versão impressa ISSN 0101-8108
Rev. psiquiatr. Rio Gd. Sul v.30 n.2 Porto Alegre maio/ago. 2008
Carla Fonseca ZambaldiI; Amaury CantilinoII; Everton Botelho SougeyIII
IPsychiatrist. Assistant of the Postpartum
Depression Clinic, Universidade Federal de Pernambuco (UFPE), Recife, PE, Brazil.
MSc. student, Graduation in Neuropsychiatry and Behavioral Sciences, UFPE.
IIPsychiatrist. Head, Women's Mental Health Program, UFPE. PhD student, Graduation in Neuropsychiatry and Behavioral Sciences, UFPE.
IIIPsychiatrist. Post-PhD. Associate professor, Department of Neuropsychiatry, UFPE. Head, Graduation in Neuropsychiatry and Behavioral Sciences, UFPE.
Postpartum depression is the most common affective disorder in the puerperium. There are some particular symptoms in its clinical presentation, and one might be the higher frequency of obsessions and compulsions. We report six cases identified from the analysis of medical charts of puerperal women receiving care at the Women's Mental Health Program of Universidade Federal de Pernambuco, Brazil. All the women were diagnosed with postpartum depression using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and had associated obsessive-compulsive symptoms. We report time of onset, types, course and treatment response of these symptoms. Obsessive-compulsive symptoms preceded depressive symptoms in two women, and were succeeded in two other women. There was exacerbation of preexisting obsessions and compulsions in two puerperal women. The most frequent theme was aggressive thoughts toward the baby. Improvement in depressive symptoms tended to reduce obsessive-compulsive symptoms.
Keywords: Postpartum depression, puerperium, obsessions, compulsions, comorbidity.
Postpartum depression (PPD) is the most frequent
affective disorder in the puerperium, affecting about 13% of women in this period.1
In studies performed in Brazil, the prevalence rate ranges between 12- 37.1%.2-5
The clinical status is characterized by depressed mood, despondency, loss of
pleasure, fatigue, lack of concentration, sleep and appetite changes, with onset
around 2-3 weeks after delivery.6
Clinical practice and scientific research has
suggested the presence of obsessive-compulsive symptoms comorbid with PPD.7-9
The most common themes in these cases are aggressive obsession with thoughts
or images involving the baby and checking and washing compulsions.9,10
Occurrence of obsessions and compulsions in the
puerperium seems to be related to reduction of gonadal hormones and their influence
on the serotoninergic system,11,12 associated with the situation
of stress and increased responsibility that represents this period in a woman's
This study reports six clinical cases of PPD with obsessive-compulsive symptoms. A retrospective analysis of medical records of patients receiving care from September 2006 to January 2008 at the Postpartum Depression Clinic of the Women's Mental Health Program at Universidade Federal de Pernambuco was performed. Cases with diagnosis of PPD according to the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), and that had significant obsessions and compulsions in the clinical status were identified.
A 28-year-old, married woman, complete high school,
required blood transfusion due to hemorrhage after normal delivery of her first
child. Three weeks after delivery, she started having obsessive thoughts, with
a recurrent concern of being contaminated with the HIV virus during the transfusion.
The patient could not suppress such thoughts, despite the laboratory test being
negative for the virus. This symptom caused her intense anxiety and suffering.
A few days later, she started having depressive mood, easy and frequent crying, despondency, and lack of pleasure. In addition, she started having intrusive aggressive thoughts against the infant, such as letting him fall. She was also afraid of contaminating him with the virus by holding him in her lap, changing diapers or breastfeeding, despite considering such thoughts irrational. She was afraid of being alone with her son and felt insecure to take care of him. She sought treatment 10 weeks after delivery and was diagnosed as having PPD with obsessions of somatic and aggressive themes. She had unaltered thyroidal function and biochemical tests. Paroxetine 20 mg was started and progressively increased to 40 mg. There was improvement in depressive and obsessive symptoms 3 weeks after the treatment. The patient was still breastfeeding and was followed until complete remission.
A 42-year-old, married woman, complete high school, had previous history of treatment for panic disorder in 2001. Four weeks after cesarean birth of her first child, she had depressed mood, insomnia, weight and appetite loss, despondency, anxiety and feeling of emptiness. She had aggressive thoughts against the infant and horrible recurrent and intrusive images, such as dead infant in the cradle, the baby bleeding, or falling down. She felt guilt because she thought she had no skills and security to take care of her son. Six weeks after delivery, a treatment with sertraline and lorazepam was started. Sertraline was progressively increased until 200 mg/day, and there was symptom improvement after 4 weeks. She interrupted breastfeeding 4 months after delivery and followed the maintenance treatment of depression.
A 37-year-old, married woman, incomplete elementary school, had no previous history of psychiatric disorder. After cesarean birth of her fourth child, she had puerperal infection, requiring hospitalization and use of antibiotic therapy. Twelve weeks after delivery, she started having a recurrent thought that her infection could have been avoided if she had sought maternity care soon after her symptoms started. The patient recognized such thoughts were excessive, but could not prevent them from returning to her mind, which brought her anxiety and suffering. She had depressed mood, insomnia, anhedonia, easy and frequent crying, and anxiety. Twenty-four weeks after delivery, paroxetine was started; since the patient had sleepiness, the medication was replaced by fluoxetine, increasing up to 40 mg. She responded to the treatment after 8 weeks.
A 16-year-old, single adolescent, 2 weeks after delivery of her first child, started having aggressive obsessions against the infant, such as impulses of pinching him and throwing him in the wastebasket, in addition to recurrent images of letting him fall. She presented sadness, anxiety, irritability, impatience, easy crying, and fatigue. She was not dedicated to caring for her child and was not breastfeeding. She sought our clinic 12 weeks after delivery. Fluoxetine 20 mg was started. The patient had partial improvement and abandoned treatment.
A 29-year-old, divorced woman had complete high school and was unemployed. She had previous history of PPD after giving birth to her child 7 years ago, and two depressive episodes not in the postpartum period, which were treated with fluoxetine. Three weeks after the delivery of her third child, she had depressive mood, tiredness, despondency, anxiety, self-depreciative feelings, loss of appetite, and insomnia. She also had recurrent aggressive thoughts against the infant, such as throwing him against the wall and pouring hot water on him. This caused her anxiety, concern, fear that such thought in fact came true, and guilt. For this reason, she started moving away from the infant and was afraid of being left alone with him. Seven weeks after delivery, she sought care at our clinic, and PPD with obsessive-compulsive symptoms was identified. Paroxetine was used, and the dose had to be increased until 50 mg/day, combined with cloxazolam. After 4 weeks, she had partial improvement of depressive symptoms and no longer had obsessive symptoms.
A 40-year-old, single woman with complete high school. Her first pregnancy was interrupted at 22 weeks, with induced delivery, due to dead fetus. About 10 days later, she reported feeling sad and anxious; she used to cry a lot, had difficulties concentrating, despondency, anhedonia, and social withdrawal. The patient already had obsession about symmetry and alignment a few years ago, followed by magical thought, which did not cause her significant consequences. Throughout this period, there was a considerable intensification of symptoms. She stopped walking between a pole and a house wall, as she thought something bad could happen to her; the objects in her house were aligned to form a combination of the number three, otherwise she thought her plans would go wrong. She felt compelled to act in such a way, even recognizing that these thoughts were excessive and irrational. She was medicated with citalopram 40 mg and referred to psychotherapy. After 3 weeks of treatment, she had improvement in depressive symptoms and reduction in intensity and consequences of obsessive-compulsive symptoms, returning to her previous pattern.
Mean age in reported cases was 32 years; three
patients were married, two were single and one was divorced. Depressive symptoms
started between 10 days and 4 weeks after delivery, and obsessive-compulsive
symptoms preceded depressive symptoms in two women. The opposite occurred in
two patients, and in two women there was exacerbation of preexisting obsessions
Aggressive thoughts against the infant were the
most common theme in depressed mothers; in two cases, the patients reported
fear of being with their infant. Puerperal women who had aggressive obsessive
thoughts can consider themselves as a dangerous person and are usually afraid
of being alone with the infant. They also avoid being close to him as an attempt
to prevent concretization of their aggressive obsessive thoughts,14
which damages the mother-infant relationship.
The women in this study took 2-12 weeks to seek
treatment after symptom onset, probably because many did not reveal their depression
symptoms due to guilt and fear of stigmatization,15 since it is socially
expected from them to be very happy after their infants are born.
The antidepressive treatment brought improvement
in depressive symptoms and obsessive-compulsive symptoms. Mean treatment response
time was 4 weeks. The patient in case 3 needed 8 weeks to obtain improvement
in her symptoms and had the longest latency period between symptom onset and
search of treatment. It is known that the higher the delay between PPD onset
and start of pharmacological or psychological intervention, the higher the duration
of mood disorder.16
PPD has negative consequences on women's quality
of life, family dynamics, mother-infant relationship, and cognitive and affective
development of the child.17-20 Further studies are needed to investigate
whether obsessive-compulsive symptoms in PPD worsen these consequences and make
treatment more difficult and longer.
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Correspondence: Received March 17, 2008.
Carla Fonseca Zambaldi
Rua Uriel Paes Barreto, 40/302, Madalena
CEP 50710-500, Recife, PE, Brazil
Tel.: (11) 5573.0379
Fax: (11) 5084.2858
E-mail: firstname.lastname@example.org, email@example.com
Accepted April 4, 2008.
Received March 17, 2008.