The psychosis of childbearing
Written by: Ian Brockington
Psychosis after childbirth was first mentioned by Hippocrates, who reported delirium complicating puerperal sepsis in 8/17 case histories in women (covering the whole of medicine) – a prominence puerperal psychosis has never regained. These psychoses complicate about 1/1,000 births, so that there are about 125,000 cases worldwide each year. They are severe disorders, that even now result in several weeks hospital admission, disrupt families at a critical time, recur and sometimes lead to suicide or filicide. Furthermore, the link to an event precisely located in time offers an unusual opportunity to study the aetiology and pathogenesis of psychoses.
Cambridge University Press are publishing a thorough review of this subject under the title The Psychoses of Childbearing and Menstruation. It reports the author’s experience over the course of 40 years, with a review of more than 2,400 works (90% of the known literature) and more than 4,000 cases, together with a personal series of more than 300 cases, many of which were followed for over 20 years.
This thorough reappraisal has led to a radical revision of the problem that Paffenbarger called ‘the picture puzzle of postpartum psychosis’.
Postpartum psychosis is not one, but a score of distinct disorders. Many are organic (neuropsychiatric) disorders, of which there are at least 15 varieties.
The non-organic forms are also heterogeneous, and only two thirds are bipolar or cycloid (acute polymorphic) disorders.
The case-by-case analysis has led to an improved classification of non-organic forms, for example the division of postpartum episodes into those of early and late onset, and to sharper definitions – almost all early postpartum episodes start between the onset of labour and the 15th day.
It has been known for hundreds of years that these psychoses are recurrent, often affecting subsequent births. The present study, with extensive data on the long-term course, has shown that recurrences of bipolar/cycloid episodes are not limited to the early puerperium; they also occur during pregnancy, after abortion, later in the postpartum period and probably after weaning. ‘Puerperal psychosis’ is merely the most common of a group of childbearing psychoses, with several distinct reproductive triggers, which have the same high recurrence rate (>70%) whatever the onset of the first episode. This profoundly affects the search for the causes of this group of psychoses.
The bipolar/cycloid group have a tendency to relapse, sometimes repeatedly. This offers an excellent opportunity to study the pathogenesis of psychotic episodes.
In the search for causal clues, evidence was found from many sources for the role of menstruation in the triggering of bipolar/cycloid childbearing episodes.