Zela's Case Study - Postpartum Psychosis (DSM-IV-TR)

Postpartum Piety 

Zela is a 30-year-old high-school teacher living in Lagos, Nigeria. She is married and has five children. The birth of her last child was complicated by hemorrhage and sepsis, and she was still hospitalized in the gynecology ward 3 weeks after delivery when her gynecologist requested a psychiatric consultation. Zela was agitated and seemed to be in a daze. She said to the psychiatrist, "I am a sinner. I have to die. My time is past. I can not be a good Christian again. I need to be reborn. Jesus Christ should help me. He is not helping me." A diagnosis of Postpartum Psychosis was made An antipsychotic drug, chlorpromazine, was prescribed, and Zela was soon well enough to go home.

Three weeks later, she was readmitted, this time to the psychiatric ward, claiming that she had had a "vision of the spirits" and was "wrestling with the spirits." Her relatives reported that at home she had been fasting and keeping vigil" through the nights and was not sleeping. She had complained to the neighbors that there was a witch in her house The "witch" turned out to be her mother. Zela's husband, Peter, who was studying engineering in Europe, hurriedly retured and took over the running of the household, sending his mother-in-law away and supervising Zela's treatment himself. She improved rapidly on an antidepressant medication and was discharged in 2 weeks. Her improvement, however, was short-lived. She threw away her medications and began to attend mass whenever one was given pursuing the priests to ask questions about scriptures. Within a week she was readmitted.

On the ward she accused the psychiatrist of shining powerful torch- lights on her and taking pictures of her, opening her chest, using her as a guinea pig poisoning her food, and planning to bury her alive. She claimed to receive messages from Mars and Jupiter and announced that there was a riot in town. She clutched her Bible to her breast and accused all the doctors of being "idol worshipers, calling down the wrath of her God on all of them.

After considerable resistance, Zela was finally convinced to accept electroconvulsive treatment, and she became symptom free after six treatments. At this point, she attributed her illness to a difficult child birth, the absence of her husband, and her unreasonable mother. She saw no further role for the doctors, called for her priest, and began to speak of her illness as a religious experience that was similar to the experiences of religious leaders throughout history. However, her symptoms did not retum, and she was discharged after 6 weeks of hospitalization. 

Discussion of "Postpartum Piety" 

The African psychiatrist who submitted this case says that the usual diagnosis for cases of this kind is Postpartum (Puerperal) Psychosis, Depressed Type. However, if the disturbance persisted well beyond the postpartum period, as it did in this case, the diagnosis would be changed to some other psychotic disorder. Most patients with Puer- peral Psychosis seek treatment by traditional healers or spiritual church healers. Zela's case demonstrates the way in which even highly educated Nigerians, such as this patient and her family, understand illness in terms of witchcraft or demonology.

This woman had recurrent, brief, psychotic episodes beginning shortly after the birth of her child. Her psychotic symptoms in- cluded delusions of guilt and visual and auditory hallucinations with religious content. Although the diagnosis and successful treatment given by her African psychiatrist assumed the presence of depression, the case report actually does not describe depressed mood or anhedonia.

In discussing the diagnosis from the perspective of DSM-IV-TR, let us first consider the initial evaluation. At that time Zela was delusional, agitated, and in a daze. Psychotic symptoms with a duration of at least 1 day and no more than 1 month that occur in the absence of a full mood syndrome and are not due to the direct effects of a substance or a general medical condition are diagnosed as Brief Psychotic Disorder (DSM-IV-TR). Since the onset was within 4 weeks postpartum, With Postpartum Onset can be specified. This diagnosis is noted as Provisional, pending the expected recovery within a month.

Many clinicians believe that the biological effects of parturition are responsible for postpartum psychoses. However, because of the difficulty of separating the psychological and physiologic stresses associated with pregnancy and delivery, DSM-IV-TR would not consider such cases to be Psychotic Disorder Due to a General Medical Condition.

What about the diagnosis of the two later psychotic episodes? The second episode also seemed to last less than 1 month. The DSM-IV-TR classification does not adequately deal with recurrent and apparently brief psychotic experiences separated by periods of full remission. Therefore, the only option would be to repeat the diagnosis of Brief Psychotic Disorder for the second episode. The duration of the third episode is more ambiguous. The observation that she became symptom free after six electroconvulsive treatments suggests that remission may have occurred within a month which would justify, once again the same diagnosis. If there were significant residual symptoms that necessitated the 6-week hospital stay, then the diagnosis would be changed to Schizophreniform Disorder (DSM-IV-TR) because of the bizarre delusions, ‘prominent hallucinations, and duration of disturbance greater than 1 month. We would specify With Good Prognostic Features because of the onset of psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning, her good premorbid functioning, and the absence of blunted affect.

Follow-Up 

During the following year, Zela had several brief relapses, with vivid and frightening dreams, which she described as a “loss of definition between reality and dream.” Her priest believed that she was going through a difficult religious experience. Her mother thought that witchcraft might be the source of her problems and proposed a traditional religious solution. However, it was her husband who prevailed, and each relapse was treated with medication. 

Zela returned to the psychiatry department 2 years later to visit the staff and to offer condolences on the death of one of the professors who had treated her. She reported that she was well and living a full life. This was in spite of her having occasional experiences of “presences” and “spirits.” She recalled that the first time she reported these experiences to her husband, Peter, his response was, “Oh my God! Where are those tablets?” She herself, however, had a religious explanation of her experiences.

Although she is thought by some to be excessively religious, Zela has been able to function quite satisfactorily at her job and at home without any further psychiatric support.