A CASE REPORT: Prepartum or Postpartum Psychosis?
Did this woman have (untreated) postpartum psychosis when she became pregnant a second time-- or was this a separate, rare case of prepartum psychosis?
Postpartum psychosis is not a rare occurrence. Onset is usually sudden, and it is estimated that 1 or 2 out of 1000 women will be affected.1,2 Psychosis in early pregnancy, however, is rarer and has been far less studied.
[[{"type":"media","view_mode":"media_crop","fid":"49799","attributes":{"alt":"Vladimir Prusakov/Shutterstock.com","class":"media-image media-image-right","id":"media_crop_5439778378496","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6052","media_crop_rotate":"0","media_crop_scale_h":"125","media_crop_scale_w":"186","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Vladimir Prusakov/Shutterstock.com","typeof":"foaf:Image"}}]]Here I describe the case of a woman in whom psychotic symptoms developed following a miscarriage; she conceived a second time 6 months later. During this pregnancy her mental and physical health precipitously worsened, which led to termination of pregnancy. The question is: did she have (untreated) postpartum psychosis when she became pregnant the second time, or was this a separate, rare case of prepartum psychosis?
Case description
Claire, a nulliparous 40-year-old woman 4 to 5 weeks pregnant, presented at a medical clinic complaining of extreme anxiety, panic, delusions, depression, and strong suicidal ideation. She had a long history of anorexia nervosa and depressive episodes, but not psychosis. She had miscarried 6 months earlier at 4 to 5 weeks. After the miscarriage, severe anxiety and psychotic-like symptoms had developed. She had visited 3 mental health providers and a gynecologist between pregnancies and had been given clonazepam to relieve her anxiety. Every time she thought she might be pregnant, she immediately ceased all medication, which led to great and sudden shifts in her treatment regimen.
Upon presentation she was given diazepam for her anxiety, which provided temporary relief. However, because of the risks to her fetus, it was soon discontinued. Her general state declined, and she was referred to a psychiatrist who recommended quiet bed rest. Ten days later, the patient returned to her city home from the country. Her symptoms had worsened and were compounded by severe constipation, unrelenting insomnia (she was able to sleep at most 1 to 2 hours a night), and intense morning sickness that had resulted in considerable weight loss.
Claire was convinced she could not carry the pregnancy through (either physically or mentally). She exhibited violent suicidal ideation (typical of postpartum psychosis), whereas her previous episodes of suicidal ideation had been nonviolent. She was unable to eat or drink anything. She was extremely weak and had difficulty standing up and walking; her BMI was 13 to 14, and she passed out at a counseling session preceding the abortion. The pregnancy was terminated at 10 weeks.
After the termination, her gastrointestinal symptoms resolved (she had not had a bowel movement for at least 5 weeks) and she was placed on a combined treatment of fluoxetine, clonazepam, and olanzapine. Her BMI and sleep patterns improved, but her general mental state steadily worsened, and she felt tremendous grief and guilt at having terminated her pregnancy.
Two years later, following several episodes of visual and auditory hallucinations, she received a diagnosis of bipolar disorder type II, which she was told undoubtedly explained her severe symptoms during and after pregnancy. A psychiatrist who specialized in bipolar disorder made the diagnosis on the basis of her description of lifelong symptoms (including lack of response to antidepressants). It should be noted that she had not been screened for mental illness after her first pregnancy or during her second.
Discussion
Bipolar disorder can potentially complicate pregnancy toward the end of term or postpartum, but worsening of symptoms can also occur during the first trimester.3 Women with bipolar disorder may be at higher risk for psychiatric disorders during pregnancy than women with other mental illnesses4; schizophrenia is an important risk factor as well, although less of a risk factor for postpartum psychosis.2
Eating disorders have also been shown to compound bipolar disorder.5 Moreover, for reasons that are not entirely clear, women with a history of anorexia nervosa are more likely to seek abortion.6 Up to 40% of women who present for termination of pregnancy have been sexually and/or physically abused at least once.7 Furthermore, a correlation between eating disorders and a history of sexual abuse has been made.8,9
Claire had all of these risk factors. In addition, she probably suffered from hyperemesis gravidarum, which likely led to her chronic constipation. Undoubtedly because of anorexia (and the stigma that accompanies it), these 2 ailments went untreated, leaving her in great physical discomfort.
Were Claire’s psychotic symptoms triggered by conception or by abortion (both spontaneous and induced), or did she experience 2 separate episodes? Go to the comments section below, and let us know what you think.
Screening tools are needed that differentiate between bipolar disorder and MDD, since the risks of severe psychiatric symptoms are not the same.10 Data suggest that postpartum psychosis may be an “overt presentation of bipolar disorder” that coincides with the tremendous hormonal shifts induced by childbirth.2 Recent findings indicate that half of major depressive episodes that present after childbirth may actually have begun during pregnancy.11
If Claire had been screened for bipolar disorder-either after her miscarriage or at the beginning of her second pregnancy-she might have benefited from treatment options and notably from ECT, which is considered a safe intervention in pregnancy.12
Such options might have allowed her to carry the pregnancy through to delivery. The combined effects of psychotic illness and termination of a wanted pregnancy led to her depressive episodes (and some episodes of hypomania), grief, and guilt. After several years of unrelenting depression, she was administered ECT, which had a strikingly beneficial effect.
Conclusion
If the global lifelong prevalence of bipolar disorder is between 0.3% and 1.5% (in both sexes, but with type II higher in women) and if 0.3% to 1% of women experience anorexia nervosa at some point in their lives, then we are dealing with a significant cohort of women who are at risk for both prepartum and postpartum psychosis.13,14 Women and girls with bipolar disorder and/or anorexia nervosa before childbearing should be assessed for individual risk of severe psychiatric complications during pregnancy.
Perinatal psychiatry is a domain that deserves more attention, particularly owing to the fact that aside from ECT, no drug intervention has been shown to be completely safe and physicians must weigh the relative dangers for both maternal and fetal/infant health.15
Disclosures:
Dr. Balinska is Research Associate and Medical Knowledge Manager in the Medical Department of Médecins Sans Frontières in Geneva, Switzerland. She reports no conflicts of interest concerning the subject matter of this article.
Acknowledgments: I thank Dr. Bacha Kaoutar (Paris) for sharing with me the details of this case.
The research carried out to describe this case was done so independently of Médecins Sans Frontières.
References:
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