Psychotic Denial Research Articles

Negación psicótica del embarazo. Reporte de caso

Denial of pregnancy is a rare, potentially dangerous disorder that can be divided into two variants: psychotic and nonpsychotic. Psychotic denial of pregnancy is typically accompanied by a history of mental illness. Negative effects include psychological distress, unsupported births outside of hospital, and a potential rise in mother and newborn morbi-mortality. It is crucial to include a personal and/or family history of psychopathology as part of the anamnesis because this condition should be treated by a psychiatrist. Regarding the management of this disorder during pregnancy or puerperium, there are no specific recommendations. To provide comprehensive care, a multidisciplinary approach is typically required. A case of psychotic denial of pregnancy is presented. Keywords: Psychotic denial of pregnancy, Pregnancy denial, Mental illness, Psychiatry, Mental health.

Ethical challenges in the treatment of psychotic pregnancy denial.

There is a paucity of literature regarding ethical strategies for treating pregnant people with psychosis. While not uncommon, psychotic pregnancy denial is a psychotic illness in which patients have the delusion that they are not pregnant. The authors provide a literature review regarding psychotic pregnancy denial, present an unpublished case and its questions and dilemmas, and offer recommendations for resolving the ethical challenges these cases raise. A 26-year-old, single, unemployed woman of no fixed residence was admitted for suicidal ideation. She had a history of psychosis, had multiple ER visits and at least one previous hospitalization, had minimal contact with psychiatric outpatient clinics, and had been poorly compliant with treatment recommendations. She was discovered to be about 31 weeks pregnant in the emergency room. Ultrasound exams revealed no fetal anomalies. This was the patient's second pregnancy; her previous pregnancy resulted in an abortion. Her sole psychotic symptom was the delusional belief that she was not pregnant. On the rare occasions when the patient acknowledged being pregnant, she requested termination of pregnancy. Despite intensive pharmacological treatment of her psychosis, the patient continued believing that she was not pregnant and repeatedly said she would not participate in the labor and delivery process. She disagreed with the induction of labor or a cesarean section if needed. The patient developed gestational hypertension, an obstetric indication for delivery. Induction of labor was offered to avoid potentially disastrous outcomes for the pregnant woman and the fetus. Psychotic pregnancy denial is potentially life-threatening. Delivery of the fetus requires carefully weighing risks and benefits and thoroughly considering the ethical framework. Treatment of birthing people with psychotic denial of pregnancy is complex; it requires special clinical and ethical skills to determine the patient's level of decision-making impairment and to find a middle ground between the pregnant person's right to autonomy and the physicians' beneficence-based duties. Using a well-coordinated, interdisciplinary approach and a solid ethical framework, the decision to deliver the fetus while engaging the pregnant person, to the extent possible, in the decision-making process is essential.

Clinical management of psychotic pregnancy denial: what do we know? Case report and narrative review.

IntroductionDenial of pregnancy is the lack of awareness of being pregnant. It associates with increased morbidity and mortality of mother and child and can be classified as non-psychotic or psychotic. There is few literature regarding the latter, making it difficult to recognize, let alone to treat, since we do not have robust data on the incidence nor approved interventions.ObjectivesTo get a better understanding on the standard of care for patients with psychotic denial of pregnancy.MethodsWe present a case report alongside a narrative literature review on the topic.ResultsWe report the case of a 39-year-old caucasian woman, foreign, undomiciled, who was admitted to a Psychiatry unit due to psychotic symptoms. Her birthplace and prior medical records were unknown. She did not recognize being pregnant and showed great irritability when asked; her responses ranged from delusional attributions of symptoms related to the pregnancy to partially acknowledging her state but refusing to answer questions. Obstetric ultrasound revealed a low risk 35 weeks pregnancy. Treatment included quetiapine up to 700mg daily and psychological approach. A multidisciplinary team managed the case and arranged a plan for delivery. Eventually, delusional symptoms remitted and she accepted the gestation. She showed full collaboration during delivery, giving birth to a healthy female and presented transient recovery. After being separated from her daughter, her clinical situation worsened.Psychotic denial of pregnancy is rather uncommon. It is usually seen in patients with prior history of major mental illness, most frequently schizophrenia, and important psychosocial vulnerability. It associates with several negative outcomes for mother and baby, including neonaticide. Most studies agree on the need of a multidisciplinary intervention including obstetrics, psychiatry, and others (social agents, ethical consultants…) to generate a plan for mother and baby. Biopsychosocial aspects should always be considered and each case individually formulated. Pregnant women must be given clear and concise information about the process. For some, seeing obstetric ultrasound might help them accept the pregnancy. Some authors propose labour induction prior to 39 weeks and performing a C-section, especially in cases of uncontrolled psychosis or risk of noncompliance. Most studies also recommend antipsychotic treatment. In cases of persistent denial or acute crisis, especially during the third trimester, patients should be admitted to a psychiatry unit with easy access to obstetric care. Supportive psychotherapy and psychosocial intervention should try to identify precipitating stressors for denial, such as prior or anticipated custody loss, which has been linked to psychotic denial.ConclusionsPsychotic denial is a serious illness which requires a multidisciplinary treatment including biopsychosocial and obstetrical aspects.Disclosure of InterestNone Declared

Denial of pregnancy: a review

IntroductionDenial of pregnancy is a condition that the pregnant woman is not aware that she is pregnant. It appears in one in every five hundred pregnancies, approximately. Women who present denial of pregnancy do not usually present comorbidity with another psychiatric pathology, although dependent personality traits, low self-esteem, loneliness and poor communication with the partner have been described as features among patients.ObjectivesThe objective of this work is to present the current information on the denial of pregnancy.MethodsA review about denial of pregnancy.ResultsDenial of pregnancy can be classified as psychotic denial (the woman may misinterpret the symptoms and physical changes of pregnancy, usually in strange ways. These people do not hide their pregnancy and those around them are often aware of the situation) or non-psychotic (the patient has the judgment of reality preserved). Non-psychotic denial can be affective: (the woman intellectually recognizes that she is pregnant but does not experience the emotional or behavioral changes that usually occur. This type of denial is related to feelings of detachment from the baby) or generalized (occurs when the The woman not only does not suffer the emotional changes of pregnancy, but also does not know the existence of pregnancy itself. Weight gain, amenorrhea and other changes inherent to this state may not be present or be misinterpreted. It may be that neither the family nor the environment realizes the pregnancy and then there is a collective denial of the pregnancy.)ConclusionsResearch and prevention of perinatal pathology should be a priority.DisclosureNo significant relationships.

“There is no baby”—A Case of New Onset Psychotic Denial of Pregnancy in the Third Trimester [01E

INTRODUCTION: Psychoanalytic theory states that pregnancy denial stems from a woman's inability to adapt to her new maternal role and leads to increased morbidity and mortality of mother and neonate. METHODS: A 33-year-old primigravida at 37 6/7 weeks gestation presented with new onset psychotic pregnancy denial. She was previously treated for major depressive disorder and discontinued pharmacotherapy during pregnancy. She had no history of psychosis. At 37 5/7 weeks, she reported to her husband, “There is no baby.” She was admitted to the antepartum service. Followed by a team of obstetricians, Maternal Fetal Medicine specialists, and psychiatrists, it was decided to initiate antipsychotic pharmacotherapy after delivery of the fetus. She was found to have capacity for decision making and provided informed consent for a cesarean section. She delivered a male infant at 38 1/7 weeks. She was started on psychotropic medication, and showed poor response. On postpartum day six she was transferred to inpatient psychiatry and underwent 12 bilateral electroconvulsive therapy (ECT) treatments during her 4-week inpatient and 2-week outpatient partial hospitalization. She has since returned to work, follows with outpatient psychiatry, and has a healthy relationship with her neonate. RESULTS: Patient informed consent was obtained for submission of a case report. CONCLUSION: This case highlights the interplay between medical, ethical, and legal systems. It presents challenges of peripartum psychiatric care and shows successful use of ECT for psychotic denial of pregnancy. It's reasonable to deliver before 39 weeks for worsening psychiatric disease. Proper care of mother and fetus depends on interdisciplinary care.

Interpreted statues: collapse of femininity and psychotic denial of incest in The Winter’s Tale

ABSTRACTThe Winter’s Tale (1610/1999), a late romance by William Shakespeare, on one level presents the delusional jealousy of Leontes regarding his wife Hermione, the visitations of death undoing the omnipotent defenses employed by Leontes, who is fatefully confronted by grief and the guilt of having wronged those close to him. The final two acts present us with the redemptive powers of nature and love, re-establishing the family unit through mutual forgiveness and a deus ex machina in the coming-to-life of Hermione’s statue. The comic formula Shakespeare utilizes after the first three acts attempts to undo the tragic plot unfolding thus far, inviting us to abandon the knowledge we acquired and adopt the solution of a safe Oedipal triangulation, materialized when the statue comes to life. On a darker note, Shakespeare undoes important dimensions of the source material, which provides a tragic ending to the Leontes character (Pandosto) after he lusts after his daughter. As Shakespeare alters the fates of the characters through largely disavowing the incestuous urges of Leontes, we are taunted with both knowing and not knowing that pairing off Leontes in the end with an adult female partner is an aesthetic resolution to much more troubling psychic realities.

O Fenômeno da Negação Não Psicótica da Gravidez na Perspectiva Winnicottiana

This is a theoretical study which addresses the phenomenon of non psychotic denial of pregnancy which a woman does not know she is pregnant during a significant part of the pregnancy or even until labor. This situation is explored from the Winnicottian perspective addressing aspects related to the maternal psychic condition, especially concerning the concept of primary maternal preoccupation as an essential factor in the relationship between mother and child. Some hypotheses are presented concerning a conflict which unable the mother to recognize her own pregnant condition as well as we discuss about the consequences of this impossibility in the quality of the relationship mother-child.

Identifying Psychotic Defenses in a Clinical Interview

The Defense Mechanisms Rating Scales (DMRS), one of the most widely used and validated instruments in the study of defense mechanisms, does not include psychotic defenses. The Psychotic-DMRS (P-DMRS) has been developed to include 6 psychotic defense mechanisms: psychotic denial, autistic withdrawal, distortion, delusional projection, fragmentation, and concretization. We discuss psychotic defenses, including the difference between psychotic defenses and psychotic symptoms. Six clinical illustrations demonstrate how the 6 P-DMRS defenses can be identified in patients' narratives selected from the transcripts of dynamic interviews. Implications with respect to patient evaluation and treatment are discussed.

Déni, négation et dénégation : aspects psychopathologiques et cas cliniques

The word “denial” has several meanings; in psychoanalytically inspired psychopathology, it signifies a refusal to recognize sensory evidence, and it has a defensive function. Denial makes the perception of certain realities disappear from mental and unconscious life, whereas repression, while performing a similar task, integrates the intolerable reality into the unconscious. The term “negation” points to the negating of a psychic reality; it is the refusal to recognize a thought, a desire, or a feeling that is a source of intrapsychic conflict as one's own. Psychotic denial is multifactorial; it includes the existence of psychic troubles, but also the medico-legal behaviors that result from these. Neurotic denial is partial; it plays the role of a defense mechanism in that, it rejects the reality of a perception perceived as dangerous or painful for the ego. Perverse denial is characterized by the coexistence – within the same personality – of two contradictory judgments, unrelated to external reality. In order to maintain emotional stability in the face of anxieties concerning his physical or psychological soundness, the subject resorts to banalization and minimization. These mechanisms are not limited to the unconscious. The denial of an act and/or its consequences characterizes psychopathic denial; this also includes law and authority. Anosognosia is not a defense mechanism, but rather a pathological symptom, demonstrating a neuropsychological deficit or a cerebral dysfunction. “Insight” is an Anglo-Saxon term related to denial, anosognosia, and introspection, depending on the context. Two clinical examples illustrate different types of denial in different psychiatric pathologies.

Psychotische und nicht psychotische Verleugnung der Schwangerschaft

We report about two patients with denial of pregnancy. While the first patient was free of psychopathological symptoms besides denial of pregnancy until rupture of the membranes, and was able to accomodate the new born, the second patient with psychotic denial of pregnancy could not accomodate the child because of the schizophrenia, so that an adoption was necessary. On the basis of the two cases aetiological, epidemiological, clinical und prognostic implications of psychotic and non-psychotic denial of pregnancy are discussed.

Lessons Learned About Poor Insight

Lessons Learned About Poor Insight

Focus on Patient Management: Responsibly Managing Psychiatric Inpatient Refusal of Medical or Surgical Diagnostic Work-Up

Focus on Patient Management: Responsibly Managing Psychiatric Inpatient Refusal of Medical or Surgical Diagnostic Work-Up

Psychotic Denial of Pregnancy

Denial is a defense that can help reduce anxiety when coping with a stressful event, but can be detrimental to an individual if it prevents adaptation. Three types of denial of pregnancy have been described: affective, pervasive and psychotic denial. The pregnancies of women with schizophrenia can be complicated by psychotic denial of pregnancy. Misinterpretations of the symptoms of pregnancy, grief from prior loss of custody of a child, and active psychiatric symptoms may increase the risk for denial of pregnancy. The consequences of failing to accept a pregnancy can be severe, including lack of prenatal care, limited time to prepare for parenting (with subsequent risk of custody loss), and neonaticide. These risks can be alleviated by early identification of women with psychotic denial of pregnancy and implementation of medication, psychotherapy and social support. At the individual level, education about family planning may be helpful in preventing further episodes. At the public policy level, Safe Haven laws may prove to be beneficial in preventing neonaticide. Keywords: Psychotic, denial, pregnancy, schizophrenia, complications, interventions

Assisted and Surrogate Decision Making for Pregnant Patients Who Have Schizophrenia

Because of a dearth of literature, we developed preventive ethics strategies for managing the pregnancies of patients with schizophrenia. Schizophrenia can chronically and variably impair a woman's decisions concerning the management of pregnancy, including the decision about whether to continue the pregnancy through to viability and term. The psychiatrist must balance autonomy-based and beneficence-based obligations to the pregnant woman with schizophrenia, and both the psychiatrist and pregnant woman have beneficence-based obligations to the fetus when the fetus is a patient. We discuss the assessment of the decision-making capacity of pregnant patients with schizophrenia and describe the strategies of assisted decision making that aim to diminish chronically and variably impaired autonomy. When patients are severely impaired in decision-making capacity, as, for example, in psychotic denial of pregnancy, the standard of surrogate decision making applies. This should be guided by the substituted judgment standard. When patients' values are not known or have not been consistently held over time, surrogate decision making should be guided by the best interests standard. These strategies should substantially enhance patients' autonomy in the psychiatrist-patient relationship and contribute to the quality of their psychiatric and obstetric care.

Shutter Island • Shrink Rap

Shutter Island • Shrink Rap

Homosexuality: coming out of the confusion.

The author asserts that earlier theoretical assumptions contribute to the conceptual confusion about homosexuality in much contemporary psychoanalytic research. Bergeret's article, recently published in this Journal, is exemplary of this confusion. The author refutes his contention that homosexuality is not 'true' sexuality but merely a defensive, narcissistic fixation away from, or a nearly psychotic denial of, heterosexuality. He then clarifies specific areas of conceptual confusion regarding homosexuality still prevalent in psychoanalytic discourse that derive from earlier theoretical premises. These areas of confusion include manifest versus latent homosexuality, narcissism and bisexuality, oedipal dynamics and development, and transference and technique.

Denial of Pregnancy: A Case Study and Literature Review

A case is presented of a young active duty woman who experienced nonpsychotic denial of pregnancy until she precipitously delivered a healthy full-term infant. Despite the lack of prenatal care and the requirement for neonatal resuscitation, the child has apparently developed normally. The woman had no ongoing psychiatric illness. She was able to make appropriate use of medical, nursing, and social work resources to function well with her child at home. The recent literature on denial of pregnancy is reviewed, and the clinical differences between nonpsychotic and psychotic denial of pregnancy are described. Clinical management and mobilization of social support structures can improve the chances of successful clinical outcomes in nonpsychotic denial of pregnancy.

Zur Schwangerschaftsverdrängung - Darstellung eines Phänomens anhand einiger Ergebnisse von 28 Fällen und Vorstellung einer prospektiven regionalen Verbundstudie für Berlin

Es wird über Ergebnisse einer Fallsammlung zur verdrängten Schwangerschaft berichtet. Zwischen August 1986 und Mai 1995 (8 Jahre und 8 Monate) wurden an der eigenen Klinik insgesamt 28 Frauen bekannt, deren Schwangerschaften erst zu einem sehr fortgeschrittenen Gestationszeitpunkt bzw. erst durch die Geburt offenkundig wurden. Darunter waren sieben unerwartete Geburten zu Hause. Sechs Neugeborene waren Frühgeburten, zwei verstarben, insgesamt acht wurden auf die Neonatologie verlegt. Fünf Kinder wurden zur Adoption freigegeben. Mit 23 Frauen wurde ein postpartales Interview durchgeführt. Obwohl zehn Patientinnen einen Arzt aufgesucht hatten, wurde die Schwangerschaft in keinem Fall diagnostiziert. 21 Frauen gaben menstruationsähnliche Blutungen an, ein bis heute ungeklärtes Phänomen. Geburten nach spät oder gar nicht wahrgenommener Schwangerschaft sind selten; in bezug zur Gesamtgeburtenzahl ergab sich eine Relation von 1:586. Ähnliche Angaben zur Häufigkeit werden auch von anderen Autoren berichtet. Zum merkwürdig anmutenden Bild der Schwangerschaftsverdrängung werden mögliche zugrundeliegende Mechanismen und anhand der Literatur einige wesentliche theoretische Überlegungen zur Psychodynamik erläutert. Ferner wird eine derzeit laufende einjährige prospektive Verbundstudie für Gesamt-Berlin vorgestellt.

Psychotic Denial of Pregnancy: Phenomenology and Clinical Management

Psychotic denial of pregnancy in chronic mentally ill women may place the women and their fetuses at high risk of postpartum emotional disturbance, precipitous or unassisted delivery, fetal abuse, and neonaticide. Psychotic denial of pregnancy is illustrated with case reports from an inpatient program for pregnant mentally ill women. Women who denied their pregnancies tended to have a diagnosis of chronic schizophrenia, to have previously lost custody of children, and to anticipate separation from the baby they were carrying. The author suggests that treatment for such patients should take place in a setting that integrates comprehensive psychiatric and obstetrical care and may include pharmacotherapy, supportive psychotherapy, and evaluation of the patient's parenting skills and support network to assess whether she is able to keep her baby.