A 27-year-old woman is brought to the office by her husband due to anxiety. The patient had an uncomplicated vaginal delivery a week ago and was discharged on postpartum day 2. Her husband notes that she was "really nervous" after returning home. The patient would watch the infant overnight to check for respirations and followed a strict feeding regimen. At the first well-child visit, she expressed concerns about the newborn's weight but was told he had surpassed his birth weight and was healthy and doing well. Despite this reassurance, the patient has continued to worry. For the past 2 days, she has been pacing around the house, sleeping poorly, and eating minimally. This morning, the husband found the patient mixing protein powder with formula due to concern that the infant was "shrinking." The patient says, "I know my baby is sick, but the doctors won't tell me the truth. They're trying to hurt my baby." She has no psychiatric history. Vital signs and physical examination are within normal limits. The patient appears tearful and exhausted. Which of the following is the most likely diagnosis?

Question

A 27-year-old woman is brought to the office by her husband due to anxiety.  The patient had an uncomplicated vaginal delivery a week ago and was discharged on postpartum day 2.  Her husband notes that she was "really nervous" after returning home.  The patient would watch the infant overnight to check for respirations and followed a strict feeding regimen.  At the first well-child visit, she expressed concerns about the newborn's weight but was told he had surpassed his birth weight and was healthy and doing well.  Despite this reassurance, the patient has continued to worry.  For the past 2 days, she has been pacing around the house, sleeping poorly, and eating minimally.  This morning, the husband found the patient mixing protein powder with formula due to concern that the infant was "shrinking."  The patient says, "I know my baby is sick, but the doctors won't tell me the truth.  They're trying to hurt my baby."  She has no psychiatric history.  Vital signs and physical examination are within normal limits.  The patient appears tearful and exhausted.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient's acute onset of agitation, mood symptoms, and delusions shortly after giving birth is consistent with postpartum psychosis, a relatively rare condition (1-2 of every 1,000 births) that generally occurs within the first 2 weeks after delivery. Clinical features include depressed and/or manic moods, severe insomnia, agitation, disorganized behavior, and delusions and/or hallucinations, with content frequently related to the infant (eg, this patient's delusions that the infant is "shrinking" and that doctors are trying to hurt her baby). Postpartum psychosis is a medical emergency because affected patients, under the influence of delusions, may harm the child and are also at high risk for suicide. Hospitalization to ensure safety and rapid intervention with antipsychotic medication are often necessary. Postpartum psychosis is most often seen in patients who have a history of bipolar disorder or who are later diagnosed with bipolar disorder based on mood episodes occurring outside the postpartum period. These patients are at especially high risk for recurrent episodes in subsequent pregnancies. (Choice A) Acute stress disorder involves nonpsychotic symptoms (eg, intrusion, negative mood, avoidance, hyperarousal, dissociation) that develop within a month of exposure to a traumatic event. (Choice B) Adjustment disorder is diagnosed when nonpsychotic symptoms (eg, depressed, anxious mood) develop within 3 months of a stressor. Although this patient has severe anxiety related to her newborn's health, adjustment disorder would not explain her psychosis. (Choice C) A diagnosis of delusional disorder requires delusions lasting ≥1 month in the absence of other psychotic or mood symptoms. It is not consistent with this patient's 1-week history of symptoms characterized by delusions and prominent mood symptoms. (Choice D) Although high levels of anxiety are seen in obsessive-compulsive disorder (OCD), this patient's 1-week history of mood symptoms and delusions about the infant is not consistent with this disorder. OCD is characterized by prominent obsessions and compulsions and would not explain this patient's paranoid delusions that doctors are trying to harm her infant. (Choice E) Postpartum blues is a common, self-limited condition of mild depressive symptoms, tearfulness, and irritability. It typically peaks at day 5 postpartum and resolves within 14 days. It does not include psychotic symptoms. Educational objective: Postpartum psychosis is characterized by an acute onset of delusions, hallucinations, and disorganized behavior within the first 2 weeks postpartum. It is typically accompanied by mood symptoms, agitation, and severe insomnia. References: Postpartum psychosis: madness, mania, and melancholia in motherhood. (http://www.ncbi.nlm.nih.gov/pubmed/27609245) Treatment of psychosis and mania in the postpartum period. (http://www.ncbi.nlm.nih.gov/pubmed/25640930) Risk of postpartum relapse in bipolar disorder and postpartum psychosis: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/26514657)

A 27-Year-Old Woman Is Brought to the Office by Her