Ms. A was a 27-year-old white woman with a 10-year history of OCD. She presented approximately 5 weeks after giving birth to a healthy child. There was no history of tic disorder or OCD in her family. Because of the pain from a fourth-degree perineal tear requiring surgical repair, Ms. A was given a dose of the opiate oxycodone. She observed that her obsessions ceased entirely for several hours immediately following administration of the oxy­codone. Following the birth of her child, Ms. A’s symptoms worsened. For example, she developed time-consuming rituals around the preparation of her child’s formula and spent hours smoothing out wrinkles in crib sheets to prevent her baby from succumbing to sudden infant death syndrome. She required constant reassurance from her spouse and other family members.

At the time of presentation, Ms. A had a Yale-Brown Obsessive Compulsive Scale +(6) score of 26. Because of her previous response to opiates, a regimen of tramadol was initiated. Within 24 hours, she reported by telephone that her obsessions and compulsions had diminished significantly with the tramadol, 50 mg b.i.d. A week later, her Yale-Brown Obsessive Compulsive Scale score had dropped to 19. A dose of fluoxetine, 20 mg daily, was then added (after a discussion of possible serotonergic syndrome). Three weeks later, the fluoxetine dose was increased to 40 mg daily. During the first month of treatment, Ms. A required up to 350 mg p.r.n. daily of tramadol in divided doses (50 mg–100 mg q.i.d.) to diminish her OCD symptoms; her doses of tramadol were increased by approximately 50 mg–100 mg increments weekly over the first 3 weeks because of her tolerance to the anti-obsessive effects. Side effects of tramadol consisted only of initial nausea and mild sedation. Six weeks after the initiation of the two medications, Ms. A found that she no longer required the as-needed doses of tramadol, and her Yale-Brown Obsessive Compulsive Scale score had dropped to 10.