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.
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?
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.
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.
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