Postpartum psychosis and postpartum thyroiditis

Postpartum Psychosis as a Consequence of Thyroiditis Versus Relapse: A Diagnostic Dilemma

Thyrotoxicosis can exhibit overlapping symptoms of psychosis in the general population. Each of these pathologies has well-established workups and management. Rare presentations of thyroiditis and psychosis in the postpartum state have been seen in case studies mostly, but data on the prevalence of postpartum psychosis in association with postpartum thyroiditis are not available. Here, we present a unique case of a patient with a history of bipolar disorder who originally presented with postpartum thyroiditis that was worked up and managed appropriately. However, on follow-up, the patient was found to have progressed into prominent psychosis. Both thyroiditis and psychosis were managed individually with full remission upon discharge and is doing well today. The co-occurrence of postpartum psychosis and thyroiditis presents a unique challenge for timely diagnosis and management. We present a case of a young woman initially diagnosed with postpartum thyroiditis needing further management of postpartum psychosis due to persistent symptoms. Clinical presentation supported with a prior history of mood disorder increases the likelihood of these diagnoses together.

The role of the immune system in postpartum psychosis

Postpartum psychosis is the most severe psychiatric disorder associated with childbirth. The risk is particularly high for women with a history of bipolar disorder or schizoaffective disorder, or those who have suffered a previous episode of postpartum psychosis. However, the aetiology of the illness remains unclear. Pregnancy and the early postpartum are times of significant immunological change. Furthermore, alterations to the immune system have been implicated in the onset and course of various psychopathologies, both related and unrelated to childbirth. Emerging evidence, from studies on immune related disorders, immune cells and inflammatory markers, suggests that the immune system might also be involved in the pathophysiology of postpartum psychosis. Furthermore, recent research has also begun to explore the potential mechanisms underlying immune dysfunction in postpartum psychosis (e.g., disturbances in the Treg-CCN3 protein-(re)myelination axis). Nevertheless, more research is required to understand whether immune dysfunction is a cause or consequence of postpartum psychosis and to clarify the exact mechanisms involved. The aim of this short review is to present the current findings on immune system dysregulation in postpartum psychosis, discuss possible mechanisms underlying the association, highlight potential challenges and confounders and provide suggestions for future research.

Late onset postpartum psychoses

It has been known since the eighteenth century that postpartum psychoses can begin several weeks after childbirth, not during the first fortnight. There are almost 400 non-organic episodes in the literature, starting more than 3 weeks after the birth; some of them are recurrent. The distinction of this disorder from early onset puerperal psychosis is supported by the distribution of onsets (which shows a steep fall after 14-15 days), survey data and the association with later pregnancies, not the first. Marcé believed that these late onsets were related to the resumption of menstruation. This is a hypothesis worth investigating.

Graves' Thyrotoxicosis Presenting as Schizophreniform Psychosis: A Case Report and Literature Review

Psychosis, as the first presentation of thyrotoxicosis, is extremely rare. Consequently, it is often misdiagnosed as a primary psychiatric disorder, especially in developing countries with poor healthcare facilities. Owing to the high level of illiteracy and lack of knowledge, it is fairly common to ascribe many illnesses to spiritual attacks in Nigeria and other African countries, especially when the disease is rarely seen or is associated with psychiatric manifestations. Herein, we present the case of a teenage female Nigerian and review the literature on this subject.

Non-reproductive triggers of postpartum psychosis

Bipolar disorders, and other psychoses, are known to be triggered by a number of agents apart from the reproductive process. In some women, pregnant or recently delivered, psychosis may be due to these alternative triggers. There are substantial numbers of mothers suffering from childbearing psychoses, who have been prescribed bromocriptine or steroids, have had surgical operations or developed thyrotoxicosis. It is best to eliminate these episodes and cases from study samples of puerperal psychosis.

Bipolar disorder and antithyroid antibodies: review and case series

Mood disorders and circulating thyroid antibodies are very prevalent in the population and their concomitant occurrence may be due to chance. However, thyroid antibodies have been repeatedly hypothesized to play a role in specific forms of mood disorders. Potentially related forms include treatment-refractory cases, severe or atypical depression, and depression at specific phases of a woman’s life (early gestation, postpartum depression, perimenopausal). With regard to bipolar disorder, studies of specific subgroups (rapid cycling, mixed, or depressive bipolar) have reported associations with thyroid antibodies. Offspring of bipolar subjects were found more vulnerable to develop thyroid antibodies independently from the vulnerability to develop psychiatric disorders. A twin study suggested thyroid antibodies among possible endophenotypes for bipolar disorder. Severe encephalopathies have been reported in association with Hashimoto’s thyroiditis. Cases with pure psychiatric presentation are being reported, the antithyroid antibodies being probably markers of some other autoimmune disorders affecting the brain. Vasculitis resulting in abnormalities in cortical perfusion is one of the possible mechanisms.

Transient psychosis due to painless thyroiditis in a patient with anxiety disorder: a case report

Introduction

There are few reports on thyrotoxic psychosis caused by diseases other than Graves' disease or toxic nodular goiter.

Case presentation

A 64-year-old Japanese woman was treated for anxiety disorder in our clinic for 10 years. She had five episodes of transient psychosis during the first five years. When she developed psychosis without neck pain 10 years after her first visit, a laboratory reexamination revealed that she had subclinical hyperthyroidism, and tested positive for antithyroid autoantibodies, negative for thyroid stimulating hormone receptor antibody and had decreased radioactive iodine uptake. She was diagnosed as having painless thyroiditis. The hyperthyroidism disappeared within a month, and the psychosis lasted for three months.

Conclusion

To the best of our knowledge, this is the first report of psychosis due to painless thyroiditis-induced hyperthyroidism. Physical symptoms of painless thyroiditis are often so mild that careful differential diagnosis is necessary in the cases of transient psychosis.

Some neurological and psychiatric complications in the disorders of the thyroid gland

A pajzsmirigyhormonok alapvető fontosságúak a központi idegrendszer perinatális fejlődéséhez és a felnőtt agy működéséhez, elsősorban a specifikus célgének transzkripciójának szabályozásával. Fokozzák a kortikális szerotoninerg transzmissziót, szerepet játszanak a noradrenerg funkciók szabályozásában, és érintik a GABA-funkciót. A csecsemő- és kisgyermekkori hypothyreosis mentális retardációhoz vezet, felnőttkorban a demencia és a depresszió a leggyakoribb, de előfordulhat myxoedemás kóma, cerebellaris és agyidegtünetek, megnő a hajlam a cerebrovascularis kórképekre. A periféria részéről polyneuropathia, carpalis alagút syndroma, myalgia gyakori; ritka szövődmény a myokymia. Csaknem minden hyperthyreotikus betegnél előfordulnak minor pszichiátriai tünetek, ritkábban alakul ki pszichózis, demencia, konfúziós állapot, depresszió, apátiás thyreotoxicosis, thyreotoxikus krízis, epilepszia, pyramistünetek vagy chorea. A periféria részvételét krónikus thyreotoxikus myopathia, infiltratív ophthalmomyopathia, myasthenia gravis, thyreotoxikus periódikus hypokalaemiás bénulás és polyneuropathia jelezheti. A figyelemhiányos hiperaktivitásban szenvedők jelentős részénél generalizált pajzsmirigyhormon-rezisztenciát igazoltak. Magas antithyroid antitest titer jellemzi az akut-szubakut indulású, remissziókkal és relapszusokkal jellemezhető, súlyos, életveszélyes, de szteroidra jól reagáló, autoimmun, ritkán előforduló Hashimoto-encephalopathiát.

The role of estrogen therapy in postpartum psychiatric disorders: an update

OBJECTIVES

The aim of this review is to assess and summarize the existing literature data about the efficacy of estrogen replacement therapy (ERT) in preventing and treating postpartum psychiatric disorders.

METHODS

An extensive and unrestrictive computerized search (from 1970 to June 2005) on MEDLINE/PubMed, TOXNET, EMBASE, and Cochrane Databases was conducted with the following search terms: estradiol, estrogen-treatment, hormonal treatment, therapy, postpartum depression, postnatal depression, puerperal depression, postpartum blues, postpartum psychosis, lactation, and breastfeeding.

RESULTS

In assessing available literature information about the role of ERT in preventing and treating puerperal psychiatric diseases, all reviewed studies were found to suffer from severe methodological limitations.

CONCLUSION

Well-designed and strictly focused multicenter trials are warranted in order to firmly establish the effectiveness of ERT in puerperal psychiatric disorders.

Alterations in platelet serotonin transporter binding in women with postpartum onset major depression

There is considerable debate as to whether postpartum depression (PPD) is biologically distinct from other depressive syndromes. Although abnormalities in serotonergic neural systems have repeatedly been reported in depression, few such studies have been conducted in PPD. In the present study, platelet serotonin transporter (SERT) binding was assessed using [(3)H]paroxetine in 14 depressed pregnant women, 31 normal healthy pregnant women, 39 depressed postpartum women, and 27 normal healthy postpartum women; all of the subjects were drug-free. Significant differences were detected among the 4 groups with respect to the dissociation constant (Kd) of platelet binding sites for [(3)H]paroxetine with the highest Kd values among those with PPD. The density (Bmax) of platelet binding sites for [(3)H]paroxetine did not differ between the study groups. These data suggest that PPD may be associated with unique alterations in serotonergic function that are specific to the puerperium.

Role of sleep loss in the causation of puerperal psychosis

Puerperal psychosis is a rare but serious psychiatric disorder following delivery. Although controversy continues to surround its nosological status, puerperal psychosis is generally considered a mood episode with psychotic features occurring in the context of bipolar disorder or schizoaffective disorder. Due to the close temporal association with childbirth, the etiological role of gonadal steroids, particularly estrogen, has been considered. Familial factors have also been implicated in the triggering of episodes of puerperal psychosis. Sleep deprivation arising from an array of diverse factors is a common occurrence surrounding parturition. The author suggests that sleep loss plays a pivotal role in the causation of puerperal psychosis. Clinical implications of this hypothesis are discussed. Studies on the aetiology and pathogenesis of puerperal psychosis are urgently needed not only for prevention and better treatment strategies of puerperal psychosis but also for understanding the biological underpinnings of bipolar disorder.

Delusion of pregnancy. A case report and review of the literature

This case report describes the longstanding course of a delusion of pregnancy in a 51-year-old schizophrenic Ghanaian woman suffering from multiple symptoms of delusions and hallucinations. In addition to these symptoms, the patient was affected by multiple coenesthesias, ego disturbances and bizarre delusions of being influenced by external forces. A multi-causal aetiology of delusional pregnancy is discussed.

Postpartum mood disorders

Depression is a common disorder in women of childbearing age. Many women experience depressive symptoms during the postpartum period, ranging from mild postpartum blues to significant mood disorders such as postpartum depression and postpartum psychosis. The 'baby blues' are extremely common, affecting 30-75% of new mothers. This form of postpartum mood change is self-limited and requires no specific treatment other than education and support. While less common, occurring in 10-15% of births, postpartum depression has the potential for significant impact on both the health of the mother and baby. Unfortunately, affective illness in women frequently goes unrecognized and untreated. While there are effective pharmacological treatments for postpartum depression, the treatments for postpartum depression are often not utilized due to concerns about lactation. Postpartum psychosis is extremely rare, affecting one to two women per 1000 births; each case represents a true psychiatric emergency. Identifying and treating postpartum affective illness in women is critical to the health of both mother and infant. This paper reviews the literature on the diagnosis and treatment of mood disorders in the postpartum period: postpartum blues, postpartum depression and postpartum psychosis.

Sleep loss and postpartum psychosis

Postpartum psychosis is a rare but severe psychiatric disorder. Its diagnostic status remains controversial, but several studies have shown that the majority of patients who develop psychosis immediately following childbirth suffer from bipolar disorder. The pathophysiology of postpartum psychosis is poorly understood, but factors such as primiparity, difficult labor, genetic predisposition, and hormonal changes have been suggested as etiological factors. This paper reviews the literature on the relationship of sleep disruption and postpartum psychosis. It is argued that sleep loss resulting from the interaction of various putative causal factors may be the final common pathway in the development of psychosis in susceptible women. Clinical significance of these findings, including strategies to prevent postpartum psychosis, are discussed and suggestions are made for future research directions.