A 31-year-old woman comes to the office for a 6-week postpartum visit. The patient is accompanied by her husband who says, "We haven't been getting much sleep since the baby was born, but he's healthy and doing well. My wife is doing a great job-I'm just worried she's too overwhelmed." Her husband shares that she spends hours every night reading about breastfeeding and baby formula instead of sleeping. The patient says, "Lots of things get passed on to the baby in breast milk. I don't want him to get exposed to something bad or hurt him in some way." She wears sterile surgical gloves when preparing formula and showers every time before breastfeeding. The patient washes fruits and vegetables 3 times to "get all the pesticides out" and does not eat at restaurants anymore from fear of getting food poisoning. She does not drink alcohol or use illicit drugs. Medical history is insignificant. Physical examination is within normal limits. The patient appears tired and anxious; she has no suicidal ideation. Which of the following is the most likely diagnosis?

Question

A 31-year-old woman comes to the office for a 6-week postpartum visit.  The patient is accompanied by her husband who says, "We haven't been getting much sleep since the baby was born, but he's healthy and doing well.  My wife is doing a great job-I'm just worried she's too overwhelmed."  Her husband shares that she spends hours every night reading about breastfeeding and baby formula instead of sleeping.  The patient says, "Lots of things get passed on to the baby in breast milk.  I don't want him to get exposed to something bad or hurt him in some way."  She wears sterile surgical gloves when preparing formula and showers every time before breastfeeding.  The patient washes fruits and vegetables 3 times to "get all the pesticides out" and does not eat at restaurants anymore from fear of getting food poisoning.  She does not drink alcohol or use illicit drugs.  Medical history is insignificant.  Physical examination is within normal limits.  The patient appears tired and anxious; she has no suicidal ideation.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d7d9_ba41_bc81_ddc1612ab6db_MD0003_00 This patient's new onset of time-consuming, intrusive obsessions (ie, excessive preoccupation about contamination of breast milk, obsessional fears of harming the baby) and associated compulsive behaviors (excessive washing and showering) are consistent with obsessive-compulsive disorder (OCD). Pregnancy and the postpartum period are associated with increased risk for new onset, recurrence, or exacerbation of OCD. As in this case, the obsessional thoughts and compulsions often relate to the health and safety of the baby (eg, fears of contaminating and harming the baby, excessive washing). New mothers with OCD may be reluctant to disclose their symptoms and come to clinical attention only when a partner or family member becomes concerned. Mild cases of postpartum OCD are treated with cognitive-behavioral therapy; management of moderate to severe cases may include a serotonergic antidepressant after consideration of the risks of pharmacotherapy versus the risks of untreated OCD. (Choice A) Adjustment disorder with anxiety is characterized by emotional or behavioral disturbances within 3 months of the onset of a stressor (eg, childbirth). However, this patient's time-consuming, intrusive thoughts and compulsions make OCD a more likely diagnosis. Adjustment disorder is not diagnosed when the criteria for a more specific mental disorder (eg, OCD) are met. (Choice B) Generalized anxiety disorder is characterized by multiple worries about everyday events lasting ≥6 months and would not explain this patient's compulsive behaviors. (Choice C) This patient's mood is anxious, and she does not have other key depressive symptoms (eg, decreased interest, impaired concentration, feelings of worthlessness/guilt, decreased appetite). (Choice E) It may be difficult to differentiate delusions seen in postpartum psychosis from the obsessions seen in OCD. However, this patient does not have other psychotic symptoms (eg, hallucinations, disorganized speech or behavior) that would be seen in postpartum psychosis. Her compulsive checking and cleaning behaviors are characteristic of OCD. (Choice F) Specific phobia is characterized by severe anxiety upon exposure to a specific situation or object, typically leading to avoidance of the feared stimulus (eg, heights, needles). It would not explain this patient's compulsive behaviors. Educational objective: Pregnancy and the postpartum period are associated with increased risk for new onset, recurrence, or exacerbation of obsessive-compulsive disorder. Obsessions and compulsions frequently center around fears of contaminating and harming the baby. References: Obsessive-compulsive disorder and female reproductive cycle events: results from the OCD and reproduction collaborative study. (http://www.ncbi.nlm.nih.gov/pubmed/24421066) Obsessive-compulsive disorder in the postpartum period: diagnosis, differential diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/26246310) Risk of obsessive-compulsive disorder in pregnant and postpartum women: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/23656845)

A 31-Year-Old Woman Comes to the Office for a 6-Week