Case Report

POST PARTUM PSYCHOSIS

Dayanandan Rajarathanam, Wayan Westa, Nyoman Ratep
Psychiatry Department Medical Faculty of Universitas Udayana
Sanglah Hospital

Abstract
In general, majority of women are disturbed emotionally after giving birth. The common forms
of postpartum disturbance are depression and psychosis. This emotional disturbance happens to
women both primipara or multipara especially primipara. A birth can cause a severe stress load to
a mother. As a mother, they feels burdened by the responsibility of taking care of the husband and
the baby, till they have no confidence on their ability to be a mother. The psychological
distruptions which formed tend to decrease the happiness and strain the mother and child
relationship. Postpartum psychosis as per the case, can last for a year and also there is a
possibility of a recurrence after every post partum.
Keyword: Postpartum, Psychosis, depression
Abstrak
Secara umum, kebanyakan wanita terganggu secara emosi setelah persalinan. Bentuk umum dari
gangguan postpartum adalah depresi dan psikosis. Gangguan emosional ini terjadi pada wanita
baik primipara atau multipara terutama primipara. Kelahiran dapat menyebabkan beban stres
berat untuk seorang ibu. Sebagai seorang ibu, mereka merasa terbebani oleh tanggung jawab
mengurus suami dan bayi, sampai mereka tidak memiliki keyakinan pada kemampuan mereka
untuk menjadi seorang ibu. Gangguan psikologis yang terbentuk cenderung menurun
kebahagiaan dan ketegangan hubungan antara ibu dan anak. Seperti kasus ini, post partum
psikosis dapat berlangsung selama satu tahun dan juga ada kemungkinan kekambuhan setelah
setiap post partum .
Kata Kunci: Postpartum, Psikosis, Depresi

1.Introduction

First known in 1850, postpartum psychosis is a severe mental condition which require prompt medical
attention. Interestingly, a study on the level of disturbance potrays that the numbers of women suffering
from post partum psychosis did not change from the mid of year 1800.(1)
Postpartum psychosis is a syndrome marked by severe depression and suspicion. Generally, postpartum
psychosis occurs during the first week after postpartum. Women who suffers from bipolar disorder or other
psychotic illness which is known as Schizoaffective disorder have a higher risk to suffer postpartum
psychosis. Other symptoms that usually present are delusion, hallucination, insomnia and obsession towards
her baby. They also may suffer from drastic mood changes, from depression to anger and then to a euphoric
state in a short period of time.(2) We report here a case of a woman who suffered from postpartum psychosis
woman who experienced psychosis after delivering her first child.
2. Case Presentation
Ms N is a 20 year old Balinese without any previous personal or family neurological nor psychiatric history.
Not only that, she has no history of substance abuse. Ms N came to the hospitals psychiatry polyclinic with her
husband with a chief complaint, which is hearing whispering sound in fear for more than 1 month right after
patient deliver her first child. From that point, Ms N said that she always feels anxious and threatened, Not only
that, Ms N also claims that she is having palpitations, trembling and has been suffering from insomnia and lack
of appetite and this affects her daily lifestyle. The whispering voice Ms N heard was said to be an unknown
voice and sometimes there are a lot of different voices. She claimed that the voices tells her that someone wants
to harm her baby. So, she started to distance herself and her baby from the other family members including her
husband. Other than that, Ms N is well known as a talkative person changed drastically and speaks less.
Besides that, misunderstanding between Ms N and her mother in law always bothers her mind making her
depressed and anxious. Her husband added that she always distanced herself and always looked sad and
depressed. He claimed that Ms N would get very angry if anyone nears her baby.
However, at the moment Ms N said she still hears whispering noise but has reduced ever since she started to
take Risperidone, Trihexyperidyl, and Fluoxetin. Ms N still complained that she having trouble sleeping and it
has been three days ever since she slept peacefully.
Ms N came for her fortnight check up wearing brown t shirt and a blue jeans and sporting a straight long
black hair. Ms N was interviewed in face to face position with the Psychiatry specialist and was conducted
in Indonesian language. Before the interview started, Ms N was relaxed and composed. During the
interview, Ms N could story and able to answer all the questions clearly. At times, Ms Ns lineament seem
rather anxious with good eye contact with the doctor. Ms N could answer her name, age, address, and day
and date of the check up.
When asked to calculate 100 minus 7 then minus 7 again, Ms N could answer correctly. Not only that, Ms N
could identify pencil, paper and book, and could explain the difference between tennis ball and a orange
correctly. Ms N could also say the name of the doctor which he introduced earlier.

After exactly 2 weeks after medication given are consumed, Ms N came back to polyclinic for medication. Ms
N admitted feeling way better after started consuming medicine because rarely hears whispering sound despite
the she still suffering from insomnia and lack of appetite. Not only that, Ms N said she have not gain self
esteem to start working next week.
Ms N is said to be active person in the community before she felt ill, but now she keep quiet and only
communicate within her family members. According to Ms Ns husband, she does not like to be criticized by
other people and usually ignores those who does. At first, Ms N usually stories her personal problems to her
husband but most of the time the husband would not be able to find a solution for Ms N. Since she felt ill, Ms N
prefers to keep her problems and rarely stories them to her husband.
Her husband said that Ms N is the eldest child out of 5 siblings in her family. Since before marriage till after
marriage, Ms N always scolded by her parents. Besides that, her husband also admits Ms N was beaten many
times before marriage.
From the physical examination Ms . Based on psychiatric examination reveals general impression is dress
neatly, seemed anxious, cooperative, verbal and sufficient visual contact with the examiner.

In terms of sensories and cognition, we found that Ms N awareness is conscious, orientation on time,
place, and people is good, able to concentrate n pay attention. Ms Ns memory, ability to count, general
knowledge, and insight is under normal limit. Mood and affect is anxious but appropriate yet she is
depressive state. Her thought process which is form is logic, and realistic, rate coherent, and content is
without delusion, although there was previous history of delusion.
In term of perception, Ms N facing auditoric hallucination, but no illusion, and her intelligence is
suitable for education level and Ms N has insomnia, and no hipobulia, no rapture.

3.Discussion
As per the report, we have described this rare case of postpartum psychosis under
psychosocial problems in post partum obstetric patient. The prevalence in general is
around 1-2 per 1000 birth, and somehow the rate is increased to almost 100 times in
women with bipolar or a previous postpartum psychosis.(4) Initial diagnosis that should be
taken into account is a woman presenting postpartum psychosis is bipolar disorders.
Besides that, postpartum psychosis must be suspected in any patient presenting with
postpartum depression or mania and previous history of undiagnosed or misdiagnosed
mood episodes and family history of bipolar disorders. Postpartum psychosis develops
within few weeks after delivery. Our patient experienced loss of reality and hallucination.
(5) The diagnosis was made according to the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision(DSM-IV-TR). Although, there is no specific
diagnostic criteria for postpartum psychosis to diagnosed this patient under mood
disorders not otherwise specified with postpartum onset. (5)Meanwhile, using PPDGJ III,
criteria for postpartum psychosis is under F.53.(6) The patients complaints were very
much identical for the diagnostic criteria for postpartum psychosis, which are fluctuating
course and mood lability. When delusions present, they often concern the newborn infant
for example, devil possessed infant, has supernatural ability, or is destined for a dreadful
fate. In both the psychotic and nonpsychotic presentations, there may be suicidal ideation,
obsessional thoughts regarding violence to the child, lack of concentration, and
psychomotor agitation.
Proves for Ms Ns postpartum psychosis are portrayed by her delusional thoughts
about her babys health, her paranoid belief whereby someone wants to cause hurt towards
her baby, confusion, insomnia and agitation state.(5)

1. Summary
Postpartum psychosis is a syndrome marked by severe depression and delusion. Specific
features for postpartum psychosis consist of agitation, anxiety, labile emotion, including
euphoria, insomnia, crying, confused, and finally causing a severe psychotic episode with
manic and delirium phase. Postpartum psychosis is a emergency condition which requires
immediate attention and therapy.

Consent

Verbal informed consent was given by the patient for the publication of this report.

Reference
1. American Psychiatric Association(APA).1994. Diagnostic and Statistical Manual
of Mental Disorder (DSM-IV) 4th ed. Washington DC
2. Riordan, Jan. EdD, Prof: Postpartum Depression in Breastfeeding and Human
Lactation, Third Edition, Jones and Bartlett publisher, London, 2004. Page 476484
3.

Margaret G. Spinelli, M.D Postpartum Psychosis: Detection and Risk and

Management published in 2008, page 405-408

4. Kaplan. Usmle Step2 CK Obstetrics and Gynecology Lecture Notes. 2008-2009

edition. Kaplan medical,2009. Page 146-148
5. American Psychiatric Association(APA),1994. Diagnostic and Statistical Manual
of Mental Disorders(DSM IV TR)4th ed. Washington,DC
6. Rusdi Maslim.Dr, Diagnosis Gangguan Jiwa Rujukan Ringkas dari PPDGJ III
Jakarta,2002.Page 125-126