Understanding Postpartum Psychosis and InfanticidePosted April 29, 2016 | By Diana Lynn Barnes and Jerrod Brown
The reproductive years are a time of tremendous psychological vulnerability for women, with psychiatric admissions occurring more around childbirth than any other time in the female life cycle. In rare cases, some mothers have been known to commit infanticide. When a mother takes the life of her infant anytime in the first year postpartum, it is referred to as infanticide. One mental illness that may precipitate acts of infanticide is postpartum psychosis, which is characterized by disorganized thinking, mania, insomnia, depersonalization, hallucinations, and/or delusions. Such delusions may drive mothers to take the lives of their babies out of fears about their infants’ safety in current circumstances. Fortunately, this psychiatric emergency is relatively easy to screen for because postpartum psychosis has a clearly defined period of onset and clinical picture. Mothers who receive treatment within the first month after giving birth have considerably better short- and long-term outcomes.
When a mother takes the life of her own child, her actions fly in the face of our beliefs about the maternal instinct to nurture and protect one’s young (Dobson & Sales, 2000; Gauthier, Chaudoir, & Forsyth, 2003). Infanticide engenders unimaginable shock, horror, confusion, and so many unanswered questions of how and why (Brookman & Nolan, 2006; Temrin, Buchmayer, & Enquist, 2000). Despite these reactions, as many as several hundred women commit infanticide each year in this country (Altshuler, Hendrick, & Cohen, 1998; Parry, 1995; Porter & Gavin, 2010).
The reproductive years are a time of tremendous psychological vulnerability for women. In fact, psychiatric admissions occur more around childbirth than any other time in the female life cycle (Kendall, Chalmers, & Platz, 1987; Wisner, Gracious, Piontek, Peindl, & Perel, 2003). There are certain symptoms of mental illness that drive the thinking of postpartum women. Postpartum psychosis challenges us to put aside our normal and ordinary understanding of events and step into the thought process of a mother who is so seriously ill. Her perception of objective reality is distorted and altered beyond anything that logical minds can possibly grasp.
Although the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) links postpartum psychosis to infanticide, the DSM-5 does not distinguish psychosis related to childbearing as a unique diagnostic category. Nonetheless, research clearly indicates that the symptom presentation of psychosis in child-bearing women looks markedly different than psychotic episodes that are unrelated to childbirth (Boyce & Barriball, 2010; Wisner et al., 2003). These childbirth-related psychotic symptoms include extremely disorganized thinking, mania, insomnia, and depersonalization. Hallucinations may be auditory or visual. In addition, mixed affective states may be present where moods change rapidly from euphoria to melancholia (Friedman, Resnick, & Rosenthal, 2009). Postpartum psychosis is also unique in its waxing and waning presentation. A woman’s thoughts may fluctuate in any given moment from clarity to delusion (Brockington, 1996).
Dr. Phillip Resnick created a filicide classification system based on motive in one of the early studies of the topic. Although some postpartum delusions generally involve perceptions that infants are evil, that is not always the case. More often, these mothers take the lives of their babies because of delusional fears about their infants’ safety in current circumstances. Specifically, a mother’s very rigid and fixed beliefs evolve into an altruistic delusion that taking the life of her infant is saving the child from a fate worse than death. In his review of 131 case reports, Dr. Resnick found that 42% of women took the lives of their children out of love. In these cases, there was a real or imagined belief that the children were in danger and these women acted to relieve this delusional belief. Resnick further divided altruistic filicide into several other categories including psychotic altruism and associated suicide (Resnick, 1969). Among those women who are psychotic, it is not unusual for a mother to attempt suicide concurrently or immediately after taking her child’s life. This may be due to the delusional belief that she cannot leave her child alone without her either in the earthly world or beyond. Resnick’s other categories that establish a woman’s motives include the unwanted child and the child who is killed because of spousal revenge. In addition, he identifies accidental filicide that results from severe child abuse and the acutely psychotic woman (Resnick, 1969).
Resnick also found higher rates of pre-existing psychosis, depression, and suicidality among mothers who have committed filicide. Subsequently, several other researchers have expanded on Resnick’s original theories, recognizing that there are significant links between a woman’s own history of trauma and later psychosis in the child-bearing years (Edwards, Holden, Felitti, & Anda, 2003; Read, Fosse, Moskowitz, & Perry, 2014; West, 2007). Further, it is critical that an understanding of a mother’s state of mind in the first year exists within the framework of her psychosocial and pre-existing psychiatric history (Meyer & Oberman, 2001; Spinelli, 2004).
In the United States, law and mental health are at odds when cases involving insanity are considered. The M’Naghten statute, widely used to establish an insanity defense, maintains that a defendant must prove by a preponderance of evidence that she was incapable of distinguishing right from wrong during the commission of the crime due to mental disease or defect (M’Naghten, 1843). In contrast, mental health recognizes that the psychotic mind has its own internal subjective logic. For the woman who is so seriously ill that her thoughts and emotions lose contact with reality, the difference between right and wrong can only be understood by understanding that her thinking will never make sense to our logical minds.
Because of this discrepancy between law and psychology, the United Kingdom established a lesser category of homicide known as infanticide with “The Infanticide Act” in 1938 (Infanticide Act, 1938). This law presumes that if a mother harms her child during the first year after birth, the act likely occurred because “the balance of her mind was disturbed by reason of her not having fully recovered from the effect of giving birth to the child or by reason of the effect of lactation….the offence, which would have amounted to murder, is deemed to be infanticide and is dealt with and punished as if it was manslaughter” (Infanticide Act, 1938). Consequently, there are more lenient sentences for a mother found guilty of killing her infant than the life or death sentences that would be levied in many cases in the United States. Twenty-nine other countries have followed suit recognizing the biological vulnerability to psychiatric illness following childbirth.
Postpartum psychosis is considered a psychiatric emergency. Because this disorder has a clearly defined period of onset and clinical picture, postpartum psychosis can be identified with the proper screening and risk assessment during pregnancy and after birth. Although the risk for recurrence in subsequent pregnancies is upwards of 50% (Jones, Chandra, Dazzan, & Howard, 2014), postpartum psychosis is a treatable illness. Women who receive treatment within the first month after birth have considerably better outcomes (Boyce & Barriball, 2010).
Diana Lynn Barnes, Psy.D, is a past president of Postpartum Support International and currently sits on its President’s Advisory Council. She is a member of the training faculty of the Los Angeles County Perinatal Mental Health Task Force as well as the California statewide Maternal Mental Health Collaborative. She is widely published in the academic literature on all facets of perinatal mental health and wrote the guidelines on Assessment and Treatment of Perinatal Mood and Anxiety Disorders for the Perinatal Advisory Council of Los Angeles. In addition to private practice specializing in women’s reproductive mental health, Dr. Barnes presents nationally and internationally and is often retained by legal counsel on cases of infanticide, pregnancy denial, and neonaticide where perinatal illness has been at issue. In 2009, Dr. Barnes received a Lifetime Achievement Award for her contributions to the field of child-bearing related mood disorders. She is a member of the Marce´ Society, North American Society of Psychosocial Obstetrics and Gynecology, as well as a clinical fellow of the American Psychotherapy Association, the California Association, and the American Association of Marriage and Family Therapists. Dr. Barnes is the co-author of The Journey to Parenthood: Myths, Reality and What Really Matters (Radcliffe Publishing, 2007) and the editor and a contributing author of a recently published reference text on Women’s Reproductive Mental Health Across the Lifespan (Springer, 2014).
Jerrod Brown, M.A., M.S., M.S., M.S., is the Treatment Director for Pathways Counseling Center, Inc. Pathways provides programs and services benefiting individuals impacted by mental illness and addictions. Jerrod is also the founder and CEO of the American Institute for the Advancement of Forensic Studies (AIAFS), and the Editor-in-Chief of Forensic Scholars Today (FST). Jerrod is currently in the dissertation phase of his doctorate degree program in psychology.