Elsevier

Medical Hypotheses

Volume 61, Issue 4, October 2003, Pages 477-481
Medical Hypotheses

Role of sleep loss in the causation of puerperal psychosis

https://doi.org/10.1016/S0306-9877(03)00200-7Get rights and content

Abstract

Puerperal psychosis is a rare but serious psychiatric disorder following delivery. Although controversy continues to surround its nosological status, puerperal psychosis is generally considered a mood episode with psychotic features occurring in the context of bipolar disorder or schizoaffective disorder. Due to the close temporal association with childbirth, the etiological role of gonadal steroids, particularly estrogen, has been considered. Familial factors have also been implicated in the triggering of episodes of puerperal psychosis. Sleep deprivation arising from an array of diverse factors is a common occurrence surrounding parturition. The author suggests that sleep loss plays a pivotal role in the causation of puerperal psychosis. Clinical implications of this hypothesis are discussed. Studies on the aetiology and pathogenesis of puerperal psychosis are urgently needed not only for prevention and better treatment strategies of puerperal psychosis but also for understanding the biological underpinnings of bipolar disorder.

Introduction

The effect of parturition on a woman’s mental and physical health has been the subject of inquiry since antiquity. Hippocrates is generally given the credit for providing the first clinical description of puerperal psychosis (1). Puerperal psychosis is a rare but serious psychiatric disturbance following childbirth. The term generally refers to a heterogeneous mix of symptoms such as rapid mood changes, psychomotor disturbance, disorganization of thought, hallucinations in different sensory modalities, disorientation, and confusion occurring in the context of a mood disorder or schizoaffective disorder [2], [3], [4]. Women with puerperal psychosis, especially those with a family or personal history of puerperal or non-puerperal episodes, are at a high risk of developing subsequent psychopathology [5], [6] but up to 40% of women do not experience any further episodes in spite of further deliveries (7). Manic episodes are more likely to have an earlier onset after delivery than episodes of major depression and patients with mania also get hospitalized sooner than women with other puerperal disorders [7], [8]. There is a significant diagnostic consistency between the index episode of puerperal psychosis and future recurrences [5], [6], [7], [9].

The issue of whether puerperal psychosis constitutes a distinct entity remains a topic of debate. While DSM-IV-TR does not consider it as a separate diagnosis, it allows the use of a postpartum specifier to denote a major depressive, manic, or mixed episode in major depressive disorder, bipolar I disorder, bipolar II disorder; or brief psychotic disorder occurring within 4 weeks of delivery (10). Proponents of puerperal psychosis as a distinct diagnosis have argued that the presence of symptoms including perplexity, non-organic confusion, and Schneidnerian first rank symptoms distinguishes puerperal from non-puerperal episodes [2], [5], [11], [12], [13].

In spite of rather impressive data on the topic, the aetiology of puerperal psychosis remains poorly understood. Various risk factors including primiparity, caesarean section, perinatal death, history of bipolar disorder and a family history of bipolarity or puerperal psychosis have been described but the nature of the precipitant that provokes a puerperal psychotic episode remains elusive [6], [8]. For an understanding of the aetiology, consideration of three factors including nature of the diathesis, nature of the trigger, and the variables that determine the polarity of the puerperal episode, is essential (14).

Section snippets

The diathesis

A large body of literature suggests that bipolar disorder constitutes a diathesis for the development of puerperal psychosis [3], [8]. Brockington et al. (3) described puerperal psychosis as ‘an acute affective psychosis with florid psychotic symptoms, with manic and depressive mood being approximately equal in occurrence’. Others reached a similar conclusion that puerperal psychosis is essentially manic-depressive illness precipitated by childbirth (8). Supporting evidence in this regard comes

The trigger

Due to its close temporal association with puerperal psychosis the causal role of parturition has long been suspected. The early postpartum period is characterized by dramatic physiological changes including a drop in the levels of estrogen, progesterone [21], [22], melatonin (23), β-endorphins and corticotrophin releasing hormone, all of which have been linked to puerperal disorders (24). Most notable, however, is the drop in the level of estrogen which falls nearly 1000-fold from its peak

Discussion

Cross-sectional and follow-up studies provide evidence that depression is common following parturition and is more frequent than mania. Although 10–15% of women develop depression at some time during the three months after delivery (45), there is an excess of episodes in the first few weeks of childbirth. Psychotic depression, like mania, tends to occur soon after childbirth. Depression developing within two weeks of delivery is considered a manifestation of bipolar disorder due to early onset,

Acknowledgements

Mrs. Anita Sharma is thanked for her help in the preparation of the manuscript. The Ontario Mental Health Foundation is thanked for their support of this work.

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