Obsessive-Compulsive and Related Disorder Symptoms in the Perinatal Period: Prevalence and Associations with Postpartum Functioning

Abstract

Purpose:

Obsessive-compulsive disorder (OCD) symptoms are more likely to develop or be exacerbated during pregnancy and the postpartum period, which can cause significant distress and impairment. However, the disorders grouped with OCD in the DSM-5, obsessive-compulsive and related disorders (OCRD; e.g., hoarding disorder (HD), body dysmorphic disorder (BDD), trichotillomania (TTM), excoriation disorder (ED)), have rarely been examined in the perinatal period. This study aimed to explore: 1) the prevalence of all clinically significant OCRD symptoms in pregnancy and the postpartum period; and 2) the correlations between OCRD psychopathology and postpartum functioning.

Methods:

Participants were recruited during their second trimester of pregnancy from a Midwestern medical center. Participants completed an online questionnaire and a semi-structured clinical interview during pregnancy (28-32 weeks gestation, N =276) and the postpartum period (6-8 weeks, N =221).

Results:

BDD and OCD symptoms were the most prevalent. In pregnancy, 14.9% (N = 41) of participants endorsed clinically significant BDD symptoms and 6.2% (N = 17) endorsed clinically significant OCD symptoms. In the postpartum period, 11.8% (N = 26) endorsed clinically significant BDD symptoms and 14% (N = 31) endorsed clinically significant OCD symptoms. Poorer postpartum functioning was associated with elevated OCRD symptoms in pregnancy and postpartum.

Conclusions:

OCRD symptoms occur during pregnancy and the postpartum period at rates similar or higher than other life periods. Elevated OCRD symptoms are associated with poorer postpartum functioning across domains. Future research should explore how all OCRD symptoms may affect functioning in the perinatal period, not only OCD symptoms.

Introduction

One of the most common times for a woman to experience obsessive-compulsive disorder (OCD) symptoms is during pregnancy and the postpartum period (Chaudron & Nirodi, 2010; Fairbrother et al., 2021; Munk-Olsen et al., 2006). Perinatal women are approximately 1.5-2 times more likely to experience OCD symptoms than other populations of women (Russell et al., 2013). OCD symptoms are often distressing and impairing, and perinatal psychopathology is associated with long-term psychiatric and medical consequences for the entire family (Meltzer-Brody & Stuebe, 2014).

OCD is now classified with obsessive-compulsive and related disorders (OCRD) in the Diagnostic and Statistical Manual of Mental Disorders (Diagnostic and Statistical Manual of Mental Disorders (DSM-5^®), APA, 2013). Along with OCD, the OCRD category includes body dysmorphic disorder (BDD), hoarding disorder (HD), trichotillomania (hair-pulling disorder; TTM), and excoriation disorder (skin-picking; ED). Disorders are arranged in the DSM taxonomy based on shared phenomenological features (e.g., repetitive, compulsive behaviors) and possible shared etiology. There has been some debate over classification of OCD with the disorders grouped in the OCRD category (Abramowitz & Jacoby, 2015), yet there are substantial similarities between OCD and BDD in phenomenological presentation and treatment response (Phillips et al. 2010; Veale & Riley 2001; Windheim et al. 2011). OCD is the only disorder in the OCRD category that has been extensively studied in a perinatal-specific context. If there are etiological and phenomenological similarities between OCD and other similar disorders, the perinatal period may also be a high-risk time for the development or exacerbation of other OCRD symptoms and these, may also affect postpartum functioning (Phillips et al., 2010).

In the most recent study of perinatal OCD symptoms in a community sample, prevalence rates were approximately 3% in pregnancy and gradually increased over the perinatal period until prevalence peaked at 9% at 8 weeks postpartum (Fairbrother et al., 2021). Up to a third of women with pre-existing OCD experience exacerbation of symptoms during pregnancy, while up to half report worsening in the postpartum period (Labad et al., 2005; Williams & Koran, 1997; Vulink et al., 2006). There have been few empirical studies conducted on other OCRD symptoms during the perinatal period (Lochner et al., 2005; Keuthen et al., 1997). When examining perinatal trichotillomania, Lochner et al. (2005) found approximately 7.7% of participants reported onset while pregnant or within one month postpartum, while Keuthen et al. (1997) found both exacerbation and lessening of trichotillomania symptoms during pregnancy. To our knowledge, there is no empirical literature on hoarding disorder, body dysmorphic disorder, or excoriation in the perinatal period, nor is there any information on trichotillomania in the postpartum period. While there have been some significant gains in understanding perinatal OCD, there is a lack of rigorous studies examining prevalence of all OCRD symptoms and how they may be associated with postpartum functioning.

Pregnancy and the postpartum period are times of great change to body shape, features, and function (Hodgkinson et al., 2014). With so many changes occurring, pregnancy is often regarded as a “stress test” for any individual (Bilhartz et al., 2011). Exposure to significant life events (e.g., bullying, job loss, family illness, adolescent stressors) has been linked to development or exacerbation of all OCRD symptoms (Buhlmann et al., 2012; Coles et al., 2011; França et al., 2019; Landau et al., 2011; Odlaug et al., 2013). OCRD symptoms, except for hoarding disorder, often have a focus on body parts (e.g., pulling hair, checking on body parts). Pregnancy and the postpartum period may highlight what might be very subtle outside of the perinatal period (e.g., increase in OCRD symptoms in relation to increased stress and high rate of bodily change). The combination of change to the body alongside a period of increased stress may present vulnerability to a higher prevalence of body focused OCRD symptoms compared to other life periods.

It is also worth considering that the perinatal period may create or exacerbate pre-existing body image concerns due to bodily changes (e.g., weight gain, skin/hair changes). Individuals who place high importance on body image are more likely to struggle with body dissatisfaction during pregnancy, which may become heightened in the postpartum period (Fuller-Tyszkiewicz et al., 2012). This may be particularly damaging for those with existing BDD symptoms or those who may be vulnerable to its onset. BDD involves intense preoccupation with imaginary flaws, often consistent with the societal ideal of what a Western woman should look like (thin, symmetrical features; Wilhelm & Neziroglu, 2002). Yet, pregnancy is characterized by physiological changes that are the opposite of this ideal, that happen without any control over the process (Skouteris, 2011). This could lead to a possible opportunity for an increase in symptoms of BDD during pregnancy and the postpartum. However, more research is needed to understand how OCRD symptoms manifest during pregnancy and the postpartum period.

Given how common and impairing OCD symptoms can be during the perinatal period, it is important to determine if the perinatal period may also be a vulnerable time for all OCRD symptoms. Prospective studies on OCRD, including OCD, are limited in the perinatal period (Forray et al., 2010; Uguz et al., 2007). Further, while the base rate of women meeting diagnostic criteria for an OCRD is expected to be low, subthreshold symptoms may be more prevalent and may affect postpartum functioning. Thus, it is important to understand what role OCRD psychopathology plays in postpartum functioning. This study aims to explore: 1) the prevalence of all OCRD symptoms in pregnancy and the postpartum period, and 2) the associations between OCRD psychopathology symptoms and postpartum functioning. Our hypotheses are that 1) the highest prevalence of OCRD symptoms during pregnancy and postpartum will be BDD and OCD symptoms, given their similarities; and 2) increased OCRD symptoms will be positively associated with poorer postpartum functioning.

Materials and Methods

Procedures

This paper reports on data collected as part of a larger investigation of anxiety, depression, and OCRD symptoms in perinatal women. Participants were primarily community women who had received prenatal care at an academic medical center. Potential participants were identified through the university Institute for Clinical and Translational Science, who provided contact information to the study team. The study team sent recruitment letters to all potential participants describing the study. Individuals who did not call to decline participation upon receiving recruitment letters were contacted via telephone up to three times to determine interest and eligibility. No data were collected from potential participants who choose not to participate. Participants were also recruited through mass emails sent to all individuals with a university email address.

Eligibility included: able to read and speak English, currently in their third trimester (28-32 weeks gestation), over the age of 18, and planning on living with their infant post-delivery. Once participants verbally consented, they completed an online questionnaire assessing OCRD symptoms and risk factors during the third trimester and again at 6-8 weeks postpartum. Participants completed a semi-structured clinical interview for assessment of OCD symptoms. A total of N= 276 participants completed the pregnancy assessment (either the questionnaire and/or the clinical interview), N = 221 completed the postpartum assessment, and N = 195 completing both interview and questionnaire in pregnancy and postpartum (for full recruitment procedures see Miller, 2018).

The clinical interviews were recorded and administered by the PI and ten additional interviewers, all graduate students, or individuals in post-baccalaureate positions who had been trained in the IMAS. Training included how to establish rapport with participants, distinguish between clinically significant and normative responses, notes specifically about the perinatal period, probing techniques, and understanding the specific content of each module. The PI provided supervision throughout the project and aided with any ambiguous participant response. Approximately 10% of each interviewers’ recordings for interviews were rescored by an independent rater to provide estimates of interviewer reliability. The university institutional review board approved all study procedures.

Measures

Dysmorphic Concern Questionnaire.

The DCQ (Oosthuizen et al., 1998) is a 7-item assessment of body dysmorphic disorder symptoms (Mancuso et al., 2010). Participants rate their concern about their physical appearance on a 4-point scale, ranging from 0 (not at all) to 3 (much more than most people). It has been found to be useful as a brief, screening tool for BDD in non-psychiatric clinical settings validated against a structured clinical interview with good sensitivity and specificity (Mancuso et al., 2009; Stangier et al., 2003). Face validity and discriminant validity have also been established for this measure. Clinically significant scores were a score of 9 and above (Mancuso et al., 2010). This cutoff has been shown to correctly classify of 96.4% of body dysmorphic patients and 90.6% of undergraduates (Mancuso et al., 2010). Internal consistency was excellent (α =.88 in pregnancy and postpartum).

Interview for Mood and Anxiety Symptoms.

The IMAS (Watson et al., 2007; Kotov et al., 2015) is a semi-structured clinical interview used to dimensionally assess all symptoms of mood and anxiety disorders. The IMAS is composed of multiple specific subscales; only the OCD and Depression scales were utilized for this study. Several studies have provided support for the reliability and validity of the IMAS (Kotov et al., 2015; Ruggero et al., 2014; Watson et al., 2007, 2012). This measure shows strong associations (convergent validity) with comparable subscales from the IDAS and good discriminant validity (Watson et al., 2007; 2012; Dornbach-Bender et al., 2017). Higher scores indicate more severe symptoms. To meet criteria for clinically significant OCD, an empirically based scoring system was used where participants had to endorse symptoms consistent with DSM-IV diagnoses and endorse that the symptoms interfere in their life. To compare against a structured clinical interview, Waszczuk et al. (2017) computed polyserial correlations between the IMAS and SCID. Correlations ranged from moderately high to high, indicating that the IMAS converges with the SCID well. The IMAS demonstrated strong internal consistency in pregnancy (α =.88) and postpartum (α =.83).

Massachusetts General Hospital Hairpulling Scale.

The MGH-HPS (Keuthen et al., 1995) is a 7-item Likert scale validated against a diagnostic clinical interview used to assess frequency, intensity, and control of hair-pulling urges, behaviors, and distress associated with hair pulling (Diefenbach et al., 2005). This measure does not have sensitivity or specificity data available but has established and recent good internal consistency, reliability, and validity (Bauer, 2014; Keuthen et al., 1995). In this sample, any score at 7 or above was considered clinically significant, indicating at least some distress around/urges to/engagement in hair-pulling on every measured facet (Francazio & Flessner, 2015; Odlaug et al., 2014). This score was used as available studies suggest the mean score of healthy controls on this measure is zero (Francazio & Flessner, 2015; Odlaug et al., 2014). Internal consistency was excellent (α =.91 in pregnancy, α = .93 in postpartum).

Postpartum Adjustment Questionnaire.

The PPAQ (O'Hara et al., 1992) is a 61-item measure of postpartum adjustment in several social roles, including family member, friend, mother, wife, homemaker, and employee (outside the home). Higher scores indicate more difficulty adjusting to the postpartum period. Internal consistency was good (α =.88).

Skin Picking Scale.

The SPS (Keuthen et al., 2001) is a 6-item assessment of skin-picking (excoriation disorder) symptoms that has been validated against a structured clinical interview. This measure has been tested in a sample of clinical and non-clinical skin-pickers with moderate internal reliability (α = .80) as well as construct validity. Clinically significant scores were a score of 7 and above (Keuthen et al., 2001). This SPS cutoff of 7 was utilized to classify excoriation disorder had a sensitivity ratio of 96.4% and specificity of 92.2%. In this sample, internal consistency was good (α =.87 in pregnancy, α =.90 in postpartum).

Saving Inventory-Revised.

The SI-R (Frost et al., 2004) is a 23-item measure validated against a structured clinical interview that assesses hoarding disorder symptoms. The SI-R has shown discriminant validity in identifying hoarding specific symptoms compared to general depressive or other OCD symptoms when compared to another measure of hoarding-related beliefs and attitudes, the Saving Cognitions Inventory (SCI; Steketee, Frost, & Kyrios, 2003). Clinically significant hoarding symptoms in this study were total scores that were at least one and one-half standard deviations above the mean community scores, scores of 42 and higher (Frost et al., 2004). The SI-R cutoff that was utilized to classify clinically significant hoarding symptoms had a sensitivity of 90.48% and specificity of 83.46% (Kellman-McFarlane et al, 2019). Internal consistency was excellent (α =.92 in pregnancy, α =.94 in postpartum).

Data Analysis

Statistical analyses were performed using SPSS version 26. The prevalence of all OCRD symptoms that met clinical significance at both pregnancy and the postpartum period were reported. To determine prevalence, the DCQ, SPS, and SI-R symptom measures have similar sensitivity metrics of 90-96%. OCD symptom severity was determined with a clinical interview (IMAS) and the MGH-HPS does not have sensitivity or specificity data available. Clinical significance was defined separately for each disorder (see Measures). Postpartum incidence was calculated as OCRD symptoms that met clinical significance for the first time in postpartum. Bivariate correlations were conducted between all prenatal and postpartum OCRD scales and all postpartum functioning subscales. Listwise deletion was used for missing data. Correlations were statistically significant at alpha level α = .05.

Results

All descriptive statistics are reported in Table 2. In both pregnancy and postpartum, body dysmorphic disorder symptoms, hoarding disorder symptoms, and postpartum functioning were approximately normally distributed (skewness and kurtosis values between −2 and +2; Trochim & Donnelly, 2006). There was significant skew and kurtosis for trichotillomania, excoriation disorder, and obsessive-compulsive disorder symptoms. This is not unexpected given the non-normal distribution of clinical symptoms in a community sample, especially for less prevalent disorders such as trichotillomania and excoriation disorder.

Table. 2.

Descriptive Statistics and Clinical Significance Rates in Pregnancy and the Postpartum

Psychopathology Symptoms	Number of items	Pregnancy M(SD)	Range	Clinically Significant Pregnancy N(%)	Comorbidity N(%)	Postpartum M(SD)	Range	Clinically Significant Postpartum N(%)	Comorbidity N(%)	Exacerbation to Clinical Significance N(%)
Body Dysmorphic	7	4.68(3.85)	0-19	41(14.9)	15 (36.6)	4.01(3.61)	0-18	26(11.8)	13(50)	7(6.9)
Excoriation	6	1.60(2.80)	0-19	16(5.8)	10(62.5)	1.42(2.92)	0-21	10(4.5)	7(70)	4(40)
Hoarding	23	13.94(10.01)	0-53	5(1.8)	3(60)	11.34(10.31)	0-54	3(1.4)	3(100)	2(66)
Trichotillomania	7	0.56(2.25)	0-19	11(4)	4(36.4)	0.62(2.73)	0-23	4(1.8)	2(50)	0(0)
Obsess-Compulsive	13	0.86(1.99)	0-14	17(6.2)	7(41.2)	0.61(1.84)	0-13	31(14.0)	10(32.3)	22(71)
Depressive	28	4.17(7.27)	0-50	23(8.3)	19(82.6)	3.36(6.99)	0-44	15(6.8)	7(46.7)	6(40)

Note. M = mean; SD = standard deviation; Sx = symptoms; N/% of all participants at each time point. Diagnoses determined by clinically significant cutoff scores as determined by each disorder-specific measure for OCRD and on the IMAS according to DSM-V criteria for OCD.

Comorbidity = number of cases that had additional OCRD elevated symptoms; Exacerbation to Clinical Significance = the number of cases that became newly clinically significant in the postpartum. Of note, some clinically significant cases in pregnancy ceased to be clinically significant in the postpartum; N/% represents out of total postpartum cases.

N = 276 for pregnancy; N =221, for the postpartum

Participants

Among participants that completed study components at both time points (N =195), the mean age was 30.9 years (SD = 5.1, range 19–44; Table 1). Most participants were white (90%), partnered (91.3%), and highly educated (83.6% had at least some college experience). There were no significant differences in age, ethnicity, or severity of psychopathology between participants that only completed the study in pregnancy compared to participants that completed both time points. However, those who did not participate in the postpartum period were recruited later in their pregnancy, endorsed fewer excoriation symptoms, and were more likely to be people of color compared to study completers.

Table 1.

Participant Characteristics

All Participants		Participants who completed both assessments
	M(SD)		M(SD)
Age	30.6(5.2)	Age	30.8(5.3)
	N(%)		N(%)
Race		Race
Asian	4(2.1)	Asian	4(2.1)
Black	11(4.7)	Black	8(4.2)
White	205(88.4)	White	172(90.1)
Pacific Islander	1(0.5)	Pacific Islander	1(0.5)
More than one race	10(4.3)	More than one race	6(3.1)
Ethnicity		Ethnicity
Latina	21(8.8)	Latina	15(7.7)
Not Latina	217(91.2)	Not Latina	181(92.3)
		Education Level
		High School Degree or Less	15(7.7)
		Associates Degree/Some College	46(23.6)
		Bachelor’s Degree	72(36.9)
		Masters or Doctoral/Professional	62(31.8)
		Parity
		Multiparous	101(49.0)
		Nulliparous	104(50.5)
		Income Level
		<30,000	27(13.9)
		30-70,000	71(36.6)
		>70,000	96(49.5)
		Marital Status
		Single	14(7.2)
		Cohabitating/Engaged/Married	177(91.2)
		Separated/Divorced/Widowed	3(1.5)

Note. There were 241 participants that reported data in pregnancy and 203 participants that reported all demographic data when completing both assessments; M = mean; SD = standard deviation.

Prevalence of OCRD Symptoms

During pregnancy, there were clinically significant symptoms of hoarding disorder (n = 5, 1.8%), trichotillomania (n = 11, 4.0%), and excoriation disorder (n = 16, 5.8%). However, significant body dysmorphic disorder symptoms (n = 41, 14.9%) and obsessive-compulsive symptoms (n = 17, 6.2%) were more common. All pregnancy OCRD scales were highly correlated (Table 3). There was a high rate of comorbidity (82.6%) between clinically significant depressive symptoms and OCRD symptoms. A similar pattern was seen during the postpartum period with 1.4% (n =3) experiencing hoarding disorder, 1.8% (n = 4) experiencing trichotillomania, and 4.5% (n = 10) experiencing excoriation disorder. The most common clinically significant psychopathology symptoms in the postpartum period were again body dysmorphic disorder symptoms (n = 26, 11.8%) and obsessive-compulsive symptoms (n = 31, 14%). There was a much lower rate of comorbidity (46.7%) between clinically significant depressive symptoms and OCRD symptoms in the postpartum period.

Table 3.

Intercorrelations among Psychopathology and Postpartum Functioning

	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16	17	18	19	20
1. AN BDD
2. AN HD	.26**
3. AN TTM	.16**	.18**
4. AN ED	.37**	.30**	.11
5. AN DEP	.43**	.14*	.42**	.31**
6. AN OCD	.19*	.16*	.03	.19**	.29**
7. PP BDD	.71**	.20**	.12	.29**	.38**	.17*
8. PP HD	.20**	.71**	.05	.32**	.09	.06	.34**
9. PP TTM	.13	−.01	.41**	.13	.40**	−.01	.21**	.19**
10. PP ED	.23**	.23**	.31**	.60**	.29**	.13	.31**	.41**	.33**
11. PP DEP	.29**	.17*	.25**	.33**	.55**	.28**	.27**	.08	.15	.35**
12. PP OCD	.14*	.02	.14	.14	.30**	.56**	.13	−.00	.06	.15*	.30**
13. House	.18**	.24**	.12	.11	.29**	.05	.26**	.23**	.18*	.06	.21**	−.00
14. Work	−.00	.03	−.14	.04	.05	−.09	.11	−.02	−.04	−.02	.44**	.03	.45**
15. Friends	.41**	.03	.21**	.10	.41**	.05	.29**	.01	.32**	.08	.24**	.06	.33**	.37**
16. Family	.20**	.13	.13	.12	.32**	.24**	.18*	.05	.06	.06	.19*	.21**	.05	−.08	.22**
17. Baby	.10	.13	.04	.16*	.08	−.07	.16*	.10	.09	.09	.16**	−.08	.25**	.36**	.13	.16*
18. Kids	.07	.10	.00	.06	−.04	−.11	.12	.10	−.03	−.08	.10	−.12	.25**	.23*	.16	.15	.46**
19. Spouse	.21**	.12	−.03	.18*	.25**	.10	.18**	.16*	.05	.05	.05	.15*	.27**	.00	.40**	.25**	.15*	.15
20. Total	.35**	.19**	.21**	.22**	.42**	.15*	.33**	.17*	.22**	.16*	.31**	.16*	.66**	.47**	.67**	.48**	.48**	.46**	.67**

Note. AN = pregnancy; OCD =obsessive-compulsive disorder symptoms; BDD = body dysmorphic disorder symptoms; HD = hoarding disorder symptoms; TTM = trichotillomania symptoms; ED = excoriation symptoms; DEP = depression; PP = postpartum; Postpartum adjustment scales: House =Work in the house; Work = Work outside of the house; Family = Relatives; Baby = New baby, Kids = Other children; Spouse, Total score; N = 87-273. * p < .05, ** p < .01.

For most OCRD symptoms, there were higher prevalence rates in pregnancy compared to the postpartum period. In the postpartum period subthreshold symptoms were more likely to become clinically significant rather than new incidence of clinically significant symptoms. Of note, obsessive-compulsive symptoms had the highest percentage of cases (71%) exacerbated from non-clinical significance in pregnancy to clinical significance postpartum.

Correlations with Postpartum Functioning

OCRD symptom severity scores were significantly associated in pregnancy (r =.16-.37, p <.05; Table 3). In the postpartum period, hoarding, body dysmorphic, trichotillomania, and excoriation disorder symptom severity scores were significantly associated (r =.19-.41, p <.01). Obsessive-compulsive symptom severity scores were only significantly associated with excoriation symptoms in the postpartum period (r =.12, p <.05).

Elevated symptoms of all OCRD symptoms in pregnancy were significantly associated with poorer postpartum adjustment overall (r =.19-.35, p <.05), with the strongest association between body dysmorphic disorder symptoms and poorer postpartum adjustment (r =.35, p <.001). This pattern was also seen with elevated OCRD symptoms in postpartum (r =.16-.33, p <.05, body dysmorphic disorder symptoms (r = .33, p <.001). Outside of total postpartum adjustment, poorer adjustment to responsibilities in the home was most frequently associated with elevated OCRD symptoms in pregnancy (body dysmorphic [r =.18, p <.01]; and hoarding symptoms [r =.24, p <.01]) and in postpartum (body dysmorphic [r =.26, p <.01]; hoarding [r =.23, p <.01]; and trichotillomania [r =.18, p <.05] symptoms). Elevated body dysmorphic disorder symptoms were the OCRD symptom type most associated with poorer postpartum adjustment across several domains, in pregnancy (r =.18-.41, p <.01) and postpartum (r =.18-.33, p <.05). However, scores on postpartum adjustment subscales in all domains for this sample were low, like other community postpartum samples (O'Hara, Hoffman, Philipps, & Wright, 1992).

Discussion

The current study examined prevalence of the full spectrum of OCRD psychopathology in an understudied population, a community sample of pregnant and postpartum women, as well as associations with postpartum functioning. Consistent with previous research, clinically significant obsessive-compulsive symptoms were relatively common during pregnancy and postpartum. Body dysmorphic disorder symptoms were the OCRD symptom most endorsed. Further, trichotillomania and excoriation disorder symptoms also occurred (particularly during pregnancy) but to a lesser extent. Consistent with our second hypothesis, more severe OCRD symptoms, especially body dysmorphic symptoms, were associated with poorer postpartum functioning.

Rates for BDD symptoms were high, especially when compared to the estimated point prevalence of BDD (2.5%) for adult women (Koran et al., 2012). To meet criteria for clinical significance for BDD, a participant had to endorse concern ‘more than most people’ in at least two areas, not just general dissatisfaction with body type. The level of women endorsing clinically significant BDD symptoms is higher than expected. This may be reflecting an increased vulnerable period for the manifestation of BDD symptoms. However, it is also important to consider that the high rates of BDD symptoms in this sample may be normative, time-limited body dissatisfaction during the perinatal period or may be more strongly associated with underlying eating disorder and body image problems. Regarding normative body dissatisfaction, two reviews of body image during pregnancy demonstrate that body image challenges are frequent and qualitatively different during pregnancy than during times of non-pregnancy as well as across pregnancy (Hodgkinson et al., 2014; Watson, Fuller-Tyszkiewicz, Broadbent, & Skouteris, 2015). Of note, the reviews found that body dissatisfaction was most reflected in being physically restricted, uncomfortable, and impaired in the pregnant body, not on appearance. This suggests that underlying disordered body image or eating issues may be more critical to consider as we examine possible high rates of BDD in the perinatal period. Rates of lifetime BDD are as high as 15% in those with diagnosed eating disorders (Kollei et al., 2013), but this association hasn’t been examined in the perinatal period. A serious limitation of the study is that body dissatisfaction, preoccupation with weight and shape pre-pregnancy, or history of disordered eating were not measured (Gjerdingen et al., 2009). Future research should include perinatal measures that assess body image and disordered eating, such as the recent measure Body Image in Pregnancy Scale (BIPS; Merkitch, 2020), alongside OCRD measures.

Lastly, an additional consideration for the high rates of BDD found in this study may be the more general societal influence of misperceptions of beauty during the transmission to parenthood. Elevated rates of BDD may be less about individual pathology and more about the broader societal lack of acceptance of bodily changes that occur during the perinatal period (e.g., increased fat stores, weight gain, lack of hourglass figure). Normalizing perinatal body changes that are inconsistent with the Western ideal may be a larger public health goal rather than considering a woman’s perception of her body as flawed as pathological. However, empirical research of internalization of body parts as “flawed” based on societal standards, especially among perinatal women who do not meet criteria for BDD, is needed to sort out the complex relationship between societal beauty standards and psychopathology.

Clinically significant OCD symptoms nearly doubled in the postpartum period and most clinically significant cases were newly clinically significant in postpartum. This is of note as OCD symptoms may be even more prevalent than previously thought. Recent literature estimate prevalence rates closer to 7-11% across the perinatal period, rather than 2-3% rates previously described (Fairbrother et al., 2021; Miller et al., 2013; Russell et al., 2013). Yet, except for OCD symptoms, all psychopathology symptoms showed decline in rates from pregnancy to postpartum. Future research should examine OCRD across the lifespan to determine if rates of OCRD in pregnancy are comparable to other periods or if they signify a period of increased risk.

Elevated OCRD symptoms across the perinatal period are significantly related to more difficulty adjusting to the postpartum period. Higher scores of OCRD in pregnancy and/or postpartum were significantly associated with domains of responsibility inside the house, friendships, family relationships, relationship with new baby, relationship with spouse, and total adjustment to the postpartum period. The only domains of work outside the house and other children were unrelated to severity of OCRD symptoms. This is consistent with prior research that elevated psychopathology during the perinatal period is associated with poorer functioning for the mother and her infant (O’Hara & McCabe, 2013). Maternal psychopathology during infanthood is associated with poorer maternal and child outcomes (Slomian et al., 2019), including well past the postpartum period and across the lifespan (Aktar et al., 2019; Glover et al., 2018). Notably, mothers often provide most of the unpaid domestic labor in families, at a high personal cost. However, the PPAQ covers a wide variety of roles, including work outside of the home and relationships with family and friends, and is sensitive to the problem of too much time spent in a particular role. Most domains, not just work in the home, were negatively associated with more severe OCRD symptoms. OCRD symptoms appear to affect functioning in the postpartum and future research needs to explore the role OCRD symptoms in the perinatal period may have in maternal and child outcomes.

This study had some limitations. First, a significant limitation to note is that the measure used to capture OCRD symptoms in the current study was not specifically designed for the perinatal period. Future research should explore OCRD symptoms with perinatal-specific measures, while also accounting for other confounding variables, such as eating behaviors, perceptions of acceptance of body changes during the postpartum, and body image, to better understand the extent to which the perinatal period represents a time of increased prevalence of OCRD symptoms. Another measure limitation is that not all symptom measures had similar sensitivity and specificity metrics to allow for gold-standard comparisons. The DCQ, SPS, and SI-R symptom measures have similar sensitivity metrics and the IMAS is a diagnostic interview, but the MGH-HPS did not have sensitivity or specificity data available. There may be some discrepancies in comparisons across prevalence rates. Future research should utilize perinatal-specific measures with very similar sensitivity and specificity metrics. Second, there was a significant change in number of women who completed questionnaires and interviews in pregnancy compared to postpartum. Women who were struggling the most with high levels of OCRD psychopathology may have decided to not participate in the postpartum period, resulting in undercounts of perinatal OCRD prevalence. Third, there is lack of data on OCRD symptoms outside the perinatal period in these participants. While there were higher rates of OCRD symptoms during pregnancy than postpartum, it was not possible to conclude if those rates were increased or just like other life periods. Relatedly, there is a lack of structured clinical interview data for OCRD symptoms besides OCD. Future studies should utilize a structured clinical interview for all OCRD symptoms. Lastly, the study sample also only was able to utilize a homogenous sample of mostly middle to upper class, White, married, employed, educated women. However, if OCRD symptoms are found at these levels in a community sample with limited risk factors, future research should examine perinatal OCRD symptoms in higher-risk, clinical samples to better understand prevalence and strength of risk factors.

In conclusion, the perinatal period is a vulnerable time for a variety of OCRD symptoms, not only OCD symptoms, as previously thought. BDD and OCD symptoms appear to be especially prevalent in pregnancy and the postpartum period. Elevated OCRD symptoms are associated with many domains of postpartum functioning, including overall poorer adjustment to the postpartum period. Future research should include assessment of OCRD symptoms in perinatal prevention and intervention work to better understand how OCRD symptoms affect the perinatal period.