I came into this note expecting commentary on polypharmacy and instead discovered a nuanced and insightful look into an interesting controversy. Thank you Dr. Reilly!
I have to chime in. Discontinuation of SSRIs and SNRIs is child’s play compared to tapering opioids, benzodiazepines, alcohol, and even nicotine.
Are you seeing psychiatrists who are unaware of how to taper via cross-titration to fluoxetine and then use half-life kinetics if need be? Is there an old guard who does not acknowledge that discontinuation can be a bear for some folks? I finished training in 2016 for reference.
Thanks for your kind comment - totally agree, these other drugs can be even more difficult to stop.
I would hope most practicing psychiatrists would be able to handle a tapered withdrawal, switching to fluoxetine if necessary. But for sure as a field we have downplayed withdrawal from SSRIs, particularly the small group who experience really severe effects
Fluoxetine won't cover the norepinephrine part of withdrawals from an SNRI. I've also seen discussion about each SSRI having a different profile of how it affects serotonin reuptake receptors, meaning that cross-tapering or bridging won't necessarily prevent withdrawals.
Thank you for this post. A sensible look at side effects of antidepressants is long overdue. There is just no need for doctors and psychiatrists to close this issue down as something that could cast doubt on their status. The research field into pharmaceuticals is never going to be completed, and that’s the nature of it, so I don’t know why some get so defensive when matters like this come up. They’re always going to come up, so it’s always constructive to talk about these issues. Individual differences abound in tolerances to different medications. Personally, I have found fluoxetine to be very effective at eliminating voices and bizarre delusions but less effective at preventing non bizarre delusional paranoia and moderate depression. I have no idea why this is. I know it’s not just a placebo in my case because I was prescribed it when I described symptoms of depression to my doctor. What neither of us realised at the time was that I was floridly psychotic after a head injury which I had no insight about. My hallucinations faded away, with the main persecutory voice actually announcing “I think I’m becoming less controlling”. A few years later I switched to Sertraline and I find this more effective as a mood improver. However, I get really severe vertigo and nausea if I even miss one tablet, so I would definitely need to taper off it gradually if I ever change medication. I’m personally really interested in what works and what doesn’t, and why, but I haven’t come across a clinician who is prepared to cover the topic with any other audience than colleagues, so thank you 🙏
This was very enlightening! This is something that is not talked about enough in medicine and I often take care of elderly patients who are on an endless list of medications because nobody is working on deprescribing unnecessary medications. Thank you for sharing!
It's the absence of informed consent that bugs me... Patients are not told about a 3% risk of severe withdrawal symptoms or the sexual side effects prior to initiating antidepressants, often for life difficulties (med student observing here) - I see them given information I would find negligently insufficient for informed consent if I was the patient. (Lesson from a med student - never be a patient - I'd be appalled to be treated like our patients are treated) Also speaking as someone with a SMI who has stopped psych meds cold turkey well over three or four if not five dozen times in my life, with absolutely no ill effects, the modern mantra that you must never stop a psych med cold turkey except on medical advice is equally idiotic... Even my cat's prescription for Prozac says don't stop suddenly!!!
Sorry to hear this. I would hope that prescribers would discuss common side effects including sexual dysfunction and withdrawal symptoms.
Agree there is much inter-individual variability and I’ve seen people who seem able to stop psychotropic medication suddenly without apparent adverse effects.
I choked on my coffee a few months ago when Mark H told Dr. Josef that he'd "never seen" melancholia. Thats great when we live in a world were clinicians have "never seen" withdrawal effects.
I’m going to be contrarian on one of your posts again. As someone in a withdrawal support group, I have to say: deprescribing isn’t the real issue—in fact, it’s creating a major one of its own.
There’s a growing movement, a kind of discipleship, that has spilled over from the benzo withdrawal groups, preaching the gospel of the 10% taper. Its leading figure? None other than Mark Horowitz. According to this group, all drugs and their effects are “hyperbolic,” and all harms can be avoided with a slow enough “hyperbolic” taper. Now, we have people stuck on multiple ineffective medications, experiencing serious adverse reactions—intracranial hypo/hypertension, autoimmune disease, glaucoma—yet tapering so slowly that they’ll die of a dozen other conditions before finishing withdrawal from just one drug. And if you suggest the effort isn’t worth the outcome, they’ll throw the Maudsley deprescribing guidelines at your head.
The reality is, most of the harm has already been done. The old taper speeds were based on sound clinical observation—things happening in front of doctors' eyes. The real problem isn’t tapering; it’s the harm and inefficacy of these drugs in the first place. We’re talking about medications that don’t work well, that people take for years, suffer from, and then—rather than reassessing the drugs themselves—the latest fad is to tell them to spend the rest of their lives shaving pills with a razor blade.
The bigger issue is that we’ve gotten bad at recognizing harms. We caught tardive dyskinesia and dystonia with first-gen antipsychotics. We noticed lithium’s tremor and toxicity. But somewhere along the way, we stopped seeing side effects in the clinic. The PI often identifies them, but they don’t seem to register with prescribers. I had a stark realization of this while working on a case series of lamotrigine withdrawals—many people reported a lupus-like syndrome. When I went searching, the only reference I found was in the PI.
Sure, there are cases like Horowitz’s—someone doing fine, trying to come off, and realizing they’re dependent. But that’s not the most common story I hear. More often, people are in absolute turmoil on multiple drugs, ignoring side effects until they try to come off and everything falls apart. And it’s not clear whether that’s due to dependence or the sheer state they’re in that made them want to stop in the first place. Many are terrified of what the drugs are doing to them, and they’re in such a mess that it’s impossible to tease apart cause and effect.
Then comes the promise: if they just follow the sacred 10% taper, no harm will come to them. So, like a terrified child clinging to a tree, they begin inching their way down, with no real way to know if they’re actually in danger or if it’s just the overwhelming fear and emotional turmoil that’s making everything worse. The last thing people in that state need is to drag out that suffering for years. And since polypharmacy is almost always involved, that’s exactly what happens—withdrawal timelines stretch so long that all-cause mortality becomes a factor.
And after all that? Once they’re finally off the drug—are they okay? Almost always, no. Nothing has been solved.
Great article, I'm so glad I stumbled across your Substack!
I am a PMHNP whose entire mindset changed after experiencing an extreme episode of hormonal/biologic "depression" after childbirth.
I had just finished my doctorate degree and had yet to start practicing. About 36 hours after birth, and after almost 70 hours without sleep, I became severely psychiatrically ill.
This paragraph resonates - "Those with early morning wakening, diurnal variation in mood, weight loss, anhedonia. What used to be called melancholia. In some cases, they may experience nihilistic delusions that they themselves are dead, that their internal organs are rotting. They may hear derogatory auditory hallucinations that they are worthless or guilty of a horrendous crime. These patients invariably do not spontaneously remit but often respond well to appropriate medication and in some cases ECT."
I was sure I was dying. I could not sleep. I could not eat. I lost all of the weight I had gained during pregnancy in a little under two weeks. I lost orientation to time, I began to have difficulty reading and writing, I could not remember anything, it was difficult to perform even the most basic task. I was slow to move or speak. It was torture. After 11 days I was started on sertraline and rather quickly titrated up to 75 mg. Within 4-6 weeks I felt mostly like myself again, albeit with some trauma surrounding the entire episode occurring in the first place. I have no personal or family history of mental health problems and don't have any known risk factors for something like this occurring. Around 8 months I slowly tapered myself off with no recurrence of symptoms. (I have not had another child yet.)
This experience really changed the way I practice. I relate to my patients deeply. And of course, I do notice categorically that there are patients with more biologic, hormonal etiologies, and patients whose problems are based in the psychosocial sphere. For all of these patients I recognize the importance of education, lifestyle changes, and complementary practices; however, I am so thankful for prudently prescribed, and de-prescribed, medications.
Here is ChatGPT's latest attempt to explain it, I think its pretty good.
🧠 Ratlosigkeit in the WKL Tradition
1. Not just confusion—existential perplexity
Unlike general confusion or delirium (where orientation to time, place, or identity is lost), Ratlosigkeit is a more subtle and haunting experience. The person may know where they are, who they are, and what day it is—but they are profoundly unsettled, as though something in reality no longer fits. It is a confusional affect more than a cognitive deficit.
2. Seen at the onset of major psychotic or cycloid episodes
WKL psychiatrists observed Ratlosigkeit as a hallmark of the sudden, dramatic break from normality that characterizes conditions like cycloid psychosis, acute polymorphic psychosis, and some atypical affective psychoses. It was particularly common in reactive psychoses, postpartum states, and periodic catatonia.
3. Wernicke’s Origin
Carl Wernicke initially described it as part of his elementary symptomatology, noting that some patients seemed to experience a break in the expected structure of reality—a disruption in the synthesis of perception and meaning. Things feel strange, threatening, or unreal, but not in a hallucinatory way.
4. Kleist’s Elaboration
Karl Kleist emphasized how Ratlosigkeit could precede or accompany other symptoms such as mood swings, psychomotor agitation, and delusions. He treated it as a marker of organicity or affective disruption, not a trivial or nonspecific symptom.
5. Leonhard’s Classification
Karl Leonhard maintained that Ratlosigkeit helped distinguish cycloid psychoses and non-system schizophrenias from chronic, deteriorating forms like system schizophrenias. The preserved insight and fluctuating course in people with Ratlosigkeit was one reason Leonhard viewed these disorders as more episodic and benign in long-term prognosis.
✨ Summary:
Ratlosigkeit is a lucid bewilderment—a sudden, disorienting shift in the person's internal grasp of reality, without gross disorientation. It's a state of knowing something is terribly wrong without being able to say what. It's the first crack in the sense of coherence. In WKL psychiatry, it's a meaningful sign: not random confusion, but a signature of a particular kind of psychotic process—often sudden, often recoverable, and deeply human in its subjective intensity.
That sounds awful. Its a terrifying thing to experience and I can imagine how it has changed your outlook.
Post partum episodes offer the firmest rebuttal to those who doubt biological causes. I wouldn't be too quick to credit the sertraline though, post partum episodes are notorious for their spotaneous remission. I say this because it may be important if it ever happens again.
Postpartum episodes are sometimes accompanied by a dream-like "perplexity," and often the symptoms fluctuate polymorphically, so one moment the person is melancholic and has retarded psychomotor function, the next they are filled with psychic agitation. Brockington and Perris also noticed that such cases had greater dread and preoccupation with death than in melancholia occurring outside the peripartum.
Below I have pasted Perris and Brockington's famous criteria for cycloid psychosis, a concept that is linked strongly to peripartum episodes. Some of the symptoms are closer to what we might call schizophrenia, but to me what is important is the sudden "bolt from the blue" onset, the "perplexity," the intensity of the anxiety and dread with its expansive colouring of death. Some cases also report a sense of overwhelming "inner tension", which is quite similar to PMDD or akathisia.
Perplexity, which is "Ratlosigkeit," in german is a very important concept, and one that anyone working in women's mental health should fully familiarise themselves with. It's a Wernicke, Kleist, Leonhard concept. It's a sort of confusional state—expansive, puzzled—but it's not delirium, so the person knows their date of birth, who the president is etc but they feel an "odd" sense that something is "very very wrong". They can be quite "hazy" or "dazed". Some people who experience it describe it as "dreamlike"; others say it's like something is very wrong but they can't articulate it. It's also a bit like knowing you're delusional and being puzzled by it. I asked ChatGPT to translate the concept of Ratlosigkeit and it said "the feeling of being lost in a familiar place." It went on to describe the Gen Z concept of liminal spaces, which I thought was very interesting. I would also recommend reading David Healy's book Mania: A Short History of Bipolar—his ideas about postpartum episodes are among the most interesting out there. The debate over whether this is bipolar is quite old, Emil Kraepelin ultimately decided that post partum and cycloid psychosis are part of the bipolar spectrum. However, as experts like Brockington and Healy have noticed, there is a group of post partum cases without a personal history of or family history of bipolar disorder. These cases have very sudden onset that resolves just as suddenly a few weeks after the the birth.
1. An acute psychotic condition, not related to the administration or the
misuse of any drug, or to brain injury, occurring for the first time in
subjects aged 15–50 years.
2. The condition has a sudden onset with a rapid change from a state of
health to a full-blown psychotic condition within a few hours or at the
most a few days.
3. At least four of the following must be present:
a. Confusion of some degree, mostly expressed as perplexity or
puzzlement
b. Mood-incongruent delusions of any kind, mostly with a persecutory
content
c. Hallucinatory experiences of any kind, often related to themes of death
d. An overwhelming, frightening experience of anxiety, not bound to
particular situations or circumstances (pan-anxiety)
e. Deeper feelings of happiness or ecstasy, most often with a religious
coloring
f. Motility disturbances of an akinetic or hyperkinetic type, which are
mostly expressional
g. A particular concern with death
h. Mood swings in the background, and so pronounced as to justify a
diagnosis of affective disorder
4. There is no fixed combination of symptoms; in contrast, the symptoms
may change frequently during an episode and show bipolar characteristics.
I came into this note expecting commentary on polypharmacy and instead discovered a nuanced and insightful look into an interesting controversy. Thank you Dr. Reilly!
I have to chime in. Discontinuation of SSRIs and SNRIs is child’s play compared to tapering opioids, benzodiazepines, alcohol, and even nicotine.
Are you seeing psychiatrists who are unaware of how to taper via cross-titration to fluoxetine and then use half-life kinetics if need be? Is there an old guard who does not acknowledge that discontinuation can be a bear for some folks? I finished training in 2016 for reference.
Thanks for your kind comment - totally agree, these other drugs can be even more difficult to stop.
I would hope most practicing psychiatrists would be able to handle a tapered withdrawal, switching to fluoxetine if necessary. But for sure as a field we have downplayed withdrawal from SSRIs, particularly the small group who experience really severe effects
You’re 100% correct
Fluoxetine won't cover the norepinephrine part of withdrawals from an SNRI. I've also seen discussion about each SSRI having a different profile of how it affects serotonin reuptake receptors, meaning that cross-tapering or bridging won't necessarily prevent withdrawals.
Thank you for this post. A sensible look at side effects of antidepressants is long overdue. There is just no need for doctors and psychiatrists to close this issue down as something that could cast doubt on their status. The research field into pharmaceuticals is never going to be completed, and that’s the nature of it, so I don’t know why some get so defensive when matters like this come up. They’re always going to come up, so it’s always constructive to talk about these issues. Individual differences abound in tolerances to different medications. Personally, I have found fluoxetine to be very effective at eliminating voices and bizarre delusions but less effective at preventing non bizarre delusional paranoia and moderate depression. I have no idea why this is. I know it’s not just a placebo in my case because I was prescribed it when I described symptoms of depression to my doctor. What neither of us realised at the time was that I was floridly psychotic after a head injury which I had no insight about. My hallucinations faded away, with the main persecutory voice actually announcing “I think I’m becoming less controlling”. A few years later I switched to Sertraline and I find this more effective as a mood improver. However, I get really severe vertigo and nausea if I even miss one tablet, so I would definitely need to taper off it gradually if I ever change medication. I’m personally really interested in what works and what doesn’t, and why, but I haven’t come across a clinician who is prepared to cover the topic with any other audience than colleagues, so thank you 🙏
Thanks for sharing your personal experience - completely agree that individual differences in response to medication is hugely important!
This was very enlightening! This is something that is not talked about enough in medicine and I often take care of elderly patients who are on an endless list of medications because nobody is working on deprescribing unnecessary medications. Thank you for sharing!
It's the absence of informed consent that bugs me... Patients are not told about a 3% risk of severe withdrawal symptoms or the sexual side effects prior to initiating antidepressants, often for life difficulties (med student observing here) - I see them given information I would find negligently insufficient for informed consent if I was the patient. (Lesson from a med student - never be a patient - I'd be appalled to be treated like our patients are treated) Also speaking as someone with a SMI who has stopped psych meds cold turkey well over three or four if not five dozen times in my life, with absolutely no ill effects, the modern mantra that you must never stop a psych med cold turkey except on medical advice is equally idiotic... Even my cat's prescription for Prozac says don't stop suddenly!!!
Sorry to hear this. I would hope that prescribers would discuss common side effects including sexual dysfunction and withdrawal symptoms.
Agree there is much inter-individual variability and I’ve seen people who seem able to stop psychotropic medication suddenly without apparent adverse effects.
I choked on my coffee a few months ago when Mark H told Dr. Josef that he'd "never seen" melancholia. Thats great when we live in a world were clinicians have "never seen" withdrawal effects.
I’m going to be contrarian on one of your posts again. As someone in a withdrawal support group, I have to say: deprescribing isn’t the real issue—in fact, it’s creating a major one of its own.
There’s a growing movement, a kind of discipleship, that has spilled over from the benzo withdrawal groups, preaching the gospel of the 10% taper. Its leading figure? None other than Mark Horowitz. According to this group, all drugs and their effects are “hyperbolic,” and all harms can be avoided with a slow enough “hyperbolic” taper. Now, we have people stuck on multiple ineffective medications, experiencing serious adverse reactions—intracranial hypo/hypertension, autoimmune disease, glaucoma—yet tapering so slowly that they’ll die of a dozen other conditions before finishing withdrawal from just one drug. And if you suggest the effort isn’t worth the outcome, they’ll throw the Maudsley deprescribing guidelines at your head.
The reality is, most of the harm has already been done. The old taper speeds were based on sound clinical observation—things happening in front of doctors' eyes. The real problem isn’t tapering; it’s the harm and inefficacy of these drugs in the first place. We’re talking about medications that don’t work well, that people take for years, suffer from, and then—rather than reassessing the drugs themselves—the latest fad is to tell them to spend the rest of their lives shaving pills with a razor blade.
The bigger issue is that we’ve gotten bad at recognizing harms. We caught tardive dyskinesia and dystonia with first-gen antipsychotics. We noticed lithium’s tremor and toxicity. But somewhere along the way, we stopped seeing side effects in the clinic. The PI often identifies them, but they don’t seem to register with prescribers. I had a stark realization of this while working on a case series of lamotrigine withdrawals—many people reported a lupus-like syndrome. When I went searching, the only reference I found was in the PI.
Sure, there are cases like Horowitz’s—someone doing fine, trying to come off, and realizing they’re dependent. But that’s not the most common story I hear. More often, people are in absolute turmoil on multiple drugs, ignoring side effects until they try to come off and everything falls apart. And it’s not clear whether that’s due to dependence or the sheer state they’re in that made them want to stop in the first place. Many are terrified of what the drugs are doing to them, and they’re in such a mess that it’s impossible to tease apart cause and effect.
Then comes the promise: if they just follow the sacred 10% taper, no harm will come to them. So, like a terrified child clinging to a tree, they begin inching their way down, with no real way to know if they’re actually in danger or if it’s just the overwhelming fear and emotional turmoil that’s making everything worse. The last thing people in that state need is to drag out that suffering for years. And since polypharmacy is almost always involved, that’s exactly what happens—withdrawal timelines stretch so long that all-cause mortality becomes a factor.
And after all that? Once they’re finally off the drug—are they okay? Almost always, no. Nothing has been solved.
Great article, I'm so glad I stumbled across your Substack!
I am a PMHNP whose entire mindset changed after experiencing an extreme episode of hormonal/biologic "depression" after childbirth.
I had just finished my doctorate degree and had yet to start practicing. About 36 hours after birth, and after almost 70 hours without sleep, I became severely psychiatrically ill.
This paragraph resonates - "Those with early morning wakening, diurnal variation in mood, weight loss, anhedonia. What used to be called melancholia. In some cases, they may experience nihilistic delusions that they themselves are dead, that their internal organs are rotting. They may hear derogatory auditory hallucinations that they are worthless or guilty of a horrendous crime. These patients invariably do not spontaneously remit but often respond well to appropriate medication and in some cases ECT."
I was sure I was dying. I could not sleep. I could not eat. I lost all of the weight I had gained during pregnancy in a little under two weeks. I lost orientation to time, I began to have difficulty reading and writing, I could not remember anything, it was difficult to perform even the most basic task. I was slow to move or speak. It was torture. After 11 days I was started on sertraline and rather quickly titrated up to 75 mg. Within 4-6 weeks I felt mostly like myself again, albeit with some trauma surrounding the entire episode occurring in the first place. I have no personal or family history of mental health problems and don't have any known risk factors for something like this occurring. Around 8 months I slowly tapered myself off with no recurrence of symptoms. (I have not had another child yet.)
This experience really changed the way I practice. I relate to my patients deeply. And of course, I do notice categorically that there are patients with more biologic, hormonal etiologies, and patients whose problems are based in the psychosocial sphere. For all of these patients I recognize the importance of education, lifestyle changes, and complementary practices; however, I am so thankful for prudently prescribed, and de-prescribed, medications.
Here is ChatGPT's latest attempt to explain it, I think its pretty good.
🧠 Ratlosigkeit in the WKL Tradition
1. Not just confusion—existential perplexity
Unlike general confusion or delirium (where orientation to time, place, or identity is lost), Ratlosigkeit is a more subtle and haunting experience. The person may know where they are, who they are, and what day it is—but they are profoundly unsettled, as though something in reality no longer fits. It is a confusional affect more than a cognitive deficit.
2. Seen at the onset of major psychotic or cycloid episodes
WKL psychiatrists observed Ratlosigkeit as a hallmark of the sudden, dramatic break from normality that characterizes conditions like cycloid psychosis, acute polymorphic psychosis, and some atypical affective psychoses. It was particularly common in reactive psychoses, postpartum states, and periodic catatonia.
3. Wernicke’s Origin
Carl Wernicke initially described it as part of his elementary symptomatology, noting that some patients seemed to experience a break in the expected structure of reality—a disruption in the synthesis of perception and meaning. Things feel strange, threatening, or unreal, but not in a hallucinatory way.
4. Kleist’s Elaboration
Karl Kleist emphasized how Ratlosigkeit could precede or accompany other symptoms such as mood swings, psychomotor agitation, and delusions. He treated it as a marker of organicity or affective disruption, not a trivial or nonspecific symptom.
5. Leonhard’s Classification
Karl Leonhard maintained that Ratlosigkeit helped distinguish cycloid psychoses and non-system schizophrenias from chronic, deteriorating forms like system schizophrenias. The preserved insight and fluctuating course in people with Ratlosigkeit was one reason Leonhard viewed these disorders as more episodic and benign in long-term prognosis.
✨ Summary:
Ratlosigkeit is a lucid bewilderment—a sudden, disorienting shift in the person's internal grasp of reality, without gross disorientation. It's a state of knowing something is terribly wrong without being able to say what. It's the first crack in the sense of coherence. In WKL psychiatry, it's a meaningful sign: not random confusion, but a signature of a particular kind of psychotic process—often sudden, often recoverable, and deeply human in its subjective intensity.
That sounds awful. Its a terrifying thing to experience and I can imagine how it has changed your outlook.
Post partum episodes offer the firmest rebuttal to those who doubt biological causes. I wouldn't be too quick to credit the sertraline though, post partum episodes are notorious for their spotaneous remission. I say this because it may be important if it ever happens again.
You should check out the work of Ian Brockington and Carlos Perris. Here is a lecture Brockington gave recently: https://www.youtube.com/watch?v=Ajl2H4Fh8wo&t=1s
Postpartum episodes are sometimes accompanied by a dream-like "perplexity," and often the symptoms fluctuate polymorphically, so one moment the person is melancholic and has retarded psychomotor function, the next they are filled with psychic agitation. Brockington and Perris also noticed that such cases had greater dread and preoccupation with death than in melancholia occurring outside the peripartum.
Below I have pasted Perris and Brockington's famous criteria for cycloid psychosis, a concept that is linked strongly to peripartum episodes. Some of the symptoms are closer to what we might call schizophrenia, but to me what is important is the sudden "bolt from the blue" onset, the "perplexity," the intensity of the anxiety and dread with its expansive colouring of death. Some cases also report a sense of overwhelming "inner tension", which is quite similar to PMDD or akathisia.
Perplexity, which is "Ratlosigkeit," in german is a very important concept, and one that anyone working in women's mental health should fully familiarise themselves with. It's a Wernicke, Kleist, Leonhard concept. It's a sort of confusional state—expansive, puzzled—but it's not delirium, so the person knows their date of birth, who the president is etc but they feel an "odd" sense that something is "very very wrong". They can be quite "hazy" or "dazed". Some people who experience it describe it as "dreamlike"; others say it's like something is very wrong but they can't articulate it. It's also a bit like knowing you're delusional and being puzzled by it. I asked ChatGPT to translate the concept of Ratlosigkeit and it said "the feeling of being lost in a familiar place." It went on to describe the Gen Z concept of liminal spaces, which I thought was very interesting. I would also recommend reading David Healy's book Mania: A Short History of Bipolar—his ideas about postpartum episodes are among the most interesting out there. The debate over whether this is bipolar is quite old, Emil Kraepelin ultimately decided that post partum and cycloid psychosis are part of the bipolar spectrum. However, as experts like Brockington and Healy have noticed, there is a group of post partum cases without a personal history of or family history of bipolar disorder. These cases have very sudden onset that resolves just as suddenly a few weeks after the the birth.
1. An acute psychotic condition, not related to the administration or the
misuse of any drug, or to brain injury, occurring for the first time in
subjects aged 15–50 years.
2. The condition has a sudden onset with a rapid change from a state of
health to a full-blown psychotic condition within a few hours or at the
most a few days.
3. At least four of the following must be present:
a. Confusion of some degree, mostly expressed as perplexity or
puzzlement
b. Mood-incongruent delusions of any kind, mostly with a persecutory
content
c. Hallucinatory experiences of any kind, often related to themes of death
d. An overwhelming, frightening experience of anxiety, not bound to
particular situations or circumstances (pan-anxiety)
e. Deeper feelings of happiness or ecstasy, most often with a religious
coloring
f. Motility disturbances of an akinetic or hyperkinetic type, which are
mostly expressional
g. A particular concern with death
h. Mood swings in the background, and so pronounced as to justify a
diagnosis of affective disorder
4. There is no fixed combination of symptoms; in contrast, the symptoms
may change frequently during an episode and show bipolar characteristics.