Psychiatric Emergency -Post Partum Psychosis

Psychiatric Emergency -Post Partum Psychosis

Rakesh Gupta, Yarish Sadri, Sheetal Jaisingh, Sayli Shinde

 Abstract- Puerperal psychosis is a condition in which the mother develops frank psychosis, cognitive impairment and grossly disorganized behaviour after delivery¹.  It is harmful to the mother and the people around her.

The  mother may harm her baby, which can affect the child’s survival. In modern medicine anti psychotic drugs are administered. Homoeopathy has a very good scope in such cases as there are various remedies covering both mania as well as the depressive phase. According to the Textbook of Organon of Medicine, Dr Hahnemann had mentioned the treatment of such mental disorders.

Keywords-Puerperal Psychosis,Organon, Hahnemann, Belladonna, Hyoscyamus, Psychiatry, Veratrum Alb, Stramonium, Paranoia.

Introduction:

Postpartum psychosis or puerperal psychosis is observed in about 0.14-0.26% of mothers¹.  The onset is usually within the first 4 days of delivery. During the psychosis episode women may have Bizarre or grandiose or paranoid delusions, mood swings, confused thinking, suicidal and infanticidal impulses^1,2.

In such cases separation of the mother and baby is necessary till the time she recovers. However a combination of frank psychosis and lapsed insight and judgement post partum can lead to devastating consequences in which the safety and well being of the affected mother and child are at stake¹.

Risk of recurrence is 20-25% and there is increased risk of psychotic illness outside pregnancy also. According to ICD 10 code it is classified under Mental and Behavioural Disorders associated with puerperium, It covers maternity patients aged 12- 55 years inclusive³

Case History:

24-year-old female was brought to the hospital IPD with attached intravenous catheter by her relatives in a maniacal state with violent and, disoriented behavior.  She had delivered a baby boy 4 days back. She tried running away from the previous hospital three times unsuccessfully.

Her baby was suffering from neonatal jaundice, so the child was admitted in NICU where he received phototherapy. She was suspicious that her child will get exchanged for other children. She ran away with her son from the previous hospital on a fourth attempt.

She had violent behaviour⁺³ was uncooperative, had poor self care. She wants to run away from the hospital. Aversion to touch⁺³ – Wants to be alone and not talk with anyone. She had fear of death⁺³ (fear of incurable disease). Patient was complaining of anxiety in chest⁺³ region. She was continuously weeping⁺³(weeping alternating with violence).

Hallucination and  Delusions

Life situation Background: – Patient stays with her mother in law. Mother in law is very conservative, orthodox, Dominating and always critical about her. She always look down upon patient.

Physical Complaints

• Sleeplessness since 4 days
• Headache since 1 day > Pressure+++
• Appetite – not eating anything
• Thirst- thirsty with dryness of mouth but not drinking anything.
• Scanty lochia

On Examination:

Pulse- 82 beats/min                             BP- 120/80 mm of hg

RR- 24/min                                         Temp – Afebrile

Pallor present++                                  Systemic examination: NAD

 

MINI MENTAL STATE EXAMINATION

 Mood/affect – Depressed

1. Affect – changeable
2. Speech – incoherent, incomphrensible, rude with relatives
3. Perception – clear
4. Complete loss of discrimination with complete disconnect with reality

Important Points exhibited at mental level :-

 

Clinical Diagnosis- Postpartum/Puerperal Psychosis (ICD code- F53.1)³

ICD 10 Code ³

F53 has Mental and behavioural disorders associated with puerperium, not elsewhere classified³. 

F53.1 is Applicable to maternity patients aged 12- 55 years inclusive. Applicable to

                        : Post partum psychosis³

                        : Puerperal psychosis³

 

           Psychodynamic Understanding of the Patient

Being cornered, deprived, restricted a harsh treatment by her in-laws, repressed all her emotions

   Anger                                        VIOLENT BEHAVIOUR

Hahnemannian Classification of disease: –   Dynamic acute mental individual disease.

REPORTORIAL Approach-  Kentian Approach due to qualified mental symptoms

Susceptibility– Moderate to High

• Reversal of symptoms with acute psychosis
• peculiar mental symptomatology
• high sensitivity at the level of mind
• lack of physical symptoms

Repertorial Totality⁴

1. Mind: Violent
2. Mind: Escape attempt to
3. Mind: Fear, death of
4. Mind: Shrieking
5. Mind: Company, aversion to
6. Mind: Weeping
7. Mind: Mania, puerperal
8. Head: Pain, pressure – external, amel

Differential remedies: –

1. Belladonna
2. Hyoscyamus
3. Veratrum Alb
4. Stramonium

 

	Belladonna	Hyoscyamus	Veratrum Album	Stramonium
Mental symptoms	–Great agitation -Desire to die , groans , cries and tears. –Fear of approaching death -Restlessness with desire to escape.Desire for solitude and irritation from noise – fiery violent behavior6	Suspicious, anxious and fearful -Jealousy with rage – mania with consciousness – Erotic mania – Fear of being poisoned, of being pursued5,6 – Restless, jumps out of bed, wants to escape6.	– tired of life yet fear to die – delirium with madness -deadly anguish with disposition to be angry at the least thing. – Mental alienation and insanity. – haughty notion – cannot bear to be left alone yet persistently refuses to talk6.	Hysterical beseeching, Entreating patient -can’t bear solitude or darkness. -Many unconscious dreams. -puerperal women with absurd notions – desire to run away with audible hallucinations6
Head	Headache > by pressure7+++	Needle like stitches in the head especially on forehead6.	Heaviness of the head with bruised feeling of the brain6.	Headache with vertigo and tendency to speak incoherently better by bending head backward6

 

Belladonna has a potential destructiveness with high level activity and sense of paranoia;  they can exhibit  psychotic behaviour⁸

Reference from 6^th edition of Organon By Hahnemann :

Aphorism no 221.

If, however , insanity or mania ( caused by fright, vexation, the abuse of spirituous liquors etc.) have suddenly broken out as an acute disease in the patients ordinary calm state, although it almost always arises from internal psora like a flame bursting forth from it, yet when it occurs in this acute manner it should not be immediately treated with antipsorics , but in the first place with remedies indicated for it out of the other class of proved medicaments ( e.g. Aconite , Belladonna, Stramonium , Hyoscyamus , Mercurius etc.) in highly potentized, minute, homeopathic doses, in order to subdue it so far that the psora shall for the time revert to its former, latent state , wherein the patient appears as if quite well¹⁰.

Selection of remedy: Belladonna

Posology:  Belladonna 1M⁹

High Potency⁹: 1. High Susceptibility

2. Acute episode of psychosis (Predominant Mentals)
3. High medicinal correspondence with totality.
4. Rapid Pace of the Disease.
5. Fulminant response of the underlying mental derangement.

Repetition of the Dose :  1^st dilution  every 10 mins¹⁰

According to Aphorism 247¹⁰

Under these conditions the smallest doses of the best selected homoeopathic medicines may be repeated with the best, often with incredible results, at intervals of fourteen, twelve, ten, eight, seven days, and, where rapidity is requisite, in chronic diseases resembling cases of acute diseases, at shorter intervals, but in acute diseases at very much shorter period every twenty four, twelve, eight, four, hours, in the very acutest every hour, up to as often as every five minutes, in every cases in proportion to the more or the less rapid course of the disease and of the action of the medicine employed, as is more distinctly explained in the last note¹⁰

 FINAL PRESCRIPTION: Belladonna¹⁰ 1M 1^st dilution every 10 minutes.

 FOLLOW UP CRITERIA:

1. General sense of well being
2. Sleep
3. Headache
4. Violent behavior
5. Orientation to time, place and person
6. Thoughts
7. Self-care
8. Weeping, screaming, howling

Date and time	Progress	Treatment
15/01/208 8 am	Patient’s vitals stable Did not sleep whole night Headache —-sq— Not responding to any questions -laughing alternating with crying (hysterical behavior) -Did not eat anything – self care poor Patient was tied due to violence,  screaming and howling	Belladonna 1m First dilution refused to take dilution medicines after 2 doses so shifted to Belladonna 1M  every 20 minutes
11am	Patient did not sleep partially oriented to person responding to commands Affect- flat Headache – better++ Patient co-operative.	Belladonna 1M 1 hourly
15/01/2018 10 pm	Patient started shouting and screaming Weeping loudly, Oriented to people Response – reluctant to follow command Un co-operative Headache – better++ Did not sleep yet	Patient was kept in isolation. Belladona 1M every 20 minutes
16/01/2018 9am	Patient slept for 4 hours Headache better by 90% Responding to command Oriented to place and person. Patient had food	Belladonna 1M 2 hourly
17/01/18	Patient slept well                                                                               Headache –0—, Well oriented to people, place and time. Self-care-eating well, patient started feeding her baby Delusions better+++ Crying better+++ Generals – normal	Rx SL30 tds x 7days Discharged

 

Lessons of the Case: –

• Concept of management of psychiatric emergency.
• Concept mental diseases from Organon of Medicine and

Psycho-dynamics of psychosis.

• Concept of concomitant symptoms
• Differentiation and conceptualization of remedies
• Importance of Team efforts and team work

Acknowledgement: –

We thank Dr Mohanbhai Patel, Chairman, The Homoeopathic Education Society (Smt. Chandaben Mohanbhai Patel Homoeopathic College), Dr Asmita Parikh; General Secretary, The Homoeopathic Education Society (Smt. Chandaben Mohanbhai Patel Homoeopathic College) and Dr Parizad Damania, Principal, Smt Chandaben Mohanbhai Patel Homoeopathic College, Mumbai.

References: 

1. Dorothy Sit, M.D, Anthony J, Rothschild, M.D., and Katherine L.Wisner, M.D.,M.S A Review of Postpartum Psychosis, Journal of women health (2002), www.ncbi.nlm.nih.gov
2. Dr DC Dutta’s Textbook of Obstetrics 9^th Edition Publisher- JAYPEE BROTHERS MEDICAL PUBLISHERS.{Pg no 415}.
3. ICD-10-CM Diagnosis Code (2020) F53.1:Puerperal psychosis https://icd10data.com .
4. Radar opus computer program. Version 10.5, Belgium 2012. Synthesis Repertory
5. Dr S.R. Phatak Materia Medica of Homoeopathic Medicines- Second edition Revised & Enlarged 22^nd New Delhi , Publisher- B. JAIN PUBLISHERS(P) LTD Year-:2018 {Pg no – 113-118, 353- 356, 667-670, 727-731}.
6. Dr John Henry Clarke A Dictionary of Practical Materia Medica Vol1, Vol2, Vol3 M.D Student Edition; Publishers- B. JAIN PUBLISHERS(P) LTD Year- 2006. {Vol1-256-269, 940-947, Vol3- 1272-1281,1507-1520}.
7. William Boericke, Boerickes New Manual of Homeopathic Materia medica with Repertory, Second Revised and Re Augmented Edition: 2000 33^rd New Delhi B Jain Publisher (P) Ltd Year- 2014 {page no-100-103,297-298, 539-540, 585-587}.
8. Philip M. Bailey Homoeopathic psychology – Personality profiles of the Major Constitutional Remedies 10^th New Delhi Publishers- B. JAIN PUBLISHERS(P) LTD Year- 2013. {Pg 42-45, 76-80, 337-342, 398-401}
9. Dr M.L.Dhawale MD, Principles and Practice of Homoeopathy,Third Edition Reprint 2004, Mumbai, Dr.M.L.Dhawale Memorial Trust,2004 (Page no 276-277)
10. Samuel Hahnemann; translated  by R.E.Dudgeon, MD, William Boericke, MD, Organon of medicine word index included, Fith and Sixth edition combined:2014,31^st impression, India, New Delhi, B Jain Publisher (P) Ltd Year- 2014 (Page no 199,Pg 220-221).