Confounding Psychosis in the Postpartum Period
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- Castro, J., Billick, S., Kleiman, A. et al. Psychiatr Q (2014) 85: 91. doi:10.1007/s11126-013-9271-5
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This case report alerts the psychiatric clinician to consider nonpsychiatric etiologies of psychosis appearing during the postpartum period besides postpartum psychosis. The case includes a description of the patient’s psychiatric presentation, admission to the inpatient psychiatric unit with subsequent transfer to the medicine department including neuroimaging and neurological consultation. The patient had a remission of psychosis after only two and half days of antipsychotic medication administration. Positive findings on the MRI suggested a demyelinating disease and a 4-month follow up MRI continued to be positive. The etiology was presumed to be a demyelinating disease. In conclusion, psychiatrists need to be alert to include nonpsychiatric pathologies in the differential diagnosis when a patient presents with psychosis in the postpartum period.
KeywordsPsychosomatic medicinePsychiatric misdiagnosisPostpartum psychosisMultiple sclerosisDemyelinating diseasesPsychosis
Psychosis appearing in the postpartum period may be of a different etiology than postpartum psychosis. Psychiatrists and physicians in general probably have a tendency to consider the latter as the etiology of psychosis that presents during the puerperium. Psychoses during the period are potentially quite catastrophic as they can lead to maternal death and infanticide. It’s not uncommon that if a mother kills her newborn she would be found to be psychotic. It’s also important to establish the current diagnosis in the differential choices.
Usually postpartum psychosis affects 1–2 per 1,000 postpartum women. The onset can be as early as 48–72 h postpartum but it usually manifests within the first 2 weeks. The earliest symptoms include restlessness, irritable mood and insomnia [1, 2]. Postpartum psychosis evolves rapidly and is characterized by depressed, elevated or labile mood, disorganized behaviors, delusions and hallucinations . The delusions usually involve the mother–infant bond and neuroimaging is negative. Also, women with a history of postpartum psychosis require close monitoring to quickly identify any recurrence of this mental illness in order to safeguard both the infant and the mother. Postpartum psychosis can herald schizophrenia, bipolar disorder or a recurrent psychotic depression, all of which have their different treatment implications. On the other hand, there are other etiologies for psychosis appearing in the postpartum period. Psychiatrist may not immediately consider neurological, systemic or drug-induced psychosis.
Multiple sclerosis (MS) is characterized by various signs and symptoms of CNS dysfunction such as paresthesias, limb weakness, visual disturbances, partial blindness, eye pain and others . A significant percentage of MS patients will develop neuropsychiatric symptoms during their lifetime. Affective and mood symptoms are most common, but psychosis is reported in approximately 1 % .
Aggarwal et al. of the Department of Psychiatry at Indira Gandhi Medical College, India, noted that demyelinating diseases could be associated with psychiatric disorders. They presented a case of acute MS which manifested with the clinical phenotype of acute psychosis. He stressed that these demyelinating diseases should prompt clinicians to include them in differential diagnoses . MS during pregnancy has a lower risk of progression and exacerbation but relapse rate increases during the first 3 months postpartum  and 30 % of all patients suffer from relapses during this period[8, 9]. Neuroimaging is positive.
Posterior reversible leuko-encephalopathy syndrome (PRES) is a constellation of signs and symptoms caused by reversible ischemia most commonly affecting the parietal-occipital vasculature. It is caused by hypertension, various medications, preeclampsia, eclampsia and other systemic factors (sepsis, autoimmune, chemotherapy, thrombotic thrombocytopenic purpura). The pathophysiology involves a failure of cerebrovascular auto-regulation resulting in disruption of blood brain barrier and vasogenic edema. Clinically, patients present with seizures (74 %), altered mental status, headache, visual changes and aphasia. Demyelinating lesions in the anterior aspect of the brain could account for psychotic symptoms [10, 11]. Neuroimaging is positive.
Many medications have been reported to be implicated in producing psychosis as a side effect. Of relevance to the case below, methyldopa produces depression as a side effect, but psychosis may also result . Methyldopa acts as a false transmitter that competes with actual catecholamines in CNS resulting in lowering of blood pressure. In some individuals, methyldopa can also stimulate dopamine receptors resulting in psychosis. Neuroimaging is negative.
Pregnancy is a state with increased coagulability due to several factors such as decreased venous flow. Most critically, during the immediate postpartum period there is a considerable risk for increased clot formation presumably because of thromboplastic substances released by the placenta at the site of separation. Pregnancy-specific conditions such as preeclampsia and eclampsia also increase the risk for blood clotting. Cesarean delivery (C-section) has also been shown to be associated with 3–12 times increased risk for peripartum/postpartum cerebral vascular accident (CVA) . Neuroimaging is positive.
Presentation of Case
A 44 year-old black woman from Senegal, married, unemployed, domiciled with her husband and 4 children (aged 6–18) was brought to the medical ER with chief complaint “I was brought here because I did something”. The patient had a C-section 10 days prior to psychiatric evaluation and delivered a 32-week preterm male baby. Pregnancy had been complicated with preeclampsia, placenta previa and vaginal bleeding. At the time of assessment her baby boy was in the neonatal intensive care unit (NICU) for prematurity since delivery. The patient was significant psychological stress, visiting her baby in the NICU every day while still recuperating from the C-section. The day prior to psychiatric evaluation she had been diagnosed with elevated blood pressure that was partially controlled with methyldopa. On returning home she couldn’t sleep at all and became progressively disorganized during the course of the night. Her husband described her behavior and thoughts as “incoherent”. On psychiatric assessment she verbalized she was feeling fatigued and was concerned that she would be “abandoned in the morgue”. She thought that the ER was the morgue.
There was no prior history of psychiatric illness. Her medical history included diabetes mellitus type II and positive PPD treated with INH. Her home medications included glyburide 5 mg daily, methyldopa 500 mg BID, ferrous sulfate supplement, prenatal vitamins and acetaminophen with codeine for C-section pain. There was no history of substance abuse and no family history of psychiatric illness.
Social and family histories were as follows: She was born in Senegal, into a Muslim family, immigrated to the US at age 26 with her husband who is a naturalized American citizen. He was described as supportive of her; the patient denied abuse of any kind. She graduated from high school and attended 2 years of college in Africa for business and secretarial studies. She had been working as a nursing assistant until just before giving birth.
Mental Status Examination
The patient appeared to be her stated age of 44. She was cooperative and had submissive stance. She looked frightened, was tucked in her hospital sheets which covered half of her face. Her psychomotor activity was decreased and she was still for the most part. She was approachable, had fair eye contact and was hypervigilant. Her speech was slow, soft, with a noticeable foreign accent, alternating between French and English. She required frequent prompting to ascertain specifics. She described her mood as “fatiguée”. Her affect was flat, reduced in intensity and mood congruent. She had intermittent blocking of her thought process and tangentiality with looseness of associations. Thought content was delusional as she thought she was in the morgue and was afraid she would be abandoned there. She also had remorseful thoughts, stating that she was in the morgue because “I did something” although she wouldn’t explain what exactly. She added that “I don’t want to disturb anyone anymore” and thought that the other live patients on the medical stretchers were actually dead bodies in the morgue. She denied suicidal and homicidal ideation or hallucinations and did not seem to be responding to internal stimuli. She was alert and oriented to person but not to place (“in the morgue”) or time. It was not possible to assess cognitive function (proverbs, similarities, arithmetic, serial 7s, etc.). She had poor insight and judgment and was lacking reality testing.
Vital Signs and Laboratory Work
Vital signs on admission were significant for an elevated heart rate (106 per minute) and blood pressure (156/104 mmHg). Respirations and temperature where within normal limits. The patient’s complete blood count and clotting factors were all within normal limits as well. Basic metabolic profile and hepatic function panel were normal except for increased glucose (197 mg/dL) and decreased albumin (3.2 g/dL). Urinalysis was abnormal only for an elevated protein (100) and glucose (500). TSH was within normal limits. VDRL was nonreactive. Urine toxicology and blood alcohol level were all negative. Her EKG reported no abnormalities.
The patient was medically cleared and admitted to the psychiatric service. The initial diagnosis included psychosis nos; r/o postpartum psychosis; and r/o methyldopa-induced psychosis. She was started on quetiapine 25 mg BID and a low sodium/low calorie diet. The internal medicine service was consulted for hypertension and diabetes mellitus and recommendations included adding aspirin 81 mg (ASA) daily; metformin 1,000 mg BID and lisinopril 10 mg daily. A Computerized Tomography scan (CT) of the brain without contrast was ordered. The CT report found patchy foci of decreased attenuation (hypointense patches) on the left subinsular region and left anterior–superior temporal lobe. Also mild-to-moderate cerebral and cerebellar atrophy with compensatory ventricular dilation and a <1 cm calcification in the left aspect of the superior falx was noted. A neurology consult was also requested. The patient reported a 4/10 headache and the blood pressure remained elevated at 150/100. Their working diagnosis was PRES and r/o CVA. They recommended that the patient be sent for an magnetic resonance imaging (MRI) and be started on simvastatin 80 mg daily along with better blood pressure control.
The patient was subsequently transferred from the psychiatric ward to telemetry in the medical service to r/o a possible paroxysmal atrial fibrillation etiology and r/o CVA. Metoprolol 25 mg BID was added for better hypertension control. The brain MRI without contrast reported multiple hyper-intense foci in the white matter, most prominent on the left ventricular atrium with a differential diagnosis of ischemic, inflammatory or demyelinating disease.
Quetiapine 25 mg had actually only been given to the patient 5 times while on the psychiatric service. On transfer to medicine, the antipsychotic treatment was discontinued as her psychosis had remitted. While in the medical floor the patient complained of “flashes of light” in peripheral vision and “fullness” in her head but no frank headache. However, she gradually felt better and her blood pressure was finally brought under control. Her discharge medications included simvastatin 40 mg daily, metoprolol 25 mg BID, lisinopril 10 mg daily, metformin 1,000 mg BID and ASA 81 mg daily. Her discharge diagnosis was unspecified encephalopathy.
The diagnosis explaining the patient’s psychosis remains unclear. The initial clinical picture suggested pospartum psychosis. However, pospartum psychosis does not present with radiologic findings and her MRI showed images suggestive of a demyelinating disease but she is not known to have developed any other symptom than psychosis. Therefore, it is important that when a clinician is called to evaluate a postpartum woman with psychosis, he or she doesn’t automatically diagnose her with postpartum psychosis since other etiologies may very well be implicated in the clinical presentation confounding the diagnosis.