Psychiatry's manual once erased postpartum psychosis, then restored it in 1994
About one or two births in every thousand are followed by a sudden psychosis, usually within two weeks. Symptoms can flicker on and off within hours, baffling doctors and families. Physicians have written about it since the sixteenth century, yet one edition of psychiatry's main diagnostic manual decided it was not a distinct illness at all.
Around 50 short accounts appeared between the sixteenth and eighteenth centuries, already noting that episodes could recur and struck whether or not a mother was breastfeeding. In 1797 the Tubingen obstetrician Osiander described two cases in detail, and in 1819 Esquirol surveyed admissions to the Salpetriere and began long-term follow-up. The early DSM editions listed the condition, but the third edition removed it on the argument that illnesses around childbirth were no different from others. The 1994 DSM-IV restored it as a specifier, now called with perinatal onset.
Diagnosis requires at least one psychotic symptom, such as delusions, hallucinations, disorganised speech or catatonia. Delusions about the baby are the most common. Compared with schizophrenia, the delusions tend to be less bizarre and hallucinations more often visual than auditory, and mood swings, mania, confusion and disorientation are frequent. Rarely, patients develop misidentification beliefs such as Capgras syndrome, the conviction that a familiar person has been replaced by an impostor. Unlike the unwanted, distressing thoughts of postpartum OCD, psychotic beliefs may feel reasonable to the person holding them.
Childbirth is the trigger, but the deeper cause remains unclear. The biggest known risks are a previous episode and a personal or family history of bipolar disorder, and many experts now see the condition as part of the bipolar spectrum set off by birth. Yet many cases arise in people with no psychiatric history, which is why first pregnancy is sometimes listed as a risk. Hormones shift sharply after every delivery, in affected and unaffected women alike, and trials of estrogen replacement have not supported a hormonal cause; genetics, immunity and disrupted sleep are under study.
Because thoughts of harm to self or infant appear in as many as half of cases, the condition is treated as a psychiatric emergency, usually with urgent hospital admission. Treatment can include lithium, antipsychotics, benzodiazepines and electroconvulsive therapy, and for those at known risk, preventive lithium around delivery has reduced episodes. No screening tool yet exists.
Source: Postpartum psychosis
