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3. Psychosis > Postpartum Psychosis + Delusional Parasitosis > Flashcards

Postpartum Psychosis + Delusional Parasitosis Flashcards

1
Q

incidence of PPP

A

1-2 per 1000 women

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2
Q

what is the prognosis for those with PPP

A

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

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3
Q

how are PPP and suicide/infanticide related

A

PPP is associated with high rates of suicide and infanticide

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4
Q

name a good prognostic factor in PPP

A

prognosis if better if symptoms occur within 4 weeks of delivery

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5
Q

what is the risk of recurrence of PPP with each subsequent delivery, if the woman had a post partum episode with psychotic features

A

30-50%

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6
Q

what is the strongest risk factor for PPP

A

personal history of bipolar disorder

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7
Q

what % of those with previously diagnosed with bipolar disorder experience PPP with delivery

A

20-30%

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8
Q

what % of those who present with PPP have a prior psychiatric history?

A

only 33%

this means that 2/3 of women who present with PPP have no prior psych history

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9
Q

PPP should be considered what until proven otherwise

A

bipolar disorder–> assoc. is so strong, must rule out bipolar disorder first

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10
Q

risk factors for PPP other than personal hx bipolar disorder

A

family history bipolar disorder

sleep loss

prior episodes of PPP

higher risk in first pregnancy

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11
Q

what is the typical onset of PPP

A

sudden

usually within first two weeks of postpartum period

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12
Q

how will those with PPP typically present

A

disorganization

confusion

depersonalization

insomnia

irritability

abnormal thought content

abnormal mood

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13
Q

what % of cases of PPP are characterized by mania and/or agitation

A

1/3

*irritability is much more common than elevated mood

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14
Q

what % of cases of PPP are most characterized by depression and/or anxiety

A

about 40%

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15
Q

what % of those presenting with PPP have atypical or mixed profile

A

about 20-25%

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16
Q

is there a standardized screening tool for PPP

A

no

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17
Q

what is the theory behind the pathophysiology of PPP

A

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

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18
Q

ddx PPP

A

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)

19
Q

what is sheehans syndrome

A

ADRENAL-PITUITARY insufficiency caused by severe blood loss (hypovolemia) which can present with neuropsychiatric symptoms such as psychosis

20
Q

investigations for PPP

A

basic metabolic panel

CBC

urinalysis

UDS

TSH
free T4

TPO antibdoies

21
Q

how should you manage PPP

A

considered a PSYCHIATRIC EMERGENCY

requires IMMEDIATE HOSPITALIZATION AND TREATMENT

22
Q

what medications can be used in PPP

A

difficult to do studies

may use antipsychotics, benzos, mood stabilizers (especially lithium), hormones, propanolol, ECT

23
Q

do the benefits seem to outweigh the risks with regard to using lithium to treat PPP in pregnancy and breastfeeding?

A

yes

24
Q

list a 5 step treatment protocol for acute PPP

A

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)

25
Q

how should you treat patients with pharmacotherapy in future pregnancies, if have past hx PPP

A

begin prophylactic lithium monotherapy during pregnancy or immediately post partum

26
Q

what are other names for delusional parasitosis

A

Ekbom syndrome

Morgellons Disease (specifically related to fibers)

27
Q

what is delusional parasitosis

A

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

28
Q

in what population does delusional parasitosis classically present

A

middle aged women of caucasian descent

may have underlying psychiatric disorders

29
Q

what is the prognosis for delusional parasitosis

A

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

30
Q

risk factors for delusional parasitosis

A

SUDs–> esp. stimulant or amphetamine misues

31
Q

is delusional parasitosis an official DSM diagnosis

A

no–> most closely resembles delusional disorder, somatic type

32
Q

what is Morgellons disease specifically

A

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

33
Q

what % of those with Morgellons disease studied in one CDC study were female, caucasian and middle aged

A

77%

34
Q

what is the “baggie sign”

A

when people collect skin pickings compulsively to display to medical providers as proof of infestation

35
Q

what are the three categories of delusional parasitosis etiology

A
  1. primary–> delusional disorder, somatic type
  2. secondary functional–> in context of schizophrenia, psychotic depression
  3. secondary organic–> occurring in context of medical condition or substance use
36
Q

ddx delusional parasitosis

A
  1. true cutaneous infection
  2. illness anxiety disorder
  3. primary psychiatric disorder (i.e related to schizophrenia, bipolar etc)
  4. SUD
  5. nutritional deficiencies–> B12 and folate most common
  6. neurologic disorders–> MS, strokes, trauma, encephalitis, meningitis
  7. med related
37
Q

what nutritional deficiencies can be known to lead to delusional parasitosis

A

B12 and folate

38
Q

adverse reactions to which medications have been described as causing secondary delusional parasitosis (in case reports)

A

topiramate

ciprofloxacin

amantadine

steroids

ketoconazole

phenelzine (formication symptoms)

39
Q

what is the mainstay of treatment for delusional parasitosis

A

antipsychotics

*can also consider other meds like antidepressants as adjunct esp. if underlying mood, anxiety disorders

40
Q

what antipsychotic was historically favored for treatment of Morgellons disease

A

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

41
Q

how might you dose Pimozide for delusional parasitosis

A

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

42
Q

why might you avoid pimozide for delusional parasitosis

A

risk of QTc prolongation, EPS, drug interactions, drug-induced depression

43
Q

what other antipsychotics are considered the drugs of choice for delusional parasitosis

A

second generation antipsychotics

3. Psychosis (10 decks)

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