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Delusional denial of pregnancy: Unique presentation of Cotard’s syndrome in a patient with schizophrenia
Asian Journal of Psychiatry 30 (2017) 26–27
Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Letter to the Editor Delusional denial of pregnancy: Unique presentation of Cotard’s syndrome in a patient with schizophrenia
MARK
1. Introduction Pregnancy is an important biopsychosocial event which causes physical and emotional changes in women. Denial of pregnancy is a red flag sign. Incidence of denial of pregnancy, ranging from 1 in 475 at 20+ weeks of gestation to 1 in 2455–2500 has been comparable to obstetric complications such as eclampsia (Jenkins et al., 2011). Denial of pregnancy has been operationally defined using criteria such as sudden delivery after nearly or totally absent prenatal care or late onset prenatal care after 20 weeks of gestation (Wessel and Buscher, 2002); or women who have no subjective perception of pregnancy until 20 weeks gestation (Beier et al., 2006). The morbid form of denial of pregnancy is psychotic in origin, which may be primarily affective or delusional. Psychotic denial of pregnancy may be considered more serious with complications such as lack of antenatal care, unassisted or precipitous delivery, lack of bonding, maternal emotional disturbance, fetal abuse and neonaticide. (Miller, 1990) With this background, we present an interesting case of a patient suffering from schizophrenia who presented with delusion of denial of pregnancy. 2. Case report A 24-year-old housewife in second week of post-partum period was brought to psychiatry outpatient-clinic with complaints of not taking care of her baby saying that she was never pregnant. She was maintaining well till the second month of pregnancy, after which she was reluctant to receive antenatal care saying that she was no longer pregnant as her uterus and fetus were dead. Patient would not agree to evidence of pregnancy provided by family such as amenorrhea, increasing abdominal girth and ultrasound scan, suggestive of a live fetus. She would also report that a goddess was controlling all her activities such as walking, sitting, offering prayers by making her limbs move against her will. Her sleep and food intake had decreased significantly along with impaired self-care. She had to be coaxed to make the antenatal care visits. She was taken to faith healers during the entire pregnancy and received no active psychiatric intervention. Caesarean section had to be conducted due to a lack of maternal effort during delivery. Past history revealed another episode four years back characterised by fearfulness, persecutory delusion, made volition, and decreased sleep lasting for a year, which remitted spontaneously. Physical examination was unremarkable. On mental status examination, patient appeared irritable. Delusional denial of pregnancy associated with nihilistic delusion of having a “dead” uterus was elicitable. No thoughts of harm towards the baby was noted. Insight was absent. Routine blood tests were within normal limits. An ICD-10 diagnosis of Paranoid schizophrenia was made. At the time of treatment seeking,Brief Psychiatric Rating Scale (BPRS) was 46. Risperidone 2 mg was started and optimized to 6 mg/day. At the end of eight weeks, BPRS score reduced to 22, along with a significant improvement in terms of delusions and care of the baby. 3. Discussion Psychotic denial of pregnancy is one of the rare presentation which may pose a high risk situation for the developing fetus during pregnancy and even after delivery (Solari et al., 2009). Psychotic denial of pregnancy had been reported as a special form of Cotard’s syndromesince nihilistic delusions in Cotard’s syndrome can encompass beliefs on loss of structure or function of a body part, entire body, soul, and/or world. (Walloch et al., 2007) This patient reported that her uterus was “dead”. Psychotic denial of pregnancy as a part of Cotard’s syndrome has been reported both in cases of chronic schizophrenia (Miller, 1990) as well as severe depression (Wani et al., 2008). This case is unique in several aspects such as occurrence in a case of paranoid schizophrenia with episodic course in a primi-gravida, compared to previous reports in chronic undifferentiated schizophrenia. (Miller, 1990)This patient had onset of a psychotic episode during pregnancy. Usually, pregnancy has been thought to be protective for the onset of psychosis, however there have been variable reports where schizophrenia has made its onset or had worsened during pregnancy as well (Terp and Mortensen, 1998; Krener et al., 1990; McNeil et al., 1984). This case also brings to light the role of culture in accommodating the delusional denial of pregnancy as well as help seeking behaviors (Wani et al., 2008). An early psychiatric intervention would have alleviated the need of caesarean section and facilitated breastfeeding which is important for the infant’s health. It also highlights the importance of comprehensive psychiatric and psychological assessment during pregnancy. Potential ethical and legal concerns also need to be discussed in the context of psychotic denial of pregnancy. Some important ethical issues include maternal decisional capacity, conflict between ethical principles of maternal and fetal beneficence versus autonomy of the mother and need for involuntary or coerced admission, controlled delivery, termination of parental rights (Jenkins et al., 2011; Slayton and Soloff, 1981). Despite patient being on irregular antenatal check-ups, she had never received any psychiatric assessment over the entire antenatal period. Thereby, clinical suspicion and need for psychiatric referral and assessment for psychotic denial of pregnancy must be emphasized during training of residents in Obstetrics in addition to Psychiatry. As reflected from this case, a close attention to psychiatric aspects during pregnancy is much needed in fulfillment of maternal and fetal health, which have also been recognized as Millennium Development Goals. http://dx.doi.org/10.1016/j.ajp.2017.07.005 Received 2 July 2017 1876-2018/ © 2017 Published by Elsevier B.V.
Asian Journal of Psychiatry 30 (2017) 26–27
Letter to the Editor
Conflict of interest None. References Beier, K.M., Wille, R., Wessel, J., 2006. Denial of pregnancy as a reproductive dysfunction: a proposal for international classification systems. J. Psychosomatic Res. 61, 723–730. Jenkins, A., Millar, S., Robins, J., 2011. Denial of pregnancy – a literature review and discussion of ethical and legal issues. J. R. Soc. Med. 104, 286–291. Krener, P., Simmons, M.K., Hansen, R.L., Treat, J.N., 1990. Effect of pregnancy on psychosis: life circumstances and psychiatric symptoms. Int. J. Psychiatry Med. 19, 65–84. McNeil, T.F., Kaij, L., Maimquist-Larsson, A., 1984. Women with nonorganic psychosis: pregnancy’s effect on mental health during pregnancy. Acta Psychiatr. Scand. 70, 140–148. Miller, L.J., 1990. Psychotic denial of pregnancy: phenomenology and clinical management. Hosp. Community Psychiatry 41, 1233–1237. Slayton, R.I., Soloff, P.H., 1981. Psychotic denial of third-trimester pregnancy. J. Clin. Psychiatry 42, 471–473. Solari, H., Dickson, K.E., Miller, L., 2009. Understanding and treating women with schizophrenia during pregnancy and postpartum. Can. J. Clin. Pharmacol. 16, e23–e32. Terp, I.M., Mortensen, P.B., 1998. Postpartum psychoses: clinical diagnoses and relative risk of admission. Br. J. Psychiatry 172, 521–526. Walloch, J.E., Klauwer, C., Lanczik, M., Brockington, I.F., Kornhuber, J., 2007. Delusional denial of pregnancy as a special form of Cotard’s syndrome. Psychopathology 40, 61–64. Wani, Z.A., Khan, A.W., Baba, A.A., Khan, H.A., Wani, Q.U.A., Taploo, R., 2008. Cotard’s syndrome and delayed diagnosis in Kashmir, India. Int. J. Ment. Health Syst. 2, 1. Wessel, J., Buscher, U., 2002. Denial of pregnancy: population based study. BMJ 324, 458.
Pooja Patnaik Kuppili Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, 605006, India E-mail address: [email protected] Rishab Gupta Department of Psychiatry, SUNY Downstate Medical Center, Brooklyn, NY, United States E-mail address: [email protected] ⁎
Raman Deep Pattanayak Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, 110029, India E-mail address: [email protected]
Sudhir K. Khandelwal Department of Psychiatry, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
⁎
Corresponding author.
27
Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
Letter to the Editor Delusional denial of pregnancy: Unique presentation of Cotard’s syndrome in a patient with schizophrenia
MARK
1. Introduction Pregnancy is an important biopsychosocial event which causes physical and emotional changes in women. Denial of pregnancy is a red flag sign. Incidence of denial of pregnancy, ranging from 1 in 475 at 20+ weeks of gestation to 1 in 2455–2500 has been comparable to obstetric complications such as eclampsia (Jenkins et al., 2011). Denial of pregnancy has been operationally defined using criteria such as sudden delivery after nearly or totally absent prenatal care or late onset prenatal care after 20 weeks of gestation (Wessel and Buscher, 2002); or women who have no subjective perception of pregnancy until 20 weeks gestation (Beier et al., 2006). The morbid form of denial of pregnancy is psychotic in origin, which may be primarily affective or delusional. Psychotic denial of pregnancy may be considered more serious with complications such as lack of antenatal care, unassisted or precipitous delivery, lack of bonding, maternal emotional disturbance, fetal abuse and neonaticide. (Miller, 1990) With this background, we present an interesting case of a patient suffering from schizophrenia who presented with delusion of denial of pregnancy. 2. Case report A 24-year-old housewife in second week of post-partum period was brought to psychiatry outpatient-clinic with complaints of not taking care of her baby saying that she was never pregnant. She was maintaining well till the second month of pregnancy, after which she was reluctant to receive antenatal care saying that she was no longer pregnant as her uterus and fetus were dead. Patient would not agree to evidence of pregnancy provided by family such as amenorrhea, increasing abdominal girth and ultrasound scan, suggestive of a live fetus. She would also report that a goddess was controlling all her activities such as walking, sitting, offering prayers by making her limbs move against her will. Her sleep and food intake had decreased significantly along with impaired self-care. She had to be coaxed to make the antenatal care visits. She was taken to faith healers during the entire pregnancy and received no active psychiatric intervention. Caesarean section had to be conducted due to a lack of maternal effort during delivery. Past history revealed another episode four years back characterised by fearfulness, persecutory delusion, made volition, and decreased sleep lasting for a year, which remitted spontaneously. Physical examination was unremarkable. On mental status examination, patient appeared irritable. Delusional denial of pregnancy associated with nihilistic delusion of having a “dead” uterus was elicitable. No thoughts of harm towards the baby was noted. Insight was absent. Routine blood tests were within normal limits. An ICD-10 diagnosis of Paranoid schizophrenia was made. At the time of treatment seeking,Brief Psychiatric Rating Scale (BPRS) was 46. Risperidone 2 mg was started and optimized to 6 mg/day. At the end of eight weeks, BPRS score reduced to 22, along with a significant improvement in terms of delusions and care of the baby. 3. Discussion Psychotic denial of pregnancy is one of the rare presentation which may pose a high risk situation for the developing fetus during pregnancy and even after delivery (Solari et al., 2009). Psychotic denial of pregnancy had been reported as a special form of Cotard’s syndromesince nihilistic delusions in Cotard’s syndrome can encompass beliefs on loss of structure or function of a body part, entire body, soul, and/or world. (Walloch et al., 2007) This patient reported that her uterus was “dead”. Psychotic denial of pregnancy as a part of Cotard’s syndrome has been reported both in cases of chronic schizophrenia (Miller, 1990) as well as severe depression (Wani et al., 2008). This case is unique in several aspects such as occurrence in a case of paranoid schizophrenia with episodic course in a primi-gravida, compared to previous reports in chronic undifferentiated schizophrenia. (Miller, 1990)This patient had onset of a psychotic episode during pregnancy. Usually, pregnancy has been thought to be protective for the onset of psychosis, however there have been variable reports where schizophrenia has made its onset or had worsened during pregnancy as well (Terp and Mortensen, 1998; Krener et al., 1990; McNeil et al., 1984). This case also brings to light the role of culture in accommodating the delusional denial of pregnancy as well as help seeking behaviors (Wani et al., 2008). An early psychiatric intervention would have alleviated the need of caesarean section and facilitated breastfeeding which is important for the infant’s health. It also highlights the importance of comprehensive psychiatric and psychological assessment during pregnancy. Potential ethical and legal concerns also need to be discussed in the context of psychotic denial of pregnancy. Some important ethical issues include maternal decisional capacity, conflict between ethical principles of maternal and fetal beneficence versus autonomy of the mother and need for involuntary or coerced admission, controlled delivery, termination of parental rights (Jenkins et al., 2011; Slayton and Soloff, 1981). Despite patient being on irregular antenatal check-ups, she had never received any psychiatric assessment over the entire antenatal period. Thereby, clinical suspicion and need for psychiatric referral and assessment for psychotic denial of pregnancy must be emphasized during training of residents in Obstetrics in addition to Psychiatry. As reflected from this case, a close attention to psychiatric aspects during pregnancy is much needed in fulfillment of maternal and fetal health, which have also been recognized as Millennium Development Goals. http://dx.doi.org/10.1016/j.ajp.2017.07.005 Received 2 July 2017 1876-2018/ © 2017 Published by Elsevier B.V.
Asian Journal of Psychiatry 30 (2017) 26–27
Letter to the Editor
Conflict of interest None. References Beier, K.M., Wille, R., Wessel, J., 2006. Denial of pregnancy as a reproductive dysfunction: a proposal for international classification systems. J. Psychosomatic Res. 61, 723–730. Jenkins, A., Millar, S., Robins, J., 2011. Denial of pregnancy – a literature review and discussion of ethical and legal issues. J. R. Soc. Med. 104, 286–291. Krener, P., Simmons, M.K., Hansen, R.L., Treat, J.N., 1990. Effect of pregnancy on psychosis: life circumstances and psychiatric symptoms. Int. J. Psychiatry Med. 19, 65–84. McNeil, T.F., Kaij, L., Maimquist-Larsson, A., 1984. Women with nonorganic psychosis: pregnancy’s effect on mental health during pregnancy. Acta Psychiatr. Scand. 70, 140–148. Miller, L.J., 1990. Psychotic denial of pregnancy: phenomenology and clinical management. Hosp. Community Psychiatry 41, 1233–1237. Slayton, R.I., Soloff, P.H., 1981. Psychotic denial of third-trimester pregnancy. J. Clin. Psychiatry 42, 471–473. Solari, H., Dickson, K.E., Miller, L., 2009. Understanding and treating women with schizophrenia during pregnancy and postpartum. Can. J. Clin. Pharmacol. 16, e23–e32. Terp, I.M., Mortensen, P.B., 1998. Postpartum psychoses: clinical diagnoses and relative risk of admission. Br. J. Psychiatry 172, 521–526. Walloch, J.E., Klauwer, C., Lanczik, M., Brockington, I.F., Kornhuber, J., 2007. Delusional denial of pregnancy as a special form of Cotard’s syndrome. Psychopathology 40, 61–64. Wani, Z.A., Khan, A.W., Baba, A.A., Khan, H.A., Wani, Q.U.A., Taploo, R., 2008. Cotard’s syndrome and delayed diagnosis in Kashmir, India. Int. J. Ment. Health Syst. 2, 1. Wessel, J., Buscher, U., 2002. Denial of pregnancy: population based study. BMJ 324, 458.
Pooja Patnaik Kuppili Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, 605006, India E-mail address: [email protected] Rishab Gupta Department of Psychiatry, SUNY Downstate Medical Center, Brooklyn, NY, United States E-mail address: [email protected] ⁎
Raman Deep Pattanayak Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), Ansari Nagar, New Delhi, 110029, India E-mail address: [email protected]
Sudhir K. Khandelwal Department of Psychiatry, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
⁎
Corresponding author.
27