At the center of the high-profile trial of Lindsay Clancy, a Massachusetts mother facing a first-degree murder charge in the deaths of her three children, is a lesser-known perinatal mental health disorder: postpartum psychosis. Clancy’s defense has argued that she should not be held criminally responsible because she was experiencing the condition at the time of their deaths.
Postpartum psychosis is often misunderstood, said Uruj Kamal Haider, medical director of the Massachusetts Child Psychiatry Access Program for Moms and assistant professor of psychiatry, obstetrics and gynecology at UMass Chan Medical School. The symptoms can vary from person to person and may not be readily apparent to the people around them, though they often include hallucinations — hearing voices or seeing things that aren’t there — as well as delusions, confusion and paranoia. For instance, a person may become deluded that harming themselves or their child is what’s best for the greater good.
“This is not a flaw of the character,” Haider said. “This is a medical illness.”
Perhaps contributing to the poor awareness of postpartum psychosis is the fact that it is not included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the reference book of diagnoses for mental health clinicians. Instead, people may be officially diagnosed with a listed condition such as brief psychotic disorder or bipolar disorder with the addition of the words “with peripartum onset.” Many maternal health experts are pushing for postpartum psychosis to be added to the DSM.
Postpartum psychosis is rare, estimated to affect 1 to 2 per 1,000 women after childbirth — which makes it difficult to study. (Postpartum depression, on the other hand, affects 1 in 7 women post-birth.) One major risk factor for postpartum psychosis is a prior diagnosis of bipolar disorder, which raises risk by 20 to 30 percent, Haider said.
But at least half of people with postpartum psychosis have no history of mental illness. Many women “have normal baselines and then have this episode in the context of [triggers] that we think include big hormonal changes and sleep deprivation,” said Sarah Oreck, a reproductive psychiatrist and founder of the maternal mental health platform Mavida Health.
Experts consider it a psychiatric emergency requiring inpatient treatment, meaning hospitalization is often necessary. The onset can be rapid, typically occurring within the first days to two weeks after childbirth (though symptoms can also arise several weeks later).
We asked experts to share the three most common misunderstandings they’ve encountered about postpartum psychosis and what to know about how the condition manifests.
Misconception: People with postpartum psychosis experience a consistent or obvious break from reality.
There’s a dangerous misunderstanding that a person “has to be hallucinating that aliens are stealing her baby or hearing a voice telling her to throw her baby over a bridge to qualify for postpartum psychosis,” Haider said. “But in fact, the condition is a spectrum.” It often starts with quieter symptoms: “pink flags that come before the red flags,” she said.
Initially, patients tend to just feel like something is “off” with them and they’re not themselves, Haider said. The earliest signs include hypervigilance and some degree of confusion, which may be easy to brush off as the effects of new motherhood. It’s also common to experience mood changes before any kind of psychosis sets in. These generally resemble a mix of manic episodes — for instance, “a mother having increased energy on very little sleep,” Haider said — and depressive episodes, which can be intermittent or may not seem especially alarming.
Even when psychotic symptoms emerge, they can wax and wane, Oreck said, “so, sometimes, people can have a functional conversation, and then be swept up into their delusional content or their paranoia” shortly thereafter. Women with the condition generally lack insight into what’s happening, Oreck said, so they may not be able to reliably communicate how they feel if asked.
Those with postpartum psychosis could also be easily agitated or disorganized in their thinking, Oreck added, and some may feel the need to conceal their delusions for fear of being judged — all of which can make it tougher for their loved ones to identify what’s going on too.
Misconception: Postpartum psychosis is the same thing as having intrusive thoughts as a new mother.
The truth is that occasional intrusive thoughts are common and normal in the postpartum phase. “We think they happen because the amygdala, which is the alarm system of the brain, gets bigger during pregnancy,” Oreck said. It’s a natural adaptation designed to ensure you keep your baby safe. She offered an example: If you see a knife, you might have a scary image of hurting your baby. Not because you want to hurt your baby, but because your brain is keenly aware of the safety risk.
A constant flurry of these thoughts can be a feature of anxiety or obsessive compulsive disorder arising in the wake of childbirth — both of which commonly overlap with postpartum depression — but it does not indicate postpartum psychosis because of a clear distinction: how these thoughts make you feel. Intrusive thoughts feel horrifying and reflect something that ultimately these women would never want to do or experience, Oreck said. By contrast, the delusions of postpartum psychosis align with what a person feels is right, because they’ve had a break from reality. “For example, a mother might think that if they don’t harm their child, then that child will kill everyone on the planet,” Oreck explained.
“A lot of times in postpartum psychosis, we see delusions that are altruistic in nature,” Haider said. “The mom may actually believe the world is better off without her baby or that she should hurt the baby in an effort to protect them.”
Misconception: Women with postpartum psychosis pose a long-term threat to their children, families or themselves.
Cases like Clancy’s can make it seem as if postpartum psychosis is an inherently violent condition. In reality, the vast majority of cases do not involve harm, Oreck said. Research suggests untreated postpartum psychosis carries a 4 percent risk of infanticide.
Swift medical intervention, including inpatient care, can also resolve symptoms in 98 percent of women, according to a 2015 study. Almost all women who get the right treatment can fully recover, and most do not go on to deal with future psychotic symptoms, Oreck said.
A typical medication protocol for postpartum psychosis includes a benzodiazepine (to slow down the central nervous system), an antipsychotic and a mood stabilizer like lithium, both Haider and Oreck said. The first two categories of drugs are generally used to address acute agitation and psychotic symptoms and are then tapered off, and lithium is the main maintenance medication that people may stay on for several months or longer.
Electroconvulsive therapy (ECT) — which involves passing a current through the brain under anesthesia — is also an option, Haider said, and may be used in women with the condition who are catatonic (displaying little-to-no reactivity or movement) or having thoughts of suicide, as well as in those who are nursing and want to avoid the risk of passing certain psychiatric medications along to their infant via breast milk.
The key point, Haider said, “is that a lot of these women, with timely and prompt treatment, can go on to have perfectly normal and healthy lives with their families.”
A silver lining of the Clancy trial’s widespread publicity is the opportunity it’s provided for education on postpartum psychosis, Oreck said. If more people are aware, it raises the chance that family and friends will be able to better identify when a new mother needs help.
“The sooner we connect at-risk women to care,” Haider said, “the sooner we can get them the treatment they need and the better the outcomes for society.”
If you or someone you know needs help, the national suicide and crisis lifeline in the U.S. is available by calling or texting 988. If you’re struggling with a perinatal mood or anxiety disorder, contact the Postpartum Support International helpline at 1-800-944-4773.
The post 3 things people get wrong about postpartum psychosis appeared first on Washington Post.
