What is psychosis?
Psychosis is not one illness, rather it is a constellation of symptoms which may present with a variety of disorders. Typically, we consider two groups of symptoms when discussing psychosis:
- Hallucinations are sensory experiences where an individual will see, hear, smell, feel something that is not real.
- Delusions are false beliefs that are untrue and not believed by the person’s family or community.
Perinatal psychoses are typically seen among patients during the postpartum. We will emphasize postpartum psychosis in this document.
Postpartum psychosis typically presents within the first days to weeks after delivery. This psychiatric emergency may require that the patient be hospitalized for the safety of the patient and their offspring.
Patients with a history of psychotic illness like schizophrenia should be followed closely during their pregnancies. Due to changes in body composition and metabolism, their medication dosage may require adjustment.
What does postpartum psychosis feel like to the patient?
Insight is often very limited in the patient suffering from postpartum psychosis, and they may ignore the changes that others may see.
- The individual with postpartum psychosis will often present as excited and energetic, or depressed and anxious. Her moods may rapidly change from high to low.
- The patient often has either hallucinations or delusions and may appear confused, unable to explain her thoughts or behavior.
- Changes in speech are frequent, speaking more loudly or rapidly than baseline.
- Thoughts as well as conversation may appear to jump from topic to topic and may be very difficult for the listener to follow.
- A decreased need for sleep. Most new parents crave the opportunity to sleep, but one with postpartum psychosis may sleep only an hour or two and not feel tired.
- Uncharacteristic behavior may be displayed, with the patient acting in a manner that is not normal for them.
- Paranoia and suspicion.
- Irrational thoughts, such as believing that they possess special powers or that they are receiving special messages from the television, computer, or billboards that are meant only for them.
- Beliefs that the newborn is unique and imbued with special powers. The infant may be thought to be demonically possessed or divinely chosen.
Patient Example 1: Mae delivered her son two days previously and just returned home from her hospital stay. Despite having slept only a few hours since going into labor, Mae is extremely energetic. Mae’s husband Jon awoke the next morning to find his wife had painted the living room while he slept. Jon encouraged his wife to lie down as he cared for their baby. An hour later, Jon found his wife rearranging their closet. Jon found it difficult to understand Mai, her speech was fast and her thoughts were jumbled. Jon called the OB for advice.
Patient Example 2: June had an unplanned C/S due to failure to progress. She refused pain medication due to her desire to breastfeed. Her pain limited sleep to minutes at a time. Nurses’ concern began when June refused to allow the baby to go to the nursery for the pediatrician’s evaluation. The afternoon of her second postpartum day, June barricaded the door to her room, preventing staff from entering.
How does psychosis differ from postpartum OCD?
Postpartum psychosis is often confused with postpartum obsessive compulsive disorder (OCD). In both disorders, there often is preoccupation with the infant, as well as religion. In the case of OCD, the individual is extremely fearful that harm will come to the infant; the parent typically is help seeking. The psychotic patient may feel that harming the child is inevitable and necessary and will resent any intervention from family or medical professionals who want to care for them.
When this is the first presentation of psychosis for the patient, the patient is likely experiencing their first manic episode. To clarify if the patient is suffering from postpartum psychosis, in addition to administering the EPDS or the PHQ-9, it is strongly encouraged that the patient be given the Mood Disorder Questionnaire (MDQ). If the patient does not screen positive on the MDQ, but you continue to have concerns about the patient, please call PEACE for Moms to assist in the evaluation.
Medical intervention is the safest treatment for postpartum psychosis. Both suicide and infanticide are complications of postpartum psychosis and thus hospitalization may be necessary. Treatment for postpartum psychosis focuses on treating the underlying disorder and ensuring the safety of the patient. A combination of antipsychotics and mood stabilizers may be required to help the patient normalize their thoughts, behavior, and mood.
Frequently asked questions
If a patient has had postpartum psychosis with a previous pregnancy, what is recommended regarding future pregnancies?
After becoming psychotic in the puerperium, over 60% of the affected women who have been studied were noted to have subsequent episodes of psychosis, mania, or depression. There is no way to predict whether a patient will or will not have a future episode and it may be in the patient’s best interest to remain on medication until there are no further plans to conceive. PEACE for Moms will happily work with clinicians to help develop a plan to limit risk for the patient and the fetus.
My new patient is 10 weeks pregnant. The records show that she is followed at the community service board in our county for schizophrenia and she receives a long acting injectable (LAI) antipsychotic. What should we do?
LAIs are typically prescribed for patients who have difficulty remaining compliant with their medication regimen. While the data on LAIs during pregnancy is limited, it may be in the patient’s and the unborn baby’s best interest to continue administering the LAI. Problems including placental abruption, low birthweight and cardiac anomalies are more common in individuals with untreated schizophrenia. Those who stop their prescribed medications are more often to use nicotine, alcohol, and illicit drugs. Call PEACE for Moms if you have further concerns.