Postnatal psychosis Very serious mental illness Dr Andrew Mayers

2 Postnatal psychosis  Overview  Definitions and diagnosis  Prevalence  Causes  Consequences  Treatment

3 Post-natal psychosis (PNP)  PNP needs same DSM-IV diagnosis as any psychotic disorder  Schizophrenia and associated disorders  Manic stages of bipolar disorder  But PNP is specifically diagnosed in perinatal period  Usually immediately after birth  Or within a few weeks  But psychotic episodes can also occur during pregnancy

4 What is psychosis?  Extreme impairment in several areas of functioning  Clarity of thought  Emotional response  Communication  Understanding reality  Behaviour  Illustrated by two key features  Hallucinations  Delusions  Severely interfere with normal life

5 Schizophrenia  DSMIV – A (characteristic symptoms)  Two or more of following (must be present for a significant portion of time during one-month period):  Delusions  Hallucinations  Disorganised speech  Grossly disorganised or catatonic behaviour  Negative symptoms  Mood, speech and behaviour

6 Schizophrenia  DSMIV – B (social/occupational dysfunction)  Function must be ‘markedly below’ what patient normally achieves in key area:  Work  Interpersonal relations  Self-care  DSMIV – C (duration)  Continuous signs of disturbance for at least 6 months  DSMIV – D to F  Exclusion criteria – not important for this exercise

7 Delusions and hallucinations  Delusions: firmly held (erroneous) beliefs  Distorted reasoning/perception… examples…  External forces ‘control’ patient’s thought and behaviour  …receiving special messages from newspaper headlines  The baby is not mine  Hallucinations: perceiving sensations not ‘apparent’ to others  But vivid, substantial, and real to the patient  Can relate to any of the senses  Most commonly auditory and visual  PNP mums may hear voices telling her to harm child

8 ‘Negative’ symptoms & disorganised behaviour  Negative symptoms  Affective flattening (reduced range/intensity of emotion)  Facial expression, voice tone, eye contact, body language  Alogia (poverty of speech)  Often illustrated by short, empty replies to questions  Avolition (reduction or difficulty with goal-directed behaviour)  e.g. staying at home for long periods doing nothing  Disorganised behaviour  Inability to think clearly and respond appropriately  Most commonly associated with irregular speech  Talking in sentences that do not make sense  Rambling loose associations  Can also be related to behaviours (‘odd’ movement)

9 Manic stage of Bipolar Disorder  Elevated, expansive, or irritable mood  AND 3 from: (4 if mood is irritable)  Psychomotor agitation or increased goal-directed behaviour  Excessive/rapid talking  Flights of ideas and/or racing thoughts  Reduced need for sleep  Grandiosity or inflated self-esteem  Easily distractible  Excessive involvement in (negative) pleasurable activities

10 PNP - features  Very serious illness  Potential risks for mother and baby  Needs quick intervention, usually hospital  High risk of suicide and infanticide  Delusions may be directed at baby  “The child is not mine… it is evil incarnate… must be terminated or he will kill me…”  Also called puerperal psychosis  Prevalence  1 in 1000 mums may get post-natal psychosis (0.1%)  Contrast with baby blues and PND

11 PNP - features  First signs…  Can start suddenly a few weeks after birth  Mum becomes very restless, or elated, and unable to sleep  Becomes confused and disorientated  May not recognise friends or family members (or baby)  May make bonding with baby difficult  May have delusions or hallucinations  May misconstrue events  May be manic or have wild mood swings  Behaviour may become increasingly bizarre  May lose touch with reality

12 PNP - Causes  Depletion of oestrogen immediately after birth  Hormone abnormalities more likely with PNP than with PND  Sleep disruptions (before and after birth)  Postpartum psychosis may be related to bipolar disorder  Psychotic episodes and mood swings may actually represent first bipolar episodes  Especially in new mothers  Previous bipolar disorder or schizophrenia is major risk factor  Or family history of one of these conditions  Previous history of PND or psychosis also a risk factor

13 Living with postnatal psychosis  Watch this clip from BBC2 Newsnight (August, 2012)

14 Exercise  How much more serious is postnatal psychosis than PND?  What signs should we look out for?  Should mother and baby be separated?  What is the impact of stigma?  What are the options?  What are the consequences of PNP for mother and child?

15 PNP and the child  Serious illness with extremely serious implications for infant  Potentially dangerous delusions  Paranoid symptoms may cause mum to hide symptoms  Attention and cognition also a problem  Both of those are important in caring for baby  Or care for herself  Mum may harm baby  She may not be able to focus properly  Or act quickly enough  May damage bonding and attachment

16 PNP and the child  Other evidence of SMI in mums and effect on children  Developmental problems  Significantly increased rates of delayed walking  Disturbed behaviour  Poor social competence  Greater risk behaviours  Postnatal psychosis (PP) presents dangers to mum and child  70-fold increase in maternal suicide risk  Leading cause of maternal death in first year after birth  Homicidal behaviour is rare  But 28%–35% PP mums described delusions about infants  Only 9% had thoughts of harming the infant

17 PNP treatment  Often mum needs to be admitted to hospital  Sometimes in mother and baby unit in psychiatric ward  Probably needs medication  Stabilising drugs (e.g. lithium)  Antipsychotic drugs: olanzapine, risperidone, or aripiprazole  Antidepressants  But medication needs to be carefully considered  Because of the breastfeeding implications  CBT may also be used  But usually as ‘add-on’ to medication  Where meds not appropriate, ECT has been successful

18 Summary  Postnatal psychosis very serious  Diagnosis of schizophrenia-related illness or manic state  Sense of reality severely compromised  Also associated with erratic behaviour  Problems with attention processes  Consequences for mother and baby  Mostly of harm to mother  Effect on bonding  Risk of hospitalisation and/or separation?  We should look for signs and risk factors  Early intervention crucial