Recommended Assessment and Treatment of Perinatal OCD - Information for health professionals

Recommendations for clinical best practice with perinatal OCD

The increased prevalence, distinctive symptom presentation, and potentially unique impacts associated with OCD in the perinatal period (‘Perinatal OCD’ or ‘PnOCD’) indicates the need for considerations and specific guidelines to inform best-practice in working with new/expecting parents with OCD.

This 2023 study addresses the gap in the literature and is the first to collate and outline a set of clinical best practice recommendations for assessing, managing, and treating individuals with perinatal OCD and their families.

It is also intended to increase health practitioners’ understanding of this disorder and its treatment.

One hundred and two statements were endorsed for inclusion in the final set of recommendations for clinical best practice with perinatal OCD. These recommendations inform practice across eight themes:

• Psychoeducation

• Screening

• Assessment

• Differential diagnosis

• Case care considerations

• Treatment

• Partners and families

• Culture and diversity

Some of these are listed below:

Psychoeducation

• Psychoeducation should be provided to normalise the experience of intrusive thoughts in the general population
• Psychoeducation should be provided to explain that intrusive thoughts may be more frequent during the perinatal period for a range of reasons (e.g., lack of sleep, role transitions, increased feelings of responsibility, stress)
• Psychoeducation should be provided that normal, everyday intrusions can become OCD when parents worry about the intrusions representing their true values and desires, or that their intrusions might influence them to act against their values, or that their intrusions need to be responded to with behaviours aimed at restoring a sense of safety or certainty (e.g., cleaning, checking).
• Psychoeducation should be provided that there is no evidence that parents experiencing harm-related intrusions, no matter how horrific in content, will act on these thoughts
• Common themes of perinatal obsessions and/or intrusive thoughts, including fear of contamination, harm (occurring to the baby or others), violence, perfectionism, and uncertainty about something which the parent did or did not do should be discussed with the parent/s.

Screening

• Health practitioners should be aware that many parents may decline an assessment or not be forthcoming about their PnOCD symptoms due the parents’ anxious concerns that disclosure will result in child safeguarding.
• Mental health professionals should provide a list a common intrusions and compulsive behaviours in the perinatal period to help parents identify symptoms and prompt disclosure
• Mental health professionals should ask directly about the presence of any intrusive thoughts/obsessions and/or compulsions
• Mental health professionals should directly ask about, while also normalising, the presence of taboo intrusions such as thoughts that they might physically or sexually harm their child despite having no wish or intention to do this.

Differential Diagnosis

• Clinicians should determine whether any taboo thoughts present are experienced as ego-syntonic (consistent with the parent’s beliefs, desires and wishes) or ego-dystonic (inconsistent with the parent’s beliefs, desires and wishes and therefore experienced as senseless, unwanted and intrusive).
• Clinicians should differentiate pnOCD fears that are bizarre and senseless (e.g., contaminating the baby by nappy changing), from depressive ruminations that are typically sad or pessimistic thoughts about themselves, the world and the future (e.g., “I’m an inadequate parent”) and from delusions, which represent fixed false beliefs which are accepted by the parent as being self-evidently true (e.g., “The FBI is coming to take my baby”).

Case Care Considerations

• Organisations should have a clear policies and procedures regarding treatment, referrals, collaboration with other services, and follow-ups when working with individuals with pnOCD.
• Health professionals should encourage bonding between the parent with pnOCD and the infant (e.g., encourage attentive feeding, play) where possible to reduce pnOCD related avoidance
• Health professionals should be aware of the availability of hospital mother-baby units if an infant is under 12 months of age or adult mental health inpatient admission in severe circumstances of pnOCD
• Psychoeducation resources should be offered to the individual at all stages of care.

Treatment

• Clinicians should be aware that psychological and pharmacotherapy treatment options exist for treating pnOCD, both with empirical evidence supporting their efficacy.
• Where possible, advice should be sought from an experienced perinatal psychiatrist regarding pharmacological treatment for pnOCD.
• When pnOCD inpatient care is provided, where possible a mother baby unit admission should be sought so the baby can remain in the mother’s care.

Partners and Families

• The individual with pnOCD should be asked about whom from their family they would like to be involved in their care
• Parents and significant others should be provided with psychoeducation about pnOCD (including about intrusive thoughts), the nature and goals of treatment, and advice on how to best support the person experiencing pnOCD to engage in treatment

Culture and Diversity

• Assessment and treatment of pnOCD should be offered to all parents where relevant, regardless of if they are the biological parent, their sex, gender identity, sexual identity, age, race, cultural beliefs, and religious beliefs
• Treatment and assessment of pnOCD should take into account the individual's cultural and/or religious beliefs where the consumer believes this to be relevant to their care.