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Graduate Student Journal of Psychology                                                                             Copyright 2010 by the Department of Counseling & Clinical Psychology  
2010, Vol. 12                                                                                                                        Teachers College, Columbia University                          
  
Onset or Exacerbation of OCD During Pregnancy: Clinical Characteristics and 

Etiological Considerations  
 

Eleni Vousoura 
Teachers College, Columbia University 

 
Although there are a large number of studies on postpartum illnesses, such as depression and 
psychosis, only recently have perinatal anxiety disorders received attention.  A number of studies 
indicate that there can be a rapid onset or exacerbation of Obsessive-Compulsive Disorder (OCD) 
during pregnancy.  This article reviews the extant research on pregnancy-related OCD.  Due to their 
small samples and the retrospective nature of most of the studies, the prevalence and course of 
pregnancy-related OCD remains unclear.  However, research in this area has demonstrated that in 
contrast to the heterogeneous symptomatology generally observed in OCD, the clinical 
characteristics of obsessions and compulsions in pregnancy are relatively homogeneous, with fear 
of contamination and compulsive cleaning the predominant features.  The article discusses 
biological and psychosocial factors as possible causes of OCD, as well as potential directions for 

 
 
 

Historically, pregnancy has been regarded as a period 
of emotional well-being, which protects the mother from 
psychological distress.  However, it is now acknowledged 
that the perinatal period can be a time of increased 
vulnerability for the onset of mental disorders.  In addition, 
pregnancy and the postpartum are considered to be high-
risk periods for women with preexisting psychiatric 
illnesses.  Although there are a large number of studies on 
postpartum depression and puerperal psychosis, the 
literature on perinatal anxiety disorders has only developed 
recently.  Within this literature, research on Obsessive-
Compulsive Disorder (OCD) has focused mainly on the 
postpartum period (for a review, see Abramowitz, 
Schwartz, Moore & Luenzmann, 2003), with pregnancy-
related OCD remaining largely understudied, despite 
preliminary findings indicating development or 
exacerbation of OCD symptoms during that period.   

Obsessive Compulsive Disorder is an anxiety disorder 
characterized by (a) recurrent, excessive, and intrusive 
thoughts that cause significant distress, and/or (b) 
compulsive behaviors or mental acts that are performed to 
neutralize or suppress these thoughts (American Psychiatric 
Association [DSM-IV-TR], 2000).  Patients with OCD are 
also characterized as having some insight into their 
symptoms, recognizing that these thoughts are excessive, 
unreasonable, and maladaptive.  A common element of the 
disorder is avoidance of situations related to the obsessional 
concerns (DSM-IV-TR, 2000).   

                                                                                                  
The author would like to thank Charlie Baily, M.A., and Sarah 

Bellowin-Weiss, M.A., for their numerous helpful suggestions. 
Correspondence concerning this article should be addressed to 

Eleni Vousoura, Teachers College, Columbia University, 525 W 
120th Street, New York, New York 10027-6696, Email: 
ev2225@columbia.edu. 

Obsessive Compulsive Disorder is one of the most 
common psychiatric disorders with a lifetime prevalence of 
2-3% in the general adult population (Karno, Golding, 
Sorenson, & Burnam, 1988; Ruscio, Stein, Chiu, & Kessler, 
2008).  Data from the Epidemiologic Catchment Area 
program (ECA) show a 12-month prevalence of 1.2-2.4% 
(Fullana et al., 2009; Karno et al., 1988).  The male to 
female ratio is approximately equal, but men have an earlier 
age of OCD onset (Nestadt, Bienvenu, Cai, Samuels, & 
Eaton, 1998).  In women, the age of onset has a bimodal 
distribution (the first peak between 13-16 years of age, and 
the second between 22-32 years of age); though some 
evidence has found OCD onset in later life (Nestadt et al., 
1998; Neziroglu, Anemone, & Yaryura-Tobias, 1992).  The 
clinical picture of OCD is strikingly heterogeneous: 
obsessional thoughts may be fear of contamination, 
excessive doubting, symmetry, aggression, as well as sexual 
and religious obsessions, whereas compulsive behaviors 
may include cleaning, checking, counting, praying, and 
repeating words silently.  These symptoms have been meta-
analytically clustered into four symptom dimensions: 1) 
symmetry obsessions and ordering compulsions, 2) 
aggressive obsessions and checking compulsions, 3) 
contamination obsessions and cleaning compulsions, and 4) 
hoarding obsessions and compulsions (Bloch, Landeros-
Weisenberger, Rosario, Pittenger, & Leckman, 2008).  The 
prognosis of OCD is mixed, but if it is not effectively 
treated, it usually has a deteriorating and chronic course 
(Abramowitz et al., 2003).   
 
 
Prevalence of Pregnancy-Onset O C D 

The exact prevalence of OCD during pregnancy is 
unknown, but there is evidence that pregnant women have a 



VOUSOURA 
  

   38 

greater likelihood of manifesting OCD symptoms compared 
to the general population.  Several early studies report an 
association between OCD symptoms and significant life 
events, including pregnancy and childbirth.  In a study of 
150 OCD patients, Pollitt (1957) found that 62% (n = 93) 
reportedly linked the onset of their symptoms with a 
specific life event with three patients reporting the 
development of OCD symptoms during pregnancy, and 
seven after childbirth.  Ingram (1961) found that out of 89 
OCD patients, 69% (n = 61) developed OCD within a year 
of a significant life event.  Moreover, of those 61 patients, 
15 (25%) associated the onset of symptoms with pregnancy, 
the strongest precipitating correlate of obsessive symptoms.  
In contrast, Lo (1967) found that of 56 patients only 5% 
reported that pregnancy triggered OCD.  This conflicting 
evidence is likely due in part to the several limitations of 
the above cited studies: they were retrospective, did not 
differentiate based on gender, and used vague diagnostic 

(Pollitt, 1957, p. 194).  
In a more recent study of 60 patients (39 females and 

21 males) diagnosed with OCD as defined by the 
Diagnostic and Statistical Manual of Mental Disorders, 
Third Edition  Revised (DSM-III-R), six women first 
manifested OCD during their pregnancy (Buttolph & 
Holland, 1990).  Neziroglu and colleagues (1992) similarly 
found that of 59 mothers who met criteria for OCD 
according to DSM-III, 23 (39%) linked pregnancy with the 
onset of OCD.  Based on these findings, the authors 
hypothesized that pregnancy is indeed an important life 
event that may precipitate OCD.  Additional evidence 
supports the association between OCD onset and 
pregnancy.  For example, Williams & Koran (1997) 
document that the onset of OCD was associated with 
pregnancy in 5 (13%) of the 38 study participants, while a 
controlled study of Nigerian women, Adewuya, Ola, Aloba, 
and Mapayi (2006) found that pregnant women were three 
times more likely to have OCD.  

In contrast, a study of 136 Italian participants 
conducted by Maina, Albert, Bogetto, Vaschetto, and 
Ravizza (1999) did not find a significant association 
between pregnancy and OCD onset, with only two out of 35 
women (0.05%) reporting first-onset OCD during 
pregnancy.  The authors however suggested that these 
findings deserve critical consideration as the low rates of 
first-onset OCD in this sample compared to other studies 
might be attributable to the exclusion of co-morbid 
depression, suggesting that pregnancy may be a risk factor 
for the development of OCD particularly for those with 
concomitant depression.  In one recent prospective study 
assessing women before and after childbirth, Uguz and 
colleagues (2007a) found that three of 16 participants 
(18.8%) experienced OCD symptoms for the first time 
during pregnancy.  While the sample size is small, the 
strength of this study lies in its prospective methodology.  
In a larger subsequent study with 434 women, the same 
authors reported that 3.5% (n = 15) of participants 

developed OCD as defined by the Structured Clinical 
Interview for DSM-IV Axis I Disorders [SCID-I] in the 
third trimester of pregnancy (Uguz et al., 2007b).   
 
Exacerbation of O C D During Pregnancy 

Besides OCD with perinatal onset, there is evidence 
supporting the exacerbation of OCD symptoms during 
pregnancy.  Buttolph and Holland (1990) reported 
exacerbation of OCD symptoms in 8% of the 39 female 
patients.  In a case study, Chelmow and Halfin (1997) 
reported exacerbated OCD symptoms in a 28-year-old 
pregnant woman with previously diagnosed OCD following 
her first pregnancy.  Other studies show a bidirectional 
change in symptom severity during pregnancy.  Williams 
and Koran (1997) found that of 29 pregnant patients with 
preexisting OCD, five (17%) reported worsening, four 
(14%) described improvement, and 20 (69%) described no 
change in symptoms during pregnancy.  Vulink, Denys, 
Bus, and Westenberg (2006) assessed symptom severity 
using the Yale-Brown Obsessive Compulsive Scale (Y-
BOCS) symptom checklist in 52 women meeting criteria 
for OCD according to the Diagnostic and Statistical Manual 
of Mental Disorders, Fourth Edition (DSM-IV).  Pregnancy 
was associated with a worsening of OCD symptoms in 33% 
of patients (severe worsening for 23% of them), and a 
moderate improvement in 21% of patients.  Uguz and 
colleagues (2007b) reported worsening of preexisting OCD 
in six patients (46.1%), compared with amelioration of 
symptoms in three patients (23.1%); four patients (30.8%) 
reported no change in OCD symptoms during pregnancy. 

Overall, these findings suggest that pregnancy may be 
associated with the onset of OCD, or exacerbation of the 
ongoing disorder in pregnant women.  However, due to the 
retrospective design of the majority of the studies, no causal 
relationships can be inferred.  Also, discrepancies in the 
data reported above could be due to small sample sizes, 
methodological variability, and the lack of standardized 
diagnostic criteria for OCD.   
 

Clinical Character istics of Pregnancy-Related O C D 
 

Contrary to the varied symptom pattern in typical 
OCD, pregnancy-related OCD tends to be remarkably 
homogeneous.  Findings from case studies with pregnant 
OCD patients reveal a relatively consistent content of 
obsessions and compulsions.  Buttolph and Holland (1990) 
described two women with onset of OCD during 

compulsive washing rituals and obsessions involving fear 
of the fetus becoming contaminated by toxic agents.  In 
another case study of pregnancy-induced OCD, Kalra, 
Tandon, Trivedi, and Janca (2005) described a patient who 
had fears of contamination; while she recognized her 
thoughts as irrational, she continued to engage in 
compulsive washing rituals.  Similarly, in a case of 
pregnancy-complicated OCD, Chelmow and Halfin (1997) 



OCD DURING PREGNANCY 
 

   39 

presented a patient who experienced a fear of blood-borne 
disease and engaged in compulsive cleaning and organizing 
of household items. 

More recent studies have used the Y-BOCS symptom 
checklist to assess the severity and type of OCD symptoms.  
In the study by Uguz and colleagues (2007b), the most 
common obsessions among pregnant women with OCD 
were fear of contamination (80%) and preoccupation with 
symmetry/exactness (60%), while the most common 
compulsions were cleaning/washing (86.7%) and checking 
(60%).  The authors found similar results in their 
prospective study of 16 women (Uguz et al., 2007a), noting 
that the most common obsessions reported by women in the 
38th gestational week were fear of contamination (81.3%), 
preoccupation with symmetry/exactness (50%), aggressive 
(43.3%), and religious obsessions (37.5%), whereas the 
most common compulsions were cleaning/washing 
(81.3%), checking (56.3%), and ordering/arranging 
(43.8%).  In a more recent study, Labad and colleagues 
(2010) interviewed 90 female outpatients with OCD.  The 
authors found that patients who predominantly had 
obsessions about contamination and compulsions about 
cleaning had greater chance of developing these symptoms 
during the perinatal period.  Conversely, patients in the 
hoarding dimension mostly reported onset of OCD at 
menarche.   

 
Course and Comorbidity of Pregnancy-Related O C D 

Though the course of pregnancy-related OCD has 
received little empirical attention, there is some evidence 
that OCD symptoms improve during the postpartum period.  
In their prospective study of 16 OCD patients, Uguz and 
colleagues (2007a) found that 11 patients (69%) reported a 
decrease in OCD symptoms at six weeks after birth.  Kalra 
and colleagues (2005) presented a case of a 30-year-old 
primigravid woman with onset of OCD in the fourth month 
of gestation who fully recovered two weeks after delivery 
without psychiatric intervention.  In contrast, there is ample 
evidence that women with anxiety disorders during 
pregnancy are at higher risk of presenting depressive 
symptoms at early postpartum, even after controlling for 
antenatal depression (Heron, O'Connor, Evans, Golding, & 
Glover, 2004; Milgrom et al., 2008; Moss, Skouteris, 
Wertheim, Paxton, & Milgrom, 2009; Sutter-Dallay, 
Giaconne-Marcesche, Glatigny-Dallay, & Verdoux, 2004).  
Therefore, while pure OCD symptoms might improve 
postpartum, it is possible that pregnancy-related OCD is a 
precipitating factor for postnatal depression.  However, no 
definitive conclusions can be drawn since, to date, there has 
been no prospective study exploring the relationship 
between postpartum depression and OCD specifically.   

Results from epidemiological studies demonstrate that, 
in general, OCD patients manifest a number of additional 
psychiatric conditions, predominantly major depressive 
disorder (Hollander et al., 1997).  In addition, research on 
the postpartum period shows a strong association between 

OCD symptoms and postpartum depression (Abramowitz, 
Schwartz, & Moore, 2003b; Wisner, Peindl, Gigliotti, & 
Hanusa, 1999; Zambaldi, Cantilino, Montenegro, Paes, de 
Albuquerque & Sougey, 2009).  However, there are few 
studies exploring the comorbidity of OCD with depression 
during pregnancy; in the majority of studies on pregnancy-
related OCD, concomitant depression has been regarded as 
an exclusion criterion rather than a focus for investigation.   
 

Etiological Considerations 
 
The etiology of OCD remains largely unknown.  

Several biological (genetic, neurochemical and anatomical) 
and psychosocial factors may contribute to the development 
of OCD in pregnancy. 
 
Biological Factors 

The well-established efficacy of serotonin reuptake 
inhibitors (SRIs), particularly clomipramine, in the 
treatment of OCD symptoms (Ackerman & Greenland, 

(Barr et al., 1993).  According to this neurochemical model, 
obsessive-compulsive symptoms are generated due to 
deficits in the serotonin neurotransmitter system.  However, 
not all OCD patients respond positively to SRI 
monotherapy.  Findings regarding the role of serotonin on 
OCD have been equivocal (Rauch & Jenike, 1993).  During 
pregnancy there is a significant increase in sex hormones, 
mainly estrogen and progesterone, which is followed by an 
abrupt drop after parturition.  There is evidence that 
fluctuations in gonadal steroid levels may alter serotonergic 
transmission, reuptake, and binding (Rubinow, Schmidt & 
Roca, 1998).  Research has also shown that OCD symptoms 
begin or worsen during the premenstruum (Labad et al., 
2005; Williams & Koran, 1997).  Thus, it has been 
proposed that OCD during pregnancy or following 

on serotonergic functioning (Sichel et al., 1993).   
Investigation beyond the serotonergic system shows 

that neuropeptides may be involved in the pathogenesis of 
OCD.  Of particular interest is oxytocin, a nonapaptide 
synthesized in the hypothalamus and released into the blood 
from the pituitary gland (Leckman et al., 1994a).  Oxytocin 
has been implicated in the promotion of grooming behavior.  
It has been suggested that contamination obsessions and 
excessive cleaning rituals are analogous to oxytocin-

body or appearance (allogrooming) commonly observed in 
social animals.  In addition, oxytocin attenuates memory 
retrieval, which offers a plausible explanation to 
pathological doubting and checking compulsions in OCD 
(McDougal et al., 1999).  Several findings suggest an 
association of OCD with oxytocin.  In one well-known 
study (Leckman et al., 1994b), patients with OCD had 
significantly increased oxytocin levels in their cerebrospinal 
fluid (CSF).  During late pregnancy and the postpartum 



VOUSOURA 
  

   40 

period, oxytocin concentration in the bloodstream increases, 
stimulating uterine contractions and milk ejection for 
lactation.  Therefore, it is possible that OCD during 
pregnancy is oxytocin-induced.  However, other studies 
have not reported the same correlation between OCD 
symptoms and oxytocin levels (Altemus et al., 1999).   

While biological theory has proved intriguing, findings 
from genetic and family investigations have provided some 
support for a genetic basis for OCD.  The concordance rate 
of OCD is higher for monozygotic twins than for dizygotic 
twins and genetic influence ranges from 27% to 47% (for a 
review, see van Grootheest et al., 2005).  In addition, the 
prevalence of OCD is higher among first-degree relatives of 
affected probands than those of control probands, 12% and 
3%, respectively (Nestadt et al., 2000).  There is also 
evidence that a family history of OCD is associated with 
early onset of the disorder (Hanna, Himle, Curtis, & 
Gillespie, 2005).  Genetic studies in OCD during pregnancy 

 knowledge, only one study has 
addressed this issue.  Uguz and colleagues (2007b) found 
that pregnant women with OCD were significantly more 
likely to have a positive family history of OCD compared to 
pregnant women without OCD.  However, family history of 
OCD was based on self-reports rather than structured, 
standardized diagnostic interviews. 
 
Psychosocial Factors 

While biological theories are largely successful at 
explaining the unique etiological factors of pregnancy-
related OCD, a growing body of research suggests that 
there may also be psychosocial determinants of the 
disorder.  One such finding is that the male partners of 
pregnant women appear to be susceptible to the 
development of OCD symptoms.  Abramowitz and 
colleagues (2001) reported four cases of male spouses who 

or after delivery.  All four fathers reported intrusive ego-
dystonic thoughts of harming the child (e.g., intrusive ideas 
of stabbing the baby with sharp objects, shaking the baby to 
death, etc.), a finding that points out the inadequacy of 
purely biological theories to explain the onset of symptoms 
during this period.  The high prevalence of obsessions 
among new fathers was further corroborated in a survey of 
600 childbearing women and their partners (2003). Twenty-
three (57.7%) out of 40 male respondents endorsed some 
intrusive obsessive thoughts, a rate similar to this of 
mothers (Abramowitz, Schwartz, & Moore, 2003).  

Furthermore, it may be valuable to consider the 
interaction between biological vulnerability and 
environmental stressors in the development of OCD during 
pregnancy.  Not all women associate their pregnancy with 
positive emotions, an oft-held notion.  Some women 
experience pregnancy as a stressful life event (Geller, 
2004).  Among a growing body of literature investigating 
the role of Stressful Life Events (SLE) in the onset of 
depressive and anxiety disorders (Paykel & Dowlatshahi, 

1988), evidence suggests that SLEs are associated with the 
onset of OCD (Cromer, Schmidt, & Murphy, 2007).  
Research has identified other risk factors for pregnancy-

pregnancy, comorbid premenstrual dysphoric disorder 
(PMDD), prior history of abortion and miscarriage, 
obstetric complications and medical conditions, unplanned 

mother (Adewuya et al., 2006; Fontenelle & Haler, 2006; 
Labad et al., 2005; Neziroglu et al., 1992).  Moreover, lack 
of social support with household responsibilities and 
childcare is associated with a poorer prognosis of the 
disorder (Uguz et al., 2007a) and greater likelihood of 
developing depression postnatally (Webster et al., 2000).  

Drawing on D. W. 

researchers hypothesize that mothers may be genetically 
predisposed to demonstrate increased protectiveness and 

safe environment that ensures the survival of the infant 
(e.g., Leckman et al., 2004). Obsessive-compulsive 
behavior could thus be conceptualized as an extension of an 
adaptive maternal behavior.  Findings by Jennings and 
colleagues (1999) lend support to this, showing that as high 
as 6.5% of asymptomatic postpartum women experienced 
aggressive thoughts towards their infants.  The Cognitive 
Appraisal Model (Salkovskis, 1999) supports the 
evolutionary perspective by theorizing that the majority of 
adults experience intrusive, upsetting, ego-dystonic 
thoughts, which are indistinguishable from clinical 
obsession in terms of content.  Vulnerable individuals tend 

threatening.  For example, they falsely believe that thinking 
about a violent act is equivalent to committing such an act 
(morality bias), or that thinking about something increases 
the probability that it will actually occur (probability bias).  
It is when individuals misappraise these thoughts as 
threatening that clinical obsessions occur, further leading to 
attempts to prevent or neutralize the thoughts by engaging 
in ritualistic behaviors (Salkovskis & Harrison, 1984).   

 
Clinical Implications and Recommendations 

Obsessive Compulsive Disorder during pregnancy 
causes significant disturbance and has a negative impact on 
physical and psychological well-being, as well as social 
relationships (Gezginc et al., 2008).  In addition, a 
significant body of research supports a link between 
prenatal anxiety and neonatal outcomes, such as preterm 
labor, heart defects, and growth retardation (see Talge, 
Neal, & Glover, 2007 for a review).  Moreover, prenatal 
anxiety can have long-
cognitive, behavioral, and emotional functioning (Huizink, 
Mulder, & Buitelaar, 2004).  Furthermore, in the absence of 
treatment, anxiety disorders are a strong precipitating factor 
in postpartum depression (Skouteris, Wertheim, Rallis, 
Milgrom, & Paxton, 2009), and thus, OCD may have 



OCD DURING PREGNANCY 
 

   41 

negative implications for the mother-infant relationship 
(Chelmow & Halfin, 1997).  Research in the postpartum 

ability to care for the infant and engage the infant in social 
interactions (Murray, Cooper, & Hipwell, 2003).  
Depressed mothers may talk less to their infants, manifest 
fewer facial expressions, show less physical affection, have 
impaired bonding, and negatively influence the affective 
regulation of their child (Moehler, Brunner, Parzer, Wiebel, 
Reck, & Resch, 2006; Tronick, & Reck, 2009).  Maternal 
depression may also have adverse effects on infan
cognitive and emotional development (Murray & Cooper, 
1996; Murray, Hipwell, Hooper, Stein, & Cooper, 1996).  
However, there is evidence indicating that the association 
between prenatal anxiety and child adjustment is not fully 
explained by the mediation of postnatal depression.  For 

significant effect of antenatal anxiety on child behavioral 
and emotional problems after accounting for postnatal 
depression.  Together these findings point to the importance 
of detection and treatment of OCD in pregnancy. 

Clinical surveillance for OCD during pregnancy should 
be part of the screening process in obstetrical and primary 
care.  Screening should first include simple questions 
regarding intrusive, unwanted thoughts (i.e., contamination) 
and compulsive behaviors (i.e., excessive washing and 
checking behaviors).  Should the patient endorse such 
symptoms, the frequency and severity of the symptoms 
should be assessed using measures of OCD with well-
established psychometric properties (e.g., YBOCS).  In the 
event of clinically significant OCD symptoms, a referral for 
psychiatric consultation and/or treatment should be 
considered (Brandes, Soares, & Cohen, 2003).  Several 
selective serotonin reuptake inhibitors have demonstrated 
efficacy and tolerability in the treatment of OCD, among 
them fluoxetine, sertraline, fluvoxamine, and paroxetine 
(see Pigott & Seay, 1999 for a review).  However, 
antidepressant medication may not be a viable treatment 
option during pregnancy; despite their low side-effect rates, 
SSRIs have not been approved by the Food and Drug 
Administration (FDA) for use during pregnancy (Weisberg 
& Paquette, 2002).  

Among non-pharmacologic treatments, cognitive-
behavioral therapy (CBT) is the most widely tested 
psychosocial approach for OCD.  Within the CBT 
paradigm, numerous different treatment models for OCD 
exist, such as exposure (imaginal or in-vivo), response 
prevention, cognitive therapy (CT), and rational-emotive 
therapy (RET).  A number of randomized controlled trials 
(RCTs) attest to the efficacy of exposure in combination 
with response prevention (ERP) for treating OCD either in 
an individual or group format (Deacon &  Abramowitz, 
2004).  However, there has been no research on the efficacy 
of CBT or other psychosocial intervention in the treatment 
of OCD in pregnancy.   

 
Conclusion 

 
Existing findings indicate that a sizeable proportion of 

women experience a sudden onset or exacerbation of OCD 
during pregnancy suggesting that pregnancy is a vulnerable 
period for the development or exacerbation of OCD.  
Several biological and psychosocial factors are implicated 
in the etiology of OCD in pregnancy, yet the exact 
mechanism of pathogenesis is unknown.  Due to limited 
research and methodological shortcomings, future research 
is needed to further explore the prevalence, course, and 
etiology of the disorder. 

Prospective studies are needed to further elucidate the 
prevalence and course of OCD during pregnancy and to 
identify at-risk subgroups.  Longitudinal studies should 
commence prior to conception, if possible, and follow-up 
should be performed postpartum.  Future studies need 
larger samples and assessment of OCD symptoms should be 
carried out at multiple points during gestation, ideally 
during each trimester.  In addition, pregnant women with 
OCD should be compared with control groups of 
nonpregnant women matched for demographic and clinical 
variables such as age, marital status, socioeconomic status, 
family history of the disorder, and co-morbid mental 
disorders.  Future studies should incorporate a number of 
additional parameters.  Inclusion of patients with concurrent 
depression is needed in order to clarify the nature of the 
relationship between OCD and major depression.  Studies 
would also benefit from the inclusion of subclinical 
obsessive-compulsive symptoms (Abramowitz et al., 
2003a) because cut-off scores tend to simplify the clinical 
picture of the disorder.  Finally, given the possible 
association between OCD symptoms and complications in 
pregnancy, future studies should record a detailed medical 
and gynecological history, including obstetric 
complications (e.g., pre-eclampsia), premenstrual 
symptoms, and number of previous pregnancies, 
miscarriages, and abortions.  

 A better understanding of the prevalence and 
pathogenesis of the disorder is vital as OCD in pregnancy is 
a debilitating condition that deserves attention in its own 
right.  Additionally, pregnancy-related OCD is associated 
with postnatal depression and may have long-term negative 
effects on th
identification and treatment of pregnancy-related OCD is 
likely to have preventative benefit for the mother as well as 
the infant.  Given its important clinical implications for 
both the mother and the infant, future research should adapt 
and test psychosocial treatments for OCD in pregnancy.  
 

 



VOUSOURA 
  

   42 

References  
 

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. Anxiety Disorders, 17, 461-478. 

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 Medical 
Settings, 10(3), 157-164. 

Abramowitz, J. S., Moore, K. M., Carmin, C., Wiegartz, P., 
& Purdon, C. (2001). Obsessive-compulsive disorder in 
males following childbirth. Psychosomatics, 42, 429-431.  

Ackerman, D. L., & Greenland, S. (2002). Multivariate 
meta-analysis of controlled drug studies for obsessive 
compulsive disorder. Journal of Clinical 
Psychopharmacology, 22, 309-17. 

Adewuya, A. O., Ola, B. A., Aloba, O. O., & Mapayi, B. 
M. (2006). Anxiety disorders among Nigerian women in 
late pregnancy: a controlled study. 
Mental Health, 9, 325-328. 

Altemus, M., Jacobson, K. R., Debillis, M., Kling, M., 
Pigott, T., Murphy, D. L., & Gold, P. W. (1999). Normal 
CSF oxytocin and NPY Levels in OCD. Biological 
Psychiatry, 45, 931-933.  

American Psychiatric Association. (2000). Diagnostic and 
statistical manual of mental disorders, (4th ed., text 
revision). Washington, DC: American Psychiatric 
Association.  

Barr, L. C., Goodman, W. K., & Price, L. H. (1993). The 
serotonin hypothesis of obsessive-compulsive disorder. 
International Clinical Psychopharmacology, 8(Suppl. 2), 
79-82. 

Bloch, M. H., Landeros-Weisenberger, A., Rosario, M. C., 
Pittenger, C., & Leckman, J. F. (2008). Meta-analysis of 
the symptom structure of obsessive-compulsive disorder. 
Am J Psychiatry, 165, 1532-1542. 

Brandes, M., Soares, C. N., & Cohen, L. S. (2003). 
Postpartum onset obsessive-compulsive disorder: 
Diagnosis and management. Arch Womens Ment Health, 
7, 99-110. 

Buttolph, M. I., & Holland, A. (1990). Obsessive-
compulsive disorders in pregnancy and childbirth. In M. 
A. Jenike, J. Baer, & W. E. (Eds.), Obsessive-compulsive 
disorders: theory and management (2nd ed, pp 89-97). 
Chicago: Year Book Medical.  

Chelmow, D. & Halfin, V. P. (1997). Pregnancy 
complicated by obsessive-compulsive disorder. The 
Journal of Maternal-F etal Medicine, 6, 31-34. 

Cromer, K. R., Schmidt, N. B., & Murphy, D. L. (2007) An 
investigation of traumatic life events and obsessive-
compulsive disorder. Behav Res Ther, 45, 1683-1691. 

Deacon, B. J., & Abramowitz, J. S. (2004). Cognitive and 
behavioral treatments for anxiety disorders: A review of 
meta-analytic findings. Journal of Clinical Psychology, 
60, 429-441.  

Fontenelle, L. F. & Hasler, G. (2008). The analytical 
epidemiology of obsessive-compulsive disorder: Risk 
factors and correlates. Progress in Neuro-
psychopharmacology & Biological Psychiatry, 32, 1-15. 

Fullana, M. A., Mataix-Cols, D., Caspi, A., Harrington, H., 
Grisham, J. R., Moffitt, T. E., & Poulton, R. (2009). 
Obsessions and compulsions in the community: 
prevalence, interference, help-seeking, developmental 
stability, and co-occurring psychiatric conditions. Am J 
Psychiatry, 166, 329-336. 

Geller, P. A. (2004). Pregnancy as a stressful life event. 
CNS Spectr, 9(3), 188-97. 

Gezginc, K., Uguz, F., Karatayli, S., Zeytinci, E., Akin, R., 
Guler, O., Sahin, F., Murat Emul, H., Ozbulut, O. & 
Gecici, O. (2008). The impact of obsessive-compulsive 
disorder in pregnancy on quality of life. International 
Journal of Psychiatry in Clinical Practice, 12(2), 134-
137. 

Hanna, G. L., Himle, J. A., Curtis, G. C., & Gillespie, B. 
W. (2005). A family study of obsessive-compulsive 
disorder with pediatric probands. American Journal of 
Medical Genetics Part B: Neuropsychiatric Genetics, 
134, 13-9. 

Heron, J., O'Connor, T. G., Evans, J., Golding, J., & 
Glover, V. (2004). The ALSPAC Study Team. The 
course of anxiety and depression through pregnancy and 
the postpartum in a community sample. Journal of 
Affective Disorders, 80, 65-73. 

Hollander, E., Greenwald, S., Neville, D., Johnson, J., 
Hornig, C. D., & Weissman, M. M. (1997). 
Uncomplicated and comorbid obsessive-compulsive 
disorder in an epidemiologic sample. Depression and 
Anxiety, 4, 111-19. 

Huizink, A. C., Mulder, E. J. H., & Buitelaar, J. K. (2004). 
Prenatal stress and risk for psychopathology: Specific 
effects or induction of general susceptibility? 
Psychological Bulletin, 130, 115-142.  

Ingram, I. M. (1961). Obsessional illness in mental hospital 
patients. Journal of Mental Science, 107, 382-402. 

Jennings, K. D., Ross, S., Popper, S., & Elmore, M. (1999). 
Thoughts of harming infants in depressed and 
nondepressed mothers. Journal of Affective Disorders, 
54, 21-28. 

Kalra, H., Tandon, R., Trivedi, J. K., & Janca, A. (2005). 
Pregnancy-induced obsessive-compulsive disorder: a case 
report. Ann Gen Psychiatry, 4, 12. 

Karno, M., Golding, J. M., Sorenson, S. B., Burnam, M. A. 
(1988). The epidemiology of obsessive-compulsive 
disorder in five US communities. Arch Gen Psychiatry, 
45, 1094-1099. 

Labad, J., Menchon, J. M., Alonso, P., Segalas, C., 
Jimenez, S., & Vallejo, J. (2005). Female reproductive 
cycle and obsessive-compulsive disorder. J Clin 
Psychiatry, 66, 428-35. 

Leckman, J. F., Feldman, R., Swain, J. E., Eicher, V., 
Thompson, N., &. Mayes, L. C. (2004). Primary parental 



OCD DURING PREGNANCY 
 

   43 

preoccupation: circuits, genes, and the crucial role of the 
environment. J Neural Transm, 111, 753-771. 

Leckman, J. F., Goodman, W. K., North, W. G., Chappell, 
P. B., Price L. H., Pauls D. L., Anderson, G. M., Riddle, 
M. A., Barr L. C., & Cohen, D. J. (1994a). The role of 
central oxytocin in obsessive compulsive disorder and 
related normal behavior. Psychoneuroendocrinology, 
19(8), 723-49. 

Leckman, J. F., Goodman, W. K., North, W. G., Chappell, 
P. B., Price L. H., Pauls D. L., Anderson, G. M., Riddle, 
M. A., McSwiggan-Hardin M., McDougle C. J., Barr L. 
C., & Cohen, D. J. (1994b). Elevated cerebrospinal fluid 
levels of oxytocin in obsessive-compulsive disorder: 
Comparison with Tourette's syndrome and healthy 
controls. Archives of General Psychiatry, 51(10), 782-92. 

Lo, W. H. (1967). A follow-up study of obsessional 
neurotics in Hong Kong Chinese. British Journal of 
Psychiatry, 113, 823-832. 

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. 

McDougle, C. J., Barr, L. C., Goodman, W. K., & Price, L. 
H. (1999). Possible role of neuropeptides in obsessive 
compulsive disorder. Psychoneuroendocrinology, 24, 1-
24. 

Milgrom, J., Gemmill, A. W., Bilszta, J. L., Hayes, B., 
Barnett, B., Brooks, J., Ericksen, J., Ellwood, D., & 
Buist, A. (2008). Antenatal risk factors for postnatal 
depression: A large prospective study. Journal of 
Affective Disorders, 108(1-2), 147-157.  

Moehler, E., Brunner, R., Parzer, P., Wiebel, A., Reck, C., 
& Resch, F. (2006). Maternal depressive symptoms in the 
postnatal period are associated with long-term 
impairment of mother-child bonding. Arch Womens Ment 
Health, 9, 273-8.  

Moss, K. M., Skouteris, H., Wertheim, E. H., Paxton, S. J., 
Milgrom, J. (2009). Depressive and anxiety symptoms 
through late pregnancy and the first year post birth: an 
examination of prospective relationships. Arch Womens 
Ment Health, 12, 345-349. 

Murray, L. & Cooper, P. J. (1996). The impact of 
postpartum depression on child development. 
International Review of Psychiatry, 8, 55-63.  

Murray L, Hipwell A, Hooper R, Stein A, & Cooper P. 
(1996). The cognitive development of 5-year-old children 
of postnatally depressed mothers. J Child Psychol 
Psychiatry, 37, 927-35. 

Murray, L., Cooper, P., Hipwell, A. (2003). Mental health 
of parents caring for infants. l 
Health, 6(suppl. 2), S71-S77.  

Nestadt, G., Bienvenu, O. J., Cai, G., Samuels, J., Eaton, 
W. W. (1998). Incidence of obsessive-compulsive 
disorder in adults. J Nerv Ment Dis, 186, 401-406. 

Nestadt, G., Samuels, J., Riddle, M., Bienvenu, J., Liang, 
K., LaBuda, M., Walkup, J., Marco Grados, M., & 
Rudolf Hoehn-Saric, R. (2000). A family study of 

obsessive-compulsive disorder. Archives of General 
Psychiatry, 57(4):358-63. 

Neziroglu, F., Anemone, R., & Yaryura-Tobias, J. A. 
(1992). Onset of obsessive-compulsive disorder in 
pregnancy. American Journal of Psychiatry, 149, 947-50. 

Glover, V. (2002). Maternal antenatal anxiety and 

Report from the Avon Longitudinal Study of Parents and 
Children. British Journal of Psychiatry, 180, 502-508.  

Pigott, T. A, & Seay, S. M. (1999). A review of the efficacy 
of selective serotonin reuptake inhibitors in obsessive-
compulsive disorder. Journal of Clinical Psychiatry. 
60(2), 101-106.  

Pollitt, J. (1957). Natural history of obsessional states. 
British Medical Journal, 9, 133-40. 

Rauch, S., & Jenike, M. (1993). Neurobiological models of 
OCD. Psychosomatics, 34, 20-32. 

Rubinow, D. R., Schmidt, P. J., & Roca, C. A. (1998). 
Estrogen-serotonin interactions: Implications for affective 
regulation. Biological Psychiatry, 44, 839-850. 

Ruscio, A. M., Stein, D. J., Chiu, W. T., & Kessler, R. C. 
(2008). The epidemiology of obsessive-compulsive 
disorder in the National Comorbidity Survey Replication. 
Molecular Psychiatry, 1-11. 

Salkovskis, P. M. (1999). Understanding and treating 
obsessive-compulsive disorder. Behaviour Research and 
Therapy, 37 (Suppl 1), S29-52. 

Salkovskis, P. M., & Harrison, J. (1984). Abnormal and 
normal obsessions: A replication. Behaviour Research 
and Therapy, 22, 549-552. 

Sichel, D., Cohen, L., Dimmock, J., & Rosenbaum, J. 
(1993). Postpartum obsessive-compulsive disorder: a case 
series. Journal of Clinical Psychiatry, 54, 156-159. 

Skouteris, H., Wertheim, E. H., Rallis, S., Milgrom, J., 
Paxton, S. J. (2009). Depression and anxiety through 
pregnancy and the early postpartum: An examination of 
prospective relationships. J Affect Disord, 113, 303-308.  

Sutter-Dallay, A. L., Giaconne-Marcesche, V., Glatigny-
Dallay, E., & Verdoux, H. (2004). Women with anxiety 
disorders during pregnancy are at increased risk of 
intense postnatal depressive symptoms: a prospective 
survey of the MATQUID cohort. European Psychiatry, 
19(8), 459-463. 

Talge, N. M., Neal, C., Glover, V., 2007. Antenatal 
maternal stress and long-term effects on child 
neurodevelopment: how and why? J. Child Psychol. 
Psychiatry, 48, 245-261. 

Tronick, E., & Reck, C. (2009). Infants of depressed 
mothers. Harv Rev Psychiatry, 17(2), 147-56. 

Uguz, F., Gezginc, K., Zeytincia, I. E., Karatayli, S., 
Askina, R., Guler, O., Sahin, F. K., Emul, H. M., 
Ozbulut, O., & Gecici, O. (2007a). Course of obsessive-
compulsive disorder during early postpartum period: a 
prospective analysis of 16 cases. Comprehensive 
Psychiatry, 48, 558-561.    



VOUSOURA 
  

   44 

Uguz, F., Gezginc, K., Zeytinci, I. E., Karatayli, S., Askin, 
R., Guler, O., Kir Sahin, F., Emul, H. M., Ozbulut, O., & 
Gecici, O. (2007b). Obsessive-compulsive disorder in 
pregnant women during the third trimester. 
Comprehensive Psychiatry, 48, 441-445. 

van Grootheest, D. S., Cath, D. C., Beekman, A. T., & 
Boomsma, D. I. (2005). Twin studies on obsessive-
compulsive disorder: a review. Twin Research and 
Human Genetics, 8(5), 450-458. 

Vulink, N. C. C., Denys, D., Bus, L., & Westenberg, H. G. 
M. (2006). Female hormones affect symptom severity in 
obsessive-compulsive disorder. International Clinical 
Psychopharmacology, 21, 171-175. 

Webster, J., Linnane, J. W., Dibley, L. M., Hinson, J. K., 
Starrenburg, S. E., & Roberts, J. A. (2000). Measuring 
social support in pregnancy: Can it be simple and 
meaningful? Birth, 27, 97-101. 

Weisberg, R. B., & Paquette, J. A. (2002). Screening and 
treatment of anxiety disorders in pregnant and lactating 
women. Health Issues, 12(1), 32-36. 

Williams, K. E, & Koran, L. M. (1997). Obsessive-
compulsive disorder in pregnancy, the puerperium, and 
the premenstruum. Journal of Clinical Psychiatry. 58(7), 
330-4.  

Winnicott, D. W. (1956). Primary maternal preoccupation. 
In Collected Papers. New York: Basic Books. 

Wisner, K. L., Peindl, K. S., Gigliotti, T., & Hanusa, B. H. 
(1999). Obsessions and compulsions in women with 
postpartum depression. Journal of Clinical Psychiatry, 
60, 176-180.  

Zambaldi, C. F., Cantilino, A., Montenegro, A. C., Paes, J. 
A., de Albuquerque, T. L., & Sougey, E. B. (2009). 
Postpartum obsessive-compulsive disorder: prevalence 
and clinical characteristics. Comprehensive Psychiatry, 
50, 503-509. 
  


