POSTPARTUM PSYCHOSIS

Dr.Deddy Soestiantoro SpKJ MKes

POSTPARTUM (PUERPERAL) PSYCHOSIS

* psychotic disorder not otherwise specified * occurs in woman who have recently delivered a baby * syndrome:depression,delusions,thought of harming herself/infant (ideation of suicide/infanticide) * a close relation with mood disorders (bipolar & major depressive disoder)

EPIDEMIOLOGY -1-2 per 1000 childbirths -50-60% affected the first childbirth -50% associated with nonpsychiatric perinatal complications -50% have (+) family history of mood disorders -rare case---affect fathers (feel displaced by the child and may compete for the mothers love and attention/exacerbated by fatherhood stress)

ETIOLOGY -multifactorial -essentialy an episode of mood disorder (bipolar or depressive disorder) -relative hystory same as in mood disorders -the validity verified in the year after birth as two thirds have a second episode -non specific stressperhaps through a major hormonal mecahanism -result from a general medical condition ass.with perinatal events:infection,drug intoxication,toxemia,blood loss,andthe sudden decrease in estrogen&progesterone concentration -purely psychosocial causal (primiparous mother&recent stressfull events,conflicted feelings/motherhood experience, may have not wanted to became prgnant,trapped in unhappy marriages by motherhood,marital discord during pregnancy ass.with increased incidence of illness -maybe closely related with a defect of personality

DIAGNOSIS *can be made when psychosis occurs in close temporal association with childbirths *characteristic symptoms include delusions, cognitive deficits,motility disturbance, mood abnormalities,and occasional hallucinations *the contents of the psychotic material revolves aroud mothering & pregnancy

CLINICAL FEATURES *begin within days of delivery,mean time of onset is 2-3 weeks and almost always within 8 weeks of delivery *begin to complain of fatique,insomnia,restlessness,and may have an episode of tearfullness & emotional lability *later,suspiciousness,confusion,incoherence,irrational statements,and obsessive concerns about the babys health and welfare maybe present *50% ----delusions an 25 % hallucinations *complains regarding the ability to move,stand or walk are also common *feelings of not want to care/not loving the baby,of wanting to do harm to the baby/themselves or both *delusional ideas:the baby is dead or defective,deny the birth (being unmarried,virginal,etc) *hallucinations voices telling to kill the baby

DIFFERENTIAL DIAGNOSIS *psychotic disorder due to a general medical condition (hypothyroidism and Cushings syndrome) a substanceinduced psychotic (scopolamine,meperidine,pentazocine or antihypertensive agent during pregnancy), toxemia, infections, neoplasms * hystory of mood disorders---classified as a recurrence * postpartum bluesnormal in 50% (self limited,last only a few days,characterized by tearfulness,fatique,anxiety,and irratibilty shortly after birth and lessen over the course of a week) * postpartum nonpsychoticndepressions lacks in delusional and hallucinatory activity,occurs in 10-20%,despondent mood,feeling inadequacy as a parent & sleep disturbances there maybe a ruminative or obsessional thoughts of harming the baby but they lack of delusional conviction & these sometimes difficult to differentiate

COURSE AND PROGNOSIS *onset preceded by prodromal signs:insomnia,restlessness, agitation,lability of mood and mild cognitive deficits *occurs:dangerous depending upon the delusional contents and degree of agitation *5% commited suicide and 4% commited infanticide *a favorable outcome is associated with a good premorbid adjustment and a supportive family network *the course may be similar to mood disorders,usually episodic, and later often experience another episode of symptoms within a year or two of the birth *subsequence pregnancies increasing the risk,sometimes as high as 50%

TREATMENT * a psychiatric emergency / need a holistic approach * treatments of choice: antidepressants and lithium sometimes in combination with an anti psychotic * no pharmacological agents should be prescribed to a woman who is breast feeding * suicidal patientstransfer to psychiatric units * if she desire to contact with the baby, the visits must be be closely supervised * psychotherapy after the periode of acute psychosis, directed to the conflictual areas/accepting the mothering role,changes in environmental factors,increasing support from the husband and others * high rate of recovery reported from the acute illness