Obsessive Compulsive Disorder | Information for Professionals
What is perinatal OCD?
Obsessive Compulsive Disorder, or OCD, is a psychiatric illness which presents commonly with two problems: obsessions and compulsions. When these obsessions and compulsions present during pregnancy or shortly after a woman has had a baby, this is known as Perinatal OCD.
How does the patient experience perinatal OCD?
Obsessions are unwanted, intrusive thoughts, images or urges. These thoughts are more than annoying; they are distressing to the patient. Compulsions are behaviors that are done to make the obsessions disappear or to lower anxiety. Among the most common obsessions and compulsions are those that deal with harm, safety, and cleanliness or order.
Patient Example 1: Within a week of her positive pregnancy test, Tami believed she was poisoning her fetus (obsession) and she would either lose the pregnancy or maim her baby. Initially she only ate organic food, but only until her own garden produced fruits and vegetables she trusted. She had lost 15 pounds when she presented to you.
Patient Example 2: After giving birth to her baby, Joi began having intrusive thoughts she would molest the baby (obsession). To prevent doing so, Joi refused to be alone in the house with the baby. She required constant reassurance from her husband that she had not mistreated the baby, and demanded supervision if the baby needed to be bathed or changed (compulsion).
Screening options
We recommend using the Florida OCD Inventory (FOCI) Adult screening tool. This is a self administered tool. The Perinatal Anxiety Screening Scale (PASS) will also provide information regarding your patient’s obsessive thinking.
Non-pharmacologic treatments
- Psychotherapy: There are specific forms of psychotherapy that have been found beneficial for OCD, including exposure therapy, habit reversal, and/or cognitive therapy. Clinicians with a specific interest and training in OCD can be found at iOCDf.org. Psychotherapy is the first line treatment for OCD.
- Write or speak about the thoughts: Writing thoughts down may allow the patient to see that their thoughts are irrational, and seeing them on the written page can make them less frightening. Likewise, speaking about them to a safe individual can reduce the thoughts’ power.
- Meditation: Meditation can help the individual clear their mind of disturbing thoughts.
Pharmacologic treatments
For the patient with OCD who is not responding to psychotherapy or other treatment, it may be necessary to initiate medication. Antidepressants are the first line medication used for the treatment of OCD. FDA-Approved Antidepressants for OCD include:
| Medication | Dose Range | Comments |
|---|---|---|
| Clomipramine | 75-300 mg | Tricyclic Antidepressant, which is typically the final choice of treatment |
| Fluoxetine | 20-60 mg | Common Side Effects: drowsiness; dry mouth; insomnia; nervousness nausea diarrhea; dizziness; headaches; reduced libido; anorgasmia; blurred vision |
| Fluvoxamine | 50-300 mg | Common Side Effects: drowsiness; dry mouth; insomnia; nervousness nausea diarrhea; dizziness; headaches; reduced libido; anorgasmia; blurred vision |
| Paroxetine | 20-50 mg | Common Side Effects: drowsiness; dry mouth; insomnia; nervousness nausea diarrhea; dizziness; headaches; reduced libido; anorgasmia; blurred vision |
| Sertraline | 50-200 mg | Common Side Effects: drowsiness; dry mouth; insomnia; nervousness nausea diarrhea; dizziness; headaches; reduced libido; anorgasmia; blurred vision |
Psychiatrists prescribe antidepressants differently for OCD than they do for Major Depressive Disorder. For depression, a psychiatrist may choose to wait only 6 weeks before switching to another medication if the first has not shown efficacy. In the case of OCD, a patient should remain on a therapeutic dose of the medication for at least 12 weeks before switching to another agent.
How does perinatal OCD differ from postpartum psychosis?
One of the biggest challenges for a clinician faced with an anxious patient with distressing thoughts is determining whether the patient is suffering from psychosis and thus is at greater risk of harming themselves or someone around them.
| Perinatal OCD | Postpartum Psychosis | |
|---|---|---|
| What kind of thoughts is the patient having? | Patient finds the thoughts disturbing and repugnant; knows that such thoughts are inappropriate. | Such thoughts are acceptable to the individual’s current belief system or personality. |
| What are the associated behaviors? | Commonly avoidance, attempts at reversal, cleaning, reassurance seeking. | No compulsive behavior to remove the thought, but individuals may follow through with associated actions. Decreased need for sleep. |
| What other symptoms may be present? | Anxiety, sleeplessness, overly concerned with infant’s welfare. Possibly frustrated friends and family. Good insight into the situation. Seeking help. | Presence of psychotic symptoms: hallucinations, delusions, disorganized thoughts, and behaviors. Poor grasp on reality. Poor insight into situation. Rejecting help. |
| Who is likely to develop this syndrome? | Current symptoms or previous history of depression. Personal or family history of OCD or anxiety. | Most often occurs among women with history of bipolar disorder. |
| Treatment | Cognitive therapy, antidepressants | Hospitalization, mood stabilizers and antipsychotics |
Common Issue: Pharmacophobia
Pharmacophobia, or a fear of taking medication, is very common for patients with OCD. Pressuring, threatening or belittling will not result in a medication-compliant patient. Try these suggestions to help your patient initiate pharmacologic treatment.
- Listen to your patient to discover their concerns. Answer any questions they may have. Simply talking with the patient may attenuate their angst.
- Low and Slow. Start out with very small dosages. Some medications will dissolve in liquids allowing the patient to take only a fraction of a particular dosage (e.g., fluoxetine in cranberry juice). Compounding pharmacists can also formulate smaller dosages.
- Offer the opportunity to take the medication in the office, during an appointment, to help the patient feel safer.
- Exposure Therapy can help desensitize the patient to the pill and their fear of swallowing it.