Postpartum psychosis

Postpartum psychosis
Other names	Puerperal psychosis
Rates of psychoses among Swedish first-time mothers
Specialty	Psychiatry
Symptoms	Hallucinations, delusions, mood swings, confusion, restlessness, personality changes[1]
Causes	Genetic and environmental
Risk factors	Family history, bipolar disorder, schizophrenia, difficult pregnancy[1]
Treatment	Anti-psychotics, mood stabilizers, anti-depressants

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 but less than 4 weeks postpartum.^[2] PPP is a condition currently represented under "Brief Psychotic Disorder" in the Diagnostic and Statistical Manual of Mental Disorders, Volume V (DSM-V).^[3] Symptoms may include delusions, hallucinations, disorganized speech (e.g., incoherent speech), and/or abnormal motor behavior (e.g., catatonia).^[3] 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.^[2][4]

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,^[5] as well as genetics and circadian rhythm disruption.^[6] 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.^[2] More recent reviews have added to growing evidence that prior psychiatric diagnoses, especially bipolar disorder, in the individual or her family may raise the risk of a new-onset psychosis triggered by childbirth.^[2][6][7][8] 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-V (see Diagnosis).^[2][6]

While PPP is seen only in 1 to 2 of every 1000 childbirths,^[2][4] the rapid development of psychotic symptoms, particularly those that include delusions of misidentification or paranoia,^[9] raises concerns for the safety of the patient and the infant; thus, PPP is considered a psychiatric emergency, usually requiring urgent hospitalization.^[2][4][6] Treatment may include medications such as benzodiazepines, lithium, and antipsychotics, as well as procedures such as electroconvulsive therapy (ECT).^[2][4][6] In some cases where pregnant women have 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.^[2][4][6]

PPP is not an independently recognized diagnosis in the DSM-V; instead, the specifier "with peripartum onset" is used for both "Brief psychotic disorder" and "Unspecified bipolar and related disorders."^[3] Recent literature suggests that, more frequently, this syndrome occurs in the context of known or new-onset bipolar illness (see Postpartum Bipolar Disorder).^[6] 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 - a non-exhaustive sample of these other causes is examined below (see Organic postpartum psychoses and Other non-organic postpartum psychoses).^[6]