Obsessive-compulsive disorder in pregnant and postpartum women.pdf

Official reprint from UpToDatewww.uptodate.com ©2013 UpToDate

AuthorsShaila Misri, MD, FRCPCShari I Lusskin, MD, FAPA

Section EditorMurray B Stein, MD, MPH

Deputy EditorRichard Hermann, MD

Obsessive-compulsive disorder in pregnant and postpartum women

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 havebeen widely recognized, obsessive-compulsive disorder (OCD) has not received as much attention. OCD may alsooccur 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 suggestthe 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 asare subsequent relapses [1]. Presentations during pregnancy and postpartum frequently go undetected anduntreated.

This topic reviews OCD during pregnancy and postpartum. The presentation, assessment, and treatment of OCDin 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 comparedthe prevalence of obsessive-compulsive disorder (OCD) among pregnant (12 studies) or postpartum women (7studies) with the prevalence of OCD in 10 regionally matched studies of 17,955 women drawn from the generalpopulation of eight countries [2]. Estimates of the prevalence of OCD in pregnant and postpartum women werefound 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 andpostpartum, and on whether OCD prevalence differs by trimester.

Several earlier, retrospective studies [3-5] suggest that OCD may be more common among pregnant andpostpartum women than in the general United States population, where the estimated one-year prevalence isbetween 0.5 to 2.1 percent [6,7]. The only prospective study of OCD in pregnancy found a prevalence of 1.2percent 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 researchfindings vary on this point [3,4,9-11]. The largest of these studies found a prevalence of 4 percent among 302postpartum women, but this study was limited by a high rate of nonparticipation (38 percent) among the randomlyselected sample [11]. Studies suggest that OCD may occur at a higher rate in the presence of postpartumdepression [12,13].

Although the overwhelming majority of reported cases of postpartum OCD are women, men have been reported todevelop OCD after the birth of a child [14]. Differences between women and men in age of onset of OCD havebeen observed. Onset in women peaks between 20 to 29 years of age, and is most common during thechildbearing years, while onset in men is highest in mid-adolescence [6]. (See "Obsessive-compulsive disorder inadults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis", section on 'Epidemiology'.)

®®

Obsessive-compulsive disorder in pregnant and postpartum women http://www.uptodate.com/contents/obsessive-compulsive-disorder-in-p...

1 de 6 02/12/2013 05:05

ETIOLOGY — Obsessive-compulsive disorder (OCD) is a brain-based neurobiological disorder, but more specificknowledge 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 levelsin the brain, leading to OCD symptoms [5,15]. Preliminary evidence suggests that onset or worsening of OCDsymptoms may be associated with fluctuations of these hormones at specific points of the female reproductivecycle [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, anddiagnosis", section on 'Pathogenesis'.)

One hypothesis derived from cognitive-behavioral theory describes a possible path for the development ofpostpartum obsessions and compulsions [5,19]. Many new parents may experience fleeting thoughts of harmingtheir 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 thethought, the parent engages in compulsive rituals that produce emotional relief. This conceptualization suggeststhat treatment with cognitive-behavioral therapy should focus on helping the patient to understand and addressmaladaptive 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 orcontamination [20,21]. An example of contamination is a mother's belief that she is infected and if she holds herbaby the infection will spread to the baby as well. Postpartum, obsessive thoughts, or mental images of harmingthe baby are common, as are fears of contamination of the baby. Examples of aggressive thoughts or mentalimages include dropping the baby onto the floor, drowning the baby in the bathtub, throwing the baby out thewindow, 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 tobirth, 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 rateat which aggressive obsessions toward the baby lead to harmful behaviors is not known, but such acts arebelieved to be relatively rare. (See "Obsessive-compulsive disorder in adults: Epidemiology, pathogenesis, clinicalmanifestations, course, and diagnosis", section on 'Clinical manifestations'.)

Patients with OCD often have insight into their obsessions, recognizing them as intrusive and inappropriate, thoughtheir degree of insight can vary. When severe obsessive thoughts persist over a long period of time, they canresemble fixed delusional thinking. On very rare occasions, these thoughts can progress to psychosis, where thepatient 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 harmfulacts, 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 withmore than usual needs. Avoidance of the baby carries a risk for neglect, with the potential for severe harm or evendeath.

Course — The course of OCD during pregnancy and postpartum has not been well studied. Studies have hadsmall samples and found mixed outcomes, with varying proportions of patients improving, worsening, and/orstaying the same [9,10,20,27].

Clinically, we have observed that women often present for the first time with obsessional thoughts duringpregnancy and postpartum, and these obsessions can occur with or without associated compulsions. Women whohave new onset of OCD in the perinatal period tend to have a milder course. In our experience, among women withpreexisting OCD, earlier onset and greater severity tends to be associated with a more severe course duringpregnancy or postpartum. These patients typically experience their usual obsessions and compulsions with theaddition of those that are baby-centered.


2 de 6 02/12/2013 05:05

SCREENING AND ASSESSMENT

Screening — Although screening for obsessive-compulsive disorder (OCD) among pregnant and postpartumwomen has not been rigorously studied, based on our experience we suggest that obstetricians or primary careclinicians administer a one-question screening in the course of prenatal and postpartum care. We suggest thatclinicians caring for the mother or baby similarly screen the mother for the disorder periodically during the first sixmonths after childbirth, beginning between week two and week four. Patients with a history of OCD should beassessed more frequently. Two illustrative screening questions include:

Assessment — Patients who screen positive should receive a thorough psychiatric assessment that includes adiagnostic 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, anddiagnosis", section on 'Assessment and diagnosis'.)

In evaluating the patients’ mental status, it is important to distinguish the obsessional thoughts of OCD frompsychotic thoughts or ideas. The interviewer should explore whether the patient has insight into the false ideas andrelated behaviors (obsessions and compulsions) or if she believes they are real (psychosis). Particularly when thepatient lacks insight into his or her illness, assessment should rule out the presence of accompanying psychoticsymptoms (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 beevaluated for comorbid disorders, including depression and generalized anxiety disorder.

Whenever possible, assessment for OCD should include secondary sources of information, such as the patient'spartner or a close family member. Women with OCD are often secretive about their symptoms and may bereluctant to disclose them to a clinician due to stigma, shame, or fear that disclosure would lead to the baby beingtaken away. We have observed that the symptoms may come to clinical attention only when the partner or otherfamily 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, anddiagnosis", section on 'Clinical manifestations'.)

TREATMENT

General principles — Obsessive-compulsive disorder (OCD) is a challenging disorder to treat; only 20 percent ofpatients are estimated to achieve a full remission [1]. Treatment of the illness in pregnant and postpartum womencan be more complex, with additional risk factors to consider and little data available to inform treatment. Somegeneral 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 ofharm' above), safety should be the foremost consideration. Interventions should be based on the likelihood ofharm. In lower-risk situations, outpatient interventions may be sufficient, such as a partner or family members whowill provide support, child care, and ensure the patient is not alone with the baby. In higher-risk circumstances, themother may require hospitalization and intervention by the state department of child protective services may berequired 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 primarycare clinician and a mental health specialist), communication among providers is important. Patients can beselective 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 theserotonergic 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,

"It's not uncommon for new mothers to experience intrusive, unwanted thoughts that they might harm theirbaby. Have any such thoughts occurred to you?" [28].

●

"Have you had any scary thoughts, for example, that you might accidentally harm the baby? Many womenexperience such thoughts, but are afraid to mention them."

●


3 de 6 02/12/2013 05:05

as it is for all patients, on a careful weighing of the benefits and risks of treatment, including:

Decision-making is made more difficult by the paucity of research on the efficacy and adverse effects ofmedications. Thus, the physician may want to emphasize educating the patient and partner about risks and benefitsand helping them come to an informed decision. Patient preferences can vary widely and similar patients maymake 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 singleuncontrolled study examined quetiapine augmentation following an inadequate response to an SSRI in 17postpartum women with OCD. After 12 weeks of treatment, 11 of the 17 women experienced a 50 percent orgreater reduction in symptoms [30].

When comorbid postpartum depression and OCD are treated with medication, first-line treatment is a serotonergicantidepressant, which can be effective for both disorders. Treatment should aimed at remission of both OCD anddepression. At the start of treatment with these medications, a benzodiazepine such as lorazepam or clonazepamcan be used to treat the anxiety and insomnia that may accompany the disorder or develop secondary to themedication. (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-compulsivedisorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis"). No placebo-controlled trials have been reported on the efficacy of psychotherapy for pregnant or postpartum women withOCD. One trial compared cognitive-behavioral therapy (CBT) and paroxetine with paroxetine alone in 35postpartum women with comorbid depression and anxiety disorders [13]. No differences were seen between thegroups 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 OCDinterferes with attachment and bonding between the mother and child [31,32]. Filial therapy trains the motherthrough instruction, demonstration play, and supervision to create positive interactions with the baby, recognizingand responding to his or her emotions in an accepting environment. Symptoms suggesting the possible utility of thisapproach include the mother avoiding the infant, being intrusive, or being excessively clingy. Although evaluated fornumerous populations, filial therapy has not been studied specifically for OCD.

SUMMARY AND RECOMMENDATIONS

The severity and chronicity of the obsessions and compulsions, and the degree to which they impair patientand family functioning

●

The risks that untreated illness present to the mother and baby (eg, avoidance, neglect, suicidality, orhomicidality)

●

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")

●

Estimates of the prevalence of obsessive-compulsive disorder (OCD) in pregnant and postpartum womenappears 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 thebaby. Thoughts about contaminating or harming the baby are a common theme. Harmful behaviors arerelatively rare but warrant careful assessment and intervention as needed to ensure safety. (See 'Clinicalmanifestations' above.)

●

OCD may go undetected during prenatal or postpartum care. Obstetricians and primary care clinicians shouldconsider routine screening during pregnancy and for several months post-delivery. (See 'Screening andassessment' above.)

●

For mild OCD without immediate risks to the mother or child, we suggest treatment with cognitive-behavioral●


4 de 6 02/12/2013 05:05

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 504 Version 14.0

therapy (CBT) (Grade 2C). Adjunctive attachment therapy may be useful if an attachment or bonding issue ispresent. (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 carefuldiscussion among the physician, the patient, and her partner of the potential risks of the medication versusthe potential risks of the untreated illness. (See 'Medication' above.)

●

When moderate-to-severe OCD is refractory to first-line treatment (serotonergic antidepressant), we suggestthe 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 andbaby, although their use has not been studied for OCD. (See 'Psychotherapy' above.)

●


5 de 6 02/12/2013 05:05

GRAPHICS

Obsessions and compulsions in pregnancy or postpartum

Obsessions Associated compulsions

Pregnancy Fear of fetal death Checking for fetal movements

Fear of contaminating the fetus by toxic agents Excessive washing and cleaning

Aggressive obsessions towards fetus

Postpartum Fear of intentional or accidental harm to theinfant (including sexual abuse)

Avoidant behavior (eg, avoidingknives, infant)

Fear of misplacing the baby Compulsive checking of theinfant (eg, at night)

Intense fear of Sudden Infant Death Syndrome

Fear of contaminating the infant Excessive washing and cleaning

Fear of criticism of mothering skills

1. Wenzel, A, et al. The occurrence of panic and obsessive compulsive symptoms in women with postpartumdysphoria: 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 postpartumdepression. J Clin Psychiatry 1999; 60:176.4. Labad, J, Menchon, JM, Alonso, P, et al. Female reproductive cycle and obsessive-compulsive disorder. JClin Psychiatry 2005; 66:428.5. Brockington, IF, Macdonald, E, Wainscott, G. Anxiety, obsessions and morbid preoccupations inpregnancy and the puerperium. Arch Womens Ment Health 2006; 9:253.6. Sichel, DA, Cohen, LS, Dimmock, JA, Rosenbaum, JF. Postpartum obsessive compulsive disorder: a caseseries. J Clin Psychiatry 1993; 54:156.7. Jennings, KD, Ross, S, Popper, S, Elmore, M. Thoughts of harming infants in depressed and nondepressedmothers. 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 CompulsiveDisorders, Theory and Management, 2nd Ed, Jenike, M, Baer, L, Minichiello, WE (Eds), Yearbook MedicalPublishers, Chicago 1990.10. Sichel, DA, Cohen, LS, Rosenbaum, JF, Driscoll, J. Postpartum onset of obsessive-compulsive disorder.Psychosomatics 1993; 34:277.


6 de 6 02/12/2013 05:05

Documents

Obsessive-compulsive disorder in pregnant and postpartum women.pdf