When obsessive-compulsive disorder (OCD) occurs during the postpartum period, women may experience typical OCD symptoms related to contamination and cleaning, catastrophic thoughts and checking, or symmetry and ordering. However, many women with postpartum OCD, as well as those with other postpartum mood and anxiety disorders, have intrusive, ego-dystonic thoughts of harming the infant. These intrusive thoughts contribute to significant distress, and may ultimately compromise bonding and overall functioning. These disturbing symptoms are often not disclosed by mothers, and many of the scales we use to screen women for perinatal psychiatric symptoms, including the Edinburgh Postnatal Depression Scale (EPDS), do not include questions related to obsessions or intrusive thoughts.
Tools for Assessing Postpartum-Specific OCD Symptoms
One scale specifically designed to capture the broad range of symptoms associated with postpartum OCD is the postpartum version of the Perinatal Obsessive-Compulsive Scale (POCS, Lord et al, 2011). The POCS consists of a checklist covering 19 obsessions and 14 compulsions, as well as scales measuring severity and an interference with functioning. Since its preliminary validation in 2011, no follow-up studies have been published.
Another scale which includes postpartum-specific OCD symptoms is the 10-item Postpartum Distress Measure (PDM, Allison et al, 2011), however, this scale includes only four items assessing postpartum checking behaviors, fear of harm, illness anxiety, and intrusive thoughts.
Probably the most comprehensive measure of postpartum OCD is the Parental Thoughts and Behaviors Checklist (PTBC, Abramowitz et al, 2006). The PTBC is a semi-structured interview assessing the frequency, severity, resistance to and control over a broad range of obsessions and compulsions. Its structure and format were modeled after the gold standard measure of OCD severity, the Yale-Brown Obsessive Compulsive Scale (Y-BOCS).
Parental Thoughts and Behaviors Checklist – Self-Report Version
While the PTBC is comprehensive, there may be drawbacks to interview-based assessments of postpartum OCD. For one, these interviews are time-consuming and require training to administer properly. But most importantly, women may be more reluctant to report shameful or frightening thoughts of harming their infant in a face-to-face interview compared to a self-report format.
In a recent study, researchers adapted the PTBC to a self-report version and investigated the psychometric properties of this measure (Thiséus et al, 2019) . The study included 488 women who had given birth during the past 12 months. Using an online survey format, they found that the self-report version of the PTBC possessed good psychometric properties and had a factor structure that largely overlapped with the structure of the interview-based version.
Consistent with our clinical experience, this study found that postpartum OCD symptoms were strongly associated with higher rates of other psychiatric disorders, especially anxiety and general OCD, as well as lower quality of life and higher parental stress. Being aware of these symptoms would impact selection of treatment and would undoubtedly improve outcomes in women with postpartum mood and anxiety disorders.
Ruta Nonacs, MD PhD
Abramowitz JS, Khandker M, Nelson CA, Deacon BJ, Rygwall R. The role of cognitive factors in the pathogenesis of obsessive-compulsive symptoms: a prospective study. Behav Res Ther. 2006 Sep;44(9):1361-74.
Allison KC, Wenzel A, Kleiman K, Sarwer DB. Development of a brief measure of postpartum distress. J Womens Health (Larchmt). 2011 Apr;20(4):617-23.
Lord C, Rieder A, Hall GB, Soares CN, Steiner M. Piloting the perinatal obsessive-compulsive scale (POCS): development and validation. J Anxiety Disord. 2011 Dec;25(8):1079-84.
Thiséus J, Perrin S, Cervin M. Intrusive thoughts and compulsive behaviors in postpartum women: Psychometric properties of the Parental Thoughts and Behaviors Checklist. Psychiatry Res. 2019 Aug; 278:194-198.