Transcript Hi There - Andrew Mayers

Postnatal psychosis
Very serious mental illness
Dr Andrew Mayers
[email protected]
Postnatal psychosis
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Overview
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Definitions and diagnosis
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Prevalence
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Causes
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Consequences
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Treatment
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Post-natal psychosis (PNP)
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PNP needs same DSM-IV diagnosis as any psychotic disorder
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Schizophrenia and associated disorders
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Manic stages of bipolar disorder
But PNP is specifically diagnosed in perinatal period
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Usually immediately after birth
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Or within a few weeks
But psychotic episodes can also occur during pregnancy
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What is psychosis?
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Extreme impairment in several areas of functioning
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Clarity of thought
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Emotional response
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Communication
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Understanding reality
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Behaviour
Illustrated by two key features
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Hallucinations
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Delusions
Severely interfere with normal life
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Schizophrenia
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DSMIV – A (characteristic symptoms)
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Two or more of following (must be present for a significant
portion of time during one-month period):
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Delusions
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Hallucinations
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Disorganised speech
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Grossly disorganised or catatonic behaviour
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Negative symptoms
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Mood, speech and behaviour
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Schizophrenia
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DSMIV – B (social/occupational dysfunction)
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Work
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Interpersonal relations
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Self-care
DSMIV – C (duration)
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Function must be ‘markedly below’ what patient normally achieves
in key area:
Continuous signs of disturbance for at least 6 months
DSMIV – D to F
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Exclusion criteria – not important for this exercise
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Delusions and hallucinations
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Delusions: firmly held (erroneous) beliefs
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Distorted reasoning/perception… examples…
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External forces ‘control’ patient’s thought and behaviour
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…receiving special messages from newspaper headlines
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The baby is not mine
Hallucinations: perceiving sensations not ‘apparent’ to others
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But vivid, substantial, and real to the patient
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Can relate to any of the senses
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Most commonly auditory and visual
PNP mums may hear voices telling her to harm child
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‘Negative’ symptoms & disorganised
behaviour
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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
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Inability to think clearly and respond appropriately
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Most commonly associated with irregular speech
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Talking in sentences that do not make sense
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Rambling loose associations
Can also be related to behaviours (‘odd’ movement)
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Manic stage of Bipolar Disorder
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Elevated, expansive, or irritable mood
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AND 3 from: (4 if mood is irritable)
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Psychomotor agitation or increased goal-directed behaviour
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Excessive/rapid talking
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Flights of ideas and/or racing thoughts
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Reduced need for sleep
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Grandiosity or inflated self-esteem
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Easily distractible
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Excessive involvement in (negative) pleasurable activities
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PNP - features
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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
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PNP - features
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First signs…
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Can start suddenly a few weeks after birth
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Mum becomes very restless, or elated, and unable to sleep
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Becomes confused and disorientated
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May not recognise friends or family members (or baby)
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May make bonding with baby difficult
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May have delusions or hallucinations
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May misconstrue events
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May be manic or have wild mood swings
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Behaviour may become increasingly bizarre
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May lose touch with reality
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PNP - Causes
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Depletion of oestrogen immediately after birth
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Hormone abnormalities more likely with PNP than with PND
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Sleep disruptions (before and after birth)
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Postpartum psychosis may be related to bipolar disorder
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Psychotic episodes and mood swings may actually represent first
bipolar episodes
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Previous bipolar disorder or schizophrenia is major risk factor
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Especially in new mothers
Or family history of one of these conditions
Previous history of PND or psychosis also a risk factor
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Living with postnatal psychosis
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Watch this clip from BBC2 Newsnight (August, 2012)
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Exercise
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How much more serious is postnatal psychosis than PND?
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What signs should we look out for?
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Should mother and baby be separated?
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What is the impact of stigma?
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What are the options?
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What are the consequences of PNP for mother and child?
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PNP and the child
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Serious illness with extremely serious implications for infant
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Potentially dangerous delusions
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Paranoid symptoms may cause mum to hide symptoms
Attention and cognition also a problem
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Both of those are important in caring for baby
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Or care for herself
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Mum may harm baby
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She may not be able to focus properly
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Or act quickly enough
May damage bonding and attachment
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PNP and the child
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Other evidence of SMI in mums and effect on children
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Developmental problems
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Significantly increased rates of delayed walking
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Disturbed behaviour
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Poor social competence
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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
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PNP treatment
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Often mum needs to be admitted to hospital
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Probably needs medication
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Stabilising drugs (e.g. lithium)
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Antipsychotic drugs: olanzapine, risperidone, or aripiprazole
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Antidepressants
But medication needs to be carefully considered
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Because of the breastfeeding implications
CBT may also be used
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Sometimes in mother and baby unit in psychiatric ward
But usually as ‘add-on’ to medication
Where meds not appropriate, ECT has been successful
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Summary
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Postnatal psychosis very serious
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Diagnosis of schizophrenia-related illness or manic state
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Sense of reality severely compromised
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Also associated with erratic behaviour
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Problems with attention processes
Consequences for mother and baby
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Mostly of harm to mother
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Effect on bonding
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Risk of hospitalisation and/or separation?
We should look for signs and risk factors
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Early intervention crucial
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