Introduction
Bromocriptine
A 24-year old was delivered of her 1st child by Caesarean section because of a suspected foetal facial cyst. She was treated with bromocriptine 5 mg/day. She felt excited because the baby was normal. On day 4 she began to behave strangely and became increasingly anxious, overactive, emotionally labile and disinhibited. She was talkative and cheerful, and gave a running commentary on her actions. Admitted to hospital, she was confused and perplexed; she did not know the day of the week. She was unable to think clearly, and spoke little, with slow and deliberate answers. The possibility of a toxic delirium secondary to bromocriptine was raised; it was stopped and she was treated with chlorpromazine. She rapidly recovered, but, a month later, was ‘over the top’ for two days. She remained well in the next 32 years.
Post-operative psychosis
A 25-year old developed a puerperal cycloid episode, with onset day 9, after her 1st birth. She had only two other episodes, both following surgery: after hysterectomy she was briefly hypomanic, and after a double knee replacement she suffered an acute psychosis, with pressure of speech, incoherence, violence and delusions of reference, poisoning and jealousy.
Corticosteroid therapy
A 29-year old became pregnant for the 1st time. Because of foetal distress, she was delivered @ 35 weeks gestation by emergency Caesarean section. She had two doses of dexamethasone at the time of delivery. On day 2 she became sleepless and began writing copious notes. By day 7 she became overactive and aggressive, and said the television and radio referred to her, and her husband was trying to infect her and the baby with AIDS, which he had contracted during an affair. She later had a second episode of postpartum mania, with onset six weeks after the birth.
A 35-year old, after six years of infertility, conceived with gamete intra-fallopian transfer, and became pregnant with twins. At 30 weeks gestation, she was given dexamethasone to increase the maturity of the foetal lungs. A week later she was admitted to the maternity hospital with antepartum bleeding. She became excited, elated and sleepless and expressed persecutory ideas. She was talking constantly, giving a running commentary on everything that was happening. At 32 weeks gestation, she gave birth; one of the twins had Down’s syndrome. Three weeks later her psychosis recurred, with head-banging, restlessness, insomnia and racing thoughts. On admission to hospital she was depressed, and did not recover until five months later. She remained well for the next 20 years.
A 28-year old gave birth to her 1st child. For two weeks she was ‘on a high’, talking non-stop. Six weeks later she developed pityriasis rosea, treated with steroids. She became very high, ‘brilliant’, her mind racing. This lasted a week until she stopped the steroids. She then became depressed for a year. Her baby also became high on steroids.
A 35-year old, who for several years had suffered from poly-arthritis and Crohn’s disease, developed pre-eclamptic toxaemia during her 1st pregnancy, and was delivered by Caesarean section. On day 12 she developed a cycloid psychosis – slow, confused and perplexed – from which she recovered within three weeks. When the baby was four months old, her arthritis recurred. Treated with ibuprofen, she developed a purpuric vasculitis with bullous lesions (Stevens-Johnson syndrome), together with laboratory evidence of systemic lupus erythematosus. She was treated with prednisolone 60 mg/day. Within four days she became withdrawn and mute, staring into the distance. She washed obsessively, complaining of sweating and halitosis. A CAT scan showed diffuse cerebral abnormalities, and an EEG low frequency activity. She was again treated with steroids, and recovered in three months.
A 24-year old, whose mother suffered from puerperal psychosis after her own birth, became pregnant for the 1st time. Two days before the onset of labour she developed a rash, which was treated with prednisone 20 mg/day. After the birth, on day 7, she became weepy, and disorientated, then elated and confused. She felt her brain was exploding. She thought her partner was trying to kill her and believed she was the Messiah. She telephoned a minister to say she had the solution to the Irish problem. She was writing reams of gibberish, which she believed was important to the future of humanity. After recovery she suffered severe bonding problems, which continued after the second baby was born. In 28 years she suffered one further manic episode.
A 28-year old, @ 35 weeks gestation, was treated with prednisolone for idiopathic thrombocytopenia. At 39 weeks she was delivered by forceps, and steroids were discontinued. On day 3 she became agitated, weepy and perplexed, with confusion and ‘paranoid’ ideation. On admission to hospital, prednisolone was started again. She remained retarded, vague, staring into space, suspicious, speaking in a monotonous voice of being evil, hopeless and a failure. She denied the existence of her husband and the baby. She suddenly disrobed and started shouting, “Let me die!” Seven days later she abruptly improved. Two weeks later steroids were stopped, but soon started again because a diagnosis of systemic lupus erythematosus was made. She had no further episode in the course of nine years.
Thyrotoxicosis
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.A 35-year old gave birth to twins. Seven months later she presented with increased energy, lack of the need for sleep, racing thoughts, preoccupation with bible reading, and the belief that God had fathered her babies. She collapsed and was admitted. She had myxoedema due to postpartum thyroiditis. With thyroxin and risperidone she recovered within six days.
First author | Clinical features | Evidence of thyrotoxicosis | Comment |
---|---|---|---|
Johnstone 1884
| Onset of psychosis 6 months after the birth of her third child | Signs of exophthalmic goitre developed concurrently | Late postpartum onset |
Knauer 1897
Case 65 | Onset of a chronic depressive psychosis after her sixth birth | She developed thyrotoxicosis | No data on timing |
Sivadon 1933
Case 15 | Onset of psychosis on day 9 after her first birth | She had an enlarged thyroid and tremor. She also had a fever of 38° | She died on day 22, infection possible |
Schröder 1936
case 38 | She gave birth at 38, and on day 11 developed a psychosis | She had a goitre at the age of 10 and puerperal psychosis at 38; 7 months later, while still psychotic, she was noted to have slight exophthalmos and sweaty hands | Thyrotoxicosis was noticed 7 months later |
Abély et al. 1947
| Onset of psychosis shortly after the second, third, fourth and fifth births | During two episodes, thyroid enlargement was noted. During the fourth episode, tests showed transitory hyperthyroidism, whose disappearance coincided with improvement in the clinical state | Only the fourth episode of postpartum psychosis was affected |
Retzeanu et al. 1960
| Onset of psychosis in the ninth month of gestation | She had a large soft thyroid and tachycardia; she refused surgery on her goitre and was treated with psychotropic drugs and radioactive iodine. Improvement in mental state and reduction in goiter were concurrent | Prepartum psychosis, with a possible response to anti-thyroid treatment. She also had pleurisy and galactorrhoea |
Butts 1968
| Psychosis of unknown onset after first birth, and with onset day 7 after the second | During the second episode, she had an enlarged thyroid, systolic murmur and tremor; but her protein-bound iodine was only 4.4 μg/100 ml and her basal metabolic rate minus 12 % | Only the second episode of postpartum, psychosis was affected. Evidence of thyrotoxicosis was equivocal |
From my series | Onset of depressive psychosis 7 months after the birth | Goitre, loss of weight and tremor during her second pregnancy | Late postpartum onset, response to ECT |
Psychosis on day 5 after both her first and second births | She had a goitre and clinical signs; the diagnosis was confirmed by laboratory tests. Treatment included radioactive iodine | Only the second episode of postpartum, psychosis was affected |