The perinatal period is a high risk time for the onset or. Obsessions and Compulsions in Postpartum Women Without Obsessive Compulsive Disorder

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1 JOURNAL OF WOMEN S HEALTH Volume 00, Number 0, 2015 ª Mary Ann Liebert, Inc. DOI: /jwh Original Article Obsessions and Compulsions in Postpartum Women Without Obsessive Compulsive Disorder Emily S. Miller, MD, MPH, 1 Denada Hoxha, PhD, 2 Katherine L. Wisner, MD, MS, 2 and Dana R. Gossett, MD, MSCI 1 Abstract Background: To describe the prevalence of obsessions and compulsions and the specific symptoms present in postpartum women without obsessive compulsive disorder (OCD). Methods: In this prospective cohort, women were screened with the Yale Brown Obsessive Compulsive Scale at 2 weeks postpartum. Demographics and comorbid psychiatric symptoms were compared between women with screen-positive OCD, screen-negative OCD but with some endorsed symptoms (subclinical OCD), and no OCD symptoms. The prevalence of each specific set of obsessive and compulsive symptoms and the rate of impairment from those symptoms were compared. Results: Of the 461 women included, 52 (11.2%) screened positive for OCD, while 173 (37.5%) reported experiencing subclinical obsessions. This subclinical OCD was associated with an increased rate of depression (24%) and state-trait anxiety (8%) compared with women who did not endorse experiencing any obsessions. Aggressive, religious, and somatic obsessions as well as obsessions with symmetry, when present, were most likely to result in OCD screen positivity. Conclusions: Nearly half of all women who screen negative for OCD experienced obsessions that did not result in OCD screen positivity. However, the presence of these subclinical obsessions and compulsions is associated with an increased rate of depression or anxiety. Introduction The perinatal period is a high risk time for the onset or exacerbation of psychiatric disorders. 1 Obsessive compulsive disorder (OCD) is one type of anxiety disorder that has a propensity for onset or exacerbation after birth. In retrospective studies, pregnancy is the most frequently reported precipitating event for the onset of OCD. 2 4 In addition, more recent prospective data show that the occurrence of obsessive compulsive symptoms postpartum is common. 2,5 7 However, some obsessions and compulsions, such as intense concern about securing the crib or rigorous attention to hand washing, may be teleologically advantageous and may not be disruptive to a new mother s life. The boundaries between adaptive concern, subclinical symptoms, and functionally impairing disorder (with diagnostic criteria for OCD) are often difficult to define. Severity of symptoms and impairment in function are the main criteria for clinical assessment. Understanding the specific symptoms and their impact on the function of postpartum women will improve our understanding of symptoms that warrant further evaluation and which are normative. Existing data suggest that women with perinatal OCD are more likely to experience comorbid depression or statetrait anxiety compared with women without OCD. 8 Whether women who endorsed obsessions and compulsions but screened negative (subclinical OCD) have comorbid mood or anxiety disorders more frequently than women without any OCD symptoms is uncertain. If an increased risk exists, this may influence recommended screening practices. Prior studies have examined the specific obsessions and compulsions reported by women experiencing postpartum OCD. Aggressive, contamination, and miscellaneous obsessions are common and cleaning and checking are the most common compulsions. 6,9 12 To the best of our knowledge, no previous study has reported on specific obsessions and compulsions endorsed by women who do not meet criteria for screen-positive OCD. Understanding symptomatology is critical to differentiating postpartum OCD symptoms from postpartum psychosis and informing treatment. 13 The goals of this study are (1) to describe the prevalence of individual obsessions and compulsions endorsed by postpartum women without screen-positive OCD, (2) to compare Departments of 1 Obstetrics and Gynecology and 2 Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois. 1

2 2 MILLER ET AL. the prevalence of depression and state-trait anxiety in women with subclinical OCD to those without any obsessive or compulsive symptoms (OCS) and (3) to characterize the specific obsessions and compulsions present and identify those most likely to be associated with screen positivity. Materials and Methods Study design This is a secondary analysis of a prospective cohort study of 461 postpartum women. Details of the methods have been previously described. 5 In brief, between June and September 2009, English-speaking postpartum women who delivered a live-born infant at Northwestern Memorial Hospital (Chicago, Illinois) were approached and invited to participate. Demographic and clinical information were obtained on women who provided informed consent. These mothers were contacted at 2 weeks and again at 6 months postpartum and screened for depression, state-trait anxiety, and obsessions and compulsions at each time point. The measures included the Patient Health Questionnaire-9 (PHQ9), the State Trait Anxiety Inventory (STAI), and Yale Brown Obsessive Compulsive Scale (YBOCS) checklist. Northwestern University s institutional review board approved this project prior to its initiation. Variables The PHQ9 is a validated and reliable self-report of depressive symptoms that mirror the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria for depression and is used to define depression symptom levels. 14,15 A score of 4 or more (out of a possible 27) with a severity score of at least 1 or a total score of at least 6 defined a positive screen for depression. The STAI is a self-reported series of questions pertaining to frequency of various symptoms of state or trait anxiety. 16 A score of more than 100 (of 160) defines a positive screen. The YBOCS and checklist is a self-reported measure of 37 obsessive symptoms and 21 compulsive symptoms. 17,18 The subject is asked to rate the impact of any reported obsessions and compulsions on her well-being in a manner that mirrors the DSM-IV criteria for OCD. A score of 8 or more (of 40) represents the presence of screen-positive OCD. Women who reported experiencing various obsessions and/ but who did not have an impact score of 8 or more were defined as having subclinical OCD. Women who did not note the presence of any obsessions were defined as OCS negative. Demographics obtained included age, race/ethnicity, educational background, marital history, the presence of another living child, and history of family violence. Analyses Women were initially divided into those with screenpositive OCD, women with subclinical OCD, and women who were OCS negative were compared to identify differences in demographics. The frequency of depression and anxiety, both as dichotomous and continuous variables, were compared by OCS subtype to identify the psychiatric comorbidities associated with subclinical OCD. The prevalence of individual subtypes of obsessions and compulsions endorsed among women who were OCD screen negative were estimated at each time point. Obsession subtypes included aggressive, contamination, sexual, hoarding, religious, symmetry, somatic, and miscellaneous obsessions. Miscellaneous obsessions included the following: needing to know or remember certain things, fearing saying certain things, fear of losing things, intrusive mental images, intrusive nonsense sounds or words, being bothered by certain sounds/ noises, obsession with lucky or unlucky numbers, having colors with special significance, or having superstitious fears. Compulsions included cleaning/washing, checking, repeating, counting, ordering, hoarding/collecting, and miscellaneous. Miscellaneous compulsions included mental rituals other than checking/counting, need to tell/ask/confess things, need to touch/tap/rub things, ritualized eating behavior, having superstitious behaviors, and trichotillomania. Finally, the most common specific obsessions and compulsions were identified. The frequency of YBOCS screen positivity and the odds of screening positive for OCD was calculated for each type of obsessive and compulsive symptom endorsed to determine whether specific symptoms were more likely to result in OCD screen positivity than others. Statistical methods All analyses were performed using Stata 13 (StataCorp LP, College Station, TX). ANOVA, chi-squared, or Fisher s exact tests were used, as statistically appropriate. Post-hoc comparisons were made using Bonferroni correction for multiple comparisons. All tests were two tailed and p < 0.05 was used to define statistical significance. Results A total of 461 women were recruited, successfully completed the 2-week follow-up, and constituted our analyzable sample. Three hundred thirty one women (72%) completed the 6-month follow-up surveys. Patient flow charts for each time point are shown in Figures 1 and 2. Of the 461 women FIG. 1. Patient flowchart at 2 weeks postpartum. OCD, obsessive compulsive disorder.

3 POSTPARTUM SUBCLINICAL OBSESSIONS AND COMPULSIONS 3 FIG. 2. Patient flowchart at 6 months postpartum. included, 52 (11.3%) women screened positive for OCD using the YBOCS. Of the 409 who screened negative for OCD, 173 (42.3%) reported either obsessions that did not meet criteria of OCD screen positivity (i.e., subclinical OCD). The demographics of women are presented in Table 1; they are divided by the presence of OCD symptom status (i.e., OCD screen positive, subclinical OCD, or OCS negative). There were no statistically significant differences between the subgroups in age, race/ethnicity, education, income, the presence of another living child, or history of family violence between OCD screen negative women with or without subclinical OCD symptoms. However, women who were OCD screen positive were less likely to be married and had fewer living children. Positive PHQ9, analyzed as a categorical variable, were significantly different amongst the groups; a positive depression screen was more prevalent in women with subclinical OCD compared to OCS negative women ( p = 0.003) and in screen-positive OCD compared with those with subclinical OCD ( p < 0.001) (Table 2). Similarly positive STAI results differed by groups and was more prevalent in women with subclinical OCD compared to OCS negative women ( p = 0.026) and in screen-positive OCD compared to those with subclinical OCD ( p < 0.001). Furthermore, depression and anxiety scores as measured by the PHQ9 and STAI differed among the groups and were higher in women with subclinical OCD compared to OCS negative women ( p < for both) and higher in OCD positive women compared to those with subclinical OCD ( p < for both). Table 3 presents the most prevalent obsessions and compulsions among women who screened negative for OCD at 2 weeks postpartum. The most common obsessions were aggressive, contamination, and miscellaneous obsessions with prevalences of 11.5%, 16.1%, and 18.0%, respectively. The most commonly reported compulsions included cleaning/ washing, checking, and miscellaneous with a prevalence of 6.6%, 8.8%, and 6.6%, respectively. At 6 months postpartum, similar obsessions (aggressive, contamination, and miscellaneous) and compulsions (cleaning/washing, checking, and miscellaneous) prevailed in the OCD negative cohort. The most commonly identified specific obsessions and compulsions are depicted in Table 4. Concern with dirt and germs was the most common obsession and checking about Table 1. Demographics for Women at Two Weeks Postpartum, Stratified by the Presence of Obsessions and Compulsions no obsessions with obsessions OCD screen positive n = 236 n = 173 n = 52 p Age Race/ethnicity White 172 (72.9%) 136 (78.6%) 36 (67.9%) Black 15 (6.4%) 14 (8.1%) 4 (7.5%) Hispanic 31 (13.1%) 11 (6.4%) 10 (18.9%) Education Completed college 200 (84.7%) 153 (88.4%) 42 (79.3%) Completed high school 33 (14.0%) 18 (10.4%) 10 (18.9%) Did not complete high school 3 (1.3%) 1 (0.6%) 1 (1.9%) Annual houseline income Less than $50K 10 (5.5%) 13 (9.1%) 4 (9.8%) $50K $99K 40 (22.1%) 33 (23.1%) 6 (14.6%) At least $100K 131 (72.4%) 97 (67.8%) 31 (75.6%) Married 211 (89.4%) 159 (91.9%) 42 (79.3%) Prior living child 97 (41.1%) 79 (45.7%) 19 (35.8%) Number of living children History of family violence 19 (8.1%) 19 (10.8%) 7 (13.2%) Data presented as mean standard deviation or n (%). OCD, obsessive compulsive disorder.

4 4 MILLER ET AL. Table 2. Psychiatric Comorbidities for Women at Two Weeks Postpartum, Stratified by the Presence of Obsessions and Compulsions no obsessions with obsessions OCD screen positive n = 236 n = 173 n = 52 p Depression PHQ9 score < PHQ9 screen positive 26 (11.0%) 41 (23.7%) 28 (53.9%) < Anxiety STAI score < STAI screen positive 4 (1.7%) 14 (8.1%) 14 (26.4%) < Data presented as mean standard deviation or n (%) PHQ9, Patient Health Questionnaire-9; STAI, State Trait Anxiety Inventory. mistakes was the most common compulsion. The prevalence of specific obsessions and compulsions were similar between 2 weeks and 6 months postpartum. The rate of OCD and the odds of OCD screen positivity among women who endorsed symptoms within each class of obsessions and compulsions are shown in Table 5. Women with aggressive, religious, or somatic obsessions as well as those with obsessions with symmetry were numerically more likely to screen positive for OCD than were women with other subtypes of obsessions. All endorsed compulsions were associated with increased likelihood of OCD screen positivity. Discussion To the best of our knowledge, this is the largest cohort to describe specific obsessions and compulsions experienced by postpartum women who screened negative for OCD. We found that nearly half of women who screened negative for OCD experienced some obsessions and/. The Table 3. Subtypes of Obsessions and Compulsions Endorsed by OCD Screen Negative Women Two weeks Six months postpartum postpartum n = 409 n = 296 Obsessions Aggressive 47 (11.5%) 51 (17.2%) Contamination 66 (16.1%) 54 (18.2%) Sexual 4 (1.0%) 2 (0.7%) Hoarding 9 (2.2%) 4 (1.4%) Religious 6 (1.5%) 8 (2.7%) Symmetry 17 (4.1%) 5 (1.7%) Somatic 22 (5.4%) 15 (5.1%) Miscellaneous 74 (18.0%) 74 (25.0%) Compulsions Cleaning/washing 27 (6.6%) 25 (8.4%) Checking 36 (8.8%) 34 (11.5%) Repeating 15 (3.7%) 15 (5.1%) Counting 7 (1.7%) 7 (2.4%) Ordering 14 (3.4%) 7 (2.4%) Hoarding/collecting 2 (0.5%) 1 (0.3%) Miscellaneous 27 (6.6%) 21 (7.1%) Data presented as n (%). Table 4. The Most Commonly Endorsed Specific Obsessive and Compulsive Symptoms Obsessions Fear of doing something embarrassing Fear will harm others because I m not careful enough Fear will be responsible for something else terrible happening Concerned with dirt or germs Have obsessions about symmetry or exactness Feel need to know or remember certain things Fear not saying just the right thing Two weeks Six months postpartum postpartum n = 461 n = (4.6%) 16 (5.4%) 18 (4.4%) 21 (7.1%) 18 (4.4%) 21 (7.1%) 57 (13.9%) 48 (16.2%) 17 (4.1%) 5 (1.7%) 18 (4.4%) 10 (3.4%) 12 (2.9%) 21 (7.1%) Fear losing things 20 (4.9%) 12 (4.1%) Compulsions Bothered by certain sounds or noises 25 (6.1%) 12 (5.7%) Have superstitious fears Bothered by intrusive (neutral) mental images Washing hands excessively or in a ritualized way Checking that I did not make a mistake Needing to reread or rewrite things Data presented as n (%). 14 (3.4%) 11 (3.7%) 6 (1.5%) 19 (6.4%) 13 (3.2%) 16 (5.4%) 27 (6.6%) 24 (8.1%) 14 (3.4%) 15 (5.1%)

5 POSTPARTUM SUBCLINICAL OBSESSIONS AND COMPULSIONS 5 Table 5. Rates of OCD Screen Positivity at Two Weeks Postpartum, by Category of Obsessions and Compulsions Frequency of OCD screen positive if category present Odds ratio for OCD screen positive if category present Obsessions Aggressive (n = 73) 26 (35.6%) 7.44 ( ) Contamination 27 (29.0%) 5.41 ( ) (n = 93) Sexual (n = 5) 1 (20.0%) 1.95 ( ) Hoarding (n = 12) 3 (25.0%) 2.67 ( ) Religious (n = 17) 11 (64.7%) ( ) Symmetry (n = 29) 12 (41.4%) 6.77 ( ) Somatic (n = 39) 17 (43.6%) 8.33 ( ) Miscellaneous 34 (31.5%) 8.13 ( ) (n = 108) Compulsions Cleaning/washing 17 (38.6%) 6.70 ( ) (n = 44) Checking (n = 64) 28 (43.8%) ( ) Repeating (n = 33) 18 (54.6%) ( ) Counting (n = 13) 6 (46.2%) 7.35 ( ) Ordering (n = 26) 12 (46.2%) 8.28 ( ) Hoarding/ 2 (50.0%) 8.00 ( ) collecting (n = 4) Miscellaneous (n = 56) 29 (51.8%) ( ) Data presented as n (%) or odds ratio (95% confidence interval). majority of these reported obsessions involved aggressive, contamination, or miscellaneous obsessions. The majority of compulsions included those about cleaning/washing, checking, or miscellaneous compulsions. Yet of women who endorsed the presence of OCD symptoms, only 23% screened positive for OCD and thus endorsed that these symptoms were disruptive to their lives. Thus, the majority of obsessions and compulsions experienced postpartum are subclinical. Interestingly, similar obsessions and compulsions were reported in OCD negative women at both 2 weeks and 6 months postpartum, suggesting that these subclinical symptoms, when present, often persist. In addition, the obsessions and compulsions reported overlap with those reported in prior studies of women with overt clinical OCD. This overlap suggests that these symptoms, regardless of their impact on a woman s function, are common. Our data also show that women with even subclinical obsessions and/ are much more likely to be experiencing depression and/or state-trait anxiety compared to women not experiencing these symptoms. In fact, nearly a quarter of women who experienced subclinical obsessions screened positive for at least mild postpartum depression. Thus, if a woman endorses experiencing obsessions, even in a subclinical manner, she should be screened for the presence of other underlying psychiatric morbidities. The overlap between the presence of subclinical obsessions and compulsions and perinatal depression lends credence to the notion that the neurobiological vulnerability to major mood disorders in the postpartum period also confers vulnerability to obsessions and compulsions. Indeed, the postpartum period is characterized by a dramatic decline in circulating estradiol, a hormone with significant pro-monoaminergic effects, and a corresponding increase in the risk of depression. 19 This same estrogen fluctuation has been associated with anxiety and estrogen supplementation mitigates these anxiety symptoms. 20,21 This is a prospective study using self-reported screens for depression, state-trait anxiety, and OCD that were not confirmed with a clinical interview. However, as this analysis focused on the clinical and subclinical symptoms endorsed by each woman and not clinical diagnoses, our conclusions are not affected by the absence of a clinical confirmation. Another limitation is loss to follow up. Specifically, more women with subclinical symptoms were lost to follow up (45%) compared with those who screened positive (33%) or those without any OCD symptoms (15%). Thus the subtypes and specific symptoms endorsed at six months postpartum may be less representative of all women experiencing symptoms. What is unique and powerful about our study design is the inclusion of a large cohort of postpartum women during their routine obstetric postpartum course. While the patient population is from a single hospital with unique patient characteristics, the inclusion of obstetrical patients rather than a psychiatric sample allows the application of these findings to the general postpartum patient population. Conclusions Nearly half of all women experience obsessions and compulsions postpartum. This research is the first to specifically examine the presence and type of obsessions and compulsions experienced by patients without psychiatric morbidity. The majority of postpartum obsessions and compulsions do not represent overt OCD, and so reassurance should be provided regarding symptoms not disruptive to a woman s life. Yet even if the reported obsessions and compulsions are and remain subclinical, women who experience them are much more likely to have comorbid perinatal depression and should be screened appropriately. Author Disclosure Statement No competing financial interests exist. References 1. Munk-Olsen T, Laursen TM, Pedersen CB, Mors O, Mortensen PB. New parents and mental disorders: A populationbased register study. JAMA 2006;296: Chaudron LH, Nirodi N. The obsessive-compulsive spectrum in the perinatal period: A prospective pilot study. Arch Womens Mental Health 2010;13: Forray A, Focseneanu M, Pittman B, McDougle CJ, Epperson CN. Onset and exacerbation of obsessive-compulsive disorder in pregnancy and the postpartum period. J Clin Psychiatry 2010;71: Neziroglu F, Anemone R, Yaryura-Tobias JA. Onset of obsessive-compulsive disorder in pregnancy. Am J Psychiatry 1992;149: Miller ES, Chu C, Gollan J, Gossett DR. Obsessivecompulsive symptoms during the postpartum period. A prospective cohort. 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6 6 MILLER ET AL. 6. Uguz F, Akman C, Kaya N, Cilli AS. Postpartum-onset obsessive-compulsive disorder: Incidence, clinical features, and related factors. J Clin Psychiatry 2007;68: Uguz F, Kaya N, Sahingoz M, Cilli AS, Akman C. One year follow-up of postpartum-onset obsessive-compulsive disorder: A case series. Pro Neuropsychopharmacol Biol Psychiatry 2008;32: Miller ES, Hoxha D, Wisner KL, Gossett DR. The impact of perinatal depression on the evolution of anxiety and obsessive-compulsive symptoms. Arch Womens Mental Health 2015;18: Arnold LM. A Case series of women with postpartum-onset obsessive-compulsive disorder. Prim Care Companion J Clin Psychiatry 1999;1: Sichel DA, Cohen LS, Dimmock JA, Rosenbaum JF. Postpartum obsessive compulsive disorder: A case series. J Clin Psychiatry 1993;54: Wisner KL, Peindl KS, Gigliotti T, Hanusa BH. Obsessions and compulsions in women with postpartum depression. J Clin Psychiatry 1999;60: Zambaldi CF, Cantilino A, Montenegro AC, Paes JA, de Albuquerque TL, Sougey EB. Postpartum obsessivecompulsive disorder: Prevalence and clinical characteristics. Compr Psychiatry 2009;50: Hudak R, Wisner KL. Diagnosis and treatment of postpartum obsessions and compulsions that involve infant harm. Am J Psychiatry 2012;169: Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med 2001;16: Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. Primary care evaluation of mental disorders. Patient Health Questionnaire. JAMA 1999;282: Meades R, Ayers S. Anxiety measures validated in perinatal populations: A systematic review. J Affect Disord 2011;133: Goodman WK, Price LH, Rasmussen SA, et al. The Yale- Brown Obsessive Compulsive Scale. II. Validity. Arch Gen Psychiatry 1989;46: Goodman WK, Price LH, Rasmussen SA, et al. The Yale- Brown Obsessive Compulsive Scale. I. Development, use, and reliability. Arch Gen Psychiatry 1989;46: Moses-Kolko EL, Berga SL, Kalro B, Sit DK, Wisner KL. Transdermal estradiol for postpartum depression: A promising treatment option. Clin Obstet Gynecol 2009;52: Hiroi R, Handa RJ. Estrogen receptor-beta regulates human tryptophan hydroxylase-2 through an estrogen response element in the 5 untranslated region. J Neurochem 2013;127: Misra M, Katzman DK, Estella NM, et al. Impact of physiologic estrogen replacement on anxiety symptoms, body shape perception, and eating attitudes in adolescent girls with anorexia nervosa: Data from a randomized controlled trial. J Clin Psychiatry 2013;74:e Address correspondence to: Emily S. Miller, MD, MPH Departments of Obstetrics and Gynecology Northwestern University Feinberg School of Medicine 250 East Superior Street, Suite Chicago, IL Emily-miller-1@northwestern.edu