Postpartum Psychosis + Delusional Parasitosis Flashcards by Alana Meikle

incidence of PPP

1-2 per 1000 women

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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

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how are PPP and suicide/infanticide related

PPP is associated with high rates of suicide and infanticide

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name a good prognostic factor in PPP

prognosis if better if symptoms occur within 4 weeks of delivery

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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%

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what is the strongest risk factor for PPP

personal history of bipolar disorder

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

20-30%

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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

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PPP should be considered what until proven otherwise

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

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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

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what is the typical onset of PPP

sudden

usually within first two weeks of postpartum period

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how will those with PPP typically present

disorganization

confusion

depersonalization

insomnia

irritability

abnormal thought content

abnormal mood

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

1/3

*irritability is much more common than elevated mood

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

about 40%

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

about 20-25%

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is there a standardized screening tool for PPP

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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

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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

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

ddx delusional parasitosis

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

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