Background
Melanie, who delivered a healthy baby a day ago, presents the symptoms of postpartum psychosis. A range of differential diagnoses should be considered, including postpartum psychosis, postpartum depression, obsessive-compulsive disorder, and “baby blues.”
Diagnostic Impressions
- 296.33 (F33-41). Postpartum psychosis. “Mental or behavioral disorders associated with pregnancy, childbirth or the puerperium, with psychotic symptoms” (American Psychiatric Association, 2022). The duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to the premorbid level of functioning.
- 296.33 (F33-41). Postpartum depression (like postpartum psychosis, but without psychotic symptoms). Individuals with brief psychotic disorder typically experience emotional turmoil or overwhelming confusion.
- 265 (F42.2). Obsessive-compulsive disorder. Unspecified (recurring, uncontrollable thoughts and behaviors).
The client reports experiencing the sensation of hearing the radio (specifically, “24 karat magic,” with news reporting her name) and feeling that the radio is hidden in her pillow. Melanie is also presenting with attentiveness and alertness to her baby, irritability to her husband (one episode of throwing a diaper at him), a lack of depressed mood, and coherent speech. Considering Melanie’s symptoms that are presented above, one should emphasize that she lacks depressive thoughts and behaviors. The patient is alert and well-oriented; her pregnancy and delivery were smooth, requiring only routine interventions.
Melanie had no psychosocial factors that could lead to postpartum depression (no drug and alcohol abuse), her weight gain was normal, and she had no anxiety, delusions, or panic attacks. In contrast, the patient presents feeling suspicious and hearing auditory hallucinations, which refer to psychotic disorder symptoms (Hazelgrove et al., 2021). The onset of symptoms was abrupt and within 24-48 hours, which also points to postpartum psychosis, while postpartum depression usually gradually appears within two weeks (Hazelgrove et al., 2021). Bipolar disorder is not characteristic of this patient since she lacks rapid emotional highs and downs.
In addition, “baby blues” should be excluded to identify a proper diagnosis (approximately 80% of women experience “baby blues) (Fairbrother et al., 2021). However, since Melanie denies feeling sadness, concentration problems, and mood changes, it is better to focus on psychotic changes. Obsessive-compulsive disorder is another issue that should be considered since it often presents for the first time during or after pregnancy.
For instance, Fairbrother et al. (2021) report a prevalence of 7.8% during pregnancy and 16.9% in the postpartum period. It is possible to suggest that Melanie’s hallucinations may serve as the onset of obsessive-compulsive disorder, which means that she should be hospitalized for further examination. The preferred way of hospitalization is referring the patient to a psychiatric unit called a mother and baby unit (MBU) to support her breastfeeding.
Required Information
I do feel that it would be helpful for the treating therapist to be aware of any past traumatic experiences of stress. Therefore, I think any issues related to family psychotic diseases or her own episodes should be clarified. It would also be important to ask about any details of her pregnancy, including preeclampsia and family history regarding psychiatric disorders.
Okayasu et al. (2021) report the case of a 24-year-old woman who experienced auditory hallucinations while also having hyperemesis gravidarum (extreme nausea and vomiting). In this connection, it would be useful to ask about the frequency and intensity of these symptoms in Melanie, thus identifying potential dependencies between postpartum psychosis and hyperemesis gravidarum.
Treatment Goals
For Melanie, it is important to develop a range of health care goals. First, it is critical to develop coping strategies to eliminate auditory hallucinations and irritation (Nevid, 2021). Second, there is a need to establish a safety plan to identify any other emerging symptoms, making sure that Melanie, her partner, and family are aware of the disorder and how to approach it.
Third, to reduce the risk of postpartum psychosis for future pregnancies, there will be a need for a perinatal psychiatrist, pre-birth planning meeting, and an agreed care plan (Nevid, 2021). Finally, in some cases, a patient may develop anxiety, depression, and frustration after postpartum psychosis, which requires planning a recovery from postpartum psychosis.
Therapeutic Interventions
Hospitalization is critical to better understand Melanie’s condition and choose proper coping strategies. Furthermore, both the midwife and the mental health nurse should visit her to monitor the improvement of her mental status (Teodorescu et al., 2021). It is vital to make sure that medication is acceptable during breastfeeding, considering that the patient prefers to continue it. Furthermore, antidepressants and mood stabilizers may be considered if the patient’s mental status deteriorates (Teodorescu et al., 2021).
Cognitive behavioral therapy (CBT) seems to be the most appropriate for Melanie as a speaking method that helps better understand the way the patient thinks and behaves, and adjust it (Teodorescu et al., 2021). It is important to note that patients experiencing postpartum psychosis and those who have recovered from it may communicate with each other through inpatient units or charities. For example, the Action on Postpartum Psychosis (APP) provides support for women who have experienced the given disorder. Among their services are a forum, guidelines, and useful materials.
Regarding multicultural considerations, in this case, no cultural or social issues are reported, which makes it essential to learn more about them from the patient. However, multicultural considerations may include messages in the family around psychic disorders, namely, the presence or absence of abuse, shame, neglect, or any other negative features (Nevid, 2021). From a multicultural perspective, it can also be important to take an in-depth history analysis, including important details regarding urban living, migration, ethnic problems, and emotional abuse or discrimination experience.
Additional Considerations
There is currently strong evidence that there is a difference between Postpartum Depression and Depression. These two differences can be characterized by understanding that depression is unrelated to childbirth; however, what often happens to the mother after the birth of the baby is considered postpartum depression (baptishealth.com). However, for some new mothers, severe mood changes that occur around the time of childbirth are classified as a type of major depression.
This means that it needs to be distinguished from a much less common but more severe reaction, called postpartum psychosis. This is a case in which a new mother (Melanie, as the new mother presented in this case study) loses touch with reality and experiences symptoms such as hallucinations, delusions, and irrational thinking. I feel that questions remain about whether to diagnose these reactions as psychotic disorders or as forms of bipolar disorder with psychotic features. I chose the former. However, Melanie did not meet the DSM-5 major depression diagnostic criteria. These symptoms would consist of a change in appetite, losing or gaining weight, sleeping too much or not sleeping well (insomnia), fatigue and low energy most days, feeling worthless, guilty, and hopeless.
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association Publishing.
Fairbrother, N., Collardeau, F., Albert, A. Y., Challacombe, F. L., Thordarson, D. S., Woody, S. R., & Janssen, P. A. (2021). High prevalence and incidence of obsessive-compulsive disorder among women across pregnancy and the postpartum. The Journal of Clinical Psychiatry, 82(2), 1-10.
Hazelgrove, K., Biaggi, A., Waites, F., Fuste, M., Osborne, S., Conroy, S., & Dazzan, P. (2021). Risk factors for postpartum relapse in women at risk of postpartum psychosis: The role of psychosocial stress and the biological stress system. Psychoneuroendocrinology, 128, 1-12.
Nevid, J. S., Rathus, S. A., & Greene, B. (2021). Abnormal psychology in a changing world (11th ed.). Pearson.
Okayasu, H., Yasui‐Furukori, N., & Shimoda, K. (2021). A pregnant woman who experienced auditory hallucinations concurrent with hyperemesis gravidarum: A case report. Neuropsychopharmacology Reports, 41(4), 548-550.
Teodorescu, A., Dima, L., Popa, M. A., Moga, M. A., Bîgiu, N. F., & Ifteni, P. (2021). Antipsychotics in postpartum psychosis. American Journal of Therapeutics, 28(3), 341-348.