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Psychiatric disorders of pregnancy
Journal of Psychosomatic Research. Vol. 12. pp. 95 to 100. Persamon Press 1968. Printed in Northern Ireland
Session 6 CHAIRMAN: PSYCHIATRIC
H.
H.
DISORDERS MYRE
WOLFF OF
PREGNANCY
SIM*
IT IS NOT POSSIBLE and
neither is it intended to deal with the vast range of psychiatric As frequently happens in medicine, some, disorders associated with pregnancy. which have attracted much attention are very rare and it is most unlikely that any single psychiatrist could have been so unfortunate as to have gained an appreciable personal experience of them. It may be expedient to mention briefly those problems which either are rare in themselves or rarely come to the attention of the psychiatrist. Suicide The rarity of this event in pregnant women has been stressed by a number of investigators since Durckheim, and include Dahlgren, Lindberg and Stengel. My own experience is still nil, and my researches in Birmingham with the help of Her Majesty’s Coroner over a twelve-year period revealed only one instance. That there may be local variations in incidence is evidenced by the report from Bristol by Seager who, in a five-year period, found three cases. Suicide following pregnancy as a sequel of a post-partum psychosis is more common, though still very infrequent. Hyperemesis gravidarum This is generally considered to be a psychosomatic disorder, and Harvey and Sherfey [l] in a study of twenty hospital admissions found a history of vomiting in response to emotional difficulties. Coppen [2] was unable to confirm this. He undertook a controlled study of fifty primiparae of whom twenty-nine had vomited in pregnancy and twenty-one had not, and found no significant differences in the two groups. This work is not strictly comparable to that of Harvey and Sherfey for Coppen’s patients were all out-patients and probably less severe. Furthermore, the criteria he employed were scores on the Maudsley Personality Inventory which many would not regard as the most reliable index of instability leading to psychosomatic disorder. Mild forms of the condition are common (emesis rather than hyperemesis) but are only rarely referred to the psychiatrist. Severe forms requiring hospital admission were occasionally referred until ten years ago. I doubt if the obstetrician expected a psychiatric cure, but in addition to the alarming physical state, these patients were mentally abnormal. They had a wayward, contrary attitude not only to feeding but to general nursing attention, and this would excite a reaction in the nursing staff which tended to aggravate matters. It was probably to deal with the nursing staff rather than with the patient that the psychiatrist was called in, though this was never overtly declared. * United Birmingham Hospitals, Queen Elizabeth Hospital, Edgbaston, Birmingham. 95
MYRE SIM
96
The few patients I was asked to see did not lend support to the traditional psychiatric interpretation of hyperemesis as a symbolic rejection of the pregnancy. The babies were wanted, though a patient who was depressed and dehydrated with persistent vomiting was beyond caring whether she or her baby lived or died. Correction of the electrolytes, particularly the hypokalaemia, improved the mental state and discussion of the problem with the nursing staff improved the climate in the ward. In the past ten years, though my links with the obstetric department of the medical school have grown stronger, only one such patient has been referred. They do not let them get into such dire straits any more and are treating them successfully with correction of the electrolytes, indoctrination of nursing staff and occasionally tranquillizers. Pseudocyesis This must be a rare condition and is seldom seen by the psychiatrist. Several years ago my colleague, Dr. Tibbetts, and I mustered six cases between us including In every case there proved to be an organic element, four of whom one male patient. had a low intestinal obstruction due to a string cancer of the sigmoid. We are now very sceptical of the diagnosis. Pica This is common but is rarely declared because of the patient’s of shame. It has been regarded as a normal aspect of pregnancy requires no treatment. Toxaemia
associated sense and apparently
of pregnancy
There have been a few reports of the psychosomatic links with this disorder, but the evidence is based on relatively few cases and much more investigation will be necessary before one can with confidence attach such a label to all toxaemias. In my own experience I have had a few patients with a history of toxaemia, but it is doubtful if this is of any significance from the psychosomatic aspect. Present study Over a fifteen-year period (1951-1966) I have personally had fifty-four pregnant patients referred with a variety of psychiatric problems, fifty-one of whom were followed up. The range of problems is diffuse and in many instances it is not possible to say if the pregnancy directly contributed to the instability. Yet they do represent the types of problems which are most commonly referred for psychiatric help and Furthermore as in not one instance did we though selective, they are relevant. resort to therapeutic abortion we were able to follow up both mother and child, except in the three instances where the baby died. As a number of these patients had been referred by psychiatrists to gynaecologists for therapeutic abortion they provide a check on the validity or otherwise of their recommendations: in other words, a control group where otherwise it would have been unethical to provide a control group. We had however come to the conclusion on considerable evidence that the psychiatric hazards of pregnancy did not warrant abortion, and this study can be used as a measure of the soundness of our policy and may also shed some light on the reasons why psychiatrists recommend abortion. These questions are not
97
Psychiatric disorders of pregnancy
All we have at present are entirely answered. questions which are rarely put can be of interest. The following data are therefore based on with a bias in favour of treating the relatively pregnancy rather than asking the gynaecologist rare but treatable conditions could be avoided.
partial
answers
but even these to
the experience of one psychiatrist uncommon psychiatric sequelae of to terminate in the hope that these
TABLE 1. AGE AT PREGNANCY
Up to 20yr
21-25 yr 2630yr 13
6
12
31-35 yr 3640yr 13
Over 40yr 3
8
TABLE2. AGE AT MARRIAGE Up to 20 yr 21-25 yr 26-30yr 22
16
31-53 yr
36-40 yr
4
2
2
Over 40 yr -
Family history of mental illness 24;
of whom 9 had sibs or parents who had to have specialist psychiatric treatment.
Instability
in childhood
16 had no instability 11 came from disturbed or broken homes 26 exhibited neurotic traits of varying type, e.g. fear of dark, nocturnal enuresis. Instability
before pregnancy
20 had no such history
16 were already under my surveillance for previous breakdowns either associated or not with previous pregnancy 10 had received psychiatric treatment previously in hospital 8 had seen their family doctor in the past for depression, nervousness, irritability, etc. but had not been referred to a psychiatric clinic. Instability
during pregnancy
17 showed no evidence of instability:
Of the remaining
37: 10
17 4 1 2 1 1 1 Of this group 2 had shown Instability
after previous
9 were under surveillance for previous mental disturbance 4 had a previous puerperal psychosis and were well 4 were referred because of a previous history of psychiatric illness unconnected with pregnancy. showed varying degrees of emotional instability of a neurotic nature associated with the pregnancy were depressed were demanding an abortion had tried to abort herself had attempted suicide had phobic anxiety in social situations was in an acute schizophrenic-cum-hallucinatory state was scared to have a baby. instability during previous pregnancies.
pregnancies
22 had no previous pregnancy
20 had no such history 12 had hospital treatment
after previous pregnancies
including 1 attempted
suicide.
MYRE
98
SIM
Treatment 27 received no active treatment 5 continued treatment commenced before pregnancy 22 had treatment during and/or after pregnancy.
Type of treatment In broad terms this included all requisite forms of psychiatric treatment provided by a busy and reasonably well staffed psychiatric department of a general hospital. The wide range of psychiatric problems which these patients presented was generally within the range of problems referred to the department [3]. The schizophrenic patients were kept under close surveillance and use was made of the Day Hospital for more prolonged spells of observation as in-patient stay rarely exceeded six weeks. TABLE
3.
DIAGNOSIS
Psychiatric condition Depression Schizophrenia or schizo-affective Anxiety state Puerperal psychosis (previous) General instability in pregnancy Psychopathic personality Inadequate personality No psychiatric features
No. of patients reaction
16 12 6 7 6 2 1 4
Incompletely investigated In addition to the group of 54 patients, 4 patients were referred during early pregnancy because of instability but a complete history was not obtained. Of these 4: 1 was treated \;ith drugs ai an out-patient. Her baby died, but she recovered and later had an uneventful pregnancy and normal delivery. 1 failed to keep her appointment. She remained depressed during pregnancy with an exacerbation in the puerperium and was eventually admitted to a mental hospital. She has now recovered. had her appointment cancelled by her general practitioner because she had improved. She menstruated after two months amenorrhoea ?abortion. failed to keep her appointment. According to the gynaecologist she recovered completely and had a normal delivery and puerperium. Schizophrenic
mothers
In a previous enquiry [4] a number of schizophrenic and schizo-affective puerperal reactions were described. The following group of 12 patients are those who had a history of a schizophrenic reaction prior to their pregnancy and include only 6 of the previous group. Age at pregnancy. 1 aged 21 yr; 2 aged 27 and 29 yr; 9 aged 30 yr. Age at marriage. 1 under 20 yr; 9 between 21 and 30 yr; 2 over 30 yr. Family history of mental illness. 5 had a positive family history. 1 came from a disturbed home; 7 exhibited Instability in childhood. 4 had no instability; neurotic traits. Instability before pregnancy. 4 had no such history; 5 had received psychiatric treatment previously in hospital; 3 had seen their family doctor in the past for instability, but had not been referred to a psychiatric clinic. Instability during pregnancy. 5 showed no evidence of instability; 3 were already under surveillance; 2 were referred in the puerperium.
99
Psychiatric disorders of pregnancy
Of the remaining 7: 3 were depressed; 3 showed general instability; 1 was in an acute schizophrenic-cum-hallucinatory state. Instability after previous pregnancies. 5 had no previous pregnancy; 1 had no such history; 6 had hospital treatment after previous pregnancies. 8 had treatment during and/or after pregnancy. Treatment. 4 received no active treatment;
Prognosis 26 recovered completely, one after a further admission 20 although not completely recovered were well and were maintained outside hospital 1 is improving and is still under review 1 (psychopathic personality) adjusted to the pregnancy 1 was found not to be pregnant, but later had a normal pregnancy 1 has had recurring admissions to mental hospitals 1 referred during pregnancy developed a puerperal psychosis and had to be admitted to a mental hospital. Discussion These patients represent a variety of psychiatric problems, of whom most presented with gross disability during or prior to pregnancy. The outcome of these pregnancies have on the whole been very favourable and the adverse prognosis which had been made in those cases where termination had been advised was not confirmed. This does not mean that all the questions have been answered. We should like to have answers to the following: 1. What is the effect on the children whose mothers are psychotic? There have been reports on such children, particularly that of Cowie [5] but the situation here is different. The condition is recognized and the patient is under treatment in a clinic which has assumed a particular responsibility Even when the patient is very disfor her and in which she has confidence. turbed, one has been able to secure a reasonable degree of co-operation and we have recently had a chronic paranoid schizophrenic patient who first came to our notice fifteen years ago, seek our help in a state of relapse. Her family doctor had during the years become adjusted to the rigid system of catchment areas and had not considered us in the first place. It was when the patient refused to attend the local clinic and he was contemplating formal admission that the patient suggested she see us again. 2. What is the effect of a psychotic
mother
on family life?
3. How does one begin to assess this effect? It is one thing to say that psychiatrists usually take all things into consideration but quite another when one asks exactly what is taken into consideration and how does one evaluate it. 4. What are the standards
on which these assessments
are based?
5. What criteria do doctors use for recommending abortion and how valid are these criteria? It is not enough to say that each case is decided on its merits if the various factors taken into account are not even defined, let alone validated. With the new Abortion Law these questions perhaps paradoxically take on an even greater significance. Psychiatrists will be less frequently called in to They will be left with the greater support a recommendation for termination.
loo
MYRE SIM
responsibility of advising patients who are suffering from mental illness or have such a history, about the continuation of a wanted pregnancy. If they advise abortion they must be prepared to cope with the psychiatric sequelae which may ensue. If they advise that the pregnancy continue uninterrupted they should know what is likely to happen and the type of therapeutic challenge they may have to face. This one-man enquiry only begins to ask the right questions.
to provide
these answers,
but it also begins
REFERENCES 1. HARVEYW. A. and SHERFEYM. J. Vomiting in pregnancy: a psychiatric study. Psychosorn. Med. 16, 1 (1954). 2. COPPEN A. J. Vomiting of early pregnancy: psychological factors and body build. Lancet i, 172 (1959). 3. ORWIN A. and SIM M. The mental hospital: effects of an alternative psychiatric service. Lancer i, 644 (1965). 4. SIM M. Abortion and the psychiatrist. Br. Med. J. ii, 1061 (1963). 5. COWIEV. Children of psychotics: a controlled study. Proc. R. Sot. Med. 54, 675 (1961).
Session 6 CHAIRMAN: PSYCHIATRIC
H.
H.
DISORDERS MYRE
WOLFF OF
PREGNANCY
SIM*
IT IS NOT POSSIBLE and
neither is it intended to deal with the vast range of psychiatric As frequently happens in medicine, some, disorders associated with pregnancy. which have attracted much attention are very rare and it is most unlikely that any single psychiatrist could have been so unfortunate as to have gained an appreciable personal experience of them. It may be expedient to mention briefly those problems which either are rare in themselves or rarely come to the attention of the psychiatrist. Suicide The rarity of this event in pregnant women has been stressed by a number of investigators since Durckheim, and include Dahlgren, Lindberg and Stengel. My own experience is still nil, and my researches in Birmingham with the help of Her Majesty’s Coroner over a twelve-year period revealed only one instance. That there may be local variations in incidence is evidenced by the report from Bristol by Seager who, in a five-year period, found three cases. Suicide following pregnancy as a sequel of a post-partum psychosis is more common, though still very infrequent. Hyperemesis gravidarum This is generally considered to be a psychosomatic disorder, and Harvey and Sherfey [l] in a study of twenty hospital admissions found a history of vomiting in response to emotional difficulties. Coppen [2] was unable to confirm this. He undertook a controlled study of fifty primiparae of whom twenty-nine had vomited in pregnancy and twenty-one had not, and found no significant differences in the two groups. This work is not strictly comparable to that of Harvey and Sherfey for Coppen’s patients were all out-patients and probably less severe. Furthermore, the criteria he employed were scores on the Maudsley Personality Inventory which many would not regard as the most reliable index of instability leading to psychosomatic disorder. Mild forms of the condition are common (emesis rather than hyperemesis) but are only rarely referred to the psychiatrist. Severe forms requiring hospital admission were occasionally referred until ten years ago. I doubt if the obstetrician expected a psychiatric cure, but in addition to the alarming physical state, these patients were mentally abnormal. They had a wayward, contrary attitude not only to feeding but to general nursing attention, and this would excite a reaction in the nursing staff which tended to aggravate matters. It was probably to deal with the nursing staff rather than with the patient that the psychiatrist was called in, though this was never overtly declared. * United Birmingham Hospitals, Queen Elizabeth Hospital, Edgbaston, Birmingham. 95
MYRE SIM
96
The few patients I was asked to see did not lend support to the traditional psychiatric interpretation of hyperemesis as a symbolic rejection of the pregnancy. The babies were wanted, though a patient who was depressed and dehydrated with persistent vomiting was beyond caring whether she or her baby lived or died. Correction of the electrolytes, particularly the hypokalaemia, improved the mental state and discussion of the problem with the nursing staff improved the climate in the ward. In the past ten years, though my links with the obstetric department of the medical school have grown stronger, only one such patient has been referred. They do not let them get into such dire straits any more and are treating them successfully with correction of the electrolytes, indoctrination of nursing staff and occasionally tranquillizers. Pseudocyesis This must be a rare condition and is seldom seen by the psychiatrist. Several years ago my colleague, Dr. Tibbetts, and I mustered six cases between us including In every case there proved to be an organic element, four of whom one male patient. had a low intestinal obstruction due to a string cancer of the sigmoid. We are now very sceptical of the diagnosis. Pica This is common but is rarely declared because of the patient’s of shame. It has been regarded as a normal aspect of pregnancy requires no treatment. Toxaemia
associated sense and apparently
of pregnancy
There have been a few reports of the psychosomatic links with this disorder, but the evidence is based on relatively few cases and much more investigation will be necessary before one can with confidence attach such a label to all toxaemias. In my own experience I have had a few patients with a history of toxaemia, but it is doubtful if this is of any significance from the psychosomatic aspect. Present study Over a fifteen-year period (1951-1966) I have personally had fifty-four pregnant patients referred with a variety of psychiatric problems, fifty-one of whom were followed up. The range of problems is diffuse and in many instances it is not possible to say if the pregnancy directly contributed to the instability. Yet they do represent the types of problems which are most commonly referred for psychiatric help and Furthermore as in not one instance did we though selective, they are relevant. resort to therapeutic abortion we were able to follow up both mother and child, except in the three instances where the baby died. As a number of these patients had been referred by psychiatrists to gynaecologists for therapeutic abortion they provide a check on the validity or otherwise of their recommendations: in other words, a control group where otherwise it would have been unethical to provide a control group. We had however come to the conclusion on considerable evidence that the psychiatric hazards of pregnancy did not warrant abortion, and this study can be used as a measure of the soundness of our policy and may also shed some light on the reasons why psychiatrists recommend abortion. These questions are not
97
Psychiatric disorders of pregnancy
All we have at present are entirely answered. questions which are rarely put can be of interest. The following data are therefore based on with a bias in favour of treating the relatively pregnancy rather than asking the gynaecologist rare but treatable conditions could be avoided.
partial
answers
but even these to
the experience of one psychiatrist uncommon psychiatric sequelae of to terminate in the hope that these
TABLE 1. AGE AT PREGNANCY
Up to 20yr
21-25 yr 2630yr 13
6
12
31-35 yr 3640yr 13
Over 40yr 3
8
TABLE2. AGE AT MARRIAGE Up to 20 yr 21-25 yr 26-30yr 22
16
31-53 yr
36-40 yr
4
2
2
Over 40 yr -
Family history of mental illness 24;
of whom 9 had sibs or parents who had to have specialist psychiatric treatment.
Instability
in childhood
16 had no instability 11 came from disturbed or broken homes 26 exhibited neurotic traits of varying type, e.g. fear of dark, nocturnal enuresis. Instability
before pregnancy
20 had no such history
16 were already under my surveillance for previous breakdowns either associated or not with previous pregnancy 10 had received psychiatric treatment previously in hospital 8 had seen their family doctor in the past for depression, nervousness, irritability, etc. but had not been referred to a psychiatric clinic. Instability
during pregnancy
17 showed no evidence of instability:
Of the remaining
37: 10
17 4 1 2 1 1 1 Of this group 2 had shown Instability
after previous
9 were under surveillance for previous mental disturbance 4 had a previous puerperal psychosis and were well 4 were referred because of a previous history of psychiatric illness unconnected with pregnancy. showed varying degrees of emotional instability of a neurotic nature associated with the pregnancy were depressed were demanding an abortion had tried to abort herself had attempted suicide had phobic anxiety in social situations was in an acute schizophrenic-cum-hallucinatory state was scared to have a baby. instability during previous pregnancies.
pregnancies
22 had no previous pregnancy
20 had no such history 12 had hospital treatment
after previous pregnancies
including 1 attempted
suicide.
MYRE
98
SIM
Treatment 27 received no active treatment 5 continued treatment commenced before pregnancy 22 had treatment during and/or after pregnancy.
Type of treatment In broad terms this included all requisite forms of psychiatric treatment provided by a busy and reasonably well staffed psychiatric department of a general hospital. The wide range of psychiatric problems which these patients presented was generally within the range of problems referred to the department [3]. The schizophrenic patients were kept under close surveillance and use was made of the Day Hospital for more prolonged spells of observation as in-patient stay rarely exceeded six weeks. TABLE
3.
DIAGNOSIS
Psychiatric condition Depression Schizophrenia or schizo-affective Anxiety state Puerperal psychosis (previous) General instability in pregnancy Psychopathic personality Inadequate personality No psychiatric features
No. of patients reaction
16 12 6 7 6 2 1 4
Incompletely investigated In addition to the group of 54 patients, 4 patients were referred during early pregnancy because of instability but a complete history was not obtained. Of these 4: 1 was treated \;ith drugs ai an out-patient. Her baby died, but she recovered and later had an uneventful pregnancy and normal delivery. 1 failed to keep her appointment. She remained depressed during pregnancy with an exacerbation in the puerperium and was eventually admitted to a mental hospital. She has now recovered. had her appointment cancelled by her general practitioner because she had improved. She menstruated after two months amenorrhoea ?abortion. failed to keep her appointment. According to the gynaecologist she recovered completely and had a normal delivery and puerperium. Schizophrenic
mothers
In a previous enquiry [4] a number of schizophrenic and schizo-affective puerperal reactions were described. The following group of 12 patients are those who had a history of a schizophrenic reaction prior to their pregnancy and include only 6 of the previous group. Age at pregnancy. 1 aged 21 yr; 2 aged 27 and 29 yr; 9 aged 30 yr. Age at marriage. 1 under 20 yr; 9 between 21 and 30 yr; 2 over 30 yr. Family history of mental illness. 5 had a positive family history. 1 came from a disturbed home; 7 exhibited Instability in childhood. 4 had no instability; neurotic traits. Instability before pregnancy. 4 had no such history; 5 had received psychiatric treatment previously in hospital; 3 had seen their family doctor in the past for instability, but had not been referred to a psychiatric clinic. Instability during pregnancy. 5 showed no evidence of instability; 3 were already under surveillance; 2 were referred in the puerperium.
99
Psychiatric disorders of pregnancy
Of the remaining 7: 3 were depressed; 3 showed general instability; 1 was in an acute schizophrenic-cum-hallucinatory state. Instability after previous pregnancies. 5 had no previous pregnancy; 1 had no such history; 6 had hospital treatment after previous pregnancies. 8 had treatment during and/or after pregnancy. Treatment. 4 received no active treatment;
Prognosis 26 recovered completely, one after a further admission 20 although not completely recovered were well and were maintained outside hospital 1 is improving and is still under review 1 (psychopathic personality) adjusted to the pregnancy 1 was found not to be pregnant, but later had a normal pregnancy 1 has had recurring admissions to mental hospitals 1 referred during pregnancy developed a puerperal psychosis and had to be admitted to a mental hospital. Discussion These patients represent a variety of psychiatric problems, of whom most presented with gross disability during or prior to pregnancy. The outcome of these pregnancies have on the whole been very favourable and the adverse prognosis which had been made in those cases where termination had been advised was not confirmed. This does not mean that all the questions have been answered. We should like to have answers to the following: 1. What is the effect on the children whose mothers are psychotic? There have been reports on such children, particularly that of Cowie [5] but the situation here is different. The condition is recognized and the patient is under treatment in a clinic which has assumed a particular responsibility Even when the patient is very disfor her and in which she has confidence. turbed, one has been able to secure a reasonable degree of co-operation and we have recently had a chronic paranoid schizophrenic patient who first came to our notice fifteen years ago, seek our help in a state of relapse. Her family doctor had during the years become adjusted to the rigid system of catchment areas and had not considered us in the first place. It was when the patient refused to attend the local clinic and he was contemplating formal admission that the patient suggested she see us again. 2. What is the effect of a psychotic
mother
on family life?
3. How does one begin to assess this effect? It is one thing to say that psychiatrists usually take all things into consideration but quite another when one asks exactly what is taken into consideration and how does one evaluate it. 4. What are the standards
on which these assessments
are based?
5. What criteria do doctors use for recommending abortion and how valid are these criteria? It is not enough to say that each case is decided on its merits if the various factors taken into account are not even defined, let alone validated. With the new Abortion Law these questions perhaps paradoxically take on an even greater significance. Psychiatrists will be less frequently called in to They will be left with the greater support a recommendation for termination.
loo
MYRE SIM
responsibility of advising patients who are suffering from mental illness or have such a history, about the continuation of a wanted pregnancy. If they advise abortion they must be prepared to cope with the psychiatric sequelae which may ensue. If they advise that the pregnancy continue uninterrupted they should know what is likely to happen and the type of therapeutic challenge they may have to face. This one-man enquiry only begins to ask the right questions.
to provide
these answers,
but it also begins
REFERENCES 1. HARVEYW. A. and SHERFEYM. J. Vomiting in pregnancy: a psychiatric study. Psychosorn. Med. 16, 1 (1954). 2. COPPEN A. J. Vomiting of early pregnancy: psychological factors and body build. Lancet i, 172 (1959). 3. ORWIN A. and SIM M. The mental hospital: effects of an alternative psychiatric service. Lancer i, 644 (1965). 4. SIM M. Abortion and the psychiatrist. Br. Med. J. ii, 1061 (1963). 5. COWIEV. Children of psychotics: a controlled study. Proc. R. Sot. Med. 54, 675 (1961).