Other Types of Postpartem Mood Disturbance

Excerpted from the CAMH publication: Postpartum Depression: A Guide for Front-Line Health and Social Service Providers, Chapter 1 - Clinical Overview

On this page:

• Postpartum, or “baby,” blues
• Postpartum pinks
• Postpartum anxiety
• Diagnosis
• Puerperal, or postpartum, psychosis

In this section we will describe other mood disorders that can occur following childbirth.

Postpartum affective disorders generally involve three categories: the blues (baby blues, maternity blues), PPD, and puerperal, or postpartum, psychosis, each having different symptoms and severity and requiring different management (see Table 1–1). This section also discusses anxiety following childbirth.

Table 1-1
Common Postpartum Mood Disturbances:
Summary of Onset, Duration & Treatment

Condition	Prevalence	Onset Often During	Duration	Treatment
Table adapted with permission from Nonacs & Cohen, 1998.
Blues	30-75%	Day 3 or 4	Hours to days	No treatment needed other than reassurance
Postpartem Depression	10-15%	Within weeks to 12 months	Weeks to months	Treatment generally required
Puerperal Psychosis	0.1-0.2%	Within 2 weeks, usually first week	Weeks to months	Hospitalization usually required

Postpartum, or “baby,” blues

Postpartum blues are the most common perinatal mood disturbance, affecting an estimated 30 to 75 per cent of women. The blues tend to appear in the first few hours to days after birth, usually peaking on day three or four. The symptoms only last a few days and generally cease within a week. Typically, the blues appear in a woman who is happy but experiences increased “emotional” responses to stimuli. She may change rapidly from being happy to tearful, and have inexplicable spells of irritability, weepiness, anxiety and sleep and appetite disturbances. Researchers have suggested that some of these effects may result from the rapid hormonal changes occurring.

The blues are mild, generally requiring no treatment other than support and reassurance. By definition, blues do not last longer than two weeks. And while most women remain well thereafter, up to 20 per cent of women with the blues develop major depression within the first year of having a baby. In some cases, women’s symptoms worsen and become depression, while others can recover from the blues and then subsequently experience depression.

Postpartum pinks

While “the blues” refers to mood lability (or changes in mood from happy to sad), some women experience mild elation, or “the pinks,” following childbirth; again, this elation lasts for a few hours to days until a more normal level of happiness returns (Glover et al., 1994). Similar to the baby blues, the pinks do not require treatment, and others may not notice the pinks if they view mild elation as a “normal” reaction to childbirth.

In some situations, symptoms of the blues or pinks require clinical attention. One of the core features of both the blues and pinks is that the mood changes are mild and transient. Extremes of either the blues or pinks are definitely a cause for concern—prolonged mood changes (longer than a few days) or big mood swings from high to low are indications of a more serious mood disorder developing and will require follow-up (see Chapter 6).

Postpartum anxiety

As for depression, anxiety occurring around pregnancy or following the birth of a child is clinically no different from anxiety that occurs at any other time. However, research data on postpartum anxiety is limited compared with data on other postpartum disorders. Studies indicate that between four and 15 per cent of women experience anxiety following childbirth (Wenzel et al., 2003; Matthey et al., 2003; Heron et al., 2004).

Some women experience anxiety only during pregnancy, some only following childbirth, and others throughout pregnancy and the postpartum period. In a recent large study of 8,323 pregnant British women, Heron et al. (2004) found that 7.3 per cent of women reported high levels of anxiety during pregnancy, as measured by a self-report questionnaire. Of those women who had high levels of anxiety during pregnancy, 1.4 per cent also scored high levels of anxiety when measured at eight weeks postpartum. Of the women who did not report high levels of anxiety during pregnancy, 2.4 per cent reported high levels of anxiety postpartum.

Many mothers feel anxious, overwhelmed and scared following the birth of their baby. This is understandable given the changes involved in becoming a new parent. However, for some women the level of anxiety is so severe that it interferes with their daily lives, and represents a change in normal character and functioning.

Diagnosis

The formal classification of anxiety disorders in the DSM-IV covers a range of disorders that may be specific in nature; that is, a specific phobia (such as fear of heights or spiders), panic disorder or obsessive-compulsive disorder. For some people, no one source or situation causes the anxiety, so clinicians consider their condition to be generalized anxiety.

For some women with postpartum anxiety, the fear or anxiety is general, but for others the symptoms may relate to something more specific (i.e., bathing the baby, taking the baby out in the car, coping with grocery shopping) or the symptoms may focus solely on the child (i.e., is the baby feeding properly and breathing properly, is the woman competent as a mother and able to look after the baby?). The mother’s anxiety typically exhibits itself as constant and/or excessive worry, fear or apprehension. She may appear edgy, tense and perpetually keyed up. In some cases, women will avoid certain situations because the fear is so overwhelming.

People with anxiety often describe physical symptoms or panic attacks that accompany the anxiety feelings, including:

• sweating
• palpitations
• nausea
• faintness
• an overwhelming urge to run away.

Women with anxiety problems do not experience the persistently low mood and anhedonia (loss of pleasure) that typifies depression, although as previously stated, mothers with PPD may also feel anxious.

Puerperal, or postpartum, psychosis

In contrast to the blues and PPD, postpartum (or puerperal) psychosis is the most severe and rare form of postpartum mood disorder, with rates of one to two episodes per 1,000 deliveries. The onset of symptoms is rapid, in many cases within 48 to 72 hours after birth, and most cases develop within the first two weeks postpartum. Studies (e.g., Jones & Craddock, 2001) suggest that postpartum psychosis has a genetic or biological cause and is more common in women diagnosed with bipolar disorder or with a family history of mood disorders.

The most common symptoms are extreme depressed or elated mood (mania), similar to that seen in bipolar disorder (or manic depression). Women with puerperal psychosis often fluctuate rapidly between mania and depression, or may experience a “high” (mania) followed by a depression. Women often exhibit bizarre or disorganized behaviour, and are often confused or perplexed.

Most women with postpartum psychosis experience psychotic symptoms. Clinicians define delusions as false fixed beliefs that have no rational basis in reality and that the individual’s culture deems unacceptable. Common types of delusions involve persecution, love and guilt, for example. Clinicians define hallucinations as perceptual distortions that have no external stimulus. The most common hallucinations are auditory (hearing noises or voices that nobody else hears) or visual (seeing things that are not present and that other people cannot see) (Dubovsky & Buzan, 1999). Examples of psychotic symptoms include the mother believing that she or her baby has special powers or superior intelligence (e.g., the mother believes that she will write a best-selling book or that she is a famous artist, the mother thinks that she and her baby could be on television because they are so talented). Some women may hear voices telling them to do things or saying things to them (which may be positive or negative).

As previously stated, cases of infanticide and suicide are rare but are a serious risk in women with postpartum psychosis. The symptoms of postpartum psychosis fluctuate rapidly, and a woman who was lucid and calm upon first interview can be suicidal and psychotic within a matter of hours.

The nature of the psychosis is very unpredictable and even an experienced psychiatrist can have difficulty detecting it (see Spinelli, 2004). Any woman exhibiting extreme mood changes (high to low) or psychotic symptoms requires an immediate emergency psychiatric referral (see Chapter 6).

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