NURU MAHMUD--------------------(PRESENTER)

SALIYAT KEDIR
RAHEL YOHANIS
Genet Gemeda

08/03/2025
 PSYCHIATRY
AND REPRODUCTIVE
MEDICINE
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 OBJECTIVE
 Define and differentiate PMDD, postpartum blues, postpartum depression, postpartum
psychosis, and pseudocyesis.

 Identify key clinical features and DSM-5 diagnostic criteria.

 Explain the neurobiological and hormonal factors involved in these reproductive-

related psychiatric disorders.

 Outline appropriate treatment strategies, including pharmacological and

psychotherapeutic approaches.

 Recognize the importance of early detection and intervention to improve maternal

mental health outcomes.
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O
NR
O
IN
T
CI
U
D

Psychiatry and reproductive medicine are interconnected, as

reproductive processes such as menstruation, pregnancy, and
childbirth can affect mental health. Hormonal fluctuations during
these phases may trigger or worsen psychiatric disorders,
necessitating integrated clinical care. Recognizing the impact of
reproductive events on mental well-being and mental health
disorders can affect fertility, sexual function, and pregnancy.
4
 COMMON PROBLEMS
IN PSYCHIATRY AND
REPRODUCTIVE
MEDICINE

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……

 Premenstrual Dysphoric Disorder (PMDD)

 Postpartum Blues ("Baby Blues")
 Postpartum Depression
 Postpartum Psychosis
 Pseudocyesis (False Pregnancy)

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  PREMENSTRUAL DYSPHORIC DISORDER (PMDD)

premenstrual dysphoric disorder are the expression of mood liability,

irritability, dysphoria, and anxiety symptoms that occur repeatedly
during the premenstrual phase of the cycle and remit around the onset
of menses or shortly thereafter.

These symptoms may be accompanied by behavioral and physical

symptoms.

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 CLINICAL PRESENTATION OF (PMDD)

 Mood swings, irritability, or  Difficulty concentrating

anger  Appetite changes or food

cravings
 Depressed mood, feelings of
 Sleep disturbances (insomnia or
hopelessness
hypersomnia)
 Lethargy or fatigue
 Physical symptoms (breast

 Decreased interest in usual tenderness, bloating, headaches,

joint/muscle pain)
activities
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  COURSE OF (PMDD)

PMDD follows a recurrent, cyclical course, directly tied to the menstrual

cycle. Symptoms typically emerge during the late luteal phase,
approximately 1–2 weeks before menstruation begins, and peak just before
the onset of menses. These symptoms then resolve within a few days after
menstruation starts, with a symptom-free interval during the follicular
phase. The pattern repeats with almost every menstrual cycle. In some
individuals, the severity of symptoms may increase with age, particularly
around perimenopause, likely due to fluctuating hormone levels.
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 EPIDEMIOLOGY OF (PMDD)

The 12-month prevalence of premenstrual dysphoric disorder in

the community has been estimated at 5.8% based on a large study
from Germany. And 1.3% of Women in the United States.
The prevalence of premenstrual dysphoric disorder symptoms in
adolescent girls may be higher than that observed in adult women.

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 ETHOLOGY OF (PMDD)

The exact etiology is not fully understood but is thought to

involve a complex interplay of factors .

Biological: Hormonal Sensitivity: PMDD is not due to abnormal

absolute levels of ovarian hormones (estrogen and progesterone),

but rather an abnormal cellular response or sensitivity to normal

cyclical changes in these hormones. .

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…….

Neurotransmitter Dysregulation: Imbalances in serotonin (5-

HT) systems are strongly implicated. Fluctuations in ovarian
steroids (estrogen, progesterone) can affect serotonin synthesis,
receptor sensitivity, and reuptake. .
Genetic Predisposition: There's evidence of familial clustering,
suggesting genetic vulnerability. .
Psychological/Social: Stress, trauma history, and personality
traits (e.g., neuroticism) may exacerbate symptoms
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 DSM-5 DIAGNOSTIC CRITERIA OF (PMDD)

A-In the majority of menstrual cycles during the past year, at least five symptoms must be
present in the final week before the onset of menses, start to improve within a few days after the
onset of menses, and become minimal or absent in the week post-menses

B-One (or more) of the following symptoms must be present:

1. Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful, or increased
sensitivity to rejection). .
2. Marked irritability or anger or increased interpersonal conflicts. .
3.Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts
4. Marked anxiety, tension, and/or feelings of being keyed up or on edge.(feeling tense, restless, or nervous
—like you’re always alert, anxious, or easily startled
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…….

C-one or more Symptoms additionally be present (to make a total of 5)when combined
with CB

1. Losing interest in usual activities

2. Trouble concentrating

3. Feeling tired or low energy

4. Changes in appetite or food cravings

5. Sleeping too much or too little

6. Feeling overwhelmed or out of control

7. Physical symptoms like breast tenderness, muscle pain, bloating, or weight gain
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…….

D-Symptoms cause real problems and impact work, school, social life, or relationships.

E- The disturbance is not merely an exacerbation of another disorder, such as Major

Depressive Disorder, Panic Disorder, Persistent Depressive Disorder (Dysthymia), or
other mental disorder (although it may co-occur with any of these disorders).

F-. Criterion A should be confirmed by prospective daily ratings during at least two
symptomatic cycles.

G. The symptoms are not attributable to the physiological effects of a substance or

another medical condition.

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DDX
• Premenstrual syndrome

• Dysmenorrhea

• major depressive disorder, and

• persistent depressive disorder.

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  RISK FACTORS AND PROGNOSIS

Risk factors Prognosis

-History of anxiety or mood PMDD is a chronic, recurring disorder
disorders.
-Family history of PMDD or with symptoms during the luteal phase
mood disorders.
and improvement after menstruation.
-Trauma history.
-Stressful life events. Without treatment, it can cause
-Obesity (some studies
significant distress and impair daily life.
suggest).
Symptoms often improve with treatment

and may lessen after menopause.

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 MANAGEMENT
Pharmacological: SSRIs (Selective Serotonin Reuptake Inhibitors):
First-line treatment. Can be administered continuously or only during the
luteal phase (intermittent dosing). Examples: Fluoxetine, Sertraline, Paroxetine,

Citalopram.

Oral Contraceptives: Specifically, drospirenone and ethinyl estradiol

(Yaz) is FDA-approved for
PMDD. .
Psychotherapy: Cognitive Behavioral Therapy (CBT): Helps patients
identify
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…..

Lifestyle Modifications: Diet: Reduce caffeine, alcohol, salt, and

refined sugars; increase complex carbohydrates.

Exercise: Regular aerobic exercise can alleviate mood symptoms.

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 BABY BLUES
Postpartum blues, often referred to as "baby blues," is a common,
transient, and mild mood disturbance experienced by many women in the
immediate postpartum period. .
It’s happen due to sudden physical, emotional, and hormonal changes after
childbirth.

It is considered a normal physiological adjustment rather than a mental

disorder and typically resolves spontaneously without specific
intervention
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 CLINICAL PRESENTATION

Symptoms are typically mild and fluctuating. They include:

-Emotional lability (sudden, unprovoked crying spells).
-Irritability, Anxiety, Sadness, Insomnia (despite fatigue),Feelings of
overwhelmedness. Difficulty concentrating. Fatigue. .

These symptoms are usually not severe enough to impair daily

functioning or significantly interfere with the mother's ability to care
for herself
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 COURSE OF PPB
Symptoms typically begin within 2-3 days after childbirth, peak
around day 4-5, and generally resolve spontaneously within 10-14
days postpartum. If symptoms persist beyond two weeks or worsen, it
raises concern for postpartum depression. .
Prevalence: Extremely common, affecting 50-85% of women
after childbirth

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DDX
Postpartum Depression (PPD) .
Postpartum Psychosis(PPP) .
Medical Conditions: (e.g., thyroid dysfunction, anemia) that might cause
similar symptoms .

Prognosis: Postpartum blues is self-limiting and resolves

spontaneously within two weeks postpartum for the vast majority of
women. It does not typically require formal psychiatric treatment.
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  MANAGEMENT

Reassurance and Education: Inform the new mother and her family that
these feelings are common, normal, and temporary.

Support: Encourage practical and emotional support from partners, family,

and friends (e.g., help with chores, infant care, allowing the mother to rest).
Self-Care: Emphasize rest, nutrition, hydration, and gentle exercise.
Monitoring: Advise the mother and family to seek professional help if
symptoms persist beyond two weeks or worsen significantly.

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 POSTPARTUM DEPRESSION
 Postpartum depression (PPD) is a major depressive episode that
occurs during pregnancy or within 4 weeks postpartum

 It is classified in the DSM-5 as Major Depressive Disorder with

Peripartum Onset Specifier.

 It involves a range of physical, emotional, and behavioral changes

that are more severe and long-lasting than postpartum blues,
significantly interfering with a woman's ability to function.
  CLINICAL PRESENTATION
Symptoms are similar to those of a Major Depressive Episode but occur in
the peripartum period. They often include:
.
Mood:-Persistent sadness, hopelessness, emptiness, anhedonia (loss of
pleasure in activities), irritability, anxiety. .
Cognitive:-Difficulty concentrating, memory problems, excessive guilt,
feelings of worthlessness, recurrent thoughts of death or suicide (including
thoughts of harming the baby, which must be taken very seriously).
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……

Behavioral:-Social withdrawal, crying spells, decreased

energy/fatigue, changes in sleep (insomnia or hypersomnia
unrelated to infant's sleep patterns), changes in appetite.

Infant-Related:-Lack of interest in the baby, feeling detached

from the baby, fear of harming the baby.

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  COURSE OF THE DISORDER
 PPD can begin anytime during pregnancy or in the first 4
Weeks postpartum.

 Onset is most common within the first 4 Weeks.

 Without treatment, symptoms can last for many months, and

in some cases, over a year. Early intervention significantly
improves outcomes. Relapse risk exists in subsequent
pregnancies.
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  EPIDEMIOLOGY

 WHO Perspective: PPD is a significant global health concern,

affecting women in all cultures and socioeconomic groups. It impacts
maternal and child health, development, and family well-being.
WHO estimates up to 13% of women globally experience a mental
disorder (primarily depression) after childbirth.

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  ETIOLOGY
Etiology: A multifactorial etiology involving biological, psychological, and
social factors:
Biological: -
 Hormonal Fluctuations: Rapid drop in estrogen, progesterone, and
other hormones (e.g., thyroid hormones, cortisol) after delivery.
• Neurochemical Changes: Dysregulation of neurotransmitters (serotonin,
norepinephrine, dopamine). .
• Genetic Predisposition: Family history of mood disorders.

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……

Psychological: History of depression or anxiety, neuroticism,

perfectionism, unrealistic expectations of motherhood, poor coping
skills.

Stressors: Sleep deprivation, demanding infant care, financial

difficulties, relationship problems.

Lack of Support: Insufficient practical or emotional support from

partner, family, or friends.
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  DSM-5 DIAGNOSIS CRITERIA
A. Core Symptoms
3-Weight/appetite changes (gain or
Must have 5 or more symptoms in loss)
the same 2-week period, with at 4-Sleep problems (insomnia or
least one being: hypersomnia)
(1) Depressed mood 5-Psychomotor changes (agitation or
(2) Loss of interest or pleasure slowing)
 The 9 possible symptoms: 6-Fatigue or loss of energy

1-Depressed mood (most of the day, 7-Worthlessness or excessive guilt

nearly every day) 8-Poor concentration or
indecisiveness
2-Loss of interest or pleasure in
activities 9-Thoughts of death or suicide
……..

B. Functional Impact -Symptoms cause significant distress or

impair social/work functioning
C. Not Due to Substance/Medical Condition Symptoms are not
caused by drugs, alcohol, or physical illness
D. Not Better Explained by a Psychotic Disorder Symptoms
are Not due to disorders like schizophrenia or schizoaffective
disorder and others.
E. No Manic/Hypomanic Episode Patient has never had a
manic or hypomanic episode

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………

NOTE-PPD is not a standalone diagnosis in DSM-5. It is a specifier for Major

Depressive Disorder known as "With Peripartum Onset.

 DDX

+ Postpartum Blues
+ Postpartum Psychosis
+ Adjustment Disorder with Depressed Mood
+ Anxiety Disorders
+ Obsessive-Compulsive Disorder (OCD
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  RISK FACTORS
-History of depression (especially - Lack of social support.

prior PPD), anxiety, or other mental • Difficult or traumatic birth experience.

health disorders.
• Medical complications for mother or
• Family history of depression. baby.
• Prior PMDD. • Unplanned or unwanted pregnancy.
• Significant life stressors • Having an infant with a difficult
(financial problems, relationship temperament or health issues.
conflicts, recent moves).
• Lower socioeconomic status.
  PROGNOSIS

With timely and appropriate treatment, the prognosis for PPD is

generally good, with many women experiencing full remission.
However, if left untreated, PPD can persist for months or even years,
leading to chronic depression and negative impacts on maternal-infant
bonding, child development, and family dynamics.

There is a 30-50% recurrence risk in subsequent pregnancies for

women with a history of PPD.
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  MANAGEMENT

Pharmacological:
Antidepressants (SSRIs): First-line pharmacological treatment.
Sertraline is initiated at 50 mg once daily and titrated to 50–100 mg/day. It is
considered the safest SSRI during lactation because of its minimal transfer into
breast milk and limited adverse effects on infants.
Fluoxetine is started at 20 mg once daily and increased to 20–40 mg/day
as needed. It has a long half-life, which helps with adherence but may
remain longer in the infant's system through breast milk.
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.......
Psychotherapy:

Cognitive Behavioral Therapy (CBT): Highly effective in addressing negative

thought patterns, developing coping skills, and improving problem-solving.

Interpersonal Therapy (IPT): Focuses on improving interpersonal

relationships and communication, particularly relevant to relationship changes
with the partner and adapting to motherhood.

Support Groups: Offer peer support, reduce isolation, and provide a sense of
community

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  POSTPARTUM PSYCHOSIS(PPP)

 Postpartum psychosis (PPP) is a rare but severe psychiatric

emergency characterized by a rapid onset of psychotic
symptoms (e.g., delusions, hallucinations), mood lability, and
disorganized behavior following childbirth.

 It is the most severe form of peripartum psychiatric illness and

carries a high risk of harm to the mother and/or the infant.

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 CLINICAL PRESENTATION
Symptoms typically develop suddenly and dramatically, often within
the first 2-4 weeks postpartum (most commonly within the first few
days to two weeks).

Psychotic Symptoms: Delusions: Often persecutory, grandiose, or bizarre

(e.g., about the baby being evil, possessing special powers, or being
exchanged).

Hallucinations: Auditory (hearing voices telling them to harm themselves or

the baby), visual, or tactile.
………..
Cognitive and Behavioral Symptoms: Disorganized thoughts and speech.
Disorganized or bizarre behavior. Rapidly fluctuating energy levels. Severe
insomnia (often total sleep deprivation). .

Epidemiology: Prevalence: Rare, affecting approximately 1 in

500 to 1 in 1000 women after childbirth (0.1-0.2%).

WHO Perspective: WHO highlights PPP as a critical public health

concern due to its severity and potential for tragic outcomes,
emphasizing the need for early recognition and urgent intervention.
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 COURSE OF PPP

 Extremely rapid onset and progression. Without immediate

treatment, it can lead to severe impairment, risk of suicide (5%)
and infanticide (4%), and prolonged illness.

 With treatment, symptoms can resolve within weeks to months, but

full recovery may take longer, and there's a high recurrence risk
(up to 50-70%) in subsequent pregnancies.
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  DDX
DSM-5 Diagnostic Criteria: PPP is not a separate diagnosis in DSM-5
It typically meets criteria for:
Brief Psychotic Disorder with Peripartum Onset: If symptoms last less than
one month.
Schizophreniform Disorder with Peripartum Onset: If symptoms last 1-6
months.
Schizophrenia Disorder with Peripartum Onset: If symptoms last more
than 6 months.
Bipolar I Disorder, Current Episode Manic or Depressed, With Psychotic
Features, With Peripartum Onset:.
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  PROGNOSIS
PPP is a psychiatric emergency. The prognosis depends on prompt
recognition and aggressive treatment.

Acute Phase: Can be life-threatening due to high risk of suicide and

infanticide.

Long-Term: With treatment, acute symptoms usually resolve within weeks

to months

.Recurrence: High recurrence risk in subsequent pregnancies.

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 MANAGEMENT
Postpartum psychosis requires immediate medical attention, often
hospitalization, due to the high risk of harm to mother and baby.
Hospitalization: is necessary for safety, rapid stabilization, and thorough
assessment.

Pharmacological: Antipsychotics: Essential for controlling psychotic

symptoms (e.g., haloperidol, olanzapine, risperidone, quetiapine).

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…….

Psychotherapy:

Used after the acute phase stabilizes to help the mother process the
experience, improve coping skills, and address any ongoing symptoms
or relational difficulties.

Social Support: Intensive support for the family is crucial, including

education, assistance with infant care, and planning for ongoing care.

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  PSEUDOCYESIS

Pseudocyesis, also known as false pregnancy, is a rare psychological

condition in which a non-pregnant woman believes she is pregnant
and exhibits many of the physical signs and symptoms of pregnancy,
despite not actually being gravid. It is classified under Somatic
Symptom and Related Disorders in the DSM-5.

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 CLINICAL PRESENTATION
The woman genuinely believes she is pregnant and develops objective
physical signs. Common signs and symptoms include:

Amenorrhea: Cessation of menstruation (the most common symptom).

Abdominal Enlargement: Often caused by a combination of lordosis,
gas, and fat accumulation, but the woman feels it is due to a growing
fetus.

Morning Sickness/Nausea and Vomiting

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 ……

Breast Changes: Enlargement, tenderness, pigmentation changes (areola

darkening), and even lactational changes

Perceived Fetal Movement: The woman reports feeling fetal Weight

Gain. .
Note- True pseudocyesis involves negative pregnancy tests and
the absence of a fetus on ultrasound. .
Prevalence: Very rare in Western countries, with estimates
ranging
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  ETIOLOGY

The etiology is complex and primarily psychological, often rooted in

intense emotional conflicts or desires regarding pregnancy:

Intense Desire for Pregnancy: Often seen in women who desperately

want to conceive but are unable to (e.g., infertility, recurrent
miscarriages, advancing age). The strong desire can lead to
misinterpretation of normal bodily sensations as pregnancy signs

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 ……
 Intense Fear of Pregnancy: Less commonly, a profound fear of
pregnancy can also manifest as pseudocyesis, as the body
unconsciously mimics the symptoms.
• Psychological Factors: History of sexual abuse, loss of a child, or
significant grief.
• Depression/Anxiety: Underlying mood or anxiety disorders are
common.
• Psychotic Features: In rare, severe cases, pseudocyesis can occur in
the context of a psychotic disorder, where the belief is a delusion.

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……
 DSM-5 Diagnostic Criteria: Pseudocyesis is categorized under Other
Specified Somatic Symptom and Related Disorders.

 The individual presents with signs and symptoms of pregnancy

 The individual has a conviction that she is pregnant.

 Medical examination, including imaging and laboratory tests, confirms that

the individual is not pregnant.

 The disturbance is not better explained by another mental disorder (e.g., a

delusional disorder or substance/medication-induced condition).
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  MANAGEMENT
Medical Confirmation: The first and most crucial step is a definitive medical
diagnosis through ultrasound (to show absence of fetus) and negative pregnancy
tests.

Psychotherapy: I
Supportive Psychotherapy → First-line

provides emotional support, builds trust, and helps the patient cope with distress
and loss. .
Essential to address the underlying psychological conflicts, unmet needs, grief,
trauma, or desires related to pregnancy and motherhood.
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…….

Cognitive Behavioral Therapy (CBT) Why? Helps address irrational

beliefs (e.g., false interpretation of bodily symptoms).

Focus: Restructure distorted thoughts, reduce symptom preoccupation,

improve coping strategies.

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SUMMARY
PMDD: A severe form of premenstrual syndrome marked by mood swings, irritability,
and depression during the luteal phase; treated with SSRIs or hormonal therapy.
Postpartum Blues: Common, mild mood changes within the first week after childbirth;
resolves spontaneously within 2 weeks without treatment.
Postpartum Depression: A major depressive episode occurring during pregnancy or
within 4 weeks postpartum; requires antidepressants and/or psychotherapy.
Postpartum Psychosis: A psychiatric emergency with delusions, hallucinations, and
mood instability shortly after birth; needs urgent antipsychotic treatment and possible
hospitalization.
False Pregnancy (Pseudocyesis): A rare condition where a woman believes she is
pregnant and shows physical signs, despite not being pregnant; managed with
psychotherapy.
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REFERENCE
DSM-5
Kaplan & Sadock’s Synopsis of Psychiatry
World Health Organization (WHO)
American Psychiatric Association (APA)
National Institute for Health and Care Excellence (NICE)

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