Mental or behavioural disorders associated with pregnancy, childbirth or the puerperium, without psychotic symptoms

Essential Features:

• Onset of a syndrome involving significant mental and behavioural features occurring during pregnancy or the puerperium (i.e., up to about 6 weeks following delivery).
• The syndrome does not include delusions, hallucinations, or other psychotic symptoms.
• The symptoms are not a manifestation of another medical condition (e.g., a brain tumour) and are not due to the effects of a substance or medication on the central nervous system (e.g., benzodiazepines), including withdrawal effects (e.g., from stimulants).
• The disturbance results in significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.

Note: If the symptoms meet the diagnostic requirements for a specific mental disorder (e.g., a Mood Disorder, an Anxiety or Fear-Related Disorder, Obsessive-Compulsive Disorder, Adjustment Disorder), that diagnosis should also be assigned. If the symptoms do not meet the diagnostic requirements for a specific mental disorder, the presentation can be described using codes from the section on Mental or Behavioural Symptoms, Signs or Clinical Findings.

Additional Clinical Features:

• This diagnosis may be assigned regardless of whether biological factors related pregnancy, childbirth or the puerperium are known to be etiologically related to the syndrome.
• Common presentations of Mental or Behavioural Disorders Associated with Pregnancy, Childbirth or the Puerperium, without psychotic symptoms include:
• Depressive symptoms: These may include depressed mood, excessive crying; difficulty bonding with the baby; withdrawing from family and friends; loss of appetite or eating much more than usual; inability to sleep (insomnia) or sleeping too much; overwhelming fatigue or loss of energy; reduced interest and pleasure in usually enjoyable activities, intense irritability and anger; fears of not being a good mother, feelings of worthlessness, shame, guilt or inadequacy; diminished ability to think clearly, concentrate or make decisions; thoughts of harming oneself or the baby.
• Anxiety symptoms: These may include excessive worry, general apprehensiveness not restricted to any particular environmental stimulus, phobic responses (e.g., related to dirt or germs), and panic attacks.
• Obsessions and compulsions: Obsessions are repetitive and persistent thoughts, images, or impulses/urges that are experienced as intrusive and unwanted and are commonly associated with anxiety. Compulsions are repetitive behaviours or rituals, including repetitive mental acts, that the individual feels driven to perform in response to an obsession. Obsessions and compulsions typically focus on the newborn (or unborn) infant, e.g., obsessions about the baby getting hurt, contaminated, or lost; compulsive rituals involving checking, mental rituals, and seeking-reassurance. Unwanted sexual obsessions may also be present. There may also be excessive avoidance, such as avoiding bathing or holding the baby, in response to the obsessions.

Boundary with Normality (Threshold):

• This diagnosis should not be used to describe mild and transient depressive symptoms that do not meet the diagnostic requirements for a Depressive Episode, which may occur soon after delivery (so-called ‘postpartum blues’ or ‘baby blues’).
• Postpartum depression may be mistaken for ‘baby blues’ at first, but the signs and symptoms are more intense, last longer, and interfere with functioning, including the ability to care for the baby. If the diagnostic requirements are met for a Depressive Episode, a diagnosis of Single Episode Depressive Disorder or Recurrent Depressive Disorder should also be assigned.
• Worries and fears about the baby during pregnancy and after childbirth and some degree of intrusive thoughts about possible harms are common and should not be diagnosed as Mental or Behavioural Disorders Associated with Pregnancy, Childbirth or the Puerperium unless they are persistent, associated with substantial distress, and interfere with functioning, including the ability to care for the baby.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• This diagnosis may be assigned even if the syndrome represents a recurrence or exacerbation of a pre-existing disorder (e.g., a Mood Disorder).