The methods and objectives of psychotherapy for paranoia are discussed fully by Manschreck. We have no way of deciding whether psychotherapy has influenced this state. In a general hospital, where most of our paranoid patients have been depressed, manic, or demented, we have several times been gratified by the effects of antidepressant or antipsychotic medication. In the treatment of patients with pathologic jealousy, Mooney found phenothiazine drugs to be useful.
From what has been said, the clinical analysis of patients with delusions requires a careful study of mood and intelligence to rule out bipolar disease and dementia. If either of these two states exists, the treatment proceeds along the lines discussed in Chaps. 20 and 48. A matter of practical importance is for the physician to evaluate carefully the nature of the delusional ideas and try to judge whether the patient is homicidal or suicidal. Occasionally, physicians and others have been killed or maimed by patients with paranoia who thought they were being mistreated.
Parturition, associated as it is with many biologic disturbances such as the effects, drugs, eclampsia, hemorrhage, infection, and perhaps most prominently, an abrupt hormonal adjustment, is frequently associated with a disturbance of mood. Obstetricians have repeatedly observed that the woman may feel extraordinarily well immediately postpartum, only to lapse in the following days into a weepy, depressed state in which she may be distressed by lack of feeling for her newborn infant. Usually this lasts for only a few days (“postpartum blues”), being quelled by the return home, responsibility for the infant, and nursing. In some patients, the depressive symptoms persist for months (see later). Depression during pregnancy may be a separate entity and is noted in Chap. 48 as well as in the review by Stewart.
The period after childbirth is also one in which there is a strong disposition to psychosis. Opinion varies as to whether there is a special puerperal, or postpartum psychosis. Most psychiatrists believe that the psychotic break that may occur at this time is either a confusional-delirious state or a schizophreniform or depressive psychosis, and that these illnesses do not differ from those occurring at other times in life. As mentioned in the previous chapter, some authors have questioned the existence of a special depressive illness that is linked to the postpartum period, an opinion that is not supported by our clinical experience (see Brockington).
Additionally, there has been described a postpartum psychosis that cannot be easily categorized. Usually it has its onset between 48 and 72 h after a delivery that may have been complicated by excessive bleeding or infection. The patient alternates between periods of noisy hyperactivity and of mutism and inactivity. She is disoriented and incapable of thinking clearly. The baby is sometimes rejected as not belonging to her (instances of infanticide are not unknown). Although the illness has some features of delirium, it may merge with a schizophrenic or depressive type of psychosis that persists for months. In a series of such cases, Boyd found that approximately 40 percent were predominantly affective, 20 percent schizophreniform, and the remainder self-limited confusional psychoses of the type previously described. In some patients, a typical depressive illness has followed each of several pregnancies, disabling the patient for weeks to months at a time. Some women with bipolar disease have had their early depressive attacks only after delivery.
In the diagnosis of postpartum psychosis, one must also keep in mind the possibility of eclampsia, the consequences of pituitary infarction, cerebral vein thrombosis or transitory stroke of arterial type, ergot-induced psychosis, and hypotensive-hypoxic cerebral injury. The treatment of such patients follows the methods described in Chap. 48 and in the following text.