Psychiatric disorder after birth

1. Psychiatric disorder after birth

2. The majority of postpartum onset psychiatric disorders are affective (mood) disorders. However, symptoms other than those due to a disorder of mood are frequently present. Conventionally three postpartum disorders are described: • the ‘blues’ • puerperal (postpartum) psychosis • postnatal depression. • The ‘blues’ is a common dysphoric, self-limiting state, occurring in the first week postpartum

3. Puerperal (postpartum) psychosis • Globally, puerperal psychosis, the most severe form of postpartum affective (mood) disorder has been recognized • to 2 in 1000 women • admitted to a psychiatric hospital following childbirth, mostly in the first few weeks postpartum. • Although a relatively rare condition, there is a marked increase in the risk of suffering from a psychotic illness following childbirth

4. Risk factors • Most women who suffer from this condition will have been previously well, without obvious risk factors, and the illness comes as a shock to them and their families. • some women will have suffered from a similar illness following the birth of a previous child, some may have suffered from a non-postpartum bipolar affective disorder from which they have long recovered or they may have a family history of bipolar illness. • generally accepted that biological factors (neuroendocrine and genetic) are the most important aetiological factors for this condition. This implies that puerperal psychosis can and does strike without warning, women from all social and occupational backgrounds – those in stable marriages with much-wanted babies as well as those living in less fortunate circumstances

6. Clinical features • Puerperal psychosis is an acute, early onset condition. • majority of cases present in the first 14 days postpartum. • They most commonly develop suddenly between day 3 and day 7, at a time when most women will be experiencing the ‘blues’. • Differential diagnosis between the earliest phase of a developing psychosis and the ‘blues’ can be difficult. • puerperal psychosis y deteriorates over the following 48 hours while the ‘blues’ tends to resolve spontaneously. • During the first 2–3 days of a developing puerperal psychosis there is a fluctuating rapidly changing, undifferentiated psychotic state. • The earliest signs are fear – even terror – and restless agitation associated with insomnia. Other signs include: purposeless activity, uncharacteristic behaviour, disinhibition, irritation and fleeting عابر anger, and resistive behaviour and sometimes incontinence. • A woman may have fears for her own and her baby's health and safety, or even about its identity. • variably throughout the day, elation and grandiosity, suspiciousness, depression or unspeakable ideas of horror رعب.

7. the familiar symptoms and signs of a manic or depressive psychosis, symptoms of schizophrenia (delusions and hallucinations) may occur. Depressive delusions about maternal and infant health are common. The behaviour and motives of others are frequently misinterpreted in a delusional fashion • A mood of perplexityحيرة and terror • delusions about the passage of time and other bizarre delusions • Women can believe that they are still pregnant or that more than one child has been born or that the baby is older than it is. • Women seem confused and disorientated • In the very common mixed affective psychosis, along with the familiar pressure of speech and flight of ideas, • a mixture of grandiosity, elation • alternating with states of fearful tearfulness, • guilt and a sense of foreboding. • restless and agitated, resistive, seeking senselesslyعبثا to escape and difficult to reassure. • they are usually calmer in the presence of familiar relatives.

8. unable to attend to her own personal hygiene and nutrition and unable to care for her baby. • concentration is grossly impaired and she is distractible and unable to initiate and complete tasks. • Over the next few days her conditio deteriorates and the symptoms usually become more clearly those of an acute affective psychosis. • Most women will have symptoms and signs suggestive of a depressive psychosis, a significant minority a manic psychosis and very commonly a mixture of both – a mixed affective psychosis.

9. Relationship with the baby • Some women are so disturbed, distractible and their concentration so impaired that they do not seem to be aware of their recently born baby. • Others are preoccupied with the baby, reluctant to let it out of their sight and forever checking on its presence and condition. • Although delusional ideas frequently involve the baby and there may be delusional ideas of infant ill health or changed identity • it is rare for women with puerperal psychosis to be overtly hostile to their baby and for their behaviour to be aggressive or punitive. • The risk to their baby lies more from an inability to organize and complete tasks, and to inappropriate handling and tasks being impaired by their mental state.

11. Management • will require admission to hospital, which should be to a specialist mother and baby unit, • This ensures that the physical and emotional needs of both mother and baby are met and the developing relationship with the baby promoted.

12. Prognosis • resolve relatively quickly over 2–4 weeks. • initial recovery is fragile and relapses are common in the first few weeks. • As the psychosis resolves, it is common for women to pass through a phase of depression and anxiety and preoccupation with their past experiences and the implications of these memories for their future mental health and their role as a mother. • Sensitive and expert help is required to assist women through this phase, to help them understand what has happened and to acquire a ‘working model’ of their illness. • majority of women will have completely recovered by 3–6 months postpartum. However, they face at least a 50% risk of a recurrence should they have another child and some may go on to have bipolar illness

13. Postnatal depressive illness • 10% of all postnatal women will develop a depressive illness. • .. According to the symptomatology, duration and severity, they may be graded as mild to moderate or severe, and subtypes • anxiety and obsessional phenomena. • postnatal depressive illness is popularly accepted, with the exception of the most severe forms, it is no more common than during pregnancy or in non-childbearing women of the same age • The term ‘postnatal depression’ a generic term for all forms of psychiatric disorder presenting following birth • The term postnatal depression should only be used for a non-psychotic depressive illness of mild to moderate severity which arises within 3 months of childbirth.

14. Severe depressive illness • Severe depressive illness affects at least 3% of all women who have given birth, • the majority of women who suffer from this condition will have been previously well. • However, women with a previous history of severe postnatal depressive illness or severe depression at other times or a family history of severe depressive illness or postnatal depression are at increased risk. • Psychosocial factors are more important in the aetiology of this condition than in puerperal psychosis, although biological factors play an important role in the most severe illnesses. • severe postnatal depression can affect women from all backgrounds not just those facing social adversity.

15. severe depressive illness the woman commonly does not regain her normal emotional state following birth. However, • the illness develops over the next 2–4 weeks • . The more severe illnesses tend to present early, by 4–6 weeks postpartum, but the majority present later, between 8 and 12 weeks postpartum.

16. Risk factors • those associated with depressive illness at other times. • To these can be added ambivalence about the pregnancy • high levels of anxiety during pregnancy • adverse birth experiences • previous perinatal death • a family history of severe affective disorder • a family history of severe postnatal depressive illness • developing a depressive illness in the last trimester of pregnancy • loss of the previous infant (including stillbirth). • There may also be an increased risk in those women who have conceived through IVF.

17. Clinical features • The ‘somatic syndrome’ (biological features) of • broken sleep • and early morning wakening, • diurnal variation of mood • , loss of appetite and weight, • slowing of mental functioning • , impaired concentration, • extreme tiredness • and lack of vitality can easily be misattributed to a crying baby, understandable tiredness and the adjustment to new routines. • The all-pervasive anhedonia or loss of pleasure in ordinary everyday tasks, the lack of joy and fearfulness for the future may be misattributed by the woman herself to ‘not loving the baby’ or ‘not being a proper mother’ and all too easily described as ‘bonding problems’ by professionals. • Anhedonia is a particularly painful symptom at a time when most women would expect to feel overwhelmed with joy and happiness and in turn contributes to feelings of guilt, incompetence and unworthiness

18. It is also common to find overvalued morbid beliefs and fears for the woman's own health and mortality and that of her baby. • She may misattribute normal infant behaviour to mean that the baby is suffering or does not like her. • Commonplace problems with establishing breastfeeding may become the subject of morbid rumination. • Some women with severe postnatal depressive illness may be slowed, withdrawn and retreat easily in the face of offers of help, avoid the tasks of motherhood and their relationship with the baby. Others may be agitated, restless.

19. Anxiety and obsessive–compulsive symptoms • (OCD) frequently experience relapses or recurrences postpartum, • severe anxiety, panic attacks and obsessional phenomena are common following birth. • mental health crises, calls for emergency attention and maternal fears for the infant. • Repetitive intrusive, and often deeply repugnantبغيض, thoughts of harm coming to loved ones, particularly the infant, are commonplace, often leading to repetitive doubting and checking. • The woman may doubt that she is safe as a mother and believe that she is capable of harming her infant. • anxiety and panic attacks may result from the baby's crying or being difficult to settle and may lead the mother to be frightened to be alone with her child. This is easily misinterpreted by professionals who may fear that the child is at risk.

21. Obsessional, unable to cope with everyday tasks in marked contrast to premorbid levels of competence. While complex obsessive–compulsive behavioural rituals are relatively rare, obsessive cleaning, housework and checking are common. Intrusive obsessional thoughts and the typical catastrophic cognitions associated with panic attacks frequently lead to a fear of insanity and loss of control.

22. Relationship with the baby • They may find smiling and talking to their babies difficult. Most affected women feel a deep sense of guilt and incompetence and doubt whether they are caring for their infant properly.

23. a fear of harming the baby is commonplace, overt hostility and aggressive behaviour towards the infant is extremely uncommon.

24. Management • early contact with professionals • The use of antidepressants together with good psychological care should result in an improvement of symptoms within 2 weeks and the resolution of the illness between 6 and 8 weeks.

25. Prognosis • With treatment, these women should fully recover. Without, spontaneous resolution may take many months can still be ill when their child is 1 year old.

26. Mild postnatal depressive illness • This is the commonest condition following childbirth, • Risk factors • unsatisfactory marital or other relationships • inadequate social support. • older, educated and married for a long time • problems conceiving • previous obstetric loss • high levels of anxiety during pregnancy. • stressful life events such as moving house, family bereavement, a sick baby

27. Clinical features • tearful, • difficulty coping • complains of irritabilityand a lack of satisfaction and pleasure with motherhood. Symptoms of anxiety, a sense of loneliness and isolation • dissatisfaction with the quality of important relationships • Affected mothers frequently have good days and bad days • difficulty getting to sleep and appetite difficulties, both over-eating and under-eating.

28. Relationship with the baby • Lack of pleasure in the baby, combined with anxiety and irritability marked irritability and even overt hostility towards their baby that the infant is at risk of being harmed.

29. Management • Early detection and treatment is essential for both mother and baby • psychological • social support • active listening from a health visitor

30. Prognosis • improve within weeks and recover by the time the infant is 6 months old. • social adversity, has been demonstrated to have an adverse effect not only on the mother–infant relationship but also on the later social, emotional and cognitive development of the child.

31. Breastfeeding • There is no evidence that breastfeeding increases the risk of developing significant depressive illness, nor that its cessation improves depressive illness. Continuing breastfeeding may protect the infant from the effects of maternal depression and improve maternal self-esteem.

32. Treatment of perinatal psychiatric disorders • The role of the midwife • Midwives need knowledge psychiatric drugs in pregnancy and lactation. This knowledge is required because the women themselves may wish for advice,

33. Midwives should routinely ask all women at antenatal booking clinic whether they have had an episode of serious mental illness in the past and whether they are currently in contact with psychiatric services. • The psychiatric team may not be aware of the pregnant woman who is taking psychiatric medication at the time when the midwife first sees her should be advised not to abruptly stop her medication.

34. Psychological treatments • adjustment need good psychological care. • This can only be based upon an understanding of the normal emotional and cognitive changes and common concerns of pregnancy and the puerperium. • ‘the listening visit’, • Social support