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Postpartum Psychosis - A Rare Mental Illness Post Pregnancy

Updated on March 30, 2017
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Sahana is pursuing PhD in the field of medical informatics & medical decision support system. She writes on the subject of women's health.

The Story of Lillie

Lillie and her husband were delighted when they realized that she was pregnant. She loved every moment of the nine months she carried her daughter Alice. But once she was born and Lillie held her for the first time, she felt absolutely no emotion or attachment.

Over time things became worse. Lillie began resenting washing, feeding or dressing Alice. She also became very restless and didn't sleep much. She also started hearing voices in her head telling her to strangle her daughter. Though she never harmed the baby, Lillie at times imagined putting a pillow over her daughter's mouth. She presumed it would make the voice go away.

She was also delusional and were seeing things that were not there. Sometimes she would look at the smiling face of Alice and see a grotesque terrifying face instead. The voice in her head began telling her the baby was an evil.

Her mother and husband noticed the changes in her and advised her to see a doctor. Lillie didn't reveal anything about hearing voices in her head when she visited the doctor. She feared they would then take the baby away from her. Eventually when the problem became unbearable Lillie told her mother everything. She was diagnosed with postpartum psychosis, a rare psychiatric disorder that affects one in 1000 women after giving birth.

It is a severe mental disorder which may begin suddenly days or weeks after having a baby. Symptoms can change rapidly. These may include mania, depression, hallucination and delusions.

There are cases when the mother even ended up killing or severely harming the child when she was in a state of delusion.


Source

What is Postpartum Psychosis

Postpartum Psychosis (PP) also called Puerperal Psychosis is a severe mental illness that occurs to 1 - 2 per 1000 women after childbirth. The word psychosis means out of touch wit reality. The onset is usually sudden. In most cases it occurs within 2 - 4 weeks after the baby is born, but it can occur later than this. It represents a bipolar disorder and not just depressive disorder. It was found that about 50% - 60% sufferers had their first child.

It is characterized by extreme difficulty in responding emotionally to the baby. It can even include the thoughts and desires to harm the newborn.

With treatment a patient usually makes full recovery. But there are chances of recurrence in subsequent pregnancies.


It is a psychiatric emergency that requires immediate intervention because there is a risk of infanticide as well as suicide.

Symptoms

Onset of the symptom is usually rapid with a dramatic change in the woman's behavior. The earliest symptoms are restlessness, irritability and insomnia. Symptoms can change very rapidly.

Some of the symptoms to watch out for are:

  • Feeling elated, over-excited or too active at one moment and low mood and tearfulness the next.
  • Hallucinations and delusions. Patient keeps hearing and seeing things she knows are not there e.g. one may think the baby is possessed by the devil.
  • Confusion, rapid or muddled thinking.
  • Difficulty in bonding with the baby.
  • Changes in appetite or eating.habits.
  • Being more talkative, than usual.
  • Attempt to harm oneself or the baby.
  • Finding it hard to sleep or not wanting to sleep.
  • Feeling paranoid, suspicious and fearful. One tends to become suspicious of friends and family.

Clinical Features of PP

Onset
Acute, within 2 wks of delivery. But can be as early as 24 hrs
 
Cognitive
Poor concentration, delirium like impaired orientation.
 
Behavioral
Agitated, hyperactive,emotional distance, perplexity.
 
Mood
Elated, less frequently depressed.
 
Speech
Rambling
 
Sleep
Insomnia
 
Thought Content
Delusion of being controlled, harming or killing the infant.
 
Thought Process
Disorganized
 
Perception
Visual, auditory, olfactory hallucination
 
Suicide/Infanticide
Suicide 5%, Infanticide 4%
 

Causes

The causes are not well understood. But some of the following may be the likely causes:

  • Abrupt shift in hormones during delivery and disrupted sleep could trigger the condition.
  • Genetic factors. A woman is highly likely to have PP if a close relative had suffered from it.
  • Women who suffered from bipolar disorder or schizophrenia are at a high risk of developing PP.

Diagnosis

Screening

Women coming for obstetric care during or after pregnancy should be screened for mental health problems and a family history of mental illness. Patients screening positive for any of these items should be further assessed for a history of mania, psychotic depression, or a psychotic disorder.

Patients with a personal or family history of one of these conditions should be educated and monitored during the first weeks of the postpartum period. More intensive monitoring and prophylactic treatment should be considered for patients with a history of bipolar or schizophrenic disorder.

Diagnosis

Medical Evaluation

Before diagnosing PP as the primary disorder, doctors perform other clinical evaluations to rule out other causes of psychosis. Major lab tests that are performed are:

  • Intoxication or withdrawal: prescription medications, dietary supplements, and over-the-counter medications are reviewed; serum and urine toxicology reports are obtained.
  • Metabolic delirium: basic serum electrolytes, glucose, CBC with differential, BUN and creatinine, liver function tests, urinalysis, and oxygen saturation are checked.
  • Endocrine dysfunction: check basic serum electrolytes such as sodium, potassium,calcium, thyroid stimulating hormone, and thyroid function tests.
  • CNS events: Neurological examination; head CT or MRI may be performed to rule out trauma or neoplasms.

Psychiatric Evaluation

Postpartum psychosis is a heterogeneous group of mental disorders including bipolar disorder, psychotic depression, and schizoaffective disorder. Instead, diagnosis is based on their mood or psychotic disorder, with a "postpartum-onset" specifier if psychotic symptoms developed within 30 days of birth. Psychiatric examination will in particular consider the following elements:

  • The onset and course of psychotic symptoms i,e. episodic versus chronic.
  • The nature of the symptoms i.e, depressed, manic, or mixed state.
  • The impact of these symptoms on the patient's behavior and functioning.
  • The patient's history and family history of prior psychotic episodes.


Other psychotic disorders that need to be ruled out
Other psychotic disorders that need to be ruled out | Source

Postpartum Psychosis: Some real life stories

Differences between Postpartum Psychosis, Postpartum Depression and Baby Blues
Differences between Postpartum Psychosis, Postpartum Depression and Baby Blues
Mental health problems post pregnancy in pie chart
Mental health problems post pregnancy in pie chart | Source

Treatment

There are three different types of medications that are used to treat the range of symptoms:

  • Mood stabilizers - help to stabilize the mood and help reduce the likelihood of relapse.
  • Antidepressants - are used to treat the symptoms of depression.
  • Anti-psychotics - treats both manic and psychotic symptoms such as delusions or hallucinations.

Electroconvulsive Therapy (ECT)

ECT is a specialist treatment that may be essential in the treatment of postpartum psychosis. It works by stimulating the neurons in the brain via an electric current. ECT is an effective way of treating the symptoms of mania, psychosis and severe depression.

Recovery may be slow and time consuming. In order to recover fully a patient needs minimum stress and maximum sleep beside medication and therapy. Hospitalization is thus essential in most cases of PP.

Prognosis and Future Pregnancies

Studies of several PP episodes suggest that though the prognosis for recovery from the initial episode is very good, the woman remains at risk of subsequent PP and non-PP episodes.

Recurrence rates in subsequent pregnancies are greater than 50%. About 50% of women have further non-PP episodes.

If a woman who suffered and recovered from PP, decides on further pregnancies she and her family should consult the specialist first. The specialist can help develop a relapse prevention plan. These plans may include:

  • Early warning signs - such as sleeplessness, elevated mood, hyper-activity, overly suspicious, agitation.
  • Self care strategies - good sleep, regular exercise, eating well, socializing,
  • Identifying the sources of help and assistance in advance - Additional support from friends and family as well as appointments with specialists throughout the pregnancy to monitor any mood swings and possible symptoms.

Could You Be Exhibiting Symptoms of Postpartum Depression (not intended to be a substitute for informed medical advice or care;Sources: National Institute of Me

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