Formal definition of OCD [1]
Additional features specific to postpartum OCD
Obsessive thoughts and/or compulsive acts present most days for at least 2 successive weeks that are a source of distress or interfere with activities
Obsessive thoughts: repetitive ideas, images, or impulses. Often violent, obscene, or perceived to be senseless, the person cannot dismiss them
The patient recognizes them as her own thoughts or impulses. Compulsive acts: stereotyped behaviors that are repeated to reduce anxiety caused by obsessions. For instance, a sufferer who has obsessive thoughts of her baby dying of sudden infant death syndrome (SIDS) may engage in compulsively checking of baby’s breathing numerous times at night
Rapid onset [2]. Mean time of onset is 2 to 4 weeks after delivery but may be as early as the second postpartum day [3–5]
Non-postpartum OCD typically has a gradual onset
The presence of aggressive obsessions is more common in postpartum than in non-postpartum women [5]
Aggressive obsessions in the postpartum period are frequently linked to the theme of harming the newborn, i.e., dropping, suffocating, molesting, or becoming sexually aroused when caring for the baby [5–8]
Obsessions in non-postpartum OCD are highly heterogeneous in content
4.4.1.2 How to Distinguish Normative Intrusive Thoughts in Postpartum from Clinically Significant Symptoms That Warrant Further Assessment?
More than half of women report mild and transient intrusive thoughts upon giving birth [9]. The content of these thoughts may be similar to those seen in postpartum OCD, such as fears of harming the infant or the infant dying of sudden infant death syndrome (SIDS), yet they are never that intense nor do they trigger dysfunction or behavioral modifications [9]. Most new mothers check on the newborn to ensure his or her well-being. This is normal behavior. In women with postpartum OCD, excessive checking eventually impairs the mother’s ability to take care of the newborn due to distressing symptoms. When symptoms negatively interfere with the person’s regular activities and functioning in the social, occupational, and family spheres, further assessment is necessary.
4.4.1.3 What Is the Incidence and Prevalence of Obsessive-Compulsive Disorder?
4.4.1.4 What Are the Most Common Themes of Postpartum Obsessions and Compulsions?
Women may experience one or several themes of obsessive thoughts at the same time. These are the most common types of obsessive symptoms:
Thoughts, images, or urges of intentional harm to the infant such as:
Dropping the baby from a high place
Putting the baby in a microwave
Choking or shaking the baby
Pressing the baby’s soft spot on the head (fontanel)
Drowning the baby while giving bath
Stabbing the baby
Molesting the baby
Experiencing sexual arousal when caring for the baby
Other thoughts:
Baby suffocating or dying of SIDS
Accidents
Losing the baby, images of the baby being dead
Baby contracting an infectious disease or getting poisoned by harmful substances (such as mercury, lead) via touch and contact with improperly washed foods, bottles, or other objects
The most common types of compulsions in postpartum OCD:
Overt:
Cleaning/washing and related rituals to prevent contamination of the baby
Checking behaviors to prevent harm to the baby
Avoidance of the baby or of objects associated with aggressive images or thoughts, i.e., avoidance of kitchen knives when obsessive thoughts center on stabbing the baby
Covert:
Mental rituals, i.e., praying, attempts to suppress the thought, and counting
4.4.1.5 What Are the Differences Between Postpartum OCD and Postpartum Depression (PPD)?
Postpartum OCD is highly correlated with postpartum depression [15, 16]. To avoid mistaking obsessive content for depressive symptoms, distinction between the two needs to be made (Table 4.3).
Table 4.3
Differences between obsessive and depressive thoughts
Obsessive | Depressive |
|---|---|
Repetitive, specific, and fixed themes Center on events that may be realistic but have low probability of occurring Primarily induce fear and anxiety | Broad, nonspecific, and changing themes Center on actual circumstances Primarily induce sadness |
4.4.2 Postpartum Psychosis
4.4.2.1 What Is the Definition of Postpartum Psychosis?
PP is the most severe type of postpartum mental illness that requires immediate treatment. Onset of PP most often takes place within the first week after delivery. Hospitalization is warranted. Some symptoms of PP are the same as in non-postpartum psychosis. These are:
False beliefs not based in reality (delusions) such as fear of being followed or watched, thoughts broadcasting, thoughts insertion, and conviction that thoughts and/or actions are controlled by outside forces
Hearing, seeing, or feeling unreal things (hallucinations)
Disorganized thinking patterns
Additional symptoms specific to PP include severe insomnia, agitation, bizarre, disorganized behavior, thoughts of harming the baby, incoherent and illogical speech, and rapid mood changes.
4.4.2.2 How to Distinguish Normal Cognitive Disturbances or Dysfunctions (Confusion, Memory Problems, Loss of Insight) in Postpartum from Clinically Significant Symptoms That Warrant Further Assessment?
Cognitive disturbances in the postpartum period could, in rare occasions, occur as a consequence of inflammatory, autoimmune, or metabolic causes. It is imperative to rule out any potential medical causes that could trigger cognitive distortions. The first steps are to obtain a comprehensive laboratory panel and, rarely, complete brain imaging. Several symptoms distinguish PP from other potential causes of cognitive distortion in postpartum; these are insomnia coupled with agitation, fluctuating mood symptoms, and rapid changes in the clinical presentation as well as insight into the illness. Other illnesses that may induce cognitive disturbances have a steady progression and lack mood fluctuations.
4.4.2.3 What Is the Incidence and Prevalence of Postpartum Psychosis?
4.4.2.4 What Are the Most Common Themes of Delusions in Postpartum Psychosis?
Delusional themes in PP are heterogeneous in nature. The following types of delusions have been identified:
Of altruistic homicide in which the woman is convinced that she needs to kill her baby to save it from a fate worse than death [23]
Of religious nature in which the woman believes she or her baby has a special relationship with God or the devil [24]
Of grandeur (often related to religion) in which the woman believes she has special powers or authority [25]
Of paranoia and/or persecution in which the woman believes that the baby is not hers or that someone wants to hurt her or the baby (among other things) [25]
Of influence/control in which the woman feels she is being controlled by an outside force [25]
4.4.2.5 What Are the Differences Between Postpartum Psychosis and Postpartum Depression?
In Table 4.5, the key differences between PPD and PP are summarized.
Table 4.5
Key differences between postpartum depression and postpartum psychosis
Features | Postpartum depression | Postpartum psychosis |
|---|---|---|
Onset | Gradual | Abrupt |
Mood | Persistent sadness and/or loss of interest | Rapidly fluctuating depressive and manic symptoms |
Reality testing | Intact | Disturbed |
Psychotic symptoms | Occasionally present, mood congruent, and develop gradually | Always present, mood incongruent, and develop abruptly |
4.4.2.6 What Are the Symptoms Distinguishing Non-postpartum Psychosis from Postpartum Psychosis?
In Table 4.6, the key differences between non-PP and PP are described [18, 20, 25–30].
Table 4.6
Differences between symptoms of postpartum and non-postpartum psychosis
Non-postpartum | Postpartum |
|---|---|
Can occur in a variety of psychiatric diagnoses, such as schizophrenia, schizoaffective disorder, and mood disorders, and in many medical conditions | |
Hallucinations most often affect one sensory system at a time | Hallucinations affect all senses (tactile, visual, olfactory, and auditory) [25] |
Affective symptoms of one type (depression and/or mania) may or may not be present | Interchangeable and fluctuating mood symptoms, both elation and depression [27] |
Lack of obvious confusion | |
Symptoms develop gradually | Symptoms develop abruptly after delivery (2 to 7 days) [27] |
In the acute phase, symptoms progress in a mostly steady manner |
4.4.2.7 What Is the Postpartum Psychosis Classification in Leading Mental Health Diagnostic Manuals?
As is depicted in Table 4.3, in practice there is a distinct clinical presentation and treatment of postpartum psychosis. However, neither the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) [1], nor the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) [31], recognizes it as a separate diagnosis. This has been subject to ongoing debate. Women with PP are formally diagnosed with mental behavioral disorders associated with the puerperium, not elsewhere classified per ICD-10, and with unspecified bipolar and related disorders with peripartum onset per DSM-5.
4.4.2.8 What Is the Differential Diagnosis of Postpartum Psychosis?
The differential diagnoses of PP are:
Acute confusion due to medical conditions
Alcohol withdrawal
Psychotic disorders such as schizophrenia, schizoaffective, and schizophreniform disorder
Major depressive disorder with psychotic features
4.4.2.9 What Are the Differences Between Postpartum Psychosis and Postpartum Obsessive-Compulsive Disorder?
It is imperative to distinguish obsessive thoughts from psychotic process due to different treatment approaches for each diagnostic entity [3–5, 16, 27, 32] (Table 4.7). Notably, in severe, persistent postpartum OCD, obsessions may take on a delusional quality.
Table 4.7
Key differences between postpartum psychosis and obsessive-compulsive disorder
Features | Obsessive-compulsive disorder | Postpartum psychosis |
|---|---|---|
Onset | Within 1 week after childbirth [27] | |
Risk of harm to the infant | High [32] | |
Disturbance in sensory perception | None | Hallucinations affect all senses |
Insight into symptoms | Present | Absent |
4.4.2.10 What Are the Potential Consequences of Untreated Postpartum Psychosis?
4.5 Etiology and Pathogenesis
4.5.1 Postpartum Obsessive-Compulsive Disorder
4.5.1.1 What Are the Main Theories That Explain the Emergence of Obsessive-Compulsive Symptoms in Postpartum?
Many theories seek to explain the etiology and pathogenesis of postpartum OCD (Table 4.8) [5, 6, 15, 34–37]. Consensus exists that the causes are multifactorial and include cognitive, psychosocial, and biological factors. Dysfunctional cognitive beliefs (conviction that normal, albeit unwelcome, thoughts about the infant are dangerous and significant and need to be suppressed or otherwise gotten rid of) give rise to OCD symptoms and impairment. Psychosocial stresses of new motherhood (such as sleep deprivation, changes in role, identity, priorities and routines, responsibility of caring for the infant, etc.) may create pressures that render the woman less able to cope with disturbing thoughts. Additionally, some women appear to be particularly vulnerable to change in levels of serotonin effected by abrupt post-childbirth drop in estrogen and progesterone.
Table 4.8
Main etiological theories of postpartum obsessive-compulsive disorder
Cognitive behavioral theory | Symptoms triggered by (1) stressors associated with motherhood, (2) misinterpretation of normal thoughts and worries, and (3) ensuing emergence of maladaptive coping responses [34, 35] Risk increased by cognitive tendencies, such as overestimation of threat/inflated responsibility; importance of, and need to control, intrusive thoughts; perfectionism and intolerance of uncertainty [35] |
Biological theory | Role of neurotransmitters or hormones [36] Abrupt drop in estrogen and progesterone levels following childbirth adversely affects serotonin functioning [6, 15, 37] Higher concentration of oxytocin in the postpartum has been linked to OCD severity [37] Possible genetic component that is not fully understood [5] |
Evolutionary theory | Intrusive thoughts about the infant evolved to ensure sensitivity to infant safety. This adaptive pattern may trigger obsessive-compulsive symptoms in vulnerable women [15] The theory lacks evidence but would explain why healthy postpartum women report subclinical obsessive thoughts |
Sociobiological theory | Susceptibility to anxiety and stress [15] |
4.5.1.2 What Are the Risk Factors for Postpartum Obsessive-Compulsive Disorder?
Risk factors for postpartum OCD are:
Preexisting obsessive-compulsive symptoms
Dysfunctional cognitive beliefs linked to frequent intrusive worries in new mothers
History of:
Major depressive disorder
Generalized anxiety disorder
Premenstrual dysphoric disorder
Personality disorders (obsessive-compulsive or avoidant personality disorder)
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