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BMJ Case Reports 2012; doi:10.1136/bcr.11.2011.5176
  • Reminder of important clinical lesson

A father with postpartum psychosis

  1. Lokesh Shahani
  1. Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, Illinois, USA
  1. Correspondence to Dr Lokesh Shahani, lokesh83{at}hotmail.com

Summary

Postpartum psychosis is a rare, however severe mood disorder in the perinatal period. It is most commonly associated with postpartum bipolar disorder. The author reports a case where a male patient with psychosis was admitted to the psychiatric unit 5 days after his wife gave birth to their male child. The patient was very concerned about the well being of his child and was afraid that something bad would happen to his child. The patient was diagnosed with an acute manic episode with psychotic symptoms and treated with olanzapine and lithium. The patient has been continued on therapeutic dose of lithium without any relapse of the symptoms, 3 months after the initial episode. The role of psychological stress in precipitating such a severe mood or psychotic disorder needs to be highlighted.

Background

Postpartum psychosis is a rare, however the most severe mood disorder in the perinatal period. It is most commonly associated with postpartum bipolar disorder. The most common symptoms of the disorder include auditory or visual hallucination associated with grandiose or paranoid delusions. Majority of the delusion are focused around the newborn infant.1 It presents within 2 weeks postpartum, and most commonly presents rapidly within the first 2–3 days postpartum.2 The combination of frank psychosis and limited insight and judgment in postpartum psychosis can lead to damaging consequences in which the safety and well being of the affected mother and her child can be jeopardised.3

There have been a few studies in the past which have evaluated the prevalence of mood disorder in fathers during the perinatal period. Depression has been most studied and estimated to develop in approximately 4–6% in the early periods after child birth.4,,9 Few case reports have described the development of psychosis in father after the birth of the child.10 11 The author reports a case where a male patient with psychosis was admitted to the psychiatric unit 5 days after his wife gave birth to their child.

Case presentation

A 28-year-old Caucasian male presented to the emergency department for evaluation 5 days after the birth of his male child. The patient was very concerned about the well being of his child and was afraid that something bad would happen to the child. His wife and both parents accompanied the patient to the emergency room and provided collateral history after a verbal consent was obtained from the patient. They said that the patient had become excessively concerned about his child’s safety. The mother and the child had come home a day ago and since then the patient had been irritable and continuously keeping a watch over the child. He had not slept in the past 48 h and had been pacing around at home and making sure that the house was locked. Further the family mentioned him speaking too fast and was jumping from one topic to another when having a normal conversation. This was the first such episode that the family was aware of.

The patient had delusions of reference where he mentioned getting religious messages through the newspaper that bad spirits were trying to harm his baby. He wanted to protect his baby from such spirits and believed God had given him special powers to do so. He mentions his mood was good and he was just worried about his child. He denied any auditory and visual hallucination. The family mentioned that the patient was doing well till a day ago, when his wife returned home with the new born child. There was no previous psychiatric or medical illness in the patient. He used to consume alcohol socially and his last use was around a month ago. He denied any illicit drug use. There was history of depression in the mother, who was adequately treated with antidepressant medication. No family history of other mood or psychotic disorders. He had a master’s level education and was working at a managerial position. He was married to his wife for the past 3 years and this was their first child.

He was alert and aware of his surroundings. His speech was pressured and mild motor aggression was evident. He appeared very concerned about his child’s safety. The remaining physical examination including a complete neurological examination was within normal limit.

Investigations

Laboratory investigation including a complete blood count, comprehensive metabolic profile and thyroid panel were within normal limit. His urine toxicology screen did not show any evidence of recent drug ingestion. MRI of the brain did not reveal any intracranial abnormality.

Treatment

The patient was admitted to the acute psychiatric unit for further management. He was diagnosed with an acute manic episode with psychotic symptoms. He was started on lithium 300 mg twice a day and administered oral olanzapine 10 mg at bedtime for the first 4 days of hospitalisation.

Outcome and follow-up

His symptoms started to show response on the current medication regimen by the 2nd day of hospitalisation and the patient was back to his normal level of functioning by day 6 of hospitalisation. The patient was discharged after a week of hospital stay and was followed as an outpatient. Over the next 2 weeks his lithium was increased to 900 mg twice daily to achieve a therapeutic level of 0.82 mEq/l. The patient has been continued on therapeutic dose of lithium and has not had a relapse of the symptoms, 3 months after the initial episode.

Discussion

Previous case reports have discussed similar pathology seen in fathers and even adoptive mothers.10 11 Couvade’s syndrome seen in males is a similar example where the male partner experiences symptoms and behaviour of an expectant mother which are of psychogenic origin.12 Variety of psychoanalytical, psychosocial and paternal theories has been offered to account for the origins of the syndrome.13 Similar theories could be applied to the phenomenon of psychotic or mood disorders in males seen right after the birth of their child. Male patients diagnosed previously with mood disorders have been described to decompensate during birth of their child.10 The role of psychological stress in precipitating such episodes needs to be highlighted. Psycho-social factors which predispose a father towards distress after the birth of their baby have been described.14 Birth of a child could distress the father on sharing his marital relationship with the infant, which can increase the distress especially in cases of marital dysfunction. Also fatherhood predisposes the male to give up the more carefree independent lifestyle and adopt the responsibilities and restrictions of the parent role. Men with higher levels of neuroticism and who use more immature defence mechanisms would be less likely to cope with these changes and thus would experience distress. Men also often adopt the traditional role of ‘protector’, and feel more comfortable when in control of situations and able to nurture their partners. During the perinatal period the mother usually gets a lot of support from various avenues and the husband, especially with poor self image could perceive this as a threat to his current role. Further the male who lacked good parenting model during his childhood struggles with what kind of father he would like to be. These psycho-social traits should be considered in screening of high risk individuals who are likely to decompensate during the birth of their child. Providing a high risk male support during the early fatherhood seems reasonable to prevent such episodes.

Learning points

  • Postpartum psychosis is a rare, however the most severe mood disorder in the perinatal period. It is most commonly associated with postpartum bipolar disorder.

  • The combination of frank psychosis and limited insight and judgment in postpartum psychosis can lead to damaging consequences in which the safety and well being of the affected mother and her child can be jeopardised.

  • Couvade’s syndrome seen in males is a similar example where the male partner experiences symptoms and behaviour of an expectant mother which are of psychogenic origin.

  • Few studies in the past have evaluated the prevalence of mood disorder in fathers during the perinatal period and estimated development of depression in approximately 4–6% of fathers in the early periods after child birth.

  • The role of psychological stress in precipitating such episodes needs to be highlighted. Screening of high risk individuals who are likely to decompensate during the birth of their child and providing them support seems reasonable to prevent such episodes.

Footnotes

  • Competing interests None.

  • Patient consent Obtained.

References

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