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Etiology
Extensive research has been conducted on the causes of
OCD within the general population, but gaps remain in the
literature regarding the etiology of perinatal OCD and obsessive-compulsive symptoms (OCS). Development is believed
to result from an interaction of biological and psychological
factors (Abramowitz et al., 2003; Chaudron & Nirodi, 2010;
Speisman et al., 2011).
Pregnancy and the postpartum period have been associated with an increase in the onset and worsening of psychiatric conditions such as mood disorders, psychotic disorders,
and anxiety disorders. Obsessive-compulsive disorder (OCD),
a chronic anxiety disorder first described 100 years ago
(Samuels & Nestadt, 1997), is characterized by persistent,
intrusive, and unwanted thoughts (obsessions) and physical or mental acts ritualistically completed to decrease high
levels of anxiety associated with the thoughts (compulsions;
Christian & Storch, 2009). A correlation between pregnancy
and the onset of OCD appears to exist, with studies proposing pregnancy and childbirth to be the most frequent life
events to initiate OCD onset and exacerbation (Christian
Biological Factors
Alterations in serotonin, a neurotransmitter in the brain,
has been linked to the development of OCD symptoms. In
addition to serotonin, estrogen, progesterone, and oxytocin
are also thought to be involved in OCD onset. The reproductive hormones estrogen, progesterone, and oxytocin are significantly increased during pregnancy. Evidence has revealed
that fluctuations in estrogen and progesterone, occurring in
late pregnancy, may alter serotonin transmission, reuptake,
and binding. The onset of OCD or the exacerbation of
symptoms may result from the rapid shifts in these hormones, affecting serotonin functioning, which in turn affects
a patients mood state (Abramowitz, Schwartz, Moore, Lucontinued on next page
Psychological Factors
Biological factors are etiologically important in the
onset of OCD; however, other factors such as psychological stress also play a role in its initiation. Biological factors
alone, for example, do not explain incidence of OCD in
the partners of childbearing women. Abramowitz, Moore,
Carmin, Wiegartz, and Purdon (as cited in Fairbrother &
Abramowitz, 2007) studied four previously healthy fathers
who experienced a sudden onset of OCD symptoms during
their partners pregnancy or after the birth of the child. The
results were similar to those in the studies of females with
postpartum OCS. In a later study conducted by Abramowitz,
Schwartz, and Moore (as cited in Fairbrother & Abramowitz, 2007), 40 fathers of newborns were surveyed, and 58%
reported unwanted and distressing thoughts related to the
possibility of harm to the newborn.
Epidemiology/Incidence
OCD, once considered a rare psychiatric disorder,
affecting only 1 in 1,000 individuals, is currently known to
occur more frequently in varying degrees of intensity (Kalra
& Swedo, 2009). OCD is the fourth most common mental health disorder in Canada and the United States and is
diagnosed almost as often as asthma and diabetes mellitus
(Tzu-Chi et al., 2010). OCD may develop during pregnancy,
or pregnancy may aggravate and increase exacerbation of
previously present OCS (Uguz et al., 2007). Recent studies
have shown a higher than expected prevalence of OCD in
pregnant women when compared to the general population,
with prevalence of postpartum OCS ranging from 4% to 9%
(Uguz, Kaya, Gezgin, Kayhan, & Cicek, 2011).
OCD, which can arise as a primary or secondary disorder, is not always accurately diagnosed. According to the
Diagnostic and Statistical Manual of Mental Disorders (as cited
in Varcarolis & Halter, 2010), OCD is an anxiety disorder
that includes the presence of either obsessions or compulsions, awareness that the obsessions and compulsions are
excessive and unreasonable, and the obsessions or compulsions must cause increased distress and be time-consuming.
Because those suffering from the disorder are often embarrassed and attempt to hide their obsessions and compulsions,
inaccurate diagnosis commonly occurs. Women suffering
from postpartum OCD are disinclined to discuss symptoms
with healthcare providers because of fear that the newborn
will be taken away by child welfare authorities (Brandes et
al., 2004). OCD often occurs simultaneously with other
mental health disorders, making misdiagnosis relatively common. A woman with OCD, who suffers from depression and
hides her obsessions and compulsions, may be misdiagnosed
with only depression. These factors may lead to inappropriate referrals to specialists, impair diagnosis, and prolong
accurate and efficient treatment (Taylor, 2009).
Treatment
Treatment for postpartum OCD should be similar to
the treatment used for OCD in the general population.
Cognitive-behavioral therapy and pharmacotherapy with
selective serotonin reuptake inhibitors (SSRIs) are two
options for OCD symptom management. Treatment must
focus on the specific features of postpartum OCD including
sudden onset, uncertain course of symptoms, and the fact
that many medications have not been tested in breastfeeding
women. The treatment must also be individualized, must address risks and benefits, and incorporate patient preferences
(Brandes et al., 2004; Speisman et al., 2011).
Cognitive-Behavioral Therapy
Cognitive-behavioral therapy (CBT) is considered to
be the most effective psychological treatment for OCD in
the general population (Pence, Aldea, Sulkowski, & Storch,
2011). CBT may also be successful for postpartum OCD,
especially in mothers who present with both obsessions
and compulsions. CBT is a beneficial treatment option for
mothers choosing to breastfeed because it eliminates the
possibility of exposing the newborn to psychotropic medications through breast milk (Brandes, et al., 2004). CBT
often involves altering the patients dysfunctional thoughts
and reducing compensatory rituals through exposure and
response prevention (ERP; Pignotti & Thyer, 2011). During ERP, therapists expose the patient to stimuli that evoke
their symptoms. After exposure, the patient is encouraged to
withhold from completing the anxiety-reducing compulsion
for at least an hour or until the anxiety is relieved. The clinician and patient work together to determine the situations
that trigger symptoms, and the clinician then demonstrates
the activities before it is actually conducted. To increase
effectiveness, therapists recommend that the patient attend
90-minute sessions three to five days a week for several
weeks, during which time homework is also assigned. ERP
therapy has produced 60%-80% improvement in those who
complete the treatment (Pignotti & Thyer, 2011). A case
study by Christian and Storch (as cited in Speisman, et al.,
2011) reported substantial improvement and long-term remission of postpartum OCD in a woman after eight sessions
of ERP.
Pharmacotherapy
Despite evidence of effectiveness in some patients, the
use of ERP in patients experiencing obsessive thoughts without compulsions, which is often seen in postpartum OCD,
has produced inconsistent results. Pharmacological treatment may be an effective treatment option with this specific
clinical presentation. The clinician, however, must carefully consider the risks if the mother chooses to breastfeed
(Brandes et al., 2004). SSRIs are the first-line medications
used in OCD. SSRIs include fluoxetine (Prozac), sertraline
(Zoloft), fluvoxamine (Luvox), paroxetine (Paxil), citalopram
(Celexa), and escitalopram (Lexapro). Pharmacotherapy
should be continued for at least one year in patients with
postpartum OCD because the relapse period, which may occur with premature discontinuation of the medication, has a
poor response to treatment (Brandes, et al., 2004). Although
no current evidence suggests that postpartum OCD patients
will respond differently to the standard treatment used for
OCD outside the perinatal period, controlled studies need
to be conducted in order to determine the true efficacy
of pharmacotherapy and cognitive-behavioral treatments
(Abramowitz, et al., 2003; Speisman, et al., 2011).
Description
References
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