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Postpartum psychosis

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This condition is uncommon. It occurs in only one to two women per 1,000 births.

In most cases it begins within the first two to four weeks following the birth of the baby but can occur later than this.

This is a serious and sometimes even life threatening condition and urgent treatment is required. The babyís safety may also be at risk.

The word psychosis means to be out of touch with reality.

A person may be out of touch with reality if they are experiencing delusions or hallucinations (or both).

Delusions

Unusual or oddly inaccurate beliefs that a person is convinced are true.

The beliefs are not explained by the personís cultural/sub-cultural beliefs.

Examples might be the belief that someone was out to harm you, that you were guilty of a major sin, or that you had a serious medical illness when all tests had been negative, or that your baby was going to die.

Alternatively, a person with delusions might think that they or their baby had special powers such as communicating with God or being able to breathe underwater.

Hallucinations

Having perceptions that are not real but being convinced that they are real.

These perceptions are most commonly those of hearing voices but may be hearing other things; seeing, smelling or feeling things that are not real.

An example could be the belief that you can hear your neighbours talking about you when in fact this would not be possible.

If someone is experiencing psychosis their behaviour is usually very out of character, abnormal or disorganised.

This is usually the most obvious problem - the bizarre thought(s) or experiences are not always apparent to others and require professional assessment.

Behaviour

  • Behaviour in postpartum psychosis can be very out of character and unpredictable.
  • Periods of agitation and disorganisation with very poor concentration are common.
  • Alternatively a woman may seem inactive and unable to get going.
  • She may seem confused at times.
  • Her mood might seem to fluctuate from being disinhibited and overly confident to low and apathetic.
  • She may seem frightened or suspicious.
  • A wide range of behaviours may be seen.

Causes

Most, but not all cases of postpartum psychosis are episodes of bipolar disorder.

They may be due to other psychiatric conditions or other medical conditions causing delirium. These are what psychiatrists call ďmixed mood statesĒ (part of bipolar disorder) and which can result in big fluctuations in how a person is feeling and behaving. Women seem to be particularly prone to these states after having a baby.

It is not known why women, especially those with a history of bipolar disorder, either in themselves or other family members, are particularly vulnerable to getting unwell at this time. Many theories abound.

Some women are particularly vulnerable to the mental effects of sudden changes in hormone levels (this seems to set off an underlying mood disorder).

Sleep deprivation may also be an important trigger.

Treatment and outcome

Fortunately there is good news Ė most women with postpartum psychosis respond well to treatment with medication (yes, medication is needed) and to intensive nursing.

Unfortunately, there is currently only one inpatient Mothers and Babies Service in New Zealand - this service is in Christchurch - although some smaller centres will also admit baby with mother. Intensive home nursing is sometimes possible but usually women suffering from postpartum psychosis need admission to hospital.

Full recovery usually occurs but future relapses - both after having a baby and at other times - are possible (see Bipolar disorder).

Janes Story

Jane was excited about having her first baby. Her partner Mike was also looking forward to the arrival of this planned addition to their family. Jane enjoyed her work as a primary school teacher and felt confident with children. Fortunately, the birth coincided with the beginning of the next school term so she finished work at the end of the third term and had time to feel well prepared. After the birth Mike was due to take two weeks leave from work and Janeís mother, who lived in another town, was due to come and stay to help out.

Janeís waters broke late in the evening and she didnít get much sleep that night (neither did Mike!), as the contractions started shortly after. Labour went on all the next day and finally Fred was born late the next evening. Everyone was exhausted but happy. Jane felt ecstatic. She wanted to look at her baby all the time and she wanted Mike to listen to her talking Ė all the time. She didnít get a lot of sleep that night either.

The next day Jane felt anxious - very anxious - with a knot in her stomach and thoughts that Fred couldnít breathe properly. As the day went on she had times of sitting staring into space and mumbling and then other times when she couldnít settle and felt as if something awful would happen but she didnít know what.

Jane wanted to do things but she couldnít organise herself or think clearly. She didnít want to be left alone (with or without the baby) but she didnít want any visitors. She started to think that the glass of wine she had had before she had known she was pregnant had caused major brain damage in Fred.

She was determined to breastfeed. When her milk came in on day three she started to feel worse. Breastfeeding was hard. During the next week Jane continued to feel more and more anxious, to be unsettled and to believe, with increasing conviction, that she had caused Fred irreparable damage. A voice told her she was a bad mother. She didnít know what to do with Fred, especially if he was crying. She thought she should be punished.

Mike had tried to reassure Jane. He sat with her when she fed the baby and he changed the nappies but nothing seemed to be helping. At first, he wondered if this was what it was like when someone like Jane (a bit of a worrier at times) had a baby. However, she had never behaved like this before Ė one minute quiet and the next pacing about the place. The things she was saying were getting more and more irrational Ė he rang Janeís Mum. Together they wondered what to do. Jane didnít want to go and see a doctor but she did talk to her midwife and it was her midwife who persuaded Jane to get professional help.

References

Attia E, Downey J, Oberman M. Chapter 6: Postpartum psychoses. In: Miller LJ, ed. Postpartum Mood Disorders. Washington, DC: American Psychiatric Press, 1999.
Barnett B, Morgan M. Postpartum psychiatric disorder: who should be admitted and to which hospital? Australian and New Zealand Journal of Psychiatry 1996; 30:709-714.
Brockington I. Diagnosis and management of post-partum disorders: a review. World Psychiatry 2004; 3:89-95.
Brockington IF. Postpartum Psychoses. In: Brockington IF, ed. Motherhood and Mental Health. Oxford: Oxford University Press, 1996.
Harlow BL, Vitonis AF, Sparen P, Cnattingius S, Joffe H, Hultman CM. Incidence of hospitalization for postpartum psychotic and bipolar episodes in women with and without prior prepregnancy or prenatal psychiatric hospitalizations. Archives of General Psychiatry 2007; 64:42-48.
Kendell RE, Chalmers JC, Platz C. Epidemiology of puerperal psychoses. British Journal of Psychiatry 1987; 150:662-673.
Klompenhouwer JL, van Hulst AM. Classification of postpartum psychosis: a study of 250 mother and baby admissions in The Netherlands. Acta Psychiatrica Scandinavica 1991; 84:255-261.

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