Endocrinology and physiology of pseudocyesis

No Little Feet: Managing Pseudocyesis in a Homeless, Acutely Manic Patient with Schizoaffective Disorder, Bipolar Type

Pseudocyesis is a complex psychiatric manifestation of the physical symptoms of pregnancy. Although not pregnant, the pseudocyetic patient displays signs and symptoms consistent with pregnancy, such as abdominal distention, cramping, and/or sensations of fetal movement. Pseudocyesis is more common in developing countries than in the developed world, possibly due to the importance that traditional societies attach to childbearing and the low social status that these societies assign to women who are unable to produce children. Socioeconomically disadvantaged women in developed countries may also be at increased risk. Although the etiology, pathogenesis, diagnosis, and management of pseudocyesis are poorly understood, it manifests with real symptoms, which may complicate both the patient's perspective about her condition and the medical and psychiatric teams' approach to the patient. This case report is one of only a few in the literature to present an example of pseudocyesis developing in the context of acute mania. After describing the patient's clinical course, from her initial symptoms of pseudocyesis to their eventual resolution, this report will provide recommendations for the sensitive care of patients with this rare but significant condition.

Pregnancy Denial: Toward a New Understanding of the Underlying Mechanisms

PURPOSE OF REVIEW

Pregnancy denial is the lack of awareness of being pregnant. The aim of the review is to understand why the affected women do not recognize the signs of pregnancy.

RECENT FINDINGS

Twelve case reports of pregnancy denial were published in the last ten years. While in five cases the women had an underlying mental disorder, the rest of the cases involved women who either exhibited no physical symptoms or perceived themselves to be not pregnant despite the symptoms (i.e., repression mechanisms). Pregnancy denial is considered to be a pathological issue, a likely consequence of trauma, the wish to not have a child, or a psychiatric problem. However, it appears that the majority of cases cannot be linked to any of the above reasons. We argue, therefore, that, in most cases, pregnancy denial is not associated with mental or physiological problems. Under certain circumstances, it can affect any woman.

Factors affecting gastrointestinal function recovery after cesarean section among Chinese mothers: A cross-sectional study

This study was conducted to explore the influencing factors of gastrointestinal function recovery after cesarean section (CS), which could provide a reference for the enhanced recovery after surgery in obstetrics. This is a cross-sectional survey on Chinese mothers receiving CS. The participants's socio-demographic characteristics, perioperative diet, medical condition and gastrointestinal function after surgery were collected by a self-designed questionnaire. Binary logistic regression analysis was employed to explore the influencing factors of gastrointestinal function recovery after CS. A total of 1501 (94.76%) valid questionnaires were collected. The first borborygmus was 2.21 ± 0.63 hours, and the first anal exhaust was 35.73 ± 14.85 hours after the CS. The incidence of abdominal distension and intestinal obstruction were 15.1% and 0.7%, respectively. The parity, type of CS, 2-hours bleeding after surgery, time of first meal after surgery, whether taking peppermint water after surgery were the independent influencing factors for gastrointestinal function recovery after CS. We should pay more attention to the mothers with scarred uterus, manage the labor process strictly, and reduce 2-hours bleeding after surgery. The mothers with CS should also be encouraged to eat early and take peppermint water to promote intestinal peristalsis actively.

A rare case report of pseudo-pregnancy in a menopausal female

Pseudo-pregnancy is an uncommon psychiatric presentation, often having a complex interplay of psycho-social factors making it difficult to manage. It is common to present in the reproductive age range, rarely in postmenopausal women. We are reporting a rare presentation of a 48-year post-menopausal widowed HIV-positive female with no live issues having two years of secondary amenorrhea complaining to have documented weight gain and experience of perceiving fetal movements for the past 5 months. However, she persistently insisted on antenatal care despite repeated reports of ultra-sonographic pelvis imaging and gynecological examination pointed toward menopausal changes and the absence of any live issue. This case report emphasizes the clinical presentation and management strategies for patients with pseudocyesis, a peculiar and rare psychiatric manifestation.

[Mother brain: Bayesian theory of maternal interoception during pregnancy and postpartum]

The perinatal period, including pregnancy and postpartum, causes major morphological, endocrinal, and thermal transitions in women. As the fetus grows, abdominal muscle fibers stretch, internal organs such as the bladder or colon move, and the uterine anatomy changes. Many of these changes involve interoception, the perception of internal body signals such as muscle and visceral sensations. Despite the importance of these interoceptive signals, few studies have explored perinatal interoception. We propose an innovative theory of maternal interoception based on recent findings in neuroscience. We show that interoceptive signals processing during pregnancy is crucial for understanding perinatal phenomenology and psychopathology, such as maternal perception of fetal movements, maternal-infant bonding, denial of pregnancy, phantom fetal movements after childbirth, pseudocyesis or even puerperal delusion. Knowing the importance of these interoceptive mechanisms, clinicians in obstetrics, gynecology and mental health should be particularly vigilant to maternal interoception during the perinatal period.

Delusion of Pregnancy in Down Syndrome: Two Case Reports

Individuals with intellectual disability (ID) are more vulnerable to psychotic disorder and schizophrenia than the general population. However, psychotic symptoms have not been widely described in this population. Here, we deeply investigated the cases of two young women with ID and Down syndrome (DS) who developed a delusion of pregnancy, a rare condition defined as a fixed belief of being pregnant despite factual evidence to the contrary. The assessment included psychopathological and neuropsychological examination, as well as the evaluation of cognitive and adaptive functioning. In these cases, delusion manifested as a psychotic symptom of a cyclothymic disorder (case 1) or as an independent delusional disorder (case 2). However, some similarities emerged: both women exhibited good pre-morbid adaptive functioning and family history of psychiatric disorders; moreover, in both cases delusion emerged in association with an external trigger. Difficulties in verbally expressing one's thoughts and beliefs were found, as well as poor abstract reasoning skills that may have affected the ability to deeply conceptualize the delusional idea itself. These findings may provide crucial insights into the clinical manifestation of psychosis in individuals with DS and underscore the importance of a routine psychological and neuropsychological follow-up to provide prompt and adequate intervention.

Delusion of pregnancy: Conception in brain

Delusional disorders are common psychiatric disorders, but a delusion of pregnancy is a rare condition. Four cases that presented at a single tertiary care psychiatry center with delusion of pregnancy as a part of different psychological disorders are illustrated here. These cases were seen over a period of 6 months and had varied presentations and associated psychopathologies. Three of the four patients showed rapid recovery to treatment, but one patient was lost to follow-up. The heterogeneity in the presentation, sociodemographic profile of the patients and even in the symptom profile and response to treatment in this condition is highlighted and discussed in this case series.

Long-term effect of repeated deslorelin acetate treatment in bitches for reproduction control

Long-acting gonadotropin-releasing hormone (GnRH) analogs, which are approved for male dogs and ferrets, have been used off-label to suppress estrus in bitches predisposed to the side effects of spaying. Health data from the past 12 years were evaluated from bitches without progestogen pretreatment that received deslorelin acetate (DA) to suppress estrus for the first time before the age of 4.5 years. The study population included 32 client-owned bitches repeatedly treated with either 4.7 mg or 9.4 mg DA implants for a period of 5.3 ± 3.4 years (range 0.5-11.3 years). Follow-up information concerning immediate side effects of DA occurring within five months after the first DA treatment (n = 23) as well as long-term side effects of sustained gonadal suppression occurring after five months up to three years (n = 2), three years up to five years (n = 2) or more than five years (n = 8) were assessed through a questionnaire. Treatment was considered successful if no major side effects requiring medical treatment occurred, which applied to 26 out of 32 (81 %) bitches. In the six remaining bitches, the following major side effects led to treatment discontinuation: persistent urinary incontinence (n = 1), reoccurring induced heat (n = 1), uterine disease (n = 3) and/or ovarian tumor (n = 3). The bitches recovered completely after surgical spaying and/or DA implant removal. Minor side effects that did not require therapy or affect animal welfare included body weight changes (n = 18), subtle behavioral changes (n = 13), induced heat (n = 12), coat changes (n = 11), pseudocyesis (n = 6), transient urinary incontinence (n = 4), and/or temporary thickening of the uterine wall with little anechogenic content (n = 2). To examine a possible causal relationship between adverse side effects and DA treatment, further studies should compare the frequency of pathologies between groups of GnRH-treated, intact and spayed bitches of similar breeds and ages. Nevertheless, DA application before the age of 4.5 years may be a means of postponing surgical spaying for several years in breeds at high risk for developing urinary incontinence. Before DA is used in bitches, owners should be fully informed regarding possible side effects.

A Rare Case of Pseudocyesis in a Patient With Bipolar Disorder

Pseudocyesis is a rare condition in which a person has a false belief of being pregnant, accompanied by objective signs and symptoms of pregnancy, despite not being pregnant. Confirmation of pseudocyesis is achieved with a negative result of beta-human chorionic gonadotropin in the blood and/or urine and negative ultrasound finding. Most cases of pseudocyesis occur in the setting of major depressive disorder or psychotic disorder, with very few occurring during a manic episode of bipolar disorder. Hence, we present a 30-year-old woman with pseudocyesis in the setting of bipolar disorder, specifically within a current manic episode with features of psychosis.

The patient was found in the woods naked, with signs of psychosis. She described symptoms of increasing abdominal size, whitish discharge from her nipple, and feeling of fetal movement. The patient continued to believe she was pregnant due to her symptoms, despite negative pregnancy tests on multiple occasions. She has a history of bipolar disorder and post-traumatic stress disorder. Her examination showed an obese woman, with a non-distended abdomen and non-palpable uterus with no breast tenderness or enlargement. The patient was given olanzapine for her agitation and was subsequently stabilized with haloperidol and lorazepam. She was restarted on her home medications, including risperidone, oxcarbazepine, and topiramate. She was later committed involuntarily and transferred to a long-term psychiatry facility.

Pseudocyesis is a rare condition often associated with other psychiatric comorbidities. Our patient's presentation highlights one of the few cases ever formally documented in a developed country, as most of the cases reported are found in developing countries. More studies, including case series and systematic reviews, need to be done to better understand this rare condition and its other variants.

Prolactin and human weight disturbances: A puzzling and neglected association

Weight gain at the outset of prolactinomas in many women is well documented. Yet, this symptom is absent from the clinical descriptions of the disease in textbooks and reviews. This omission is almost certainly due to the absence of a physiological explanation for the phenomenon, as prolactin is not a recognized fat promoting hormone. In this review we present the clinical evidence for a relationship between prolactin and fat accumulation and address some possible mechanisms involved. We put forward the hypothesis that prolactin is a component of a neuroendocrine program - maternal subroutine - aimed at optimizing the care of the young through the production of milk, promotion of maternal behavior and increase in the metabolic efficiency of the mother. These adaptations can enable her to face the extraordinary metabolic expenses of pregnancy and nursing, especially during times of suboptimal environmental conditions. We emphasize the uniqueness of prolactin in that it is a hormone that is tonically inhibited and which has its major effects on the regulation of an inter-individual (the mother - offspring dyad), rather than an intra-individual, system. This approach opens a window to consider the possibility of external events as regulators of this system. It also allows addressing a variety of hitherto unexplained findings reported in the literature. Examples include: association of prolactinomas with paternal deprivation and with stressful life events; pseudocyesis; acute life event-driven episodes of galactorrhea; episodes of rapid weight gain following a life event; prolactin surges (without associated cortisol surges) following some psychological stresses.

Biopsychosocial view to pseudocyesis: A narrative review

BACKGROUND

Pseudocyesis is a psychopathological clinical syndrome in which a non-pregnant woman firmly believes herself to be pregnant and manifests many symptoms and signs of pregnancy. Although the exact etiology of pseudocyesis has not been determined.

OBJECTIVE

This study was conducted with the aim of assessing the biopsychosocial view to pseudocyesis.

MATERIALS AND METHODS

A comprehensive search in electronic databases such as Google Scholar, PubMed, ScienceDirect, Web of Science, and Scopus was conducted between 1943-2016 to retrieve pseudocyesis related articles. For this purpose, 1149 articles were collected and 66 items were used.

RESULTS

Findings were classified into 2 main categories: a) pseudocyesis etiology, which could include (biological psychological factors and psychiatric disorders, and social factors); and b) pseudocyesis management.

CONCLUSION

Pseudocyesis results from a multidimensional group of factors, and a holistic and comprehensive approach should be taken to its treatment. Cooperation between gynecologists and psychiatrists would likely be useful in addressing the condition.

Delusions of pregnancy in older women: a case series

BACKGROUND

Delusions of pregnancy have been reported in a wide variety of functional and organic psychiatric conditions but rarely with dementia. Most such delusions arise in women of child-bearing age. We report five cases in older women all of whom had severe constipation that probably precipitated this delusion.

CASE REPORTS

Of the five women (age 74-89 years), two had dementia, two had delirium and one had both. All patients had borne healthy children. Three women reported that they were in labour, and one was concerned that the baby was not moving. All had severe constipation on examination or imaging, and three had faecal impaction. All were treated with laxatives or enemas, and only one patient required brief antipsychotic therapy. The delusions lasted from a few hours to 5 days. In general, resolution of the delusion occurred in concert with improvement in bowel function, although in one case a large bowel movement was followed by the delusion that a baby had been born.

CONCLUSION

These cases suggest that misinterpretation of abdominal symptoms due to severe constipation in cognitively impaired women may trigger the delusion of being pregnant and that treatment of constipation often leads to resolution of the delusion.

Challenges and pitfalls in the diagnosis of hyperprolactinemia

The definition of the etiology of hyperprolactinemia often represents a great challenge and an accurate diagnosis is paramount before treatment. Although prolactin levels > 200-250 ng/mL are highly suggestive of prolactinomas, they can occasionally be found in other conditions. Moreover, as much as 25% of patients with microprolactinomas may present prolactin levels < 100 ng/mL, which are found in most patients with pseudoprolactinomas, drug-induced hyperprolactinemia, or systemic diseases. On the other hand, some conditions may lead to falsely low PRL levels, particularly the so-called hook effect, that is an assay artifact caused by an extremely high level of PRL, and can be confirmed by repeating assay after a 1:100 serum sample dilution. The hook effect must be considered in all patients with large pituitary adenomas and PRL levels within the normal range or only modestly elevated (e.g., < 200 ng/mL). An overlooked hook effect may lead to incorrect diagnosis and unnecessary surgical intervention in patients with prolactinomas. Another important challenge is macroprolactinemia, a common finding that needs to be identified, as it usually requires no treatment. Although most macroprolactinemic patients are asymptomatic, many of them may present galactorrhea or menstrual disorders, as well as neuroradiological abnormalities, due to the concomitance of other diseases. Finally, physicians should be aware that pituitary incidentalomas are found in at least 10% of adult population.

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.

Emotionally induced galactorrhoea in a non-lactating female--"Pseudo- Lactation"?

BACKGROUND

Galactorrhoea is a common clinical problem in endocrinology. Visual and auditory cues from the newborn are known to stimulate prolactin secretion in lactating women. However, hyperprolactinaemia and galactorrhoea in a non-lactating female due to visual and auditory stimuli from an unrelated newborn has not been reported in the past. We report the first such case of 'pseudo-lactation'.

CASE PRESENTATION

An 18-year-old girl with type 1 diabetes mellitus presented with galactorrhoea. Apparently galactorrhoea was preceded by seeing the baby, hearing her cries or when remembering her memories. Her menstrual cycles were normal and did not complain of any headache or visual disturbances. She was only on metformin and insulin. Symptoms have rapidly resolved after the newborn was shifted to another location. Examination revealed scanty nipple discharge with gentle pressure. Investigations revealed an elevated serum prolactin of 62.5 ng/mL (2717.4 pmol/L) and fasting plasma glucose of 142 mg/dL (7.9 mmol/L) and HbA1c of 7.6%. Her thyroid function was normal and MRI at the time of galactorrhoea was not available. At 3 months prolactin was normal and MRI revealed only a slight asymmetry of the pituitary without evidence of microadenoma.

CONCLUSION

The strong temporal relationship between her symptoms and emotional attachment to the newborn with exclusion of other causes on clinical, biochemical and radiological evidence, raise the possibility that transient hyperprolactinaemia was due to a transient lactotroph hyperplasia and hyper function which had been triggered by the stimulatory cues from the newborn.Emotionally induced "pseudo lactation" may be a rare but important cause for transient hyperprolactinaemia in a non-lactating female.

Psychosomatic disorders of gravida status: false and denied pregnancies

OBJECTIVE

The authors review the literature on two dramatic psychosomatic disorders of reproduction and offer a potential classification of pregnancy denial.

METHOD

Information on false and denied pregnancies is summarized by comparing the descriptions, differential diagnoses, epidemiology, patient characteristics, psychological factors, abdominal tone, and neuroendocrinology. Pregnancy denial's association with neonaticide is reviewed.

RESULTS

False and denied pregnancies have fooled women, families, and doctors for centuries as the body obscures her true condition. Improvements in pregnancy testing have decreased reports of false pregnancy. However, recent data suggests 1/475 pregnancies are denied to 20 weeks, and 1/2455 may go undiagnosed to delivery. Factors that may contribute to the unconscious deception include abdominal muscle tone, persistent corpus luteum function, and reduced availability of biogenic amines in false pregnancy, and posture, fetal position, and corpus luteum insufficiency in denied pregnancy. For each condition, there are multiple reports in which the body reveals her true pregnancy status as soon as the woman is convinced of her diagnosis. Forensic literature on denied pregnancy focused on the woman's rejection of motherhood, while psychiatric studies have revealed that trauma and dissociation drive her denial.

CONCLUSIONS

False pregnancy has firm grounding as a classic psychosomatic disorder. Pregnancy denial's association with neonaticide has led to misleading forensic data, which obscures the central role of trauma and dissociation. A reappraisal of pregnancy denial confirms it as the somatic inverse of false pregnancy. With that perspective, clinicians can help women understand their pregnancy status to avoid unexpected deliveries with tragic outcomes.

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.