Pretest self-assessment question (answer at the end of the case)

While OCD may develop postpartum in some cases, which is not true of postpartum OCD?

A. It is less common than postpartum blues

B. It is less common than postpartum depression

C. It occurs in up to 5% of postpartum women

D. Obsessions are most frequently related to contamination fears

Patient evaluation on intake

56-year-old woman with a chief complaint of “not doing well for many years”

Has suffered anxiety and depression for over 30 years

Psychiatric history

Was without major psychiatric symptoms until her late twenties

Lost a child in utero and a few weeks after this there was an outbreak of pinworms in her household

Since this time she has never recovered

Has been depressed, and has obsessive thoughts about contamination

Is essentially dependent on husband and family, does not drive, cannot work as a result

Admits to MDD symptoms

• – Reasonable sleep but only with medication

• – Low interest

• – Low energy

• – Poor concentration and worsening short-term memory

• – Ideational guilt but not to a psychotic level

• – Poor appetite

• – Denies suicidal thinking

Does not meet criteria for PTSD, PD (although she has frequent acute episodes of agitation), or GAD

• – She does meet criteria for SAD and the patient and husband describe her as being shy and avoidant her whole life

  • Given the longevity of rejection sensitivity, avoidant personality disorder might be considered

Meets criterion for OCD

• – Obsessions of excessive contamination are frequently encountered

• – Compulsively, she used to wash hands hundreds of times a day

  • A course of exposure and response prevention (ERP) therapy helped to decrease this many years ago

  • Interestingly, this compulsion was largely replaced by her actions of living in her car in her garage for extended periods of time

• She often will leave the house in the morning and spend the whole day in her car in the garage reading books as the car is not contaminated nearly as much as the rest of the house

• Denies other OCD symptoms

• It is clear that much of daily routine and life revolves around the symptoms of OCD, which are deemed more disabling

While screening for mania, she and her husband do acknowledge bipolar-like symptoms with sustained hypomania and possible mania in the distant past

• – These are ill defined and without any clear consequences

• – There is subtle mood elevation at times

• – More often, these appear to be sustained agitation episodes

There is no evidence of eating disorder or substance abuse

Social and personal history

Graduated high school and was gainfully employed as a clerk/secretary thereafter, but stopped work after she was married and started a family

Now is married with grown children

Drinks coffee in the morning, does not smoke or take drugs

Medical history

Hyperlipidemia

HTN

No drug allergies, no vision problems, no skin problems

Family history

SAD, avoidant personality, MDD in the patient’s mother

Medication history

Has tried a myriad of TCA, SSRI, SNRI, and BZ throughout the years

Augmented with low-dose atypical antipsychotics in the past

Psychotherapy history

Eclectic, supportive psychotherapy intermittently attended over last 30 years

Some behavioral therapy but unclear if a full ERP behavioral therapy protocol was completed

Little to no sustained response to these psychotherapeutic interventions, as she continues with fluctuating symptoms that never fully remit

Patient evaluation on initial visit

Acute onset of apparent MDD symptoms associated with trauma of loss of an unborn child

• – Will need to consider postpartum MDD, or even postpartum OCD

Symptoms of MDD have remitted at times

OCD has not ever fully remitted

Has fair insight, at best, into the OCD symptoms and better insight into the distress caused by the depressive symptoms

Possible history of hypomania

Despite symptoms, she has no suicidal ideation and no recent history of psychiatric inpatient admissions

• – 30 years ago, admitted twice for inpatient hospitalizations for suicidal thoughts, which in retrospect may have been postpartum induced

Reports no current side effects but does have pre-existing metabolic illness