ED: Obsessive-compulsive disorder (OCD) is common in the perinatal period. If detected it is very amenable to treatment.
OCD is characterised by distressing repetitive thoughts or images (obsessions), related behavioural or mental acts to neutralise the distress (compulsions) and associated functional impairment. The overall population prevalence is 1.2%, rising to between 4-9% for women in the perinatal period.
The OCD-like symptoms generally relate to thoughts of risk or harm to the baby. For most, these thoughts pass without problem, but for those with OCD, these thoughts are compellingly and distressingly real. The obsessions can vary from generic thoughts of harm to detailed visual images of their baby being harmed (e.g. an image of baby dead in the bath or of a baby with a knife wound).
The distress and desire to keep baby safe drives compensatory compulsions which may provide temporary relief, but tend to reinforce the OCD. Mothers may start avoiding situations related to their obsessions such as not using stairways or bridges, not bathing their baby, or changing the home environment (e.g. packing away sharp knives). For many, the compulsions are cognitive in nature, which are far less apparent but no less disabling, as much time and energy is spent in methodically attending to the cognitive compulsion.
Mothers are often reluctant to disclose OCD symptoms as they fear their sanity or that their child may be removed from their care. It generally takes direct and careful questioning to uncover OCD symptoms. A good probe question is: Do you have repetitive thoughts or images of something bad happening to you, your baby or someone else in your life?
Treatment of OCD
This varies according to the severity, duration and presence of other symptoms. Mothers are relieved to know that these thoughts are a manifestation of a treatable condition and that there is no link between them having the thought of harm and acting it out. In fact, they are less likely to harm their babies that those without OCD.
SSRI medication is considered first line due to its efficacy and safety profile in breastfeeding and pregnancy. Doses in the high therapeutic range may be necessary. Augmentation with a benzodiazepine is often helpful to ameliorate the initiation side-effects of SSRI medication and to allow rapid de-escalation of anxiety.
CBT is a successful evidence-based treatment for OCD. Treatment provided by a perinatal and infant mental health specialist is not always necessary but is preferable, as the attachment relationship will almost certainly have been affected.
Perinatal OCD is common and responsive to treatment, especially when identified early. Misdiagnosis can lead to protracted symptoms that appear resistant to standard treatment, with a subsequent negative impact on the attachment relationship, which can have lifelong implications for the wellbeing of the baby.
Questions? Contact the editor.
Author competing interests: nil relevant disclosures.
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