Look for Signs of Psychosis in Mother When Evaluating Infanticidal Thoughts


NEWPORT BEACH, CALIF. — When a new mother reports having infanticidal thoughts, how should one decide whether she poses an imminent danger to the child? The key is to assess several risk factors, Gagan Dhaliwal, M.D., said at the annual meeting of the American College of Forensic Psychiatry.

Dr. Dhaliwal, of the University of South Alabama, Mobile, discussed the hypothetical case of a 19-year-old woman with a 2-week-old son who is seen in an outpatient psychiatric clinic. She reports feeling depressed and lacking energy, and has a loss of appetite and frequent crying spells. She says she's not being a good mother and has thoughts of killing her son.

“First of all, we have to figure out whether these thoughts are in the context of psychosis,” Dr. Dhaliwal said. Upon further questioning, the woman reported that she felt suspicious of others and cannot trust other people. She says that she hears a voice in her head saying, “do it,” a command hallucination related to hurting her son.

The woman says she lives alone, is not sure of the identity of the child's father, and doesn't want to involve her family. She's concerned that her child will be taken away if she's admitted for inpatient treatment, but she agrees to take medication as an outpatient.

At this point there's sufficient cause to break confidentiality and contact the woman's family, Dr. Dhaliwal said. The family reports the woman had been taking medication for bipolar disorder but discontinued it during pregnancy.

Now the physician must answer several questions. Does the woman have a mental illness? Clearly she does, because of her previous history of bipolar disorder.

But is she imminently dangerous to her child? Should inpatient or outpatient treatment be recommended? Should she be committed involuntarily? How does one weigh the issue of mother-child privacy, compared with the governmental intrusion that would be involved in involuntary treatment? What effect would involuntary commitment have on the mother-child relationship? Is that presumably deleterious effect enough to outweigh the mother's potential dangerousness to the child?

Clearly, there's no reason to commit all mothers with aggressive or infanticidal thoughts. Studies have shown that many women post partum have obsessive thoughts about harming their children. The physician must differentiate those common obsessive thoughts from true psychosis, which involves a loss of touch with reality.

The mother with obsessions will attempt to suppress these obsessions and generally recognizes they're products of her own mind. The psychotic mother, believes the thoughts are imposed by an outside force.

In the hypothetical case, the woman's history, her command hallucinations, and her lack of insight argue for psychosis. She also has other risk factors linked with infanticide.

Among the risk factors identified in one study are maternal age less than 17 (relative risk 10.9), second or subsequent-born infants (relative risk 9.3), lack of prenatal care (relative risk 10.3), and low education levels (relative risk about 8 for women who did not complete high school) (N. Engl. J. Med. 1998;339:1211ndash;6).

Other factors that increase the risk are substance abuse; a history of major mental illness, especially major depression or bipolar disorder; a family history of psychiatric illness; childhood abuse; self-doubt as a mother; poverty, a poor support system; and an unavailable partner.

The hypothetical woman doesn't exhibit all of those risk factors. But Dr. Dhaliwal says she exhibits enough to warrant involuntary commitment.

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