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Postnatal psychosis
Overview
Definitions and diagnosis
Prevalence
Causes
Consequences
Treatment
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Post-natal psychosis (PNP)
PNP needs same DSM-IV diagnosis as any psychotic disorder Schizophrenia and associated disorders Manic stages of bipolar disorder
But PNP is specifically diagnosed in perinatal period Usually immediately after birth
Or within a few weeks But psychotic episodes can also occur during pregnancy
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What is psychosis?
Extreme impairment in several areas of functioning Clarity of thought Emotional response Communication Understanding reality Behaviour
Illustrated by two key features Hallucinations Delusions
Severely interfere with normal life
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Schizophrenia
DSMIV – A (characteristic symptoms) Two or more of following (must be present for a
significant portion of time during one-month period): Delusions Hallucinations Disorganised speech Grossly disorganised or catatonic behaviour Negative symptoms
Mood, speech and behaviour
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Schizophrenia
DSMIV – B (social/occupational dysfunction) Function must be ‘markedly below’ what patient
normally achieves in key area: Work Interpersonal relations Self-care
DSMIV – C (duration) Continuous signs of disturbance for at least 6 months
DSMIV – D to F Exclusion criteria – not important for this exercise
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Delusions and hallucinations
Delusions: firmly held (erroneous) beliefs Distorted reasoning/perception… examples…
External forces ‘control’ patient’s thought and behaviour
…receiving special messages from newspaper headlines
The baby is not mine Hallucinations: perceiving sensations not ‘apparent’ to
others But vivid, substantial, and real to the patient Can relate to any of the senses
Most commonly auditory and visual PNP mums may hear voices telling her to harm child
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‘Negative’ symptoms & disorganised behaviour
Negative symptoms Affective flattening (reduced range/intensity of emotion)
Facial expression, voice tone, eye contact, body language
Alogia (poverty of speech) Often illustrated by short, empty replies to questions
Avolition (reduction or difficulty with goal-directed behaviour)
e.g. staying at home for long periods doing nothing Disorganised behaviour
Inability to think clearly and respond appropriately Most commonly associated with irregular speech
Talking in sentences that do not make sense Rambling loose associations
Can also be related to behaviours (‘odd’ movement)
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Manic stage of Bipolar Disorder
Elevated, expansive, or irritable mood
AND 3 from: (4 if mood is irritable)
Psychomotor agitation or increased goal-directed behaviour
Excessive/rapid talking
Flights of ideas and/or racing thoughts
Reduced need for sleep
Grandiosity or inflated self-esteem
Easily distractible
Excessive involvement in (negative) pleasurable activities
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PNP - features
Very serious illness Potential risks for mother and baby
Needs quick intervention, usually hospital High risk of suicide and infanticide
Delusions may be directed at baby “The child is not mine… it is evil incarnate… must be
terminated or he will kill me…” Also called puerperal psychosis
Prevalence 1 in 1000 mums may get post-natal psychosis (0.1%)
Contrast with baby blues and PND
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PNP - features
First signs… Can start suddenly a few weeks after birth Mum becomes very restless, or elated, and unable to
sleep Becomes confused and disorientated May not recognise friends or family members (or baby)
May make bonding with baby difficult May have delusions or hallucinations May misconstrue events May be manic or have wild mood swings Behaviour may become increasingly bizarre May lose touch with reality
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PNP - Causes
Depletion of oestrogen immediately after birth Hormone abnormalities more likely with PNP than with
PND Sleep disruptions (before and after birth) Postpartum psychosis may be related to bipolar disorder
Psychotic episodes and mood swings may actually represent first bipolar episodes
Especially in new mothers Previous bipolar disorder or schizophrenia is major risk
factor Or family history of one of these conditions
Previous history of PND or psychosis also a risk factor
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Living with postnatal psychosis
Watch this clip from BBC2 Newsnight (August, 2012)
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Exercise
How much more serious is postnatal psychosis than PND?
What signs should we look out for?
Should mother and baby be separated?
What is the impact of stigma?
What are the options?
What are the consequences of PNP for mother and child?
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PNP and the child
Serious illness with extremely serious implications for infant Potentially dangerous delusions
Paranoid symptoms may cause mum to hide symptoms
Attention and cognition also a problem Both of those are important in caring for baby
Or care for herself Mum may harm baby She may not be able to focus properly
Or act quickly enough May damage bonding and attachment
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PNP and the child
Other evidence of SMI in mums and effect on children Developmental problems
Significantly increased rates of delayed walking Disturbed behaviour Poor social competence Greater risk behaviours
Postnatal psychosis (PP) presents dangers to mum and child
70-fold increase in maternal suicide risk Leading cause of maternal death in first year after
birth Homicidal behaviour is rare
But 28%–35% PP mums described delusions about infants
Only 9% had thoughts of harming the infant
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PNP treatment
Often mum needs to be admitted to hospital Sometimes in mother and baby unit in psychiatric ward
Probably needs medication Stabilising drugs (e.g. lithium) Antipsychotic drugs: olanzapine, risperidone, or
aripiprazole Antidepressants
But medication needs to be carefully considered Because of the breastfeeding implications
CBT may also be used But usually as ‘add-on’ to medication
Where meds not appropriate, ECT has been successful
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Summary
Postnatal psychosis very serious Diagnosis of schizophrenia-related illness or manic state
Sense of reality severely compromised Also associated with erratic behaviour Problems with attention processes
Consequences for mother and baby Mostly of harm to mother Effect on bonding Risk of hospitalisation and/or separation?
We should look for signs and risk factors Early intervention crucial
