postnatal psychosis very serious mental illness dr andrew mayers

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  • Slide 1
  • Postnatal psychosis Very serious mental illness Dr Andrew Mayers
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  • 2 Postnatal psychosis Overview Definitions and diagnosis Prevalence Causes Consequences Treatment
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  • 3 Post-natal psychosis (PNP) PNP needs same DSM-IV diagnosis as any psychotic disorder Schizophrenia and associated disorders Manic stages of bipolar disorder But PNP is specifically diagnosed in perinatal period Usually immediately after birth Or within a few weeks But psychotic episodes can also occur during pregnancy
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  • 4 What is psychosis? Extreme impairment in several areas of functioning Clarity of thought Emotional response Communication Understanding reality Behaviour Illustrated by two key features Hallucinations Delusions Severely interfere with normal life
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  • 5 Schizophrenia DSMIV A (characteristic symptoms) Two or more of following (must be present for a significant portion of time during one-month period): Delusions Hallucinations Disorganised speech Grossly disorganised or catatonic behaviour Negative symptoms Mood, speech and behaviour
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  • 6 Schizophrenia DSMIV B (social/occupational dysfunction) Function must be markedly below what patient normally achieves in key area: Work Interpersonal relations Self-care DSMIV C (duration) Continuous signs of disturbance for at least 6 months DSMIV D to F Exclusion criteria not important for this exercise
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  • 7 Delusions and hallucinations Delusions: firmly held (erroneous) beliefs Distorted reasoning/perception examples External forces control patients thought and behaviour receiving special messages from newspaper headlines The baby is not mine Hallucinations: perceiving sensations not apparent to others But vivid, substantial, and real to the patient Can relate to any of the senses Most commonly auditory and visual PNP mums may hear voices telling her to harm child
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  • 8 Negative symptoms & disorganised behaviour Negative symptoms Affective flattening (reduced range/intensity of emotion) Facial expression, voice tone, eye contact, body language Alogia (poverty of speech) Often illustrated by short, empty replies to questions Avolition (reduction or difficulty with goal-directed behaviour) e.g. staying at home for long periods doing nothing Disorganised behaviour Inability to think clearly and respond appropriately Most commonly associated with irregular speech Talking in sentences that do not make sense Rambling loose associations Can also be related to behaviours (odd movement)
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  • 9 Manic stage of Bipolar Disorder Elevated, expansive, or irritable mood AND 3 from: (4 if mood is irritable) Psychomotor agitation or increased goal-directed behaviour Excessive/rapid talking Flights of ideas and/or racing thoughts Reduced need for sleep Grandiosity or inflated self-esteem Easily distractible Excessive involvement in (negative) pleasurable activities
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  • 10 PNP - features Very serious illness Potential risks for mother and baby Needs quick intervention, usually hospital High risk of suicide and infanticide Delusions may be directed at baby The child is not mine it is evil incarnate must be terminated or he will kill me Also called puerperal psychosis Prevalence 1 in 1000 mums may get post-natal psychosis (0.1%) Contrast with baby blues and PND
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  • 11 PNP - features First signs Can start suddenly a few weeks after birth Mum becomes very restless, or elated, and unable to sleep Becomes confused and disorientated May not recognise friends or family members (or baby) May make bonding with baby difficult May have delusions or hallucinations May misconstrue events May be manic or have wild mood swings Behaviour may become increasingly bizarre May lose touch with reality
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  • 12 PNP - Causes Depletion of oestrogen immediately after birth Hormone abnormalities more likely with PNP than with PND Sleep disruptions (before and after birth) Postpartum psychosis may be related to bipolar disorder Psychotic episodes and mood swings may actually represent first bipolar episodes Especially in new mothers Previous bipolar disorder or schizophrenia is major risk factor Or family history of one of these conditions Previous history of PND or psychosis also a risk factor
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  • 13 Living with postnatal psychosis Watch this clip from BBC2 Newsnight (August, 2012)
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  • 14 Exercise How much more serious is postnatal psychosis than PND? What signs should we look out for? Should mother and baby be separated? What is the impact of stigma? What are the options? What are the consequences of PNP for mother and child?
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  • 15 PNP and the child Serious illness with extremely serious implications for infant Potentially dangerous delusions Paranoid symptoms may cause mum to hide symptoms Attention and cognition also a problem Both of those are important in caring for baby Or care for herself Mum may harm baby She may not be able to focus properly Or act quickly enough May damage bonding and attachment
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  • 16 PNP and the child Other evidence of SMI in mums and effect on children Developmental problems Significantly increased rates of delayed walking Disturbed behaviour Poor social competence Greater risk behaviours Postnatal psychosis (PP) presents dangers to mum and child 70-fold increase in maternal suicide risk Leading cause of maternal death in first year after birth Homicidal behaviour is rare But 28%35% PP mums described delusions about infants Only 9% had thoughts of harming the infant
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  • 17 PNP treatment Often mum needs to be admitted to hospital Sometimes in mother and baby unit in psychiatric ward Probably needs medication Stabilising drugs (e.g. lithium) Antipsychotic drugs: olanzapine, risperidone, or aripiprazole Antidepressants But medication needs to be carefully considered Because of the breastfeeding implications CBT may also be used But usually as add-on to medication Where meds not appropriate, ECT has been successful
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  • 18 Summary Postnatal psychosis very serious Diagnosis of schizophrenia-related illness or manic state Sense of reality severely compromised Also associated with erratic behaviour Problems with attention processes Consequences for mother and baby Mostly of harm to mother Effect on bonding Risk of hospitalisation and/or separation? We should look for signs and risk factors Early intervention crucial