Case 3.8 A Postpartum Change Ian Jones, M.R.C.Psych., Ph.

Ursula Norman, a 32-year-old nurse, was brought to an emergency department 6 days after giving birth.
Her husband indicated that she had been behaving very strangely and that she had become convinced
that she had smothered and killed her baby.

Her husband reported that after a normal pregnancy and uncomplicated delivery, Ms. Norman had
happily gone home with their first child. On the third day after delivery, however, her mood and affect
began to shift rapidly between elation and weepiness. She became irritable and anxious. She slept only
an hour a night, even where her baby was asleep. Her behavior became irritable and anxious. She slept
only an hour a night, even when her baby was asleep. Her behavior became increasingly bizarre, with
overactivity and agitation. Her speech was rapid and digressive. Although not previously a religious
person, she became convinced that God was speaking through her and that she had special powers that
could solve the problems of the world. She told her husband that she could identify evil people by
looking into their eyes and had begun to worry that she was surrounded by evil people, including her
own mother. Most disturbing for her, whenever she was out of sight of her son, she became totally
convinced that she had smothered him, and no one could convince her otherwise.

Ms. Norman had a history of three episodes of major depression in her teens and early 20s. these
episodes resolved with psychotherapy and antidepressant medication. She also had a psychiatric
admission for mania three years prior to the delivery of her child, after a flight from Asia to Europe.
Following treatment with antipsychotic medication, she became depressed for several months.
Although a diagnosis of bipolar disorder was discussed at this time, she was reluctant to accept this
label, attributing the episode to stress and jet lag. She had discontinued the psychiatric medication in
anticipation of getting pregnant.

Ms. Norman’s own mother had been admitted to a psychiatric hospital shortly after the birth of her first
child. This episode was not talked about in the family, and there were few other details. She had no
other family history of note.

Until just before delivery of her child, Ms. Norman had been a highly functional nurse in a renal unit. Her
husband was the head of a sales team, and they lived in comfortable social circumstances. She had no
history of illicit drug use, and, prior to pregnancy, drank only 2 or 3 classes of alcohol a week.

On mental status examination, Ms. Norman wandered around the room, seemingly unable to sit for
more than a few moments. She was distractible and overtalkative, and demonstrated flight of ideas,
flitting from one subject to another. Her mood was labile. At times she appeared happily euphoric. At
other times she was tearful, and she could become quickly irritable when she felt she was not being
understood. It was clear that she had a number of delusional beliefs but was unwilling to discuss most of
them with the examiner. She did insist that she had already killed her own child, which led to several
minutes of tears, but she returned to an edgy euphoria within a few minutes. She denied intent to harm
herself or anyone else. She appeared inattentive, with poor concentration, but would not participate in
formal cognitive testing.

Physical examination and laboratory testing results were all within normal limits.