Case-based discussion. Seminar Consultation-Liaison Psychiatry, Hospital Pulau Pinang. 2 September 2013.

1. WOMEN’S MENTAL HEALTH &
PERINATAL PSYCHIATRY
CASE VIGNETTE-BASED DISCUSSION
Dr Umi Adzlin Silim,
Psychiatrist
Hospital Putrajaya

3. 5 CASE VIGNETTES
“It is more that breast pain..”
A clean kitchen is a sign of a wasted life
“Don’t quote me” : A dilemma for TOP in a muslim
rape victim with antenatal depression and PTSD
“Should a cancer kills twice?”: A dilemma for TOP
in a stable advanced breast cancer patient
“I am pregnant but where is my baby?”

4. OVERVIEW
 Introduction to Women Mental Health & Perinatal
Psychiatry
 Case-vignette based discussion
 Case presentation
 Discussion & Learning Points
 Conclusion

5. Women’s Mental Health
 Traditionally focus on women’s reproductive health,
eg:
 Puberty
 Pregnancy
 Menopause
 Expanding to include disorders and conditions more
prevalent in females than in males, or different in
clinical features and risk factors.

6. ‘Disorders more prevalent in women’
Image from “Women Mental Health’ booklet, US Department of Health & Human Services

7. Perinatal Psychiatry
 Concerning mental health issues in pregnancy i.e.
antenatal and postpartum e.g:
• Antenatal depression
• Postnatal blues
• Postpartum depression
• Postpartum psychosis

8. Confidentiality
 All cases are real patients
 All names are not real
 All pictures of patients are for illustrative purpose
 Ensure confidentiality

9. IT IS MORE THAT BREAST
PAIN…
CASE 1

10. Puan Zurina
Puan Zurina
36, Malay, teacher,
married with 3 children,
had undergone multiple
investigations for severe
bilateral breast pain with
no medical explanation…

11. Background history
 First presented in surgical clinic c/o enlarged, mildly
‘engorged’ breast, sharp pain bilaterally, past 6
months.
 Diagnosed mastitis and bilateral cyst.
 Debilitating pain, caused her lots of sufferings.
 More investigations done, no medical explanation
 She was referred to Chronic Pain Clinic.

12. Consult Request
 In Chronic Pain Clinic, management is
multidisciplinary and comprehensive; Puan Zurina
was referred for psychological assessment.
What do you think Puan Zurina
might reveal?

13. Psychiatric assessment
 Puan Zurina finally revealed physical and emotional
abuse by her husband since early marriage.
 Depressive symptoms with prominent anxiety
symptoms and PTSD symptoms
 Her breast pain worsened each time her husband
requested for sex, pain served as an excuse for her
to refuse him.

14. Psychiatric assessment
 Ambivalent about what she has to do - to stay or
divorce
 Started to strongly feel the impact of abuse to her
& children
 Can’t tolerate husband anymore

15. Diagnosis
 Major Depressive Disorder with prominent anxiety
symptoms and unexplained breast pain

16. Case Formulation
 Women who are a victim of domestic violence
typically experience a phenomenon called ‘learned
helplessness’ and trapped in a ‘cycle of violence’,
they may not readily come forward for help and
may present with other symptoms, including chronic
pain.

18. Learned Helplessness

19. Management
 Aim
1. To alleviate her psychological symptoms (depression,
anxiety, PTSD)
2. To control breast pain symptoms and improve
functionality
3. To develop a plan addressing domestic violence
1. To ensure safety
2. To empower her with information, resources and ongoing
support to prevent further violence

20. Treatment
 Antidepressant (SSRI) & Gabapentin (From Pain
Clinic)
 Supportive psychotherapy.
 Psychoeducation on depression, domestic violence
 Decision making process
 Practical assistance via Social Worker for legal
procedures related to domestic violence

21. Progress
 With treatment, her depressive symptoms improved
and her breast pain reduced to 5/10 (no more her
major concern).
 She proceeded with her decision for divorce with
the mental health team’s support.

22. Discussion
 Colegrave S (2001) reported that patients with
breast pain experiences more anxiety and
depressive and somatic symptoms, and recalled a
higher incidence of emotional abuse by comparison
with patients with breast lump patients.
 Therefore as a good practice, clinical management
of patients presenting with breast pain should be
sensitive to the evidence that pain is a marker of
emotional abuse in some women and is associated
with widespread somatic and emotional distress.

23. Learning Points
 Think of underlying psychological factors in
medically unexplained symptoms eg unexplained
chronic pain
 Management of domestic violence requires
understanding of:
 Cycle of abuse
 Learned helplessness
 Legal aspects

24. Case 2

25. Puan Miza
 A 33 year old school
teacher, married for 6
years with no child,
attending fertility clinic
but had been avoiding
sexual relationship…

26. Consult Request
 Puan Miza was referred by her gyneacologist for
dyspareunia, with no medical causes found. .

27. Background History
 She has recently diagnosed to have endometriosis.
 She complained of dyspareunia since past 6 months,
started while she was on hormonal treatment for
endometriosis.
 Dyspareunia persisted after treatment was
stopped.

28. Further History
 Apparently she had been having problem with
vaginal dryness during sexual intercourse for a long
time.
 She would need lubricants most of the time although
there were also times when she was able to enjoy
sex and achieved orgasm
Is there any psychological
factors contributing to her
dryness and later
dyspareunia even after
endometriosis treatment
stopped?

29. Further history…
 Pn. Miza has obsessive & anxious trait; was
particularly obsessive with housekeeping, always
ensure house in a perfect condition and sink must
dry all the time.
 She was unable to ‘switch off’ her thoughts from
day to day house chores to completely ‘switch on’
for sex.

30. Chronology of event
Long standing vaginal
dryness
On hormonal rx & vaginal dryness
worsened causing her lots of pain
during penetration (dyspareunia).
Fearful & anxious for
sex
Rx stopped,
dyspareunia persisted
(pain score 6/10)
More fearful, anxious & avoid sex
Frequency of sex reduced from
2-3/week to 2/month.
Dyspareunia continued

31. Diagnosis
 Dyspareunia
 Painful sexual intercourse due to medical or
psychological problems. (An evaluation must be done to
rule out physical causes, before attributing it to
psychological causes).
 Obsessive Compulsive Personality Trait
 Preoccupation of orderliness, perfectionism in the
expense of flexibility & efficiency

32. Case Formulation
 Patient’s ongoing ‘obsessive’ personality contributed
to her vaginal dryness & predisposed her to
dyspareunia
 In the bed, but her mind is in the kitchen
 On top of that, hormonal Rx caused more dryness &
precipitated onset of dyspareunia.
 Once hormonal rx was stopped, pain persisted
because ‘self-perpetuating pain’ became a factor
after the original cause is removed

34. Management (1/4)
 Aim
1. To control psychological symptoms & pain symptoms
2. To break the vicious cycle of pain
3. To increase functionality (ie sexual function)
4. To modify personality traits causing difficulties

35. Management (2/4)
 Chronic pain management approach for dyspareunia.
 Psychoeducation: concept of chronic pain - no more
damaging, a ‘wrong signal’ to the brain from
hypersensitized pain nerve.
 Cognitive behavioural therapy (CBT) principles to improve
her sexual functioning.
 Cognitive modification: learn to cope and live with pain rather
than aiming for a cure.
 Behaviour therapy: engage in activities rather than avoiding to
break the vicious cycle of pain
 Relaxation techniques
 Overcome distress & enjoy sexual activities

36. Management (3/4)
 CBT principles were also applied to modify her
compulsive behavior that cause difficulties.
 She aimed to join her husband for meal and dry her
sink only after meal.
 ‘Distraction coping’ to reduce her anxiety symptoms
when she did not dry her kitchen after cooking or each
time after washing hands.

37. Management (4/4)
 Mobilizing support from pt’s husband as well as
giving him support
 Acknowledging his difficulties living with the patient
and support along the way.
 Couple sessions & individual sessions with each
partner were arranged.

39. Progress
 Dyspareunia, after 3 sessions
 patient was able to increase the frequency of sex from
2x/monthly to 1-2/weekly and
 reduced her pain score from 6/10 to 2/10.
 Obsessive personality trait
 she had been able to join her husband in the middle of
mealtime, compared to before, when she only finished her
kitchen cleaning after her husband finished eating.
 4 months in the therapy sessions; and while receiving
treatment for endometriosis; the patient has a
spontaneous pregnancy.

40. Discussion
 Literature review supported the principles of chronic
pain management to be applied in dyspareunia
with psychological components.

41. Learning Points
 Think of psychological factors contributing to
medical symptoms esp.
 eg Personality & Coping factors
 Address psychological factors with appropriate
psychological intervention
 Multimodal approach
 Cognitive behavior therapy
 Relaxation techniques

42. “DON’T QUOTE ME”: A
DILEMMA ON TERMINATION
OF PREGNANCY FOR A
MUSLIM RAPE VICTIM

43. Munira
Munira, 17 years old,
Malay, single college
student, who found
herself pregnant at 7
weeks. She was gang-
raped earlier…

44. Consult Request
 Munira was referred in view of her request for
termination of pregnancy (TOP) after discovering
her pregnancy at 7 weeks POG. She had history of
gang-raped earlier.

45. Psychiatric Assessment
 Munira presented with abdominal pain and just
discovered that she was pregnant at 7 weeks.
 Gang raped earlier but never informed anybody
 Frequent nightmares, flashbacks and re-
experiencing of the event. Easily startled and would
avoid walking alone.
 Depressed with insomnia, poor appetite and
significant weight loss. Stated that she would not be
able to love the baby. Hopeless and worthless but
not having suicidal ideation.

46. Further history
 Her decision for TOP was fully supported by her
parents.
 They anticipated negative consequences on patient’s
emotion & her future.
 Mental state examination showed a teenager
dressed moderately with a muslim hijab, depressed
but rationale about her decision, understood the
procedure and the risks.

47. Diagnosis
 Rape victim with a pregnancy of 7 weeks with
major depressive disorder and PTSD.
 Are you going to recommend a termination
of pregnancy for her?

48. Multidimensional views of TOP
 Medical
 Psychological
 Legal
 Ethical
 Religion
 Moral

49. Medical indications
 From medical point of view, if continuing a
pregnancy is life threatening to the mother then
TOP may be indicated.

50. Psychological indications (1/2)
 Best practice in clinical decision: balance between
risks and benefits.
 Continuing or TOP imposes certain risks, physically
& psychologically.
 Psychological trauma of rape encompasses a broad
spectrum of psychological reactions and psychiatric
morbidities2.

51. Psychological indications (2/2)
 An unintended pregnancy causes impaired mother-
child relationship quality and risks of poorer infants’
physical and mental health3.
 Conversely, TOP may expose women to grief and
regret. However, Bonevski & Adams (2001) found
that legal TOP carried out for various reasons
rarely caused negative psychological consequences4

52. Legal and ethical provision
According to the Malaysian law, abortion is legal if:
1. A medical practitioner registered under the Medical
Act 1971 undertakes the procedure;
2. The practitioner is of the opinion, formed in good
faith, that the continuance of the pregnancy would
involve risk to the life of the pregnant woman, or
injury to the mental or physical health of the pregnant
woman, greater than if the pregnancy were
terminated5.
 Ethically, an informed consent must be obtained
following adequate counseling.

53. Religious provision in Islam (1/4)
 Patient’s perspective: In a review by Bonevski &
Adams (2001), religious objections to abortion were
the trigger for negative outcomes4.
 Muslim practitioners’ perspective: the Islamic ruling
on TOP contributes a great weightage in decisions
exceeding other judgments.

54. Religious provision in Islam (2/4)
 The basic Islamic principle concerning abortion is
that it is forbidden because Islam gives a very high
priority to the protection of life6.
 Kiarash Aramesh (2007) reviewed the viewpoint of
scholars from different Islamic jurisprudence and
found that abortion is permissible only in very
narrow exceptions7.

55. Religious provision in Islam (3/4)
 Most scholars only allow abortion before the time
of ensoulment when physicians declare with
reasonable certainty that the continuation of
pregnancy will endanger the woman's life or put
her in intolerable difficulties.

56. Religious provision in Islam (4/4)
 A hadith suggests that the moment of ensoulment is
120 days8.
 In Indonesia, abortion due to rape is allowed
before 40 days9.

57. Fatwa in Malaysia
Malaysian Fatwa Committee on TOP due to rape;
1. it is prohibited to terminate pregnancy more than
120 days as it is considered as a crime against the
unborn baby as the soul has already entered the
foetus, except abortion to save the mother's life.
2. aborting foetus before 120 days is permissible if
the foetus is defective and terminally ill that it
could seriously harm the mother.
The fatwa is literally silent on psychological
indications.

58. Fatwa in other countries
 Yusuf Al Qardhawi (2002), approved a fatwa
allowing TOP for raped Bosnian muslim10.
 Muhammad Sayed Tantawi (2004) issued a
controversial draft law allowing raped women to
abort even after 120 days, provided that they are
"of good reputation, chaste and pure"11.
(Both are leading scholars in the sunni jurisprudence
dominantly practiced in Malaysia).

59. Moral values
 Patient moral will partly influence her preference:
to keep / to terminate
 Therapist moral: if you find you are uncomfortable
to handle the case, not non-judgemental or neutral,
be fair to the patient and refer to other therapist.

60.  Are you going to recommend a termination of
pregnancy for her?

61. The verdict
 “Don’t quote me”

63. Learning Points
 A multidimensional viewpoint on TOP for rape
victims is very important for a comprehensive clinical
management.
 Case to case basis: it should not be encouraged, but
options should be made available and clear.

64. SHOULD CANCER KILLS
TWICE?
Case 4

65. Puan Nurin
 31 years old, ousewife,
with 2 children,
diagnosed to have
breast cancer with liver
metastases after
delivery of her second
baby, underwent
surgery and completed
chemotherapy….

66. Consult Request
 Puan Nurin was referred because she was pregnant
again (10 weeks POG) after she has completed her
active intervention for her breast cancer and she
now requested for TOP.
Is there any indication for TOP
for Puan Nurin, should we allow
cancer ‘to kill twice’?

67. Background history
 Puan Nurin 31 years old housewife was known to
have advanced breast carcinoma T2N0M1 (lung
metastases)
 She had detected a breast lump in her 2nd
pregnancy but thought it was a benign.
 After confinement, she had a biopsy and was
diagnosed to have cancer.

68. Background history…
 She had chemotherapy in July 2012, left
mastectomy with axillary clearance & lymph
drainage in August and radiotherapy in Oct & Nov.
 Her LMP was in Dec 2012.

69. The oncologists, surgeons &
obstectricians views
 There is no immediate harm for continuation of
pregnancy to mother & baby
 Chemotherapy had completed 5 months before
pregnancy & ultrasound normal
 There is no more active management, completed
surgery & chemotherapy
 The lung lesion was not affected by chemotherapy
(?unlikely metastases)
 Her breast cancer: “stable disease”.

70. Pregnancy & Cancer Therapy:
The Facts
 Chemotherapy can safely be given in 2nd trimester
onward
 Chemotherapy should stop 6 weeks before delivery
to allow blood cells to recover
 Surgery can be done throughout pregnancy
 Radioimaging e.g. ct scan, bone scan are
contraindicated

71. Psychiatric assessment (1/4)
FROM
THE
NOTES
The couple’s main concerns:
1. Pregnancy is associated with disease progress. Pt
had her breast lump in her 2nd pregnancy, brought
it to med attention after confinement. The couple
felt that the cancer was so aggressive because it
metastasized very fast to the lung.
2. Lung metastases - not decreased even after all
Rx.
3. If her disease worsened will she be able to carry
on with the pregnancy?

72. Psychiatric assessment (2/4)
FROM
THE
NOTES
4. The planned bone scan cannot be done due
to pregnancy. So it is not known whether
there is any metastases in other organs. Will
it delay any treatment? Will it affect further
treatment and her disease progress?
4. Pt & husband are aware that medically
(after sessions with the oncologist, surgeons &
O&G) all are allowing her to proceed with
the pregnancy that the risk is low for the
disease to progress. But they prefer & wish
not to take any risk no matter how low it is.

73. Psychiatric assessment (3/4)
FROM
THE
NOTES
6. Completed family. Both feels if they are not having
any children yet, they might proceed with the
pregnancy. But since they are already having 2
children; their priority is on the patient's health so
that she continues to be healthy to care for the
other children.
7. Patient’s preference. On their part, they have
'decided' for the TOP - they have discussed among
themselves, asked religious personnels, discussed
with family members and close friends. They
anticipate that they have to deal with lots of
emotional consequences/stress (physical & mental)
of continuing the pregnancy.

74. Psychiatric Assessment (4/4)
FROM
THE
NOTES
 Patient is not persistently depressed, not
having anhedonia, no sleep or appetite
disturbances or other sx of depressive sx.
No excessive worrying or other anxiety sx.
She has already accepted her diagnosis,
able to cope living with with the illness,
keeping herself busy with her children &
has a good family support from her
husband & family members.

75. Impression
FROM
THE
NOTES
No psychiatric sx that may affect their
decision about requesting for TOP.
No psychological indication for TOP.
Is there any medical ground for TOP?
Apparently no immediate danger but this is a
case of ?lung metastases, so should we give
the benefit of the doubts to the patient?

76. Management
1. Acknowledged & validated all patients concerns &
their difficulties.
2. Explained to patient that the decision for TOP is
made in a team, considering
medical/psychological/moral/religious & ethical
ground. Advised patient to keep an open mind.
3. Recommend a discussion at the ethical committee.

77. Progress
 Ethical Committee was attended by Hospital
director, senior specialists, ‘neutral’ surgeon &
psychiatrist not involved in managing patient.

78. The verdict
 The ethical committee achieved a concencus to allow
patient terminate her pregnancy based on the ?lung
metastases that may be worsened in pregnancy.

79. Learning points
 A multidimensional viewpoint is the ideal approach
for TOP
 Input from the ‘neutral’ ethical committee may assist
clinicians

80. “I AM PREGNANT BUT
WHERE IS MY BABY?”
CASE 1

81. Puan Atika
 Puan Atika, 32, Malay
executive, married for
8 years, G2P0+1 at
term plus 2 days, found
to actually have ‘no
baby’!

82. Consult request
Puan Atika was admitted in her ‘term’ pregnancy c/o
vaginal bleeding with clots but no product of conception
and USG showed empty uterus! The patient and family
were in shock. Kindly do the needful.
What do you have in mind?

83. Differential Diagnosis
 Psychotic disorder eg Delusional disorder?
 False pregnancy?
 Malingering/Lying?

84. Psychiatric assessment
 Pt was very shocked, pregnant but no baby!
 Pt & family had observed pregnancy changes, urine
positive, morning sickness, enlarging abdomen, fetal
movements, fetal parts.
 Pt was regretful he had no regular antenatal follow
care due to work commitment.
 No depressive/anxiety sx
 No hallucination
 Not deluded

85. Further history
 Married for 8 years with no child.
 A complete spontaneous abortion 3 years ago.
 Had fertility treatment, stopped in fear of adverse
effects.
 She said she was no more as eager to have a child
& accepted God’s plan.
 Prior to ‘pregnancy’, had taken care of a baby who
was their grandchild for a month, and in the
following month she missed her menses

86. Further history…
 Husband observed wife’s abdomen growing but
noted it stopped enlarging towards the end of
pregnancy.
 He had palpated the fetal parts.
 They showed pictures of her in pregnancy

87. Provisional Diagnosis
 Psychotic disorder eg Delusional disorder?
 False pregnancy? PSEUDOCYESIS
 Malingering/Lying?

88. Case Formulation
 Puan Atika’s intense desire for a baby was further
enhanced by temporarily taking care of her grandchild.
 The fact that her husband had divorced his other wife
(they had no child from the marriage) had induced a
sense of insecurity in her.
 With the intense desire, her body produced symptoms
of pregnancy such as amenorrhoea, morning sickness
and abdominal distension.
 That explained Mdm ZA’s appearance in her photos of
pregnancy. She might even have false positive urine
tests.

89. “But doc, I have seen my baby in
ultrasound before…”

90. Provisional Diagnosis Reviewed
 Psychotic disorder eg Delusional disorder?
 False pregnancy? PSEUDOCYESIS
 Malingering/Lying? SIMULATED PREGNANCY /
DECEPTIVE PREGNANCY

91. Management (1/3)
 Even without a definite diagnosis, psychiatric
management was tailored towards providing
psychological support to the patient and the family
in going through the ‘disappointment’ as in a ‘grief
work’.
 The patient was allowed to ventilate her feelings of
shock, sadness, regret, anger and ‘bargaining’ on
the circumstances of the loss.

92. Management (2/3)
 The therapist also provided them relevant medical
explanation of the condition.
 The therapist explained that without the ultrasound
images, what she had experienced was a
‘pseudocyesis’; however with the presence of
ultrasound images, there was no medical
explanation available.
 The couple was reassured that the diagnosis was not
categorized as a psychotic disorder that had made
them concerned on the implication to her career.

93. Management (3/3)
 The possibility about the images being not genuine
was not raised up not just because there was no
evidence, but most importantly to prevent further
psychological damage to the patient as it may
interfere with her marital and family dynamic.
 if necessary, it may be explored later and to be
done sensitively and individually first, not in a
confronting manner.

94. Progress
 The patient did not turn up for follow-up
 The truth revealed

103. Case Formulation Reviewed
 With the widely used ultrasound, Puan Atika might
easily discover the truth.
 A very upsetting, disappointing and even embarrassing
experience that she had to find ways to cope with it.
 She ‘evolved’ from having pseudocyesis to becoming
deceptive partly as a way to cope.
 She had had a true pseudocyesis but later after the
truth revealed she intentionally and consciously feigns
pregnancy (simulated pregnancy or deceptive
pregnancy).

105. Discussion (1/5)
 According to DSM-5, a somatoform disorder,
termed as pseudocyesis is a condition whereby a
person has a false belief of being pregnant that is
associated with objective signs and reported
symptoms of pregnancy
 which may include abdominal enlargement, reduced
menstrual flow, amenorrhea, subjective sensation of fetal
movement, nausea, breast engorgement and secretions, and
labor pains at the expected date of delivery.

106. Discussion (2/5)
 Pseudocyesis has become increasingly rare when
accurate pregnancy tests particularly
ultrasonography have become widely available.
 High rates in cultures that place high value on
pregnancy; where fertility still defines womanhood
and a person’s worth; and secure the woman’s place
in her husband’s family.

107. Discussion (3/5)
 The intense desire to get pregnant due to the
psychosocial and cultural pressure may precipitate
pseudocyesis as a psychological defense to the
intense stress in fulfilling the expectations.
 Complex involvement of corticol, hypothalamic,
endocrine and psychogenic factors are postulated
to lead to the secretion of hormones which translate
into physical changes similar to those during
pregnancy.

108. Discussion (4/5)
 An illness presentation may evolve in the era of
technology
 Technology helps in figuring out the initially ‘medically
& psychiatrically unexplained presentation’ (ie the
presence of ultrasound images in supposedly a
pseudocyesis).

109. Discussion (5/5)
 The irony is, when technology contributes to so many
advancement in medicine including to the declining
rate of pseudocyesis, this patient’s family might
have gone home still believing that what happened
to them was something supernatural
 Having such belief may be helpful for some people
to move on!

110. Learning Points
 Pseudocyesis is a ‘Somatoform disorder’
 Handle ‘somatoform disorder’ sensitively because
the medical symptoms are real to patients; and the
underlying psychological factors may be
‘overwhelming’.

111. 5 CASE VIGNETTES
“It is more that breast pain..”
A clean kitchen is a sign of a wasted life
“Don’t quote me” : A dilemma for TOP in a muslim
rape victim with antenatal depression and PTSD
“Should a cancer kills twice?”: A dilemma for TOP
in a stable advanced breast cancer patient
“I am pregnant but where is my baby?”

112. Take Home Message
 To care for a women’s mental health : be
comprehensive, multidisciplinary & ethical
 To address medically unexplained symptoms:
explore psychological issues
 To understand presentation of physical symptoms:
explore personality & coping styles
 To prevent is better than to cure : always manage
psychological aspects of illness

113. THANK YOU
umiadzlin@gmail.com