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Is puerperal psychosis bipolar mood disorder?: A phenomenological comparison
Is Puerperal Psychosis Bipolar Mood Disorder?: A Phenomenological Comparison Piet Oosthuizen, Hilda Russouw, and Mimi Roberts The most widely held current view on puerperal psychosis (PP) is that it is a mood disorder; some researchers have even suggested that it may be linked to bipolar mood disorder (BMD). To compare the phenomena of PP and BMD, 20 patients with PP were compared with 20 concurrent age-matched women with BMD, using the Structured Clinical Interview for DSMIII-R (SCID). To exclude patients with possible unipolar disorder, subjects with depression were not consid-
ered for inclusion in the study. A significantly greater proportion of the PP group experienced delusions of control, auditory hallucinations, blunted affect, and emotional turmoil. Seven (35%) of the PP patients fulfilled DSM-III-R criteria for BMD. These results do not support the hypothesis that PP and BMD are the same illness. Further research is necessary to explore the possibility of a link between these two conditions.
HE RISK FOR PSYCHOTIC illness is dramatically elevated in the first few months after childbearing, especially in patients with bipolar mood disorder (BMD). 1 Although the present weight of evidence indicates that puerperal psychosis (PP) is a mood disorder] -4 a few studies have suggested that PP may be a variant of BMD. 1,5 A large study of records obtained over a 12-year period for all Edinburgh women with a psychiatric admission or contact in the postpartum period revealed that most patients met Research Diagnostic Criteria (RDC) for a manic or depressive disorder. The risk of psychiatric illness in the puerperium was higher in women with a history of manic depressive illness than in those with a history of schizophrenia. The investigators conclude that, "Probably... puerperal psychoses are manic depressive illnesses and unrelated to schizophrenia." Brockington et al? found PP patients to be more likely to have affective symptoms or diagnoses than a non-PP control group and suggested that, "While there is no case for placing postpartum psychosis within the group of schizophrenias.., there is a case for including them with the manic-depressive group." They proposed that detailed clinical comparisons of PP and BMD should be performed to establish the differences, if any, between these two disorders. To our knowledge, no studies have attempted to compare nondepressed patients with PP and BMD on clinical grounds. We have attempted to test the hypothesis that PP is the same as BMD in a sample of South African patients by comparing a group of nondepressed patients with PP and a nonpuerperal group with BMD (manic phase) in terms of selected symptoms on
the Structured Clinical Interview for DSMIII-R (SCID-P). 6
T
ComprehensivePsychiatry, Vol. 36, No.
Copyright © 1995 by W.B. Saunders Company
METHOD The study sample consisted of 20 patients from the Western Cape region of Cape Town who had presented at one of three psychiatric inpatient units with psychotic symptoms originating within 90 days after delivery. 1.7Sample sizes were calculated before the start of the study and were based on binomial proportions from samples of equal size, with a type I error probability of 0.05 and a type II error probability of 0.20. The null hypothesis was that the proportion of nondepressed PP patients fulfilling DSM-III-R criteria for BMD would be equal to that of a group of patients diagnosed as BMD. The hypothesized proportion under the null hypothesis was 95%, to allow for some observer error in making a diagnosis. We decided to reject the null hypothesis if the proportion of PP patients fulfilling DSM-III-R criteria was less than 60%. Doctors in charge of the admission wards of the three units were aware of the study and were reminded of it at least once a week by the two principal investigators (P.O., H.R.), ensuring (as far as possible) that a consecutive series of postpartum admissions was selected. When a suitable patient was identified, either P.O. or H.R. was contacted. Delirious patients and (to exclude patients with unipolar mood disorder) those with persistent dysphoric mood were not considered for inclusion in the study. They were compared with an age-matched concurrent control group of 20 women diagnosed as manic by the ward doctor. Either P.O. or H.R. presented the subject to the other investigator, who was unaware of the patient's history and diagnosis. This second investigator examined the patient's mental state using a structured interview consisting of questions and criteria for "Current Manic Syndrome" and "Psychotic and Associated Symptoms" from the SCID-P and also rated the patient's orientation, concentration, and
From the Department of Psychiatry, Tygerberg Hospital, Stellenbosch University, Tygerberg, South Africa. Address reprint requests to Piet Oosthuizen, M.B., Ch.B., Department of Psychiatry, University of Stellenbosch, PO Box 19063, Tygerberg 7505, South Africa. Copyright © 1995 by W.B. Saunders Company 0010-440X/95/3601-0006503. 00/0
1 (January/February), 1995: pp 77-81
77
78
OOSTHUIZEN, RUSSOUW, AND ROBERTS
level of consciousness. All symptoms from the SCID-P were rated on a five-point scale of severity (0 to 4). The first investigator, who had identified the patient, collected demographic, medical, past psychiatric, and family history data on each patient from case notes and from the patient herself. After all interviews had been completed, P.O., blinded to all data except for the SCID-P questions, assessed whether each patient fulfilled DSM-III-R criteria for BMD. Interrater reliability for each SCID-P item was tested on a separate group of psychotic patients, using the K for dichotomous nominal data. The statistical significance of differences between groups was determined using an uncorrected chi-square test or Fisher's Exact Test (categorical data) and the Mann-Whitney U test (numeric data). The Spearman rank-order correlation coefficient was used to test the significance of correlations between ordinal or numeric variables.
RESULTS
Twenty-two patients were interviewed by P.O. (10 PP, 12 BMD) and 18 by H.R. (10 PP, eight BMD). The difference in age between the study sample of PP patients (median, 28.5; range, 16 to 36 years) and BMD (manic phase) patients (median, 30.5; range, 17 to 44 years) was not significant. Nine (45%) PP and eight (40%) BMD subjects were married. Except for one white subject in the BMD group, all patients were black.
Obstetric History A detailed obstetric history was obtained only in the PP group. Six of the 20 pregnancies had been planned, but 14 mothers accepted or wanted the baby. Eight of the babies were boys, nine were girls, and three were of unknown gender because this information could not be obtained from the patients or their records. Twelve patients were breast-feeding at the time of presentation. Complications of pregnancy and delivery included antepartum hemorrhage (1), hypertension (4), postpartum hemorrhage (2), prolonged labor (1), perineal laceration (3), sepsis (1), cesarean section (2), and perinatal death (4). In all, six patients (30%) had experienced complications of delivery. Cesarean section and perinatal death rates were not significantly different from those for the Tygerberg Hospital maternity unit in 1992 (chi-square goodness-of-fit test).
Psychiatric History Table 1 compares the groups by psychiatric history and Table 2 by family history of psychiatric illness. A significantly greater proportion of
Table 1. Previous Psychiatric History in the Two Groups
Previous psychiatric history Psychotic episode History of BMD History of schizophrenia PP Premenstrual tension Unipolar depression
PP (n = 19)*
BMD (n = 20)
13 (68) 13 (68) 3 (16) 7 (37) 1 (5) 5 (26) 0 (0)
17 (85) 16 (80) 17 (85)1 0 (0):1: 3 (15) 2 (10) 1 (5)
NOTE. Results are presented as n (%). *An adequate past psychiatric history could be obtained in only 19 patients in this group. tP < .0001. $P < .005 (Fisher's Exact Test).
BMD patients had a previous psychiatric diagnosis of BMD. The PP group had a significantly greater proportion of patients with a history of treatment for schizophrenia. Family histories of psychiatric disturbance did not differ significantly.
Psychiatric Mental State Differences between the groups by selected DSM-III-R criteria found in the SCID-P are tabulated in Table 3 (mood syndromes-current manic state) and Table 4 (psychotic and associated symptoms). Interrater agreement exceeded that predicted by chance alone for each of the 28 items in the mental state examination questionnaire (P < .05). The following criteria occurred significantly more often in the BMD group than in the PP group: elevated, expansive, or irritable mood; inflated self-esteem or grandiosity; decreased need for sleep; pressure of speech; flight of ideas; increase in psychomotor activity or agitation; excessive involvement in pleasurable activities; and grandiose delusions. Table 2. Family History of Psychiatric Illness in the Two Groups
Psychiatric treatment History of psychosis BMD Schizophrenia PP Unipolar depression Anxiety disorder
PP (n = 19)*
BMD (n = 19)*
7 (37) 3 (16) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
10 (53) 8 (42) 3 (16) 0 (0) 1 (5) 0 (0) 0 (0)
NOTE. Differences were not statistically significant. Results are presented as n (%). *A family history could be obtained from only 19 patients in each group.
PUERPERAL PSYCHOSIS
79
Table 3. Number of Patients in Each Group Fulfilling Selected Criteria From SCID-P Part A: Mood Syndromes-Current Manic State PP Abnormally and persistently elevated, expan10/18 (56) sive, or irritable mood Inflated self-esteem or 8/19 (42) grandiosity 7/18 (39) Decreased need for sleep 9/19 (47) Pressure of speech 9/19 (47) Flight of ideas* 13/19 (68) Distractibility* Increased psychomotor 6/15 (40) activity* Excessive involvement in 3/'12 (25) pleasurable activities* Disorder sufficiently severe to cause marked impairment in occupational, social, or interpersonal functioning or to necessitate hospital19/19 (100) ization~:
BMD
P
20/20 (100)
<.001
19/20 18/19 19/20 18/20 18/20
< .0005 <.0005 <.005 < .005 NS'I"
(95) (95) (95) (90) (90)
17/19 (89)
<.005
10/13 (77)
<.05
Time of Onset of Symptoms After Delivery in the PP Group The time from delivery to hospital admission was used as an approximate indicator of onset of symptoms after delivery. The median time to admission was 22 days. PP patients fulfilling DSM-III-R criteria for BMD tended to be admitted later (median, 49 days; range, 13 to 76 days) than those not fulfilling these criteria (median, 16.5 days; range, 6 to 51 days; P = .06). "Persecutory delusions" was the only SCID-P item in which the severity of the symptom correlated near-significantly with time since delivery (rs = -.44, n = 19, P = .072). DISCUSSION
The results of this study indicate a clear phenomenological difference between nonde20/20 (100)
NS'I"
NOTE. The numerator signifies the number of patients fulfilling the criteria. The denominator signifies the number in which an adequate assessment of the presence or absence of the criterium could be made. The percentage is enclosed in parentheses. %< = .45 to .75 (moderate agreement). In all other cases, K > .75 (excellent agreement). I"P > .05. :[:The SCID-P contains the words "mood disturbance," but for the purpose of this study this item was regarded as referring to the psychiatric disorder.
Criteria occurring more frequently in the PP group were delusions of control, auditory hallucinations, blunted affect, and emotional turmoil. Emotional tumoil was reported in 10 (50%) of PP cases, and in seven of these the patient was thought to be perplexed. Only one case of perplexity was reported in the BMD group. The groups did not differ significantly regarding clouding of consciousness (none in either group), disorientation (four PP, one BMD), and poor concentration (six PP, four BMD).
Diagnosis According to DSM-III-R Nineteen of the 20 BMD patients (95%) were regarded as meeting DSM-III-R criteria for BMD by the blinded interviewer, whereas only seven (35%) of the PP patients were thought to fulfill these criteria (×2= 15.8, dr= 1, P = .0003).
Table 4. Number of Patients in Each Group Fulfilling Selected Criteria From SCID-P Part B: Psychotic and Associated Symptoms PP Delusions of reference* Persecutory delusions Grandiose delusions Somatic delusion Other delusions, e.g., nihilism Delusion of being controlled* Thought broadcasting* Systematized delusions Bizarre delusions* Auditory hallucinations Visual hallucinations Tactile hallucinations* Other hallucinations, e.g., olfactory* Marked motor anomalies Flat affect Grossly inappropriate affect Incoherence Marked loosening of associations1" Emotional turmoil (rapid shifts from one intense affect to another, or overwhelming perplexity or confusion)
6/18 9/18 8/18 3/18 0/18 7/18 7/18 0/18 4/18 11/19 3/19 1/19
BMD
P
(33) 6/20 (30) NS (50) 14/20 (70) NS (44) 18/19 (95) <.001 (17) 3/20 (15) NS (0) (39) (39) (0) (22) (58) (16) (5)
2/20 1/20 4/20 2/20 2/20 5/20 1/20 2/20
(10) NS (5) < .05 (20) NS (10) NS (10) NS (25) <.05 (5) NS (10) NS
1/18 (6) 2/20 (10) NS 13/19(68) 10/19(53) NS 15/20 (75) 4/20 (20) <.001 7/19 (37) 5/20 (25) NS 13/19 (68) 9/20 (45) NS 10/19 (53)
7/20 (14)
NS
10/19 (53)
4/20 (20) <.05
NOTE. The numerator signifies the number of patients fulfilling the criteria. The denominator signifies the number in which an adequate assessment of the presence or absence of the criterium could be made. The percentage is enclosed in parentheses. NS indicatesP > .05. *K = .45 to .75 (moderate agreement). I"K < .45 (poor agreement). In all other cases, K > .75 (excellent agreement).
80
pressed patients with PP and patients with BMD (manic phase). A significantly greater proportion of the PP group experienced delusions of control, auditory hallucinations, blunted affect, and emotional turmoil. If PP is the same as BMD, one would expect the proportion of nondepressed PP patients fulfilling DSM-III-R criteria for BMD to be equal to that of a group of patients diagnosed as BMD. We rejected this hypothesis, since the proportion of PP subjects who fulfilled these criteria was significantly lower (35%) than the proportion of BMD patients fulfilling these criteria (95%). The PP group also had significantlymore subjects with a history of schizophrenia and fewer with a previous psychiatric history of BMD than the BMD group. A few studies have suggested that PP may have unique distinguishing features. Platz and Kendell2 found perplexity to be the only symptom that might indicate that PP is a unique entity. In our study, emotional turmoil was significantly more common in the PP group. Perplexity, which was one of the symptoms included under the item "emotional turmoil," was more common in the PP group (35%) than in the BMD group (5%), but differences were not statistically significant. Kadrmas et al. s found that Schneiderian symptoms were more common in patients with bipolar disorder occurring in the puerperium than in nonpuerperal patients with BMD. Although we did not perform a full evaluation of criteria for schizophrenia, symptoms suggestive of this disorder (delusions of control, blunted affect, and auditory hallucinations) were more common in the PP group than in the BMD group. Dean and Kendell9 and Agrawal et al. 1° found depressed PP patients to be more hallucinatory, deluded, and labile than a nonpuerperal control group matched for RDC diagnosis, and a number of studies have shown that confusion and disorientation may be a distinguishing feature of pp.s.9-N None of our subjects had clouding of consciousness, and this may have been due to the fact that delirious patients were specifically excluded. However, there was, a tendency for more PP subjects to be disoriented (20% v 5%), but this difference was not statistically significant. Various explanations may be proposed for the differences between our findings and those
OOSTHUIZEN, RUSSOUW, AND ROBERTS
of the two studies 1,5 in which it was suggested that PP is linked to BMD. We applied DSMIII-R criteria rather than the more commonly used RDC classification. Klompenhouwer and van Hulst 11 have shown that a patient with PP may receive different diagnoses, depending on the classification scheme used. Sixty-eight percent of their PP patients had either unspecified functional psychosis or schizoaffective disorder. If DSM-III-R criteria had been used, only 28% of their psychotic patients would have been classified as having mood disorders. Agrawal et al., 10 in a study in India, found unspecified functional psychosis (RDC) to be the most common diagnosis in patients with PP. If these patients had received International Classification of Diseases (ninth edition) diagnoses, the majority would have been in the category of schizophrenia. Since our puerperal patients were exclusively black, cultural differences may also have accounted for the findings. The study by Brockington et al. 5 examined patients presenting within the first 2 weeks after childbirth. There is evidence that these patients are more likely to have manic or schizoaffective manic disorders than those presenting after this initial period. 9 Our reasons for using the 90-day rather than the stricter 2-week cutoff were twofold: First, Kendell et al. 1 found that although the first 30 days showed the highest risk for psychiatric admission, the admission rate is higher between 30 and 90 days than at any time after that. Second, patients with important findings may be excluded if only those presenting within 2 weeks after childbirth are selected, since some subjects whose symptoms may have started soon after delivery may only be admitted to the hospital after this initial period. In our study, PP patients fulfilling DSM-III-R criteria for BMD tended to be admitted later after delivery than those not fulfilling these criteria, and the severity of persecutory delusions showed a near-significant inverse relationship with the time since delivery. This may reflect the urgency with which paranoid puerperal patients are likely to be hospitalized. However, because of the small sample size and the fact that the date of admission was used merely as an approximate indicator of onset, these results should be interpreted with caution. Klompenouwer and van Hulst, 11in a large study of puerperal psychi-
PUERPERAL PSYCHOSIS
81
atric admissions, did not find an association between any one category of psychiatric disorders and onset of symptoms in the first 2 weeks. Apart from the small sample size, this study has a few important limitations. It was largely a cross-sectional study based on current symptomatology; we did not perform further follow-up evaluations for research purposes or evaluate family members for current or past psychopathology,z Since neither group was randomly drawn from a defined population but instead consisted of consecutive admissions to state institutions, they may have been unrepresentative of the total population of nondepressed PP and BMD patients. Those admitted to private institutions may have differed in their presentation, and the results can therefore at most be generalized only to patients typically admitted to state-owned hospitals. Nott 7 has pointed out the problem of finding a suitable control group in studies of psychiatric illness in the puerperium, and notes that, "any suggested control
group is likely to differ systematically from a postpartum group in numerous ways." The use of hospitalized control groups may lead to "admission rate" bias, ~2 which may result in misleading conclusions if patients are either more or less likely to be hospitalized for specific symptoms than controls. On the basis of clinical presentation alone, our findings do not support a hypothesis that PP and BMD are the same condition. However, since patients with BMD have been shown to be at special risk for developing PP,~ studies examining differences between puerperal and nonpuerperal cases of BMD in terms of family history, patterns of relapse, and biological variables t3 may shed more light on the possibility of a link between these disorders.
ACKNOWLEDGMENT
We are grateful to Professors R. Emsley and S. Shapiro for their helpful comments.
REFERENCES
1. Kendell RE, Chalmers JC, Platz C. Epidemiology of puerperal psychoses. Br J Psychiatry 1987;150:662-673. 2. Platz C, Kendell RE. A matched-control follow-up and family study of "puerperal psychoses." Br J Psychiatry 1988;153:90-94. 3. Rehman AU, St Clair D, Platz C. Puerperal insanity in the 19th and 20th centuries. Br J Psychiatry 1990;156:861865. 4. Stewart DE, Klompenhouwer JL, Kendell RE, Van Hulst AM. Prophylactic lithium in puerperal psychosis: the experience of three centres. Br J Psychiatry 1991;158:393397. 5. Brockington IF, Cernik KF, Schofield EM, Downing AR, Francis AF, Keelan C. Puerperal psychosis: phenomena and diagnosis. Arch Gen Psychiatry 1981;38:829-833. 6. Spitzer R, Williams JB, Gibbon M, First MB. Structured Clinical Interview for DSM-III-R-Patient Edition (SCID-P). New York, NY: Biometrics Research Department, New York State Psychiatric Institute, 1989.
7. Nott PN. Extent, timing and persistence of emotional disorders following childbirth. Br J Psychiatry 1987;151:523527. 8. Kadrmas A, Winokur G, Crowe R. Postpartum mania. Br J Psychiatry 1979;135:551-554. 9. Dean C, Kendell RE. The symptomatology of puerperal illnesses. Br J Psychiatry 1981;139:128-133. i0. Agrawal P, Bhatia MS, Malik SC. Postpartum psychosis: a study of indoor cases in a general hospital psychiatric clinic. Acta Psychiatr Scand 1990;81:571-575. 11. Klompenhouwer JL, van Hulst AM. Classification of postpartum psychosis: a study of 250 mother and baby admissions in The Netherlands. Acta Psychiatr Scand 1991; 84:255-261. 12. Dawson-Saunders B, Trapp RG. Basic and Clinical Biostatistics. Norwalk, CT: Appleton & Lange, 1990:266. 13. McGorry P, Connell S. The nosology of puerperal psychosis: a review. Compr Psychiatry 1990;31:519-533.
ered for inclusion in the study. A significantly greater proportion of the PP group experienced delusions of control, auditory hallucinations, blunted affect, and emotional turmoil. Seven (35%) of the PP patients fulfilled DSM-III-R criteria for BMD. These results do not support the hypothesis that PP and BMD are the same illness. Further research is necessary to explore the possibility of a link between these two conditions.
HE RISK FOR PSYCHOTIC illness is dramatically elevated in the first few months after childbearing, especially in patients with bipolar mood disorder (BMD). 1 Although the present weight of evidence indicates that puerperal psychosis (PP) is a mood disorder] -4 a few studies have suggested that PP may be a variant of BMD. 1,5 A large study of records obtained over a 12-year period for all Edinburgh women with a psychiatric admission or contact in the postpartum period revealed that most patients met Research Diagnostic Criteria (RDC) for a manic or depressive disorder. The risk of psychiatric illness in the puerperium was higher in women with a history of manic depressive illness than in those with a history of schizophrenia. The investigators conclude that, "Probably... puerperal psychoses are manic depressive illnesses and unrelated to schizophrenia." Brockington et al? found PP patients to be more likely to have affective symptoms or diagnoses than a non-PP control group and suggested that, "While there is no case for placing postpartum psychosis within the group of schizophrenias.., there is a case for including them with the manic-depressive group." They proposed that detailed clinical comparisons of PP and BMD should be performed to establish the differences, if any, between these two disorders. To our knowledge, no studies have attempted to compare nondepressed patients with PP and BMD on clinical grounds. We have attempted to test the hypothesis that PP is the same as BMD in a sample of South African patients by comparing a group of nondepressed patients with PP and a nonpuerperal group with BMD (manic phase) in terms of selected symptoms on
the Structured Clinical Interview for DSMIII-R (SCID-P). 6
T
ComprehensivePsychiatry, Vol. 36, No.
Copyright © 1995 by W.B. Saunders Company
METHOD The study sample consisted of 20 patients from the Western Cape region of Cape Town who had presented at one of three psychiatric inpatient units with psychotic symptoms originating within 90 days after delivery. 1.7Sample sizes were calculated before the start of the study and were based on binomial proportions from samples of equal size, with a type I error probability of 0.05 and a type II error probability of 0.20. The null hypothesis was that the proportion of nondepressed PP patients fulfilling DSM-III-R criteria for BMD would be equal to that of a group of patients diagnosed as BMD. The hypothesized proportion under the null hypothesis was 95%, to allow for some observer error in making a diagnosis. We decided to reject the null hypothesis if the proportion of PP patients fulfilling DSM-III-R criteria was less than 60%. Doctors in charge of the admission wards of the three units were aware of the study and were reminded of it at least once a week by the two principal investigators (P.O., H.R.), ensuring (as far as possible) that a consecutive series of postpartum admissions was selected. When a suitable patient was identified, either P.O. or H.R. was contacted. Delirious patients and (to exclude patients with unipolar mood disorder) those with persistent dysphoric mood were not considered for inclusion in the study. They were compared with an age-matched concurrent control group of 20 women diagnosed as manic by the ward doctor. Either P.O. or H.R. presented the subject to the other investigator, who was unaware of the patient's history and diagnosis. This second investigator examined the patient's mental state using a structured interview consisting of questions and criteria for "Current Manic Syndrome" and "Psychotic and Associated Symptoms" from the SCID-P and also rated the patient's orientation, concentration, and
From the Department of Psychiatry, Tygerberg Hospital, Stellenbosch University, Tygerberg, South Africa. Address reprint requests to Piet Oosthuizen, M.B., Ch.B., Department of Psychiatry, University of Stellenbosch, PO Box 19063, Tygerberg 7505, South Africa. Copyright © 1995 by W.B. Saunders Company 0010-440X/95/3601-0006503. 00/0
1 (January/February), 1995: pp 77-81
77
78
OOSTHUIZEN, RUSSOUW, AND ROBERTS
level of consciousness. All symptoms from the SCID-P were rated on a five-point scale of severity (0 to 4). The first investigator, who had identified the patient, collected demographic, medical, past psychiatric, and family history data on each patient from case notes and from the patient herself. After all interviews had been completed, P.O., blinded to all data except for the SCID-P questions, assessed whether each patient fulfilled DSM-III-R criteria for BMD. Interrater reliability for each SCID-P item was tested on a separate group of psychotic patients, using the K for dichotomous nominal data. The statistical significance of differences between groups was determined using an uncorrected chi-square test or Fisher's Exact Test (categorical data) and the Mann-Whitney U test (numeric data). The Spearman rank-order correlation coefficient was used to test the significance of correlations between ordinal or numeric variables.
RESULTS
Twenty-two patients were interviewed by P.O. (10 PP, 12 BMD) and 18 by H.R. (10 PP, eight BMD). The difference in age between the study sample of PP patients (median, 28.5; range, 16 to 36 years) and BMD (manic phase) patients (median, 30.5; range, 17 to 44 years) was not significant. Nine (45%) PP and eight (40%) BMD subjects were married. Except for one white subject in the BMD group, all patients were black.
Obstetric History A detailed obstetric history was obtained only in the PP group. Six of the 20 pregnancies had been planned, but 14 mothers accepted or wanted the baby. Eight of the babies were boys, nine were girls, and three were of unknown gender because this information could not be obtained from the patients or their records. Twelve patients were breast-feeding at the time of presentation. Complications of pregnancy and delivery included antepartum hemorrhage (1), hypertension (4), postpartum hemorrhage (2), prolonged labor (1), perineal laceration (3), sepsis (1), cesarean section (2), and perinatal death (4). In all, six patients (30%) had experienced complications of delivery. Cesarean section and perinatal death rates were not significantly different from those for the Tygerberg Hospital maternity unit in 1992 (chi-square goodness-of-fit test).
Psychiatric History Table 1 compares the groups by psychiatric history and Table 2 by family history of psychiatric illness. A significantly greater proportion of
Table 1. Previous Psychiatric History in the Two Groups
Previous psychiatric history Psychotic episode History of BMD History of schizophrenia PP Premenstrual tension Unipolar depression
PP (n = 19)*
BMD (n = 20)
13 (68) 13 (68) 3 (16) 7 (37) 1 (5) 5 (26) 0 (0)
17 (85) 16 (80) 17 (85)1 0 (0):1: 3 (15) 2 (10) 1 (5)
NOTE. Results are presented as n (%). *An adequate past psychiatric history could be obtained in only 19 patients in this group. tP < .0001. $P < .005 (Fisher's Exact Test).
BMD patients had a previous psychiatric diagnosis of BMD. The PP group had a significantly greater proportion of patients with a history of treatment for schizophrenia. Family histories of psychiatric disturbance did not differ significantly.
Psychiatric Mental State Differences between the groups by selected DSM-III-R criteria found in the SCID-P are tabulated in Table 3 (mood syndromes-current manic state) and Table 4 (psychotic and associated symptoms). Interrater agreement exceeded that predicted by chance alone for each of the 28 items in the mental state examination questionnaire (P < .05). The following criteria occurred significantly more often in the BMD group than in the PP group: elevated, expansive, or irritable mood; inflated self-esteem or grandiosity; decreased need for sleep; pressure of speech; flight of ideas; increase in psychomotor activity or agitation; excessive involvement in pleasurable activities; and grandiose delusions. Table 2. Family History of Psychiatric Illness in the Two Groups
Psychiatric treatment History of psychosis BMD Schizophrenia PP Unipolar depression Anxiety disorder
PP (n = 19)*
BMD (n = 19)*
7 (37) 3 (16) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
10 (53) 8 (42) 3 (16) 0 (0) 1 (5) 0 (0) 0 (0)
NOTE. Differences were not statistically significant. Results are presented as n (%). *A family history could be obtained from only 19 patients in each group.
PUERPERAL PSYCHOSIS
79
Table 3. Number of Patients in Each Group Fulfilling Selected Criteria From SCID-P Part A: Mood Syndromes-Current Manic State PP Abnormally and persistently elevated, expan10/18 (56) sive, or irritable mood Inflated self-esteem or 8/19 (42) grandiosity 7/18 (39) Decreased need for sleep 9/19 (47) Pressure of speech 9/19 (47) Flight of ideas* 13/19 (68) Distractibility* Increased psychomotor 6/15 (40) activity* Excessive involvement in 3/'12 (25) pleasurable activities* Disorder sufficiently severe to cause marked impairment in occupational, social, or interpersonal functioning or to necessitate hospital19/19 (100) ization~:
BMD
P
20/20 (100)
<.001
19/20 18/19 19/20 18/20 18/20
< .0005 <.0005 <.005 < .005 NS'I"
(95) (95) (95) (90) (90)
17/19 (89)
<.005
10/13 (77)
<.05
Time of Onset of Symptoms After Delivery in the PP Group The time from delivery to hospital admission was used as an approximate indicator of onset of symptoms after delivery. The median time to admission was 22 days. PP patients fulfilling DSM-III-R criteria for BMD tended to be admitted later (median, 49 days; range, 13 to 76 days) than those not fulfilling these criteria (median, 16.5 days; range, 6 to 51 days; P = .06). "Persecutory delusions" was the only SCID-P item in which the severity of the symptom correlated near-significantly with time since delivery (rs = -.44, n = 19, P = .072). DISCUSSION
The results of this study indicate a clear phenomenological difference between nonde20/20 (100)
NS'I"
NOTE. The numerator signifies the number of patients fulfilling the criteria. The denominator signifies the number in which an adequate assessment of the presence or absence of the criterium could be made. The percentage is enclosed in parentheses. %< = .45 to .75 (moderate agreement). In all other cases, K > .75 (excellent agreement). I"P > .05. :[:The SCID-P contains the words "mood disturbance," but for the purpose of this study this item was regarded as referring to the psychiatric disorder.
Criteria occurring more frequently in the PP group were delusions of control, auditory hallucinations, blunted affect, and emotional turmoil. Emotional tumoil was reported in 10 (50%) of PP cases, and in seven of these the patient was thought to be perplexed. Only one case of perplexity was reported in the BMD group. The groups did not differ significantly regarding clouding of consciousness (none in either group), disorientation (four PP, one BMD), and poor concentration (six PP, four BMD).
Diagnosis According to DSM-III-R Nineteen of the 20 BMD patients (95%) were regarded as meeting DSM-III-R criteria for BMD by the blinded interviewer, whereas only seven (35%) of the PP patients were thought to fulfill these criteria (×2= 15.8, dr= 1, P = .0003).
Table 4. Number of Patients in Each Group Fulfilling Selected Criteria From SCID-P Part B: Psychotic and Associated Symptoms PP Delusions of reference* Persecutory delusions Grandiose delusions Somatic delusion Other delusions, e.g., nihilism Delusion of being controlled* Thought broadcasting* Systematized delusions Bizarre delusions* Auditory hallucinations Visual hallucinations Tactile hallucinations* Other hallucinations, e.g., olfactory* Marked motor anomalies Flat affect Grossly inappropriate affect Incoherence Marked loosening of associations1" Emotional turmoil (rapid shifts from one intense affect to another, or overwhelming perplexity or confusion)
6/18 9/18 8/18 3/18 0/18 7/18 7/18 0/18 4/18 11/19 3/19 1/19
BMD
P
(33) 6/20 (30) NS (50) 14/20 (70) NS (44) 18/19 (95) <.001 (17) 3/20 (15) NS (0) (39) (39) (0) (22) (58) (16) (5)
2/20 1/20 4/20 2/20 2/20 5/20 1/20 2/20
(10) NS (5) < .05 (20) NS (10) NS (10) NS (25) <.05 (5) NS (10) NS
1/18 (6) 2/20 (10) NS 13/19(68) 10/19(53) NS 15/20 (75) 4/20 (20) <.001 7/19 (37) 5/20 (25) NS 13/19 (68) 9/20 (45) NS 10/19 (53)
7/20 (14)
NS
10/19 (53)
4/20 (20) <.05
NOTE. The numerator signifies the number of patients fulfilling the criteria. The denominator signifies the number in which an adequate assessment of the presence or absence of the criterium could be made. The percentage is enclosed in parentheses. NS indicatesP > .05. *K = .45 to .75 (moderate agreement). I"K < .45 (poor agreement). In all other cases, K > .75 (excellent agreement).
80
pressed patients with PP and patients with BMD (manic phase). A significantly greater proportion of the PP group experienced delusions of control, auditory hallucinations, blunted affect, and emotional turmoil. If PP is the same as BMD, one would expect the proportion of nondepressed PP patients fulfilling DSM-III-R criteria for BMD to be equal to that of a group of patients diagnosed as BMD. We rejected this hypothesis, since the proportion of PP subjects who fulfilled these criteria was significantly lower (35%) than the proportion of BMD patients fulfilling these criteria (95%). The PP group also had significantlymore subjects with a history of schizophrenia and fewer with a previous psychiatric history of BMD than the BMD group. A few studies have suggested that PP may have unique distinguishing features. Platz and Kendell2 found perplexity to be the only symptom that might indicate that PP is a unique entity. In our study, emotional turmoil was significantly more common in the PP group. Perplexity, which was one of the symptoms included under the item "emotional turmoil," was more common in the PP group (35%) than in the BMD group (5%), but differences were not statistically significant. Kadrmas et al. s found that Schneiderian symptoms were more common in patients with bipolar disorder occurring in the puerperium than in nonpuerperal patients with BMD. Although we did not perform a full evaluation of criteria for schizophrenia, symptoms suggestive of this disorder (delusions of control, blunted affect, and auditory hallucinations) were more common in the PP group than in the BMD group. Dean and Kendell9 and Agrawal et al. 1° found depressed PP patients to be more hallucinatory, deluded, and labile than a nonpuerperal control group matched for RDC diagnosis, and a number of studies have shown that confusion and disorientation may be a distinguishing feature of pp.s.9-N None of our subjects had clouding of consciousness, and this may have been due to the fact that delirious patients were specifically excluded. However, there was, a tendency for more PP subjects to be disoriented (20% v 5%), but this difference was not statistically significant. Various explanations may be proposed for the differences between our findings and those
OOSTHUIZEN, RUSSOUW, AND ROBERTS
of the two studies 1,5 in which it was suggested that PP is linked to BMD. We applied DSMIII-R criteria rather than the more commonly used RDC classification. Klompenhouwer and van Hulst 11 have shown that a patient with PP may receive different diagnoses, depending on the classification scheme used. Sixty-eight percent of their PP patients had either unspecified functional psychosis or schizoaffective disorder. If DSM-III-R criteria had been used, only 28% of their psychotic patients would have been classified as having mood disorders. Agrawal et al., 10 in a study in India, found unspecified functional psychosis (RDC) to be the most common diagnosis in patients with PP. If these patients had received International Classification of Diseases (ninth edition) diagnoses, the majority would have been in the category of schizophrenia. Since our puerperal patients were exclusively black, cultural differences may also have accounted for the findings. The study by Brockington et al. 5 examined patients presenting within the first 2 weeks after childbirth. There is evidence that these patients are more likely to have manic or schizoaffective manic disorders than those presenting after this initial period. 9 Our reasons for using the 90-day rather than the stricter 2-week cutoff were twofold: First, Kendell et al. 1 found that although the first 30 days showed the highest risk for psychiatric admission, the admission rate is higher between 30 and 90 days than at any time after that. Second, patients with important findings may be excluded if only those presenting within 2 weeks after childbirth are selected, since some subjects whose symptoms may have started soon after delivery may only be admitted to the hospital after this initial period. In our study, PP patients fulfilling DSM-III-R criteria for BMD tended to be admitted later after delivery than those not fulfilling these criteria, and the severity of persecutory delusions showed a near-significant inverse relationship with the time since delivery. This may reflect the urgency with which paranoid puerperal patients are likely to be hospitalized. However, because of the small sample size and the fact that the date of admission was used merely as an approximate indicator of onset, these results should be interpreted with caution. Klompenouwer and van Hulst, 11in a large study of puerperal psychi-
PUERPERAL PSYCHOSIS
81
atric admissions, did not find an association between any one category of psychiatric disorders and onset of symptoms in the first 2 weeks. Apart from the small sample size, this study has a few important limitations. It was largely a cross-sectional study based on current symptomatology; we did not perform further follow-up evaluations for research purposes or evaluate family members for current or past psychopathology,z Since neither group was randomly drawn from a defined population but instead consisted of consecutive admissions to state institutions, they may have been unrepresentative of the total population of nondepressed PP and BMD patients. Those admitted to private institutions may have differed in their presentation, and the results can therefore at most be generalized only to patients typically admitted to state-owned hospitals. Nott 7 has pointed out the problem of finding a suitable control group in studies of psychiatric illness in the puerperium, and notes that, "any suggested control
group is likely to differ systematically from a postpartum group in numerous ways." The use of hospitalized control groups may lead to "admission rate" bias, ~2 which may result in misleading conclusions if patients are either more or less likely to be hospitalized for specific symptoms than controls. On the basis of clinical presentation alone, our findings do not support a hypothesis that PP and BMD are the same condition. However, since patients with BMD have been shown to be at special risk for developing PP,~ studies examining differences between puerperal and nonpuerperal cases of BMD in terms of family history, patterns of relapse, and biological variables t3 may shed more light on the possibility of a link between these disorders.
ACKNOWLEDGMENT
We are grateful to Professors R. Emsley and S. Shapiro for their helpful comments.
REFERENCES
1. Kendell RE, Chalmers JC, Platz C. Epidemiology of puerperal psychoses. Br J Psychiatry 1987;150:662-673. 2. Platz C, Kendell RE. A matched-control follow-up and family study of "puerperal psychoses." Br J Psychiatry 1988;153:90-94. 3. Rehman AU, St Clair D, Platz C. Puerperal insanity in the 19th and 20th centuries. Br J Psychiatry 1990;156:861865. 4. Stewart DE, Klompenhouwer JL, Kendell RE, Van Hulst AM. Prophylactic lithium in puerperal psychosis: the experience of three centres. Br J Psychiatry 1991;158:393397. 5. Brockington IF, Cernik KF, Schofield EM, Downing AR, Francis AF, Keelan C. Puerperal psychosis: phenomena and diagnosis. Arch Gen Psychiatry 1981;38:829-833. 6. Spitzer R, Williams JB, Gibbon M, First MB. Structured Clinical Interview for DSM-III-R-Patient Edition (SCID-P). New York, NY: Biometrics Research Department, New York State Psychiatric Institute, 1989.
7. Nott PN. Extent, timing and persistence of emotional disorders following childbirth. Br J Psychiatry 1987;151:523527. 8. Kadrmas A, Winokur G, Crowe R. Postpartum mania. Br J Psychiatry 1979;135:551-554. 9. Dean C, Kendell RE. The symptomatology of puerperal illnesses. Br J Psychiatry 1981;139:128-133. i0. Agrawal P, Bhatia MS, Malik SC. Postpartum psychosis: a study of indoor cases in a general hospital psychiatric clinic. Acta Psychiatr Scand 1990;81:571-575. 11. Klompenhouwer JL, van Hulst AM. Classification of postpartum psychosis: a study of 250 mother and baby admissions in The Netherlands. Acta Psychiatr Scand 1991; 84:255-261. 12. Dawson-Saunders B, Trapp RG. Basic and Clinical Biostatistics. Norwalk, CT: Appleton & Lange, 1990:266. 13. McGorry P, Connell S. The nosology of puerperal psychosis: a review. Compr Psychiatry 1990;31:519-533.