Delusion of Triplet Pregnancy in Abdominal Cavity: A Case Report with a Review of Literature.

The two terms, pseudocyesis and delusion of pregnancy, were frequently used for pseudopregnancy. Delusion of pregnancy is a special form of hypochondriacal/somatic delusion reported in various psychiatric and organic disorders. The origin of the delusion of pregnancy in schizophrenia has often been explained by psycho-analytic interpretations attributing wish fulfilling, protective role to false beliefs, and mother establishes an undisturbed union with her fetus during pregnancy, which eliminate loneliness and helplessness. The current case is a 49-year-old married female with an illness of total duration of 10 years. Initial symptoms were delusion of infidelity and persecution and 2nd and 3rd person auditory hallucination; however, the patient started reporting around 2 years back that she was pregnant and there were three female children inside her abdominal cavity rather than in uterus. She was firm on this belief and was not convinced by family members even giving evidence contrary to her belief like showing ultrasonography report. She firmly believed that these are gift of God, and they are special children who would be delivered through special procedure. Blood investigation revealed raised prolactin level, blood sugar and ultra sonography suggestive of cholelithisis. Patient's psychiatric symptoms including delusion of pregnancy were significantly improved with treatment, and medical and surgical comorbidities were managed with appropriate consultations.

INTRODUCTION

The two terms were frequently used for pseudopregnancy; the first one is the pseudocyesis and second one is the delusion of pregnancy. Although some authors have tried to define pseudocyesis as the condition in which the patient has all the signs and symptoms of pregnancy except confirmation of pregnancy, delusion of pregnancy can be described as a false and fixed belief about being pregnant, despite factual evidence to contrary. Delusion of pregnancy is a special form of hypochondriacal/somatic delusion, but sometimes, explanation could be bizarre in nature. This Psychopathology is uncommon, though reported in various psychiatric disorders such as schizophrenia, schizo-affective disorders,[1234] delusion disorders and[56] affective disorders.[7] However, these symptoms are also reported in organic disorders such as epilepsy,[89] in dementia, and other organic brain syndromes[1011] as well as in medical conditions such as drug-induced lactation,[12] polydipsia and hyponatremia syndrome,[13] and antipsychotic-induced hyperprolactinemia.[14] Delusion of pregnancy has not only limited to female but also reported in males.[68] The origin of the delusion of pregnancy in the setting of schizophrenia has often been explained by various psychological mechanisms. The psycho-analytic interpretations attributed wish fulfilling and protective role to false beliefs. The mother establishes an undisturbed union with her fetus during pregnancy, which eliminate loneliness and helplessness in a magical way that can serve as a basis for delusion formation.[10] Similarly, loss of love and loss of a loved object (or of fertility), acute loneliness, and real/imagined loss of relationship were hypothesized to activate a delusion of pregnancy on a wish-fulfilling manner.[1516] Some unusual cases have also been published, for example, recurrent delusion of pregnancy,[17] experience of labor and parturition,[18] puppy pregnancy in humans,[19] delusion of test-tube pregnancies,[20] and delusional pregnancy persisting over decades.[45] However, very few cases of delusions of multiple pregnancies are reported in literature.[10] We are presenting a patient having delusion of triplet pregnancy in abdominal cavity (extrauterine) associated with hyperprolactinemia.

CASE REPORT

The patient in our case was a 49-year-old married female, belonging to middle socioeconomic status. The patient's family includes husband with three sons, who are staying away from the patient for the study. Her husband would have to go other places due to duty. Therefore, the patient would spend most of her time alone in the house. She presented to the psychiatry outpatient department with an illness of total duration of 10 years, subsequently admitted. It was insidious in onset and continuous, with intermittent exacerbations. The illness started gradually with disturbed sleep, irritability, and ideas of infidelity against the husband which lasted for around 2 months and was followed by the second person auditory hallucination, of a religious figure, speaking to the patient about “giving her high rank in their religion.” The patient also developed delusion of persecution against her relatives and had the third person auditory hallucinations discussing plans to harm her and her family.” These symptoms continued for the initial 8 years with frequent exacerbations in the form of irritability and anger outbursts. The patient's family members sought treatment only from faith healers and homeopathic practitioners for the first 4 years, on which they perceived minimal improvement in her symptoms. Following exacerbation of her illness, they then took the patient to private psychiatrists and she was prescribed first-generation oral antipsychotics. However, compliance of medication had been poor, and the patient had intermittent exacerbations. Two years back, the patient developed acute pain abdomen, nausea, and vomiting and was diagnosed to have acute cholecystitis. Although the patient was managed conservatively, she would frequently complain of abdominal distention and flatulence. Gradually, the patient started reporting that she was pregnant and there were three female children inside her abdominal cavity rather than in uterus. She was firm on this belief and was not convinced by family members even giving evidence contrary to her belief like showing ultrasonography report. She firmly believed that these are gift of God and they are special children who would be delivered through special procedure. The patient reported hearing the voice of the “religious figure” telling her regarding this, specifically pointing toward a particular area of her abdomen regarding the location of the children. She named all the three daughters and also reported hearing the voices of these children individually talking to the patient. The patient would claim her abdominal distention was due to the pregnancy and walked with a lordotic gait. She also had delusions of grandeur, in the form of having the special ability of granting children to any woman, through her blessings. The patient also reported extracampine second person auditory hallucinations of women crying from Baghdad for her blessings. The patient reported these frequently. Her delusions of persecution against the relatives continued in the same manner, although the ideas of infidelity against her husband disappeared. Mental status examination revealed flat affect, delusion of pregnancy (Bizarre), and 3rd person auditory hallucination. Blood investigation revealed raised prolactin level, blood sugar and ultra sonography suggestive of cholelithisis. The patient was diagnosed as a case of paranoid schizophrenia with cholelithisis and diabetes mellitus. Co-morbidites were managed with appropriate consultations. The patient's brief psychiatric rating scale and positive and negative symptoms scale scores were significantly improved with treatment. The patient's family members were psychoeducated regarding the nature of illness, need for regular treatment, and compliance of medication.

DISCUSSION

Initially, our patient presented with the ideas of infidelity, delusion of persecution, and auditory hallucination, and delusion of pregnancy appeared in the later part of psychotic illness. She was initially treated with homeopathic medication followed by allopathic medication for the past 4 years. She started reporting delusion of pregnancy for the past 2 years. Various explanations have been given by various authors for the development of delusion of pregnancy such as psychodynamic, cognitive, and antipsychotic-induced hyperprolactinemia. Some of the explanations may hold true for our patient. Our patient developed this symptom after starting allopathic treatment (antipsychotic) which could be explained by antipsychotic-induced hyperprolactinemia.[14] However, we are not having the finding of prolactin level at that time, but currently, prolactin level is raised. A previous study conducted by Ali et al., 2003,[21] suggested that delusion of pregnancy might be directly associated with rising prolactin concentration during antipsychotic treatment. She is having only three sons, but earlier she had reported a desire for girl child to her husband. She could have repressed wish to have daughter which could have led to the development of delusion, particularly having pregnancy of three daughters. This is contrary to a normal expectation of male child during pregnancy in Indian population. Previous case reports also support that Indian culture gives more significance to male child as patients were having delusion of pregnancy of son. Along this, the patient remained alone most of the time from the past 2–3 years as her husband was working outside and would spend very less time with the patient, and also, her sons started staying away from her home for the study for the past 2–3 years. Previous studies suggest that pregnancy establishes an undisturbed union of the mother and her fetus, which was supposed to eliminate loneliness and helplessness in a magical way that can serve as a basis for delusion formation, which might be psychodynamic explanations in our patient.[10] Neurocognitive models explaining delusion formation have been classically ordered in two main categories, the deficit and the motivational. Deficit models interpret delusions as a result of cognitive dysfunctions and perceptual abnormalities while motivational theories view delusions as an effort to relief unbearable distress and disintegrating anxiety.[1022] These models would explain delusion of pregnancy to a great extent.

Previously, several case studies underlined the role of bodily changes and their perception as an anomalous experience in the development of delusional pregnancy.[172324] Similarly, in our case, the patient had an episode of pain abdomen followed by frequent abdominal distention, which she misinterpreted as a sign of pregnancy. Patients with delusional pregnancy have been reported to be more treatment resistant compared with matched controls.[16] Therefore, treatment of these kind of patients should not focus on symptoms’ removal rather than treatment should be focused on improved functioning. Hence, management of such type of patients must include cognitive and supportive psychotherapy along with pharmacotherapy. Patient's family members must be psychoeducated regarding the need for regular treatment and focusing on improved functioning not on symptoms’ removal.

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