Postpartum psychosis
Encyclopedia
Postpartum psychosis is a term that covers a group of mental illnesses with the sudden onset of psychotic symptoms following childbirth. In this group there are at least a dozen organic psychoses, which are described under another heading "organic pre- and postpartum psychoses
". The relatively common non-organic form, still prevalent in Europe, North America and throughout the world, is sometimes called puerperal bipolar disorder, because of its close link with manic depressive (bipolar) disorder
; but some of these mothers have atypical symptoms (see below), which come under the heading of acute polymorphic (cycloid) psychosis (schizophreniform in the US). Puerperal mania was first clearly described by the German obstetrician Osiander in 1797, and a literature of over 2,000 works has accumulated since then. These psychoses are endogenous, heritable illnesses with acute onset, benign episodic course and response to mood-normalizing and mood-stabilizing treatments. The inclusion of severe postpartum depression under postpartum psychosis is controversial: many clinicians would allow this only if depression was accompanied by psychotic features (see below).
The onset is abrupt, and symptoms rapidly reach a climax of severity. Manic and acute polymorphic forms almost always start within the first 14 days, but depressive psychosis may develop somewhat later.
, overactivity, decreased sleep requirement, loquaciousness, flight of ideas, increased sociability, disinhibition
, irritability, violence and delusions, which are usually grandiose
or religious in content; on the whole these symptoms are more severe than in mania occurring at other times, with highly disorganized speech and extreme excitement. Others have severe depression with delusions, verbal hallucinations, mutism, stupor or transient swings into hypomania. Some switch from mania to depression (or vice versa) within the same episode. Atypical features include perplexity, confusion, emotions like extreme fear and ecstasy, catatonia or rapid changes of mental state with transient delusional ideas; these are so striking that some authors have regarded them as a distinct, specific disease, but they are the defining features of acute polymorphic (cycloid) psychoses, and are seen in other contexts (for example, menstrual psychosis) and in men.
Severe overactivity and delusions may require rapid tranquilization by neuroleptic (antipsychotic) drugs, but they should be used with caution because of the danger of severe side effects including the neuroleptic malignant syndrome. Electro-convulsive (electroshock) treatment is highly effective. Mood stabilizing drugs such as lithium are also useful in treatment and possibly the prevention of episodes in women at high risk (i.e., women who have already experienced manic or puerperal episodes). The location of treatment is an issue: hospitalization is disruptive to the family, and it is possible to treat moderately severe cases at home, where the sufferer can maintain her role as a mother and build up her relationship with the newborn. This requires the presence, round the clock, of competent adults (such as the baby's maternal grandmother), and frequent visits by professional staff. If hospital admission is necessary, there are advantages in conjoint mother and baby admission. Yet multiple factors must be considered in the subsequent discharge plan to ensure the safety and healthy development of both the baby and its mother. This plan often involves a multidisciplinary team structure to follow-up on mother, baby, their relationship and the entire family.
Suicide is rare, and infanticide extremely rare, during these episodes. It does occur, as illustrated by the famous cases summarized below. Infanticide after childbirth is usually due to profound postpartum depression (melancholic filicide) when it is often accompanied by suicide.
, is an important clue to the cause. Molecular genetic studies suggest that there is a specific heritable factor. There is evidence of linkage to chromosome 16.
wife of an English baronet
and Member of Parliament
, Sir Charles Mordaunt
. She was the respondent in a sensational divorce case in which the Prince of Wales (later King Edward VII) was embroiled and, after a counter-petition led to a finding of mental disorder. After a controversial trial lasting seven days, the jury determined that Lady Mordaunt was suffering from “puerperal mania
” (i.e. postpartum psychosis), at the time the summons was served on her and that she was unable to instruct a lawyer in her defense. Accordingly, her husband's petition for divorce was dismissed, while Lady Mordaunt was committed to an asylum, where she spent the remaining thirty-six years of her life.
, IL, committed suicide by jumping from a building on June 11, 2001. In February 2001 she gave birth to a healthy baby girl. In the weeks following the birth of her daughter, she developed severe depression, in which (4 weeks after the birth) she stopped eating and drinking and could no longer swallow. She thought her neighbors had all closed their blinds because they thought she was a bad mother (a postpartum depressive psychosis). She was in and out of Chicago area hospitals several times over a period of a few months. Her death led to the proposal of the Melanie Blocker-Stokes Postpartum Depression Research and Care Act (H.R. 846 and S. 450), intended to expand research into the condition.
in her Clear Lake City, Houston, Texas
house on June 20, 2001. Her mental health began to deteriorate with the birth of each of her children, combined with other external stressors. She attempted suicide twice and was hospitalized twice in a psychiatric facility in 1999 after delivering her fourth child. Yates was warned against having any more children, but conceived approximately 7 weeks later. 3 months after the birth of her fifth child and shortly after the death of her father, she began to rapidly degenerate. She was hospitalized twice more, and eventually released with orders that she should not be left alone. During an hour when her husband had left for work and her mother-in-law was scheduled to arrive, she killed all five of her children. She was consequently committed to a high-security psychiatric hospital. Her case attracted a great deal of media attention, particularly to the concept of serious mental illness following (and also caused by) childbirth. Some of this coverage proved to be problematic and misleading. For example, the National Organization for Women
(NOW) initially incorrectly noted on their website that Yates had suffered from postpartum depression. The Individualist Feminists
quickly pointed out that Yates suffered from postpartum psychosis, a more serious and much less common disorder, and that the clinical definition of postpartum depression does not list infanticide as a symptom. This misrepresentation of Yates' illness stigmatized
a large number of mothers and made them less likely to seek professional help for fear of being seen as a threat to their children and consequently being committed. NOW promptly revised their statement to indicate postpartum psychosis.
. In the United States, such a legal distinction is not currently made. Britain has had the Infanticide Act
since 1922.
In 2009, Texas legislator Jessica Farrar
proposed a bill that would recognize postpartum psychosis as a defense for mothers who kill their infants. Under the terms of the proposed legislation, if jurors concluded that a mother's "judgment was impaired as a result of the effects of giving birth or the effects of lactation following the birth", they would be allowed to convict her of the crime of infanticide, rather than murder. The maximum penalty for infanticide would be two years in prison.
Organic pre- and postpartum psychoses
There are many distinct forms of psychosis which start during pregnancy or after delivery . In Europe and North America, only one – acute postpartum bipolar or polymorphic psychosis – is commonly seen. But, in times past, about one quarter of psychoses after childbirth were 'organic'...
". The relatively common non-organic form, still prevalent in Europe, North America and throughout the world, is sometimes called puerperal bipolar disorder, because of its close link with manic depressive (bipolar) disorder
Bipolar disorder
Bipolar disorder or bipolar affective disorder, historically known as manic–depressive disorder, is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, and mood with or without one or...
; but some of these mothers have atypical symptoms (see below), which come under the heading of acute polymorphic (cycloid) psychosis (schizophreniform in the US). Puerperal mania was first clearly described by the German obstetrician Osiander in 1797, and a literature of over 2,000 works has accumulated since then. These psychoses are endogenous, heritable illnesses with acute onset, benign episodic course and response to mood-normalizing and mood-stabilizing treatments. The inclusion of severe postpartum depression under postpartum psychosis is controversial: many clinicians would allow this only if depression was accompanied by psychotic features (see below).
The onset is abrupt, and symptoms rapidly reach a climax of severity. Manic and acute polymorphic forms almost always start within the first 14 days, but depressive psychosis may develop somewhat later.
Symptoms
Some patients have typical manic symptoms, such as euphoriaEuphoria
Euphoria is an emotional and mental state defined as a sense of great elation and well being.Euphoria may also refer to:* Euphoria , a genus of scarab beetles* Euphoria, a genus name previously used for the longan and other trees...
, overactivity, decreased sleep requirement, loquaciousness, flight of ideas, increased sociability, disinhibition
Disinhibition
Disinhibition is a term in psychology used to describe a lack of restraint manifested in several ways, including disregard for social conventions, impulsivity, and poor risk assessment. Disinhibition affects motor, instinctual, emotional, cognitive and perceptual aspects with signs and symptoms...
, irritability, violence and delusions, which are usually grandiose
Grandiose delusions
Grandiose delusion or delusions of grandeur is principally a subtype of delusional disorder that can occur as a wide range of mental illness, including in two thirds of those in manic state of bipolar disorder, half those with schizophrenia and a substantial portion of those with substance abuse...
or religious in content; on the whole these symptoms are more severe than in mania occurring at other times, with highly disorganized speech and extreme excitement. Others have severe depression with delusions, verbal hallucinations, mutism, stupor or transient swings into hypomania. Some switch from mania to depression (or vice versa) within the same episode. Atypical features include perplexity, confusion, emotions like extreme fear and ecstasy, catatonia or rapid changes of mental state with transient delusional ideas; these are so striking that some authors have regarded them as a distinct, specific disease, but they are the defining features of acute polymorphic (cycloid) psychoses, and are seen in other contexts (for example, menstrual psychosis) and in men.
Course and treatment
Without treatment, these psychoses can last many months; but with modern therapy they usually resolve within a few weeks. A small minority follow a relapsing pattern, usually related to the menstrual cycle. Mothers who suffer a puerperal episode are liable to other manic depressive or acute polymorphic episodes, some of which occur after other children are born, some during pregnancy or after an abortion, and some unrelated to childbearing. Puerperal recurrences occur after at least 20% of subsequent deliveries, or over 50% if depressive episodes are included.Severe overactivity and delusions may require rapid tranquilization by neuroleptic (antipsychotic) drugs, but they should be used with caution because of the danger of severe side effects including the neuroleptic malignant syndrome. Electro-convulsive (electroshock) treatment is highly effective. Mood stabilizing drugs such as lithium are also useful in treatment and possibly the prevention of episodes in women at high risk (i.e., women who have already experienced manic or puerperal episodes). The location of treatment is an issue: hospitalization is disruptive to the family, and it is possible to treat moderately severe cases at home, where the sufferer can maintain her role as a mother and build up her relationship with the newborn. This requires the presence, round the clock, of competent adults (such as the baby's maternal grandmother), and frequent visits by professional staff. If hospital admission is necessary, there are advantages in conjoint mother and baby admission. Yet multiple factors must be considered in the subsequent discharge plan to ensure the safety and healthy development of both the baby and its mother. This plan often involves a multidisciplinary team structure to follow-up on mother, baby, their relationship and the entire family.
Suicide is rare, and infanticide extremely rare, during these episodes. It does occur, as illustrated by the famous cases summarized below. Infanticide after childbirth is usually due to profound postpartum depression (melancholic filicide) when it is often accompanied by suicide.
Causes
These are world-wide disorders. Their incidence has been carefully measured by state-of-the-art epidemiological studies, and is somewhat less than 1/1,000 deliveries. They are more common in first time mothers. As recognized by Marcé (1962), the link to menstruation, and especially menstrual psychosisMenstrual psychosis
-Definition:This is a comparatively uncommon form of severe mental illness, with the following characteristics:*Abrupt onset against a background of normality.*Brief duration, with full recovery....
, is an important clue to the cause. Molecular genetic studies suggest that there is a specific heritable factor. There is evidence of linkage to chromosome 16.
Harriet Mordaunt
Harriet Sarah, Lady Mordaunt (1848-1906)), formerly Harriet Moncreiffe, was the ScottishScotland
Scotland is a country that is part of the United Kingdom. Occupying the northern third of the island of Great Britain, it shares a border with England to the south and is bounded by the North Sea to the east, the Atlantic Ocean to the north and west, and the North Channel and Irish Sea to the...
wife of an English baronet
Baronet
A baronet or the rare female equivalent, a baronetess , is the holder of a hereditary baronetcy awarded by the British Crown...
and Member of Parliament
Member of Parliament
A Member of Parliament is a representative of the voters to a :parliament. In many countries with bicameral parliaments, the term applies specifically to members of the lower house, as upper houses often have a different title, such as senate, and thus also have different titles for its members,...
, Sir Charles Mordaunt
Sir Charles Mordaunt, 10th Baronet
Sir Charles Mordaunt, 10th Baronet was a wealthy English country gentleman, a Conservative Member of Parliament for South Warwickshire , High Sheriff of Warwickshire 1879, was notorious for involving the Prince of Wales in his divorce case.Sir Charles was married on 7 December 1866 to Harriet...
. She was the respondent in a sensational divorce case in which the Prince of Wales (later King Edward VII) was embroiled and, after a counter-petition led to a finding of mental disorder. After a controversial trial lasting seven days, the jury determined that Lady Mordaunt was suffering from “puerperal mania
Postpartum psychosis
Postpartum psychosis is a term that covers a group of mental illnesses with the sudden onset of psychotic symptoms following childbirth. In this group there are at least a dozen organic psychoses, which are described under another heading "organic pre- and postpartum psychoses"...
” (i.e. postpartum psychosis), at the time the summons was served on her and that she was unable to instruct a lawyer in her defense. Accordingly, her husband's petition for divorce was dismissed, while Lady Mordaunt was committed to an asylum, where she spent the remaining thirty-six years of her life.
Melanie Blocker-Stokes
Melanie Blocker-Stokes, of ChicagoChicago
Chicago is the largest city in the US state of Illinois. With nearly 2.7 million residents, it is the most populous city in the Midwestern United States and the third most populous in the US, after New York City and Los Angeles...
, IL, committed suicide by jumping from a building on June 11, 2001. In February 2001 she gave birth to a healthy baby girl. In the weeks following the birth of her daughter, she developed severe depression, in which (4 weeks after the birth) she stopped eating and drinking and could no longer swallow. She thought her neighbors had all closed their blinds because they thought she was a bad mother (a postpartum depressive psychosis). She was in and out of Chicago area hospitals several times over a period of a few months. Her death led to the proposal of the Melanie Blocker-Stokes Postpartum Depression Research and Care Act (H.R. 846 and S. 450), intended to expand research into the condition.
Andrea Yates
Andrea Yates methodically drowned her 5 children in a bathtubBathtub
A bath , bathtub , or tub is a large container for holding water in which a person may bathe . Most modern bathtubs are made of acrylic or fiberglass, but alternatives are available in enamel over steel or cast iron, and occasionally waterproof finished wood...
in her Clear Lake City, Houston, Texas
Texas
Texas is the second largest U.S. state by both area and population, and the largest state by area in the contiguous United States.The name, based on the Caddo word "Tejas" meaning "friends" or "allies", was applied by the Spanish to the Caddo themselves and to the region of their settlement in...
house on June 20, 2001. Her mental health began to deteriorate with the birth of each of her children, combined with other external stressors. She attempted suicide twice and was hospitalized twice in a psychiatric facility in 1999 after delivering her fourth child. Yates was warned against having any more children, but conceived approximately 7 weeks later. 3 months after the birth of her fifth child and shortly after the death of her father, she began to rapidly degenerate. She was hospitalized twice more, and eventually released with orders that she should not be left alone. During an hour when her husband had left for work and her mother-in-law was scheduled to arrive, she killed all five of her children. She was consequently committed to a high-security psychiatric hospital. Her case attracted a great deal of media attention, particularly to the concept of serious mental illness following (and also caused by) childbirth. Some of this coverage proved to be problematic and misleading. For example, the National Organization for Women
National Organization for Women
The National Organization for Women is the largest feminist organization in the United States. It was founded in 1966 and has a membership of 500,000 contributing members. The organization consists of 550 chapters in all 50 U.S...
(NOW) initially incorrectly noted on their website that Yates had suffered from postpartum depression. The Individualist Feminists
Individualist feminism
Individualist feminism is a term for feminist ideas which seek to celebrate or protect the individual woman....
quickly pointed out that Yates suffered from postpartum psychosis, a more serious and much less common disorder, and that the clinical definition of postpartum depression does not list infanticide as a symptom. This misrepresentation of Yates' illness stigmatized
Social stigma
Social stigma is the severe disapproval of or discontent with a person on the grounds of characteristics that distinguish them from other members of a society.Almost all stigma is based on a person differing from social or cultural norms...
a large number of mothers and made them less likely to seek professional help for fear of being seen as a threat to their children and consequently being committed. NOW promptly revised their statement to indicate postpartum psychosis.
Legal status
Several nations including Canada, Great Britain, Australia and Italy recognize post partum mental illness as a mitigating factor in cases where mothers kill their childrenInfanticide
Infanticide or infant homicide is the killing of a human infant. Neonaticide, a killing within 24 hours of a baby's birth, is most commonly done by the mother.In many past societies, certain forms of infanticide were considered permissible...
. In the United States, such a legal distinction is not currently made. Britain has had the Infanticide Act
Infanticide Act
The Infanticide Act is the name of two Acts introduced into English Law that started treating killing of an infant child by its mother during the early months of life as a lesser crime than murder...
since 1922.
In 2009, Texas legislator Jessica Farrar
Jessica Farrar
Jessica Christina Farrar is a United States politician and an incumbent in the Texas House of Representatives. She is currently serving her 9th term as the representative from District 148, located in Houston, TX...
proposed a bill that would recognize postpartum psychosis as a defense for mothers who kill their infants. Under the terms of the proposed legislation, if jurors concluded that a mother's "judgment was impaired as a result of the effects of giving birth or the effects of lactation following the birth", they would be allowed to convict her of the crime of infanticide, rather than murder. The maximum penalty for infanticide would be two years in prison.