Peripartum Depression and Psychosis – A Major Change Is Ignored
In my previous
post, I covered some of the legal, social, and cultural shortcomings affecting
peripartum and postpartum depression and psychosis. In this post I am going to cover a very basic
concept that I have discussed before and that is consciousness. It is a
major shortcoming of criteria-based diagnoses like the DSM. It is conspicuous by its absence. The DSM
makes it seem like all you need is a set of criteria, an adequate time frame,
and the ability to rule out other causes and you can make any psychiatric
diagnosis. The only time human
consciousness enters the picture is when the discussion is of altered states of
consciousness like delirium or dementia.
Even then older neurological terms like stupor and coma seem
to do a better job of capturing what is happening (1).
The additional limitation of criteria-based diagnoses is
that they do not get to a more complete description of behavior. A delusion is
not the total experience – the individual’s subjective experience is of
secondary importance. It is assumed that
behavior is either predicated on the delusion or other aspects of the person’s
life or personality. In psychiatric practice there is an entire other
constellation of factors that are typically included in a formulation, but even
then, the current subjective experience is not a focus.
We all have a baseline conscious state that we are familiar
with. Most discussions of consciousness begin with a disclaimer about no
universally accepted definitions. A good
general definition addresses 2 components – level of consciousness
(wakefulness/arousal) and contents of consciousness (specific objects and
events that one is aware of). The
content can be encyclopedic but there are also ongoing neurobiological
processes to consolidate, cue, and reinforce that content in varying ways. It
is a dynamic rather than static process. It has to be in order to give you an
integrated experience of life. The most
important product is the integrated first-person experience of oneself and the
world. But it is important to note that
consciousness is more than just that since there are additional processes
(access, intentionality, self-awareness).
Let me back up a bit and start out with the concept of phenomenal
experience. This is the subjective or “what it is like” to have an
experience. A common example in the
literature is the color red as in: “My experience of the color red is
not your experience.” That happens at a
number of levels but most people consider there is a consensus about the color
and leave it at that. Core features include qualia or the pure sensory
experience without associated information processing, first-person experience,
and distinct from other capacities like reasoning or controlling one’s
behavior.
Phenomenal experience is one aspect of human
consciousness. Additional aspects
include:
Cognitive access: content can be reported upon,
accessed, and manipulated (reasoned about and used to guide action).
Self-awareness:
awareness as oneself with a capacity for generating thought and action. Ability to distinguish oneself from the world
including other people.
Intentionality: directed perception of objects and
processes in the environment.
Reflective capacity:
knowing that the sensory experience is more than just sensation e.g.
knowing that you see is more than just seeing it leads to an integrated
experience at several levels.
Flexible cognitive control: flexible modulation of attention, processing
novel situations, decision-making, and integrating information. That includes
daydreaming, fantasizing, mental work, and directing yourself to and away from
those processes
There are numerous studies that map these functions onto
neuroanatomical structures and neurophysiological events. There is also the
interesting mapping of these functions onto ego functions that have been
extensively elaborated on since Freud.
An example of a common ego-function that most people have heard of is reality
testing. It is defined just as it
sounds: “The components are (a) the distinction between inner and outer
stimuli; (b) accuracy of perception (including orientation to time and place
and interpretation of external events), and (c) accuracy of inner reality
testing (psychological mindedness and awareness of inner states).” (From Bellak and Goldstein). I have consolidated these mappings into the
following table to illustrate what happens in psychosis.
| Feature of Human Consciousness | Corresponding Ego Function(s) | How Altered in Psychosis (with Examples) | References |
|---|---|---|---|
| Cognitive access / reportability (content broadcast for report, reasoning, action — access consciousness) |
Thought processes; judgment; regulation/control | Elevated threshold for conscious access with intact subliminal processing, attributed to disrupted top-down attentional amplification; correlates with reduced long-distance white-matter connectivity in the global-workspace network. Example: Schizophrenia patients require longer stimulus durations to consciously perceive a masked word, while unconscious priming is preserved. |
[1]–[3] |
| Self-awareness and a unified self (awareness of oneself as a persisting agent) |
Synthetic/integrative function; relation to reality (self/world demarcation) | Self-disorders with permeable ego-boundaries and disturbed agency; altered cortical-midline (mPFC, PCC/precuneus) and temporoparietal-junction activity during self-reflection and source monitoring. Examples: Thought insertion, thought broadcasting, passivity/made experiences, misattributing self-generated actions to others. |
[4]–[6] |
| Intentionality (aboutness) + distinguishing internal from external |
Reality testing (relation to reality) | Breakdown in differentiating internally generated from externally sourced experience across "reality distortion," "uncertainty of perception," and "hallucinations/delusions" domains; reduced parahippocampal/inferior-parietal activity during reality evaluation. Examples: Hallucinating a voice with no external stimulus; fixed delusional beliefs; confident memory errors misattributed to real events. |
[8]–[10] |
| Reflective / metacognitive capacities (knowing that one experiences) |
Judgment; synthetic function; observing-ego capacity | Metacognitive deficit with impaired insight and overconfidence in errors; disrupted anticorrelated balance between frontoparietal control and default-mode networks scaling with symptom severity. Examples: Poor illness insight (anosognosia for psychosis), high confidence in incorrect judgments, impaired self-monitoring. |
[10]–[12] |
| Flexible cognitive control (attention modulation, novel contexts, decision-making, cross-modal integration) |
Regulation and control of drives; autonomous functions; synthetic function | Imprecise hierarchical predictive coding — low precision of priors relative to sensory data — yielding aberrant salience and maladaptive belief updating via hippocampal-prefrontal-striatal dysfunction. Examples: Aberrant salience attributed to irrelevant stimuli seeding delusions; disorganized thought; failure to integrate prior task outputs into a working schema. |
[1], [13]–[15] |
The table is an indication of what is not in the DSM but
what has been described by psychiatrists who were focused on phenomenology in
the mid-20th century. Kurt Schneider suggested that a group of what
he called first rank symptoms were a more definite sign of schizophrenia and
represented a “radical qualitative change in the thought-processes themselves”
rather than a quantitative change. Norgaard
and Parnas expanded on this as “Kurt Schneider explicitly emphasized that the
formative matrix out of which the “first rank symptoms” emerge, was a “radical
qualitative change” in the field of consciousness, comprising a disturbed first
personal perspective(“Ichheit”) and a disturbed sense of “mineness”of
experience (“Meinhaftigkeit”). Schneider
argues that the psychosis in schizophrenia is not merely eccentric beliefs or
quantitative changes in symptoms but that it is a qualitative change in state.” In the case of schizophrenia insight and
judgment are affected by changes in experience related to these changes in
consciousness while baseline sensorium and personality are preserved.
DSM criteria do not tell you that the person affected by
psychosis is operating from an entirely different conscious state. These
observations about how a conscious state affect consciousness have been made
for centuries. The changes in processing, reality testing, and phenomenal
experience also affect moral and ethical decision making. Baseline moral frameworks are often
maintained but the decisions are affected by the changes in experiential
reality. This has been studied in
postpartum psychosis and filicide. Several
types of patterns of thought have been noted in studies of filicide and
psychosis. Before I reference those
studies, I want to add the following diagram.
It illustrates differences in usage of the term phenomenology in clinical
psychiatry.
The diagram (click to enlarge) shows that some research defines phenomenology as
descriptive psychopathology – basically defined sign and symptoms, syndromes of
disorders, or phenotypes. All of these phenomena can be described in terms of
clinical course and associations. They
can be studied with validated structured interviews and produce consistent
results at the syndrome and severity level.
Apart from the symptoms they have little to say about subjective
experience. It is phenomenology at the population level.
The first-person account of psychosis is a much different
type of phenomenology. It is focused on
how that person is experiencing the psychosis. Do they feel different? Does their world seem changed? Do familiar
people seem like strangers? Has their day-to-day experience changed? To borrow a question from the old Present
State Exam –“Are you thinking clearly or is there is something interfering with
your thinking?” Even though these are unique
experiences some researchers have developed semi-structured interviews to
capture experiences in certain conditions.
The Examination of Anomalous World Experience (EAWE) is one example
designed to capture subjective experience of people experiencing schizophrenia spectrum
disorders. It has 75 items across 6 domains of subjective experience.
The clinical interview in psychiatry combines elements of
both forms of phenomenology – basically because physicians are all taught how
to interview people around a central subjective theme called a chief
compliant. After doing many of these
interviews of people with the same or similar diagnoses – it becomes apparent
that no two people with the same diagnosis experience it the same way. In psychiatry and neurology it is more
complex because the substrate that has the problem is the same one that
produces the conscious state and the patient’s subjective experience of
it. By clinical or semi structured interview
– the focus is on psychopathology at the individual level and the effect on
consciousness.
How does all that apply to postpartum psychosis? There are
good studies of postpartum psychosis and research groups with ongoing
projects. The Massachusetts General Hospital
Postpartum Psychosis Project (MGHP3) is one research group that has published
on a large cohort of women (N=248) with postpartum psychosis (PP) (17). Data was collected by administration of the Mini
Internation Interview for Psychotic Disorder Studies (MINI-PDS).
61.7% of the sample met criteria for a
psychiatric disorder prior to an at the index episode of PP. 12.5% had a prior episode of psychosis. Substance use disorders were not excluded from
the sample to improve generalizability and 22.6% had a diagnosis of alcohol use
disorder (AUD) or substance use disorder (SUD).
Most patient were hospitalized (74.4%), received medications (93%), and
psychotherapy (65.89%). Median time to
return to psychiatric baseline was 25 weeks. This is the first time I
have seen psychiatric baseline used in the literature as an outcome criteria,
even though clinical psychiatrists have used this as a treatment standard for
decades.
Psychotic symptoms were well documented and there was
significant variability in the duration of symptoms. For 60.9% of subjects the symptoms lasted
between 1 day and 1 month, 24% lasted form 1 month to 6 months, and 10.47%
lasting greater than 6 months. Half of
the subjects said that their symptoms wax and wane. The authors point out that periods of
lucidity as possible and this may lead to a false impression that the patient
is doing better than they really are. Since most of the subjects received
atypical antipsychotics, the authors discuss the importance of determining
subgroups that may need maintenance medication and others where the medication
can be discontinued.
The issue of whether PP develops into bipolar disorder was
discussed. Not all women go on to
develop subsequent episodes, suggesting there may be a from that only occurs in
the postpartum period. The issue of
prevention of these episodes in woman with a preexisting diagnosis of bipolar
disorder was discussed and how that can be prevented with appropriate prophylactic
treatment. I would look to this group
in the future for more state-of-the-art research on PP. They appear to also have a genomics
component.
The question of child related delusions and their specificity
for PP was discussed. The authors
conclude that paranoia directed at partners and infants safety and wellbeing
were common and consistent with the idea that this may be a period of enhanced
vulnerability. I would see this paper as
a critical resource for psychiatrists interested in this disorder both at a clinical
and theoretical level.
A second paper is interesting in that it looks at women hospitalized
on a Mother-Baby Inpatient unit in the Netherlands. This group goes by the title
Onderzoeksprogramma Postpartum Psychose Erasmus MC Rotterdam (OPPER) and they
have previously published (18). The sample
size was 130 women. I wrote a post
on this setting a decade ago as an ideal resource for postpartum
conditions. Since then I am not aware of
any similar treatment setting in the US.
One of the interesting aspects of this sample is that 48% of the subjects
were admitted on an involuntary basis.
The standards described parallel most US standards for involuntary
treatment of risk to self or others or inability to care for oneself. 17% of the sample had either obsessive
concerns about harming the child or more or infanticidal thoughts.
This group used standardized questionnaires and rating
scales to characterize psychopathology including the Structured Clinical Interview
for DSM-IV Disorders (SCID), Young Mania Rating Scale (YMRS), Edinburgh Postpartum
Depression Scale (EPDS), and Hamilton Rating Scale for Depression (HAM-D). That
resulted in a total of 58 symptoms that were used to determine symptoms prevalence
and generate profiles by statistical modeling (latent class analysis). Anxiety, depression and delusions were the most
common symptoms across all profiles. A
total of 11 symptoms were used to develop profiles anxiety, depression ,
melancholia, agitation, mania, atypical , disorganization, delusions, hallucinations,
child-related, and catatonia. From these
symptoms a manic profile (34%), a depressive profile (41%), and an atypical profile
(25%) were developed. Dysphoric mania
was more likely and the authors point out it is more prevalent in woman at
baseline. Patients in the manic and
atypical categories were more likely to be treated on an involuntary basis. Like
the MGH study remission rates were high (82-94%) with fastest remission in the
manic group and slowest in the depressive group. The authors identified 2 cases
of NMDA encephalitis in the group with disorientation, disturbance of consciousness,
and disorganization suggesting it is important in the differential diagnosis of
this disorder.
The authors of this paper make the compelling argument that
PP is one of the few psychiatric disorders where the etiology (childbirth) is known.
They point out that it is a severe disorder that frequently requires
involuntary treatment, needs careful medical assessment, and although it seems
like it is on the bipolar spectrum – it should not be included there too quickly. Like the MGH group they point out that even
with the profiles they developed they are not able to predict disease course
and this would be a major advance in treatment.
There are other papers that apply to the current case and
similar cases in the last. Resnick
described cases of altruistic psychotic filicide associated with
altruistic delusions. The decisions are
associated with thoughts that the child will be protected from harm from evil,
criminal activity, or in some cases a specific family member that the mother has
delusional concerns about. In some
cases, the child is seen as already affected by evil that is irreversible. Death is the only way to protect the child
but it makes sense only in the context of an alteration in consciousness.
To summarize, a category-based diagnosis is not a comprehensive explanation of behavior. That is the main reason psychiatrists are taught additional approaches to formulation of the current problem. There is a general tendency of non-experts to lump all people with a similar diagnosis into the same category. That is an error that most second year medical students recognize when they see the vast variations in diagnostic presentations, outcomes, and treatments. In psychiatry, that variation is amplified greatly by all of the factors contributing to unique conscious states.
In forensic settings psychiatrists are called upon to
present a diagnosis, a formulation, and comment on how both inform any
statutory requirements for a defense or prosecution. As a psychiatrist who has testified in
hundreds of these hearings – the adversarial process is far from ideal. A few examples include, a judge telling me what
I can and cannot talk about, attorneys asking me questions they said they were
not going to ask, rhetorical techniques by attorneys that they thought would
shake me up, and questions that were clearly framed to distort the reality of
the situation. All of those factors suggested to me that the only way real
clinical psychiatry is expressed in court is if you have an expert witness who
is familiar with all of that rhetoric and can ignore it.
The other critical piece is what can be done to educate the
public as well as the jury. Formal
psychiatric training develops large categories that we need to cover in order
to do a good job. Thise categories exist
diagnostically but also in the mental status exam (MSE) or direct examination
of the patient. For most forensic
purpose the relevant categories are insight and judgment. Both are critical in any postpartum case of
filicide. That generally involves conclusory remarks based on connections with
other MSE categories. There is typically
no description of a conscious state, but there might be discussion of other
mitigating factors. It is probably time
to consider detailed discussion of how to include that component – not only in
court but in the DSM in general. Some of
the other proposed inclusions are probably less important.
George Dawson, MD, DFAPA
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