Postpartum psychosis (PPP), also known as puerperal psychosis or peripartum psychosis, involves the abrupt onset of psychotic symptoms shortly following childbirth, typically within two weeks of delivery. However, postpartum individuals are at risk for developing symptoms for several months after birth.
Symptoms may include delusions, hallucinations, disorganized speech (e.g., incoherent speech), or abnormal motor behavior (e.g., catatonia). Other symptoms frequently associated with PPP include confusion, disorganized thought, severe difficulty sleeping, variations of mood disorders (including depression, agitation, mania, or a combination of the above), as well as cognitive features such as consciousness that comes and goes (waxing and waning) or disorientation. Given the variety of symptoms associated with PPP, a thorough consideration of other psychiatric and non-psychiatric (or organic) causes must be ruled out through a combination of diagnostic labwork and imaging, as well as clinical presentation.
To document PPP within the DSM-5, the specifier "with perinatal onset" is used alongside a diagnosis such as "brief psychotic disorder" or "bipolar I disorder" if symptoms begin within 4 weeks of delivery. Recent literature suggests that the syndrome occurs in the context of known or new-onset bipolar illness, and some experts have recommended that PPP be classified as a distinct category within the bipolar disorders chapter of the DSM.
The cause of PPP is currently unknown, though growing evidence for the broad category of postpartum psychiatric disorders (e.g., postpartum depression) suggests hormonal and immune changes as potential factors contributing to their onset, as well as genetics and circadian rhythm disruption. There is no agreement in the evidence about risk factors, though a number of studies have suggested that sleep loss, first pregnancies (primiparity), and previous episodes of PPP may play a role. More recent reviews have added to growing evidence that prior psychiatric diagnoses, especially bipolar disorder, in the individual or their family may raise the risk of a new-onset psychosis triggered by childbirth. There are currently no screening or assessment tools available to diagnose PPP; a diagnosis must be made by the attending physician based on the patient's presenting symptoms, guided by diagnostic criteria in the DSM-5. Additionally, recent expert debate suggests that PPP may be better understood as a part of the bipolar spectrum triggered by childbirth, rather than solely a brief psychotic disorder specifier.
While PPP is seen only in one to two of every 1000 childbirths, the rapid development of psychotic symptoms, particularly those that include delusions of misidentification or paranoia, raises concerns for the safety of the patient and the infant; thus, PPP is considered a psychiatric emergency, usually requiring urgent hospitalization. Treatment may include medications such as benzodiazepines, lithium, and antipsychotics, as well as procedures such as electroconvulsive therapy (ECT). In some cases where pregnant those with a known history of bipolar disorder or previous episodes of PPP, prophylactic use of medication (especially lithium) either throughout or immediately after delivery has been demonstrated to reduce the incidence of psychotic or bipolar episodes in the postpartum period.
Medical literature
Historical reports Between the 16th and 18th centuries, about 50 brief reports regarding postpartum psychosis were published; among them is the observation that these psychoses could recur,Van Foreest P (1609) Puerperas nonnunquam phreniticas fierit & sineglectim habeantur, sibi ipsis vim inferre. Observationes, scholio 7, lib. 10. and that they occur both in breast-feeding and non-lactating individuals.Bartholomaeo de Battista a St Georgio (1784) Von der Tollsucht den Kindbetterinnen, in his Abhandlung von den Krankheiten des schönen Geschlechtes, Vienna, Sonnleithner, pages 113-114 in the 1819 edition. In 1797, Osiander, an obstetrician from Tübingen, reported two cases at length that contributed significantly to the knowledge of this disorder during that time.Osiander F B (1797). Neue Denkwürdigkeiten für Ärzte und Geburtshelfer. Göttingen, Rosenbusch, volume 1, pages 52-89, 90-128. These cases have been translated in reference 86, p19-30. In 1819, Esquirol conducted a survey of cases admitted to the Salpêtrière, and pioneered long-term studies.Esquirol J E D (1819) De l'aliénation mentale des nouvelles accouchées et des nourrices. Annuaires Médicales-chirurgiques des Hôpitaux de Paris 1: 600-632. From that time, puerperal psychosis became widely known to the medical profession. In the next 200 years, over 2,500 theses, articles and books were published. Among these many contributions were Delay's unique investigation using serial curettage Delay J, Boitelle G, Corteel A (1948. Les psychoses du postpartum: étude cyto-hormonale. Semaines d'Hôpitaux de Paris 24: 2891-2901. and Kendell's record-linkage study comparing 2 years before and 2 years after the birth. In the last few years, two monographs reviewed over 2,400 works, detailing more than 4,000 cases of childbearing psychoses from the literature and a personal series of more than 320 cases.Brockington I F (2014) What is Worth Knowing about 'Puerperal Psychosis'. Bredenbury, Eyry Press. A pdf of this limited edition can be obtained gratis on email request to [email protected]. Postpartum psychosis has historically received less research attention compared to other psychiatric disorders, limiting its understanding, treatment, and long-term outcomes.
Modern medical literature Postpartum psychosis was recognized in DSM I and II, first as Involutional Psychotic Reaction and later as Psychosis with Childbirth. It was removed in the DSMIII following arguments that psychiatric disorders associated with pregnancy and childbirth were no different than other psychiatric illnesses. it was recognized again with the 1994 release of the DSM-IV, when the specifier "with postpartum onset" was included for various diagnoses. In DSM-5, the specifier was renamed "with perinatal onset".
To document PPP within the DSM-5, "with perinatal onset" is used alongside a diagnosis such as "brief psychotic disorder" or "bipolar I disorder" if onset occurs within four weeks of childbirth. In the ICD-10, postpartum disorders are coded according to the presenting psychiatric disorder alongside a second code to denote puerperium onset, such as F53 if onset occurs within six weeks of childbirth. Because postpartum psychiatric disorders may present outside of these timeframes, the utility of these classifiers is limited.
Signs and symptoms PPP symptoms commonly occur within 2 weeks of birth, although postpartum individuals remain at risk of developing symptoms for several months postpartum. Episodes may last weeks to several months. A hallmark of PPP is rapidly changing presentation; symptoms can wax and wane over the course of hours. These fluctuations often confuse clinicians and family members.
Diagnostic criteria per the DSM-5 requires the presence of at least one psychotic symptom, defined as delusions, hallucinations, bizarre or incoherent speech (disorganized speech), or abnormal movements (psychomotor behavior) such as catatonia. Delusions, particularly about the infant, are the most commonly reported psychotic symptom associated with PPP.
Paranoid delusions are a frequently noted theme in cases of PPP, but a small review noted infrequent cases of delusional misidentification syndromes, such as Capgras syndrome (the belief that someone or something familiar has been replaced with an impostor), Fregoli syndrome (the belief that a stranger is actually a known person in disguise), and others. The latter types of delusions may have a significant negative impact on the bond between a parent and child, raising concerns for the safety of both. In addition, evidence suggests that emotion-recognition difficulties in those at risk for PPP may further impair parent-infant interaction quality and engagement.
Both postpartum obsessive–compulsive disorder (OCD) and PPP may present with concerning thoughts about the infant; typically, the thoughts associated with OCD are unwanted and distressing to the individual (who does not wish to act on their thoughts), whereas persons with PPP are often less distressed by their beliefs and may even feel the need to act on them. Compared to schizophrenia, PPP tends to feature less bizarre delusions, and associated hallucinations are more likely to be visual rather than auditory. The sensation of being outside one's body or feeling that one's surroundings are unreal (i.e., derealization) has also been described in cases of PPP. Additional distinctions in PPP compared to classical schizophrenia include the presence of mood and cognitive (or neurological) symptoms.
Rapid mood changes or the presence of unusual moods such as depression or mania (increased energy, decreased need for sleep, etc.) tend to be seen in a large percentage of patients experiencing PPP. Irritability, anxiety, and general difficulties with sleep may also be present. Confusion or disorientation, disorganized thoughts, incoherent speech, or abrupt changes in a person's mental capacity may also be seen in individuals experiencing PPP, though one small study observed these neurological symptoms in only one-quarter of PPP cases. Like delirium, these symptoms may come and go in unpredictable patterns.
Thoughts of committing suicide or harming one's infant or children have also been reported as common occurrences in PPP, with as many as half of PPP cases exhibiting these features. In many cases where harmful thoughts exist, the person experiencing these thoughts does not consider their intended action to be harmful; rather, they believe that their actions are in the best interest of the child.
Risk factors Childbirth is the primary cause of PPP; other causes and risk factors remain largely under investigation.
The largest known risks for the occurrence of PPP include a history of PPP in a previous pregnancy, or a personal or family history of bipolar disorder. A significant number of PPP cases, however, occur in individuals with no prior history of psychosis. (For this reason, first-time pregnancy is itself sometimes considered to be a risk factor for PPP.) A review of pregnancy-related complications demonstrated some association between emergency caesarean sections (C-sections), excess bleeding, uterine rupture, and stillbirth (amongst other complications) and the subsequent development of PPP; however, several of the reviewed studies were contradictory and thus no consensus can confirm the relationship between problems related to pregnancy and PPP. Additional research suggests that obstetric complications alone are unlikely to be a direct cause of PPP and may instead interact with underlying biological or psychological vulnerabilities.
Lifestyle and psychological factors, such as previous trauma or single parenthood, have likewise been inconclusive as factors contributing to PPP, though a number of patients have reported a perception that social and pregnancy-related challenges were the cause of their PPP episodes.
Pathophysiology Currently, the pathophysiology of PPP is not well understood and remains an open field of ongoing research. The leading theories under investigation involve areas of genetics, hormones, immunology, and sleep disturbance processes.
Genetics Some findings suggest an association between PPP and variation in serotonin transporter genes and signaling or changes at specific chromosomes (e.g., 16p13 or METTL13). However, the majority of research devoted to genetic understanding of PPP has evaluated patients who have known bipolar disorder, so these associations may not be specific to PPP.
Hormones