How should I manage a pregnant woman who presents with skin picking and lip biting, has depression and anxiety, is currently taking fluoxetine 80 mg, and has a history of risperidone, clonidine, and alprazolam (Xanax) use?

Management of Skin Picking and Lip Biting in Pregnancy with Depression and Anxiety

Continue fluoxetine 80 mg throughout pregnancy, add cognitive behavioral therapy (CBT) specifically targeting body-focused repetitive behaviors (BFRBs), and do not restart alprazolam, risperidone, or clonidine during pregnancy. 1

Rationale for Continuing Fluoxetine

The fluoxetine should remain at the current dose of 80 mg because:

• Untreated maternal depression poses greater risks to both mother and fetus than SSRI exposure, including preterm birth, poor prenatal care, and impaired maternal-infant bonding 1
• Discontinuing antidepressants in women with severe or recurrent depression leads to high relapse rates, particularly dangerous during pregnancy 1
• Recent high-quality evidence shows no substantial increase in ASD or ADHD risk from prenatal antidepressant exposure when controlling for maternal psychiatric illness 1
• Fluoxetine and sertraline are the most studied SSRIs in pregnancy, though paroxetine and fluoxetine have stronger associations with negative outcomes compared to sertraline and citalopram 2

However, given the evidence suggesting sertraline and citalopram may have slightly better safety profiles 2, consider switching to sertraline 150-200 mg daily if the patient is willing, though this requires careful monitoring during the transition as she has a history of severe anxiety and panic attacks.

Why Benzodiazepines Must Be Avoided

Do not restart alprazolam (Xanax) during pregnancy because:

• The FDA label explicitly warns that taking alprazolam late in pregnancy causes neonatal sedation (breathing problems, sluggishness, low muscle tone) and withdrawal symptoms (jitteriness, irritability, restlessness, excessive crying, feeding problems) 3
• Benzodiazepines cross the placenta and produce respiratory depression, hypotonia, and sedation in neonates 3
• The patient has already successfully discontinued alprazolam—restarting creates dependency risk and neonatal complications 3

Why Antipsychotics Should Be Avoided

Do not restart risperidone because:

• While antipsychotics are relatively safe for the developing fetus 4, they may cause perinatal withdrawal symptoms and neonatal adaptation difficulties
• The patient's primary diagnoses are depression and anxiety with body-focused repetitive behaviors, not psychosis—risperidone is not indicated
• The skin picking and lip biting are better addressed through behavioral interventions specific to BFRBs

Addressing the Skin Picking and Lip Biting

These behaviors represent body-focused repetitive behaviors (BFRBs), likely exacerbated by anxiety:

First-Line Treatment:

• Habit Reversal Training (HRT) or Comprehensive Behavioral Model (ComB) delivered by a therapist experienced in treating trichotillomania/excoriation disorder
• These evidence-based psychotherapies are equally effective as medications for many patients and carry zero fetal risk 1

Pharmacologic Augmentation:

• If BFRBs persist despite adequate fluoxetine dosing and behavioral therapy, consider increasing fluoxetine to maximum dose of 80 mg (already at this dose)
• N-acetylcysteine (NAC) 1200-2400 mg daily can be considered as an adjunct for BFRBs, though pregnancy data are limited

Managing Panic Attacks Without Benzodiazepines

For breakthrough panic attacks during pregnancy:

1. Increase psychotherapy frequency with focus on panic-specific CBT techniques
2. Optimize SSRI dosing—the current 80 mg fluoxetine is appropriate for panic disorder 3
3. Teach acute panic management techniques: controlled breathing, grounding exercises, cognitive restructuring
4. Consider short-term propranolol 10-20 mg as needed for physical panic symptoms (palpitations, tremor) if absolutely necessary, though use cautiously in pregnancy

Monitoring Requirements

• Monthly psychiatric follow-up to assess mood, anxiety, and BFRB symptoms
• Screen for suicidal ideation at each visit, as depression severity is the most relevant parameter for treatment decisions 5
• Coordinate with obstetrics regarding SSRI exposure and plan for neonatal monitoring
• Neonatal monitoring at delivery for signs of poor neonatal adaptation syndrome (PNAS): jitteriness, irritability, respiratory distress, feeding difficulties 6

Critical Pitfalls to Avoid

• Do not abruptly discontinue fluoxetine—this will likely trigger severe relapse in a patient with recurrent depression requiring 80 mg maintenance 1
• Do not restart benzodiazepines even for "just a few doses"—the FDA explicitly warns about neonatal complications 3
• Do not undertreat the psychiatric illness out of fear of medication exposure—untreated maternal depression carries its own substantial fetal and neonatal risks 1, 6
• Do not ignore the BFRBs—these can worsen with untreated anxiety and require specific behavioral intervention

Postpartum Planning

• Breastfeeding: Sertraline and paroxetine are preferred if switching SSRIs postpartum, as they have lowest breast milk concentrations 6. Fluoxetine can be continued but requires infant monitoring
• Contraception counseling: Essential given the high-dose psychotropic requirements
• Postpartum depression screening: This patient is at very high risk and needs close monitoring