Management Patients with anorexia or bulimia should be treated by mental health professionals, preferably those with subspecialization in this area. The conditions are highly refractory to treatment; patients can resort to elaborate subterfuges to conceal their failure to eat and gain weight (185–187). There are Web sites dedicated to anorexia, with information about the minimum calories necessary to sustain life, and photographs of individuals who seem pleased with their skeletal appearance. Up to 50% of cases will become chronic, and approximately 10% of those will ultimately die of the disease. Antidepressant medication is sometimes helpful. Amenorrheic patients should not be treated with ovulation induction. Evaluation for osteopenia and osteoporosis is necessary (187).
Schizophrenia affects approximately 1% of persons worldwide (188). Since the deinstitutionalization of persons with severe and persistent mental illnesses several decades ago, most affected individuals live in the community. Often health care and other services are inadequate, leaving these women vulnerable to sexual abuse and involuntary impregnation. Overall, the fertility of women with schizophrenia approximates that of matched populations. Schizophrenia is not an absolute contraindication to successful parenting, but there is considerable stigma against psychotic disorders, and patients may avoid prenatal care because they fear loss of custody (189,190).
Diagnosis Psychotic disorders are characterized by major distortions of thinking and behavior. They include schizophrenia, schizophreniform disorders, schizoaffective disorders, delusional disorders, and brief psychotic disorders. General medical and toxic conditions must be ruled out in determining the diagnosis. Distinctions between the disorders are based on symptoms, time course, severity, and associated affective symptoms. The hallmark of psychosis is the presence of delusions or hallucinations. Hallucinations are sensory perceptions in the absence of external sensory stimuli. Delusions are bizarre beliefs about the nature of motivation of external events (188). Because there is no reliable definition of “bizarre,” a physician working with a patient from an unfamiliar culture must determine whether a given belief is normal in that culture. Delusions and hallucinations are the positive symptoms of schizophrenia. The negative symptoms include apathy and loss of connection to others and to interests. The negative symptoms may be more disabling than the positive. There is increasing evidence that schizophrenia is associated with cognitive deficits (191).
Epidemiology Onset of schizophrenia is in the late teens to mid-30s. Women succumb later in life and have more prominent mood symptoms and a better prognosis than men (191,192). The risk is 10 times greater for first-degree biologic relatives and for individuals of low socioeconomic status (192). It is unclear whether indigent status is a precipitating stress or a result of psychotic illness, but, especially as extremely few individuals have private or public coverage for adequate treatment, most people with schizophrenia are indigent.
Assessment There is wide variability in the functional impact of psychotic disorders. Patients must not be assumed to be incompetent to make medical decisions or lead independent lives, especially if they comply with treatment. Patients must be asked specifically about their living situations and coping skills. When psychotic women have responsibility for the care of children, their ability to do so should be assessed in consultation with a mental health expert. Motherhood and child custody are exceedingly sensitive matters for these vulnerable patients (191).
A relentlessly downhill course is not inevitable; remissions and recovery can occur (192). Therefore, the patient’s mental status must be examined carefully. Under the pressures of a busy medical setting, psychotic illnesses can be overlooked, only to erupt in the labor room, operating room, or recovery room. Patients who believe that conspiracies or aliens are responsible for their symptoms can answer yes-or-no medical questions without revealing their delusions. Open-ended questions (“Tell me about your symptoms”) are more useful (191).