Delusion of polygamy in proxy: An addition in delusional procreation syndrome.

The content of a delusion is of special interest to mental health professional and is still expanding. The concept of delusional procreation syndrome (DPS), containing delusions in all possible sequential steps in procreation, has been recently proposed. The authors report the case of a married woman harboring a delusion that her husband has been having 10 wives (ie, married once every year in last 10 years) and, as an extension to that, of having two children from each wife. The authors name this as "delusion of polygamy in proxy," and describe it as another dimension of DPS.

INTRODUCTION

In the history of psychiatry, contents of delusions have always interested the community of mental health professionals. A number of fascinating delusions have been named as “syndromes” either of single delusion (eg, Othello syndrome) or of clusters of delusions (eg, delusional misidentification syndrome).[12] The most recent addition to these is that of delusional procreation syndrome (DPS) described by Manjunatha et al.[3] The DPS consists of delusions based on logical thematic content in the sequential steps of procreation from developing relationships, getting married, being parents, and so on. Manjunatha et al.[3] also argued for possible addition of delusion in DPS beyond the reported ones. In the present report, the authors describe a case of an woman having “delusion of polygamy in proxy” in her monogamous husband. Authors prefer to include this under the broad rubric of term “DPS” as this delusion contains a parallel cycle of procreation.

CASE REPORT

A 28-year-old Hindu married homemaker, a mother of two daughters, educated up to class XII, hailing from a middle socioeconomic rural background presented with her husband to our community research clinic with a 10-year illness characterized by the belief that her husband was married to other women in successive years (one woman every year). She had no significant family history of psychiatric disorder and unremarkable past and personal history. She was well-adjusted premorbidly. The illness had insidious onset and a continuous course. She also had 8-year history of reduced social interactions, reduced work performance, inappropriate behavior, and smiling/talking to self without apparent reasons.

According to the patient, the belief that her husband had a plan to marry another woman had started 3 months before their actual marriage, which she falsely states as being informed by her husband after their engagement. She also reported of having unsuccessfully dissuaded her parents from her marriage, which again, was untrue in reality. She falsely believed that her husband married another lady soon after marrying her.

She further believed that her husband married 9 other women, 1 every year. She even narrated a story of her husband having married a woman when she was pregnant with her second daughter. She in fact falsely reported that her in-laws knew about the days of her husband's marriages, which they would jokingly call as “duty days.” She narrated the names of all wives, that is, “Poornima,” “Shakuntala,” “Saroja,” and so on. The “9th wife” was a teacher, and the last wife was a nurse by name “Mamatha,” whom her husband married few months back. She believed that in the last few marriages, her husband had changed his name for the purpose of getting married.

As an extension of her delusion of husband having several wives, she falsely believed that there were two children born out of each marriage, except for the last wife, in whom she was not sure about children, as “the marriage had taken place recently.” She believes that the unemployed wives are staying with their respective parents with their children in different places and working wives are staying separately at their work place with their children.

On asking how she would know about the wives and their children, she said that husband had himself informed her about them. She would even state that she met all wives, one or the other time, brought by her husband to her house with their respective children. She would also say that a few of the wives were very quarrelsome toward her when they meet. “The last meeting with the third wife had taken place” incidentally a few months back, when she was consulting doctors with her husband. According to her, the in-laws did not bother about him having married too many women and having children. In fact, the patient narrated an incidence of her husband sidelining her in a family ritual where the husband had asked her to leave the sacred place of “pooja” for his third wife and that nobody had resisted. The patient also reported that her husband met all of his wives and their children periodically. In fact she reported that her husband threatens to kill her if she revealed this “fact” to anybody. She told that her husband did not have other “extramarital affairs” apart from having these wives and children.

As per her understanding, marriage meant entering into a “sacred temple of relationship” between a man and a woman. She believed that every married couple should have sexual relationship and produce children; otherwise it (nonconsummated marriage) is like cheating each other. Entering in relationship with another woman by a man either by marrying or by having extramarital affair is a breach in this sacred relationship. According to her, marrying another woman and producing children out of that wedlock is worse than having extramarital affairs. Her preoccupation was on polygamous relationships rather than extramarital affairs or infidelity. She had never approached any legal authority for help regarding this issue. She also worried about anticipation of difficulty in arranging marriages of all his children as they had only four acres of agricultural land.

She believed that her husband wanted to marry more times than her father-in-law, who had actually married two women. On asking why her husband can’t produce more children out of one or two wives, she says that husband thinks that woman become physically weak if she becomes pregnant many times.

Her husband reported that the patient never reported to him or anybody else including previous doctors about these delusions, despite consulting them for the past 3 years. But the patient insisted that she had informed him, her in-laws, and all the doctors. The husband had been taking her to doctors for the complaints of talking and smiling without apparent reasons and for negative symptoms for the past 3½ years. However, he had suspected that she had some form of mental illness for the past 8 years.

There was no history suggestive of delusion of duplicates of any form. There was no history suggestive of other delusions, hallucinations, first rank symptoms, manic, or depressive symptoms at any point in time. She received a number of medications in the past 3 years; substantial improvement was observed with olanzapine 7.5 mg/day in 2 months trial. Currently she had approached with a history of menstrual irregularities while taking amisulpride 300 mg/day for the past 4 months.

The authors consider “delusion of polygamy in proxy” as the prominent psychopathology. A diagnosis of “undifferentiated schizophrenia” (DSM IV-TR) was made. Baseline positive and negative syndrome scale (PANSS) score[4] (positive syndrome, 21; negative syndrome, 24; general psychopathology, 44) was 89, global disability score using Indian Disability Evaluation and Assessment Scale (IDEAS)[56] was 14 out of 20 (self-care, 2; interpersonal, 3; communication 3; work, 3; and duration of illness, 3), suggesting severe disability, and clinical global impression (CGI)[7] severity score was 4.

In view of severe menstrual irregularities with amisulpride and good response with olanzapine in the past, the patient was restarted on olanzapine 10 mg/day and reduced the dosage of amisulpride to 100 mg/day (dose suggested for negative symptoms).

At the end of 3 months follow-up, total PANSS score[4] reduced to 65 (positive syndrome, 19; negative syndrome, 15; general psychopathology, 31), CGI scores[56] improved (severity score, 3; improvement score, 2) and global disability score reduced to 5 (self-care, 0; interpersonal, 1; communication, 1; work, 0; and duration of illness, 3), suggesting nil disability. Improvement was observed in menstrual irregularity, but weight gain was observed. Encapsulation of delusion had occurred with continued beliefs, but no spontaneous reporting of the same. She also had gained some insight that she had been suffering from some form of mental illness.

DISCUSSION

Content of the delusion

The authors coin the name “delusion of polygamous in proxy” for this delusion; we do not consider this as “delusion of infidelity,” as there was more to it than the belief that her husband had extramarital affairs. Classically, delusion of infidelity involves belief about unfaithfulness of one of the partners, predominantly involving emotional/sexual relationship even without marriage, which often results in marital conflict. Moreover, that the partner/spouse would hide his/her unfaithfulness is a paramount feature in delusion of infidelity, which was absent in this case. The reported delusion involves the procreation of children with simultaneous marriages involving many women (with knowledge of wife; without attempts to hide them from her), which were beyond belief about sexual relationships. Furthermore, the preoccupation in delusion of infidelity involves unfaithfulness in sexual relationships, but in this case, the preoccupation was on polygamous relationship with procreation of children. Authors stress that the patient had retrospective origin of her delusion (back dating),[89] as she would say that onset of her belief was even before her marriage, while her husband reported that she was perfectly well till at least 2 years after their marriage.

The patient believed that marriages are for procreating children and that the husband prefers to produce more number of children by way of many marriages rather than having many children from one wife. She explained that women became physically weak if they gave birth to more children in a short period of time.

Psycho-social explanation

There was a history of bigamy in her father-in-law. Based on this, the patient might have developed a belief that her husband was competing with his father by marrying more women and procreating more children than his father.

The practice of polygamy still exists among Hindus, despite being illegal. In many instances, Indian families prefer second marriage of husbands when the first wives do not beget male children. It is also widely believed that every family should have at least one male offspring to inherit and transmit the values and customs to their next generation. The content of delusion would have been more understandable if patient or her family members preferred male children. This was not so in this case.

Delusions: Self-reference vs proxy

Authors classify the referential content of delusion to be the “proxy delusion” rather than the “self-referential” delusion. The “self-referential delusions” denotes that delusions refer to himself/herself, whereas the “proxy delusions” refers to someone other than himself/herself. An example of the former is that of a manic patient who would claim that he is the president of India; if the same patient claims that his father is the president of India, it would be a “proxy delusion.” The self-referential delusion in this example is “delusion of grandiosity,” whereas “proxy delusion” is the “delusion of grandiosity in proxy.”

One common example for use of the term “proxy” is “Munchausen syndrome by proxy.”[10] The term “proxy” in this syndrome is used as “by proxy” to denote the center of attention created in patient “by someone,” that is, induction of illness “by the proxy.”. The authors use the term “in proxy” (not “by proxy”) in “delusion of polygamy in proxy,” which denotes that the content of delusion referring to another person, who is psychiatrically normal. In reported case, wife never conveyed that husband is a mentally ill person.

Why this delusion should be added in delusional procreation syndrome

The detailed description of DPS is already discussed by Manjunatha et al.[3] The “delusion of polygamy in proxy” involves multiple, parallel, and simultaneous cycle of procreation involving more than one spouse and their children. Hence it should be included in DPS, which contains all possible steps of procreation.

CONCLUSION

To the best of authors’ knowledge, this is the first case description of delusion of polygamy, even in proxy, and recommend for inclusion in DPS. The patient had delusion that her husband was having multiple wives and children, which authors wish to describe as “delusion of polygamy in proxy” and wish to add one more delusion to the list of already published DPS.