Puerperal Psychosis Puerperal Psychosis de kraambedpsyschose proefschrift Ter verkrijging van de graad van doctor aan de Erasmus Universiteit Rotterdam op gezag van de Rector Magnificus Prof. Dr. C.J. Rijnvos en volgens besluit van het collega van Dekanen. De openbare verdediging zal plaatsvinden op woensdag 20 januari 1993 om 15.45 uur Jean-Luc Klompenhouwer Geboren te 's-Gravenhage Promotor: Prof. Dr. W.J. Schudel Promotor: Prof. Dr. L. Pepplinkhuizen Overige !eden: Prof. Dr. H.C.S. Wallenburg Prof. Dr. W. van Tilburg © 1992, Jean-Luc Klompenhouwer, Horst Niets uit deze uitgave mag worden verveelvoudigd en/of openbaar gemaakt, in welke vorm dan ook, zonder voorafgaande schriftelijke toestemming van de auteur. No part of this book may be reproduced, in any form, without written permission from the author. ISBN 90-73579-05-8 VOORWOORD Dit proefschrift over de psychosen in bet kraambed heeft de klinisch-psychiatrische invalshoek als belangrijkste benaderingswijze. Het is geschreven vanuit de overtuiging dat zorgvuldig onderzoek aan de patient, gedetailleerde kennis van psychopathologische fenomenen en zicht op de belevings­ en ervaringswereld van patienten de sleutel zijn tot grensverleggend onderzoek in de psychiatrie. Hoewel moderne classificatiesystemen orde hebben gebracht in de chaotische veelheid aan diagnostische termen en "ziektebeelden" en door bet gebruik van heldere en gedefinieerde criteria bij de classificatie van psychiatrische stoornissen de internationale overdraagbaarheid en communicatie aanzienlijk is verbeterd, heeft de massale toepassing ervan ook geleid tot een verarming in bet diagnostiscb bandelen en denken. De kunst van bet goed kijken naar patienten en de fenomenologische en diagnostiscbe kennis, die in 200 jaar gedifferentieerd Europees denken in de psycbiatrie werd opgebouwd, dreigen door de overweldigende eenvoud van classificatiesystemen als de DSM-III tot voorwetenschappelijke curiositeiten te worden gemarginialiseerd. In dit proefschrift over de kraambedpsychosen wordt een paging gedaan te demonstreren dat met behoud van de voordelen van de DSM-III benadering een meer verfijnde en op de klinische realiteit geente fenomenologische classificatie en diagnostiek mogelijk is. Naast diagnostiek en classificatie komen tevens epidemiologie, risicofactoren, behandeling, beloop op korte en lange termijn en preventie aan de orde. Aan dit proefschrift bebben vele mensen direct en indirect bijgedragen. Aan AnneMarie van Hulst ben ik bijzondere dank verschuldigd voor haar bijdrage en langdurige ondersteuning. Lea Rongen wil ik bedanken voor haar uithoudingsvermogen en inzet bij bet typen van bet manuscript. Belangrijke bijdragen werden tevens geleverd door Joost Schudel, Lolke Pepplinkhuizen, Joke Tulen, Peter Moleman, Roos van der Mast, Paul Mulder, Fred Lotgering, Marloes Jacobs, Bart Jacobs, Corine Rijnberk, Madoka Sunamura, Marjan van Delft en Frits Segers. De auteur dankt ook de directie en medewerkers van het Vincent van Gogh Instituut te Venray voor hun loyale ondersteuning en de firma Dupbar Nederland B.V. die de uitgave van dit proefschrift sponsorde. Tot slot de belangrijkste personen. Lieke is steeds een beldere toetssteen geweest voor de manuscripten; aan haar en aan onze kinderen Chris, Lisa, Mirjam en Julia dank ik bet feit te zijn blijven beseffen wat ecbt van belang is. CONTENTS CHAPTER I PSYCIDATRIC DISORDERS POSTPARTUM A HISTORICAL OUTLINE CHAPTER TI THE CLINICAL FEATURES OF POSTPARTUM PSYCHOSES A DESCRIPTIVE STUDY BASED ON THE CASE-HISTORIES OF 250 PATIENTS 21 CHAPTER III PATIENTS WITH POSTPARTUM MENTAL ILLNESS OBSTETRIC AND SOCIODEMOGRAPHIC CHARACTERISTICS, PSYCHIATRIC HISTORY, TREATMENT AND COURSE OF ILLNESS 45 CHAPTER IV THE CLASSIFICATION OF POSTPARTUM PSYCHOSES A STUDY OF 250 MOTHER AND BABY ADMISSIONS IN THE NETHERLANDS 59 CHAPTER V PROGNOSIS AND LONG-TERM COURSE IN POSTPARTUM PSYCHOSES A FOLLOW-UP STUDY (1967- 1989) 72 CHAPTER VI PROPHYLACTIC LITIDUM IN WOMEN AT IDGH RISK FOR POSTPARTUM PSYCHOSES 90 CHAPTER VII PUERPERAL PSYCHOSIS A STUDY BASED ON THE PHENOMENOLOGY OF PATIENTS WITH TWO CONSECUTIVE POSTPARTUM PSYCHOTIC EPISODES 107 CHAPTER VIII PUERPERAL PSYCHOSIS THE IDENTIFICATION OF A SEPARATE PSYCHOPATHOLOGICAL SYNDROME IN POSTPARTUM PSYCHOSES 118 CHAPTER IX CONCLUDING REMARKS AND RECOMMENDATIONS 125 SUMMARY 134 SAMENV ATTING 140 CURRICULUM VITAE 147 LIST OF PUBLICATIONS 148 ADDENDUM 150 CHAPTER I PSYCIDATRIC DISORDERS POSTPARTUM, A HISTORICAL OUTLINE. 1 PSYCIDATRIC DISORDERS POSTPARTUM, A HISTORICAL OUTLINE. Introduction. The observation that a relationship may exist between childbirth and the onset of mental disorder is not a recent one; it was already mentioned in the classical writings of the ancient Greeks. In fact, more "recent" scientific literature of the past 200 years contains a large number of publications on the subject, the descriptions and reflections of which often turn out to be remarkably relevant to our times. The more one studies these historical contributions in detail, the more one realizes that the basic questions that need to be answered today are the same as they were 150 years ago. Although there certainly have been some developments and the frontiers of our knowledge have been extended in some areas, it appears that, as in many areas of psychiatry, major questions relating to recognizable clinical entities and "hard" aetiological relationships are still unanswered. Hence, the aim of this historical outline is to follow the evolution in thought of the "concept" of puerperal psychosis and related aetiological hypotheses. In order to be able to follow the argument, the works of a relatively small number of influential authors will be discussed. In addition, a number of Dutch authors will be introduced who have set their mark on the situation in the Netherlands. For a more detailed overview of the literature concerning the period between 1835 and 1960, the reader is referred to J.A. Hamilton(!), who has devoted an extensive and almost complete discussion to these publications. Finally, the recent contributions to our knowledge of postpartum mental disorder will be summarized and the main objectives of this study will be outlined. 2 Historical contributions. Hippocrates (400 b.C.) The first clinical description of a postpartum psychiatric syndrome was made by Hippocrates in the fourth century B.C. In his third book of the Epidemics, he describes the case of a woman who gave birth to twins and then six days later began to suffer severe insomnia and restlessness. On the eleventh day she became delirious and then comatose. On the seventeenth day she died. He indicated two possible mechanisms in the aetiology of this psychiatric syndrome: As a first possibility he mentioned that lochial discharge, when suppressed, could be carried toward the head and result in agitation, delirium and attacks of mania. As a second possible mechanism he mentioned that when blood collects at the breast of a woman it indicates madness. (Quote from Hippocrates given by Hamilton, (1)) Hippocrates' ideas persisted for over 2000 years and, indeed, formed the basis for the distinction still made in the nineteenth and early twentieth century between puerperal and lactation psychoses. The mechanisms described of fluids being carried (or rising) towards the head can still be found in a popular Dutch expression for madness: "Ret is hem naar bet hoofd gestegen" (It has risen to his head). J.E.D. Esquirol 1838 The more systematic study of puerperal psychoses was initiated by the French psychiatrist Esquirol. In 1838 he published his classical book: "Des maladies mentales"(2). This work became one of the basic psychiatric textbooks of the nineteenth century. Esquirol devotes a complete chapter of his book to the subject of puerperal insanity. In this chapter called "De I' alienation mentale des nouvelles accouchees et des nourrices" he describes the patients he treated in "L'Hospice de la Salpetriere" in Paris during the Napoleontic era. He begins his argument with the observation that the number of women who become psychotic after childbirth, or during breast feeding, is far larger than is generally thought. He also remarks that puerperal insanity makes an important contribution to the overall psychopathology among women. Of 1119 women admitted to the Salpetriere during the years 1811 to 1815, 92 (8%) were admitted in connection with a puerperal insanity. During the years 1812 and 1813 as many as 10% of the patients were admitted as a result of a psychiatric disorder connected with childbirth and lactation. At an earlier stage Esquirol had already noticed that in a great number of these patients the symptoms of mental illness emerged in the first weeks after childbirth. He also observed that during the postpartum period the risk of women developing a psychotic 3 condition diminished as the moment of birth became more remote. These observations made him presuppose a causal relationship between the process of childbirth and the development of psychoses. Although Esquirol based his hypothesis on hospital admissions, later epidemiological studies would prove that his conclusions as to the temporal relationship between the onset of psychosis and childbirth were correct. In relation to clinical features and symptoms he indicated that women who become psychotic during lactation can be recognized from their typical facial expression (facies), without enlarging on this. Hence the question remains whether his observation is related to a symptom which was later to be described as "amentia" or "distressed