Obsessive-compulsive disorder in the perinatal stage

Obsessive-compulsive disorder (OCD) is a disorder characterized by the presence of obsessions and compulsions . Obsessions are defined as recurrent thoughts, images, impulses, or doubts that are experienced as unwanted and distressing. Compulsions are the responses performed to neutralize the obsessions, which can take the form of overt behaviors or mental acts.

Approximately 1% of the population will develop obsessive-compulsive disorder (OCD) at some point in their lives, with a slightly higher probability in women compared to men (1.5% vs. 1%) (Fawcett et al., 2020). In the perinatal period, 2% of women will meet the criteria for OCD during pregnancy, and approximately 2.5% postpartum (Russell et al., 2013). Therefore, the likelihood of developing OCD in women is higher in the perinatal period compared to the general female population.

Characteristics of perinatal OCD

A differentiated clinical pattern has been observed in women who present with OCD in the postpartum period compared to those who present with OCD during pregnancy (Fairbrother & Abramowitz, 2016; Starcevic et al., 2020):

- OCD in pregnancy

• Gradual onset of symptoms.
• Predominance of pollution obsessions.
• Predominance of cleaning/washing and checking compulsions.

- Postpartum OCD

• Rapid onset of symptoms.
• Predominance of aggressive obsessions towards the baby (impulse phobias).
• Less prevalent compulsions. In the presence of aggressive obsessions, there may be a search for reassurance.
• Avoidance behaviors to avoid causing harm, sometimes avoidance of the baby itself for fear of harm.

Impulse phobias with the baby

Regarding the differences in clinical characteristics between OCD during pregnancy and postpartum, the tendency in the postpartum period to present aggressive obsessions toward the baby (also called impulse phobias ) is noteworthy. Impulse phobias are intrusive thoughts or images focused on the fear of causing harm. In the postpartum period, these are often directed toward the baby. They are highly aversive, unwanted thoughts that cause significant distress. They are considered unacceptable and inconsistent with one's own belief system. They are usually classified as follows:

• Passive impulse phobias , which refer to the fear of accidentally harming the baby.
• Active impulse phobias , which refer to the fear of intentionally or deliberately harming the baby.

Involuntary phobias related to the baby are common in the general population. Some prevalence studies have found that at least two out of three mothers report having experienced passive phobias, and between 19% and 50% of mothers have experienced active phobias (Abramowitz et al., 2003, 2006; Fairbrother & Woody, 2008). It is even possible that these studies are underestimating the occurrence of these types of thoughts. Therefore, the occurrence of these thoughts is normal in postpartum women, regardless of whether or not they have a disorder.

Postpartum phobias related to impulse control   These are intrusive thoughts or images focused on the fear of harming the baby. They are highly unwanted and cause significant distress.

Several factors can explain this high occurrence of intrusive thoughts and images in the postpartum period. Brok et al. (2017), in a specific review on postpartum baby-related phobias, developed a causal model of puerperal phobias, assuming specific factors for their occurrence in "healthy mothers," for the increased frequency of these phobias in more vulnerable mothers, and for mothers who present clinically significant obsessions:

"Healthy" mothers

Impulse phobias appear to be related, paradoxically, to the increased sense of responsibility associated with motherhood and caring for a baby perceived as highly vulnerable. These phobias are generally triggered by cues from the baby, which serve as a reminder of its vulnerability. Furthermore, oxytocin also seems to play a role. This hormone, which promotes maternal behaviors, could, in excess, trigger thoughts about the possibility of harm to the baby.

Mothers vulnerable to a higher frequency of impulse phobias

Stress from adapting to motherhood or caring for a demanding baby who cries more or is irritable appears to be associated with a higher incidence of impulse phobias. Dysfunction in the hypothalamic-pituitary-adrenal axis also plays a role in this increased occurrence.

Mothers with clinical obsessions

Whether impulse phobias develop into clinical obsessions depends primarily on two factors. First, it depends on the presence of meta-beliefs surrounding these thoughts. The problem isn't the occurrence of these intrusive thoughts themselves, but rather the meaning we assign to them (for example, "I'm a bad person," "If I think this, something horrible will happen").

If they are assessed as threatening or dangerous, we will implement coping strategies aimed at:

• Reduce or neutralize these thoughts (rumination, distraction, or attempts to suppress the thought).
• Check my beliefs (ask questions, get reassurance from other people, look for information on the internet).
• Avoid situations assessed as dangerous (for example, having windows open, bathing the baby, picking up sharp objects, being alone with the baby).

Impulsive phobias, as clinical obsessions, are not exclusive to women with postpartum OCD; they are also common in women with other psychiatric disorders during the perinatal period, such as postpartum depression. It is also very important to differentiate them from aggressive, infanticidal thoughts toward the baby, which can compromise the baby's safety.

Consequences of perinatal OCD

Perinatal OCD can have consequences for both mother and baby. OCD during pregnancy is associated with a poorer quality of life (Goodman et al., 2014). Regarding the presence of phobias involving the baby, the risk of harm is minimal or nonexistent. However, clinical observations of mothers with postpartum OCD who also have phobias involving the baby suggest that these phobias can affect maternal behavior and bonding.

The mother may exhibit avoidance behaviors towards the baby that can limit her ability to perform the most basic care or even cause her to reject the baby.

This impairment can manifest as overprotective and obsessive checking behaviors (especially with passive impulse phobias), or as avoidance behaviors toward the baby (especially with active impulse phobias). This avoidance of the baby can functionally limit the mother, who may feel unable to perform some basic care tasks (for example: feeding, going out, bathing, changing diapers), thus impacting her interaction with her baby and, in severe cases, potentially leading to feelings of rejection.

Treatment of perinatal OCD

There are well-established treatments that have shown efficacy for OCD in the general population. In the perinatal period, OCD should be addressed from a multidisciplinary perspective , through an individualized treatment plan. Behavioral therapy , and specifically exposure and response prevention, is the psychological therapy of choice for treating OCD. This type of intervention, particularly in an intensive format, has shown efficacy in mothers with postpartum OCD (Challacombe et al., 2017). In cases of severe phobias involving the baby, this intensive intervention, conducted with the baby in a controlled environment (such as a mother-baby day hospital), can be very beneficial.

Regarding psychopharmacological treatment , it is essential to conduct a shared decision-making process with the woman affected by OCD during the perinatal period. This process should include an assessment of the risks and benefits of taking psychotropic medication during pregnancy or breastfeeding, as well as the effects of the untreated maternal illness. As a first-line treatment, both during pregnancy and breastfeeding, the possibility of initiating treatment with a selective serotonin reuptake inhibitor (SSRI), specifically sertraline, should be considered.