Introduction
Four weeks after childbirth a 20-year old, rather melancholy and anxious by temperament, had a severe fright - she ‘saw’ the ghost of her long-dead mother. Three days later she became confused and started to rave. She was restless, talked day and night (mainly in rhyme), and ate and drank little, but had no fever. The infant was given to a wet-nurse, leaches were applied to her feet, and medicines given to bring on the menses; but her raving increased more and more, and she had to be restrained. It was 2 months before she calmed down. She immediately became pregnant again remained well.
Onsets of postpartum psychosis
Week | Literature | My series | ||||
---|---|---|---|---|---|---|
All cases | Bipolar/cycloids | |||||
Episodes | % fall | Episodes | % fall | Episodes | % fall | |
1 | 610 | 159 | 139 | |||
2 | 405 | 34 | 59 | 63 | 45 | 68 |
3 | 92 | 77 | 11 | 81 | 6 | 87 |
4 | 106 | 6 | 4 | |||
5 | 26 | 11 | 3 | |||
6 | 73 | 10 | 4 | |||
7 | 14 | 4 | 4 | |||
8 | 82 | 5 | 1 |
Month | Literature | My series |
---|---|---|
1 | 1213 | 235 |
2 | 195 | 30 |
3 | 80 | 8 |
4 | 61 | 4 |
5 | 34 | 3 |
6 | 35 | 2 |
7 | 19 | 3 |
8 | 19 | 2 |
9 | 19 | 2 |
10 | 13 | 1 |
11 | 6 | nil |
4–13 week onsets
A labourer’s wife, aged 19, gave birth to her second child in 1834; on day 3 she became manic, and remained ill for 7 months. In 1837 she gave birth for the 3rd time, and breast-fed for 2 months, at which point she became manic for 11 months. In 1839 she gave birth for the 4th time and breast-fed for 1 month, when she became manic for an entire year. In 1841 she had her 5th child, whom she breast-fed for 2½ months; when she weaned the child she became manic for 13 months. In 1844, after her 6th delivery, she failed to lactate, and immediately became manic, lasting 8 months. In 1847 she gave birth to her 7th child, who died on the 8th day; she broke out into mania, less severe but chronic with remissions. In 34 years’ observation, she also had four episodes unrelated to childbearing.
Late postpartum onset
A French woman gave birth to six children. Five months after her 3rd birth she ‘heard’ people walking about in her bedroom - she opened the window and called for a ladder to make her escape. Admitted to hospital, she was in a state of terror with severe hallucinations, including left-sided hallucinations of hissing, barking, mewing and ticking clocks. She soon recovered and was discharged after 18 days. She gave birth again and, after 13 months lactation, developed a similar episode with terrifying auditory, visual, gustatory, olfactory and somatic hallucinations. Most of the time she was mute and stuporose, but she suddenly emerged to fight off a wild boar, and a man who was trying to shove her into a stove. She rapidly recovered and was discharged after 28 days. Three months after the 6th child was born, she had a similar episode that lasted 15 days, and, 1 year later, long after weaning, she had the fourth episode that lasted 3 weeks, followed, 7 months later by a 5th episode with mutism and visual hallucinations of intruders and flames, for 1 day only.A gentle, hard-working, and exemplary Polish housewife had her first mental illness after 4–5 months of lactation. This took the form of confusion with disorientation, stupor and later excitement. She saw the judgment of God, the Virgin Mary and dead people everywhere - everyone had died, including her brothers, one of whom was buried as a woman wearing stockings, covered with a towel; she heard their voices. She gave birth 11 times, and had similar episodes (with similar content) in the lactation phase after the 6th, 9th and 11th births, always with complete recovery.
Weaning onset
A 30-year old was the mother of three infants. Two days after ‘incautiously’ weaning her 4th child, she suffered délire général with religious ideas, and recovered after 4 months. At 39 she gave birth to her 5th child: seven months later, the day after weaning, she developed a rash and délire and imaginary fears; she spent 20 months in the Salpêtrière in a state of hopeless melancholy with religious terrors.
A woman always became mad in the third month of lactation. She had seven or eight children. With each new birth she insisted on breast-feeding her child, and every time, in the third month, her milk was suppressed and mania broke out.
A 26-year old, working as a domestic at the Salpêtrière, breast-fed her 2nd child for 14 months. After an argument with her boss she abruptly weaned the child, and, 3 days later, became overactive, sleepless and incoherent. Admitted to the same hospital, she was excited and overtalkative. Three days later she menstruated for the 1st time since the birth. She recovered and was discharged well after only 8 days.
A 30-year old, while breast-feeding her 3rd child, had a scare that one of her children had been run over by a carriage; although this was not true, she immediately developed a folie, which lasted 2 years. The author did not know whether suppression of her milk came before, after or simultaneously with this event. Five years later, after breast-feeding her next child for a year, she weaned it abruptly and immediately became manic for 4 months. The same happened with the next pregnancy – the psychosis started at the moment of weaning, and lasted 18 months. In the course of 8–9 years she had one other episode unrelated to childbearing.
A 31-year old, whose father probably committed suicide, breast-fed her 1st child for 12 months; her milk had been drying up but the child appeared to initiate the weaning. Immediately afterwards, she developed a manic episode that lasted 6 weeks and was followed by depression lasting 4–5 months. Two years later, within a week of weaning her 2nd child, aged 6 months, she developed another psychosis, with perplexity, insomnia, restlessness, over-activity, over-talkativeness, pressure of speech and flight of ideas. She recovered within 3 weeks.
Discussion
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They are all based on records of episode onset, which is difficult to determine precisely
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Delayed hospitalization, rather than delayed onset, is possible. The fact that there are proportionately more cases in the literature than in my series (and there is No impediment to the admission of late onset cases to British mother-and-baby units) is in line with this explanation.
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Onset in the second month could be due to the development of depressive psychoses later than acute mania; but although depressive psychoses were more frequent in the 4–13 week onset group, they were still a small minority; so most mothers who become ill in this time frame are not suffering from depression, triggered by the birth but slow to develop or reach psychiatric care.
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It is possible that late onset does not reflect the activity of a late trigger, but just the length of the pathogenetic process and late appearance of symptoms, that is, a long tail in the skewed distribution of onsets. But the shape of the distribution in Table 1, which is bimodal in my series, and shows a sharp fall after the second week in all three groups, is against this explanation. It seems unlikely that a trigger that has maximum effect in the first 15 days can incubate a psychosis that erupts a month later.
The first postpartum menses exercises, on the development of puerperal insanity, an influence that Baillarger was the first to notice, and which my observations confirm beyond doubt [my italics]: of 44 mothers who developed puerperal psychosis, and who did not lactate, 11 became ill in the 6th week, precisely at the return of the menses. Sometimes the psychosis preceded the menses by 5–6 days, but it usually began at the onset of bleeding or during menstrual flow. I have also seen it break out when the menses were expected, but failed to appear. Mothers, who breast-feed for some months, become ill after weaning, very often at the moment the menses reappear after a long interval.
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The general proposition that, in pregnancy, antibody titres decrease to protect the foetus, and rebound in the puerperium, with a flaring up of pre-existing auto-immune disorders.
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Evidence that bipolar disorder is associated with immune/inflammatory dysfunction, including auto-immune thyroiditis (Kupka et al. 2002); but a Danish population study involving nearly 1000 cases of bipolar disorder and over 3.5 million births found only one association – pernicious anaemia (Eaton et al. 2010).
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Bergink and her colleagues in Rotterdam found that 6/31 mothers with puerperal psychosis had evidence of auto-immune thyroid disease at 4 weeks, and nine at 9 months postpartum, both being more frequent than 117 controls (p = 0.02). This finding has not yet been replicated by another group.
Eleven weeks after her 3rd child was born, a 29-year old developed insomnia, weight loss and fatigue intolerance. She appeared confused and was disorientated in time and place. She heard Jesus talking to her, and also had visual hallucinations. She believed she was pregnant with the Christ child, and would be killed by hospital staff. She had thyrotoxicosis, associated with thyroiditis. Her psychiatric symptoms improved concurrently with its treatment.