Obsessive compulsive disorder during the perinatal period

Obsessive compulsive disorder (OCD) can be particularly challenging during the perinatal period.

Antenatal OCD can cause significant distress and poorer perinatal outcomes. Specific behaviours may affect the pregnancy (eg obsessions about contaminated food may lead to restricted eating and malnutrition). OCD is more prevalent among pregnant females than those who are not pregnant; up to 40% of females who develop OCD experience its onset during pregnancy.

Postnatal OCD can impair a parent’s ability to care for their infant.

• Compulsions (eg cleaning or performing other rituals) can dominate the parent’s time and attention, preventing them from adequately caring for the infant.
• The parent may develop obsessions and compulsions that centre on their infant, including:
  • fears that the infant will become contaminated, leading to repetitive cleaning of the infant and items associated with them (eg bottles)
  • fears that the infant will be harmed, leading to compulsive checking.

Thoughts of intentional infant harm (eg physical or sexual abuse) are distressing but common after a person gives birth. Most people dismiss such thoughts but people with OCD may obsess over them and become concerned about unwillingly acting upon them. This can lead them to experience feelings of extreme guilt and fear, and worry that they want to harm their infant or there is ‘something wrong with them’.

If a person expresses thoughts of harming their infant, determine whether there is a risk of infant harm (eg the patient has delusions that could indicate postpartum psychosis and potential for infanticide or suicide; the patient expresses definite intent). Mothers with OCD rarely pose a risk of harm to their infant. Thoughts of infant harm are likely to be associated with OCD if the mother:

• experiences the thoughts when they are not angry or frustrated (rather than only when frustrated and overwhelmed)
• finds the thoughts intrusive, distressing and repulsive (rather than only feeling guilty about having them)
• avoids their infant or takes measures to reduce their risk of harming them.

Respond to thoughts of infant harm tactfully. If the thoughts are obviously related to OCD and reflect anxiety rather than risk of infant harm, provide the patient and, if they consent, their partner with reassurance and psychoeducation. Overreacting (eg by reporting a patient with OCD to child protection services or not allowing them to be alone with their infant) can worsen OCD, disrupt the family and impair parent–infant attachment. Comorbid severe depression, psychosis, substance use disorders and reduced impulse control (eg personality disorder) pose a higher risk of infant harm. Consider referring the patient to a psychiatrist, particularly if the risk of harm to the infant is uncertain. If the risk of harm seems high, consider an urgent psychiatric assessment (eg by a community mental health team, in an emergency department).

People who experience postnatal obsessional thoughts about their infant may not have OCD—almost half of patients with postnatal depression have such thoughts.

For additional considerations in managing anxiety disorders such as OCD in the perinatal period, see here or for considerations in partners, see here.