OBSTETRICS AND GYNECOLOGICAL NURSING

CLINICAL DISCUSSION

ON

POSTPARTUM OBSESSIVE COMPULSIVE DISORDER

Submitted to; Submitted by;

Mrs Giggy john Aleena Davis

Asst. Professor II Yr MSc Nursing

Govt. College of nursing Govt. College of nursing

 Postpartum Obsessive-Compulsive Disorder

Introduction

Postpartum Obsessive-Compulsive Disorder (OCD) is the most misunderstood and

misdiagnosed of the perinatal disorders. It is estimated that as many as 3-5% of new mothers
and some new fathers will experience these symptoms. The repetitive, intrusive images and
thoughts are very frightening and can feel like they come “out of the blue.”

Obsessive Compulsive Disorder (OCD)

OCD is characterized by intrusive, troubling thoughts (obsessions), and repetitive, ritualistic

behaviours (compulsions) which are time consuming, significantly impair functioning and
cause distress.

Obsessions

Recurrent and persistent thoughts, impulses, or images that are experienced, at some time
during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress.
They are not simply excessive worries about real life problems. The person attempts to ignore
or suppress them, or to neutralize them with some other thought or action. The person
recognizes that the obsessive thoughts, impulses, or images are a product of his or her own
mind (not imposed from outside).

Compulsions

Repetitive behaviors that the person feels driven to perform in response to an obsession,
according to rules that must be applied rigidly. Aimed at reducing distress or preventing some
dreaded event or situation; however, these behaviors or mental acts either are not connected in
a realistic way with the obsession or are clearly excessive.

Postpartum OCD

Postpartum OCD is a type of postpartum anxiety disorder. It is characterized by intrusive

thoughts and behaviors that are in response to a perceived danger toward their baby. These
thoughts and behaviors are constant and repetitive, and they can severely disrupt daily life.
Postpartum OCD is a severe condition that requires treatment in order to manage and control
symptoms.

Women with postpartum OCD are aware of their intrusive thoughts but they cannot control
them. Instead, the thoughts cause counteractive behaviors and other symptoms as well.

Symptoms

Postpartum OCD symptoms include a combination of obsessions and compulsions. These

manifest as thoughts and behaviors.

Symptoms of perinatal Obsessive-Compulsive symptoms can include:

• Obsessions, also called intrusive thoughts, which are persistent, repetitive thoughts or
mental images related to the baby. These thoughts are very upsetting and not something
the woman has ever experienced before.
• Compulsions, where the mom may do certain things over and over again to reduce her
fears and obsessions. This may include things like needing to clean constantly, check
things many times, count or reorder things.
• A sense of horror about the obsessions
• Fear of being left alone with the infant
• Hypervigilance in protecting the infant
• Moms with postpartum OCD know that their thoughts are bizarre and are very unlikely
to ever act on them.

Research also indicates that postpartum OCD most often involves scary obsessions related to
harm befalling the newborn infant (in contrast to obsessions having to do with contamination,
paperwork mistakes, order and symmetry, and hoarding). In some instances, sufferers report
obsessions having to do with accidental harm, while in others the obsessions involve unwanted
thoughts or ideas of intentionally harming the newborn. Some examples of the kinds of
postpartum obsessions encountered in our clinic are as follows:

• The idea that the baby could die in her sleep (S.I.D.S).
• The thought of dropping the baby from a high place.
• The thought of putting the baby in the microwave.
• An image of the baby dead.
 • Thoughts of the baby choking and not being able to save him.
• Unwanted impulses to shake the baby to see what would happen.
• Thoughts of yelling at the baby.
• Thoughts of poking the baby in the soft spot in her head (fontanel).
• Thought of stabbing the baby.
• Thoughts of drowning the baby during a bath.

Compulsive rituals among mothers with postpartum OCD often include checking on the baby,
for example, during the night to make sure that the baby is still alive. New parents with OCD
also report mental compulsions, such as praying over and over to prevent disastrous outcomes.
Finally, many postpartum OCD sufferers engage in compulsive reassurance-seeking, including
looking their symptoms up on the internet and asking others if it’s “normal” to have bad
thoughts about the baby. Avoidance is also a problem.

Many women who had ongoing OCD before childbirth find that having a baby worsens their
symptoms, as a new baby provides more uncertainties and responsibilities that can aggravate
intrusive and anxious thoughts.

Here are some of the common obsessions mothers with postpartum OCD will experience:

• Unwanted images of hurting the baby such as dropping or throwing him/her

• Concerns about accidentally causing the baby harm through carelessness
• Intrusive and unwanted thoughts of suffocating or stabbing the baby
• Unwanted and disturbing thoughts of sexually abusing the baby
• Scared of making poor decisions that will cause the baby harm or death
• Fear that the baby will develop a serious disease
• Fear of exposing the baby to toxins and chemicals and other environmental pollutants

It’s important to note that mothers who suffer from postpartum OCD are hyper-vigilant and
sensitive to anything that may be related to child abuse, whether is physical, sexual or
otherwise.

Here are some of the common compulsions experienced by those with postpartum OCD:

• Getting rid of sharp objects such as knives or scissors

• Not feeding the baby out of fear of poisoning him/her
 • Not changing diapers out of fear of sexually abusing the baby
• Not consuming certain foods or medications out of fear of harming the baby
• Deliberately avoiding watching or reading the news when it involves child abuse
• Continuously monitoring self when it comes to possible inappropriate sexual thoughts
• Obsessively checking the baby while he/she sleeps
• Asking family members for reassurance that the baby has not been harmed or abused
• Going over the day’s events mentally to ensure that nothing bad has happened to the
baby

Postpartum OCD symptoms typically start showing up in the first 2 to 3 weeks after giving
birth; however, they may not be noticed by the woman or her family until months later. Without
treatment, postpartum OCD symptoms can evolve and worsen and may not go away on their
own.

Causes and Risk Factors of postpartum OCD

There is not one single reason that points to why a mother has this disorder. Postpartum could
be the triggering event, likely linked to hormonal changes.

Postpartum OCD affects anywhere between 3 to 5 percent of women after giving birth. New
fathers have also been known to exhibit signs of postpartum OCD. Though not common like
postpartum blues, postpartum OCD is likely underdiagnosed. This is due to the embarrassment
and shame that women with postpartum OCD feel and the fears they will lose their baby if they
speak up. Therefore, many women don’t come forward about their OCD symptoms after giving
birth and suffer in silence.

Additionally, postpartum OCD symptoms are often confused with anxiety or depression, so it
is often misdiagnosed. There is also limited awareness about postpartum OCD as its own
unique condition. This lack of awareness prevents reporting and diagnoses.

Like most mental health conditions, there is no one exact cause of postpartum OCD. Its onset
has a lot to do with the woman’s mental health history and other elements in her life.

Sudden and drastic decreases in hormones after giving birth may contribute to certain
postpartum OCD symptoms. These changes, combined with chronic fatigue and overwhelming
feelings as they care for the new baby, can lead many women to develop severe anxiety that
evolves into OCD.

Here are some possible risk factors of developing postpartum OCD:

• A history of OCD at other times in life

• Unmet expectations regarding motherhood that cause negative thoughts and self-doubt
• Gestational complication
• Positive family history of OCD
• Primiparity (6.57% vs 1.81% multiparous ones)
• The first 4 weeks of postnatal period
• Higher levels of anxiety
• Obsessive-compulsive personality disorder
• Avoidant personality disorder
• Personal history of major depression
• The existence of OCD related dysfunctional belief

Postpartum OCD Treatment

Postpartum OCD treatment is available to new mothers and fathers struggling with this terrible
condition. Treatment options usually combine medication and therapy in order to fully manage
symptoms and help the person cope.

Cognitive Behavioral Therapy (CBT) and other forms of psychotherapy help people work
through their intrusive thoughts in a safe and non-judgemental environment. Psychologists,
psychiatrists and other mental health professionals are trained to understand mental health
issues and teach coping skills to improve the quality of life.

Physicians and psychiatrists will likely also suggest a course of medications such as
antidepressants, specifically SSRIs. Antipsychotic medications may also stop obsessive and
compulsive thoughts from taking over the mind. Anti-anxiety medications called
benzodiazepines are also effective at immediately providing relief from the nervous energy and
fears associated with postpartum OCD symptoms.
OCD is a challenging disorder to treat; only 30% of patients show significant improvement.
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.
When the patient's illness is accompanied by factors suggesting a risk of harm to mother or
baby, 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.
Psychotherapy
Cognitive-Behavioural therapy( CBT ) has been suggested as a first-line treatment of OCD in
pregnant and breastfeeding women.
Other techniques that can be used:
• Filial therapy
• Psychoeducation
• Exposure and response prevention
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.
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.
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.
Deciding whether or not to prescribe one of these medications for a pregnant or nursing woman
should be based, 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.
• Selective serotonin reuptake inhibitors (SSRIs) are the first line medications for
treatment of OCD in pregnant and breastfeeding women.
Consider Avoid ;
• During pregnancy : Sertraline Fluvoxamine Fluoxetine Paroxetine
• During breastfeeding : Sertraline Fluvoxamine Paroxetine Fluoxetine
Augmentation with atypical antipsychotics
 Reserved for refractory cases
 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% or greater reduction in symptoms.
Postpartum OCD in men

Postpartum OCD in men doesn’t share the same biological causes as postpartum OCD in
women. Therefore, it is believed that a big contributing factor to developing postpartum OCD
is the natural fear and anxiety that comes with the pressure and responsibility of caring for an
infant.

Advice to family members

It is incredibly important as a family member to be loving and supportive. It is encouraged to

make sure the sufferer gets connected with good mental health resources who have experience
with postpartum OCD. We should recommend family members to think about how some of
your accomodating behaviors could have a detrimental affect on the sufferer.
Conclusion
Estimates of the prevalence of (OCD) in pregnant and postpartum women appears to be
approximately two times estimates of OCD prevalence in women in the general population. 
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.  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. For mild OCD without immediate risks to the mother or child, treatment
with cognitive-behavioral therapy (CBT) is recommended. Adjunctive attachment therapy may
be useful if an attachment or bonding issue is present.

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.  When
moderate-to-severe OCD is refractory to first-line treatment (serotonergic antidepressant),
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.
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.

References:

1. http://ocdla.com/postpartum-ocd
2. http://www.babycenter.com/0_postpartum-depression-and-
anxiety_227.bc?page=2#articlesection4
3. http://www.maternalocd.org/aboutocd.php
4. https://iocdf.org/expert-opinions/postpartum-ocd/
5. http://beyondocd.org/information-for-individuals/symptoms/postpartum-ocd-ppocd