Postpartum Obsessive-Compulsive Symptoms

Postpartum obsessive compulsive symptoms are unwanted, repeated, distressing thoughts, images or urges (obsessions), usually about harm coming to the baby, with rituals or avoidance (compulsions) in the weeks to months after birth. They affect a minority of women, and are more common in women with previous anxiety. They matter because they cause great distress and shame, they are often hidden, and they are different from psychosis because the woman recognises the thoughts as unwanted and does not act on them.

• Risk factors: previous obsessive compulsive disorder, anxiety, depression, family history, perfectionism, birth trauma, sleep loss, thyroid disease.
• Women with these thoughts almost never harm the baby.
• Disclosure is often delayed for months.

Women have intrusive thoughts or images of dropping, drowning, stabbing or contaminating the baby, with fear of being alone with the baby, excessive checking, washing, sterilising, counting, reassurance seeking and avoidance of bathing or feeding. They are horrified by these thoughts.

• Insight is retained and the woman finds the thoughts abhorrent.
• Rituals consume more than 1 hour a day.
• Differential diagnosis: normal intrusive thoughts of new parents, postpartum psychosis, postpartum depression with ruminations, generalised anxiety, post traumatic stress disorder, thyroid disease, Tourette syndrome, schizophrenia.
• Complications: depression, exhaustion, avoidance of baby care, impaired bonding, social withdrawal, marital strain, chronic obsessive compulsive disorder, suicidal thoughts.

The approach is a calm, non-judgemental interview to separate obsessions from psychosis and to assess risk.

• Ask about the content, frequency and distress of thoughts, rituals and avoidance; the Yale-Brown Obsessive Compulsive Scale score of 16 or more indicates moderate or worse illness.
• Confirm insight, absence of hallucinations or delusions, and absence of intent to harm the baby.
• Edinburgh Postnatal Depression Scale and Generalised Anxiety Disorder 7 item score for coexisting depression and anxiety.
• Thyroid stimulating hormone, haemoglobin and HIV test; question on suicidal thoughts.

The principle is to reassure, give exposure and response prevention therapy, and add an antidepressant for moderate or severe symptoms.

• Supportive: explain that intrusive thoughts are common and do not mean the woman will act on them; avoid separating mother and baby unless psychosis or intent to harm is present; psychoeducation for the partner; cognitive behavioural therapy with exposure and response prevention for 12 to 20 sessions; support groups; sleep protection; safeguarding review only when risk is real.
• Pharmacological: sertraline 25 mg oral once daily for 7 days then 50 mg once daily, increased by 50 mg every 2 weeks to a usual dose of 100 to 200 mg, with 8 to 12 weeks needed at the full dose before judging effect and continued for at least 12 months; fluoxetine 20 mg oral once daily increased to 40 to 60 mg for women who do not breastfeed; clomipramine 25 mg oral at night increased by 25 mg every 4 to 7 days to 100 to 150 mg at night (maximum 250 mg) for treatment resistant illness under specialist advice.
• Procedures: none.
• Special groups: breastfeeding women prefer sertraline at the lowest effective dose with infant feeding and weight monitored; clomipramine is used only under specialist advice because of infant sedation; women with psychosis, mania or intent to harm the baby need urgent admission and treatment under specialist care.
• Red flags: hallucinations or delusions, intent or urges to act, suicidal thoughts, refusal to feed or care for the baby, severe agitation, inability to function.
• Follow-up: review at 2 weeks and every 4 weeks during treatment; repeat Yale-Brown score every 4 to 6 weeks; taper sertraline over 4 weeks when stopping; review at 3 and 6 months; plan support before a later birth.