postpartum psychosis postpartum psychosis postpartum psychosis (ppp), also known as puerperal psychosis or peripartum psychosis, involves the abrupt onset of psychotic symptoms shortly following childbirth, typically within two weeks of delivery but less than 4 weeks postpartum. ppp is a condition currently represented under "brief psychotic disorder" in the diagnostic and statistical manual of mental disorders, volume v (dsm-v). symptoms may include delusions, hallucinations, disorganized speech (e.g, incoherent speech), and/or abnormal motor behavior (e.g., catatonia). other symptoms frequently associated with ppp include confusion, disorganized thought, severe difficulty sleeping, variations of mood disorders (including depression, agitation, mania, or a combination of the above), as well as cognitive features such as consciousness that comes and goes (waxing and waning) or disorientation. postpartum psychosisother namespuerperal psychosisrates of psychoses among swedish first-time mothersspecialtypsychiatry symptomshallucinations, delusions, mood swings, confusion, restlessness, personality changescausesgenetic and environmentalrisk factorsfamily history, bipolar disorder, schizophrenia, difficult pregnancytreatmentanti-psychotics, mood stabilizers , anti-depressants the cause of ppp is currently unknown, though growing evidence for the broad category of postpartum psychiatric disorders (e.g., postpartum depression) suggests hormonal and immune changes as potential factors contributing to their onset, as well as genetics and circadian rhythm disruption. there is no agreement in the evidence about risk factors, though a number of studies have suggested that sleep loss, first pregnancies (primiparity), and previous episodes of ppp may play a role. more recent reviews have added to growing evidence that prior psychiatric diagnoses, especially bipolar disorder, in the individual or her family may raise the risk of a new-onset psychosis triggered by childbirth. there are currently no screening or assessment tools available to diagnose ppp; a diagnosis must be made by the attending physician based on the patient's presenting symptoms, guided by diagnostic criteria in the dsm-v (see diagnosis). while ppp is only seen in 1 to 2 of every 1000 childbirths, the rapid development of psychotic symptoms, particularly those that include delusions of misidentification or paranoia, raises concerns for the safety of the patient and the infant; thus, ppp is considered a psychiatric emergency, usually requiring urgent hospitalization. treatment may include medications such as benzodiazepines, lithium, and antipsychotics, as well as procedures such as electroconvulsive therapy (ect). in some cases where pregnant women have a known history of bipolar disorder or previous episodes of ppp, prophylactic use of medication (especially lithium) either throughout or immediately after delivery has been demonstrated to reduce the incidence of psychotic or bipolar episodes in the postpartum period. ppp is not an independently recognized diagnosis in the dsm-v; instead, the specifier "with peripartum onset" is used for both "brief psychotic disorder" and "unspecified bipolar and related disorders." recent literature suggests that, more frequently, this syndrome occurs in the context of known or new-onset bipolar illness (see postpartum bipolar disorder). given the variety of symptoms associated with ppp, a thorough consideration of other psychiatric and non-psychiatric (or organic) causes must be ruled out through a combination of diagnostic labwork and imaging, as well as clinical presentation - a non-exhaustive sample of these other causes is examined below (see organic postpartum psychoses and other non-organic postpartum psychoses). clinical presentation by its diagnostic definition (under the name "brief psychotic disorder with peripartum onset"), ppp occurs either during pregnancy or within 4 weeks of delivering the infant. generally, ppp symptoms have been observed within 3–10 days of childbirth, though women with a past history of bipolar disorder may experience symptoms even sooner. the persistence of symptoms varies; while the average reported length of an episode may last weeks to several months, there is currently no strong literature documenting the course of individual episodes. recurrence rates for psychotic episodes, on the other hand, have stronger supporting studies and are covered in more detail below (see prognosis and outcomes). depression, as well as other mood symptoms like mania and irritability, is a relatively common feature of postpartum psychosis. diagnostic criteria per the dsm-v require the presence of at least one psychotic symptom, defined as delusions, hallucinations, bizarre or incoherent speech (disorganized speech), or abnormal movements (psychomotor behavior) such as catatonia. delusions, particularly about the infant, are the most commonly reported psychotic symptom associated with ppp. paranoid delusions are a frequently noted theme in cases of ppp, but a small review noted infrequent cases of delusional misidentification syndromes, such as capgras syndrome (the belief that someone or something familiar has been replaced with an impostor), fregoli syndrome (the belief that a stranger is actually a known person in disguise), and others. the latter types of delusions may have a significant negative impact on the bond between a mother and child, raising concerns for the safety of both (see prognosis and outcomes). both postpartum obsessive-compulsive disorder (ocd) and ppp may present with concerning thoughts about the infant; typically, the thoughts associated with ocd are unwanted and distressing to the individual (who does not wish to act on their thoughts), whereas persons with ppp are often less distressed by their beliefs and may even feel the need to act on them. compared to schizophrenia, ppp tends to feature less bizarre delusions, and associated hallucinations are more likely to be visual rather than auditory. the sensation of being outside one's body or feeling that one's surroundings are unreal (i.e., derealization) has also been described in cases of ppp. additional distinctions in ppp compared to classical schizophrenia include the presence of mood and cognitive (or neurological) symptoms. rapid mood changes or the presence of abnormal moods such as depression or mania (increased energy, decreased need for sleep, etc.) tend to be seen in a large percentage of patients experiencing ppp. irritability, anxiety, and general difficulties with sleep may also be present. confusion or disorientation, disorganized thoughts, incoherent speech, or abrupt changes in a person's mental capacity may also be seen in individuals experiencing ppp, though one small study observed these neurological symptoms in only one-quarter of ppp cases. like delirium, these symptoms may come and go in unpredictable patterns. thoughts of committing suicide or harming one's infant or children have also been reported as common occurrences in ppp, with as many as half of ppp cases exhibiting these features. in many cases where harmful thoughts exist, the person experiencing these thoughts does not consider their intended action to be harmful; rather, they believe that their actions are in the best interest of the child. in addition to the rapid onset of symptoms (less than two weeks) with the presence of a psychotic symptom, further diagnostic criteria defined by the dsm-v for "brief psychotic disorder with peripartum onset" include that the symptomatic episode ends within one month and involves a return to the individual's previous functional ability, as well as confidence that the episode is not a different psychiatric illness (e.g., depressive or bipolar disorder with psychotic features) or the result of substance-induced psychosis. risk factors childbirth is the primary cause of ppp; other causes and risk factors remain largely under investigation. the largest known risks for the occurrence of ppp include a history of ppp in a previous pregnancy, or a personal or family history of bipolar disorder. a significant number of ppp cases, however, occur in individuals with no prior history of psychosis. (for this reason, first-time pregnancy is itself sometimes considered to be a risk factor for ppp.) a review of pregnancy-related complications demonstrated some association between emergency caesarean sections (c-sections), excess bleeding, uterine rupture, and stillbirth (amongst other complications) and the subsequent development of ppp; however, several of the reviewed studies were contradictory and thus no consensus can confirm the relationship between problems related to pregnancy and ppp. lifestyle and psychological factors, such as previous trauma or single parenthood, have likewise been inconclusive as factors contributing to ppp, though a number of patients have reported a perception that social and pregnancy-related challenges were the cause of their ppp episodes. pathophysiology currently, the pathophysiology of ppp is not well understood and remains an open field of ongoing research. the leading theories under investigation involve areas of genetics, hormones, immunology, and sleep disturbance processes. genetics some findings suggest an association between ppp and variation in serotonin transporter genes and signaling or changes at specific chromosomes (e.g., 16p13 or mettl13). however, the majority of research devoted to genetic understanding of ppp has evaluated patients who have known bipolar disorder, so these associations may not be specific to ppp. hormones despite significant hormone changes that occur around pregnancy and childbirth, there is little evidence supporting hormonal causes behind ppp. changes in corticotropin-releasing hormone (crh) and adrenocorticotropic hormone (acth), as well as rapid changes in estrogen and progesterone, are known effects associated with delivering a child, and they are present in both those affected and unaffected by ppp; therefore, a relationship between hormonal change and the onset of psychosis is not well-supported, though some researchers continue to explore whether postpartum disorders might be related to differences in sensitivity to rapid hormone changes. estrogen has known impacts on various neurotransmitters, including serotonin and dopamine), which prominent theories associate with schizophrenia; however, investigations of estrogen concentrations and dopamine receptor sensitivity, and trials of estrogen replacement following birth, do not support an association between estrogen changes and ppp onset. immune system alteration due to above-average rates of ppp in individuals experiencing immunologic complications such as anti-n-methyl-d-aspartate (nmda) receptor encephalitis and autoimmune thyroid disorders, as well as the known heightened immune response post-childbirth, some theories suggest a connection between ppp and the immune system. there is some evidence connecting ppp with changes to levels of peripheral immune cells (e.g., lymphocytes and nk or natural killer cells) traveling in the bloodstream, but more research is required to identify the specific mechanisms and cell types involved which might be related to ppp onset. no direct evidence has shown a link between cytokine levels and ppp. sleep disturbance a link between sleep difficulty and ppp is not strongly supported by current evidence; however, some studies have demonstrated an increased risk for postpartum psychosis in women with bipolar disorder who have had manic episodes triggered by sleep disturbance. diagnosis and screening diagnosis there are no tests designed to diagnose postpartum psychosis. a complete blood count, pictured above, may be part of the initial work-up to rule out other organic causes of psychotic symptoms. not recognized as its own distinct disorder, ppp is instead classified by the dsm-v as a "brief psychotic disorder with peripartum onset." clinical requirements for the diagnosis of a brief psychotic disorder require the presence of at least one of the following psychotic symptoms: delusions, hallucinations, disorganized speech, and/or grossly disorganized or catatonic behavior. additional requirements include that the psychotic symptom lasts between one day and one month, eventually resulting in the person recovering their previous level of functional ability, and that the symptoms are not better related to a different psychiatric illness (including the result of ingesting substances such as alcohol or drugs). the specifier, "with peripartum onset," requires the development of the above within 4 weeks of delivering a child. there are no laboratory or imaging tools available to diagnose ppp, though a work-up of different laboratory analyses and imaging of the brain may be conducted to ensure other potential confounding diagnoses (e.g., vascular disorders, infective delirium, etc.) are not the cause of the patient's presentation (see differential, other non-organic postpartum psychoses, and organic postpartum psychoses). these may include, but are not limited to, a complete blood count, comprehensive metabolic panel, urinalysis and urine drug screen, and tests for thyroid functioning; further workup in the setting of classically neurological symptoms (such as delirium-like confusion) may include magnetic resonance imaging (mri), a test of cerebrospinal fluid (csf), or electroencephalogram (eeg). screening currently, no screening tools exist to evaluate for ppp, though providers may choose to use standard screens for postpartum depression and mania to evaluate the presence of these particular symptoms. it may be difficult for providers and family-members to identify ppp, due to the presence of several symptoms that are classically associated with other postpartum conditions such as postpartum depression, as well as overlap with often-benign changes that accompany new parenthood (anxiety, irritability, poor sleep). therefore, clinical recommendations advise healthcare providers to directly ask new mothers about thoughts of harming themselves or their children. differential the presentation of ppp includes a large differential overlapping neurological and psychiatric diseases and syndromes. neurological, or cognitive, symptoms like disorientation