A study done by Kamperman et al. examined the phenotypic characteristics of postpartum psychosis, or more simply said, the way the disease presents. A cohort of 130 women was studied to better understand the presentation of postpartum psychosis symptoms and to try to identify potential subgroups from symptom profiles.
Kamperman and colleagues identified 3 symptom profiles:
The manic profile was characterized by a significant presence of manic symptoms, along with agitation. It also included a low amount of anxiety and depressive symptoms. In the cohort, 44 (34%) women demonstrated having the manic profile.
The depressive profile was characterized by high depressive and anxiety symptoms, and a low prevalence of agitation and manic symptoms. In the cohort, 54 (41%) of women were considered to have the depressive profile. Risk for suicidal or self-injurious behavior was more common amongst those women with a depressive profile
Lastly, the atypical profile included disturbance of consciousness and disorientation (whereas the other profiles did not exhibit this symptomatology). Interestingly, these symptoms were present in all women who fit the atypical profile, and 18% of the women in this profile experienced both symptoms. This profile is also characterized by high levels of anxiety, mania, depression and agitation. In the cohort 32 (25%) women fit the atypical profile.
Kamperman and colleagues found several significant results. In this cohort, depressive and anxiety symptoms were found in the majority of subjects. Key symptom findings include:
Suicidal thoughts were observed in 1 out of 5 patients. The typical melancholic symptomatology did not have high prevalence.
Regarding manic symptomatology, there was a high prevalence of irritability (73% of women).
Irritability was a more common symptom than was elevated mood (39% of women).
Also, 50% of the women in this cohort experienced a decrease in need for sleep as well as an increase in the rate of their speech.
There are several other symptoms that were present in women in this cohort including disorganized behavior (one out four patients), disorientation (20% of women), disturbance of consciousness (10% of women) and catatonic symptoms (5% of women).
Interestingly, 72% of women experienced abnormal thought content, with the most prevalent being persecutory delusions and delusions of reference.
Also, 49% of women presented having auditory hallucinations, and visual hallucinations presented in 1 out of 3 women.
25% of the women experienced pregnancy- and childbirth-associated delusions. These included: 5 women who believed they were pregnant, 6 women who thought that their child was not theirs, and 12 women who believed that their child was already dead, and if not, that they would die.
On the other hand, grandiose or spiritual delusions were rare, with only 3 women experiencing these kinds of abnormal thoughts.
Obsessive thoughts regarding the child were present in 12 women (9%), which mostly consisted of anxiety about hurting the child.
Ten women (8%) experienced infanticidal thoughts, while 4 women had suicidal thoughts.
Kamperman et al. also analyzed demographic characteristics amongst the three profiles and found that there was no significant difference. They did find that there were more women who were identified as having the manic profile who previously had a diagnosis of bipolar disorder before their first pregnancy. The researchers also found that there was no significant difference in treatment outcomes amongst women in the three profiles. However, it is interesting to note that women who were characterized as having a manic profile experienced symptom remission around 4 days earlier after the start of treatment. Also, women who fit the depressive profile received treatment significantly later (~2 weeks) than women who fit the manic or atypical profiles. For women with a depressive profile, the majority of hospitalizations were voluntary, whereas for women with the manic or atypical profiles, hospitalizations were often the result of civil detention.
Strengths and Limitations:
This is the largest cohort study of women diagnosed with postpartum psychosis. This study was able to gather data from women as they were admitted which allowed the researchers to avoid recall bias. However, a limitation of the study was that depressive symptomatology was garnered using self report, which could be influenced by subjective reporting. Also, some symptoms were collected from medical records, which is vulnerable to the quality of reporting by the clinician treating the women, though likely more accurate than self-report alone.
Why are these findings important?
This study confirms the affective nature of postpartum psychosis because of the presence of manic, depressive and other similar symptoms. As previously mentioned, there was a high prevalence of delusions in this cohort. Irritability is an important symptom of postpartum psychosis. Kamperman and colleagues note that disturbance of consciousness and disorientation as some of the most important symptoms of postpartum psychosis. They suggest that this might demonstrate a bias because these symptoms are extraordinary. However, these symptoms were only present in the atypical profile, suggesting that they are much less relevant than they were previously thought to be.
The researchers in this study were able to identify three profiles of postpartum psychosis: manic, depressive and atypical, which may be useful in diagnosis. Interestingly, the results show that the depressive profile was the most prevalent. However, it is often undetected which can have serious consequences in terms of treatment outcomes and can potentially increase the risk of suicidal behaviors. This suggests that clinicians should consider postpartum psychosis when women present with these symptoms, whether or not psychotic symptoms are present yet.
Written by Molly Nadel
Kamperman, A., Veldman-Hoek, M., Wesseloo, R., Robertson Blackmore, E. and Bergink, V. (2017). Phenotypical characteristics of postpartum psychosis: A clinical cohort study. Bipolar Disord, 19(6), pp.450-457.