Obsessive-Compulsive

Disorder in the Perinatal Period

by Kayla Johnson, BSN

Abstract: Obsessive Compulsive Disorder

(OCD), classified as a chronic anxiety
disorder, is the fourth most prevalent
mental health illness. A relationship exists between the perinatal period and the
initiation or worsening of OCD symptoms. Pregnancy and childbirth have been
acknowledged as the most frequent life
events to initiate OCD onset and exacerbation. OCD is characterized by persistent, intrusive obsessions and recurring,
anxiety-reducing compulsions. Aggressive
obsessions are the most commonly reported symptoms in the perinatal period, with
thoughts predominately focusing on the
fear of having an unhealthy baby, inadequacy as a mother, or fear of accidently
or intentionally harming the newborn.

& Storch, 2009). OCD has dramatic effects on a pregnant

womans quality of life, requiring knowledge of contemporary theories of OCD etiology and pathogenesis, incidence,
characteristics and symptoms, assessment and diagnosis, and
treatment of perinatal OCD. Nurses are in a unique position
to offer awareness, education, and support in the identification and treatment of perinatal OCD.

Etiology
Extensive research has been conducted on the causes of
OCD within the general population, but gaps remain in the
literature regarding the etiology of perinatal OCD and obsessive-compulsive symptoms (OCS). Development is believed
to result from an interaction of biological and psychological
factors (Abramowitz et al., 2003; Chaudron & Nirodi, 2010;
Speisman et al., 2011).

Intrusive unwanted thoughts (thats

dirty) are obsessions. Pressure to repeat
unnecessary ritualistic tasks (hand
washing) are compulsions.

Keywords: obsessive-compulsive disorder, pregnancy, postpartum

Pregnancy and the postpartum period have been associated with an increase in the onset and worsening of psychiatric conditions such as mood disorders, psychotic disorders,
and anxiety disorders. Obsessive-compulsive disorder (OCD),
a chronic anxiety disorder first described 100 years ago
(Samuels & Nestadt, 1997), is characterized by persistent,
intrusive, and unwanted thoughts (obsessions) and physical or mental acts ritualistically completed to decrease high
levels of anxiety associated with the thoughts (compulsions;
Christian & Storch, 2009). A correlation between pregnancy
and the onset of OCD appears to exist, with studies proposing pregnancy and childbirth to be the most frequent life
events to initiate OCD onset and exacerbation (Christian

Biological Factors
Alterations in serotonin, a neurotransmitter in the brain,
has been linked to the development of OCD symptoms. In
addition to serotonin, estrogen, progesterone, and oxytocin
are also thought to be involved in OCD onset. The reproductive hormones estrogen, progesterone, and oxytocin are significantly increased during pregnancy. Evidence has revealed
that fluctuations in estrogen and progesterone, occurring in
late pregnancy, may alter serotonin transmission, reuptake,
and binding. The onset of OCD or the exacerbation of
symptoms may result from the rapid shifts in these hormones, affecting serotonin functioning, which in turn affects
a patients mood state (Abramowitz, Schwartz, Moore, Lucontinued on next page

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enzmann, 2003). Leckman et al. (as cited in Abramowitz et
al., 2003) found a link between OCD severity and oxytocin
levels. An increased concentration of oxytocin, a hormone
involved in uterine contractions and lactation during late
pregnancy and the postpartum period, may be associated
with an increase in OCD symptoms in the perinatal period
(Abramowitz et al., 2003; Chaudron & Nirodi, 2010).

Psychological Factors
Biological factors are etiologically important in the
onset of OCD; however, other factors such as psychological stress also play a role in its initiation. Biological factors
alone, for example, do not explain incidence of OCD in
the partners of childbearing women. Abramowitz, Moore,
Carmin, Wiegartz, and Purdon (as cited in Fairbrother &
Abramowitz, 2007) studied four previously healthy fathers
who experienced a sudden onset of OCD symptoms during
their partners pregnancy or after the birth of the child. The
results were similar to those in the studies of females with
postpartum OCS. In a later study conducted by Abramowitz,
Schwartz, and Moore (as cited in Fairbrother & Abramowitz, 2007), 40 fathers of newborns were surveyed, and 58%
reported unwanted and distressing thoughts related to the
possibility of harm to the newborn.

Epidemiology/Incidence
OCD, once considered a rare psychiatric disorder,
affecting only 1 in 1,000 individuals, is currently known to
occur more frequently in varying degrees of intensity (Kalra
& Swedo, 2009). OCD is the fourth most common mental health disorder in Canada and the United States and is
diagnosed almost as often as asthma and diabetes mellitus
(Tzu-Chi et al., 2010). OCD may develop during pregnancy,
or pregnancy may aggravate and increase exacerbation of
previously present OCS (Uguz et al., 2007). Recent studies
have shown a higher than expected prevalence of OCD in
pregnant women when compared to the general population,
with prevalence of postpartum OCS ranging from 4% to 9%
(Uguz, Kaya, Gezgin, Kayhan, & Cicek, 2011).

Symptoms and Comorbidities

New evidence on the frequency of perinatal OCD translates into a need to understand symptoms and comorbidities
of OCD. A comorbid condition is a disorder that often occurs

simultaneously with another disorder (Varcarolis & Halter,

2010). Obsessions and compulsions are the defining characteristics of OCD. Obsessions are defined as distressing and
repetitive thoughts, feelings, or images that cannot be ignored
(Christian & Storch, 2009). Compulsions are repetitive acts,
which may be observable behaviors or covert mental rituals,
that are performed in an effort to reduce the anxiety associated with these obsessions (Christian & Storch, 2009). Completing the compulsion reduces the severe anxiety, but only
temporarily (Speisman, Storch, & Abramowitz, 2011). Because
the decrease in anxiety is only temporary, the compulsions
must be repeated, making them time consuming and causing
impairment in daily functioning (Speisman et al., 2011).
Perinatal obsessions and compulsions are specific and
relatively consistent in content. Women with OCD symptoms during pregnancy frequently report contamination
obsessions and the need for constant washing or cleaning
behaviors, while women with the onset of symptoms following birth report obsessive thoughts of harming the newborn
(Abramowitz, Schwartz, Moore, & Luenzmann, 2003; Zambaldi, et al., 2009). The obsessions and compulsions cause
extreme distress and may affect the ability of the mother to
care for her newborn, leading to negative fetal outcomes,
long-term behavioral challenges, and impaired motherinfant bonding (Chaudron & Nirodi, 2010; Fairbrother
& Abramowitz, 2007; Gezgin et al., 2008; Vythilingum,
2008). Fear of having an unhealthy baby and fear of inadequacy as a mother were the two most reported symptoms
by pregnant women with varying degress of OCD.
Distressing obsessive thoughts should be differentiated between delusions and psychosis, which are present in
postpartum psychosis. In postpartum onset OCD, women
have insight into the irrationality of their thoughts and
avoid situations related to the obsessions due to the fear of
acting on them (Brandes, Soares, & Cohen, 2004). Patients
with postpartum psychosis, however, have no such distress,
increasing the risk for the mother to act on the thoughts
and actually harm the newborn (Brandes, Soares, & Cohen,
2004; Lord, Rieder, Hall, Soares, & Steiner, 2011).
Symptoms characteristic of other psychiatric disorders
are commonly noted in individuals affected by OCD. Major
depressive disorder is a mental health illness commonly seen
with OCD. The rate of depression with OCD ranges from
13% to 75% (Fontenelle, et al., 2012; Mahasuar, Janardhan
Reddy, & Math, 2011). Women may feel ashamed for having
these thoughts and may wonder what kind of mother they
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are, contributing to the onset of depressive symptoms. In a
study of 15 women, Sichel, et al. (as cited in Brandes, et al.,
2004) reported that 60% of the participants developed secondary major depression two to three weeks after the onset
of OCD. Women with postpartum OCD and depression
have significantly more obsessions, particularly more aggressive obsessions, than women without depression (Speisman,
et al., 2011). Additional mental health illnesses that often
occur with OCD include bipolar disorder, eating disorders,
Tourette syndrome, impulse control disorders, panic attacks,
post-traumatic stress disorder, social phobia, paranoia, substance abuse, and schizophrenia (Connelly, 2008).

Assessment and Diagnosis

Anne Jordan Photography

OCD, which can arise as a primary or secondary disorder, is not always accurately diagnosed. According to the
Diagnostic and Statistical Manual of Mental Disorders (as cited
in Varcarolis & Halter, 2010), OCD is an anxiety disorder
that includes the presence of either obsessions or compulsions, awareness that the obsessions and compulsions are
excessive and unreasonable, and the obsessions or compulsions must cause increased distress and be time-consuming.

Because those suffering from the disorder are often embarrassed and attempt to hide their obsessions and compulsions,
inaccurate diagnosis commonly occurs. Women suffering
from postpartum OCD are disinclined to discuss symptoms
with healthcare providers because of fear that the newborn
will be taken away by child welfare authorities (Brandes et
al., 2004). OCD often occurs simultaneously with other
mental health disorders, making misdiagnosis relatively common. A woman with OCD, who suffers from depression and
hides her obsessions and compulsions, may be misdiagnosed
with only depression. These factors may lead to inappropriate referrals to specialists, impair diagnosis, and prolong
accurate and efficient treatment (Taylor, 2009).

A woman with OCD, who suffers from

depression and hides her obsessions and
compulsions, may be misdiagnosed with
only depression.
Primary care physicians, obstetricians, pediatricians,
and psychiatrists should screen for symptoms of OCD early
in the postpartum period, preferably within two to four
weeks following delivery. During the postpartum follow-up
or well-baby visit, women should be asked, It is not unusual
for new mothers to have unwanted thoughts about harming their newborn. Have you experienced similar thoughts?
Healthcare professionals should also assess for compulsive
behaviors, such as excessive checking, cleaning, and orderliness (Brandes, et al., 2004). Once a healthcare professional
verifies the presence of these symptoms, the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) can be used to identify
the severity of the symptoms. The severity of OCD depends
on the degree of distress the obsessions and compulsions
produce, as well as the amount of daily functioning that is
impaired (Pignotti & Thyer, 2011; Taylor, 2009).
Although a tool to assess OCD in pregnancy is currently
not available, Lord et al. (2011) developed a paper-and-pencil,
self-report scale to assess the content, context, severity, and
onset of obsessions and compulsions during the perinatal period. Lord, et al. had participants complete prenatal or postnatal
versions of the Perinatal Obsessive-Compulsive Scale (POCS),
as well as the Y-BOCS. The prenatal version of the POCS
consisted of seven pregnancy and infant-related thoughts and
nine behaviors, while the postnatal version contained nineteen
thoughts and fourteen behaviors (Lord, et al., 2011).
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Treatment
Treatment for postpartum OCD should be similar to
the treatment used for OCD in the general population.
Cognitive-behavioral therapy and pharmacotherapy with
selective serotonin reuptake inhibitors (SSRIs) are two
options for OCD symptom management. Treatment must
focus on the specific features of postpartum OCD including
sudden onset, uncertain course of symptoms, and the fact
that many medications have not been tested in breastfeeding
women. The treatment must also be individualized, must address risks and benefits, and incorporate patient preferences
(Brandes et al., 2004; Speisman et al., 2011).

Cognitive-Behavioral Therapy
Cognitive-behavioral therapy (CBT) is considered to
be the most effective psychological treatment for OCD in
the general population (Pence, Aldea, Sulkowski, & Storch,
2011). CBT may also be successful for postpartum OCD,
especially in mothers who present with both obsessions
and compulsions. CBT is a beneficial treatment option for
mothers choosing to breastfeed because it eliminates the
possibility of exposing the newborn to psychotropic medications through breast milk (Brandes, et al., 2004). CBT
often involves altering the patients dysfunctional thoughts
and reducing compensatory rituals through exposure and
response prevention (ERP; Pignotti & Thyer, 2011). During ERP, therapists expose the patient to stimuli that evoke
their symptoms. After exposure, the patient is encouraged to
withhold from completing the anxiety-reducing compulsion
for at least an hour or until the anxiety is relieved. The clinician and patient work together to determine the situations
that trigger symptoms, and the clinician then demonstrates
the activities before it is actually conducted. To increase
effectiveness, therapists recommend that the patient attend
90-minute sessions three to five days a week for several
weeks, during which time homework is also assigned. ERP
therapy has produced 60%-80% improvement in those who
complete the treatment (Pignotti & Thyer, 2011). A case
study by Christian and Storch (as cited in Speisman, et al.,
2011) reported substantial improvement and long-term remission of postpartum OCD in a woman after eight sessions
of ERP.

Pharmacotherapy
Despite evidence of effectiveness in some patients, the
use of ERP in patients experiencing obsessive thoughts without compulsions, which is often seen in postpartum OCD,
has produced inconsistent results. Pharmacological treatment may be an effective treatment option with this specific
clinical presentation. The clinician, however, must carefully consider the risks if the mother chooses to breastfeed
(Brandes et al., 2004). SSRIs are the first-line medications
used in OCD. SSRIs include fluoxetine (Prozac), sertraline
(Zoloft), fluvoxamine (Luvox), paroxetine (Paxil), citalopram
(Celexa), and escitalopram (Lexapro). Pharmacotherapy
should be continued for at least one year in patients with
postpartum OCD because the relapse period, which may occur with premature discontinuation of the medication, has a
poor response to treatment (Brandes, et al., 2004). Although
no current evidence suggests that postpartum OCD patients
will respond differently to the standard treatment used for
OCD outside the perinatal period, controlled studies need
to be conducted in order to determine the true efficacy
of pharmacotherapy and cognitive-behavioral treatments
(Abramowitz, et al., 2003; Speisman, et al., 2011).

Implications for Practice

Pregnancy is a significant life event and a period of extreme emotional change for a woman, producing stress and
anxiety. Pregnant women and those who have recently given
birth, have a substantially increased risk for the onset of various psychiatric disorders. Childbearing, from the standpoint
of psychological medicine, is the most complex event in
human experience (Brockington, Macdonald, & Wainscott,
2006, p. 253). Though postpartum psychiatric disorders have
been investigated by researchers and clinicians for decades,
focus has often centered on mood disorders; considerably
less attention has been given to anxiety and obsessivecompulsive symptoms during this period (Speisman, et al.,
2011). Identification and prevention of OCS in the perinatal
period is clinically important. Untreated and undiagnosed
maternal anxiety may negatively affect the patient and her
family, resulting in suffering and dysfunction, impairment of
mother-infant bonding, and abnormal development in the
infant (Abramowitz, et al., 2010; Brandes, et al., 2004; Speisman, et al., 2011).
Childbirth educators and other health care professionals working in specialty areas such as obstetrics, gynecology,
and pediatrics play a vital role in the early identification of
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obsessive thoughts and compulsions. The childbirth educator
may identify symptoms in new parents immediately postpartum or at prenatal contacts with the family (Speisman et
al., 2011). Psychiatric symptoms in the perinatal period are
often overlooked and misunderstood by healthcare providers, preventing adequate acknowledgment of symptoms in
the clinical setting. A failed recognition of OCD often occurs
because of the tendency for women to hide their distressing and unwanted thoughts from others. The expectation

Table 1. Postpartum Support Group Websites

Website

Description

mypostpartumvoice.com Contains various blog posts on aspects

of postpartum mood and anxiety disorders. Each week, new stories created by
women experiencing OCD or postpartum depression are featured on the
website. The website provides a place
for new parents suffering from OCD to
read about other experiences and find
support (Hale, 2012).
postpartumprogress.com Lists support groups available in the
United States and Canada for mothers
with perinatal mood and anxiety disorders. The website contains various links
for mothers, fathers, and healthcare
professionals that help educate these
individuals on the signs and symptoms
of postpartum psychiatric disorders,
feature stories from new mothers and
fathers suffering from these illnesses,
and provide healthcare professionals
with screening tools, current research
studies, training and continuing education opportunities, and information
regarding professional organizations
(Stone, 2011).
postpartum.net

Learn more about perinatal mental

health disorders and become a member
of the Postpartum Support International (PSI). The website provides
information on evidence-based professional training programs offered by PSI
that educate healthcare professionals
on the most current research pertaining to perinatal mood and anxiety
disorders. The program is designed
for nurses, physicians, social workers,
and childbirth professionals interested
in obtaining the skills needed for the
assessment and treatment of these particular psychiatric disorders (PSI, 2010).

of new mothers to be happy following the birth of a child

causes women to suppress the negative emotions and avoid
reporting the symptoms to providers (Speisman et al., 2011).
They may, however, report the symptoms more informally to
childbirth and parenting educators (National Collaborating
Centre for Mental Health, 2006).
The lack of education available to expecting parents
also contributes to inadequate diagnosis. New mothers and
fathers may not realize that OCD is more common during
pregnancy and the postpartum period (Speisman, et al.,
2011). Nurses need to be instructed during training and
should participate in continuing education on the onset and
course of perinatal OCD. The educational opportunities
may help to increase the distribution of information to new
parents. Nurses need to be aware of high-risk populations,
such as women with OCD, anxiety, or depression prior to
the childs birth.
If symptoms are identified in the mother or father, the
childbirth educator can advocate for the family and provide
referrals to local psychiatrists for appropriate assessment,
diagnosis, and treatment. Doulas also play a key role in
identification of signs and symptoms. Doulas are trained to
watch for signs of postpartum disorders. Because they work
closely with families, they shoud be able to quickly identify a
change in behavior in the mother or father that would signal
for further assessment to determine if the stress of pregnancy
and childbirth has initiated or exacerbated OCD symptoms.
Individuals affected by OCD are encouraged to attend
counseling and join support groups. Online resources are
also available for families and healthcare providers. Healthcare professionals may refer families to the My Postpartum
Voice website (http://mypostpartumvoice.com/), the Postpartum Progress (http://www.postpartumprogress.com),
and the Postpartum Support International website (http://
postpartum.net) to learn more about perinatal mental health
disorders (see Table 1).
The negative impact of maternal prenatal anxiety and
postpartum OCD on the mother and infant makes it imperative for such understanding and future research. Nurses
familiar with perinatal OCD can educate fellow nurses and
healthcare professionals on prevention, early identification, and treatment. Because postpartum OCD has been
found to occur in new fathers, healthcare professionals must
expand their awareness of postpartum psychiatric disorders
in spouses and partners, not just new mothers (Christian &
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Storch, 2009). Awareness of symptoms, illness development
and progression, and treatment options can help to ensure
that high quality patient care is consistently being provided
to this vulnerable population.

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Kayla is a BSN graduate from Middle Tennessee State University

in Murfreesboro, TN and is currently preparing for her NCLEX.

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