When Postpartum Psychosis Presents in the ER

When you read about postpartum psychosis, the word that typcially precedes the rate of occurrence is the word "rare." "Postpartum psychosis is a rare postpartum disorder," we always hear or read. But it doesn't feel so rare when it descends upon an unsuspecting woman with a new baby or her family. If this woman goes to the emergency room, which is likely to happen, it is crucial that emergency room personnel understand the diagnosis so she receives the treatment required. It is astounding how often hospital emergency room workers still miss this. Please be informed.

Below are some brief facts and guidelines for emergency room workers:

Postpartum psychosis occurs in approximately 1-2 out of every 1,000 deliveries.

The clinical onset is rapid, with symptoms occurring as early as the first 48 to 72 hours postpartum, although the majority of episodes develop within the first 2 weeks after delivery.

Postpartum psychosis is always a psychiatric emergency.

A woman with postpartum psychosis may not present with typical psychotic symptoms since she may be urgently trying to cover up her distress and return to the care of her baby. If she is in the emergency room, it is likely that she is experiencing either 1) Acute/severe anxiety symptoms and/or 2) Psychotic symptoms.

Differentiating between the two is crucial.

New mothers who experience very scary thoughts about hurting her baby are typically extremely agitated by these thoughts. This is usually a sign that these thoughts are triggered by anxiety (ego-dystonic) rather than psychosis (ego-syntonic). Her high level of distress should be reassuring to the healthcare provider assessing her, but this should not discourage a comprehensive evaluation including questions to rule out psychosis. Healthcare practitioners have traditonally presumed that if she does not express negative thoughts directed toward her baby, she must not be experiencing symptoms of psychosis. This is not true. Many women with postpartum psychosis continue to experience and exhibit loving thoughts and behaviors toward and about their babies. This is often why they are mistakenly sent home from an emergency room visit.

Therefore, the questions below should be asked of every single postpartum woman who comes to the emergency room. The assessment should include information from a family member who may be in a better position to be objective. In addition, family members who accompany a mother to the ER should be directly asked to describe any behaviors they find concerning.

Ask her, and those who are with her, the following questions:

• Does she or anyone in her family have a history of bipolar illness or previous psychosis?
• Is she talking or acting in a strange manner that is not characteristic for her?
• Is she unusually quiet and withdrawn, or speaking rapidly with little concentration?
• Does she claim to hear things or see things that others do not?
• Is she suspicious of others or expressing concern that others are out to get her or trying to harm her in some way?
• Does she have a decreased need for sleep or food and/or exhibit a high degree of confidence or an exaggerated sense of her capabilities or self-worth?
• Does she feel abnormally hyperactive with racing thoughts and/or behaviors?

Important Points to Keep in Mind

New mothers with symptoms of psychosis may be frightened and overwhelmed. Or, they may not realize anything is wrong. How the questions are asked is as important as what the questions are. Try something like this:

"I know this may be overwhelming right now. Sometimes we see mothers here who tell us they are hearing unusual voices in their head or others are telling them that they aren’t making sense. Are you experiencing anything like this?”

There is a 5% infanticide or suicide rate associated with postpartum psychosis. During the psychotic state, the delusion may take many forms and may not be destructive. However, there is always a great risk of danger because the delusional and irrational thinking will impair her judgment and ability to care for herself and her baby.

You cannot assume that if she looks good, she is fine. Postpartum women are exceptionally good at holding it together and saying all the right things, in order to maintain control and put forth the illusion that they are fine. This is true whether she is experiencing symptoms of acute anxiety or psychosis. Although symptoms of psychosis are more difficult to disguise, she still may appear to be "fine."

Psychosis Essential Reads

High-Profile Violence and How We Can Be Effective for Change

Assisted Outpatient Treatment Keeps People Out of Hospitals and Jails

The key to early intervention is to keep the possibility of psychosis in mind when evaluating any woman who has recently given birth.

You can download a pdf of our Emergency Room Guidelines for Postpartum Psychosis on our website.

Copyright 2014 Karen Kleiman, The Postpartum Stress Center.