Pregnancy is the most powerful creative process where a life grows inside a woman. Its all happiness and fun for the family in a normal pregnancy, but it ceases being jest when preoccupation with “gestation” becomes an overvalued idea or a delusion. Delusion of pregnancy is a somatic type of delusional disorder classified by the DSM-5 with schizophrenia spectrum and other psychotic disorders. At times, its confused with similar conditions, including pseudocyesis and pseudopregnancy. Pseudocyesis is characterized by belief of a nonpregnant woman that she is pregnant, in association with the development of the signs and symptoms typical of pregnancy. The clinical distinction between pseudocyesis and delusion of pregnancy is primarily based on the presence or absence of physical signs and symptoms of pregnancy.[1] Pseudocyesis can be delusional, but the term is most appropriately used when physical symptoms of pregnancy do appear.[23] On the other hand a simulated pregnancy is a factitious disorder where a person claims to be pregnant knowing that he or she is not. Pseudopregnancy is caused by an organic condition which creates bodily changes suggestive of pregnancy. Couvade syndrome occurs when the father develops a variety of somatic symptoms before, during, or after the birth of the child.[4] It bears a superficial resemblance to delusion of pregnancy, but insight is preserved in Couvade's syndrome while it is absent in delusion of pregnancy.[5]
Historically, the first documented case of delusional pregnancy was described by Esquirol at the turn of the 19th century in his treatise Des Maladies Mentales.[6] Delusion of pregnancy is an etiologically heterogeneous phenomenon. Both biological and psychological factors have been postulated in the causation of this symptom.[7] The range of psychological explanations includes cognitive misinterpretation of bodily sensations and physical changes, severe ego pathology, and poor reality testing, wish-fulfillment, separation individuation concept, an attempt to recapture the lost love object, emotional attachment, i.e. a strong emotional bond between mother and daughter, sustainment, and perpetuation of cultural beliefs, unconscious attempt to change the life situations of women in conservative societies, release of suppressed cultural attitudes and fears, and amplification of cultural themes.[7] Neuroleptic-induced hyperprolactinemia, galactorrhea and intestinal dilation may stimulate, confirm and/or reinforce the perceptions of pregnancy due to misinterpretation of somatic sensations.[8] The phenomenology appears to be nosologically nonspecific and has been reported in a variety of disorders (such as posttraumatic epilepsy, new variant of Creutzfeldt-Jakob disease, and other organic brain syndromes), and functional psychoses, (i.e. psychotic conditions for which no organic lesions and no toxins have been consistently demonstrated - e.g. schizophrenia and mood disorders) as well in medical conditions like drug-induced lactation. The literature on the topic seems to be mostly case reports except one systematic review done by Bera et al. in 2015.[7] The rarity of the delusion of pregnancy coupled with the lack of coherent data about its characteristics warrants proper documentation of literature pertaining to this symptom to inform further clinical practice and research inquiry.
CASE SERIES
Case-1
A 56-year-old Sikh, married female with no formal education from rural background, posthysterectomy status without any genetic loading or past history of psychiatric illness, was brought by her family members with history of irritability, aloofness and muttering to self since 2 years prior and a firm belief of her pregnancy for the past 10 months.
Detailed history revealed that she was asymptomatic till about 2 years back when her youngest daughter had delivered a baby through a cesarian section. However, she was not satisfied with surgery and started complaining to everyone that some fetal product had still remained inside the womb of her daughter. Nobody in her family believed in her, leading to her withdrawal and aloof behavior. She became quite irritable on trivial matters. She would seclude herself most of the time and be noticed to be muttering and laughing on her own. For the previous 10 months, she had declared herself pregnant and demanded to have an antenatal check up. Initially, her children and spouse tried to counsel her but to no avail. She was taken to a gynecologist who confirmed her negative pregnancy status after performing examination and ultrasonography (USG). She resisted the information vehemently and demanded to visit another doctor. She spent all her savings and even sold her jewelry to bear the consultation charges of multiple doctors and USGs. In spite of evidence to the contrary, she continued with her belief. She had started blaming her husband for her late age pregnancy leading to a frequent altercation. Of late, she also developed disturbed sleep with normal appetite and energy. She used to demand to get operated as she did not want this unwanted pregnancy.
Mental Status Examination at her psychiatric presentation revealed a medium-built, ill-kempt woman with variable eye contact who was suspicious and hostile toward examiner. She had perplexed affect with coherent speech. She had somatic delusion of pregnancy with no formal thought disorder.
Her routine investigations and neuro-imaging were in normal range. Brown Assessment of Belief Scale[9] gave a total score of 20. Rorschach Ink Blot Test indicated psychotic illness.
The patient was diagnosed as delusion of pregnancy and started on tablet risperidone 2 mg at night and tablet clonazepam 2 mg in divided doses. After 3–4 days, she stopped taking medication citing ill effect of medicines over fetus. She was counseled and started on depot injection risperidone 25 mg fortnightly. Her psychotic symptoms gradually decreased and by the 4th week, her delusional belief disintegrated (she was amenable to suggestions and even started considering the possibility of nonpregnant status).
Case-2
A 48-year-old Hindu female, married, educated up to 12th standard, from urban background with past history of bipolar affective disorder for the past 15 years with erratic drug compliance, was brought by her son with a history of excessive talkativeness and cheerfulness. She also had a firm belief of her pregnancy over the previous 15 days.
Apparently, she had started believing that she was pregnant and became euphoric about it. She declared the same to everyone and started purchasing clothes and baby gears. She would be over-enthusiastic about the pregnancy. She consulted a gynecologist, who examined her and performed USG which came out to be negative. However, indl did not believe the report. She had stopped performing household chores, would eat relentlessly citing pregnancy requires more calorie. She would be irritable and at times, aggressive when her actions were thwarted. In this background, she was brought to psychiatric outpatient department where initial evaluation revealed a well kempt, cheerful overweight (body mass index [BMI]-32 kg/m2) lady who walked in lordotic posture keeping hand over her abdomen. Rapport was easy to establish. She was euphoric with the belief of her being pregnant. Her appetite, energy and libido were increased and sleep was reduced.
Her routine blood investigations and imaging were normal and Youngs Mania Rating scale was suggestive of mania. She was diagnosed as BPAD relapse with current episode Mania with psychotic features. The diagnosis of delusion of pregnancy was not made separately but subsumed as a part of the larger rubric of bipolar affective disorder, as the patient was a known case of the illness, and the psychotic symptom was considered as a mood-congruent feature of the illness.
She was started on tablet risperidone 4 mg and tablet clonazepam 3 mg in divided doses. Her mood stabilizer (tablet lithium) was reinstituted in therapeutic doses, and she responded well to the treatment and recovering in 2 weeks.
Case-3
A 25-year-old Hindu married nulliparous female with the past history suggestive of psychotic breakdown at the age of 17 years was brought by her spouse for psychiatric consult with a history of abnormal behavior characterized by false belief that she was pregnant and odd beliefs and behavior related to the same. She had been married for the past 5 years and had failed to conceive despite a recent attempt at artificial reproductive technique (ART).
Further history revealed that since her ART failure, she had become aloof and was noticed to be staring blankly at the walls. Often she would stand outside, under the sun, and mutter to self. On enquiring, she would tell everyone that she was imbibing energy from Sun for her fetus. She also complained of excessive fetal movements and shortness of breath. She started having nausea and vomiting also. She was taken to the hospital where it was confirmed that she was not pregnant, but she continued with her belief. She had started behaving like a pregnant woman, and she would mutter to self the whole day, ascribing it to conversations with the baby. However, there was no report of hearing voice of the baby or other disembodied voices.
Mental status examination revealed an ill-kempt frail-looking female with downcast gaze. Rapport was difficult to establish with increased latency of speech and paucity of thought. She had blunted affect and delusion of pregnancy. Her abstract thinking and judgment were impaired. She had reduced biodrives.
Her investigations and neuroimaging were normal. Positive and Negative Symptom Scale[10] showed prominent negative features and Rorschach Ink blot test showed confabulation and contamination with many anatomical detailing suggestive of psychotic features.
She was diagnosed as a case of delusional disorder (delusion of pregnancy). However, Schizophrenia was also kept as a possible differential, considering bizarre thought processes and age of onset of the illness. She was started on tablet olanzapine 10 mg and tablet clonazepam 1 mg BD. However, she never reverted back to the hospital and was lost to follow-up.
Case-4
A 28-year-old Hindu married female with family history of psychotic illness in mother, history of hypothyroidism and polycystic ovarian disease, and premorbidly anxious personality traits was brought by spouse with belief of pregnancy over the preceding 6 months despite proof to the contrary.
History revealed that indl was functioning adequately in her sociooccupational sphere 6 months back when after seeing a pregnant dog in market, she developed sudden onset belief that she was pregnant. She declared herself pregnant even after repeated negative urine pregnancy tests. She consulted multiple doctors who denied any possibility of pregnancy and her repeated USGs were also negative. She reported feeling the fetal movements and even complained of pregnancy related discomfort. She even started hearing disembodied voices of unknown males and females discussing about her pregnancy. She had increased appetite and reduced energy, sleep, and libido.
Initial evaluation revealed an obese (BMI - 35 kg/m2) lady, ill-kempt with variable eye contact, perplexed affect. She had delusion of pregnancy and 3rd person auditory hallucinations discussing her and her baby. She had impaired judgment and poor insight into her illness. Her investigations revealed anemia and high TSH. The Rorschach inkblot test was suggestive of psychosis.
She was diagnosed as a case of schizophrenia and managed with tablet risperidone 4 mg and tablet clonazepam 1 mg BD, tablet eltroxin 75 mcg. However, she had poor compliance to medication, reportedly due to her weight gain. Tablet risperidone 4 mg was cross tapered with tablet aripiprazole 10 mg, which she tolerated better and continued. Gradually, she had started responding, with fragmentation of her delusional belief and improvement in other symptoms.
DISCUSSION
In our study, two cases were above 45 years old suggesting that menopause and peri-menopause can enhance psychological stress. Cipriani et al. in 2013 described delusion of pregnancy as a manifestation of dementia, however, none of our patients had any clinical or radiological features of dementia.[8]
Two patients were found to be obese. This leads to the possibility that a combination of primary somatic sensations arising from the abdomen and other parts of the body due to obesity were misinterpreted as signs of pregnancy leading to delusions of pregnancy. In the context of being cued to be vigilant for symptoms of pregnancy, a small amount of enteroceptor signal, that is perceived to be due to pregnancy, may result in disproportionate emotional arousal. Thus, a feedback loop may be established that keeps attention focused on these symptoms, resulting in an increasingly firm belief in the pregnancy.[11]
The role of sociocultural factors in the development of delusion of pregnancy has been reported in patients, suggesting that contextual variables may exert influence particularly when pregnancy confers a higher valued social status.[12] Chronic social deprivation[13] and excessive societal pressure to have children[14] have been suggested to lead to delusion of pregnancy. One case in our study was nulliparous and had failed ART attempts and thus may fit this causal explanation.
Regarding medical comorbidity of one patient, hypothyroidism is an established associated factor with psychiatric manifestation. Although affective disorders are more commonly associated with thyroid disorders, studies have shown that 5%–15% of myxedematous patients have some form of psychosis. Although Asher's study of 14 patients and resulting description of “myxedema madness” has often been cited as a typical example of psychosis secondary to hypothyroidism;[15] subsequent case reports have revealed considerable variation in clinical psychotic presentations.[16]
In our series, one case had clear symptoms of schizophrenia in the form of autochthonous delusion and 3rd person auditory hallucinations. Out of 4 cases, 2 had psychotic diagnoses schizophrenia and bipolar affective disorder). Bera et al. in his systematic review mentioned that the most common diagnoses associated with delusion of pregnancy were schizophrenia (35.7%), bipolar disorders (16.7%) followed by depression (9.5%).[7]
Most of them responded well to the treatment, keeping pharmacological intervention as mainstay. One patient was lost to follow-up.
CONCLUSION
The cases described highlight the symptom of delusion of pregnancy as a heterogeneous etiological phenomenon. The delusion may have many social, psychological, and biological determinants to its genesis. Obstetricians who handle these cases routinely would benefit from the understanding of the above differentials.
Declaration of patient consent
The authors declare that they have obtained consent from patients. Patients have given their consent for their images and other clinical information to be reported in the journal. Patients understand that their names will not be published and due efforts will be made to conceal their identity but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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