The patient is a 34-year-old married mother of two who was brought to our emergency department by her husband following several days of limited sleep, increased “fixation” on religious themes and other unusual behavior. She believed that she was “channeling God” and that she was soon to be the next “president of the United States of the World.” While in the emergency room, the patient told her husband about her “world plan” in which she intended, by the power of her touch, to send her parents and children to a better place until Dec. 21, 2012, “when Jesus will come and we will all be reunited.” During the initial evaluation, the patient had loud, pressured speech, and described being in a “perfect” mood with no insight of being ill. Her agitation was treated with intramuscular antipsychotics, and she was admitted to the inpatient psychiatric unit under constant observation.
The patient had been “outgoing and social” as a child, but struggled academically from an early age. She was evaluated for a learning disability at age 14 years and was found to be of average intelligence but had memory and organizational difficulties. She was not particularly devoted as a student, but was able to graduate high school on time and attend college, where she was sexually promiscuous and used alcohol and marijuana heavily. In her early 20s, there were periods of increased irritability and excitement where, on a whim, she would fly to exotic locations for unplanned vacations. For brief periods, she held jobs in tourism, retail, and marketing until she met her husband at the age of 26 years. They were married 6 months later, and she soon became a full-time wife and mother of two girls, now aged 4 and 7 years.
She was first diagnosed with major depression at age 31 years, after the birth of her second daughter. She was treated with bupropion without clear benefit. Her first reported mania occurred at age 33 years while she and her husband were living abroad. She began to journal excessively, finding special significance in her writings, which, in her words, “would change the world.” She demanded to give her journal to the president, and later told her husband that she would become the president and her friends would be her cabinet members. She was taken to a local hospital and ultimately transferred, by medical evacuation, to a hospital in the US where she was diagnosed with bipolar disorder and treated with valproate and olanzapine. After several weeks of treatment, she was ultimately switched to lithium and aripiprazole before being discharged in improved condition, but not in full euthymia.
Over the initial months following her discharge, with fair but not perfect medication adherence, there were a few brief dips in mood, but she remained mostly stable. However, she soon became excessively focused on religious themes and on bringing “world peace to the earth.” She stopped her medications, believing that they were impurities that were unnecessary since “God would take care of [her].” Her husband, now more familiar with the manifestations of mania, brought her to the emergency department for admission. Although the patient disagreed with her husband’s assessment that she was unstable, she agreed to be admitted to allay his anxiety.
During this hospitalization, the patient was again placed on lithium and was started on risperidone, which was titrated to a 4-mg daily dose. Since medication adherence had been a concern (her lithium level on admission was undetectable). she was placed on long-acting risperidone injection. After a week of treatment, the patient’s sleep was more regular, her speech less pressured and she no longer endorsed grandiose or religious delusions. There were no thoughts of injuring her family, but she did report concerns about the stress of returning to a full-time mothering role. Given her history of relapse and the family’s concern of having her unsupervised at home, she was transferred to our specialty mood disorder day hospital.
The patient was followed in the day hospital for 2 months. Although she initially appeared to be without psychotic symptoms, she soon disclosed to her husband that “world peace is still in my heart.” Her sleep and energy levels were back at baseline, but she continued to journal profusely. She came regularly to the day hospital because she needed to be an “example of good mental health” and she wanted to “help the bipolar people of the world.” Fortunately, these delusions resolved with a gradual increase in the long-acting risperidone to a 37.5-mg bimonthly dose without the need for additional inpatient hospitalization.
After weeks of stability, the patient began to express pessimistic ruminations about her ability to take care of her children. She became more dysphoric, labile, and ruminative. Of particular concern to her, and the treatment team, was a resurgence of thoughts of sending her children to “a better place.” She was urgently re-admitted to the inpatient unit, where she quickly improved on continued lithium treatment and a slightly higher dose of risperidone. The patient was discharged back to the day hospital program and the previous treatment modalities were continued. Three months on, she remains stable and continues to live with her parents.
Psychotic Bipolar Disorder
Psychotic symptoms are common in bipolar disorder, with a lifetime prevalence rate of approximately 60%.1 Most delusions occur during mania and involve typical mood-congruent themes such as heightened religiosity or special abilities. Mood-incongruent psychotic features, such as delusions of control or passivity experiences, are also not uncommon and occur in 30% to 40% of patients with psychotic bipolar disorder.2 Furthermore, approximately 25% of patients with bipolar disorder also experience psychotic symptoms during depressive episodes, which is more than four times more frequent compared with unipolar depressive episodes.3 Psychotic symptoms in bipolar disorder have generally been associated with worse overall illness course, including longer illness duration;4 more pronounced cognitive deficits;5 and poorer occupational6 and social outcomes.7
In this case, a primary concern of both the family and the treatment team was for the safety of the patient’s children. Although the patient was no longer delusional and had no filicidal thoughts, she expressed difficulties coping with the demands and stressors of her family life. Her family was concerned about a potential relapse and found themselves constantly supervising the patient in the presence of the children. With the treatment team, the decision was made to have the patient live with her parents, who lived nearby, and offer her supervised visits of her children on a daily basis. By common consent, this would be continued for at least 6 months of illness stability.
The day hospital treatment program emphasized intensive psycho-education with the patient, her husband, parents and children. Employing a multi-modal approach that included physicians, nurses, psychologists and social workers, regular illness education was provided to all participants that focused on medication adherence and the acceptance of a recurrent illness that requires life-long treatment. Therapy for the patient also focused on improving her coping and parenting skills, which helped her understand and accept why her family and treatment team insisted on a slow and gradual reintegration back to her maternal role.
Thoughts of child harm appear to be more common than is usually acknowledged,8 particularly in post-partum depression9 and obsessive-compulsive disorders.10 However, the prevalence and consequences of delusions of child harm and infanticide are unknown.
There is also a paucity of studies focusing on parental infanticide, the most dreaded consequence of such thoughts. Among the few epidemiological studies performed to date, a recent Norwegian registry-based survey found an association between parental admission to an inpatient psychiatric hospital and child homicide (not necessarily by the hospitalized parent), with similar associations for affective disorders and “schizophrenia-like disorders.”11 Most perpetrators of child homicides did not have a history of psychiatric hospitalization, with only seven of 33 (21%) perpetrators having been previously admitted to a psychiatric hospital. Fortunately, the absolute lifetime risk of being a victim of homicide was extremely low in both children of hospitalized (0.051%) and never hospitalized (0.009%) parents.11
In this patient, there were filicidal ideations associated with delusions during periods of both mania and depression, but there was no apparent intent to act upon these delusions. The patient agreed to be admitted voluntarily to the inpatient psychiatric unit, but had she not, the evaluating emergency room psychiatrist’s concern was sufficiently high that she would have met her state’s criteria for involuntary admission. Once she was admitted and treated with appropriate pharmacological therapy (a mood stabilizer and an antipsychotic), the delusions underlying the filicidal ideations rapidly improved.
After the stabilization of acute symptoms, a major focus of treatment was to improve illness insight and medication adherence, and to provide psycho-education with appropriate family involvement. Insight in manic patients typically improves with the resolution of mania, but residual insight impairment may continue as patients convalesce.12 In the described case, attenuated mood symptoms (including possible psychotic symptoms) were present through much of the outpatient follow-up period, justifying the need for continued day hospital treatment with careful observation and frequent reporting by the patient’s family.
An important therapeutic consideration that became apparent during treatment was how to address and incorporate the patient’s personality traits and vulnerabilities in the overall treatment strategy. Her tendency to be highly extroverted and easily frustrated led to frequent minimization of symptoms and repeated attempts to lessen the treatment commitments initially set forth by her family and treatment team. In response, practical but realistic goals, such as increased time with her children, were emphasized and made contingent on her ongoing participation in treatment. Discussions regarding treatment with the patient were non-confrontational, but expectations remained firm and unchanged.
As shown in this case, mothers affected by severe mental illness may pose a risk to themselves and their children. Routine screening for violent thoughts or ideations should inquire about thoughts of harming young children, and delusions with infanticidal or filicidal content should be regarded as psychiatric emergencies that often require inpatient admission. Acute stabilization of mood and psychotic symptoms is a necessary first step in treatment, but a multidisciplinary long-term therapeutic approach involving the patient and their family is essential to be able to safely re-integrate patients with their families.
- Goodwin FK, Jamison KR. Manic-Depressive Illness : Bipolar Disorders and Recurrent Depression. 2nd ed. New York ; Oxford: Oxford University Press; 2007.
- Goes FS, Zandi PP, Miao K, et al. Mood-incongruent psychotic features in bipolar disorder: familial aggregation and suggestive linkage to 2p11–q14 and 13q21–33. Am J Psychiatry. 2007;164(2):236–247. doi:10.1176/appi.ajp.164.2.236 [CrossRef]
- Goes FS, Sadler B, Toolan J, et al. Psychotic features in bipolar and unipolar depression. Bipolar Disord. 2007;9(8):901–906. doi:10.1111/j.1399-5618.2007.00460.x [CrossRef]
- Coryell W, Leon AC, Turvey C, Akiskal HS, Mueller T, Endicott J. The significance of psychotic features in manic episodes: a report from the NIMH collaborative study. J Affect Disord. 2001;67(1–3):79–88. doi:10.1016/S0165-0327(99)00024-5 [CrossRef]
- Bora E, Yücel M, Pantelis C. Neurocognitive markers of psychosis in bipolar disorder: a meta-analytic study. J Affect Disord. 2010;127(1–3):1–9. Epub 2010 Mar 15. doi:10.1016/j.jad.2010.02.117 [CrossRef]
- Tohen M, Waternaux CM, Tsuang MT. Outcome in Mania. A 4-year prospective follow-up of 75 patients utilizing survival analysis. Arch Gen Psychiatry. 1990;47(12):1106–1111.
- Rosen LN, Rosenthal NE, Dunner DL, Fieve RR. Social outcome compared in psychotic and nonpsychotic bipolar I patients. J Nerv Ment Dis. 1983;171(5):272–5. doi:10.1097/00005053-198305000-00002 [CrossRef]
- Friedman SH, Sorrentino RM, Stankowski JE, Holden CE, Resnick PJPsychiatrists’ knowledge about maternal filicidal thoughts. Compr Psychiatry. 2008;49(1):106–10. Epub 2007 Oct 18. doi:10.1016/j.comppsych.2007.07.001 [CrossRef]
- Jennings KD, Ross S, Popper S, Elmore M. Thoughts of harming infants in depressed and nondepressed mothers. J Affect Disord. 1999;54(1–2):21–28. doi:10.1016/S0165-0327(98)00185-2 [CrossRef]
- Button JH, Reivich RS. Obsessions of infanticide. A review of 42 cases. Arch Gen Psychiatry. 1972;27(2):235–240.
- Laursen TM, Munk-Olsen T, Mortensen PB, Abel KM, Appleby L, Webb RT. Filicide in offspring of parents with severe psychiatric disorders: a population-based cohort study of child homicide. J Clin Psychiatry. 2011;72(5):698–703. Epub 2010 Oct 5. doi:10.4088/JCP.09m05508gre [CrossRef]
- Peralta V, Cuesta MJ. Lack of insight in mood disorders. J Affect Disord. 1998;49(1):55–58. doi:10.1016/S0165-0327(97)00198-5 [CrossRef]