Margaret G. Spinelli

Dear friends,

This week, I would like to change our work method and give the responsibility of diagnosis to all you. I hope you enjoy playing doctors!

I present you Mrs. A, a 34-year-old married mother. I want you to read down her story, which was studied by Margaret G. Spinelli, and write a clinical comment.

You could name her symptoms one by one and, considering her particular context, find out a diagnosis. If you can add more information about it etiology, management or treatment don’t be shy and explain us, it will be really interesting!

I am going to analyze this case in detail in my conclusion so don’t forget to come back in four or five days to check your answers.

Good luck and have fun, doctors!

María Lamana Villegas

Mrs. A, a 34-year-old married mother who lived with her husband and their 5-year-old daughter, strangled her infant son to death 3 weeks after birth. She had a planned, healthy pregnancy with some depression at 28 weeks’ gestation. She had a normal spontaneous vaginal delivery, giving birth to a healthy boy, “B.” She began breastfeeding immediately. From postpartum days 2 through 11, her depression worsened. She was unable to sleep but could not get out of bed or attend to her hygiene. She was suspicious that her husband would harm B. On postpartum day 2, she began having obsessional, ego-dystonic images of throwing B out the window. She believed, despite the pediatrician’s reassurances, that she was harming B with her breast milk and that he was losing weight. She was unable to give him a bath, believing that he had “gas” or “something bad” inside and could not be moved.

On day 12, while alone in the car with B, she thought of killing herself and the baby, although “at the time I don’t think I had any idea why.” On day 13, she attempted suicide by overdose. She slept through the night and did not report the suicide attempt to anyone. She abruptly weaned B and then became disorganized and confused, unsure of what formula and size and types of bottles and nipples to use. She was agitated, calling friends day and night for opinions. On day 15 she attempted to smother B with a towel. “I don’t believe it was a thought,” she said. “It was ‘autopilot.’” Her husband came upstairs, and Mrs. A believes that his presence shook her out of the “state” she was in. “I did not have the compulsion to hurt him any more after that evening … I just thought something was wrong, and I wasn’t thinking straight.” Her husband knew that she was not herself, but he did not understand that she was depressed and psychotic. Mrs. A did not receive treatment for her illness.

On postpartum day 20, Mrs. A awoke at 6:30 a.m. to feed B when he cried. Her husband and daughter kissed her goodbye, and Mr. A walked their daughter to school before going to work. She soon felt as if she was “taken over.” She describes a dazed, trance-like state with confusion: “Something internal like a force … it was not a voice … but I did not have control. It was an instant. I don’t recall thinking anything … I had no feelings. It was happening but I wasn’t there.… At the time, nothing came into my head saying, ‘No, do not do this.’ … My inside was gone and it was something else.” She briefly placed a towel over B’s nose and mouth, but stopped. The “force” then became intense. She placed a washcloth in B’s mouth and then strangled him with a telephone cord. She felt she was not connected to her own hands. When B was dead, she washed him with a cloth, removed the remnants of his umbilical cord, changed his diaper, and left the room. She went into the bathroom, where she made an unsuccessful attempt to cut her wrists.

Mrs. A was charged with homicide and was incarcerated. She described her psychiatric history as “moody” with cycling states, every 3 days, of jocularity, creativity, and high energy alternating with an irritable, withdrawn mood and tearfulness. She had two previous episodes of major depression, including a postpartum depression after the birth of her daughter that was associated with ego-dystonic images of throwing her daughter against a wall or hitting her with a hammer. She denied psychotic thoughts. The depression resolved in 6 months without treatment. She was a successful “supermom” with her daughter and was an energetic worker in her job.

Mrs. A’s mother has a diagnosis of bipolar disorder, which worsened after the birth her second child. She had multiple psychiatric hospitalizations for psychotic episodes with chronic paranoia and grandiose, volatile moods.