User:Typemd21/Postpartum psychosis

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Postpartum psychosis (PPP), also known as puerperal psychosis or peripartum psychosis, involves the abrupt onset of psychotic symptoms shortly following childbirth, typically within two weeks of delivery but less than 4 weeks postpartum.[1] PPP is a condition currently represented under "Brief Psychotic Disorder" in the Diagnostic and Statistical Manual of Mental Disorders, Volume V (DSM-V).[2] Symptoms may include delusions, hallucinations, disorganized speech (e.g, incoherent speech), and/or abnormal motor behavior (e.g., catatonia).[2] Other symptoms frequently associated with PPP include confusion, disorganized thought, insomnia, variations of mood disorders (including depression, agitation, mania, or a combination of the above), as well as cognitive features such as waxing and waning consciousness or disorientation.[1][3]

The cause of PPP is currently unknown, though growing evidence for the broad category of postpartum psychiatric disorders (e.g., postpartum depression) suggests hormonal and immune dysregulation as potential factors contributing to their onset,[4] as well as genetics and circadian rhythm disruption.[5] There is no consensus in the evidence about risk factors, though a number of studies have suggested that sleep loss, first pregnancies (primiparity), and previous episodes of PPP may play a role.[1] More recent reviews have added to growing evidence that prior psychiatric diagnoses, especially bipolar disorder, in the individual or their families may raise the risk of a new-onset psychosis triggered by childbirth.[1][6][7][5] There are currently no screening or assessment tools available to diagnose PPP; a diagnosis must be made by the attending physician based on the patient's clinical presentation, guided by diagnostic criteria in the DSM-V (see Diagnosis).[1][5]

While PPP is only seen in every 1 to 2 of 1000 childbirths,[1][3] the rapid development of psychotic symptoms, particularly those that include delusions of misidentification or paranoia,[8] raise concerns for the safety of the patient and the infant; thus, PPP is considered a psychiatric emergency, usually requiring urgent hospitalization.[1][3][5] Treatment may include medications such as benzodiazepines, lithium, and antipsychotics, as well as procedures such as electroconvulsive therapy (ECT).[1][3][5] In some cases where expecting persons have a known history of bipolar disorder or previous episodes of PPP, prophylactic use of medication (especially lithium) either throughout or immediately after delivery has been demonstrated to reduce the incidence of psychotic or bipolar episodes in the postpartum period.[1][3][5]

PPP is not an independently recognized diagnosis in the DSM-V; instead, the specifier "with peripartum onset" is used for both Brief psychotic disorder and Unspecified bipolar and related disorders.[2] Recent literature suggests that, more frequently, this syndrome occurs in the context of known or new-onset bipolar illness (see below, Postpartum Bipolar Disorder).[5]

Clinical Presentation[edit]

By diagnostic definition (Brief psychotic disorder with peripartum onset), PPP occurs either during pregnancy or within 4 weeks of delivering the infant.[2] Generally, PPP symptoms have been observed within 3-10 days of childbirth, though individuals with a past history of bipolar disorder may experience symptoms even sooner.[1][5] The persistence of symptoms varies; while the average reported length of an episode may last weeks to several months,[5] there is currently no strong literature documenting the course of individual episodes. Recurrence rates for psychotic episodes, on the other hand, have stronger supporting studies and are covered in more detail below (see Prognosis and Outcomes).

Diagnostic criteria per the DSM-V requires the presence of at least one psychotic symptom, defined as delusions, hallucinations, bizarre or incoherent speech (disorganized speech), or abnormal movements (psychomotor behavior), such as catatonia.[2] Delusions, particularly about the infant, are the most commonly reported psychotic symptom associated with PPP.[3][5][9] Paranoid delusions are a frequently noted theme in cases of PPP,[3][10] but a small review noted infrequent cases of delusional misidentification syndromes, such as Capgras syndrome (the belief that someone or something familiar has been replaced with an imposter), Fregoli syndrome (the belief that a stranger is actually a known person in disguise), and others.[8] The latter types of delusions may have a significant negative impact on the mother-child bonding relationship, raising concerns for the safety of both the mother and child (see Prognosis and Outcomes).[8][11] Both postpartum obsessive-compulsive disorder (OCD) and PPP may present with concerning thoughts about the infant: typically, the thoughts associated with OCD are unwanted and distressing to the individual who does not wish to act on their thoughts where persons with PPP are often not as distressed by their beliefs and may even feel the need to act on their beliefs.[1][3][12] Delusions associated with PPP tend to be less bizarre than those more frequently seen in patients with schizophrenia, and hallucinations, when present, tend to be more visual than auditory (compared to schizophrenia which is often associated with auditory hallucinations).[5] The sensation of being outside one's body or feeling that your surroundings are unreal (i.e., derealization) has also been described in cases of PPP.[1]

Depression, as well as other mood symptoms like mania and irritability, is a relatively common feature of postpartum psychosis.

Additional distinctions in PPP compared to classical schizophrenia include the presence of mood and cognitive symptoms.[1][5] Rapid mood changes or the presence of abnormal moods such as depression or mania (increased energy, decreased need for sleep, etc.) tend to be seen in a large percentage of patients experiencing PPP.[1][3][5] Irritability, anxiety, and general difficulties with sleep may also be present.[5] Confusion or disorientation, disorganized thoughts, incoherent speech, or abrupt changes in a person's mental capacity may also be seen in individuals experiencing PPP,[3][5] though one small study observed these neurological symptoms in only one-quarter of PPP cases.[5][13] Like delirium, these symptoms may come and go in unpredictable patterns.[5]

Thoughts of committing suicide or harming one's infant or children have also been reported as common occurrences in PPP, with as many as half of PPP cases exhibiting these features.[1][5] In many cases where harmful thoughts exist, the person experiencing these thoughts does not consider their intended action to be harmful; rather, they believe that their actions are in the best interest of the child.[3][5]

In addition to the rapid onset of symptoms (less than two weeks) with the presence of a psychotic symptom, further diagnostic criteria defined by the DSM-V for "brief psychotic disorder with peripartum onset" includes that the symptomatic episode concludes within one month and involves a return to the individual's previous functional ability, as well as confidence that the episode is not a different psychiatric illness (e.g., depressive or bipolar disorder with psychotic features) or the result of substance-induced psychosis.[2]

Risk Factors[edit]

Childbirth is the leading cause of PPP, while other causes and risk factors remain largely under investigation.[5]

The largest reported risks for the occurrence of PPP include a prior history of having a postpartum psychotic episode, as well as having a known history of bipolar disorder (whether personally or within one's family history).[5] A significant number of PPP cases, however, represent the first time an individual may experience any psychotic episode in their life;[5][14] therefore, an individual may have no risk factors prior to developing PPP (though some may consider a first-time pregnancy to be the associated risk factor).[1][3][5] A review of pregnancy-related complications demonstrated some association between emergency caesarean sections (C-sections), excess bleeding, uterine rupture, and stillbirth (amongst other complications) and the subsequent development of PPP; however, several of the reviewed studies were contradictory and thus no consensus can confirm the relationship between problems related to pregnancy and PPP.[5][6]

Lifestyle and psychological factors, such as previous trauma or single parenthood, have likewise been inconclusive as factors contributing to PPP,[7] though reports from several of the patients who suffered from PPP suggest a perception that social and pregnancy-related challenges were the cause of the episodes.[7][15]

Pathophysiology[edit]

Currently, the pathophysiology of PPP is not well understood and remains an open field of ongoing research. The leading theories under investigation involve areas of genetics, hormones, immunology, and sleep disturbance processes.[5]

Genetics[edit]

The majority of research devoted to genetic understanding of PPP has evaluated patients who have known bipolar disorder, therefore findings uncovering variation in serotonin transporter genes and signaling or changes at specific chromosomes (e.g., 16p13 or METTL13) are not necessarily precise to PPP generally.[5][10][16][17][18][19]

Hormones[edit]

Despite significant hormone changes that occur around pregnancy and childbirth, there is little evidence supporting hormonal causes behind PPP.[5][10] Changes in corticotropin-releasing hormone (CRH) and adrenocorticotropic hormone (ACTH), as well as rapid changes in estrogen and progesterone, are known occurrences that facilitate various processes associated with delivering a child and are present in both those affected and unaffected by PPP; therefore, the relationship between hormonal change and the onset of psychosis is not well-supported,[5][10] though some researchers continue to explore potential differences in sensitivity to rapid hormone change as it relates to postpartum disorders such as postpartum depression.[20] Estrogen has known impacts on various neurotransmitters (e.g., glutamate, GABA, serotonin and dopamine), including the increase of dopamine synthesis along with its receptors[21]; the predominant theories surrounding psychosis include dysfunction in serotonin and/or dopamine systems,[22] thus strong interest was placed in the association between estrogen changes and PPP onset; however, investigations of estrogen concentrations, dopamine receptor sensitivity, and trials of estrogen replacement following birth currently do not lend support for this theory.[10]

Immune System Alteration[edit]

The theory between immune system changes and associated PPP onset has been largely spurred by higher than average occurrences of PPP in individuals also experiencing immunologic complications, such as anti-N-methyl-D-aspartate (NMDA) receptor encephalitis and autoimmune thyroid disorders,[4][5] as well as the onset of PPP occurring at the same time the body is experiencing higher immune responses (a natural process associated with the period immediately following childbirth).[5][23] There is some evidence connecting PPP with changes to levels of peripheral immune cells (e.g., lymphocytes and NK or natural killer cells) traveling in the bloodstream, but more research is required to identify the specific mechanisms and cell types involved which might be related to PPP onset.[4] No direct evidence has shown a link between cytokine levels and PPP.[4]

Sleep Disturbance[edit]

The link between sleep difficulty and PPP is not strongly supported by current evidence; however, some studies have demonstrated an increased risk for postpartum psychosis in women with bipolar disorder who have had manic episodes triggered by sleep disturbance.[5][24]

Diagnosis and Screening[edit]

Diagnosis[edit]

There are no tests designed to diagnose postpartum psychosis. A complete blood count, pictured above, may be part of the initial work-up to rule out other organic causes of psychotic symptoms.

Not recognized as its own distinct disorder, PPP is instead classified by the DSM-V as a "Brief Psychotic Disorder with peripartum onset."[2][5] Clinical requirements for the diagnosis of a brief psychotic disorder require the presence of at least one of the following psychotic symptoms: delusions, hallucinations, disorganized speech, and/or grossly disorganized or catatonic behavior.[2] Additional requirements include that the psychotic symptom lasts between one day and one month, eventually resulting in the person recovering their previous level of functional ability, and that the symptoms are not better related to a different psychiatric illness (including the result of ingesting substances such as alcohol or drugs).[2] The specifier, "with peripartum onset," requires the development of the above within 4 weeks of delivering a child.

There are no laboratory or imaging tools available to diagnose PPP, though a work-up of different laboratory analyses and imaging of the brain may be conducted to ensure other potential confounding diagnoses (e.g., vascular disorders, infective delirium, etc.) are not the cause of the patient's presentation (see Differential, Other non-organic postpartum psychoses, and Organic postpartum psychoses).[5] These may include, but are not limited to, a complete blood count, comprehensive metabolic panel, urinalysis and urine drug screen, and tests for thyroid functioning; further workup in the setting of classically neurological symptoms (such as delirium-like confusion) may include magnetic resonance imaging (MRI), a test of cerebrospinal fluid (CSF), or electroencephalogram (EEG).[5]

Screening[edit]

Currently, no screening tools exist to evaluate for PPP, though providers may choose to use standard screens for postpartum depression and mania to evaluate the presence of these particular symptoms.[5]

Due to the presence of several symptoms that are classically associated with other postpartum conditions, such as postpartum blues or depression, and often benign changes that accompany new parenthood (anxiety, irritability, poor sleep), recognition of postpartum psychosis may be difficult for providers and family-members to identify[3][5]; thus, it is recommended that providers directly address thoughts of harm for both the patient and child.[1]

Differential[edit]

The presentation of PPP includes a large differential overlapping neurological and psychiatric diseases and syndromes. Neurological, or cognitive, symptoms like disorientation and confusion raise concerns for conditions that organically affect the brain: this may include autoimmune processes resulting in various forms of encephalitis, embolism (and other vascular disorders), and infectious processes.[2][5] Physical causes as a result of chronic hormonal disease (e.g., thyroid diseases, hyperparathyroidism) or complications resulting from childbirth, such as Sheehan's syndrome or other complications resulting from excess blood loss, should also be evaluated.[3][5] Other psychiatric conditions must also be considered: postpartum blues, postpartum depression, anxiety disorders, and postpartum OCD may have many overlapping symptoms with PPP.[5] Finally, psychosis as a result of various substances (including medications such as steroids), should be ruled out.[5] If this is a first-onset episode of psychosis, new-onset bipolar disorder and schizophrenia cannot be ruled out; the diagnosis of these disorders is based on time and recurrence of episodes.[2]

Treatment[edit]

While each case is considered by individual circumstances, generally, PPP is assessed as a psychiatric emergency and requires admission to a psychiatric hospital for close care.[3][5] This admission may be to a mother-baby psychiatric unit or a general adult psychiatric unit, depending upon the availability in one's country and area.[1][5] Because few units, especially in the United States, offer mother-baby services, patients may be discharged home as soon as the worst concerns for the safety of the patient and infant are cleared, even though the patient may still be experiencing some symptoms of PPP; in this way, patients receive care to prevent harm to self and others but return home to care for their child and promote bonding as soon as they are able.[1][5]

Treatment plans are made up of a combination of education, medication, and close follow-up care and support;[1][5] the major goals of care include improving sleep and psychotic symptoms while helping to minimize major shifts in mood, such as depression and mania.[5] Medical treatment typically involves ECT, benzodiazepines, lithium, and/or antipsychotics.[1][3][5]

Electroconvulsive therapy (ECT) is one of the available treatments for postpartum psychosis.

Electroconvulsive Therapy (ECT)[edit]

Beginning in 1938, ECT as a psychiatric treatment has been long-established and well-documented, leading to a large body of literature supporting its effectiveness and safety in various psychiatric conditions, including psychosis.[25][26] Its availability prior to most psychiatric medications has also contributed to its use for postpartum psychosis for over 50 years; however, to date, data has been limited to a significant number of case series and various retrospective matched-cohort studies.[25] Thus, while there is a strong suggestion that ECT is an efficacious treatment for post-partum psychosis, future research is needed to fully validate its role in management.[25] There are few adverse effects associated with ECT, though reports of short-term memory disturbance (< 6 months) have been reported.[26] ECT has been seen as preferable for some who are adverse to the use of long-term psychiatric medications, particularly given the minimal and short-term impact that ECT-related medications (e.g., drugs for muscle relaxation and anesthesia) appear to have on breastfeeding (as compared to psychiatric medications).[25] Per current recommendations, ECT is considered an option for PPP when medications are ineffective.[5]

Lithium[edit]

Lithium is a psychiatric medication commonly classified as a "mood stabilizer" and often used for the treatment of bipolar disorder.[22] For PPP, lithium can be administered as a medication by itself ("monotherapy") or as an additional medication with other psychiatric drugs ("adjunctive therapy").[5] Research has shown strong evidence for its effectiveness as monotherapy in preventing repeat episodes of psychosis, particularly when compared to antipsychotic use alone,[1][5][10] and current recommendations suggest that it is used first in treating PPP for patients who are able to safely[1][3][5] (lithium is not advised for patients with severe kidney or heart disease, thyroid dysfunction, Brugada syndrome, or who have known allergies to the drug).[27] Lithium has been associated with side effects to the fetus when taken during pregnancy, including body and heart abnormalities (e.g., Ebstein's anomaly); these effects have been documented in all trimesters, but higher risks, particularly for structural heart problems and spontaneous abortion, are typically seen with exposure in the first trimester.[27][28]

Lithium is also currently the recommended medication for prevention of psychotic episodes in individuals who have a known history of bipolar disorder and/or previous episodes of PPP.[3][5] The preferred strategy for preventative medication is to begin lithium immediately following delivery of the infant, minimizing the exposure of the fetus to lithium while in the womb.[5] Treatment throughout pregnancy, however, may be warranted as appropriate for treatment of bipolar disorder,[14] and is dosed according to appropriate medical advisory for the patient's trimester.[11] Lithium effectiveness is based on reaching an optimum level in the individual's blood, which usually requires more frequent bloodwork and adjustment of medication dosage to find and maintain an appropriate level.[27] Stopping lithium requires slow and gradual discontinuation; sudden removal of the medication may lead to symptom relapse and suicidal thoughts.[27]

Benzodiazepines[edit]

Benzodiazepines are a class of drug commonly used for anxiety disorders and insomnia, though it also plays a role as an additive medication for psychosis and delirium.[29] According to a small study of 64 women, benzodiazepines had a minor but positive effect in reducing psychosis as a sequentially added medication for treatment of PPP (on top of lithium and antipsychotic medications);[30] with little supportive data, benzodiazepines are currently only recommended as an add-on medication to lithium and/or antipsychotic drugs, usually in the setting of continued sleep disturbance despite the use of the other medications.[3][5]

Olanzapine (Zyprexa), a second-generation antipsychotic medication, is one of this class of drugs that may be prescribed for postpartum psychosis.

Antipsychotic Medications[edit]

Antipsychotic medications are the preferred class of drug used to treat general psychosis, including schizophrenia spectrum disorders.[29] Few studies provide evidence for the efficacy of antipsychotic use in PPP, with the exception of one study of 64 women which examined antipsychotic use as a drug by itself and combined with lithium.[30] In this study, antipsychotic use was effective in both scenarios, but not as effective as lithium used by itself.[30] Despite this limited evidence in PPP specifically, current recommendations include antipsychotic use as an additional medication for patients receiving lithium, or antipsychotic use on its own for those who are unable to tolerate lithium.[5]

Treatment guidance is largely based on recommendations and data from patients with schizophrenia who become pregnant.[31] First-generation antipsychotics have a longer history of use, efficacy and safety in pregnancy, particularly chlorpromazine and haloperidol.[31] Still, second-generation antipsychotics may be preferred over first-generation antipsychotics due to the reduced risk for extrapyramidal symptoms (e.g., uncontrollable movements, tremors or muscle contractions), but given a large number of available medications in this class and their nuanced effects, antipsychotic choice is physician- and case-dependent.[32]

Breastfeeding[edit]

Disruption of continued contact with the infant may occur during hospitalization and treatment, which may impact breastfeeding capacity;[5] hospital units may provide the use of a breast pump to mitigate this concern.[5] Strategies and concerns should also be discussed regarding breastfeeding and its impact on sleep, as poor sleep related to night feedings may worsen or delay patient recovery; alternatives may include social support and bottle-feeding through the night to allow the patient time for adequate rest.[5]

The effects of various medications during breastfeeding are poorly studied.[31] According to one systematic review evaluating 37 different reports of antipsychotic use in 206 infants, olanzapine has the strongest supporting evidence for low infant exposure through breastmilk, while fewer reports support a similarly low exposure for quetiapine and ziprasidone use.[33] Chlorpromazine also demonstrates minimal transference to the infant through breastmilk.[34]

There is currently no consensus to the safety or level of lithium present in breastmilk, though several guidelines and reviews do not consider it an absolute danger to the infant which should exclude its use.[35] Several reports describe safe use of lithium during breastfeeding with no noticeable effects in the infant, though any lasting effects have not been well-studied.[35] As in adults, lithium use with breastfeeding infants requires careful monitoring of the child for serum levels, dose adjustment, and any side effects; thus, the ability to of the patient to maintain follow-up care should also be taken into consideration when lithium may be used.[35]

Short-acting benzodiazepines, like lorazepam, are preferred from this class of drugs as they demonstrate lower levels passed through breastmilk and no reported side effects in infants.[36][37]

Prognosis and Outcomes[edit]

Symptoms may last for a variable length of time (up to one year in 25% of cases) despite adequate treatment.[5] Despite most individuals (50-80%) experiencing a relapse episode and development of chronic psychiatric disorders (such as bipolar spectrum disorder), these same individuals are expected to be able to resume normal activities of their daily life with the same level of function as previously experienced.[5][38] Of the minority of persons who experience PPP and choose to have another pregnancy, evidence has shown that about 33% will have a repeat psychotic episode.[5][14] Other factors that contribute to poorer prognosis include an experience of PPP that's limited to the postpartum period (rather than a diagnosis of bipolar disorder, for example), longer initial psychotic episodes, and a higher severity in the initial episode.[5][14]

Infanticide (or filicide) is thought to occur in 1 to 4% of PPP cases,[1][3][5][39] and some evidence suggests that these incidents are more commonly related to PPP episodes that feature more depressive symptoms.[39]

Epidemiology[edit]

PPP is rare, reported to occur in about 1 to 2 of every 1000 childbirths (0.9 to 2.6 per 1,000).[5][40] Reported cases are thought to underestimate the actual occurrence of PPP due to the probability of some individuals avoiding hospitalized care to avoid separation from their child (particularly in locations with no mother-baby units) or fear of stigma, as well as the likelihood of misdiagnosis with other postpartum disorders.[11] The first month following childbirth is associated with a higher relative risk for hospital admission due to psychosis when compared to other times in an individual's life.[41] While no specific genetic factors have been linked to PPP, a family history or personal history of bipolar disorder has been strongly associated with higher risk for PPP episodes (see Risk Factors).

History[edit]

Postpartum psychosis had been recognized in earlier editions of the DSM (I and II), first as Involutional Psychotic Reaction and later as Psychosis with Childbirth.[42] It was removed in the DSMIII following arguments that psychiatric disorders associated with pregnancy and childbirth were no different than other psychiatric illnesses; it has only been more recently recognized again with the 1994 release of the DSM-IV, when the specifier "with postpartum onset" was included for various diagnoses.[42]


References[edit]

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