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

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

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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
ETIOLOGY
Biological, sociobiological, evolutionary, and cognitive-
behavioral hypotheses have been proposed in attempts to
elucidate the etiology of Obsessive-Compulsive Disorder
[see 15]. The literature predominantly focuses on a biologi-
cal hypothesis for the etiology of perinatal OCD. Bar,
Goodman, and Price [24] proposed the ‘serotonin hypothe-
sis’, which suggests that alterations in the levels of serotonin
may be responsible for the generation of obsessive-
compulsive symptoms. Specifically, fluctuations in estrogen
and progesterone may impact serotonin levels in the brain,
which may trigger obsessive-compulsive symptoms both
during pregnancy and postpartum [see 15]. High doses of
serotonin agonists have been shown to cause an increase in
symptoms in some individuals diagnosed with OCD, provid-
ing further evidence of the involvement of serotonin in OCD
symptoms [1]. Oxytocin levels have also been associated
with OCD symptomatology [25]. Oxytocin is associated with
uterine contractions and lactation [26], and therefore may
play a role in the etiology of postpartum OCD; however,
there is no direct evidence suggesting this to be the case [15].
Cognitive-behavioral explanations have also been pro-
posed to account for the presence of obsessive and compul-
sive symptoms. The premise of the cognitive-behavioral hy-
pothesis is that the majority of adults experience thoughts
that they consider intrusive and upsetting; however, some
develop clinical obsessions and compulsions as a result of
the appraisal they provide to these thoughts [27]. Proponents
of this theory believe that individuals with OCD symptoms
provide a heightened level of importance and responsibility
to these thoughts as compared with non-OCD patients [27].
Therefore, they begin engaging in compulsive rituals in at-
tempts to avoid the thoughts, but the rituals actually get rein-
forced due to the emotional relief that they provide, and they
additionally reinforce the obsessive thoughts by strengthen-
ing the belief that they are harmful [15]. As a result, both the
thoughts and behaviours persist [15].
Sociobiological and evolutionary hypotheses propose that
thoughts and behaviors associated with harming infants in-
crease the likelihood of an individual passing on her/his ge-
netic information [see 15]. Proponents of these theories sug-
gest that, in males, thoughts of harming infants may be have
originated from when men were less sure of the paternity of
infants, and had instincts to kill offspring of other males. In
women, it is suggested that obsessional thoughts of harming
the infant may, in fact, result in increased protective behav-
iors, thus better ensuring the survival of their offspring [see
15].
TREATMENT
Two modalities of treatment have demonstrated efficacy
in the treatment of OCD in the general population: pharma-
cotherapy and exposure with response prevention (ERP), a
psychological treatment that is considered a type of cogni-
tive-behavioral therapy (CBT) [28]. Notably, less research
has been conducted on perinatal OCD in particular, and no
controlled studies of this illness have been undertaken. Pre-
liminary reports examining OCD treatment during the post-
partum period indicate results similar to what is observed in
the general population [see 29 for a review]. Unfortunately,
Current Psychiatry Reviews, 2007, Vol. 3, No. 4 267
no studies to date have examined the efficacy of pharmacol-
ogical treatment for OCD during pregnancy. In this section
of treatment, the pharmacologic management is covered in
depth because it is readily accessible to clinicians but re-
mains extremely controversial at the present time. Therefore,
detailed in-depth review will hopefully guide the reader in
making an informed decision on this subject.
The use of quetiapine in the treatment of postpartum
OCD has been examined in one study [30]. These authors
enrolled 14 women with comorbid postpartum depression
and OCD, who were resistant to treatment with SSRIs or
SNRIs alone, in an open-label trial of quetiapine augmenta-
tion [30]. Eleven of the patients responded fully to this
medication, while one demonstrated partial improvement,
and two did not experience a change in their obsessive-
compulsive symptoms.
Studies on the treatment of postpartum OCD found a
reduction in symptoms following antidepressant administra-
tion [11, 12, 19, 23, 31, 32]. Meta-analyses have reported
better results in treating OCD with clomipramine than with
other SSRIs; however, these findings have not been repli-
cated in comparative studies [see 33]. In the case of one
woman with recurrent OCD related to pregnancy and post-
partum, 50 mg of clomipramine along with 0.5 mg of loraze-
pam were effective in reducing her symptoms [23]. This
woman did not, however, respond well to fluoxetine. Other
investigations of clomipramine and fluoxetine have demon-
strated efficacy in treating perinatal OCD [12, 19, 32]. One
study of 15 women who presented with a new postpartum
onset of obsessive-compulsive disorder investigated the effi-
cacy of open treatment with desipramine, clomipramine,
fluoxetine, or a combination of these medications [12]. Each
patient initially presented as being markedly ill according to
Clinical Global Impression scores (CGI = 5-7), and follow-
ing 12 weeks of treatment, four were in remission (CGI = 1),
while the remaining 11 were only mildly ill (CGI = 2-3).
Case reports of two women with postpartum onsets of obses-
sive-compulsive disorder found treatment with fluoxetine to
be associated with symptom remission and increased levels
of functioning [32]. Another case study of a woman with
postpartum-onset OCD indicated clomipramine to be effec-
tive [31]. Arnold [11] examined the efficacy of fluvoxamine
in three patients with postpartum OCD and found that one
demonstrated no improvement, and two showed a positive
response, with decreases of 56% and 41% in total YBOCS
scores.
Additional considerations must be made when treating
OCD with medications during pregnancy and the postpartum
period, as fetal and infant exposure must be taken into ac-
count. Only two case reports are presently available describ-
ing the use of quetiapine during pregnancy, and both indicate
there to be no perinatal complications [34, 35]. The informa-
tion on quetiapine during lactation is very limited; however,
preliminary data indicates that the transfer of this medication
into the breast milk is low and there does not appear to be an
association between developmental outcomes and exposure
to quetiapine through breast milk [36, 37]. Clearly, further
data is needed about the perinatal use of this medication be-
fore firm conclusions can be drawn.
Results indicate that clomipramine use during pregnancy
is associated with adverse effects in newborns, particularly
268 Current Psychiatry Reviews, 2007, Vol. 3, No. 4
mild respiratory distress, tremors, and jitteriness, as well as
other toxic symptoms [38]. However, these effects appear to
be transitory in nature, lasting no more than twenty-four to
forty-eight hours [38]. Further, studies of children exposed to
tricyclic antidepressants in utero have shown no longer term
differences in IQ, language, temperament, or mood when
compared to non-exposed children [39, 40]. Tricyclic antide-
pressants seem to be quite safe for breastfeeding mothers
[41]. Among the tricyclic antidepressants, desipramine and
nortriptyline are generally preferred to clomipramine be-
cause of their side effect profiles. Generally speaking, how-
ever, their side effects remain more problematic than those
associated with SSRIs, and therefore SSRIs may be a pre-
ferred choice for some OCD patients.
All SSRIs taken during pregnancy transfer through the
placental wall and expose the fetus to the medication [42,
43], and taken during lactation, are present in breast milk,
thereby exposing the infant [43]. Studies have examined
both the short and long-term effects of prenatal exposure to
fluoxetine. Three prospective studies evaluated more than
1,400 exposed infants and found no increase in malforma-
tions [44-46]. An association has been indicated between
fluoxetine exposure and three minor anomalies; however this
study did not account for the impact of maternal mood on
birth outcome [47]. Mhanna, Bennet, and Izatt [48] exam-
ined neonates subsequent to antenatal fluoxetine exposure
and reported withdrawal symptoms, including jitteriness,
jaundice, and hypoglycemia. Nulman and colleagues [39, 40]
conducted two studies that examined the long-term effects of
prenatal fluoxetine exposure. In one of these studies, 55 ex-
posed mother-infant dyads were followed until between 16
and 86 months after delivery [39]. No differences in IQ, lan-
guage, or behavioral development as compared both to those
exposed to TCAs and to a non-exposed group were found
[39]. The second study examined 46 exposed infants up to
71 months after birth and determined that there were no defi-
cits in the cognitive and language abilities of these children
[40]. At this time fluoxetine is the SSRI that has been most
frequently studied during lactation. Burt and colleagues [49]
reported no adverse events in 180 of 190 infants whose
mothers ingested fluoxetine while breastfeeding. Moreover,
the complications noted in the remaining 10 infants were
minor [49]. Another study, which compared fluoxetine-
treated mother-infant pairs to a control group, found that
those infants who had been exposed weighed slightly less
than the controls [50]. Of all the data accumulated, some
behavioral symptoms, such as colic and hyperactivity [51],
have been noted, but in the majority of cases no adverse out-
comes have been apparent. Fluvoxamine exposure during
pregnancy and lactation have demonstrated no increased
likelihood of adverse effects in newborns and up to three
years later [see 52]. Although studies have shown no long-
term negative impacts of SSRI exposure during pregnancy
and lactation, further studies need to be conducted before
firm conclusions can be drawn. As such, alternative methods
of treatment may be preferable.
Studies have reported ERP, a subtype of CBT, to be
highly efficacious in the treatment of OCD [28, see 53 for a
review], and it is currently considered the preferred first-line
treatment in the general population [54]. However, to our
knowledge no studies have focused specifically on the treat-
ment of OCD during the perinatal period with this type of
Misri and Kendrick
therapy alone. One study which examined the treatment of
comorbid postpartum depression and anxiety found that
combined treatment with paroxetine and CBT did not pro-
duce significantly different results from treatment with par-
oxetine alone [55]. Both groups experienced a significant
improvement in their symptoms of anxiety and depression;
however, at the end of a twelve-week trial some patients
continued to suffer from mild to moderate levels of obses-
sions and/or compulsions [55]. There is little reason to as-
sume that OCD patients would respond differentially to CBT
during pregnancy and the postpartum than patients at other
periods of time. Nonetheless, as onset and specific types of
symptoms seem to be somewhat more varied during these
time frames, specific studies in this area are necessary to be
certain.
As common compulsions in postpartum OCD involve
avoiding the infant [9, 11, 12, 32], obsessive-compulsive
symptoms can potentially have negative impacts on the ma-
ternal-infant relationship and bonding [15, 56]. If attachment
and bonding issues are of particular concern, in addition to
treatment with psychotropic medications or CBT, attachment
therapies such as filial therapy [57], or infant massage [58]
may be helpful.
FUTURE DIRECTIONS AND RECOMMENDATIONS
Few studies have focused specifically on the phenome-
non of perinatal Obsessive-Compulsive Disorder, and al-
though there is some data regarding its prevalence, etiology,
and treatment, no clear answers are evident. Further research
in this area is necessary for clinicians to better understand
how to predict and treat OCD in the postpartum period, and
even moreso during pregnancy. Specifically, prospective
studies following women from before conception, through
pregnancy, and into the postpartum period would be ideal.
Further, research comparing perinatal women experiencing
obsessive-compulsive symptoms with those who are asymp-
tomatic is imperative.
The societal stigma associated with mothers having
thoughts of harming their children may result in women not
discussing these issues, and therefore, may lead to underes-
timations of the prevalence of these thoughts. As women
may be hesitant to divulge these symptoms, and their preva-
lence seems to be relatively high, as do potential conse-
quences for both mothers and their children, it may be im-
portant for clinicians to directly ask about specific obses-
sions and compulsions during the perinatal period, especially
when dealing with women at high risk (e.g., women with a
history of obsessive-compulsive or depressive symptoms).
Further, as some women who do not meet diagnostic criteria
for perinatal OCD seem to experience similar symptoms at a
subclinical level, increased discourse on this topic may pro-
vide relief to a much larger population of women who do not
present for treatment.
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Accepted: September 19, 2007