The psychoses of childbearing

It is 50 years since the late Ralph Paffenbarger (1961) wrote a famous article on ‘the picture puzzle of postpartum psychosis. In order to solve this puzzle, it is necessary to clarify the term ‘postpartum psychosis’. One must first exclude a wide variety of disorders, occurring after childbirth, which are not ‘psychoses’. This may seem obvious, but, at one time, some psychoanalysts included disorders of the mother-infant relationship under ‘postpartum schizophrenia’ (Zilboorg 1929). One must then draw a clear boundary between organic and non-organic psychoses. The birth process is so complex, and has so many complications, that there are (depending on definition) 15–18 distinct organic psychoses occurring in pregnancy, parturition or the puerperium (Brockington 2006). Nineteenth century alienists found it difficult to distinguish these from puerperal mania, and this was not finally achieved until the work of Chaslin (1895) & Bonhöffer (1910) at the turn of the twentieth century. Even the most common of these organic psychoses—eclamptic psychosis and infective delirium—are now rare in Europe, North America, and Japan; but these nations, where most of the research is done, contribute less than 10% of the world’s births. In the rest of the world they may be important, and they may still interfere with epidemiological, genetic, and neuroscientific studies of non-organic psychoses. As for the non-organic psychoses, a few are psychogenic, but most have manic depressive features. The term ‘puerperal affective psychosis’, however, does not suffice, because there is an extensive literature on ‘atypical psychoses’, under names like hallucinatorische Irresein der Wochnerinnen (Furstner 1875), amentia, cycloid psychosis, and acute polymorphic psychosis. That is why some psychiatrists still claim that ‘puerperal psychosis’ is a specific disorder, with its own clinical features—those ‘specific features’ are the polymorphic symptoms found in ‘atypical psychoses’, and occur in women at other times, and in men. Ralph Paffenbarger’s ‘picture puzzle’, therefore, applies to the combined group of puerperal bipolar and acute polymorphic psychoses.