DREAM, Bangladesh Page 0 Bangladesh is located in a disaster prone area due to its geographical location in the world. Deltaic formation and location by the coastal side is the reason for more disaster in the area. According to the Global Climate Risk Index, 2010 published by German Watch, an international Research organization that there are 10 most disaster prone countries in the world due to climate change in the world and considering the intensity of loss and damages among these countries Bngladesh is the top most. Looking back to the disaster history of the country it is to be noted about the main devastation of life and properties of the coastal districts caused due to the severe cyclone and tidal surge of 12 November, 1970 and April, 1991.The severe cyclone (Sidre) of November, 2007, severe cyclone (Aila) of 2009 and severe cyclone (Mohasen) of 2013 caused heavy loss of life and properties of those areas also. Besides the coastal districts, the northern districts of Bangladesh are also affected widely by different calamities like cyclone, flood, drought, river erosion, cold wave etc. in each year. It has been creating a negative impact on the total economy in the area as well the whole country. Gaibandha is one of the main natural disaster affected districts of the northern area. Different types of disasters like cyclone, flood, drought, river erosion, cold wave etc are affecting the district each year and as result the normal life being hampered and causing losses of properties. Many people after losing their homesteads, livelihood assets and employment are going out to different districts in search of shelter and employment and forced to live in inhuman condition. The Ministry of Disaster and Relief, Government of Bangladesh under the Comprehensive Disaster Management Programme (CDMP) has initiated a benevolent plan to prepare Disaster Management Plan at District and Upazila level with the participation of all concerned which is considered to be praiseworthy. At the same time the cooperation provided to the Bangladesh Government for preparing the plan by UK Aid, European Union, Norwegian Embassy, Swiss Embassy, Australian Aid and UNDP also deserves praise. On behalf of the Disaster Management Committee we express our gratitude and thanks to the Government of Bangladesh and the development partner organizations for undertaking this type of programme. Our sincere thanks to "Development Research Education and Management (DREAM)" as a coordinating organization who have prepared the disaster plan after collection of different information from the field and incorporating the same in cooperation with the members of the Disaster Management Committee, different officers of the Govt. and Non-govt. organizations. We also express our sincere thanks to the Upazila Nirbahi Officer including officers of the local level Govt. and Non-govt. organizations, all members of the Disaster Management Committee, local elected representatives and the local community people who have provided different information and took active participation in preparing the plan.
Ijpp323691.qxdClinical Case Studies Cognitive Behavioral Treatment of Postpartum Onset: Obsessive Compulsive
Disorder With Aggressive Obsessions
Lisa M. Christian and Eric A. Storch Clinical Case Studies DOI: 10.1177/1534650108326974 The online version of this article can be found at: Additional services and information for
can be found at:
Clinical Case Studies
Clinical Case Studies
Volume 8 Number 1 February 2009 72-83 2009 Sage Publications Cognitive Behavioral Treatment of
Obsessive Compulsive Disorder With
Lisa M. ChristianOhio State UniversityEric A. StorchUniversity of South Florida This case study describes the application of cognitive behavioral therapy (CBT) for obsessivecompulsive disorder (OCD) with postpartum onset. Sara, a 29-year-old woman, presentedwith aggressive obsessions of strangling and drowning her 5-month-old son. When she pre-sented at the clinic, Sara had recently begun pharmacological treatment and was highly moti-vated to supplement this treatment with CBT. She showed marked improvement over thecourse of 8 CBT sessions using exposure and ritual prevention. This case study highlights cog-nitive and behavioral risk factors for OCD with postpartum onset, key considerations indifferential diagnosis, and the utility of CBT for OCD with this population.
postpartum; obsessive compulsive disorder; cognitive behavioral therapy;exposure and ritual prevention 1 Theoretical and Research Basis
The lifetime prevalence of obsessive compulsive disorder (OCD) is estimated to be 2.5%, making it the fourth most prevalent psychiatric disorder (Karno, Goldin, Sorenson, &Burnam, 1988; Stein, 2002). When considering specific etiological factors, there is increasedrisk of OCD onset and exacerbation during pregnancy and postpartum (Altemus, 2001;Diaz, Grush, Sichel, & Cohen, 1997; Williams & Koran, 1997). Although no epidemiologi-cal studies to date have examined prevalence rates of OCD in the perinatal period, retro-spective studies suggest that pregnancy and childbirth are the most frequent life events totrigger OCD onset or exacerbation (Buttolph & Holland, 1990; Neziroglu, Anemone, &Yaryura-Tobias, 1998). Symptoms of OCD prior to pregnancy predict increased risk ofpregnancy-related OCD (Maina, Albert, Bogetto, Vaschetto, & Ravizza, 1999).
Authors' Note: The authors acknowledge the contributions of Gary Geffken, PhD, and Emily Ricketts.
Preparation of this report was supported, in part, by a grant from the National Institutes of Health to the second
author (L40 MH081950-02). Correspondence concerning this article should be addressed to Lisa M. Christian,
PhD, Department of Psychiatry, Ohio State University Medical Center, OSU Harding Hospital, 1670 Upham
Drive, Columbus, OH 43210; e-mail: [email protected].
Christian, Storch / Postpartum Obsessive Compulsive Disorder In the postpartum period, OCD can interfere significantly with a mother's ability to care for and bond with her child due to anxiety-driven rituals and avoidance (Abramowitz,Schwartz, Moore, & Luenzmann, 2003). Without treatment, symptoms of postpartum OCDare likely to persist for an extended period of time. For example, among 9 women diag-nosed with postpartum OCD who did not receive any pharmacological or psychotherapeu-tic treatment, 8 continued to meet criteria for OCD at 1-year follow-up (Uguz, Kaya,Sahingoz, & Cilli, 2008). Moreover, at follow-up, 7 women exhibited equivalent orincreased symptomology as compared to baseline. These data highlight the importance ofproper diagnosis and treatment of OCD during pregnancy and postpartum.
Characterized by persistent intrusive thoughts and/or repetitive behaviors, OCD causes significant distress and interferes with functioning (American Psychiatric Association[APA], 2000). Symptoms can take a variety of forms. Obsessions commonly focus on con-tamination, aggression, exactness, symmetry, and scrupulosity. Common compulsionsinclude handwashing, reassurance seeking, ordering, and mental rituals (e.g., praying,counting). Aggressive obsessions are more commonly reported in postpartum OCD thanwhen OCD onset is not associated with pregnancy (e.g., Buttolph & Holland, 1990; Mainaet al., 1999; Uguz, Akman, Kaya, & Cilli, 2007; Williams & Koran, 1997). In postpartum,aggressive obsessions tend to focus on thoughts and images of accidental and purposefulharm including dropping, stabbing, strangling, or drowning the baby. Prevalence of obses-sions which focus on the child in the postpartum period supports the contention that symp-toms are strongly influenced by situational and cognitive factors.
Importantly, although they may be highly disturbing, aggressive obsessions do not pre- dict increased risk of committing harm (Abramowitz, Schwartz, Moore, et al., 2003). Bynature, symptoms of OCD are ego-dystonic (Abramowitz, Schwartz, Moore, et al., 2003),and patients with OCD have insight into the irrationality of their thoughts and behaviors(APA, 2000). These features differentiate OCD from psychotic spectrum disorders; char-acterized by thoughts of ego-syntonic nature and typically marked by lack of insight, post-partum psychosis involving thoughts of harming a child is associated with increased risk ofcommitting such acts (Spinelli, 2004). Thus, differential diagnosis is critical.
Postpartum OCD commonly occurs within 6 weeks of delivery and is frequently char- acterized by rapid onset (Grigoriadis & Romans, 2006). Available evidence suggests thatobsessions, rather than compulsions, tend to predominate in OCD with pregnancy or post-partum onset (Sichel, Cohen, Dimmock, & Rosenbaum, 1993). Avoidance of feared objects(e.g., knives) or situations (e.g., being alone with the baby) may be more evident andimpairing than compulsions.
Pharmacological treatment, namely serotonin reuptake inhibitors (SRIs) and cognitive behavioral therapy (CBT) utilizing exposure and ritual prevention (EX/RP) are both effec-tive treatments for OCD. The OCD Expert Consensus Guidelines recommend EX/RP as thefirst-line treatment in most cases given its superiority to pharmacological therapy (March,Frances, Carpenter, & Kahn, 1997). Among the studies which have directly compared theeffectiveness of different treatment modalities, results have favored EX/RP or combinedapproaches. For example, Foa and colleagues (2005) reported that EX/RP and EX/RP incombination with an SRI (clomipramine) produced comparable results which were supe-rior to clomipramine alone. Specifically, among treatment completers, 86% responded toEX/RP, 79% responded to EX/RP in combination with clomipramine, and 48% responded Clinical Case Studies to clomipramine alone. In addition, EX/RP has proven to be an effective supplementaltreatment for individuals who have not achieved adequate symptom reduction from phar-macotherapy alone (Simpson et al., 2008).
Due to their unique health concerns, CBT is especially appropriate for postpartum women. Although there have been no studies examining CBT for OCD specifically withpostpartum onset, there is no theoretical basis for predicting that treatment response woulddiffer between those with postpartum OCD and those with onset that is not pregnancyrelated. Moreover, importantly, all SRIs are excreted into breastmilk, and there is insuffi-cient evidence to determine whether the amounts transferred to the infant have meaningfuleffects on health or development (Hallberg & Sjöblom, 2005). Thus, although pharmaco-logical treatment is implicated in cases in which benefits clearly outweigh potential risks,given its relative safety and demonstrated efficacy, CBT alone is an excellent first-line treat-ment for postpartum OCD.
In sum, pregnancy and childbirth are associated with increased vulnerability for OCD.
Postpartum OCD is commonly characterized by aggressive thoughts of harming the new-born child. These symptoms can be quite debilitating and persist if untreated. The currentcase study describes a course of CBT for postpartum OCD. This case highlights cognitiveand behavioral risk factors for OCD with postpartum onset, key considerations in differen-tial diagnosis, and the utility of CBT for augmenting pharmacological treatment.
2 Case Presentation
Sara (pseudonym), a 29-year-old White married woman presented with symptoms of OCD that focused on thoughts of harming her 5-month-old son. Sara had been prescribedsertraline (150 mg) three weeks prior to her presentation to the clinic. Despite some bene-fit from pharmacological treatment, she was highly motivated to pursue CBT because shedesired a more active role in her treatment and preferred to discontinue psychotropic med-ications in the near future, in part due to adverse side effects including digestive problems.
3 Presenting Complaints
Sara reported intrusive, repetitive, and distressing thoughts and images of strangling and drowning her 5-month-old son, Justin. These obsessions occurred most frequently whenshe was home alone with Justin, particularly when bathing him or putting him to sleep inhis crib. Sara's typical obsessional scenario involved images of strangling or drowningJustin, her husband running into the room to try to stop her, and subsequently, beingarrested, jailed, and having her husband divorce her. At times, the obsessions would alsoinvolve Justin's funeral including images of his coffin as well as friends and relatives cryingand saying horrible things about Sara. In other scenarios, Justin would survive the murderattempt and Sara would be jailed for life.
In response to her obsessions, Sara frequently engaged in an "undoing" ritual involving kissing the baby and thinking loving thoughts. In addition, she often asked her husband forreassurance that she would not harm the baby. Sara demonstrated significant avoidance of Christian, Storch / Postpartum Obsessive Compulsive Disorder bathing her son and being alone with him, particularly when he was sleeping becauseshe perceived him to be more vulnerable. Her symptoms were highly distressing to her andsignificantly impaired her ability to care for her son.
On presentation, Sara had a master's degree and was working part-time outside home.
She reported a good relationship with her husband of two years who was employed full-time in a professional setting. She denied a history of significant trauma. She had a posi-tive relationship with her family of origin and adequate support from friends, includingother mothers with whom she interacted for regular play groups.
Sara had a history of OCD symptoms dating to childhood but had never sought pharma- cological or psychotherapeutic treatment. In the past, she experienced excessive hand-washing, avoidance of stepping on cracks/lines, and aggressive thoughts of harming herdog. Generally, her symptoms had been minimally impairing and had tended to discontinueover time. Sara sought treatment at the present time due to notable distress and interference.
Approximately 3 weeks prior to her presentation at the clinic, her aggressive thoughts andrelated anxiety resulted in difficulty eating, sleeping, and caring for her son.
On seeking treatment, Sara first consulted a therapist whom she had seen previously for couples' counseling. She was referred by this clinician to a psychiatrist who had Sara invol-untarily hospitalized because she was deemed to be a threat to her son. This measure wastaken despite Sara's willingness to be admitted voluntarily. Sara was discharged within 24hr of her admission after being prescribed sertraline (150 mg) and being referred for out-patient services at our clinic. She found her brief involuntary admission upsetting becauseshe believed that it was evidence that she may, in fact, be a threat to her son as she feared.
An experienced clinician administered a 90-min semistructured diagnostic interview, the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV; Di Nardo, Brown, & Barlow,1994), which confirmed a diagnosis of OCD. Sara did not meet diagnostic criteria for anyother anxiety, mood, or personality disorder. Diagnoses were confirmed by a second clini-cian based on a discussion of clinical materials and results from clinical measures.
Questionnaire measures assessing anxiety and mood were also administered. Her score of 27 on the Obsessive Compulsive Inventory–Revised was above a cut-off which typi-cally distinguishes those with OCD from control subjects (OCI-R; Foa et al., 2002).
Severity of OCD symptoms was assessed using the Yale-Brown Obsessive CompulsiveScale (Y-BOCS; Goodman et al., 1989). Her total score of 22 indicated moderate severityof symptoms. Data from questionnaire measures were consistent with information gatheredduring the clinical interview.
Sara also completed the Beck Depression Inventory–II (BDI-II; Beck, Steer, & Brown, 1996). Her score of 23 indicated moderate depressive symptoms. She did not meet diag-nostic criteria for major depressive disorder; in particular, she denied persistent sadness or Clinical Case Studies loss of interest in usual activities. The items which she highly endorsed related to feelingsof guilt and self-criticism. Her depressive symptoms appeared to be secondary to OCD.
Based on the severity of her symptoms, good insight, and high level of motivation, it wasdetermined that Sara was a good candidate for weekly CBT for OCD.
6 Case Conceptualization
Sara exhibited thinking patterns and behaviors which fit well with a cognitive-behavioral conceptualization of OCD. In terms of cognitive factors, Sara endorsed many faulty beliefswhich perpetuated her symptoms. She completed the Obsessive Belief Questionnaire(OBQ-44), which assesses the strength of relevant beliefs (OCCWG, 2005). At the begin-ning of therapy, Sara scored 221 points on this measure, which is above the mean reportedin a sample of OCD patients. She scored exceedingly high on a subscale assessing impor-tance/control of thoughts (71 points on a scale of 12-84). Examples of items which Sarastrongly endorsed included, "Having a bad thought is morally no different than doing a baddeed"; "If I have aggressive thoughts or impulses about my loved ones, this means I maysecretly want to hurt them"; and "I should be able to rid my mind of unwanted thoughts."During therapy, cognitive techniques were used to address faulty assumptions, particularlybeliefs reflecting thought–action fusion.
In terms of behavioral factors, Sara experienced considerable anxiety and fear in response to intrusive thoughts and images. As described above, faulty beliefs contributed tothis heightened fear response. In addition, compulsions and avoidance were perpetuated bynegative reinforcement; Sara experienced temporary anxiety reduction after engaging inthese behaviors. Thus, EX/RP was used to (a) reduce the association between fearedthoughts/situations and anxiety and (b) extinguish the association between compulsive/avoidant behaviors and anxiety reduction.
7 Course of Treatment and Assessment of Progress
Treatment involved eight 75-90 min sessions over the course of 3 months. The first 5 sessions were weekly, whereas the final 3 sessions were scheduled at 3 week intervals.
Weekly sessions were chosen rather than intensive (i.e., daily) treatment because Sara wasfunctioning reasonably well in her daily life at the time of her presentation at the clinic, pre-sumably due to benefit from SRI treatment. In addition, her anxiety was most strongly trig-gered by being home alone with her son while completing daily activities. Thus, weeklysessions allowed for greater time to practice home-based assignments repeatedly betweensessions. Treatment focused on (a) psychoeducation regarding factors which contribute todevelopment and maintenance of OCD, (b) cognitive restructuring focused on faultyassumptions relevant to OCD, and (c) EX/RP.
During the initial session, psychoeducation focused on the cognitive-behavioral concep- tualization of OCD. Sara was informed that treatment would involve progressively chal-lenging exposures to feared thoughts and images, with the goal of decreasing associationsof (a) obsessions with increased anxiety and (b) compulsions/avoidance with anxiety Christian, Storch / Postpartum Obsessive Compulsive Disorder reduction. Sara was encouraged to understand that OCD is self-perpetuating because avoid-ance and rituals are negatively reinforcing; these behaviors temporarily reduce anxiety andare therefore likely to be repeated. However, this prevents the individual from learning thatanxiety will reduce over time without avoidance or rituals. Thus, EX/RP is focused onbreaking this cycle of anxiety, ritualizing/avoidance, and temporary anxiety reduction.
It was explained to Sara that it is common for people to occasionally have passing thoughts that are disturbing or distressing; however, a key feature of those who are vulner-able to developing OCD is that they are likely to believe that such thoughts are meaningfuland must be controlled to prevent negative consequences. Sara was informed that therapywould address these types of beliefs which are believed to contribute to vulnerability toOCD. She was also informed that it is common for symptoms of OCD to develop duringpregnancy and postpartum, particularly among women with a history of OCD symptomsprior to pregnancy. Moreover, it was related to Sara that because many of her present con-cerns and daily activities focused on childcare, it was understandable that her current pat-tern of OCD symptoms related to her son's welfare.
Next, consistent with contemporary cognitive approaches in OCD treatment (e.g., Freeston, Rhéaume, & LaDouceur, 1996; Salkovskis, 1985, 1989), common cognitiveerrors were described, and alternative beliefs were suggested. For example, as alternativeto the belief, "I should be able to rid my mind of unwanted thoughts," Sara was encouragedto remind herself, "I cannot control my thoughts, but I can control my actions." As noted,Sara strongly endorsed numerous faulty beliefs reflecting thought–action fusion andassumptions that one can and should control thoughts. She was quite receptive to the cog-nitive aspect of treatment; she related that she had never considered that certain beliefswhich she held strongly may not be accurate. She also reported that challenging suchbeliefs reduced her anxiety and made her feel hopeful about treatment.
Finally, Sara and her therapist constructed a hierarchy of feared thoughts and situations.
Sara was asked to rate different scenarios on a scale of 0 to 100 in terms of subjective unitsof distress (SUDS), with 100 being the most anxiety and distress imaginable. Sara's initialhierarchy is presented in Table 1.
During the second session, EX/RP was initiated using Sara's hierarchy to select a rela- tively nonchallenging exposure. For her first exposure exercise, Sara cradled Justin whileplacing her hand on his upper chest and refraining from ritualizing. This evoked a moder-ately high level of anxiety (SUDS = 60). Sara appeared distressed and reported fearing thatshe would lose control of her hand and begin choking Justin. She continued the exposurewith encouragement, and after 35 min her anxiety had decreased substantially (SUDS =30). This exposure was repeated in session. For homework, Sara was assigned to batheJustin daily while her husband was not home. The importance of not engaging in avoidance(e.g., avoiding washing Justin's throat) or ritualistic behaviors (e.g., kissing Justin afterhaving a distressing thought) was emphasized. A relatively easy exposure was selected forthis initial homework so that Sara could gain a sense of mastery and accomplishment bysuccessfully completing her first assignment.
At the following session, Sara reported that she had bathed Justin daily as agreed. She reported significant anxiety habituation both within trials and across trials. As therapy con-tinued, Sara progressed to more difficult exposures. Sara gained confidence as she learned Clinical Case Studies Sara's Initial Hierarchy of Feared Situations
While home alone, hold baby with hand on his throat while listening to a tape of the therapist describing strangling the baby While home alone, but in a different room than the baby, listen to a tape of therapist describing strangling the baby Hold hand on baby's throat while home alone with him Hold hand on baby's throat while husband is in another room Hold hand on baby's throat with husband or therapist present Place baby in crib to sleep and remain in the room while home alone Bathe baby while home alone Put baby in the crib while husband is home Bathe baby while husband is home Note: SUDS = subjective units of distress.
that she could complete these exposures without losing control or inflicting harm as shefeared. Thus, as expected, items initially rated as highly distressing were experienced as onlymoderately distressing by the time they were selected as exposures. Over the course of ther-apy, Sara also demonstrated increasing awareness of her own cognitions and improved abil-ity to challenge faulty assumptions. As treatment progressed, she reported reductions inavoidance, frequency and intensity of obsessions, and impairment in daily life.
By Session 6, Sara was completing exposures from the top of her initial hierarchy.
Specifically, in-session exposures involved having Sara hold Justin with her hands on histhroat while the therapist described aloud how it would feel to strangle him and what therepercussions would be. For home practice, Sara completed this exposure using an audio-tape of the therapist describing the feared behavior in detail. Although Sara had initiallyrated this scenario as very highly distressing (SUDS = 100), these exposures elicited a peakSUDS rating of 80 when they were addressed at this point in treatment. In addition, habit-uation to these exposures occurred more quickly than Sara had anticipated.
It should be noted that therapists may be reluctant to engage in the most highly chal- lenging exposures due to their own fears. It is important for such exposures to be completedbecause purposely avoiding certain thoughts or scenarios may imply to the client that thesesituations are dangerous and should be avoided. Thus, the therapist serves as an importantmodel of how to approach thoughts and situations that were previously avoided.
Sara completed eight therapy sessions over 3 months. As described earlier, she com- pleted these sessions over a relatively long period of time due to the fact that she was func-tioning relatively well at intake and gained great benefit from completing daily home-basedexposures. In addition, after 5 weekly sessions, Sara was experiencing minimal impairmentand requested greater time between subsequent sessions so that she could continue therapyover a longer time period without excessive medical costs.
At the conclusion of eight sessions, Sara repeated a semistructured diagnostic interview (ADIS-IV) and questionnaire measures of mood and anxiety. The clinical interview con-firmed that she no longer met diagnostic criteria for OCD, which was consistent with Sara's Christian, Storch / Postpartum Obsessive Compulsive Disorder anecdotal account. Questionnaire measures were consistent in indicating significant reduc-tions in symptom presence and severity. Specifically, her score on the OCI-R had decreasedfrom 27 to 9, which is below a cut-off for significant symptoms. Similarly, her Y-BOCStotal score had reduced from 22 to 6 and thus was no longer in the clinically significantrange. Her score on the OBQ-44, which assesses cognitive biases which may contribute toOCD onset and/or maintenance, reduced from 221 to 106, which is similar to the mean innonanxious controls.
Notably, although treatment did not specifically address depressive symptoms, her score on the BDI-II reduced from 23 to 5, indicating no/mild depressive symptoms at the con-clusion of treatment. This improvement suggests that her depressive symptoms were sec-ondary to OCD as hypothesized at the beginning of treatment.
8 Complicating Factors
In many ways, Sara was an ideal candidate for CBT for OCD; she was highly motivated, understood the rationale for treatment, and adhered well to at-home exposure assignments.
Designing exposures involving her son presented some challenges. First, although Justinwas generally very cooperative, extended exposures in which Sara held him while he wasawake were difficult because he became fussy and fidgety when held in one position.
Therefore, special effort was made to ensure that when an exposure was ended prematurely,it was repeated as soon as possible so that avoidance of feared scenarios would not be rein-forced unintentionally. In addition, as her son grew older, Sara and her therapist chose toalter the format of exposures involving verbal accounts of harming her son. Rather thanhaving the therapist describe this aloud or playing audiotapes which Justin could hear, Saralistened to audiotapes while wearing headphones. In this way, exposures were completedwithout concern of her son hearing or understanding the content of the exposure.
Twelve weeks after termination of therapy, Sara experienced a relapse which was trig- gered when she read a magazine article about a man who had "snapped" and drowned histwo children. She reported that she had been relatively asymptomatic prior to this. In con-sultation with her psychiatrist, she had discontinued sertraline shortly after termination ofpsychotherapy. To address her symptom recurrence, Sara resumed sertraline (150 mg) andreinitiated seven 30-60 min CBT booster sessions. Her symptom severity and impairmentwas notably milder than at initial onset; although she was distressed by her symptoms, Saracontinued to care for her son without assistance or disruption of their daily routine.
Demonstrating the maintenance of previous treatment gains, Sara resumed practice of exposures that were initially at the top of her hierarchy. In addition, exposures to readingarticles similar to the one which triggered relapse were added to the treatment plan.
Resumption of regular home exposure practice was emphasized and relapse preventionstrategies were reviewed. These included discussing how to apply cognitive and behavioral Clinical Case Studies strategies when potential triggers are encountered, being aware of and addressing evensubtle avoidance, continuing occasional exposure practice after symptom remission, andoccasionally reviewing common cognitive errors. After four weekly sessions, Saraendorsed minimal avoidance and distress. She completed an additional three follow-up ses-sions at 3-week intervals thereafter to ensure that gains were maintained.
11 Treatment Implications of the Case
This case illustrates features common to OCD with postpartum onset. First, as in Sara's case, OCD with postpartum onset tends to be characterized by aggressive obsessions ofharming the child. In addition, cognitive errors are common among those with a vulnera-bility to developing OCD. As in this case, beliefs reflecting thought–action fusion andexaggerated sense of control over one's thoughts may be particularly evident in cases ofaggressive obsessions. Sara's course illustrates that a history of OCD symptoms prior topregnancy is an important risk factor for postpartum OCD. Finally, Sara's case demon-strates how postpartum OCD can interfere with a mother's ability to care for and bond withher child.
This case highlights the utility of CBT for postpartum OCD. Because she desired rapid symptom reduction, Sara's preference was a combined treatment approach involving bothCBT and pharmacotherapy. As described previously, the OCD Expert ConsensusGuidelines indicate that CBT alone or with an SRI is the preferred first-line approach.
Given these recommendations, CBT alone may be particularly appropriate for women withconcerns about taking psychotropic medications while pregnant or breastfeeding. However,combined psychotherapy and pharmacotherapy may be indicated if immediate symptomreduction is a priority.
Sara's symptom relapse at 12 weeks following treatment emphasizes the importance of identifying potential triggers for relapse and preparing for these through relevant exposuresand relapse prevention strategies (e.g., planning how cognitive and behavioral techniqueswill be used when faced with a trigger). Her case also demonstrates that prior CBT canresult in reduced symptom severity and more rapid treatment response if recurrence doesoccur.
12 Recommendations to Clinicians and Students
Though highly treatable, postpartum OCD remains largely undiagnosed and misunder- stood (i.e., mistaken for postpartum psychosis or depression). Importantly, symptoms ofpostpartum OCD frequently focus on thoughts of harming one's child. Therefore, womenare unlikely to spontaneously report symptoms due to shame and fear of legal repercussions(e.g., being involuntarily hospitalized). For these reasons, it is critical for clinicians toinquire about potential symptoms when appropriate.
Although the temporal relationship has not been elucidated, OCD is highly comorbid with postpartum depression (Humenik & Fingerhut, 2007). For example, in a study of Christian, Storch / Postpartum Obsessive Compulsive Disorder mothers of young children, 41% of those with postpartum depression reported occurrenceof aggressive thoughts whereas only 7% of those without postpartum depression reportedsuch thoughts (Jennings, Ross, Pepper, & Elmore, 1999). Importantly, postpartum depres-sion is commonly assessed in clinical settings. The routine identification of those with post-partum depression provides the opportunity for targeted assessment of potential OCDamong this higher-risk group.
Differentiating postpartum OCD from postpartum psychosis is an important diagnostic issue. Although both may be characterized by thoughts of harming one's child, the key dis-tinguishing feature is that OCD-related thoughts are ego-dystonic whereas thoughts accom-panying postpartum psychosis are ego-syntonic (Abramowitz, Schwartz, Moore, et al.,2003). Due to the ego-dystonic nature of their symptoms, women with OCD exhibit sig-nificant distress and avoidance. In contrast to postpartum psychosis, in the case of OCD,the presence of distressing thoughts does not increase the likelihood of acting on them.
Therefore, thorough assessment of factors which differentiate OCD from psychosis, includ-ing insight, motivation for treatment, and distress, is critical.
Finally, although the majority of research on postpartum OCD has focused on mothers, emerging evidence indicates that new parenthood is a period of vulnerability for men aswell as women (Abramowitz, Moore, Carmin, Wiegartz, & Purdon, 2001; Abramowitz,Schwartz, & Moore, 2003). Indeed, although neuroendocrine factors specific to pregnancyaffect only women, cognitive and situational risk factors associated with new parenthoodaffect fathers as well as mothers (Fairbrother & Abramowitz, 2007). Therefore, healthcareproviders should extend their awareness of potential postpartum psychopathology tospouses and partners as well as mothers.
Abramowitz, J. S., Moore, K. M., Carmin, K., Wiegartz, P., & Purdon, C. (2001). Obsessive-compulsive disor- der in males following childbirth. Psychosomatics, 42, 429-431.
Abramowitz, J. S., Schwartz, S. A., & Moore, K. M. (2003). Obsessional thoughts in postpartum females and their partners: Content, severity and relationship with depression. Journal of Clinical Psychology in MedicalSettings, 10, 157-164.
Abramowitz, J. S., Schwartz, S. A., Moore, K. M., & Luenzmann, K. R. (2003). Obsessive-compulsive symptoms in pregnancy and the puerperium: A review of the literature. Journal of Anxiety Disorders, 17,461-478.
Altemus, M. (2001). Obsessive-compulsive disorder during pregnancy and postpartum. In K. Yonkers & B. Little (Eds.), Management of psychiatric disorders in pregnancy (pp. 149-163). London: Oxford UniversityPress.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.
Beck, A. T., Steer, R., & Brown, G. K. (1996). Beck Depression Inventory (BDI-II). San Antonio, TX: Buttolph, M. L., & Holland, A. D. (1990). Obsessive-compulsive disorder in pregnancy and childbirth. In M. A. Jenike, L. Baer, & W. E. Minichiello (Eds.), Obsessive-compulsive disorder: Theory and management.
Chicago: Year Book Medical.
Diaz, S. F., Grush, L. R., Sichel, D. A., & Cohen, L. S. (1997). Obsessive-compulsive disorder in pregnancy and the puerperium. In M. T. Pato & G. Steketee (Eds.), OCD across the life cycle (pp. 97-112). Washington,DC: American Psychiatric Association Press.
Clinical Case Studies Di Nardo, P. A., Brown, T. A., & Barlow, D. H. (1994). Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV). San Antonio, TX: Psychological Corporation.
Fairbrother, N., & Abramowitz, J. S. (2007). New parenthood as a risk factor for the development of obsessional problems. Behavior Research and Therapy, 45, 2155-2163.
Foa, E. B., Huppert, J. D., Leiberg, S., Langner, R., Kichic, R., Hajcak, G., et al. (2002). The Obsessive- Compulsive Inventory: Development and validation of a short version. Psychological Assessment, 14, 485-496.
Foa, E. B., Liebowitz, M. R., Kozak, M. J., Davies, S., Campeas, R., Franklin, M. E., et al. (2005). Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treat-ment of obsessive-compulsive disorder. American Journal of Psychiatry, 162, 151-161.
Freeston, M. H., Rhéaume, J., & LaDouceur, R. (1996). Correcting faulty appraisals of obsessional thoughts.
Behaviour Research and Therapy, 34, 433-446.
Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Fleischmann, R. L., Hill, C. L., et al. (1989). The Yale-Brown Obsessive Compulsive Scale. I. Development, use, and reliability. Archives of GeneralPsychiatry, 46, 1006-1111.
Grigoriadis, S., & Romans, S. (2006). Postpartum psychiatric disorders: What do we know and where do we go? Current Psychiatry Reviews, 2, 151-158.
Hallberg, P., & Sjöblom, V. (2005). The use of selective serotonin reuptake inhibitors during pregnancy and breast-feeding: A review and clinical aspects. Journal of Clinical Psychopharmacology¸ 25(1), 59-73.
Humenik, A., & Fingerhut, R. (2007). A pilot study assessing the relationship between child harming thoughts and postpartum depression. Journal of Clinical Psychology in Medical Settings, 14, 360-366.
Jennings, K. D., Ross, S., Pepper, S., & Elmore, M. (1999). Thoughts of harming infants in depressed and non- depressed mothers. Journal of Affective Disorders, 54, 21-28.
Karno, M., Goldin, J. M., Sorenson, S. B., & Burnam, M. A. (1988). The epidemiology of obsessive-compulsive disorder in five US communities. Archives of General Psychiatry, 45, 1094-1099.
Maina, G., Albert, U., Bogetto, F., Vaschetto, P., & Ravizza, L. (1999). Recent life events and obsessive- compulsive disorder (OCD): The role of pregnancy/delivery. Psychiatry Research, 89(1), 49-58.
March, J. S., Frances, A., Carpenter, D., & Kahn, D. (1997). The Expert Consensus Guideline series: Treatment of obsessive compulsive disorder. Journal of Clinical Psychiatry, 58 (Suppl. 4), 65-72.
Neziroglu, F., Anemone, R., & Yaryura-Tobias, J. A. (1998). Onset of obsessive-compulsive disorder in preg- nancy. American Journal of Psychiatry, 149, 947-950.
Obsessive Compulsive Cognitions Working Group. (2005). Psychometric validation of the obsessive belief questionnaire and interpretation of intrusions inventory—Part 2: Factor analyses and testing of a brief version.
Behaviour Research and Therapy, 43, 1527-1542.
Salkovskis, P. M. (1985). Obsessional compulsive problems: A cognitive-behavioral analysis. Behaviour Research and Therapy, 23, 571-583.
Salkovskis, P. M. (1989). Cognitive-behavioural factors and the persistence of intrusive thoughts in obsessional problems. Behaviour Research and Therapy, 27, 677-682.
Sichel, D. A., Cohen, L. S., Dimmock, J. A., & Rosenbaum, J. F. (1993). Postpartum obsessive-compulsive dis- order: A case series. Journal of Clinical Psychiatry, 54, 156-159.
Simpson, H. B., Foa, E. B., Liebowitz, M. R., Ledley, D. R., Huppert, J. D., Cahill, S., et al. (2008). A ran- domized, controlled trial of cognitive-behavioral therapy for augmenting pharmacotherapy in obsessive-compulsive disorder. American Journal of Psychiatry, 165, 621-630.
Spinelli, M. G. (2004). Maternal infanticide associated with mental illness: Prevention and the promise of saved lives. American Journal of Psychiatry, 161, 1548-1557.
Stein, D. J. (2002). Obsessive-compulsive disorder. Lancet, 360, 397-405.
Uguz, F., Akman, C., Kaya, N., & Cilli, A. S. (2007). Postpartum-onset obsessive-compulsive disorder: Incidence, clinical features, and related factors. Journal of Clinical Psychiatry, 68, 132-138.
Uguz, F., Kaya, N., Sahingoz, M., & Cilli, A. S. (2008). One year follow-up of postpartum-onset obsessive- compulsive disorder: A case series. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 32,1091-1092.
Williams, K. E., & Koran, L. M. (1997). Obsessive compulsive disorder in pregnancy, the puerperium, and the premenstruum. Journal of Clinical Psychiatry, 58, 330-334.
Christian, Storch / Postpartum Obsessive Compulsive Disorder Lisa M. Christian, PhD, received her doctorate in clinical psychology from the Ohio State University. She is cur-
rently an assistant professor at the Ohio State University with joint appointments in the Department of Psychiatry
and the Institute for Behavioral Medicine Research. Her research examines effects of psychosocial stress during
pregnancy and postpartum on maternal and fetal/infant health with an emphasis on immune function.
Eric A. Storch, PhD, is an associate professor of clinical psychology in the Departments of Pediatrics and
Psychiatry at the University of South Florida. He has received funding from the National Institutes of Health
and multiple foundations for his work on child and adult OCD. He has published more than 140 peer-reviewed
articles and is the lead editor of the Handbook of Child and Adolescent Obsessive-Compulsive Disorder.
To be published in the Gazette of India, Extraordinary, Part II, Section 3, Sub-section(ii) dated 15th May 2013 Ministry of Chemicals and Fertilizers (Department of Pharmaceuticals) New Delhi Dated 15th _May 2013 25 Vaisakha Saka 1935 S.O. 1221(E).– In exercise of the powers conferred by section 3 of the Essential Commodities