Psychology

The Abnormal Psychology of Postpartum Psychosis

While postpartum depression occurs in up to 20% of women who have children, psychotic manifestations are even more rare, and thus much less understood.

As most of us know, giving birth to a baby can bring about many changes, including changes in a new mom’s mood and emotions. About 85% of individuals experience some type of mood disturbance during the postpartum period. For most, these symptoms are mild and short-lived; however, 10 to 15% of individuals can develop more significant symptoms of depression or anxiety.

While Andrea Yates’ experience was an extreme case, other stories of postpartum psychosis are just as worrisome. This abnormal piece will look at the continuum of postpartum psychiatric illness – detailing a more common manifestation of this disorder and the causes, risk factors, symptoms, and treatment associated.  

P
ostpartum psychiatric illness is divided into three categories: postpartum blues, postpartum depression, and postpartum psychosis.

It may be useful to think of these disorders as existing on a continuum, where postpartum blues is the mildest and postpartum psychosis is the most severe.

Baby Blues

Postpartum Blues affect 50 to 85% of individuals, with symptoms of the blues appearing during the first few weeks after delivery. Given how common this type of mood disturbance is, it’s often considered a normal experience following childbirth rather than a psychiatric illness. Typically, those experiencing this type of blues report exaggerated changes in mood, tearfulness, anxiety and/or irritability. These symptoms typically peak on the fourth or fifth day after delivery and may last for a few hours or a few days, often presenting spontaneously within two weeks of delivery.

While these symptoms are unpredictable and often unsettling, they usually do not interfere with a person’s ability to function. However, it should be noted that the development of this diagnosis can cause more significant mood disorders, particularly for those who have a history of depression. If symptoms of postpartum blues last longer than two weeks, the individual experiencing symptoms should be evaluated to rule out a potential more serious mood disorder.

Postpartum Depression (PPD)

PPD typically presents during the first two to three postpartum months but may also occur at any point after delivery. Some individuals even note the onset of mild depressive symptoms during their pregnancy. PPD is clinically the same as depression occurring at other times during life. Symptoms of PPD include:

  • Depressed or sad mood
  • Tearfulness
  • Loss of interest in usual activities
  • Feelings of guilt
  • Feelings of worthlessness or incompetence
  • Fatigue
  • Anxiety
  • Sleep disturbance
  • Change in appetite
  • Poor concentration
  • Suicidal thoughts
  • Significant anxiety symptoms

It can be difficult to diagnose PPD, especially if it’s a milder case, as many of the symptoms used to detect depression (i.e., sleep and appetite disturbance, fatigue) also occur in postpartum individuals who are not experiencing symptoms of depression. Despite this, individuals experiencing symptoms of PPD, or suicidal thoughts, should still seek evaluation to confirm if it’s normal symptoms associated with the postpartum phase or symptoms of depression that may need intervention.

Postpartum Psychosis

Postpartum psychosis is a rare event, that occurs in approximately 1 to 2 per 1,000 individuals after childbirth. Its presentation is often seen within the first 48 to 72 hours after delivery, with most individuals developing symptoms within the first two postpartum weeks. In most cases, postpartum psychosis represents an episode of bipolar disorder, with symptoms resembling those of a rapidly evolving manic (or mixed) episode.

It typically begins with the inability to sleep and feelings of restlessness or irritability. These symptoms then lead to more severe ones, such as psychosis, a state of mind that occurs when a person loses touch with reality, causing symptoms like:

  • Auditory hallucinations (i.e., hearing things that aren’t real, such as suggestions for a mother to harm herself or that the baby is trying to kill her)
  • Delusional beliefs related to the infant (like others are trying to harm the baby)
  • Rapidly changing moods from extreme sadness to very energetic
  • Violent thoughts (like telling a mother to hurt her baby)
  • Confusion regarding place and time
  • Erratic and unusual behavior
  • Thoughts of suicide or infanticide

A more common presentation of Postpartum Psychosis

To provide another example of this type of psychosis and detail a more common experience associated with this disorder, we look at the story of Lisa A. – which accurately describes the often-routine cycle of behaviors associated with postpartum psychosis: Mania, Psychosis, Thoughts of suicide or infanticide, Treatment.

M A N I A

When symptoms began shortly after the birth of her daughter in 2014, Lisa Abramson felt a rush of adrenaline whenever she looked into her baby’s eyes. “I actually was thinking, like, ‘I don’t get why other moms say they’re so tired, or this is so hard. I got this,’” she said. However, immediately after the first week, Abramson begins to feel the pressure when she’s advised to feed her baby every two hours, after the pediatrician noticed that the baby was losing weight. Feeling as though she couldn’t keep up with the schedule, Abramson states: “It weighed on me as, “I’ve failed as a mom. I can’t feed my child,’” she said. “I needed to feed her — that was the most important thing. And my well-being didn’t matter.”

P S Y C H O S I S

Abramson was barely sleeping. Even when she could get a break from what felt like ‘breastfeeding purgatory’ she couldn’t relax. As she got more exhausted, she started to get more confused. Then one day, when she was at home, she noticed police helicopters circling over her apartment. “There were snipers on the roof,” she recalled thinking, “and there were spy cams in our bedroom, and everyone was watching me. And my cellphone was giving me weird messages.” She waited for the police to burst in and take her away for her demonstrated failure as a mother. However, the next morning, she woke up in her own bed. Convinced that the cops must have arrested the nanny instead, she told her husband it wasn’t fair, stating that ‘it was wrong’ and that the nanny shouldn’t be punished for her crime.

S U I C I D A L   T H O U G H T S

Abramson then informs her husband of her plans of jumping off the Golden Gate Bridge, causing him to decide to tell her that he was going to drive her to the police station himself, so that she could confess. “It was like, ‘Oh, OK, he’s taking me in, and I guess I’m getting arrested,’” stated Abramson. But, instead of going to the police station, her husband brought her to the inpatient unit of the psychiatric ward at Sutter Health’s California Pacific Medical Center in San Francisco.

Her husband, David Abramson, remembers it as one of the worst days of his life. “It was really, really challenging… probably the most heart-wrenching thing…” But he knew it was the best thing to do for his wife and their family.

T R E A T M E N T

For almost a week, Abramson didn’t speak to anyone. She doesn’t remember any doctors or nurses telling her why she was there or what was going on. But she does remember, about a week into her hospitalization, her husband bringing a printout he found online regarding postpartum psychosis.

The article said “elevated hormones from childbirth — plus sleep deprivation — can trigger confusion and paranoia.” Abramson didn’t believe it. She thought her husband was tricking her and had spent hours using Photoshop to piece together a fake article. “I really was just like I’ve heard of postpartum depression… I have never heard that there’s postpartum crazy.”

After ending her week-long inpatient stay, Abramson participated in outpatient therapy at a perinatal psychiatric unit. Fast forward to 2019 (5 years later) and Lisa Abramson is a happy mother of two, with a third on the way. The psychosis did not come back with the 2nd child (even though there’s a high-risk factor that it would), due to the precautions she took like getting enough sleep and allowing herself permission to give up on breastfeeding when it became too much for her. Detailing how being mindful of your wellbeing, can mitigate negative psychological reactions. “I’m trying to put myself first — guilt-free” says Abramson, “and know that that makes me a better mom.”

The Causes of Postpartum Psychosis

“Unlike in Britain, where the mental health system watches mothers for months afterward for signs of depression and mood swings, people in America have a difficult time understanding how hormonal shifts can actually cause violent hallucinations and thoughts.” – Katherine Ramsland, writer of Andrea Yates: Ill or Evil?

While the exact causes of postpartum psychosis aren’t known, the postpartum period is characterized by a rapid shift in the hormonal environment. Within the first 48 hours after delivery, estrogen and progesterone concentrations fall dramatically. As these hormones are involved in the regulation of mood, many researchers believe this is what causes the emergence of postpartum illness. Some researchers hypothesize that some women may be more sensitive to the mental health effects of hormonal charges. Other aspects of health, such as genetics, culture, and environmental and biologic factors, can influence causes of postpartum psychosis. Sleep deprivation may also play a role.

Additionally, social, and environmental factors like martial dissatisfaction and/or inadequate social supports have been one of the most consistent findings amongst individuals who experience PPD.

Risk Factors of Postpartum Illness

Although some women can have postpartum psychosis with no risk factors, there are some known factors that can increase a person’s risk for the condition, such as:

  • History of bipolar disorder
  • History of postpartum psychosis in a previous pregnancy
  • History of schizoaffective disorder or schizophrenia
  • Family history of postpartum psychosis or bipolar disorder
  • First pregnancy
  • Discontinuation of psychiatric medications for pregnancy

Treatment

Postpartum psychosis is a medical emergency. Often the person experiencing symptoms will not recognize it as an illness, leaving loved ones with the responsibility to intervene. If you or a loved one is experiencing symptoms of postpartum psychosis, OB Doctor, Kimberly Dishman states that you should “call 911 and seek treatment at an emergency room or take the individual to an emergency room or crisis center on your own. Explain that the person you care about recently had a baby and describe what is being experienced or witnessed. State your concern for safety and well-being. Remember that individuals who are experiencing postpartum psychosis are in crisis and need help in a hospital to stay safe. Do not leave someone who is experiencing signs and symptoms of postpartum psychosis alone.”

Generally, the course of action is immediate hospitalization. Often, an individual will receive treatment at an inpatient center for a few days until their mood is stabilized and they’re no longer at risk for harming themselves or their baby. Treatments during psychotic episodes can include medications to reduce depression, regulate moods, and reduce hallucinations, such as antipsychotics and mood stabilizers. Cognitive behavioral therapy and interpersonal therapy has also been shown to be useful, and particularly effective for mild to moderate PPD.

Outlook for postpartum psychosis

Acute symptoms of postpartum psychosis can last from two to 12 weeks. Some may need longer to recover, with the disorder lasting from six to 12 months. Even after the major psychosis symptoms go away, women may have feelings of depression and/or anxiety. To fully recover from this condition, it’s important to stay on any prescribed medications and seek continued treatment and support for symptoms – as unfortunately, an estimated 31% of those with a history of postpartum psychosis will experience the condition again in another pregnancy, according to a study published in the American Journal of Psychiatry.

However, this statistic shouldn’t keep a person from having another baby, instead it should just be something to be mindful of when preparing for delivery. If the doctor’s aware of the possible development of postpartum psychosis, they will often prescribe a mood stabilizer, like lithium, for the person to take after giving birth, to potentially prevent it.

The onset of postpartum psychosis, while rare, is extremely severe and worrisome. As most individuals in psychosis are typically unaware of their erratic behavior, it’s important that their loved ones intervene and support them appropriately.

May the stories of Yates and Abramson provide a reminder of the drastically different outcomes of mental illness and prompt us all to act like David Abramson when supporting an individual we love.


References:

Since completing my undergraduate studies, I've dedicated my time to supporting and empowering individuals with behavioral health issues. This blog is to be a platform for the behavioral health community; examining the history of behavioral health and the progressions made within the field while providing information and resources to those who need it.

4 comments on “The Abnormal Psychology of Postpartum Psychosis

  1. Thank you for raising awareness about postpartum psychosis and some of the other perinatal mood & anxiety disorders.

    My name is Dyane Harwood and in 2007, I was diagnosed with postpartum bipolar disorder, which is not the same as postpartum psychosis.

    I wrote a memoir “Birth of a New Brain—Healing from Postpartum Bipolar Disorder” and I’d behappy to offer you a free PDF copy if you’d like one.

    “Birth of a New Brain” is endorsed by Kay Redfield Jamison, Dr. Samantha Meltzer-Brody, Dr. Wendy Davis (Executive Director of Postpartum Support Intl.) and by 20+ other perinatal and bipolar mental health luminaries.

    My International Bipolar Foundation “Psych Byte” Postpartum Bipolar Webinar touches on postpartum psychosis and explains the similarities and differences between the two perinatal and anxiety mood disorders.

    Thanks again for your post!

    Take care,

    Dyane

    Liked by 1 person

  2. I’m a mental health nurse specialising in psychosis but I’ve learned so much from this article! Thank you 💚

    Liked by 1 person

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