THE MAD MOTHER

Post-natal madness is common but

little understood. Alexandra Artley

recalls her own experience

ONE of the strangest things about the state of motherhood is the fact that being mad on and off seems to be almost normal. But people do not talk about it. Women have a containing sensibility and feel that by discussing their symptoms they are being disloyal to themselves and their families.

Louis Victor Marco (1828-63) was a sensitive and acutely observant doctor. To support his new wife, he took a job in the mental hospital at Ivry-sur-Seine, a place with a strong line in puerperal psychiatric cases. Varying degrees of mental disturb- ance associated with child-bearing have been noted for centuries, but Marce was the first to give them an interesting shape. His major work Traite de la folie des femmes enceintes, des nouvelles accouchees et des nourrices, was published in 1858.

Apart from being an extremely attrac- tive figure, Marce was significant because he foreshadowed endocrinology (you know, hormones). In the unfortunate women he studied, he recognised 'the simultaneous march of psychiatric symp- toms and physical changes'. As hormones had not yet been discovered, he described the connection between brain and uterus as sympathie morbide. Through the research society which bears his name, Marce is likely to do for mothers in the Nineties what Leboyer, Odent and the National Childbirth Trust did for hospital births in the Eighties. Whereas they were concerned with the physical process and emotional support of childbirth, the Marce Society hopes to make the prevention and proper treatment of post-natal mental disorders an actuality.

Post-natal depression' is not a very good term. It is always on the front of blue- coloured free leaflets showing a woman in a Seventies dress looking slightly miser- able. 'Depressed' has gone too much into everyday speech. It suggests that all you need to do is to have a stiff gin and pull yourself together. It was only after the birth of our second child that I started to recognise a maelstrom of conflicting and constantly changing symptoms of which `depression' is only one.

Our second daughter was born in Febru- ary. She was 91b 6oz and I felt very proud of her. It was the start of a month of snow. University College Hospital looks after new mothers and babies very well. After a few hours I recognised a strange painfully restless energy that I had also experienced several days after the birth of my first child. I began going backwards and for- wards to the foyer of the ward for no real reason — just for the exhilaration of moving. I knew I should be sleeping, but my eyes kept springing open. They simply could not close. This relentless energy went on and on so that I did not sleep at all for two months.

Have you ever tried not sleeping at all for two months? If you were not already mad, you soon would be. Running through all this were periods of feeling extremely feeble in the head. Writing my name on a postcard was a triumph of the will (my . . .

name . . . is . . . A . . 1 . . e . . .). Later, I thought that by making me slow-witted, perhaps Nature was keeping me totally responsive to the new baby.

In April the dreadful crashes started. I could sleep now, but only for short shallow snatches. I had the feeling that I slept with my eyes open. Down I went to a place where I could only move slowly as if under water. Everything was obscured by a grey- green veil of dots. Is that what 'being dotty' means?

Late one afternoon, I stood washing up at the kitchen sink. The water was very hot. The next thing I remember is that the water was very cold and it was dark outside. I wept over everything and every- one (most embarrassing). I was glad we lived near King's Cross station because there are a lot of trains and I could walk under one.

While writing this piece, a couple of random telephone calls revealed that two women recently killed themselves when in this condition. But I could not bear the idea of leaving my husband and children behind. What would happen to them? On days when I perked up a bit, I heard a lot of music and party chatter in my head. I was wary of chairs. The more attenuated the design, the more I feared them. I felt some chairs had either just moved or were about to.

I looked at my family in considerable despair. I knew I loved them, but I had no warmth of feeling in my heart. I had no perception of distance or speed. I almost ran the pram into passing cars several times. Even in bright summer sunlight I could not see very well.

Like the lengthening of summer even- ings, the periods of being myself returned. From the high ground of September I now look back on these things with astonish- ment and horror. Bloomsbury offers an excellent health-care service for mothers and children, but I did not seek profession- al help. I felt I was 'naturally' ill and that drugs might transform me into someone else entirely. I also thought that if I took drugs I might not be responsible enough to look after the children. If I took them, how would I know when I was better?

Most women with post-natal mental disturbances instinctively reject drugs be- cause they know that what is wrong with them is primarily hormonal. However long it takes, they have faith in self-regulation.

A colleague volunteered the information that after the birth of her second child she felt very disturbed, with violent mood swings. She experienced a terrifying hallu- cination (or waking dream) of a man scaling the outside of the house, parting the curtains and looking into a room where she and her husband were lying. She tried to treat herself with ginseng.

In the very serious cases he dealt with, Mara recognised a danger signal that, in a more minor form, I recognised in myself— the restless painful energy. After that, he went on to describe, in case after case, manic elation, melancholia, intellectual enfeeblement, hallucinations, confusion and extraordinary changeability. The `kaleidoscopic' nature of post-natal mental disturbance was noted by another medical writer later in the century: 'We cannot classify them with any degree of precision into mania, depression, melancholia and dementia. We shall note typical cases of each of these varieties, but I must premise by saying that it is common for one to pass through all these forms.'

It has been estimated that post-natal mental disturbance affects 10 to 20 per cent of mothers, with severe puerperal psych- osis (that means you are so visibly barking you are whipped into hospital) occurring at a rate of one or two per thousand deliver- ies. Dr Margaret Oates, Senior Lecturer in Psychiatry at the Mapperley Hospital, Not- tingham, runs a special service for mentally ill mothers and she puts the figure much higher than this. 'Very severe mental illness involves hallucinations, delusions and the mother being out of touch with reality. This is usually estimated at two per thousand live births, but we already know that four per thousand live births are referred to the psychiatric services. There is a strong suspicion that a better figure is the eight or nine per thousand live births who are women known to psychiatrists. That could be doubled up again from the women who go to their GPs but who are not referred. Then there are large numbers of mothers with very severe depressive illness who are supported through it by their families or just hidden away, but who recover by themselves.' If Marce got the hormonal theory right in 1858 and endo- crinal research has danced ahead this century, why are 10 to 20 per cent of the child-bearing population still mentally in- capacitated for months, often years, at a time? It seems that Marcd's sophisticated vision was rejected by early 20th-century `modern' psychiatry. After existing as a separate disease for centuries, 'puerperal psychosis' was officially struck off the psychiatric register by Emil Kraepelin, Professor of Clinical Psychiatry at Munich from 1903-22.

Kraepelin was the Linnaeus of the mind. He classified mental illness into a system which is still used today. As I understand it, poor Kraepelin found that the whirligig of post-natal madness did not fit any of the pigeon holes he had neatly constructed. For his own peace of mind, he quite simply took the disease to pieces and filed bits of it away under non-puerperal disorders. (`See Schizophrenic disorder, see Brief reactive psychosis, see Major affective disorders, see Organic brain syndrome.') See any- thing, in fact, except the perfectly sensible idea that if your hormones are gravely unbalanced after the birth of a baby, you will almost certainly go bananas.

In this century, some leading physicians have supported Marces view, but until recently they ran against the grain of the psychiatric establishment. James A. Hamilton (formerly Clinical Professor of Psychiatry at Stanford) is one. His article, `The Identity of Postpartum Psychosis' in Motherhood and Mental Illness (Academic Press 1982), is an absolutely stunning account of the way an appalling disease was dismembered and largely ignored. In Britain, the gynaecological endocrinolog- ist, Dr Katharina Dalton, is convinced that `post-natal depression' can be prevented in women known to be at risk with progester- one (which has to be given during deliv- ery). Progesterone is a natural hormone (artificial progestogens will not do) and cannot be patented by drug companies. Is that another reason why hormone replace- ment therapy has not been developed to the point where it is commonly available?

Whether mental or physical, if a disease does not officially exist, it excites no scientific research and therapeutic oppor- tunities cannot be examined. That is what happened to puerperal psychosis and to her less lurid sister, severe post-natal de- pressive illness. Now, four years after the foundation of the Marce Society by Ian Brockington, 'Charm? Kumar, Robert Kendell and James Hamilton, Britain leads the world in this extremely complex and volatile area of medical research. In the words 'of Frank Margison, current secret- ary of the Marco Society and consultant psychotherapist at the Manchester Royal Infirmary, 'This severe mental illness is becoming better understood, possibly pre- ventable and certainly treatable.'

Although Kraepelin temporarily des- troyed post-natal mental illness as a 'dis- ease entity', the sheer complexity of the illness has also been a professional hind- rance. The bio-chemical disturbance which may act as a trigger is now thought to be considerably more complex than a drop in progesterone level and may also involve hormones which are not necessarily tied to reproduction. Research carried out by Professor Robert Kendell at Edinburgh suggests a hormonal trigger. He calculated that whereas bereavement or marital separation produced the five-fold stress that could lead to mental illness, childbirth produced a 35-fold stress — an astonishing leap which suggests bio-chemicals whizzing about.

Four types of high-risk women are also emerging. There is the 'highly-adaptive professional woman' (I think that means she can do a lot of things); the genetically disposed manic-depressive (you may not have known your grandfather was loopy, but if he was, you may well become so); the woman whose partner is not committed to her (being a single mother is not a good idea) and the emergency Caesarean case (this category may be expanding to include women with other forms of birth emergen- cy such as haemorrhaging). If any woman pulls one, two, even three of these cards from the pack, a grand slam may ensue.

In the Seventies, great play was made of social factors in 'post-natal depression'. Domestic isolation, for example, and the contempt which materialistic society has for the gentle, humble, messy process of motherhood. All this is quite true, but many mothers feel that hormonal disturb- ance triggers a mental state which then makes a huge variety of external problems impossibly difficult to cope with. Another Eighties view is that many women with powerful maternal instincts (I am one) have been led to expect far too much from themselves. Having been wound up by the educational system and set down like automatons on the career track, many professional women in their thirties are now discovering that Nature alters a woman's mind for motherhood in a way that totally conflicts with the mental re- sources she needs for work.

Memory is the classic example of this. When my memory was very bad and I felt extremely vague after the birth of both my children, I also felt totally bonded to them, acutely sensitive to their every requirement and nuance of expression. I have just discovered from Frank Margison that this is called 'primary maternal preoccupation.' Of course it is, and whereas it is good for the children, it can mean that when she is away from them, a mother spends her working day in a mist of grief, pain and disorientation.

Feminism has also produced some truly destructive conflicts in the areas of mother- hood and work. The very women who endlessly bang on about natural childbirth, breast-feeding and mother-and-baby bond- ing, are often the ones scorching back to the office to prove they can do everything (and stay married and look good). How horribly confusing that is for the baby, who receives signals of intimacy and rejection simultaneously. Pretending you can do everything is Seventies talk and today's Superwoman stressed to the limit. The steady flow of women into part-time jobs is one proof that after the feminist excesses of the Seventies, many women are regain- ing their true emotional and intellectual equilibrium.

In February, a few streets away from here, a woman brought home twins. She already had three children and she and her husband were living in two rooms. As they had no washing machine or tumble drier, they all had to live in one room so that she could use the other constantly to dry the stacks of clothes and bedding five young children need. The local midwife (who could not use her bicycle because of the snow) did not, of course, tell me the woman's name. But she said she was 'a cheerful soul'. I sincerely hope she is still cheerful.

I have a loving family, kind friends and a washing machine and a tumble drier. I have only two children born in quick succession. But this time it has taken seven months (last time it took 18 months) for me to regain my usual state of mind. Objects are solid again and some are even brightly coloured. It is wonderful to be back be- cause, as I always knew, birth is a victory and not a defeat.

Donations or enquiries should be addres- sed to The Marce Society, clo The Secret- ary, Dr Frank Margison, Gaskell House, Department of Psychotherapy, Swinton Grove, Manchester M13.