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Post partum psychosis dsm 5


Essential Reads - Postpartum Psychosis: A Diagnosis for the DSMV

In a recent article, Margaret Spinelli, MD describes a proposal to the DSM-V committee of the American Psychiatric Association in 2020 arguing for the inclusion of postpartum psychosis as a unique diagnosis based on the cognitive disorganization that accompanies postpartum psychotic symptoms. The article clearly lays out the rationale for the inclusion of postpartum psychosis in the DSM, highlighting the distinctive features of postpartum psychosis and describing how the failure to appreciate these features may hinder the diagnosis and treatment of postpartum psychosis.

Spinelli starts by giving a historical perspective of the inclusion of postpartum psychiatric illness in the DSM.  The first version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) was published in 1952 to aid clinicians in the recognition and consistent classification of specific psychiatric illnesses. In this first version, postpartum psychosis was included as Involutional Psychotic Reaction.   In the second version of the DSM (1968), postpartum psychosis was again included, this time as Psychosis with Childbirth. However, postpartum psychosis was dropped from the DSM in 1980.  In fact, the word “postpartum” was expunged from the next two versions of the DSM. Despite an increased interest in and awareness of perinatal mood disorders in the following twenty years, postpartum psychiatric disorders, including postpartum psychosis, did not find their way back into the DSM until 1994.  

When the diagnosis of postpartum psychosis reappeared in the DSM IV-TR in 1994, it was incorporated using the specifier “with postpartum onset” which could be used to describe a brief psychotic disorder or a major depressive, manic, or mixed episode with psychotic features in an individual with either major depressive disorder or bipolar disorder, if the onset occurred within 4 weeks postpartum.

The postpartum onset specifier recognizes the temporal association of postpartum psychosis with childbirth; however, it fails to acknowledge how postpartum psychosis may differ from other types of psychotic experiences.   While this may seem like a minor semantic issue, not recognizing the distinctive features of postpartum psychosis may hinder diagnosis and treatment.  

Spinelli notes that since the earliest reports of postpartum psychosis in the medical literature, clinicians, including Esquirol in 1838 and Victor Louis Marce in 1858, have noted the distinctive features of postpartum psychosis.  Fairly consistently, postpartum psychosis has been described as a complex clinical picture encompassing a triad of psychiatric symptoms: mood symptoms, psychosis and cognitive disorganization, “ a delirium-like state of confusion and disorientation”.

Cognitive Disorganization or Delirium as a Unique Feature of Postpartum Psychosis

Since clinicians first began to describe postpartum psychosis, they have reported on the unusual cognitive disorganization and disorientation observed in this patient population.  Clinicians have reported a spectrum of cognitive symptoms and distortions, including distractibility, difficulties with  communication, memory problems, disorientation, confusion, depersonalization, and derealization.   These symptoms are similar to those we see with delirium, and like delirium, the symptoms of postpartum psychosis emerge rapidly, within hours or days, and can have a waxing and waning quality.  

In a report published in 1994, Wisner and colleagues tried to better characterize the differences between postpartum and non-postpartum psychosis.  This study prospectively compared women with postpartum psychosis (n?=?21) to those with psychosis unrelated to childbirth (n?=?96) using formal cognitive testing.  Women with postpartum psychosis reported higher scores on measures of cognitive disorganization psychosis or delirium. In addition, women with postpartum psychosis were more likely to report homicidal ideation, lack of insight, functional impairment and atypical visual, tactile and olfactory hallucinations. These findings also suggest that postpartum psychosis has many delirium-like features: cognitive disorganization, functional impairment, lack of insight, and unusual perceptual disturbances.

Delirium is a clinical syndrome, characterized by an acute and fluctuating alteration in awareness and cognition resulting from pathophysiological changes.  Delirium can have many different causes: severe medical illness, medication toxicity, drug intoxication or withdrawal, fever, infection, metabolic imbalances, sleep deprivation,  As a result the clinical presentation is varied and is influenced by the clinical context in which delirium occurs.  

While the symptoms of postpartum psychosis — its rapid onset, the waxing and waning quality, and the unusual quality of perceptual disturbances — overlap with delirium, we do not typically consider the physiologic changes that may trigger postpartum psychosis.  Spinelli notes that this “disregards the neurohormonal triggering factors of childbirth and the impact of the massive hormone withdrawal at the time of childbirth that generates modifications and dysregulation of brain chemicals.” 

Spinelli argues that this cognitive disorganization not only distinguishes postpartum psychosis from other types of psychosis, but it is also the feature that makes postpartum psychosis so dangerous: 

The cognitive or delirium-like state must be anticipated because of the waxing and waning, confusion, and disorientation that contributes to the mother’s poor judgment and impulsivity. “Waxing and waning,” such that the woman seems well at one moment then floridly psychotic in the next, may not be anticipated. Mother must be supervised and separated from the infant. Importantly, clinicians untrained in perinatal psychiatry have often missed the subtle symptoms. Many infants have been killed during this period of “pseudo-wellness.”

Why Postpartum Psychosis Should Be Included in the DSM-V

While postpartum psychosis is rare, affecting only one out of every 1000 women after childbirth, it causes significant morbidity and mortality in this population.  Women with postpartum psychosis are at significant risk for suicide.  In addition, postpartum psychosis puts the infant at risk, with estimates of infanticide ranging form 1 to 4.5%.

The current use of the postpartum onset specifier to classify women with postpartum psychosis is clearly insufficient:

  1. It fails to include important clinical information, more specifically the cognitive disorganization and delirium-like features which occur more commonly in postpartum psychosis than in non-puerperal psychosis.   
  2. It does not include information on medical conditions specific to the postpartum period which may cause a similar clinical picture, including autoimmune thyroiditis and NMDR encephalitis.
  3. It fails to communicate important clinical information regarding the need for ensuring the safety of the mother and the infant, given the heightened risk for suicide and infanticide.
  4. It does not highlight the strong link between postpartum psychosis and bipolar disorder, and thus does not provide important clinical information on risk for non-puerperal recurrence and possible long-term treatment strategies.  
  5. It does not include information to guide the choice of effective treatments.  Specifically many women with postpartum psychosis require treatment with antipsychotic medications and a mood stabilizer.  
  6. It does not include information which would ultimately improve clinical outcomes.   Acknowledging the recurrent nature of postpartum psychosis would allow for prophylactic interventions in subsequent pregnancies.  

While the DSM committee reviewing this information did not ultimately approve the inclusion of postpartum psychosis as a distinct diagnosis,  the committee did acknowledge that the current “with postpartum onset specifier” is insufficient for women with postpartum psychosis.  They proposed that postpartum psychosis should be included in Section 3 of the DSM: “Conditions for Further Study”.  The hope is that this would encourage further research. (Premenstrual dysphoric disorder or PMDD was placed in that section in the DSM-IV and ultimately made it into the DSM-V as a distinct diagnosis.)

Given the rarity and rapidly evolving nature of postpartum psychosis, it is extremely difficult to study.  It is nearly impossible to collect prospective data using standardized instruments.  We are now in the midst of what we call our MGHP3 Study, the MGH Postpartum Psychosis Project.   We are collecting clinical and demographic information, as well as genetic samples, from women who have experienced postpartum psychosis, in an effort to better understand the etiology of illness.  

 

Ruta Nonacs, MD PhD

 

Spinelli M.  Postpartum psychosis: a diagnosis for the DSMV.  Arch Womens Ment Health. 2021 Sep 8. 

 

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Postpartum psychosis. What is postpartum psychosis?

IMPORTANT
The information in this section should not be used for self-diagnosis or self-treatment. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For diagnosis and proper treatment, you should contact your doctor.

Postpartum psychosis is an acute mental disorder that develops in the first weeks after childbirth. Manifested by depression, insomnia, confusion, delusional ideas about the incurable illness of the child, delusions of persecution, hallucinations. The behavior of the patients becomes inadequate: they refuse to care for the newborn, harm him, and attempt suicide. Diagnosis is carried out by a psychiatrist, the main methods are clinical conversation and observation. Medical treatment, antipsychotics, antidepressants, tranquilizers are used. When the condition improves, sessions of psychotherapy and family counseling are introduced. nine0006

    ICD-10

    F53.1 Severe mental and behavioral disorders associated with the puerperium, not elsewhere classified

    • Causes
    • Pathogenesis
    • Symptoms of postpartum psychosis
    • Complications
    • Diagnostics
    • Treatment of postpartum psychosis
    • Prognosis and prevention
    • Prices for treatment

    General

    Postpartum psychosis is also called postnatal. This disorder was first described by Hippocrates in 460 BC. e. Its origin was explained by large blood loss during childbirth. More accurate studies date back to the middle of the 19th century. French psychiatrists J.-E. Esquirol and L.-V. Marse described the psychoses of young mothers as the consequences of severe somatic complications of childbirth. Currently, the prevalence of psychotic disorders has significantly decreased. In economically developed countries, their frequency is 1-1.2 cases per 1,000 women who gave birth no more than 3 months ago. The peak incidence is observed within the first 30 days after the birth of a child. nine0006

    postpartum psychosis

    Causes

    Official data confirm that more than half of women with postnatal psychosis have mental disorders (schizophrenia, depression, MDP) or a hereditary predisposition to them. The exact causes of the pathology are unknown, but several groups of triggers have been identified - factors contributing to its debut:

    • Complications of pregnancy, childbirth. An acute psychotic state is often caused by the death of a newborn, premature birth, threatened miscarriage. The association of the disorder with massive blood loss and sepsis, identified in ancient times, is confirmed. nine0016
    • Hormonal disorders. The end of pregnancy is always associated with a change in the level of hormones in a woman's body. Mental disorders develop on the basis of a sharp decrease in the synthesis of progesterone, estrogen, thyroxine.
    • CNS lesion. Psychosis often occurs with neurological diseases, after brain injuries, neuroinfections, intoxications. Sometimes the disorder is provoked by the use of scopolamine in combination with lidol for pain relief in childbirth.
    • Anxious and suspicious personality traits. Women with high emotional tension, low adaptive abilities, and a tendency to predict failures are more prone to depression and the formation of delusional ideas. The process of childbirth becomes a stressful situation for them, triggering a mental disorder. nine0016
    • Unfavorable psychosocial environment. Risk factors are unwanted pregnancy, rejection of the child by the mother, financial difficulties, unsettled life, divorce from a spouse. Psychoses are often diagnosed in parturient women leading an asocial lifestyle (drug addiction, alcoholism, prostitution).

    Pathogenesis

    According to the mechanism of origin, postpartum psychosis is reactive. It develops in response to a traumatic event - childbirth. It is based on the experience of fear of death, violation of the integrity of one's own personality, restriction of freedom, lack of love of others (shift of attention from a woman to a child). An unfavorable background for the onset of psychosis is psychophysiological asthenization - depletion of energy, a decrease in resistance to stress factors. There comes a state of decompensation of nervous adaptive mechanisms. nine0006

    At the neurophysiological level, there is a violation of reciprocal inhibitory interactions between the cortex and subcortical brain structures, between the anterior and posterior hypothalamus - the highest centers of regulation of autonomic functions and emotions. The balance of activation of the sympathetic and parasympathetic nervous system, the ratio of the main neurotransmitters (serotonin, norepinephrine, dopamine, GABA) change. According to psychodynamic theory, postpartum psychosis results from a conflict between the mother's real desires and the situation of motherhood. nine0006

    Symptoms of postpartum psychosis

    Psychosis begins to manifest 2-3 days after the completion of childbirth, when a woman is aware of the changes that have occurred in her life. Symptoms may develop gradually or rapidly. Initially, there is insomnia, anxiety, restlessness, fatigue, fatigue. The emotional background is stably reduced. Then suspicion and alertness begin to grow. Overvalued ideas are formed about the state of the child's health, about the presence of diseases in him or in himself. Consciousness becomes confused, speech - abrupt, illogical. nine0006

    Suspicion is constantly increasing. Often, mothers closely observe the newborn during sleep and feeding, examining him, listening to his breathing and heartbeat, revealing imaginary incurable, fatal diseases. Patients begin to accuse doctors and close relatives of being indifferent to the condition of the baby, of deliberate unwillingness to treat him. Secretly from those around them, they give him various medicines, carry out “procedures” that can cause real harm (dip in cold water, leave him without clothes and diapers). nine0006

    In another version of the course of psychosis, mothers lose interest in babies, do not show care and love. Overprotection turns into a feeling of hatred. Delusional thoughts are expressed about the substitution of the child, the infusion of evil spirits, demons into him, about the imminent inevitable death. In severe cases, auditory hallucinations are noted. Voices urge women to kill a newborn, attempts are often made to strangle him. Throughout the disease, the criticism of patients to their condition is disturbed - delusions and hallucinations are not recognized, they are not regarded as pathological. nine0006

    Complications

    Without timely diagnosis and treatment, postpartum psychosis is a danger to the life, health of the baby and mother. On the basis of hallucinations and delusions, inappropriate behavior is formed - patients try to commit suicide, having previously killed the baby. There are known cases of strangulation, falling from a height of a woman and a newborn. With a sluggish psychotic process, when indifference and detachment gradually increase, the child does not receive sufficient emotional and sensory stimulation, lags behind in physical and mental development, and suffers from neurotic disorders (enuresis, nightmares, phobias) from an early age. nine0006

    Diagnostics

    Postpartum psychosis presents with classic signs of acute psychopathology, so making an accurate diagnosis can be difficult. An important role in the process of identifying the disease is played by the patient's relatives, it is they who most often pay attention to changes in the behavior and emotional reactions of a young mother. Professional diagnostics is performed by a psychiatrist, in addition, pathopsychological, gynecological and neurological examinations may be required to differentiate postnatal psychosis from schizophrenia, bipolar affective disorder, depression, hypothyroidism, Cushing's syndrome. Specific diagnostic methods include: nine0006

    • History taking. The doctor examines the medical documentation about the course of childbirth and pregnancy, finds out the presence of a hereditary burden for mental disorders, the patient's existing psychiatric diagnoses, postpartum depression, psychosis after previous pregnancies. The material and living conditions of life, the presence of a spouse, the patient's attitude to conception, pregnancy, and the birth of a child are taken into account.
    • Clinical conversation. In direct contact with the patient, the psychiatrist evaluates the productivity of contact, the purposefulness of thinking and speech, and the logic of reasoning. With a psychotic disorder, women express delusional ideas in detail, are concentrated on their own experiences, and do not always answer in accordance with the questions of a specialist. nine0016
    • Surveillance. During the conversation, the doctor observes the behavior and emotions, determines their adequacy, the safety of arbitrary control, motivation. Psychosis is characterized by alertness and distrust, inconsistency of reactions to the examination situation, the predominance of dysphoric and / or depressive affect, and the absence of a critical attitude towards one's behavior.

    Treatment of postpartum psychosis

    Therapy of an acute condition is carried out in a hospital setting. Quite often, women are sent to psychiatric departments and neuropsychiatric dispensaries from the maternity hospital. At the time of intensive treatment, the child is separated from the mother, entrusting care to close relatives. Comprehensive assistance includes the following areas: nine0006

    • Pharmacotherapy. At the acute stage of the disorder, the main task is to relieve psychotic symptoms. Neuroleptics, normotimics, tranquilizers, antidepressants are prescribed. For the period of taking medications, it is necessary to exclude breastfeeding by choosing artificial mixtures for feeding the child.
    • Psychotherapy. After the elimination of the symptoms of psychosis, a period of awareness of the patient of her actions, feelings, and the presence of the disease begins. This provokes depression, guilt and self-hatred. To stabilize the emotional state and correct negative attitudes, techniques of the cognitive-behavioral direction, psychoanalysis are used. nine0016
    • Family assistance and rehabilitation. The support of loved ones and the correct organization of the daily routine are important. Relatives organize round-the-clock monitoring of the patient, perform baby care procedures together with the mother. It is important to spend time with a young mother, talk, distract from painful thoughts, control the regular intake of drugs prescribed by a psychiatrist.

    Prognosis and prevention

    Postpartum psychosis has a favorable outcome, subject to successful recovery from depression, support from loved ones, and the absence of mental illness. Prevention is based on the correct physical and psychological preparation of a woman for pregnancy and the process of childbirth. Expectant mothers need to pay attention to planning to minimize the risk of complications. It is recommended to attend courses in childcare skills, master breathing and relaxation techniques in childbirth, share your experiences with your husband, parents, close friends, and if you have severe anxiety, seek help from a psychologist. nine0006

    You can share your medical history, what helped you in the treatment of postpartum psychosis.

    Sources

    1. Features of clinical manifestations and treatment of postpartum psychosis/ Zhuk TP, Dudal LV// Medicine and ecology. – 2014.
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    4. This article was prepared based on the materials of the site: https://www. krasotaimedicina.ru/

    IMPORTANT
    Information from this section cannot be used for self-diagnosis and self-treatment. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For diagnosis and proper treatment, you should contact your doctor.

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