Imaginary pregnancy 10 years after abortion and sterilization in a menopausal woman: a case report

Delusion of pregnancy: a systematic review of 84 cases in the literature

Case reports of delusion of pregnancy have emanated from all over the world, yet the rarity of this phenomenology has precluded systematic large scale descriptive or cohort studies. This systematic review was conducted to assess the demographic characteristics, clinical profile, treatment outcome and aetiological factors from the published case reports of delusion of pregnancy. Electronic databases including PubMed, PsychInfo and Google Scholar were used to identify case reports relating to delusion of pregnancy published in peer-reviewed English language journals. All such cases were systematically evaluated by investigators, and information was extracted using a structured proforma. A total 40 articles were reviewed which included 84 cases. Demographic characteristics revealed that about half of the patients were aged 20-40 years. The most common diagnoses were schizophrenia (35.7%), bipolar disorders (16.7%) and depression (9.5%). Single foetus was reported by 79.8% of the patients, and 45.2% perceived foetal movements. Good treatment response was noted in 64.3 % of the cases. The prominent aetiological factors that were implicated included psychosocial factors, coenaesthopathological processes, socio-cultural factors and hyperprolactinaemia. Delusion of pregnancy is a heterogeneous symptom which emerges during the course of various neuropsychiatric disorders. A range of aetiopathological mechanisms have been implicated in the causation of this disorder.

Pseudocyesis, delusional pregnancy, and psychosis: The birth of a delusion

Both pseudocyesis and delusional pregnancy are said to be rare syndromes, but are reported frequently in developing countries. A distinction has been made between the two syndromes, but the line of demarcation is blurred. The aim of this paper is to review recent cases of pseudocyesis/delusional pregnancy in order to learn more about biopsychosocial antecedents. The recent world literature (2000-2014) on this subject (women only) was reviewed, making no distinction between pseudocyesis and delusional pregnancy. Eighty case histories were found, most of them originating in developing countries. Fifty patients had been given a diagnosis of psychosis, although criteria for making the diagnosis were not always clear. The psychological antecedents included ambivalence about pregnancy, relationship issues, and loss. Very frequently, pseudocyesis/delusional pregnancy occurred when a married couple was infertile and living in a pronatalist society. The infertility was attributed to the woman, which resulted in her experiencing substantial distress and discrimination. When antipsychotic medication was used to treat psychotic symptoms in these women, it led to high prolactin levels and apparent manifestations of pregnancy, such as amenorrhea and galactorrhea, thus reinforcing a false conviction of pregnancy. Developing the erroneous belief that one is pregnant is an understandable process, making the delusion of pregnancy a useful template against which to study the evolution of other, less explicable delusions.

Pseudocyesis, delusional pregnancy, and psychosis: The birth of a delusion

Both pseudocyesis and delusional pregnancy are said to be rare syndromes, but are reported frequently in developing countries. A distinction has been made between the two syndromes, but the line of demarcation is blurred. The aim of this paper is to review recent cases of pseudocyesis/delusional pregnancy in order to learn more about biopsychosocial antecedents. The recent world literature (2000-2014) on this subject (women only) was reviewed, making no distinction between pseudocyesis and delusional pregnancy. Eighty case histories were found, most of them originating in developing countries. Fifty patients had been given a diagnosis of psychosis, although criteria for making the diagnosis were not always clear. The psychological antecedents included ambivalence about pregnancy, relationship issues, and loss. Very frequently, pseudocyesis/delusional pregnancy occurred when a married couple was infertile and living in a pronatalist society. The infertility was attributed to the woman, which resulted in her experiencing substantial distress and discrimination. When antipsychotic medication was used to treat psychotic symptoms in these women, it led to high prolactin levels and apparent manifestations of pregnancy, such as amenorrhea and galactorrhea, thus reinforcing a false conviction of pregnancy. Developing the erroneous belief that one is pregnant is an understandable process, making the delusion of pregnancy a useful template against which to study the evolution of other, less explicable delusions.

[Etiopathogeny of the delusion of pregnancy using a literature review: Role of hyperprolactinemia and application of the theory of abductive inference]

INTRODUCTION

Delusions of pregnancy are not well known. The delusion of pregnancy is defined as the belief of being pregnant despite factual evidence to the contrary. The clinical picture is heterogeneous (duration, mechanisms, topics and pre-existing psychiatric disorders). Several causes have been proposed to explain the occurrence of the delusions of pregnancy: cenesthetic theory, hyperprolactinemia, polydipsia and psychodynamic conflicts. Hyperprolactinemia is an interesting hypothesis (physiologic increase during pregnancy and similar manifestations in the course of gestation). The abductive inference theory is a probabilistic model that can clarify the role of hyperprolactinemia in the delusions of pregnancy. The purpose of this paper is to study the role of hyperprolactinemia in the delusions of pregnancy using a literature review. The abductive inference model is used to specify the etiopathogeny of this pathology.

METHODS

A research in Medline, Sudoc, BIUM and PSYLINK using the following key words "delusional pregnancy" or "delusion of pregnancy" and "hyperprolactinemia" was conducted.

RESULTS

Three articles (case reports) about delusions of pregnancy associated with hyperprolactinemia were found. The cases have some similitudes. First of all, they have similar chronology: delusion appears at the same time as hyperprolactinemia and resolves with biological normalization. Secondly, hyperprolactinemia is always caused by a neuroleptic (haloperidol, olanzapine, risperidone). Concerning pre-existing disorders, a psychiatric pathology for each case was found (schizophrenia, schizo-affective disorder and bipolar disorder). Chronology, reproductivity and reversibility are strong arguments to involve hyperprolactinemia in the delusions of pregnancy (Bradford Hill criteria). Furthermore, this association is biologically plausible: physiologic increase during pregnancy (gestational signal), similar symptoms to those during pregnancy and the role in parental behavior (parental signal). Nevertheless, not everyone with hyperprolactinemia will develop a delusion of pregnancy; the interaction is more complex (non linear); the theory of abductive inference clarifies this relationship.

THEORY OF ABDUCTIVE INFERENCE

Abductive inference is a probabilistic model whose goal is to explain the occurrence of delusional beliefs. The first factor is the abnormal data. The second factor is the cognitive process (abductive inference), which uses Bayes' theorem to select the most likely hypothesis to explain the abnormal data. In the delusion of pregnancy, abnormal data is the hyperprolactinemia, signal of gestation without pregnancy. Hypotheses in order to explain this signal are then produced (pregnancy or no pregnancy). In the second part, probabilities associated with each hypothesis, given the hyperprolactinemia, are compared. Since hyperprolactinemia is a gestational signal, the pregnancy hypothesis is most likely. Probabilities associated with each hypothesis without taking hyperprolactinemia into account are compared (prior probability). Since any element of reality indicates a pregnancy, the absence of pregnancy is most likely. In the last step, the posterior probability is calculated using the first two comparisons. The probability associated with the pregnancy hypothesis (taking into account hyperprolactinemia) is relatively higher than the probability associated with the no-pregnancy hypothesis (without taking into account hyperprolactinemia). So, the posterior probability associated with the pregnancy hypothesis is more likely than the posterior probability associated with the no-pregnancy hypothesis. Thus, the subject believes in a pregnancy.

CONCLUSION

The research and the treatment of hyperprolactinemia must be conducted when faced with a delusion of pregnancy.

Pseudocyesis in peri- and postmenopausal women

Pseudocyesis or delusion of pregnancy is a rare psychopathological syndrome described in humans and higher mammals. We describe and discuss two cases of this rare syndrome in a 46-year perimenopausal and a 59-year old postmenopausal woman. Gynecologic, ultrasound examination, and biochemistry testing (β-HCG) confirm the diagnosis of nonexistent clinical and biochemical pregnancy. These examinations have the potential to confirm abdominal tumors, while psychiatric examinations generally reveal the psychic basis of the disease; which should be treated through team approach by both the psychiatrist and gynecologist. Additionally, special reference should be given to long-term psychiatric follow-up and management of the current mental stress and emotional problems by a combination of antipsychotics and psychotherapy, depending on each individual clinical picture.

Incidental Findings During Routine Antepartum Obstetrical Sonography

The standard for performing an antepartum obstetrical sonogram primarily involves the examination of the fetus; however, both the American Institute of Ultrasound in Medicine (AIUM) and American College of Radiology (ACR) guidelines suggest the evaluation of maternal structures as well. The authors present 35 incidental findings that were discovered on routine antepartum obstetrical sonography. These include abdominal wall, gastrointestinal, reproductive, urinary, and vascular anomalies in the maternal structures. A review of the literature demonstrates that many of these findings have clinical significance, which highlights the wisdom of the AIUM and ACR guidelines, and it also stresses the importance of seeking and reporting them.

[Recurrent pseudocyesis with polydipsia: a case report]

INTRODUCTION

Pseudocyesis is an imaginary pregnancy resulting from a strong desire or need for motherhood. Pseudocyesis has become increasingly rare in many parts of the world in which accurate pregnancy tests have become widely available. Cultures that place high value on pregnancy, or that make close associations between fertility and a person's worth, still have high rates of the disorder. A woman may believe in her pregnancy to the point of delusion and show acute depression when no baby is born.

CASE-REPORT

This report describes a case of recurrent pseudocyesis and polydipsia in a 49-year-old woman. She was an illiterate housewife who had been married since she was 21 years old. Four years later, she divorced because of a problem of sterility. She got remarried, five years later, and the couple had no child. The patient was admitted into the Obstetric Unit thinking that she was about to give birth. She presented all the symptoms of true pregnancy. She had abdominal distension, amenorrhea, mammary tension, nausea and vomiting, and weight gain. She claimed to have felt foetal movements. Other than this, she exhibited a polydipsia syndrome. These symptoms had evolved over 20 months. The patient had previously presented six similar episodes. All these episodes were identical. The length of these episodes varied between three and five months, after which all the signs disappeared progressively. The patient had never consulted for these symptoms before the present episode. During her stay in the Obstetric Unit, she benefited from a complete gynaecological examination, including pelvic ultrasound examinations, and laboratory tests, notably hormone assays (FSH, LH, prolactin, ss-HCG) and serum electrolyte levels. A primary sterility and menopause were confirmed. Otherwise, the psychiatric assessment confirmed the delusion of pregnancy and the presence of a depressive syndrome. The patient reported that she was possessed. She explained the normality of the imagery and laboratory tests by the intervention of the demons that hid the foetus and modified the results.

DISCUSSION

The contribution of psychological and physiological factors in the development of the delusion of pregnancy, possession and polydipsia, and the possible interactions between the two phenomena are discussed.