or fear of stigma, as well as the likelihood of misdiagnosis with other postpartum disorders. The first month following childbirth is associated with a higher relative risk for hospital admission due to psychosis when compared to other times in an individual's life. While no specific genetic factors have been linked to PPP, a family history or personal history of bipolar disorder has been strongly associated with higher risk for PPP episodes (see Risk Factors). History Postpartum psychosis had been recognized in earlier editions of the DSM (I and II), first as Involutional Psychotic Reaction and later as Psychosis with Childbirth. It was removed in the DSMIII following arguments that psychiatric disorders associated with pregnancy and childbirth were no different than other psychiatric illnesses; it has only been more recently recognized again with the 1994 release of the DSM-IV, when the specifier "with postpartum onset" was included for various diagnoses. Between the 16th and 18th centuries, about 50 brief reports regarding postpartum psychosis were published; among them is the observation that these psychoses could recur, and that they occur both in breast-feeding and non-lactating women. In 1797, Osiander, an obstetrician from Tübingen, reported two cases at length that contributed significantly to the knowledge of this disorder during that time. In 1819, Esquirol conducted a survey of cases admitted to the Salpêtrière, and pioneered long-term studies. From that time, puerperal psychosis became widely known to the medical profession. In the next 200 years, over 2,500 theses, articles and books were published. Among these many contributions were Delay's unique investigation using serial curettage and Kendell's record-linkage study comparing 2 years before and 2 years after the birth. In the last few years, two monographs reviewed over 2,400 works, detailing more than 4,000 cases of childbearing psychoses from the literature and a personal series of more than 320 cases. Postpartum bipolar disorder Signs and symptoms About 40% of patients experiencing postpartum bipolar disorder have puerperal mania, with increased energy or activity and sociability, reduced need for sleep, rapid thinking and pressured speech, euphoria and irritability, loss of inhibition, violence, recklessness and grandiosity (including religious and expansive delusions); puerperal mania is considered to be particularly severe, with highly disorganized speech, extreme excitement and eroticism. Delusions have been associated with this disorder (including delusional parasitosis, delusional misidentification syndrome, and denial of pregnancy or birth), as well as hallucinations, disorders of the will and self, catalepsy and