child & youth Mental Health Series - CHEO ED Outreach · Zambaldi et al. (2009) - Prospective study, interviewing 400 women throughout postpartum period (2-26 weeks) - 58.3% had some

Today’s topic: Stigma, Mental Health and Babies – Oh My! A personal experience with postpartum OCD. Speaker: Dr. Liisa Johnston

child & youth Mental Health Series

Date: June 20, 2018

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Declaration of conflict

Speaker has nothing to disclose with regard to commercial support.

Speaker does not plan to discuss unlabeled/ investigational uses of commercial product.

• Presenter’s slides can be inserted here

LJ

- 32y/o G2P2

- vacuum assisted VBAC at 39 weeks

- Postpartum hemorrhage and endometritis

- Discharged 36 hours after birth

- No previous psych history

- Prior c section at 35 weeks for placental abruption

- No meds

- No allergies

- Family psych history: mother with GAD, maternal grandfather SUD,

paternal grandmother with previous psych admission for “difficulty coping”

after loss of husband

Stigma

LJ

5 weeks postpartum, woke up convinced we had bedbugs (we did not)

For one month, most of the day spent

- Checking

- Cleaning

- Laundry rituals

- Reassurance seeking

- Thinking, thinking, thinking…

- Not sleeping

DSM 5 Criteria

A. Presence of obsessions, compulsions, or both

B. Time consuming (eg. more than an hour per day) or

cause clinically significant distress or impairment

C. Not attributable to the physiological effects of a

substance or another medical condition

D. Not better explained by symptoms of another mental

disorder

DSM 5 Criteria

Obsessions:

1. Recurrent and persistent thoughts, urges, or images that are

experienced, at some time during the disturbance, as intrusive

and unwanted, and that in most individuals cause marked anxiety

or distress

2. The individual attempts to ignore or suppress thoughts, urges, or

images, or to neutralize them with some other thought or action

(ie. by performing a compulsion)

DSM 5 Criteria

Compulsions:

1. Repetitive behaviours or mental acts that the individual feels driven to

perform in response to an obsession or according to rules that must be

applied rigidly

2. The behaviours or mental acts are aimed at preventing or reducing anxiety

or distress, or preventing some dreaded event or situation; however, these

behaviours or mental acts are not connected in a realistic way with what

they are designed to neutralize or prevent, or are clearly excessive

Postpartum OCD in men??

It exists, but we won’t be discussing it today!

Clinical Presentation

Often missed

- ?pressure on new mother to suppress negative emotions

- ?lack of awareness of the issues

- ?healthcare providers fail to inquire about mental health

Abramowitz et al., 2003

Clinical Presentation

- Most frequently obsessions of contamination or aggression toward the

child - Can also include symmetry/exactness and religiousness

- Lead to: - Compulsive cleaning

- Avoidance of child

- Excessive checking on child

- confession/reassurance seeking

Russell et al., 2013; Speisman et al., 2011

Clinical presentation

- 50% of women report abrupt onset of symptoms, while the other half

report gradual onset

- Of women with previous diagnosis of OCD: - Clear that large portion of women tend to have significant worsening of symptoms

following the birth of their baby

Speisman et al., 2011

DDx

Postpartum OCD vs. Postpartum Depression

1. Nature of the thoughts a. Obsessions tend to trigger fear of consequences

b. Depressive ruminations tend to be melancholy or contain negative cognitions

2. Content of the thoughts a. Obsessions tend to have more bizarre and nonsensical content

b. Depressive thoughts tend to focus on actual circumstances

3. Focus of the thoughts a. Obsessions are generally focused and specific

b. Depressive ruminations tend to drift from one topic to another


DDx

Postpartum OCD vs Postpartum psychosis

1. Presenting symptoms: a. Psychotic symptoms are not present in OCD

b. Psychosis tends to include hallucinations and/or delusions that involve dangerous content

regarding the safety of the infant as well as agitation and bizarre behaviour

2. Distress from symptoms: a. Obsessive thoughts are generally quite distressing in OCD

b. Aggressive thoughts in postpartum psychosis are typically not distressing and do not result in

fear


Importance of identification

Untreated OCD in caregiver can affect the wellbeing of the entire family

- Affect provision of care

- Interfere with mother-infant bonding

- Rituals can take away from caregiving duties (time consuming)

Russell et al., (2013)

What about harm?

Aggressive thoughts related to the child are very distressing

WOMEN WITH OCD ARE NOT AT INCREASED RISK OF HARMING THEIR

INFANTS!


What about harm?

- Not diagnostic for OCD

- 65% of new parents have obsessional thoughts

concerning the harming and safety of newborns - Normal aspects of new parenthood!

- Need to determine the degree of associated distress

and/or functional impairment

What’s “Normal”?

Zambaldi et al. (2009)

- Prospective study, interviewing 400 women throughout

postpartum period (2-26 weeks) - 58.3% had some obsessional thinking

- 42.3% had some compulsivity


Miller et al study (2015)

- 461 women screened with YBOCs at 2 weeks and 6

months postpartum - 52 (11.2%) screened positive for OCD

- 173 (37.5%) had some obsessionality and/or compulsivity


- Likely some degree of obsessionality and adaptive compulsivity is beneficial in

the newborn period

Miller et al. 2013.

PREVALENCE

Russel et al. metaanalysis:

Women are 1.5-2 times more likely to experience OCD during

or following pregnancy

Prevalence

- 1.08% for women in general population

- 2.07% during pregnancy

- 2.43% in postpartum period


Relationship to postpartum depression

- Possible relationship between depression and severity of obsessive-compulsive

symptoms - Higher number of obsessions

- More aggressive obsessions

- Depression severity positively related to time spent/day on intrusive thoughts, interference of these

thoughts on functioning, and lack of control over intrusive thoughts

- Important because postpartum depression is more highly recognized than

postpartum OCD


But Why?

Sociobiological and Evolutionary Theories

- Intrusive thoughts regarding infant safety are adaptive,

and parents are more sensitive to possible threats (more

anxious)- these adaptive behaviours may trigger

obsessional thoughts in those who are predisposed


But why? Biological factors

- Hormonal changes? - In 3rd trimester, progesterone and estrogen rise well over maximum menstrual cycle levels and return to

follicular levels within the first week after childbirth (and estrogen and progesterone are pro-serotoninergic)

- We know... - 21-22% of outpatients report onset within 1 year of menarche

- Retrospective reports- 5.7-39% women new onset OCD in pregnancy, 0-50% in postpartum period

- 8-46.1% of women experience exacerbation of OCD during pregnancy, and 29-50% in postpartum period

- 20-49% of women with OCD experience exacerbation premenstrually

- Russell et al., (2013)

But why? Psychological factors (Cognitive Behavioural Theory)

- Fairbrother and Abramowitz- believe that “heightened sense of

responsibility and increase perception of threat...result in greater

likelihood of misinterpreting benign thoughts as threatening”


But why?

Fairbrother and Abramowitz

- Four Hypotheses: - Due to increase in responsibility of new baby- overestimate possibility of harm to infant

- Those who feel increased sense of responsibility and overestimate threat will exhibit more

severe symptoms

- Those who misinterpret or grant significance to normal intrusive thoughts about infant safety

will have more severe symptoms

- Those who take precautions to avoid acting on thoughts will have more obsessional

thoughts compared to parents who do not


Treatment

- Similar as OCD in other times of life - CBT (exposure/response prevention)

- SSRI

- Mild to moderate symptoms: CBT alone

- Severe: combination

- BUT keep in mind - Sudden onset

- Unclear course

- Patient preference

- Breastfeeding

- We need more studies...


Psychosocial Treatments

E/RP- provoke anxiety and distress in short term, anxiety will habituate after

prolonged and repeated exposures

- Fear hierarchy

- Psychoeducation (role of CBT, how avoidance and rituals perpetuate distress, commonality

of worrisome thoughts)

- Imaginal exposures

- In vivo exposures



- In nonpostpartum OCD, E/RP is superior to SSRI monotherapy - 70-85% achieve clinical response with 50-60% reduction in symptoms

- Case Studies have shown significant improvement/clinical remission (8-12

sessions)



Pros

- Highly effective

treatment

- Avoidance of side

effects associated with

pharmacological

treatments

Cons

- Depends on patient’s motivation

and adherence to exposures

- Requires highly trained,

competent clinician


Pharmacological Treatments

- SSRIs first line pharmacological treatment - 40-60% of patients achieving clinical response (20-40% symptom reduction)

- Clinical remission rare

- May not be desired by some women- breastfeeding

- Case studies in postpartum women - Symptom reduction maintained after 1 year

- Relapse rates high after termination

- Quetiapine augmentation - Larger number of women with response

- ?safety in breastfeeding

- Metabolic side effects


Prevention

? role for psychoeducation

- Help parents understand normalcy of intrusive thoughts to prevent

misinterpretation and diminish precautionary behaviours

- To care providers to recognize the symptoms of postpartum OCD


Prognosis

Unknown :(

More studies are needed

Meltzer-Brody et al., 2014

Long Term Outcome - Less research than impact of depression, and really nothing on OCD

specifically

- Most studies focus on impact of anxiety during pregnancy

- No studies to show impact of postpartum anxiety on child cognitive outcomes

- Male children may have increased risk of ADHD with postpartum anxiety, but

studies unable to determine if effect due to pre or postnatal anxiety

- One study showed that maternal anxiety (at 8 weeks pp) was associated

with emotional problems in boys and conduct problems in girls at 7 years old

Long Term Outcome

- The small studies suggest that it is most likely a continued exposure

that has more of an impact than just during the postpartum period

Brand et al, 2009

LJ - 1 month in, saw physician through the physician support program

- 50% decline in symptoms with diagnosis!

- Declined medication

- Psychotherapy - exposure/response prevention

- 4 sessions over 8 weeks

- E/RP - Determined type of obsession (contamination)

- Worked on exposures depending on what areas were currently most avoided (eg. sitting in

area I had been avoiding, putting food in nightstand and then eating it with my daughter)

- What would a reasonable person do in terms of cleaning

What if this

was an

adolescent?

NICE Guidelines

(2005)

When to initiate pharmacological treatment (NICE guidelines)

• In children with moderate to severe functional impairment

• Not adequate response to CBT (including ERP) which involves family or caregivers (after 12 weeks)

• Age 8-11 MAY CONSIDER addition of SSRI to psychological treatment

• Age 12-18 SHOULD offer an SSRI in addition to psychological treatment

• If psychological treatment is declined, or unable to engage in treatment

When to initiate pharmacological treatment

• AACAP guidelines (2012)

– Consider with scores higher than 23 on the CYBOCS

– Severe impairment (time occupied, subjective distress, functional limitations)

– If unable to engage in psychotherapy

POTS II (2011)

• “Outcome data for pharmacotherapy alone, the most widely available treatment, indicate that partial response is the norm and clinically significant residual symptoms often persist even after an adequate trial.”

POTS II

• Conclusions: Among patients aged 7 to 17 years with OCD and partial response to SSRI use, the addition of CBT to medication management compared with medication management alone resulted in a significantly greater response rate, whereas augmentation of medication management with the addition of instructions in CBT did not.

Pharmacological Interventions

• NICE Guidelines:

– sertraline or fluvoxamine

– Fluoxetine with comorbid depression

– Clomipramine

• AACAP Guidelines:

– SSRIs well tolerated and safer than TCAs

References Abramowitz, J.S., S.A. Schwartz, K.M. Moore, K.R. Luenzmann. (2002). “Obsessive-Compulsive symptoms in pregnancy and the puerperium: A review of the literature.” Anxiety Disorders. 17. P. 461-478.

AACAP Official Action. (2012). “Practice Parameter for the Assessment and Treatment of Children and Adolescents with Obsessive-Compulsive Disorder.” Journal of the American Academy of Child and Adolescent Psychiatry. 51(1). P. 98-

113.

Brand, S.R., P.A. Brennan. (2009). “Impact of Antenatal and postpartum maternal mental illness: how are the children.” Clinical Obstetrics and Gynecology. 52(3), 441-455.

Franklin, M., Sapyta, J., Freeman, J. (2011). “Cognitive Behaviour Therapy Augmentation of Pharmacotherapy in Pediatric Obsessive Compulsive Disorder: The Pediatric OCD Treatment Study II (POTSII) Randomized Controlled Trial.”

Journal of the American Medical Association. 1224-1232.

Meltzer-Brody, S. A. Stuebe. (2014). “The long-term psychiatric and medical prognosis of perinatal mental illness.” Best Practice and Research Clinical Obstetrics and Gynaecology. 28(1), 49-60.

Miller, E., D. Hoxha, K.L. Wisner, D.R. Gossett. (2015). “Obsessions and Compulsions in Postpartum Women without obsessive compulsive disorder.” Journal of Women’s Health. 24(10).

National Institute for Health and Care Excellence. (2005). “Obsessive Compulsive Disorder and Body Dysmorphic Disorder: Treatment.” NICE Guidance. Avail: nice.org.uk/guidance/cg31. Accessed: June 20, 2018.

Russell, E., J.M. Fawcett, D. Mazmanian. (2013). “Risk of Obsessive-Compulsive Disorder in Pregnant and Postpartum Women: A Meta-analysis.” Journal of Clinical Psychiatry. 74:4.

Speisman, B.B., E.A. Storch, J.S. Abramowitz. (2011). “Postpartum Obsessive-Compulsive Disorder.” Journal of Obstetric, Gynecologic, and Neonatal Nursing. 40(6), 680-690.

Uguz.F., C. Akman, N. Kaya, A. Savas Cilli. (2007). “Postpartum onset obsessive-compulsive disorder: incidence, clinical features, and related factors.” Journal of Clinical Psychiatry. 68, 132-138.

Zambaldi, C.F., A. Cantilino, A.C. Montenegro, J. Alencar Paes, T.L.Cesar de Albuquerque, E.B. Sougey. (2009). “Postpartum obsessive-compulsive disorder: prevalence and clinical characteristics.” Comprehensive Psychiatry. 50, 503-509.


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child & youth Mental Health Series - CHEO ED Outreach · Zambaldi et al. (2009) - Prospective study, interviewing 400 women throughout postpartum period (2-26 weeks) - 58.3% had some