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Current Psychiatry Reviews, 2007, 3, 265-270 265

Obsessive-Compulsive Disorder in the Perinatal Period: A Review of the


Literature

Shaila Misri*,1 and Kristin Kendrick2

1
University of British Columbia, Reproductive Mental Health Program, St. Paul's Hospital and BC Women's Hospital,
Rm. 2B-185, 1081 Burrard Street, Vancouver, B.C., Canada, V6Z 1Y6
2
Reproductive Mental Health Program, St. Paul's Hospital and BC Women's Hospital, Rm. 2B-185, 1081 Burrard
Street, Vancouver, B.C., Canada, V6Z 1Y6

Abstract: Few studies have examined Obsessive-Compulsive Disorder (OCD) during the perinatal period. Existing data
suggest there to be increased rates of OCD during this vulnerable period, with both new onsets and exacerbation of pre-
existing symptoms. The course of perinatal OCD appears to be varied, although trends suggest that symptoms in women
with pre-existing OCD are likely to remain consistent throughout pregnancy and become exacerbated after delivery.
Symptoms of OCD specifically associated with the perinatal period consist of: fears of contamination or germs regarding
the fetus or infant, fears of intentional or accidental harm to the fetus or neonate, and fear of losing the baby. Associated
compulsions are excessive washing and cleaning, avoidant behavior, and checking behaviors. Although many theories ex-
ist attempting to account for the etiology of OCD to this point it remains unclear. Both pharmacological treatments and
psychological treatments have shown promise for treating perinatal OCD. Further research in this area is necessary for
clinicians to better understand how to diagnose and treat OCD in pregnancy and the postpartum period.
Keywords: Obsessive-Compulsive Disorder, anxiety, pregnancy, postpartum, perinatal.

INTRODUCTION [1, 2]. In the adult population, prevalence rates seem to be


comparable for men and women [1]. However, gender dif-
Obsessive Compulsive Disorder (OCD) once thought to ferences appear to exist in terms of age of onset. The modal
be a rare disorder because of the sufferer’s secrecy around
age of onset for women ranges from 20 to 29 years of age,
reporting it to the physician, this disorder now is recognized
and is considerably higher than the modal onset for men,
as a common, condition with a chronic course of waxing and
which seems to occur in mid-adolescence. Notably, the age
waning, Acknowledging the existence of OCD in the perina-
of onset in women coincides with common years for child-
tal period is a relatively new phenomenon although clini-
bearing [1].
cians and researchers in the past two decades have made
considerable strides in understanding the specifics of the There is a paucity of research examining obsessive-
illness both in pregnancy and the postpartum. The literature compulsive symptoms during the perinatal period. A small
dedicated this topic is evolving but at the present time is lim- number of studies have examined obsessive-compulsive
ited. In this paper we attempt to review the prevalence, symptomatology during the postpartum period, and even
symptomatology, etiology, course and finally the treatment fewer have investigated OCD during pregnancy. Reports
of this tormenting illness of OCD. have estimated prevalence rates during the third trimester of
pregnancy to range from 0.2-1.2% [3, 4] and from 2.7-4%
METHODOLOGY during the postpartum period [5-7]. Of the studies that have
been published, results indicate there to be increased rates of
MEDLINE (from 1950 to May 2007), Pubmed (1949 to OCD during these significant periods of time, with rates ap-
May 2007), and PsycInfo (1887 to May 2007) databases pearing higher postnatally than antenatally.
were searched using a variety of combinations of the follow-
ing terms: ‘obsessive-compulsive’, ‘pregnancy’, and ‘post- SYMPTOMATOLOGY
partum’. Key references cited in the articles retrieved
through these searches were also reviewed. See Table 1 for a summary of the diagnostic criteria for
Obsessive-Compulsive Disorder adapted from the Diagnos-
PREVALENCE tic and Statistical Manual of Mental Disorders, 4th Edition,
Text Revision [1]. Symptoms of OCD specifically associated
Studies have estimated the lifetime prevalence of Obses- with the perinatal period have been noted, and differences
sive-Compulsive Disorder (OCD) in the general population seem to exist between those experiencing onsets during
to be 2-3%, and the one-year prevalence to be 0.5%-2.1% pregnancy versus during the postpartum period (Table 2).
Importantly, similar subclinical obsessional thoughts and
*Address correspondence to this author at the University of British Colum- compulsive behaviors have been documented in mothers
bia, Reproductive Mental Health Program, St. Paul's Hospital and BC without OCD [8, 9].
Women's Hospital, Rm. 2B-185, 1081 Burrard Street, Vancouver, B.C.,
Canada, V6Z 1Y6; Tel: 1-604-806-8589; Fax: 1-604-806-8621; E-mail:
smisri@providencehealth.bc.ca

1573-4005/07 $50.00+.00 © 2007 Bentham Science Publishers Ltd.


266 Current Psychiatry Reviews, 2007, Vol. 3, No. 4 Misri and Kendrick

Table 1. DSM-IV-TR Diagnostic Criteria for Obsessive- events were more likely to have a history of experiencing
Compulsive Disorder symptoms of depression. Additionally, OCD symptoms have
been documented to frequently occur concurrently with
A. Obsessions as defined by: panic disorder (29%) and generalized anxiety disorder (29%)
1. Recurrent and persistent thoughts, impulses, or images, which
[11].
are intrusive and inappropriate, and cause marked anxiety. Although the obsessive thoughts that accompany perina-
2. Thoughts, impulses, or images are not simply excessive worries tal OCD can cause distress, shame, and guilt for the women
about real-life problems. experiencing them, these women rarely act on these thoughts
3. The person attempts to ignore, suppress or neutralize the [15, 16]. The thoughts are typically acknowledged by these
thoughts, impulses, or images with alternative thoughts or ac- women as being generated within their minds, not making
tions. sense, and they generally do not want to or intend to act
4. The person recognizes that the thoughts, impulses, or images upon them [15]. Rarely, women experiencing severe intru-
are a product of her/his own mind. sive thoughts may deteriorate into a delusional state [17]. In
these few cases a concern regarding infanticide exists [18].
Compulsions as defined by:
1. Repetitive behaviors (e.g., hand washing, checking) that the COURSE
person is driven to perform in response to an obsession.
Little research has examined the course of OCD across
2. The behaviors or mental acts are aimed at preventing or reduc-
ing distress. the perinatal period. Studies examining perinatal onset of
obsessive-compulsive symptoms have been widely varied.
B. The person has recognized that the obsessions or compulsions are Reports have indicated that between 6% and 39% of child-
excessive or unreasonable.
bearing women experience onset during gestation [10, 13,
C. The obsessions or compulsions cause marked distress, are time 19, 20], and between 0% and 21% during the postpartum
consuming and significantly interfere with functioning. [10, 13, 19]. When the onset of symptoms occurs during
D. Symptoms are not due to another psychiatric disorder. pregnancy, it occurs during the first pregnancy for the major-
E. Symptoms are not the result of substance use or a general medical
ity of women [13, 20]. Of patients experiencing postpartum
condition. onset of symptoms, the onset appears to be rapid, occurring
Adapted from [1]. within the first four postpartum weeks [21]. Notably, these
studies relied on retrospective accounts of events, which may
have been influenced by recall biases. Prospective studies in
Table 2. Obsessive-Compulsive Symptoms Commonly Expe- this area may serve to clarify these discrepant findings.
rienced in the Perinatal Period
In addition to precipitating an onset of symptoms in some
patients, the perinatal period has also been associated with
Obsessions Compulsions
the exacerbation of symptoms in some patients with pre-
• fears of contamination or • excessive washing
existing OCD. Buttolph and Holland [19] mailed surveys to
germs related to the fetus and cleaning [5, OCD patients and found pregnancy to be associated with
[19] 19, 26] symptom worsening for 8% of female respondents. Further,
Pregnancy • fears of intentional or
the birth of a child was reportedly associated with exacerba-
accidental harm to the fe- tion of symptoms in 15% of the females that participated in
tus or losing the baby their study. Importantly, only 33% (n=60) of the original
[19, 59] sample responded to the survey, and response biases may
• fears of contamination or • avoidant behavior have existed and skewed the results. Labad and colleagues
germs related to the in- [12, 23] [10] reported similar rates of women experiencing worsening
fant [7, 10, 19, 21, 23] during pregnancy (8%), but a much higher percentage expe-
• checking behav-
• fears of intentional or iors [5, 7, 14, 21] riencing worsening in the postpartum period (50%). Of 101
accidental harm to the women who received and returned self-report questionnaires,
neonate [5, 7, 10-12, 19, • excessive cleaning
Postpartum [5, 7, 21, 23]
17% noted a worsening of their OCD symptoms during
21, 32, 59] pregnancy, whereas 11% reported improvement during ges-
• fear of separation from tation [22]. Similarly, in a study conducted by Williams and
the infant [11] Koran [13], of 29 women with pre-existing OCD who be-
• fear of criticism of moth- came pregnant, 69% reported no change in symptoms during
ering skills [59] pregnancy, 17% described symptom worsening, and 14%
reported improvement during pregnancy. This same study
reported that 29% of women experienced exacerbation of
There seem to be high levels of comorbidity between their symptoms in the postpartum period. With patients ex-
depression and OCD symptoms, with reported rates of co- periencing prior symptoms, clinicians need to be aware of
occurrence in pregnancy reported as 5% [10] and in the their potential recurrence during subsequent pregnancies and
postpartum ranging from 25%-60% [6, 9-14]. In a study by childbirths [23], and should caution their patients in this re-
Sichel and colleagues [12], in each case of comorbidity, the gard. Much more research needs to be conducted in order to
OCD symptoms preceded the development of depressive gain a better understanding of the course of OCD during the
symptoms. Labad and colleagues [10] found that women perinatal period, and factors that may contribute to differing
whose OCD symptoms seemed to be related to reproductive courses of the illness.
Obsessive-Compulsive Disorder in the Perinatal Period Current Psychiatry Reviews, 2007, Vol. 3, No. 4 267

ETIOLOGY no studies to date have examined the efficacy of pharmacol-


ogical treatment for OCD during pregnancy. In this section
Biological, sociobiological, evolutionary, and cognitive-
of treatment, the pharmacologic management is covered in
behavioral hypotheses have been proposed in attempts to
depth because it is readily accessible to clinicians but re-
elucidate the etiology of Obsessive-Compulsive Disorder
mains extremely controversial at the present time. Therefore,
[see 15]. The literature predominantly focuses on a biologi- detailed in-depth review will hopefully guide the reader in
cal hypothesis for the etiology of perinatal OCD. Bar,
making an informed decision on this subject.
Goodman, and Price [24] proposed the ‘serotonin hypothe-
sis’, which suggests that alterations in the levels of serotonin The use of quetiapine in the treatment of postpartum
may be responsible for the generation of obsessive- OCD has been examined in one study [30]. These authors
compulsive symptoms. Specifically, fluctuations in estrogen enrolled 14 women with comorbid postpartum depression
and progesterone may impact serotonin levels in the brain, and OCD, who were resistant to treatment with SSRIs or
which may trigger obsessive-compulsive symptoms both SNRIs alone, in an open-label trial of quetiapine augmenta-
during pregnancy and postpartum [see 15]. High doses of tion [30]. Eleven of the patients responded fully to this
serotonin agonists have been shown to cause an increase in medication, while one demonstrated partial improvement,
symptoms in some individuals diagnosed with OCD, provid- and two did not experience a change in their obsessive-
ing further evidence of the involvement of serotonin in OCD compulsive symptoms.
symptoms [1]. Oxytocin levels have also been associated Studies on the treatment of postpartum OCD found a
with OCD symptomatology [25]. Oxytocin is associated with reduction in symptoms following antidepressant administra-
uterine contractions and lactation [26], and therefore may tion [11, 12, 19, 23, 31, 32]. Meta-analyses have reported
play a role in the etiology of postpartum OCD; however, better results in treating OCD with clomipramine than with
there is no direct evidence suggesting this to be the case [15]. other SSRIs; however, these findings have not been repli-
Cognitive-behavioral explanations have also been pro- cated in comparative studies [see 33]. In the case of one
posed to account for the presence of obsessive and compul- woman with recurrent OCD related to pregnancy and post-
sive symptoms. The premise of the cognitive-behavioral hy- partum, 50 mg of clomipramine along with 0.5 mg of loraze-
pothesis is that the majority of adults experience thoughts pam were effective in reducing her symptoms [23]. This
that they consider intrusive and upsetting; however, some woman did not, however, respond well to fluoxetine. Other
develop clinical obsessions and compulsions as a result of investigations of clomipramine and fluoxetine have demon-
the appraisal they provide to these thoughts [27]. Proponents strated efficacy in treating perinatal OCD [12, 19, 32]. One
of this theory believe that individuals with OCD symptoms study of 15 women who presented with a new postpartum
provide a heightened level of importance and responsibility onset of obsessive-compulsive disorder investigated the effi-
to these thoughts as compared with non-OCD patients [27]. cacy of open treatment with desipramine, clomipramine,
Therefore, they begin engaging in compulsive rituals in at- fluoxetine, or a combination of these medications [12]. Each
tempts to avoid the thoughts, but the rituals actually get rein- patient initially presented as being markedly ill according to
forced due to the emotional relief that they provide, and they Clinical Global Impression scores (CGI = 5-7), and follow-
additionally reinforce the obsessive thoughts by strengthen- ing 12 weeks of treatment, four were in remission (CGI = 1),
ing the belief that they are harmful [15]. As a result, both the while the remaining 11 were only mildly ill (CGI = 2-3).
thoughts and behaviours persist [15]. Case reports of two women with postpartum onsets of obses-
sive-compulsive disorder found treatment with fluoxetine to
Sociobiological and evolutionary hypotheses propose that
be associated with symptom remission and increased levels
thoughts and behaviors associated with harming infants in- of functioning [32]. Another case study of a woman with
crease the likelihood of an individual passing on her/his ge-
postpartum-onset OCD indicated clomipramine to be effec-
netic information [see 15]. Proponents of these theories sug-
tive [31]. Arnold [11] examined the efficacy of fluvoxamine
gest that, in males, thoughts of harming infants may be have
in three patients with postpartum OCD and found that one
originated from when men were less sure of the paternity of
demonstrated no improvement, and two showed a positive
infants, and had instincts to kill offspring of other males. In
response, with decreases of 56% and 41% in total YBOCS
women, it is suggested that obsessional thoughts of harming scores.
the infant may, in fact, result in increased protective behav-
iors, thus better ensuring the survival of their offspring [see Additional considerations must be made when treating
15]. OCD with medications during pregnancy and the postpartum
period, as fetal and infant exposure must be taken into ac-
TREATMENT count. Only two case reports are presently available describ-
ing the use of quetiapine during pregnancy, and both indicate
Two modalities of treatment have demonstrated efficacy there to be no perinatal complications [34, 35]. The informa-
in the treatment of OCD in the general population: pharma- tion on quetiapine during lactation is very limited; however,
cotherapy and exposure with response prevention (ERP), a preliminary data indicates that the transfer of this medication
psychological treatment that is considered a type of cogni- into the breast milk is low and there does not appear to be an
tive-behavioral therapy (CBT) [28]. Notably, less research association between developmental outcomes and exposure
has been conducted on perinatal OCD in particular, and no to quetiapine through breast milk [36, 37]. Clearly, further
controlled studies of this illness have been undertaken. Pre- data is needed about the perinatal use of this medication be-
liminary reports examining OCD treatment during the post- fore firm conclusions can be drawn.
partum period indicate results similar to what is observed in
the general population [see 29 for a review]. Unfortunately, Results indicate that clomipramine use during pregnancy
is associated with adverse effects in newborns, particularly
268 Current Psychiatry Reviews, 2007, Vol. 3, No. 4 Misri and Kendrick

mild respiratory distress, tremors, and jitteriness, as well as therapy alone. One study which examined the treatment of
other toxic symptoms [38]. However, these effects appear to comorbid postpartum depression and anxiety found that
be transitory in nature, lasting no more than twenty-four to combined treatment with paroxetine and CBT did not pro-
forty-eight hours [38]. Further, studies of children exposed to duce significantly different results from treatment with par-
tricyclic antidepressants in utero have shown no longer term oxetine alone [55]. Both groups experienced a significant
differences in IQ, language, temperament, or mood when improvement in their symptoms of anxiety and depression;
compared to non-exposed children [39, 40]. Tricyclic antide- however, at the end of a twelve-week trial some patients
pressants seem to be quite safe for breastfeeding mothers continued to suffer from mild to moderate levels of obses-
[41]. Among the tricyclic antidepressants, desipramine and sions and/or compulsions [55]. There is little reason to as-
nortriptyline are generally preferred to clomipramine be- sume that OCD patients would respond differentially to CBT
cause of their side effect profiles. Generally speaking, how- during pregnancy and the postpartum than patients at other
ever, their side effects remain more problematic than those periods of time. Nonetheless, as onset and specific types of
associated with SSRIs, and therefore SSRIs may be a pre- symptoms seem to be somewhat more varied during these
ferred choice for some OCD patients. time frames, specific studies in this area are necessary to be
certain.
All SSRIs taken during pregnancy transfer through the
placental wall and expose the fetus to the medication [42, As common compulsions in postpartum OCD involve
43], and taken during lactation, are present in breast milk, avoiding the infant [9, 11, 12, 32], obsessive-compulsive
thereby exposing the infant [43]. Studies have examined symptoms can potentially have negative impacts on the ma-
both the short and long-term effects of prenatal exposure to ternal-infant relationship and bonding [15, 56]. If attachment
fluoxetine. Three prospective studies evaluated more than and bonding issues are of particular concern, in addition to
1,400 exposed infants and found no increase in malforma- treatment with psychotropic medications or CBT, attachment
tions [44-46]. An association has been indicated between therapies such as filial therapy [57], or infant massage [58]
fluoxetine exposure and three minor anomalies; however this may be helpful.
study did not account for the impact of maternal mood on
birth outcome [47]. Mhanna, Bennet, and Izatt [48] exam- FUTURE DIRECTIONS AND RECOMMENDATIONS
ined neonates subsequent to antenatal fluoxetine exposure
Few studies have focused specifically on the phenome-
and reported withdrawal symptoms, including jitteriness,
non of perinatal Obsessive-Compulsive Disorder, and al-
jaundice, and hypoglycemia. Nulman and colleagues [39, 40]
conducted two studies that examined the long-term effects of though there is some data regarding its prevalence, etiology,
and treatment, no clear answers are evident. Further research
prenatal fluoxetine exposure. In one of these studies, 55 ex-
in this area is necessary for clinicians to better understand
posed mother-infant dyads were followed until between 16
how to predict and treat OCD in the postpartum period, and
and 86 months after delivery [39]. No differences in IQ, lan-
even moreso during pregnancy. Specifically, prospective
guage, or behavioral development as compared both to those
studies following women from before conception, through
exposed to TCAs and to a non-exposed group were found
[39]. The second study examined 46 exposed infants up to pregnancy, and into the postpartum period would be ideal.
Further, research comparing perinatal women experiencing
71 months after birth and determined that there were no defi-
obsessive-compulsive symptoms with those who are asymp-
cits in the cognitive and language abilities of these children
tomatic is imperative.
[40]. At this time fluoxetine is the SSRI that has been most
frequently studied during lactation. Burt and colleagues [49] The societal stigma associated with mothers having
reported no adverse events in 180 of 190 infants whose thoughts of harming their children may result in women not
mothers ingested fluoxetine while breastfeeding. Moreover, discussing these issues, and therefore, may lead to underes-
the complications noted in the remaining 10 infants were timations of the prevalence of these thoughts. As women
minor [49]. Another study, which compared fluoxetine- may be hesitant to divulge these symptoms, and their preva-
treated mother-infant pairs to a control group, found that lence seems to be relatively high, as do potential conse-
those infants who had been exposed weighed slightly less quences for both mothers and their children, it may be im-
than the controls [50]. Of all the data accumulated, some portant for clinicians to directly ask about specific obses-
behavioral symptoms, such as colic and hyperactivity [51], sions and compulsions during the perinatal period, especially
have been noted, but in the majority of cases no adverse out- when dealing with women at high risk (e.g., women with a
comes have been apparent. Fluvoxamine exposure during history of obsessive-compulsive or depressive symptoms).
pregnancy and lactation have demonstrated no increased Further, as some women who do not meet diagnostic criteria
likelihood of adverse effects in newborns and up to three for perinatal OCD seem to experience similar symptoms at a
years later [see 52]. Although studies have shown no long- subclinical level, increased discourse on this topic may pro-
term negative impacts of SSRI exposure during pregnancy vide relief to a much larger population of women who do not
and lactation, further studies need to be conducted before present for treatment.
firm conclusions can be drawn. As such, alternative methods
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Received: June 13, 2007 Revised: July 4, 2007 Accepted: September 19, 2007