Postpartum Psychiatric Problems

By James Alexander Hamilton

The present volume deals with the illness nowadays known as Postpartum Depression (PPD). The book was written by Dr. James Alexander Hamilton, a California psychiatrist who in 1980 founded the Marcé Society; its aim was to bring together psychiatrists, endocrinologists and social scientists to foster communication about PPD, which directly aligned with Dr. Hamilton’s goal, since 1955, to encourage physicians in the United States to better understand PPD in order to help victims of the illness.

“Psychiatric illness which develops after childbirth is one of the most challenging problems of modern medicine. It usually occurs acutely and unexpectedly from a state of apparent good health. The patient is disabled at precisely the moment when her responsibilities and her capacity for enjoyment of life are greatest. Successful treatment of this kind of illness is most rewarding.

“This book represents a collection and integration of widely scattered information which bears on the diagnosis and treatment of postpartum psychiatric problems. Some of this information relates to neglected physiological factors in these problems.”—Dr. James Alexander Hamilton

• Language: English
• Publisher: Muriwai Books
• Release date: Dec 12, 2018
• ISBN: 9781789128307

James Alexander Hamilton

James Alexander Hamilton was an American psychiatrist and author. He was born on June 9, 1907 in Pecatonica, Illinois, the son of Dwight Stoney and Pearl (Blake) Hamilton. He attended from the University of California, Berkeley and received his Bachelor of Arts degree in 1928 and his Ph.D. in 1935. He earned his Doctor of Medicine from Stanford University in 1941. Dr. Hamilton began his career as assistant professor of psychology and assistant dean of students at the University of California, Berk. in 1941. He then served in the United States Army during World War II, attaining the rank of major, from 1942-1948. He then went into private practice in San Francisco, California for 30 years, whilst also serving as a clinical instructor in psychiatry at Stanford University (California) from 1949-1955, and associate clinical professor in psychiatry from 1956-1975. He began researching postpartum psychosis in 1955. He acted as director and vice chairman of Chemetrics Corporation in Burlingame from 1975-1979. In 1962, Dr. Hamilton wrote the landmark Postpartum Psychiatric Problems. Interest and research in the field grew, and in 1980 he founded the International Marcé Society, headquartered in England. The Marcé Society was named after French psychiatrist Victor Marcé, who wrote the first treatise on puerperal mental illness in 1858 and advocated for research, treatment, and the promotion of social support in the area of postpartum illness worldwide. Continuing his research, in 1992, Dr. Hamilton and Patricia Neel Harberger published Postpartum Psychiatric Illness: A Picture Puzzle, which further contributed to the knowledge base regarding perinatal mental illness. In 1987, he founded Postpartum Support International (PSI) in collaboration with Jane Honikman, and members included social support group leaders from England, Canada, South Africa, Australia, and the United States. Dr. Hamilton was a member of American Psychiatric Association.

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Text originally published in 1962 under the same title.

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POSTPARTUM PSYCHIATRIC PROBLEMS

BY

JAMES ALEXANDER HAMILTON, PH.D., M.D.

TABLE OF CONTENTS

Contents

TABLE OF CONTENTS 3

PREFACE 4

Chapter 1—Introduction 6

Chapter 2—A profile of clinical features 8

VARIABILITY OF SYMPTOMS AND SYNDROMES 8

Chapter 3—Distressed perplexity 20

THE FAMILY 20

THE PHYSICIAN 20

THE PSYCHIATRIST 21

SUMMARY 24

Chapter 4—The syndrome of delirium 25

GENERAL FEATURES OF DELIRIUM 25

POSTPARTUM DELIRIUM 28

TREATMENT OF POSTPARTUM DELIRIUM 32

Chapter 5—The affective syndromes—mania and depression 39

NONPUERPERAL AFFECTIVE SYNDROMES 39

POSTPARTUM AFFECTIVE SYNDROMES 40

Chapter 6—The dissociative syndromes 52

CONCEPT OF DISSOCIATION 53

TYPES OF SCHIZOPHRENIA 53

POSTPARTUM DISSOCIATIVE SYNDROMES 54

Chapter 7—Psychological patterns and psychotherapy in postpartum mental illness 63

PSYCHOLOGICAL FACTORS IN POSTPARTUM MENTAL ILLNESS 63

SIMILARITY OF POSTPARTUM MENTAL ILLNESS AND COMBAT PSYCHOSES 66

THEORETICAL CONSIDERATIONS 67

PSYCHOTHERAPY IN POSTPARTUM MENTAL ILLNESS 68

SUMMARY 71

Chapter 8—Anxiety 73

MECHANISMS OF ANXIETY 74

SOME PRINCIPLES OF ANXIETY 75

APPLICATIONS OF PRINCIPLES TO PUERPERAL ANXIETY 79

SUMMARY 81

Chapter 9—Postpartum sex problems 82

RANGE OF MANIFESTATIONS 82

LIMITATIONS OF PRESENT TREATMENT 82

CONTROVERSY REGARDING CAUSAL FACTORS 82

PROVISIONAL EXPLANATORY SCHEME 83

TREATMENT 87

SUMMARY 89

Chapter 10—The transitory syndrome 90

REVIEW OF THE LITERATURE 90

AN INTERVIEW STUDY 91

SUMMARY 94

Chapter 11—Endocrine relationships 95

PRINCIPAL ENDOCRINE CHANGES RELATED TO REPRODUCTION 95

THE THYROID PARAMETER 96

THE PITUITARY PARAMETER 101

THE ADRENAL CORTEX PARAMETER 103

SUMMARY 106

Chapter 12—History 107

EARLY OBSERVATIONS 107

CONTRIBUTIONS OF MARCÉ 108

OTHER NINETEENTH CENTURY CONTRIBUTIONS 111

TWENTIETH CENTURY APPROACHES 113

SUMMARY 117

Chapter 13—The picture puzzle 118

Chapter 14—Conclusion 124

REQUEST FROM THE PUBLISHER 127

PREFACE

PSYCHIATRIC ILLNESS which develops after childbirth is one of the most challenging problems of modern medicine. It usually occurs acutely and unexpectedly from a state of apparent good health. The patient is disabled at precisely the moment when her responsibilities and her capacity for enjoyment of life are greatest. Successful treatment of this kind of illness is most rewarding.

This book represents a collection and integration of widely scattered information which bears on the diagnosis and treatment of postpartum psychiatric problems. Some of this information relates to neglected physiological factors in these problems.

The first physician who sees incipient postpartum illness is usually not a psychiatrist. He may be an obstetrician, a general physician, or a pediatrician. One objective of this book is to provide this physician with diagnostic criteria that will enable him to identify those patients who are likely to require specialized care.

Psychiatric opinion is divided as to the significance of physiological factors in the etiology of postpartum mental illness. Some psychiatrists believe that childbirth acts only as a trigger to activate a latent illness. This book advances the thesis that physiological changes subsequent to childbirth are highly important in the causation and course of such an illness and that psychiatric management should include attention to these changes. This thesis is supported by many lines of evidence, including reports of experimental therapy.

The incidence of serious postpartum psychiatric illness is considerable. In the United States alone, approximately four thousand women are severely disabled each year. Probably many times this number suffer lesser degrees of disability. Nevertheless, the amount of research which has been done in this area is negligible. Many factors may be responsible for this, not the least of which is the departmentalization of medical teaching and practice among such disciplines as obstetrics, biochemistry, and psychiatry. Care of the postpartum patient cuts across these divisions and suffers thereby.

It is hoped that this book will help to create an awareness of postpartum illness as an entity to be recognized immediately and treated aggressively by all appropriate measures. Furthermore, it is hoped that the focus of attention on this neglected area will help to stimulate the volume and quality of research which is merited by the magnitude of the problems involved.

I wish to acknowledge, with thanks, the advice and assistance that has been given me by many persons during the preparation of this book. Among my colleagues, the following have been particularly helpful: Dr. E. L. Ballachey, Dr. D. Bernstein, Dr. D. G. Campbell, Dr. W. Dedoff, Dr. R. Escamilla, Dr. L. Grant, Dr. A. L. Litteral, Dr. H. M. Lyons, Dr. E. Macklin, Dr. C. E. McLennan, Dr. E. Overstreet, Dr. A. Palmer, Dr. K. Schaupp, Jr., Dr. .G. Smith, Dr. R. Trapnell, Dr. A. Voris, and Miss Rose Segure. I have been aided by a remarkable and devoted group of research assistants and secretaries: Mrs. J. Auston, Mrs. G. Brimley, Miss M. Caylor, Miss R. Collins, Miss J. McCoy, and Mrs. E. Pappas. Mrs. A. V. Hoen provided valuable assistance with bibliographic material. My personal secretary, Mrs. Dorothy Fay, has made vital contributions to every phase of this book and to the work on which it is based. The superb psychiatric staff at Saint Francis Memorial Hospital, headed by Clare Greene, R.N., has provided the sensitivity and judgment that are necessary for twenty-four-hour management of acutely ill patients. My wife, Marjorie, has sustained the spark of enthusiasm and the thread of continuity throughout the years that we have been concerned with postpartum psychiatric problems.

James Alexander Hamilton

490 Post Street

San Francisco 2, Calif.

Chapter 1—Introduction

OF ALL THE AILMENTS to which the human mind and body are vulnerable, none is more catastrophic than serious psychiatric illness following childbirth. In the typical case, a woman embarks upon childbearing without a previous history of psychiatric illness. As with most pregnancies there is an element of apprehensiveness, but she has reasonable confidence and pleasurable anticipation. She endures more or less discomfort during pregnancy. At the time of delivery she receives excellent medical and nursing care. She emerges from childbirth with the gratification of having reached the goal she has anticipated for nine months. Then, within days or weeks, either with the impact of an explosion or with the slow progress of insidious erosion, she changes from a competent, productive, and happy member of society to a person paralyzed by depression or tormented by pervasive fears and perhaps by hallucinations and delusions.

If the incidence of serious psychiatric following childbirth were extremely small, the problem might be regarded with some equanimity and written off as a strange accident of fate. Unfortunately this is not the fact. Many surveys have been made, and the statistics have been consistent for well over a century. A cross section of these studies indicates that incidence of such illness is of the order of one case for each thousand births. This amounts to more than 4,000 persons each year in the United States who are sufficiently ill to need psychiatric hospitalization. Many of these women recover, after a more or less stormy course. A residual of at least 20 per cent are incapacitated permanently.{1} {2} {3}

But this is not the entire story. For every woman who is sufficiently ill to become a patient in a psychiatric hospital, there are many additional ones who experience deterioration of mood and personality. Sometimes this consists of transitory episodes of tearfulness and gloom. In other instances, subtle but long-lasting changes in attitudes and behavior gradually supervene. One of the most common sequelae to childbirth is loss of sexual responsiveness. Another is chronic and persistent fatigue.

With the enormous advances in medicine which have occurred during the twentieth century, it might be anticipated that the psychiatric problems which follow childbirth would have been subjected to intensive investigation and clarification. It is one of the anomalies of modern medicine that this is not the case. Indeed, precisely the opposite is true. There is only one comprehensive book on the subject Marcé’s{4} traité de la folie des femmes enceintes, and it was written in 1858. The most accurate descriptions of cases are found in this book and in scattered papers—most of which were published more than forty years ago. These papers, together with Marcé’s book, are left to mold in the back corridors of medical libraries. Meanwhile, serious postpartum psychiatric illness strikes as frequently as it did one hundred years ago. Statistics on recovery rates fail to demonstrate that modern treatment methods are more effective than those of the nineteenth century.

What is to explain this anomaly of neglect? Many reasons may be adduced. One is that postpartum psychiatric problems lie midway between obstetrics and psychiatry and that these problems fail to receive the attention of specialists in either field. Another reason is that the severe cases which occur are so evenly dispersed throughout the population that no psychiatrist sees more than a few of them. A third reason is that patients who suffer from postpartum psychiatric illness usually bear at least a superficial resemblance to victims of one or another of the standard varieties of mental illness; therefore, they are likely to be regarded and treated as if they were run-of-the-mill schizophrenics or manic-depressives, without regard to the special postpartum factors.

There is overwhelming evidence that the psychiatric illnesses which occur subsequent to childbirth have unique features, as compared with other psychiatric illnesses. These unique features lead to therapeutic procedures which are often quite different from those which are appropriate to the treatment of other psychiatric diseases.

One of the remarkable aspects of puerperal mental illness is the fact that important decisions regarding early diagnosis and treatment automatically fall to physicians who are not psychiatrists. It is usually the obstetrician or the general physician who hears the first complaints of the patient as she experiences symptoms of impending postpartum mental illness. Not infrequently it is the pediatrician or his nurse who first notices that the psychological events of the puerperium are disturbed. Physicians who are not psychiatrists are likely to be called upon to treat many complaints which are at first hardly distinguishable from those of patients who are developing a serious psychiatric illness. The obstetrician or the general physician has the extremely difficult task of deciding when he should enlist the aid of a psychiatrist. This book is written with the intent of assisting in these early problems of decision, diagnosis, and treatment. These problems merge into and are inseparable from those which are faced by the psychiatrist who may be responsible for treatment of the more advanced syndromes of postpartum mental illness.

This book will first present a description of the outstanding clinical features of postpartum mental illness. Subsequent chapters will consider the several psychiatric syndromes which appear in the puerperium, with an outline of treatment appropriate to each syndrome. The topic of psychotherapy will be discussed separately. Consideration will be given to transitory emotional or psychiatric problems which appear after childbirth and to the relationships of these problems to major psychiatric illness. General suggestions for the management of early or minor symptoms and the prevention of major psychiatric reactions will be presented. The relevant physiology of the puerperium is discussed. Concluding chapters deal with the history of the study of postpartum psychiatric problems and with clues for future research in this area.

Chapter 2—A profile of clinical features

VARIABILITY OF SYMPTOMS AND SYNDROMES

PSYCHIATRIC ILLNESS subsequent to childbirth manifests itself in a wide variety as symptoms and syndromes. The various clinical pictures which develop have much in common with one or another of the major categories of psychiatric illness—mania, depression, organic syndromes such as delirium, or one of the varieties of schizophrenia. To a considerable extent, the treatment of a patient is related to the particular syndrome which is outstanding at any given time. For this reason, the several syndromes and their respective treatments will be taken up separately in later chapters.

FEATURES COMMON TO POSTPARTUM SYNDROMES

The present chapter is not concerned with the differences between postpartum psychiatric patients but with their similarities. Some of these similarities have been pinpointed by statistical or experimental studies. Others represent observations from therapeutic testing. Still others consist of impressions which have been recorded by observant physicians. Some of these recorded impressions are the classic descriptions of postpartum illness, and they convey nuances of psychopathology in a manner which cannot be appreciated otherwise, except perhaps by the continued observation of scores of cases. Selections from these descriptions will be quoted.

The remainder of this chapter is devoted to a discussion of the common features which represent the profile of postpartum mental illness.

Latent period. The onset of postpartum psychiatric illness conforms to a practically immutable rule of timing—symptoms are almost never noted before the third day postpartum. This latent asymptomatic period was commented on by many of the early observers, but it was most carefully studied by Karnosh and Hope{5} in 1937, with corroboration by Paffenbarger and associates{6} in 1961. Karnosh and Hope examined the symptoms of 231 patients with postpartum illness. Extreme care was taken to determine the precise date of onset of symptoms in relation to childbirth. It was noted that only two women, both of them chronic alcoholics, developed any symptoms whatsoever before the third day postpartum. From the third day to the seventh, with a peak of incidence on the sixth day, many patients began to show their first symptoms. In over half of all the cases, symptoms had developed by the end of a fortnight.

In their discussion of the asymptomatic latent period, Karnosh and Hope state that the emergence of psychiatric symptoms seems likely to be related to some kind of chemical or hormonal development which is instigated by the events of childbirth but which always requires at least a few days to establish itself. The position of these investigators can be clarified by considering an alternative hypothesis—that postpartum psychiatric illness is precipitated by the anxiety and stress which comprise the psychological events of childbearing. Were this hypothesis true, it would be expected that there would be some continuity between the distress of childbearing and the early symptoms of postpartum illness, at least in a considerable number of cases. Such a continuity is apparent frequently in all other varieties of acute psychogenic illness. It is conspicuous by its absence in postpartum illness. The patient recovers from the immediate effects of childbearing and then a new set of symptoms appears.

Early prodromal symptoms. The onset of a frank symptom of psychiatric illness is usually preceded by a characteristic pattern of prodromal symptoms which may continue for a period of one to several days. Outstanding symptoms are insomnia, restlessness, exhaustion, depression of spirits, irritability, occasionally headache, and sometimes a rapid changeability of mood. {7} {8} {9} {10}{11} Of these, insomnia is the most distressing, well-deserving Savage’s{12} colorful term, miserable sleeplessness.

Late prodromal symptoms. Another set of symptoms merges into the early prodromal pattern and suggests that a real distortion of thinking is imminent. Among these symptoms are suspiciousness, evidence of confusion or incoherence, irrational statements, excessive concern over trivialities, and refusal of food. Sometimes the content of a nightmare is confused with reality.{13}{14}{15}

Early and late prodromal symptoms are correlated in the following observation of Robert Jones{16}:

The almost universal early symptom in puerperal cases is loss of sleep. The progress of the case is described as first sleeplessness, then a feverish and anxious restlessness, a busy concern about trivial details, distrust, a suspiciousness, loss of appetite, and a readiness to take offense when none was meant, an exacting irritability and ready reaction to outward stimulus, culminating in wild delirious excitement and mania. When sleeplessness and headache followed by an undefinable feeling of apprehensiveness occur—any sudden unaccustomed stimulus of however slight a nature tends to and may presage a mental breakdown. It is for this reason that early attention should be given to sleeplessness and headache.{17}

Omnipresence of delirium. When postpartum psychiatric illness becomes unmistakable, the physician is likely to make a provisional diagnosis according to one of the standard categories of mental illness. These include delirium, mania, depression reaction, and schizophrenia. In various studies the percentage of cases assigned to each category varies somewhat, according to the year of the study and according to fashions in diagnosis. In 1942 Boyd{18} averaged eight studies and reported an average relative incidence of 28.5 per cent delirium, 40 per cent manic-depressive psychosis, and 26 per cent schizophrenia. The most quoted study in the literature, that of Strecker and Ebaugh,{19} reported 34 per cent manic-depressive psychosis, and 26 per cent schizophrenia.

From these and other studies it is apparent that about one-third of the diagnosed cases of postpartum