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Sunday, 10 November 2013 10:09

Puerperal Psychosis

Puerperal psychosis, also known as Postpartum Psychosis, is defined as postnatal being a period after childbirth and psychosis as a serious mental illness in which a person loses contact with external reality. It is the most severe form of mental health conditions following birth and is a psychiatric emergency where the woman needs to be seen by a perinatal psychiatrist immediately following diagnosis. A perinatal psychiatrist is a medically qualified physician who specializes in the study and treatment of mental disorders from twenty two weeks gestation until ten days postpartum. Puerperal Psychosis is a rare condition, occurring in 0.1% of women (1 in 1000 births). Over half of these women will go on to have further mental illness not related to childbirth, such as Bipolar Disorder, Schizophrenia, or Clinical depression.

When Does Puerperal Psychosis Occur?

Puerperal Psychosis has a sudden and dramatic onset. Some research suggests that Puerperal Psychosis has a symptom free period in the first few postpartum days, although the majority of research conducted proposes that symptoms begin in the first few postpartum days and fully presents itself within the first two to three weeks after birth. The majority of the symptoms presented by Puerperal Psychosis occur by the 16th postpartum day and although it is rare, it can take up to several weeks for the illness to occur.

Symptoms of Puerperal Psychosis

Symptoms are variable and can change rapidly from hour to hour and from day to day. Early symptoms of Puerperal Psychosis include depression, rapid mood fluctuations, confusion, behavior that is out of character, being withdrawn, irritability, anxiety, irrational behavior, restlessness and neglect of basic needs. Severe symptoms of Puerperal Psychosis are where a woman will feel paranoid, suspicious, fearful, unreal, like she’s in a dream world, disorientated, and become detached from her environment. These symptoms may cause the woman to experience agitation, insomnia, disorganized behavior, and cognitive impairment. Puerperal Psychosis has a dramatic presentation of psychotic symptoms which includes delusions and hallucinations. Delusions are believing things that are untrue, sometimes morbid thoughts, the woman being in contact with God, being dead, or experiencing death. They can sometimes relate to her baby, such as thinking her baby has a different identity, is possessed, has been exchanged, has magical powers, or is dying. Delusions commonly cover catalepsy, a condition characterized by lack of response to external stimuli and muscular rigidity. Hallucinations are seeing and hearing things that are not really there, which may often include hearing voices telling the woman to harm herself or her baby. Everyone around the suffering woman should be able to identify her abnormal behavior to know that there is something wrong, that she is not herself, and her behavior is abnormal. Symptoms are so severe they require urgent psychiatric treatment.

Who is at Risk of Puerperal Psychosis?

There may be no warning for the onset of Puerperal Psychosis and it can happen to any woman, including women who have not been ill before. Those at high risk of puerperal psychosis are women who have experienced puerperal psychosis before, women with a family history of Bipolar Disorder or Puerperal Psychosis, or women with existing mental health disorders such as Bipolar Disorder and Schizophrenia. High risk women have a 25-50% risk of experiencing Puerperal Psychosis. There is a high risk of Puerperal Psychosis re-occurrence in subsequent pregnancies and research suggests that 50% of women go on to experience it again.

Why Does Puerperal Psychosis Occur?

Biological Model

Puerperal Psychosis presents itself during the changing levels of hormones after birth causing an imbalance which suggests it is caused by a biological factor. The hormones estrogen, progesterone and cortisol have been suggested as precipitators. 

Psychosocial Model

Puerperal Psychosis can be caused by psychosocial factors. A previous diagnosis of puerperal psychosis, pre-existing mental health disorders, or a family history of Puerperal Psychosis or mental health disorders increases a woman’s vulnerability to emotional and psychological problems during pregnancy and following birth. Women who have experienced early emotional distress from being separated, physically or emotionally, from their own mother from an early age may result in a poor mother–infant attachment or if a woman becomes socially and emotionally withdrawn from her environment, especially after the absence of a partner, close relative or close friend (divorce, separation, bereavement, relocation) and low levels of social or partner support, including lack of affection and emotional support, can contribute in increasing a woman’s vulnerability. There are existing debates whether postnatal mental health disorders are pathological illnesses or an understandable response to difficulties of motherhood.  

Treatment of Puerperal Psychosis

A rapid diagnosis of Puerperal Psychosis is essential, as the condition requires prompt medical intervention to allow immediate treatment of the mother. This will ensure that the safety of the woman, her infant, and her family is not jeopardized. There should be an immediate referral to a perinatal psychiatrist or the local mental health team as the condition can sometimes warrant hospital admission. 

Medical Interventions

Medical interventions are in the form of medication, usually antipsychotic. A combination of anti-psychotics, antidepressants, mood regulatory drugs, and hormone therapies (the use of synthetic progesterones and transdermal estrogen) can be used to treat Puerperal Psychosis. Psychotropic drugs (sedatives or tranquilizers) or electroconvulsive therapy may also be used, depending upon the severity of the condition. If the woman requires hospitalization, mother and baby should ideally be kept together at a local mother and baby psychiatric unit, although this depends on the availability as there are only twenty units throughout the UK. It is rare for a child to be taken from the mother if Puerperal Psychosis occurs. 

How do Mother and Baby Psychiatric Units Help?

All the mother and baby units in the United Kingdom have the same aim of helping the mother recover from Puerperal Psychosis. The objectives of the units are to help women to manage stress and relax, manage anger and irritability, help build support networks, and help to bond with their infant. The mental health professionals do this by teaching baby massage, which will encourage the mother-infant attachment, engaging women in activities (gardening, swimming, creative art classes, cooking classes) to improve cognitive behavior, providing parenting skills groups, to boost their confidence in parenthood, as well as providing clinical care plans, which are regularly reviewed ensuring they are tracking the mother's progress and providing the most effective care possible. Clinical care involves Psychotherapy, Occupational Therapy, Family Therapy, Cognitive Behavior Therapy, and Counseling.

Psychosocial Interventions

Psychotherapy (talking therapies) will aid the recovery of the woman through the use of individual or group counseling, non-directive counseling, interpersonal therapy, and cognitive behavior therapy. Family focused therapy, such as couple therapy and interaction focused therapy, is available to assist in improving the quality of relationships with mother and partner or mother and infant retrospectively. Patience ensures a full recovery of Puerperal Psychosis and care should also always be given to the woman’s partner and family by all health professionals involved.

Recovery of Puerperal Psychosis

It can take six to twelve months to fully recover from Puerperal Psychosis, but some sources propose with effective treatment the majority of women clinically recover within two months and go on to make a full recovery. Puerperal Psychosis is often followed by a lengthy period of depression and anxiety.

How Puerperal Psychosis Differs From Postpartum Depression

Many women experience mild mood changes after childbirth and it is common for women to feel many different emotions. Puerperal Psychosis is a mental health condition at the other end of the spectrum, being a more severe illness than Postpartum Blues or Postpartum Depression.

Effects on Mother, Infant, and Family

Puerperal Psychosis can be a frightening, shocking experience for all involved. The suffering woman may feel worried about what’s occurring which may cause her to feel alone and isolated from others. She may feel resentment towards the infant which can cause her to feel guilty or a failure from being able to holistically function as a mother. 

Current Policies in Place to help with Puerperal Psychosis

Organisation - Department of Health 

Policy - Making mental health services more effective and accessible 

Pathway – Maternal Mental Health Pathway 

https://www.gov.uk/government/policies/making-mental-health-services-more-effective-and-accessible--2

Organisation - Department of Health 

Policy - Giving all children a healthy start in life 

Pathway – Maternal Mental Health Pathway 

https://www.gov.uk/government/policies/giving-all-children-a-healthy-start-in-life

 

Maternal Mental Health Pathway

Published 9th August 2012

The Maternal Mental Health Pathway focuses on the role of the health visitor but indicates the importance of the role of the midwife in the first 28 days of the postpartum period. It endorses the practice of working with other health professionals by setting out the principles and benefits for health visitors, midwives, specialist mental health professionals, and General Practitioners working together during pregnancy and in the first postnatal year, in order to meet the physical and mental health well-being of parents, babies and families. It provides a structured approach to addressing the common issues associated with the journey that mothers experience in relation to their mental and emotional well being from midwifery to health visiting services. The pathway is drawn from two government policies; Giving all children a healthy start in life and Making mental health services more effective and accessible. It is put in place to guide health professionals to build on good practice as identified by the professional consensus The Healthy Child Programme, NICE Guidance and The Frank Field Report (a systematic solution focused approach on which to base local practice on). The pathway is underpinned by understanding the importance of pregnancy and infancy in respect to the infant’s neural development, laying a blueprint for the infant’s future health. 

Guidelines Related to helping women with Puerperal Psychosis

  • NICE Guideline Postnatal Care Guideline 37 
  • http://publications.nice.org.uk/postnatal-care-qs37
  • NICE Guideline Antenatal and Postnatal Mental Health Guideline 45
  • http://pathways.nice.org.uk/pathways/antenatal-and-postnatal-mental-health
  • NICE Guideline Quality Standard of Antenatal Care Guideline 22 
  • http://publications.nice.org.uk/quality-standard-for-antenatal-care-qs22
  • NICE Guideline Antenatal Care: Routine Care for Healthy Pregnant Women Guideline 62
  • http://guidance.nice.org.uk/CG62

References

 

  • Baston, H., & Hall, J. (2009). Midwifery Essentials Volume 4 Postnatal. London: Elsevier. 
  • Department of Health. (2012). Making mental health services more effective and accessible. Retrieved from https://www.gov.uk/government/policies/making-mental-health-services-more-effective-and-accessible--2
  • Edge, D. (2013) National Perinatal Mental Health Project Report. Retrieved from http://www.nmhdu.org.uk/silo/files/national-perinatal-mental-health-project-report-.pdf 
  • Gundersen, D. C. (2001). Postpartum Psychiatric Disorders. Retrieved from http://www.mdconsult.com.libproxy.lib.unc.edu/das/book/body/172005763-9/0/1167/1.html
  • Healthcare Improvement Guidelines Network Scotland. (2013). Postnatal Depression & Postnatal Psychosis. Retrieved from http://www.sign.ac.uk/guidelines/fulltext/60/section3.html 
  • Heron, J. Mcguiness, M. Robertson Blackmore, E. Craddock, N. Jones, I. (2008). Early Postpartum Symptoms in Puerperal Psychosis. BJOG. 115. Page 348-353.
  • Hunter, A. (1998). The Queen Charlottes Hospital Guide to Pregnancy and Birth. London: Vermilion. 
  • Kingdon, C. (2009). Sociology for Midwives. London: Quay Books Division. 
  • Martin, E. (2003). Oxford Dictionary of Nursing (4th ed.). Oxford: Oxford University Press. 
  • Medforth, J., Battersby, S., Evans, M., Marsh, B., & Walker, A. (2011). Oxford Handbook of Midwifery (2nd ed.). Oxford: Oxford University Press. 
  • NHS.UK (2013) Postnatal Psychosis. Retrieved from http://www.nhs.uk/Conditions/Postnataldepression/Pages/Symptoms.aspx 
  • NICE. (2013A). Postnatal Care. Retrieved from http://publications.nice.org.uk/postnatal-care-qs37
  • NICE. (2013B). Antenatal and Postnatal Mental Health. Retrieved from http://pathways.nice.org.uk/pathways/antenatal-and-postnatal-mental-health
  • NICE. (2013C). Quality of Antenatal Care. Retrieved from http://publications.nice.org.uk/quality-standard-for-antenatal-care-qs22 
  • NICE. (2013D). Antenatal Care: Routine Care for Healthy Pregnant Women. Retreived from http://guidance.nice.org.uk/CG62
  • Paradice, R. (2002). Psychology for Midwives. Wiltshire: Quay Books Division. 
  • Royal College of Psychiatrics. (2013). Postpartum Psychosis: Severe Mental Illness after Childbirth. Retrieved from http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/postpartumpsychosis.aspx
  • Sit, D. Rotherschild, A.J Wisner, K.L. (2005). A Review of Postpartum Psychosis. Retrieved from http://www.pandasfoundation.org.uk/?gclid=COCD4saJx7oCFe7HtAod6mYAEA 
  • The National Archives. (2013). The Mental Health Act 2007. Retrieved from http://www.legislation.gov.uk/ukpga/2007/12/contents 
  • Waite, M., & Hawker, S. (2009). Compact Oxford Dictionary and Thesaurus (3rd ed.). Oxford: Oxford University Press.

 

 

Published in Postpartum Health

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