Postpartum Psychosis: An American Orphan Diagnosis

Every June since adolescence, Lisette became extremely energetic, experienced rapid thoughts and speech, remained awake for nights, and made lots of plans. When her friend called from Paris and said, “I wish you were here,” she flew to Paris that night. Her family (from French Guiana) playfully called her “la fille de soleil,” and her symptoms of mental illness seemed to be lighthearted family anecdotes in this well-educated family. But, after the births of both of her children, she had profound depressions. She remained undiagnosed until she killed her children during an episode of postpartum psychosis.

Postpartum psychosis has been described as a rare disorder occurring with 1–2 of 1000 deliveries. Research has determined that postpartum psychosis is a bipolar episode unless proven otherwise. In fact, one third of women with bipolar disorder will have an episode of postpartum psychosis, a rate that increases to 70% if a first-degree relative experienced an episode.

Nearly 30 years ago, James A. Hamilton, MD, described patterns observed in postpartum psychiatric syndromes. Postpartum psychosis is a complex presentation of cycling mood and unusual psychotic symptoms such as olfactory or tactile hallucinations and delusions of control. In addition, a delirium with a waxing and waning quality presents an intact mental status that alternates with florid psychosis, a clinical picture that may mislead even the most experienced professional.

The diagnosis of psychosis with childbirth was included in the second edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-II) in 1968. The word “postpartum” was stricken from the official psychiatric nomenclature for 14 years, from the DSM-III in 1980 until the 1994 edition, creating a generation of American psychiatrists who disregarded the existence of mental illness associated with childbearing. At the same time, the United Kingdom, Europe, and other countries were making advances in research and clinical care in this field.

Although the field of perinatal psychiatry has made significant progress in the United States in the past 20 years, recent editions of the DSM (DSM-IV and DSM-5) continue to deny a formal diagnostic classification for postpartum illness, suggesting that postpartum psychiatric symptoms do not differ from those of nonpuerperal disorders. Per the DSM-5, a mood episode beginning during pregnancy or within 4 weeks of delivery can have the specifier “with peripartum onset” added to the diagnosis, and “with postpartum onset” can be added to a psychotic episode diagnosis. Yet, the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) provides for a distinct diagnostic classification.

As I noted in a recent commentary, the absence of formal diagnostic criteria for postpartum psychosis flies in the face of biology. It disregards the neurohormonal triggering factors of childbirth. It discounts recent findings such as a dysregulation of the immune system and genetic similarities among women with bipolar disorder who have experienced postpartum psychosis.

Recently, I examined the procedure for inclusion of diagnoses in the DSM-5. The Mood Disorder workgroup had 3 invited subgroups of advisors with expertise in anxiety, suicide, and premenstrual mood disorder. There were no experts in perinatal mood disorders. Perhaps the authors of the DSM should invite perinatal psychiatrists to provide data that support the existence of perinatal illness and the need for a formal diagnostic category in American psychiatry.

Financial disclosure:Dr Spinelli is a consultant for Eli Lilly, Pfizer, and Forest but has no relationships relevant to this blog entry.​​