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. However, women are at risk for developing symptoms for several months after birth. Symptoms may include delusions, hallucinations, disorganized speech (e.g., incoherent speech), or abnormal motor behavior (e.g., catatonia). Other symptoms frequently associated with PPP include confusion, disorganized thought, severe difficulty sleeping, variations of mood disorders (including depression, agitation, mania, or a combination of the above), as well as cognitive features such as consciousness that comes and goes (waxing and waning) or disorientation. Given the variety of symptoms associated with PPP, a thorough consideration of other psychiatric and non-psychiatric (or organic) causes must be ruled out through a combination of diagnostic labwork and imaging, as well as clinical presentation. To document PPP within the DSM-5, the specifier "with perinatal onset" is used alongside a diagnosis such as "brief psychotic disorder" or "bipolar I disorder" if symptoms begin within 4 weeks of delivery. Recent literature suggests that the syndrome occurs in the context of known or new-onset bipolar illness, and some experts have recommended that PPP be classified as a distinct category within the bipolar disorders chapter of the DSM. 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 changes as potential factors contributing to their onset, as well as genetics and circadian rhythm disruption. There is no agreement 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. More recent reviews have added to growing evidence that prior psychiatric diagnoses, especially bipolar disorder, in the individual or their family may raise the risk of a new-onset psychosis triggered by childbirth. 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 presenting symptoms, guided by diagnostic criteria in the DSM-5. Additionally, recent expert debate suggests that PPP may be better understood as a part of the bipolar spectrum triggered by childbirth, rather than solely a brief psychotic disorder specifier. While PPP is seen only in one to two of every 1000 childbirths, the rapid development of psychotic symptoms, particularly those that include delusions of misidentification or paranoia, raises concerns for the safety of the patient and the infant; thus, PPP is considered a psychiatric emergency, usually requiring urgent hospitalization. Treatment may include medications such as benzodiazepines, lithium, and antipsychotics, as well as procedures such as electroconvulsive therapy (ECT). In some cases where pregnant women 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.
Medical literature
Historical reports Between the 16th and 18th centuries, about 50 brief reports regarding postpartum psychosis were published; among them is the observation that these psychoses could recur, and that they occur both in breast-feeding and non-lactating women. In 1797, Osiander, an obstetrician from Tübingen, reported two cases at length that contributed significantly to the knowledge of this disorder during that time. In 1819, Esquirol conducted a survey of cases admitted to the Salpêtrière, and pioneered long-term studies. From that time, puerperal psychosis became widely known to the medical profession. In the next 200 years, over 2,500 theses, articles and books were published. Among these many contributions were Delay's unique investigation using serial curettage and Kendell's record-linkage study comparing 2 years before and 2 years after the birth. In the last few years, two monographs reviewed over 2,400 works, detailing more than 4,000 cases of childbearing psychoses from the literature and a personal series of more than 320 cases. Postpartum psychosis has historically received less research attention compared to other psychiatric disorders, limiting its understanding, treatment, and long-term outcomes.
Modern medical literature Postpartum psychosis was recognized in DSM I and II, first as Involutional Psychotic Reaction and later as Psychosis with Childbirth. It was removed in the DSMIII following arguments that psychiatric disorders associated with pregnancy and childbirth were no different than other psychiatric illnesses. it was recognized again with the 1994 release of the DSM-IV, when the specifier "with postpartum onset" was included for various diagnoses. In DSM-5, the specifier was renamed "with perinatal onset". To document PPP within the DSM-5, "with perinatal onset" is used alongside a diagnosis such as "brief psychotic disorder" or "bipolar I disorder" if onset occurs within four weeks of childbirth. In the ICD-10, postpartum disorders are coded according to the presenting psychiatric disorder alongside a second code to denote puerperium onset, such as F53 if onset occurs within six weeks of childbirth. Because postpartum psychiatric disorders may present outside of these timeframes, the utility of these classifiers is limited.
Signs and symptoms PPP symptoms commonly occur within 2 weeks of birth, although women remain at risk of developing symptoms for several months postpartum. Episodes may last weeks to several months. A hallmark of PPP is rapidly changing presentation; symptoms can wax and wane over the course of hours. These fluctuations often confuse clinicians and family members.
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