Pseudocyesis Versus Delusion of Pregnancy: Differential Diagnoses to be Kept in Mind.

Pseudocyesis is a condition in which the patient has all signs and symptoms of pregnancy except for the confirmation of the presence of a fetus. The literature on delusions of pregnancy in schizophrenia is however scanty. We hereby present a case of delusion of pregnancy. The case highlights the possibility of delusion of pregnancy if a patient presents with features suggestive of pseudocyesis. The obstetricians being more familiar with pseudocyesis might tend to overlook the other possibility in such cases. This would be especially true if there are no associated clearcut psychotic features.

INTRODUCTION

Pseudocyesis (greek pseudçs, false + kyçsis, meaning pregnancy) is a condition in which the patient has all signs and symptoms of pregnancy except for the confirmation of the presence of a fetus.[1]

In the case of pseudocyesis, i.e., phantom pregnancy, there is abdominal distention, enlargement of the breasts, enhanced pigmentation, cessation of menses, morning sickness and vomiting, typical lordotic posture on walking, inverted umbilicus, increased appetite, and weight gain.[23]

Pseudocyesis used to be a comparatively phenomenon in the past and the ratio of false to true pregnancies was around 1:25.[2]

Modern classifications Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revisited and International Classification of Diseases, Tenth Edition categorize pseudocyesis into somatoform disorders. It is important to distinguish pseudocyesis from delusion of pregnancy or pseudopregnancy.[4]

Several authors have reported on the psychodynamics of pseudocyesis.[25] Harwick and Fitzpatrick[4] have outlined a psychotherapeutic technique used in pseudocyesis, and Taylor and Kreeger[6] have attempted to synthesize the psychodynamic formulation with biological underpinnings.

The literature on delusions of pregnancy in schizophrenia is however scanty, with authors such as Cramer[7] reporting on a 15-year-old girl who developed a delusion of pregnancy following chlorpromazine-induced galactorrhoea. Many of the psychodynamic postulates offered for pseudocyesis could very well serve as a basis for the understanding of a delusion of pregnancy in a schizophrenic patient.[89]

We hereby present a case of delusion of pregnancy. The case needs to be differentiated from pseudocyesis. The case could present diagnostic dilemma especially if other psychotic features are not fully manifested.

CASE REPORT

A 55-year-old housewife who studied till eighth standard, hailing from nuclear family with insignificant history, and history of unknown psychiatric illness in maternal grandfather and stable well-adjusted premorbid personality presented with the first episode of 27-year-old insidious-onset illness with progressing course after the death of her only son in an accident. She came with complains of suspiciousness against people around her, decreased interaction with family, muttering to self, belief that she is pregnant, laughing and crying without reason, and decreased sleep and appetite.

During the interview, she revealed a well-systematized delusion of pregnancy. In response to the specific question on pregnancy, she answered that she had a baby in her abdomen. She was convinced that she could feel the fetal movements. When asked to account for the flatness of her abdomen, she mentioned that her abdomen had remained flat even during her earlier pregnancies. She demonstrated her pain in abdomen as a proof that she was having labor pain.

At present, in her family she has only her husband as her daughter is married and lives with her in-laws and her only son had expired in an accident.

Her general and clinical systemic examination was within normal limits. Her mental status examination at admission revealed an old obese woman of heavy built, who was irritable, guarded, and continuously muttering with normal psychomotor activity. She completely avoided an eye-to-eye contact, and rapport could not be established with her. Her speech was low in tone and volume with the normal rate productivity, and her affect was shallow and constricted. Her thought content revealed delusion of persecution, reference, and delusion of being pregnant. She did not reveal any hallucinations. She did not attempt higher mental function questions and insight was absent. Psychological testing was not performed because the patient declined it.

Her baseline Positive and Negative Syndrome Scale score was 98/210. Her liver function test, blood sugar level, kidney function test, complete hemogram, and ultrasound abdomen was within normal limits, but her contrast enhanced computed tomography of the head revealed b/l frontoparietal atrophy. Her serum prolactin level and serum follicle stimulating hormone level were much above the normal limits for her age, and her thyroid stimulating hormone was also raised, with T3 and T4 levels on the lower side of the normal range for which medical opinion was sought, and she was put on thyroxine 12.5 μm/day.

DISCUSSION

By definition, delusions are false firm ideas that cannot be corrected by reasoning and are out of keeping with patient's educational and cultural background. Delusions can also be regarded as a mode of adaptation to stress and may serve a metaphorical or allegorical function in which the patient portrays her problems and experiences. Usually this aspect of a delusion is often disregarded in the context of its apparent illogicality. In this patient, the wish-fulfilling function of the delusion may be apparent. The patient wants a son and wants to be reunited with him at any cost, and the only apparent means of doing so is through giving birth to child.

Deutsch[10] has also pointed out that a pregnancy could be used to magically avoid being abandoned and helpless. The defensive, restitutive function of this delusion is obvious in the face of the extreme insecurity being faced by the patient. Similar observations have been made in pseudocyesis by Barglow and Brown.[1] While loss of love, loss of a love object, or loss of fertility is postulated to operate in the development of pseudocyesis,[5] similar mechanisms can be seen in the development of a delusion of pregnancy.

In this case, the patient had introjected the lost love object (namely, her son). The case highlights the possibility of delusion of pregnancy if a patient presents with features suggestive of pseudocyesis. The obstetricians being more familiar with pseudocyesis might tend to overlook the other possibility in such cases. This would be especially true if there are no associated clearcut psychotic features.

It is important to consider the associated psychotic features that might be present in women with delusions of pregnancy as were present in the current case. On the other hand, women with pseudocyesis have the clinical presentation centered on the false signs and symptoms of pregnancy. There are no associated psychotic features in such cases.

The two conditions warrant a different line of management. Antipsychotics play a key role in the delusion of pregnancy. On the other hand, they are of limited role in patients with pseudocyesis. Psychodynamic and supportive psychotherapy could play a pivotal role in the management of pseudocyesis.