Postpartum Psychosis + Delusional Parasitosis Flashcards
incidence of PPP
1-2 per 1000 women
what is the prognosis for those with PPP
somewhat poor –> follow up studies after 10 years have shown that up to 40% of the women had not retained full working capacity due to ongoing psychiatric symptoms
how are PPP and suicide/infanticide related
PPP is associated with high rates of suicide and infanticide
name a good prognostic factor in PPP
prognosis if better if symptoms occur within 4 weeks of delivery
what is the risk of recurrence of PPP with each subsequent delivery, if the woman had a post partum episode with psychotic features
30-50%
what is the strongest risk factor for PPP
personal history of bipolar disorder
what % of those with previously diagnosed with bipolar disorder experience PPP with delivery
20-30%
what % of those who present with PPP have a prior psychiatric history?
only 33%
this means that 2/3 of women who present with PPP have no prior psych history
PPP should be considered what until proven otherwise
bipolar disorder–> assoc. is so strong, must rule out bipolar disorder first
risk factors for PPP other than personal hx bipolar disorder
family history bipolar disorder
sleep loss
prior episodes of PPP
higher risk in first pregnancy
what is the typical onset of PPP
sudden
usually within first two weeks of postpartum period
how will those with PPP typically present
disorganization
confusion
depersonalization
insomnia
irritability
abnormal thought content
abnormal mood
what % of cases of PPP are characterized by mania and/or agitation
1/3
*irritability is much more common than elevated mood
what % of cases of PPP are most characterized by depression and/or anxiety
about 40%
what % of those presenting with PPP have atypical or mixed profile
about 20-25%
is there a standardized screening tool for PPP
no
what is the theory behind the pathophysiology of PPP
rapid changes in ESTROGEN and PROGESTERONE in the 24 hours after childbirth thought to play a role
remains poorly understood
certain woman may be particularly vulnerable to hormonal fluctuations that increases their risk for psychosis
?immune dysregulation
ddx PPP
baby blues
post partum depression
GAD
OCD
delirium
autoimmune encephalitis
SHEEHANS syndrome
autoimmune disorders (i.e neuropsych symptoms of lupus)
SUDs
medication related events (i.e steroid induced mania)
what is sheehans syndrome
ADRENAL-PITUITARY insufficiency caused by severe blood loss (hypovolemia) which can present with neuropsychiatric symptoms such as psychosis
investigations for PPP
basic metabolic panel
CBC
urinalysis
UDS
TSH
free T4
TPO antibdoies
how should you manage PPP
considered a PSYCHIATRIC EMERGENCY
requires IMMEDIATE HOSPITALIZATION AND TREATMENT
what medications can be used in PPP
difficult to do studies
may use antipsychotics, benzos, mood stabilizers (especially lithium), hormones, propanolol, ECT
do the benefits seem to outweigh the risks with regard to using lithium to treat PPP in pregnancy and breastfeeding?
yes
list a 5 step treatment protocol for acute PPP
Step 1–> benzodiazepine (lorazepam 0.5-1.5mg TID)
Step 2–> antipsychotic (high potency preferred–i.e haldol 2-6mg or olanzapine 10-15mg)
Step 3–> lithium (to achieve serum level of 0.8-1.2 mmol/L)
Step 4–> taper benzo and antipsychotic once symptom remission achieved
Step 5–> maintenance–> continue lithium monotherapy for 9 months (can lower to achieve serum level of 0.6-0.8 after symptom remission if having severe side effects)
how should you treat patients with pharmacotherapy in future pregnancies, if have past hx PPP
begin prophylactic lithium monotherapy during pregnancy or immediately post partum
what are other names for delusional parasitosis
Ekbom syndrome
Morgellons Disease (specifically related to fibers)
what is delusional parasitosis
psychodermatological disorder
characterized by recurrent and fixed belief that they are infested by small organisms or even unanimated materials such as fibers without any objective evidence of infestation/parasitosis
in what population does delusional parasitosis classically present
middle aged women of caucasian descent
may have underlying psychiatric disorders
what is the prognosis for delusional parasitosis
patients typically reluctant to pursue psych tx and may resist discussing in psych terms
without antipsychotic treatment, patients become heavy utilizers of healthcare and may practice self destructive behaviours in attempts to clear perceived infestations
risk factors for delusional parasitosis
SUDs–> esp. stimulant or amphetamine misues
is delusional parasitosis an official DSM diagnosis
no–> most closely resembles delusional disorder, somatic type
what is Morgellons disease specifically
more specific form of delusional parasitosis
people report embedding of fibers, strands, hairs or other inanimate material in the skin
may present with multiple non healing lesions that can be ulcerated and infected
what % of those with Morgellons disease studied in one CDC study were female, caucasian and middle aged
77%
what is the “baggie sign”
when people collect skin pickings compulsively to display to medical providers as proof of infestation
what are the three categories of delusional parasitosis etiology
- primary–> delusional disorder, somatic type
- secondary functional–> in context of schizophrenia, psychotic depression
- secondary organic–> occurring in context of medical condition or substance use
ddx delusional parasitosis
- true cutaneous infection
- illness anxiety disorder
- primary psychiatric disorder (i.e related to schizophrenia, bipolar etc)
- SUD
- nutritional deficiencies–> B12 and folate most common
- neurologic disorders–> MS, strokes, trauma, encephalitis, meningitis
- med related
what nutritional deficiencies can be known to lead to delusional parasitosis
B12 and folate
adverse reactions to which medications have been described as causing secondary delusional parasitosis (in case reports)
topiramate
ciprofloxacin
amantadine
steroids
ketoconazole
phenelzine (formication symptoms)
what is the mainstay of treatment for delusional parasitosis
antipsychotics
*can also consider other meds like antidepressants as adjunct esp. if underlying mood, anxiety disorders
what antipsychotic was historically favored for treatment of Morgellons disease
Pimozide
(first gen. antipsychotic)
due to early success of drug in small RCT in 1980s –> low dose for several months yielded significant improvement to complete resolution of symptoms
how might you dose Pimozide for delusional parasitosis
pimozide 0.5 mg starting–> increase by 0.5 mg every 2-4 weeks
target dose 3mg / day
continue until symptoms gone and then 3 months after that then consider slow taper
why might you avoid pimozide for delusional parasitosis
risk of QTc prolongation, EPS, drug interactions, drug-induced depression
what other antipsychotics are considered the drugs of choice for delusional parasitosis
second generation antipsychotics
