Efficacy of a prevention program for postpartum obsessive–compulsive symptoms
Introduction
Although much research has focused on maternal depression during the perinatal (pregnancy and the first postpartum year) period (Godfrey, 2005, Logsdon et al., 2006, Robertson et al., 2004), our understanding of perinatal anxiety disorders is still in the nascent stages. This is unfortunate given that anxiety disorders as a group are the most prevalent of all psychiatric conditions (Kessler et al., 2005), and perinatal maternal anxiety in particular is associated with a number of adverse maternal and developmental repercussions including: over-activation of the maternal endocrine system, low birth weight (Lou et al., 1994, Mulder et al., 2002), postpartum depression (Ahmad et al., 1994, Sutter-Dallay et al., 2004), reduced communication with the infant (Field et al., 2005), behavioral inhibition, and insecure mother–infant attachment (Coplan et al., 2005, Manassis et al., 1995). These adverse consequences, considered along with the high prevalence of perinatal maternal anxiety problems (Heron et al., 2004), attest to the need for developing and testing effective prevention and treatment programs.
Obsessive–compulsive disorder (OCD) is among the most common postpartum anxiety disorders (Abramowitz et al., 2003b, Ross and McLean, 2006), and as such, is a desirable target for prevention or treatment. OCD occurs in approximately 2% of the general population (American Psychiatric Association, 1994) and has been identified as one of the top ten leading causes of disability world-wide (Dupont, 1993, Lopez and Murray, 1998). Although much less is known about OCD during the perinatal period, there is a growing consensus among researchers and clinicians that postpartum obsessive–compulsive symptoms (OCS) represent a serious problem that is under-identified, with many women not receiving needed services (Forray et al., 2010). Research to-date has revealed that OCS frequently occur during the perinatal period and can range in severity from mild to extremely impairing (Abramowitz et al., 2003a, Zambaldi et al., 2009). In addition, both pregnancy and childbirth have been found to trigger onset of OCD or exacerbation of OCS (Abramowitz et al., 2003b, Forray et al., 2010). Up to 40% and 30% of females with OCD report symptom onset during the perinatal period (Williams and Koran, 1997) and the postpartum (Buttolph and Hollander, 1990, Labad et al., 2005), respectively. A recent study in a small sample of women at 1 month postpartum found that 31% reported subclinical OCS (Chaudron and Nirodi, 2010). Relatively little empirical work has focused on the down-stream consequences of OCS for both the parent and child; however, in addition to causing the mother extreme distress, postpartum OCS can also influence the type of care an infant receives, family relationships and interactions, as well as increase the risk for developing further psychiatric disorders such as depression (Abramowitz et al., 2003b).
Given these data, there is a need to substantially reduce the personal, developmental and financial impact of OCD, particularly if vulnerable females can be identified during pregnancy and if an effective OCD prevention program can be developed and implemented. Longitudinal studies have identified antenatal factors that prospectively predict increases in postpartum OCS, including (a) higher levels of anxiety, (b) higher levels of pre-existing (non-clinical) OCS, and (c) the presence of certain cognitive distortions (e.g., the belief that “bad” thoughts are equivalent to bad actions) (Abramowitz et al., 2003a, Abramowitz et al., 2006). These variables represent identifiable psychological vulnerabilities to perinatal OCD and raise the possibility that at-risk individuals can be identified. The identification of potentially malleable vulnerability factors is necessary for the development of a prevention program (Kraemer et al., 2001) that could in turn demonstrably reduce the impact of postpartum OCD and OCS.
Cognitive-behavioral models of OCD (Salkovskis et al., 1998) and postpartum OCS (Fairbrother and Abramowitz, 2007) posit that symptoms arise when normally occurring, negative intrusive thoughts (e.g., unwanted thoughts of harm befalling the infant) are misinterpreted as highly significant and threatening based on faulty beliefs about the importance of such thoughts (e.g., “If I think this, it is likely to happen”) and the need to control them (e.g., “I should never have any bad thoughts about the infant) (Larsen et al., 2006). Compulsive rituals (e.g., checking on the infant) subsequently develop with the function of reducing anxiety and controlling the unwanted thoughts, but instead maintain the obsessional fear by preventing the natural extinction of obsessional anxiety. Research indicates that about 70% of postpartum women report unwanted infant-related intrusive thoughts (Abramowitz et al., 2003a), and two prospective studies found that the presence of antenatal dysfunctional beliefs predicts more severe obsessions and compulsions in the postpartum, over and above depression, general anxiety, and pre-existing OCS (Abramowitz et al., 2006, Abramowitz et al., 2007).
Cognitive behavior therapy (CBT) is one efficacious treatment for OCD, and includes techniques such as exposure, response prevention, and cognitive therapy (Foa et al., 1998). CBT is thought to work by correcting cognitive distortions and weakening urges to perform anxiety-reducing rituals (McLean et al., 2001). The knowledge of empirically supported interventions for reducing both symptoms and vulnerabilities, in combination with the identification of malleable risk factors, presents the opportunity for considering targeted prevention programs (Feldner et al., 2004). The aim of the present investigation was to develop and test the efficacy of a prevention program based on CBT principles for postpartum OCS. Specifically, expecting mothers with an empirically established, malleable risk factor for postpartum OCS—obsessive beliefs—received either a CBT prevention program or a credible control program, both of which were incorporated into traditional childbirth education classes. We hypothesized that compared to the control condition, the prevention program would be associated with lower OCS and lower scores on obsessive beliefs (e.g., importance of thoughts and the need to control them) at one month postpartum. We also hypothesized that symptom reduction would be maintained in the prevention condition across 6 months postpartum, and that these findings would be specific to OCS by statistically controlling for baseline depression symptoms.
Section snippets
Participants
The sample consisted of 71 expecting mothers who were followed from their 2nd or 3rd trimester of pregnancy into the postpartum at two sites: Florida State University in Tallahassee, FL (FSU n = 33) and the University of North Carolina at Chapel Hill (UNC n = 38). Participants were recruited from local OB/Gyn clinics, as well as print and online advertisements in the respective communities. In total, 306 women were screened: 217 did not meet inclusion/exclusion criteria and 18 declined to
Study population and baseline values
All 71 participants completed the prevention or control programs; however, only 58 (prevention = 33 and control = 25) completed the 1 month postpartum assessment, 50 (prevention = 31 and control = 19) the 3 month postpartum assessment, and 49 (prevention = 29 and control = 20) the 6 month postpartum assessment. Comparisons of completers and non-completers revealed no differences on any demographic or baseline psychological factors considered (all p’s > 0.10). Participants in the two conditions did not differ
Discussion
The current investigation represents the first example of a prevention program designed specifically to target postpartum OCS. Results provide support for the utility of incorporating a CBT-based prevention program into a traditional CBE curriculum. Our intervention falls in-line with a recent psycho-educational program developed by Fisher et al. (2010), which was found helpful in preventing general mood, anxiety and adjustment disorders in the postpartum. That program did not target specific
Conflict of interest
Authors Timpano, Schmidt, Mitchell, Abramowitz, & Mahaffey have no conflicts of interest.
Role of funding source
Funding for this study was provided by a grant from the International Obsessive Compulsive Disorder Foundation (IOCDF) to K.R. Timpano (PI). The IOCDF had no further role in study design, data collection, analysis and interpretation of data, in the writing of the report, and in the decision to submit the paper for publication.
Contributors
Authors Timpano, Abramowitz, and Schmidt designed the study and wrote the protocol. Authors Mahaffey and Mitchell helped with data collection efforts and acted as project coordinators. Author Timpano wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.
Acknowledgments
We thank Heidi Chavers and Elissa Brody, who delivered the childbirth education programs at the FSU and UNC sites, respectively.
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