus Postpartum Fear of intentional or accidental harm to the infant (including sexual abuse) Fear of misplacing the baby Intense fear of Sudden Infant Death Syndrome Fear of contaminating the infant Fear of criticism of mothering skills
1. Wenzel, A, et al. The occurrence of panic and obsessive compulsive symptoms in women with postpartum dysphoria: A prospective study. Archives of Women's Mental Health 2001; 4:5. 2. Uguz, F, Akman, C, Kaya, N, Cilli, AS. Postpartum-onset obsessive-compulsive disorder: incidence, clinical features, and related factors. J Clin Psychiatry 2007; 68:132. 3. Wisner, KL, Peindl, KS, Gigliotti, T, Hanusa, BH. Obsessions and compulsions in women with postpartum depression. J Clin Psychiatry 1999; 60:176. 4. Labad, J, Menchon, JM, Alonso, P, et al. Female reproductive cycle and obsessive-compulsive disorder. J Clin Psychiatry 2005; 66:428. 5. Brockington, IF, Macdonald, E, Wainscott, G. Anxiety, obsessions and morbid preoccupations in pregnancy and the puerperium. Arch Womens Ment Health 2006; 9:253. 6. Sichel, DA, Cohen, LS, Dimmock, JA, Rosenbaum, JF. Postpartum obsessive compulsive disorder: a case series. J Clin Psychiatry 1993; 54:156. 7. Jennings, KD, Ross, S, Popper, S, Elmore, M. Thoughts of harming infants in depressed and nondepressed mothers. J Affect Disord 1999; 54:21. 8. Abramowitz, JS, et al. The cognitive mediation of obsessive-compulsive symptoms: a longitudinal study. J Anxiety Disord 2007; 21:91. 9. Buttolph, M. Obsessive-compulsive disorders in pregnancy and childbirth, in Obsessive Compulsive Disorders, Theory and Management, 2nd Ed, Jenike, M, Baer, L, Minichiello, WE (Eds), Yearbook Medical Publishers, Chicago 1990. 10. Sichel, DA, Cohen, LS, Rosenbaum, JF, Driscoll, J. Postpartum onset of obsessive-compulsive disorder. Psychosomatics 1993; 34:277.

Associated compulsions
Checking for fetal movements Excessive washing and cleaning

Avoidant behavior (eg, avoiding knives, infant) Compulsive checking of the infant (eg, at night)

Excessive washing and cleaning

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