Differential Diagnosis on the Postpartum Depression Spectrum

 An accurate diagnosis?

It is useful to be aware that clinical presentation of the diagnoses on the postpartum depression spectrum often overlap and/or co-occur in an individual. It is useful to be aware that diagnosis is sometimes not simple, and may be confounded by a woman’s individual prior history of depression, anxiety, post-traumatic stress influenced by previous life experiences. Simpler depression and anxiety can be diagnosed and treated in primary care. For more complex cases, a psychiatric consult is recommended. Licensed mental health professionals can diagnose and treat a broad range of mental disorders. Optimal treatment is considered a combination of medication and therapy, tailored to individual needs.

Differential diagnosis of perinatal mental illness?

The following categories of perinatal mental illnesses are not recognized by the Diagnostic and Statistical Manual of Mental Disorders (DSM). However, many researchers and clinicians in the field have recognized these differential diagnoses. The authors of the references in this article are some of the specialists who recognize these differential diagnoses. There is currently a call for more active discourse in creating these new diagnoses.

Four categories of alphabet soup : BB, PPD, PPA/PPOCD, PP, PTSD/CB

  • BB –   Baby Blues
  • PPD – Postpartum Depression
  • PPA – Postpartum Anxiety
  • PP-OCD -Postpartum Obsessive-Compulsive Disorder
  • PP – Postpartum Psychosis
  • PTSD(BB) Post-Traumatic Stress Disorder (Childbirth Onset),
  • also called  Birth Trauma

While all of these categories may seem confusing, it is mostly important to know that you don’t have the burden of diagnosis. These categories are being shown to you for educational purposes, so you can have an awareness.

  • Baby Blues – BB. Not a mental illness. A normal, self-limiting condition. Occurs in the first two weeks or so of pregnancy and usually go away by themselves. The baby blues self-resolves and is normal. It is not a mild form of postpartum depression.

  • Postpartum depression – PPD.

Symptoms:When weepiness, sleeplessness, low self-esteem, change in appetite,

feelings of being abandoned, alone, anger (rage), listlessness continue past two – three weeks, it is starting to move into the realm of postpartum depression. There are often accompanying thoughts of self-harm or of harming the baby. In general, women who are depressed after birth who actually attempt and commit suicide (rather than have these thoughts) are those who have histories of previous psychiatric events and/or previous suicide attempts. However, whenever harming behaviors are mentioned, they must be taken seriously.

Other information: Many specialists in the field believe PPD can overlap the baby blues and can begin anytime in the first year,. If it looks as if the feelings of baby blues are dragging on past the two-three week delimiter, it is best to seek help, rather than continue to suffer painful debilitating symptoms while also caring for an infant.

  • Postpartum anxiety/OCD – PPA/PPOCD.

Additional risk factors pertaining to PPA/PPOCD:

Some research suggests that some women who develop PPA/PPOCD have a heightened sensitivity to hormonal levels, in particular oxytocin, and this sensitivity may over- stimulate natural maternal behaviors, thus increasing maternal behaviors to over- protectiveness (Driscoll and Sichel, 1999).

Some research suggests the pre-existence of a certain thinking styles listed below may predispose a woman to postpartum anxiety/OCD (Kleiman & Wenzel, 2011).

  • Perfectionistic tendencies
  • Rigidity (an intolerance of grey areas & uncertainty)
  • An erroneous belief and pervasive feeling that worrying is a way of controlling or preventing events
  • An erroneous belief that thoughts will truly create reality
  • An underlying lack of confidence in one’s ability to solve problems
  • Intrusive thoughts – such as from post-traumatic stress
  • Poor coping skills

Symptoms: A pervasive anxiety that expresses itself as over-concern for the baby, over concern about germs, cleanliness, sleep arrangements, parenting skills and the normal attachment process. The mom takes on a hyper-vigilant stance. She may even bring baby to the hospital or doctor over and over again. She may develop checking behaviors such as checking to see if the blankets around the baby are folded properly, checking to see if the baby is breathing over and over again. She may be using (but not talking about) checking and counting rituals, which are designed for safety for the baby and soothing for the mom. This takes the form of obsessively counting the number of ceiling tiles in a room, counting the right angles in a room, or ordering the towels and clothing in a particular way in a closet. The mom be experiencing very scary thoughts about harming t he baby or herself. As in PPD, these must be taken seriously.

  • Postpartum psychosis – PP.

    • This is a separate disorder from PPD/ PPA/PPOCD

Additional risk factors pertaining to postpartum psychosis:

***Healthcare provider screening and prevention is extremely relevant to postpartum psychosis.

Most significant risk factor for pp psychosis is previously (un)diagnosed cyclical mood disorder (bipolar disorder), a previous psychotic episode or if there is a family history of schizophrenia or bipolar illness.

Postpartum psychosis is considered a psychiatric emergency.

Postpartum psychosis is relatively rare. It occurs in approximately 1 in 1000 deliveries, or in .1% of deliveries. Women are most susceptible to psychosis in the first thirty days after childbirth.

Symptoms:

Not sleeping for a few nights in a row, delusions, speaking about nonsensical beings, thoughts about evil beings, death, blood, intense fear, mumblings, robotic movements, stiff, acting as if she can hear words coming from somewhere else (what is called command language in her head), staring, flat affect, deflated speech, one word answers, catatonia, staring, paranoia.

Remember:

***You cannot talk a person out of their delusions.

***Best to nod your head, listen, say, “I understand” or “Must be hard”

and GET HELP IMMEDIATELY.

Contact her husband, partner, mother, whomever is closest in proximity,

and have them call 911 or escort her to the emergency room for a psychiatric evaluation.

If a close family member is not available, you must contact 911 for her.

This person is not faking it.

This person is very ill and needs help, not ridicule or fear.

Note: I worked in a center for the severely mentally ill for three years, and seeing a psychotic state is pretty unnerving, especially if you are seeing it for the first time.

The key is to try to stay calm and get help. Don’t agitate the person by trying to talk her out of her delusion. Get help immediately.

  • Postpartum PTS/PTSD (or) PTSD secondary to childbirth -PSTD/CB.

The diagnosis of PSTD secondary to childbirth, while cited in research for several years, is not currently recognized in the DSM.

Trauma exists on a spectrum from uncomfortable feelings> pts > ptsd

Ayers (2009) reports 1/3 of the women in the western world consider their birth to be traumatic, ten percent report severe symptom of traumatic stress, however, most self-resolve. 1% – 2% develop clinical post-traumatic stress symptoms which should be treated.

Ayers (2009) reports that trauma depends on the interaction of the severity of birth, interpersonal factors, personal strengths and vulnerabilities.

Ayers (2009) says that the issues of the relationship between PTSD and childbrith is in its infancy, yet we are broadening our understanding of postnatal mental health.

The Listening to Mothers (2006) research indicates there is an increasing pressure to improve maternity services.

Regarding uncomfortable feelings:

Research such as Cheryl Beck’s In the Eye of the Beholder (2004) mentions feelings that women have while birthing. A predominate theme indentified in the research:

“Why couldn’t they have cared for me?”

Beck (2004) culled four themes describing the essence of women’s experiences of birth trauma:

“To care for me: Was that too much too ask? To communicate with me: Why was this neglected? To provide safe care: You betrayed my trust and I felt powerless, and The end justifies the means: At whose expense? At what price? Beck’s conclusion was that birth trauma lies in the eye of the beholder. Mothers perceived their traumatic births were viewed as routine by clinicians.”

Regarding Post-traumatic stress (PTS):

Post-traumatic stress is a normal response to stress. Behaviors used to cope, to a certain degree, such as dissociation (to a certain extent), putting it out of your mind, numbing to the experience, flashbacks, hypervigilance, are types of psychological defenses that help keep the psyche healthy. In some research, these survival behaviors/mechanisms are described as “coping ugly.” Some people have PTS or acute stress symptoms for a few weeks, and then they pass.

For a good portion of people, this normal response to trauma, or “coping ugly,” is a healthy survival response. It is classified as normal. People can evolve from trauma. Difficult birth experiences can affect psychological health, but for majority it is self-resolved. Other’s conditons do not self-resolve, but continue on for more than a few weeks or so.

Regarding Post-tramatic Stress Disorder (PTSD):

Symptoms:

Post-traumatic stress disorder is the result of the body and mind’s response to a stressful event, such as natural or man-made disasters (hurricanes, bombings, assault, crime, medical interventions, etc.). Symptoms are flashbacks, hypervigilance, triggers, anxiety, depression, b/c of overlap, can be blanketed as PPD, differential diagnosis can affect tx

Treatments for PTSD: Immediate professional treatment to process the event. Eye Movement Desensitization and Rreprocessing (EMDR) is an evidence -based treatment for trauma and PTSD. EMDR is recommended by the Substance Abuse and Mental Health Services Adminstration (SAMHSA), best practices / Irish & Israeli govts

Research Reference Specific to EMDR for PTSD Secondary to Childbirth – published in Birth March 2012

Stramrood, C. A., van der Velde, J., Doornbos, B., Marieke Paarlberg, K., Weijmar Schultz, W. C. and van Pampus, M. G. (2012), The Patient Observer: Eye-Movement Desensitization and Reprocessing for the Treatment of Posttraumatic Stress following Childbirth. Birth, 39:70–76. doi:10.1111/j.1523-536X.2011.00517.x

Treatment with eye-movement desensitization and reprocessing reduced posttraumatic stress symptoms in these three women. They were all sufficiently confident to attempt vaginal birth rather than demanding an elective cesarean section. We advocate a large-scale, randomized controlled trial involving women with postpartum posttraumatic stress disorder to evaluate the effect of eye-movement desensitization and reprocessing in this patient group. (BIRTH 39:1 March 2012)

Listening to Mothers II Survey (2006)

Listening to Mothers II (2005) is a research study developed by the Childbirth Connection, Boston University, and Harris Interactive® in partnership with Lamaze International. Second study explored core issues in more depth and alos postpartum issues. It is a study of 1573 women aged 18- 45, who had given brith to a single baby, in one hospital.

The study remidns us that there are 4 million births in America each year and that a percentage point is 40,000 people.

The study concludes that the US is on track with prenatal care.

However, with birthing practices, it was found that large segments of the health population were given clearly inappropriate care during birthing, that support for normal birth was limited; and there were large amounts of interventions, invasion and risk.

The majority of women reported feeling overwhelmed and frightened at the pivotal point of their life, childbrith. They reported suffering indignities and unaked for treatment. It was reported that clear informed consent was not followed, that side effdects of medical treatments were not fully understood. The researcers found that women suffered emotional and physical side effects at the same time they are beginning to care for newborns.

Further, the study found that in the healthy population, four in ten births were started artifically, one in three women had a c-section, and most did not experience spontaneous physiologic birthing. In addition, most women interested in VBAC were denied that option. Of these 1500 women, only a small fraction used low-risk, highly rated, drug-free measures for pain relief, such as tubs, showers, birth balls.

The study found that even though large scale prospective studies indicate healthy women require low intervention during birth, most experience birth as a technological event, with wires, tubes, machines, immobilization, high levels of surgery, and come out of the experienec burdened with health concerns while caring for a newborn.

This study also found that US to have reproductive health policies which fail to minimize unplanned pregnancies.

 

References

Ayers, S. and Ford, E. (2009). Birth trauma: Widening our knowledge of postnatal mental health. European Health Psychologist, June, 2009, (11), p. 16 – 20.

Beck, C. T. (2004) Birth Trauma – In the Eye of The Beholder. Nursing Research. 53(1): 28 – 35

Declercq E, Sakala C, Corry M, Applebaum S. 2006. Listening to mothers II: Report of the second national U.S. survey of women’s childbearing experiences. New York: Childbirth Connection.

Driscoll, D. and Sichel, J. (1999). Women’s moods: What every woman must know about hormones, the brain, and emotional health. New York: HarperCollins

Kendall-Tackett, K. (2005). Depression in new mothers. New York: Haworth Press.

Kleiman, K. (2009). Therapy and the postpartum woman. New York: Routledge Press.

Nonacs, R. (2006). A deeper shade of blue. New York: Simon and Schuster.

Postpartum Support International (2009). Components of care. Seattle: PSI

Puryear, L. J. (2007). Understanding your moods when you’re expecting. New York: Houghton Mifflin Company.

Stramrood, C. A., van der Velde, J., Doornbos, B., Marieke Paarlberg, K., Weijmar Schultz, W. C. and van Pampus, M. G. (2012), The Patient Observer: Eye-Movement Desensitization and Reprocessing for the Treatment of Posttraumatic Stress following Childbirth. Birth, 39:70–76. doi:10.1111/j.1523-536X.2011.00517.x

Twomey, T.M. (2009). Understanding postpartum psychosis: A temporary madness. Westport, Ct.: Praeger Publishers.

 

 

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