Perspectives on Postpartum Psychosis

March 20, 2023 | Anagha Srinivasan | Psychology

“It’s the ultimate roller coaster of joy and sorrow, comfort and fear, love and hate, fast and slow, past and future”, remarks Libby Chisholm Fearnley, a mother who was asked to define motherhood (Joyce, 2019).

While it’s fair to describe motherhood as a “roller coaster” of highs and lows, some postpartum disorders might make the terrain of parenting and motherhood a lot rockier. The postpartum period predisposes women to a diverse range of psychological disorders such as postpartum blues, postpartum depression, and postpartum psychosis (Upadhyay, et.al., 2017). This period also exposes women to psychiatric diseases, wherein they are 22 times more likely to experience psychotic or mania episodes (Isik, 2018).

Postpartum psychosis (PP) is a rare disorder that is characterized by sleep disturbances (mostly insomnia), changes in mood, anxiety, sadness, chattiness, euphoria, obsessive contemplation and confusion, delusions, hallucinations, along with disorganized behaviour, which manifests in 2/1000 mothers within the first 2-4 weeks after delivery (Sit, et. al., 2006). The average age of inception of this condition has been observed to be 26 years and the onset is often very rapid, with most mothers developing symptoms in less than a week after the baby is born (Isik, 2018). Postpartum psychosis is listed under the schizophrenia spectrum and other psychotic disorders section of the Diagnostic and Statistical Manual of Mental Disorders – 5 (DSM-5) as a “short psychotic disorder” (Isik, 2018).

Inside the Minds

For centuries, doctors have reported women with acute psychological disorders following childbirth (Bergink, et.al., 2016). Esquirol studied 92 postpartum psychotic women, finding that 53% exhibited primarily manic symptoms and 38% experienced depressed symptoms (Bergink, et.al., 2016). Let’s look at some examples of how postpartum psychosis unfolds as a horrific voyage.

An excerpt from a patient explaining their experience of first onset postpartum psychosis with manic symptoms:

“On day five, I sit behind my computer; in the adjacent room, my husband bottle feeds our son… Without any warning sign, suddenly my thoughts are unstoppable and fly around. My brain is in a centrifuge and is connected to the nearest electric outlet. My right-hand makes circling movements, which I cannot control… I get up and test myself—clearly, I can move and talk, but the environment feels strange. Something I have never felt before, an almighty feeling … Everything feels strange, and yet apparently nothing changed. I tell my husband, ‘I will find you another wife’. He is shocked. I see the panic in his eyes. I say to him, ‘I became God’”(Bergink, et.al., 2016).

An excerpt from a patient explaining their experience of first onset postpartum psychosis with characteristics of depression:

“Inside me is a dark force. Yesterday the shadow made me put a pillow over the baby’s face, and I might have suffocated him if my toddler hadn’t pulled my pant leg and alerted me to make the shadow go back inside. When I feel the shadow coming out, I walk outside on the porch with the baby and my daughter. If I kill myself, will the shadow go away?” (Bergink, et.al., 2016).

Postpartum psychosis is a psychiatric predicament that, if not attended to at the earliest, can accelerate into extreme symptoms such as self-harm or suicide and in rare cases, even cause harm to the baby or infanticide (Carver, 2017). Nonetheless, because infanticide frequently makes the front pages of the news, women suffering from postpartum psychosis are often concerned about the stigma of disclosing their illness, a stigma that also affects mothers suffering from other maternal mental health issues such as postpartum depression (Carver, 2017).

Catherine Carver (2017), elucidates her encounter with postpartum psychosis by recollecting her memory from that exact moment when she knew something was wrong. “From behind me, I heard a child’s voice, small but determined, counting, ‘one, two, three… one, two, three…’ in a Glaswegian accent … But I was alone … Later that evening I watched a psychedelic display of electric lions, roaring tigers and the cast of the film Jumanji cavort on the bare blue wall … a voice, this time my own, questioned how I could be seeing such a spectacle and suggested, gently, that perhaps those around me were right – things were very wrong” (Carver, 2017).

Catherine, right after the birth of her baby, Beatrix, began to have suspicions that the hospital staff was constantly talking about her and that her baby had been swamped with another. Although she felt pangs of anxiety consume her, she was convinced that if she let the others see signs of weakness in her ability to take care of her child, the “ninja social workers” would separate her from the baby. Six weeks after birth, at the request of her beloved husband, she met with a general physician, who obstructively told Catherine that her thoughts were an indication of her incompetence as a mother, and hence, Catherine hid her condition further.

“Five months after my baby was born things had reached the point where I was terrified of leaving the house for fear of murderous social workers … When she [health visitor] came round one day to find me speaking rapidly and unable to stop pacing, she put the wheels in motion to get me to help urgently”. Subsequently, Catherine was hospitalized and received the treatment that she required to recover. Although Carver’s dreadful thoughts subsided, she often found herself wondering the reasons why she developed this condition as she had never experienced a mental illness before. Let’s find some answers to this question.

Risk Factors & Etiology of Postpartum Psychosis

Currently, researchers in the field of medicine and neuroscience use different approaches such as clinical biochemistry, neuroimaging, etc., to understand postpartum psychosis (Davies, 2017). Although the exact etiology of postpartum psychosis is unknown, there are several fascinating clues (Dias & Jones, 2021).

Clinical Factors: The single most important factor that puts women in danger of PP is a personal or familial history of bipolar illness or a related psychotic condition (in roughly 40%–50% of cases), with the risk being greater for bipolar disorder type I than type II, followed by primiparity, maternal age, stress levels in the puerperium, and maternal sleep difficulties (Davies, 2017).
Obstetric Factors: Pre-eclampsia, a potentially life-threatening elevation in maternal blood pressure, is analogous to the disorder. Postpartum psychosis has also been connected to some other obstetric variables, including cesarean section, premature birth, and extended labour due to failure to descend/progress (Dias & Jones, 2021).
Changes in Hormones: Reproductive hormones (estrogen and progesterone) rise during pregnancy, but plummet quickly after delivery, along with changes in the immune system such as an increase in T cells (Dias & Jones, 2021). However, rather than the aberrant amounts of reproductive hormones, it has been proposed that vulnerable women have an abnormal response to changes in these hormones’ levels (Dias & Jones, 2021). Postpartum autoimmune thyroid problems also frequently overlap with postpartum mood disorders (Dias & Jones, 2021).
Brain Structure: According to Fuste, et.al. (2017), the volume of the parahippocampal gyrus, ACC, postcentral gyrus, and STG is reduced in women who have recently experienced a PP episode compared to at-risk women who have not experienced a PP episode. These regions have been linked to the pathophysiology of psychosis, and these changes could imply a higher risk of getting these symptoms in general (Fuste, et.al., 2017).

Diagnosis & Treatment of Postpartum Psychosis

PP is a medical emergency that mandates an instantaneous assessment, psychiatric referral, and, in some cases, hospitalisation (Sit, et. al., 2006). A thorough physical and neurological examination is required in order to rule out organic causes for acute psychosis and the existence of ischemia or hemorrhage-related stroke, respectively (Sit, et. al., 2006). It’s also necessary to differentially diagnose postpartum psychosis from depression, obsessive compulsive disorder, and primary psychotic disorders such as schizophrenia (Sit, et. al., 2006).

Screening & Psychoeducation

Women who have been previously diagnosed with bipolar disorder or PP in the past are considered to be at a greater risk of developing PP (Sit, et. al., 2006). Mood swings, bewilderment, bizarre notions, and hallucinations should be identified by her and her family, primarily in the first few weeks post childbirth, and she should contact a medical professional if these symptoms occur (Sit, et. al., 2006). Even before birth, those who have been screened for being at risk of developing PP should see a mental health professional to discuss treatment choices or treatment prophylaxis to avoid illness during delivery (Sit, et. al., 2006).

Preparing high-risk mothers for what might occur, in a responsible and educational way is essential in the process of prevention and treatment of PP. Subsequently, if the woman gets diagnosed for PP, psychoeducation, which includes explaining the condition to the patient and their family along with initiating a treatment programme, plays a significant role in the patient’s self-efficacy and competency with dealing with the illness (Sit, et. al., 2006).

Pharmacotherapy

To address the psychotic and mood-related symptoms of PP, acute pharmacotherapy is recommended. Atypical antipsychotics and mood stabilisers or antimanic medicines, such as lithium or antiepileptic medications, are among the therapeutic possibilities (Sit, et.al., 2006). However, it’s crucial for patients to only take medication that is prescribed to them by mental health or medical professionals, and not try to procure them without prescription or from unregulated sources.

Electroconvulsive Therapy

Between 1942 and 1961, the mortality rate of PP fell dramatically as ECT became more widely used and women with PP had a substantially faster and more complete remission of mood and psychotic symptoms after ECT (Sit, et.al., 3006). In individuals who have been hospitalised with acute psychosis, ECT proves to be a good alternative for symptom resolution (Sit, et.al., 2006). Patients who have failed many treatment trials have unbearable drug side effects, or who require immediate effective symptom relief due to severe deficits in self-care, cognition, or judgment that jeopardise their safety and well-being should consider ECT (Sit, et.al., 2006). Catherine Carver (2017) also says, “However it works, it certainly seems to make a big difference to some patients… Hannah tells me ECT saved her life”, as she elaborates on the story of Hannah Bissett who faced similar symptoms as Carver after the birth of her baby.

Psychotherapy

Although there is little substantiation for the use of psychotherapy in postpartum psychosis, given that the majority of such mothers have an implicit affective disorder (e.g., bipolar and schizoaffective disorder), psychotherapy can be beneficial in the larger picture, where, for example, the end of a postpartum psychotic episode may be followed by depressive episodes.

Conclusion

The process of childbirth and childrearing is not easy, and it is critical that the realities of maternity and caregiving are brought to the foreground. Postpartum psychosis can persist anywhere from two to twelve weeks in its most severe form, however, some women might take longer periods of time to recover (Bergink, 2016). It has frequently been observed that women who suffer from mental illnesses during or after pregnancy rarely ever seek assistance due to embarrassment, stigma, and fear of being deemed as a “bad mother” (Moore, et.al., 2016). Screening women who are at high risk, along with educating all pregnant women about maternal mental health can significantly improve the lives of women during pregnancy and after childbirth.