Postpartum rage attacks in a female with bipolar <scp>II</scp> disorder and obsessive‐compulsive disorder: Diagnostic and treatment challenges

Dysfunctional anger in the form of rage attacks may accompany bipolar disorder and obsessive-compulsive disorder in the postpartum period. Women presenting with postpartum depression should be routinely asked about comorbid psychiatric disorders and rage attacks. For these individuals, antidepressants should be avoided, and preference given to medications effective for the treatment of bipolar disorder. A 26-year-old first-time mother was referred for assessment and management of postpartum depression. A few weeks before her first visit to the clinic, she was prescribed sertraline which she had previously taken with for treatment of non-puerperal episodes of depression. Within 2 weeks of the retrial of sertraline 75 mg daily, there was a marked improvement in symptoms of depression and anxiety. She also had obsessions and compulsions, but these were not severe enough to reach the diagnostic criteria of obsessive-compulsive disorder (OCD). The diagnosis of major depressive disorder was confirmed due to the history of at least 10 episodes over as many years (see Figure 1). She had made two suicide attempts including a drug overdose following which she was hospitalized. She denied hypo/manic symptoms; however, she reported a history of bipolar I disorder in a sibling. Due to the history of sustained response to sertraline, we recommended continuation of the current dose (75 mg daily). She took it for several months before discontinuing it during her subsequent pregnancy. She remained well after stopping it but had a recurrence of depression immediately following her delivery. She was prescribed sertraline by her family physician, and after a few weeks, quetiapine 25 mg was added. She was also taking lorazepam 0.5 mg/daily, as needed. She was referred to our clinic again 8 months after giving birth to her second child for evaluation of intrusive thoughts of harm coming to her children. She had become increasingly worried about their safety since the abrupt cessation of breastfeeding 4 months earlier. In particular, she was afraid of them dying in a motor vehicle accident, or a fire at home. She had spent thousands of dollars on car seats, strollers, mattresses, baby monitors, car window breakers, and fire alarms to safeguard her children. She also reported a history of compulsive skin-picking and hair-pulling. She had become overly sensitive to noises in the house, such as the dishwasher, breathing sounds, and chewing. On the Mood Disorder Questionnaire, she endorsed all items with co-occurrence and moderate functional impairment. She reported having had brief hypomanic and mixed episodes lasting up to a week since her last delivery. She did not have psychotic features and denied abusing alcohol or using illicit drugs. Of her extant symptoms, she was particularly concerned about the daily occurrences of episodes of intense anger toward her husband and children. These episodes lasted 45–60 min and were accompanied by yelling, and destruction of property. There were no acts of violence, but she was afraid that she might harm others. She experienced anger attacks after her first delivery, but these were less intense, and less frequent than her rage attacks over the last few months. Her diagnosis was revised to bipolar II disorder and OCD. The sertraline dose was tapered off over 2 weeks due to lack of effectiveness and concerns about induction of manic/mixed episodes. Her quetiapine dose was gradually increased to 125 mg daily. Within 2 weeks of these changes, her sleep improved, and the rage attacks disappeared. Her partner commented on the overall improvement particularly the dramatic disappearance of rage attacks. She has maintained improvement and continues to take quetiapine. She has also been receiving individual psychotherapy. The patient provided written informed consent after reviewing the contents of this report. A rage attack is a sudden, short-lived, intense, emotional reaction to situations or stimuli that cannot be controlled. The behavior is out of proportion to the triggering event. Rage attacks may result in inappropriate verbal utterances, property damage, or aggressive actions. Sleep loss/insomnia in the postpartum period appears to worsen rage attacks.1 While irritability is a common symptom of hypo/manic episodes, the DSM-5-TR does not list rage attacks as a symptom of bipolar disorder. Some authors have distinguished between anger attacks (a form of dysfunctional anger) and rage attacks. An anger attack is a sudden outburst of anger accompanied by symptoms of autonomic arousal such as sweating, trembling, or tachycardia. Anger attacks are associated with depression2 while rage attacks have been described in various psychiatric disorders, especially attention-deficit hyperactivity disorder, borderline personality disorder, and bipolar disorder. Selective serotonin reuptake inhibitors, especially fluoxetine, are recommended for the treatment of anger attacks. Our patient had experienced panic attacks in the past but denied concurrent symptoms of autonomic arousal during rage attacks. The exact prevalence of postpartum rage attacks in women with bipolar disorder is unknown. Due to feelings of guilt and shame, women may not disclose this symptom spontaneously. Caregivers may fail to elicit this information due to the lack of awareness of their occurrence postpartum. Childbirth is a potent trigger of the first onset of hypo/manic episodes among women with major depressive disorder especially those with a family history of bipolar disorder. Over a decade, our patient had recurrent episodes of major depression characterized by symptoms such as increased sleep requirement, psychomotor retardation, and appetite changes; however, she experienced the first onset of hypomania only after her second delivery. There were however “red flags” including high frequency of depressive episodes, atypical depressive symptoms, early age at illness onset, and a family history of bipolar disorder.3 Antidepressant use may have contributed to the diagnostic switch to bipolar disorder. Due to the pathoplastic effect of birth, mixed symptoms including marked anger/rage are common in the postpartum period among women with bipolar disorder.4 This case posed unique diagnostic challenges. First, the concurrence of symptoms from various diagnostic domains including anxiety, and the rapidly evolving symptomatology gave rise to a clinical profile that can aptly be described as kaleidoscopic. Second, due to the short duration of symptoms, or insufficient symptoms, our patient did not reach the threshold for diagnoses other than bipolar disorder and OCD. However, collectively symptoms such as anxiety, rage, and insomnia caused clinically significant distress and impairment in her social and occupational functioning. And finally, it was difficult to ascribe certain symptoms to diagnostic categories. For example, she had obsessive thoughts, but these started racing after her second delivery. Similarly, excessive spending, typically a symptom of hypo/mania was rationalized as a compulsive act to deal with distressing obsessions about harm coming to her children. Thus, it was difficult to determine whether the mood disorder or the obsessions/compulsions caused marked impairment in social or occupational functioning. Bipolar II disorder and obsessive-compulsive comorbidity also poses treatment challenges, especially concerning the use of antidepressants.5 Prospectively collected data including changes in symptom profile, treatment response, and collateral information from other caregivers was crucial in clarifying the diagnosis of bipolar II disorder and informing treatment decisions. Rather than focusing on the treatment of bipolar disorder or OCD, we instead decided to focus on addressing the most distressing or impairing symptom (s) that cut across these diagnoses. Rage attacks and insomnia/sleep loss were the most frequent and distressing concerns expressed by our patient. Sertraline was tapered off as it appeared to contribute to rapid cycling and aggravate the rage attacks. Since quetiapine has been found effective in various psychiatric disorders including bipolar II disorder and OCD, we decided to optimize the quetiapine dose. This case illustrates the importance of screening women with bipolar II disorder for intense anger in the postpartum period. Conversely, women presenting with rage attacks should be assessed for bipolar disorder. For individuals with postpartum bipolar disorder, OCD, and rage attacks, treatment should be individualized with a focus on symptoms that cut across various psychiatric diagnoses. A treatment approach involving avoidance of potential triggers (such as antidepressants) and management of perpetuating factors such as insomnia was effective, safe, and above all simple. We declare no competing interests. The individual on whom this paper is written consented to participate in the research and has reviewed and approved this manuscript for publication. Data are available upon request.

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