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Pseudocyesis.

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Abstract

Pseudocyesis - a clinical syndrome seen in non-psychotic woman, known since the time of Hippocrates. Pseudocyesis has a psychological basis in which a woman's wish for pregnancy is essential to their identity and self-esteem. Normally, pseudocyesis is seen in women who desperately want to become pregnant, especially those with longstanding infertility. Basically, the treatment of Pseudocyesis is to help these patients recognize the illness and to educate and counsel them. Here is the case of pseudocyesis in which there is no history of long standing infertility. This case is rare and liable to be missed. JNMA J Nepal Med Assoc. 2008 Jul-Sep;47(171):147-150.
JNMA I VOL 47 I NO. 3 I ISSUE 171 I JUL-SEP, 2008
147
ABSTRACT
Pseudocyesis - a clinical syndrome seen in non-psychotic woman, known since the time of Hippocrates.
Pseudocyesis has a psychological basis in which a woman’s wish for pregnancy is essential to their
identity and self-esteem.
Normally, pseudocyesis is seen in women who desperately want to become pregnant, especially
those with longstanding infertility. Basically, the treatment of Pseudocyesis is to help these patients
recognize the illness and to educate and counsel them.
Here is the case of pseudocyesis in which there is no history of long standing infertility. This case is
rare and liable to be missed.
Key words: chaupadi, hormones, infertility, outcaste, psychological
Pseudocyesis
Upadhyay S
1
1
GTZ- Health Sector Support Programme
Correspondence:
Dr. Sarita Upadhyay
Medicare National Hospital and Research Center
Chabahil, Kathmandu, Nepal.
E-mail: saritachopra2003@yahoo.com
INTRODUCTION
Pseudocyesis is a “Clinical Syndrome, in which a non-
psychotic woman rmly believes herself to be pregnant
and develops objective signs and symptoms of
pregnancy in the absence of true gestation”.
1
Incidence
rates of pseudocyesis range from 1 to 6 per 22,000
births.
2
Several names have been given to this condition
including spurious pregnancy, imaginary pregnancy,
and hysterical pregnancy. John Mason Good coined
the term pseudocyesis from the Greek words pseudes
(false) and kyesis (pregnancy) in 1923.
1
One of the
psychological issues for women with pseudocyesis
is that their wish for pregnancy is essential to their
identity and self-esteem.
Here is the case of pseudocyesis in which there is no
history of long standing infertility. This case is rare and
liable to be missed.
CASE REPORT
A young married woman, 18 years of age reported
to Mangalsen District Hospital, Achham, (one of the
most remote and developmentally challenged districts
of Nepal, located in the Far-Western region of Nepal)
for her regular antenatal check up. She was found to
have normal growth of her gravid uterus and her fetal
movements were felt by one of the health workers
examining her but the fetal heart sounds were not
audible.
Her case history revealed that she was married for
almost for two years and her menses ceased soon after
CASE REPORT
J Nepal Med Assoc 2008;47(171):147-50
JNMA I VOL 47 I NO. 3 I ISSUE 171 I JUL-SEP, 2008
148
her husband left for a job in India. Her past menstrual
history showed that she was having regular menses
and was not taking any drugs or oral contraceptives in
the past. She presented initially at the antenatal care
(ANC) clinic with the complaint of cessation of menses
and gradual increase in the size of abdomen, since than
she was on her regular ANC check up. This was her
fourth ANC visit. Local health worker had maintained
her ANC card according to the details of the ANC card
she was around 30 weeks pregnant. According to the
patient she had also felt the fetus moving.
Obstetric examination revealed distension of abdomen
with mild linea nigra. The abdomen was soft, diffusely
tympanetic on percussion neither the fetal parts were
palpable nor the fetal movements felt. Pelvic examination
was suggested, but she refused. Her breasts were
examined to nd out any pregnancy related changes.
Breast were found to be enlarged to some extent,
but none of the pregnancy related changes (hyper
pigmentation of breast areola, Montgomery’s tubercles
and secretion from the nipples) were seen in the breasts.
As there were no means of imaging techniques, the
patient was requested to go for urine pregnancy test,
which was found to be negative. This further conrmed
that the patient was not pregnant.
Both the mother-in-law and the patient were counseled
regarding the unusual condition that the patient was
going through. They were told that she will resume her
menses soon and will be able to conceive in future.
They were explained that this situation arose as a
result of the patient’s strong desire for motherhood.
The mother-in-law was advised to take extra care of
her daughter-in-law and not to let her feel lonely. She
was also requested to ask her son if possible to take his
wife with him to India.
As it is difcult to further conrm the diagnoses of
pseudocyesis in such a remote district of Nepal, due
to unavailability of imaging techniques and other
diagnostic aids, it was decided to closely follow-up the
patient. Normally, pseudocyesis is seen in women who
desperately want to become pregnant, especially those
with longstanding infertility. But this case seemed
unusual and it became difcult to believe that such
problems can exist even in young married women.
After two months a health worker based in Mangalsen
District Hospital followed up the patient at her residence
and she reported that the patient had resumed her
normal periods almost one month back.
DISCUSSION
Pseudocyesis is a psychological condition occurring when
a woman's empowering fears or needs of pregnancy
manifests. It is believed that this psychological desire
or depression triggers the pituitary gland to secrete
elevated hormones, mimicking the hormone changes
of real pregnancy.
3
There has been no identication
of a single psychological process representative of all
patients with this disorder.
Several theories have been postulated regarding the
cause of pseudocyesis, of which the following are
widely accepted.
4
1. Conict theory: A desire for or fear of pregnancy
creates an internal conict and causes endocrine
changes to explain the signs, symptoms and
laboratory ndings in pseudocyesis.
2. Wish-fulllment theory: Minor body changes
initiate the false belief in pregnancy in susceptible
individuals.
3. Depression theory: Pseudocyesis may be initiated
by the neuro-endocrine changes associated with
major depressive disorder
There is evidence in the literature to support all of
these theories, and one or more may be simultaneously
appropriate for patients with pseudocyesis
“Pseudocyesis” is known since the time of Hippocrates
who recorded 12 different cases of women with this
disorder. It is said that Mary Tudor (1516-1558),
Queen of England used to react in a violent way as
a reaction to the disappointment of nding out that
she was not carrying a child and that gave her the
nickname "Bloody Mary". Other historians believe that
the queen's physicians mistook broid tumors in her
uterus for a pregnancy, as broids can enlarge a non-
pregnant uterus
3
.
The most common sign of pseudocyesis, abdominal
distension, is thought to be due to excess fat,
gaseous distension, fecal and urinary retention, and
an exaggerated lumbar lordosis causing forward
displacement of the abdominal viscera. The abdominal
distention often resolves under general anesthesia.
Laboratory ndings in patients with pseudocyesis show
variable results. Estrogen and progesterone values can
be high, low or normal; prolactin tends to be elevated
and follicle-stimulating hormone (FHS) tends to be low.
There has been a documented case of a persistent
corpus luteum in pseudocyesis.
Though, we all know that it largely belongs to the domain
of psychiatrists, spawning too many psychological
theories about the origins of the condition, but in our
Asian countries Obstetrician and Gynecologists normally
diagnose pseudocyesis.
Pseudocyesis occurs at a frequency of 1 to 6 per
22,000 births.
2
The peak incidence was between
Upadhyay. Pseudocyesis
JNMA I VOL 47 I NO. 3 I ISSUE 171 I JUL-SEP, 2008
149
1890 and 1910, when 156 cases were reported in
the English Literature; in contrast, only 42 cases were
reported between 1959 and 1979. The age range of
patients with pseudocyesis is 6 ½ to 79 years (with
an average age of 33 years). Eighty percent of women
with pseudocyesis are married, 14.6% are unmarried,
and 2.3% are widowed. Pseudocyesis is more common
in women during their second marriage than during
their rst marriage. Thirty-seven percent of women
with pseudocyesis have been pregnant at least once.
Symptoms usually last 9 months but can last for a few
months or upto several years. There have been over
500 cases of pseudocyesis reported in women and at
least three cases reported in men.
4
As this is not a very common phenomenon, even the
health workers are not aware of it. Lack of knowledge
leads to lots of problems, especially in the remote
areas, where these patients are taken to faith healers
for treatment and they undergo lot of unnecessary pain
and torture.
Prior to presenting the case, it is necessary to understand
the socio-cultural background of people of Achham.
Nepal has a patriarchal society. In Achham, women are
still having a very low status in the families, majority
of them are illiterate and unaware of their rights. They
normally fall prey to traditional practices and beliefs
In remote areas of Nepal there is a practice of isolating
women during her menstrual period. During menstrual
periods women are supposed to spend their nights
in a small hut known as "Chaupadi". These huts are
normally in the vicinity of cowsheds and are of so small
size, that hardly one can sit upright. There is no proper
bedding in these huts and women sleep over the straws
spread on the oor. During these few days of menstrual
period women are treated as an outcaste and are not
supposed to touch anyone or anything (especially
water sources, kitchen wares etc.) as it is thought that
the God will get annoyed if these untouchable women
will touch these auspicious things and will punish
them all. During this period they are not even given
nutritious food and are prohibited from entering their
own houses, but they are supposed to share the work
burden at the elds. All these traditional beliefs and
practices affect the health status including reproductive
health of a woman. As women are spending nights in
insecure places, they are sometimes sexually exploited
during this period and sometimes they meet with other
accidents such as snakebites and they die.
During menstruation and childbirth women are
emotionally very sensitive and this is the time when
they really need emotional support and in these remote
areas of Nepal they are left unattended during these
periods leading to emotional disturbances, even leading
to depression. These emotional disturbances can further
lead to menstrual disturbances.
Pseudocyesis occurs in women who desperately want
to become pregnant to maintain their identity and
self-esteem. In addition to this in our South Asian
society we still consider women to be responsible for
child bearing and rearing. If women are unable to bear
children within a year or so they are considered to
be infertile, though scientically proved that men are
almost equally responsible for infertility. When couples
are infertile, society always blame women and they are
made to suffer immensely. Usually such woman are
not taken for medical consultations, rather preparations
are made to bring in a new bride. This is a common
phenomenon even in big cities like Kathmandu; let
aside the remote districts like Achham where people
are living in poverty with no basic facility to have a
decent livelihood. In these remote parts of the country
the low status of women and the inability to negotiate
with their husbands and other family members leads to
a lot of social problem. Majority of women are left on
their own to deal with these problems, as a result they
either go into depression or lead a stressful life or start
behaving in such a way so as to attract the attention
and sympathy of others for themselves.
May be similar was the case with this woman. She was
married almost for two years, staying with her in-laws,
husband away from home, having the lowest status
among in-laws, overburdened with household work and
leading stressful life, wanted to attract attention and
sympathy of family members. May be she really had an
immense desire to become pregnant or she was going
through psychological or depressive problems. May be
she was unable to cope up with living a social outcaste
life every month or was at the risk of sexual exploitation
and wanted to get away from chaupadi life.
Menstruation is dependent on the proper functioning of
a chain made up of hypothalamus pituitary ovary
uterus; amenorrhoea presupposes a weakening or break
in one or more of the links of this chain.
Gonadotrophin Releasing Hormone (GnRH) is produced
by hypothalamus and this GnRH further inuence the
pituitary hormones (Follicle Stimulating Hormone – FSH
and Luteinizing Hormone – LH). In exciting or inhibiting
the output of pituitary hormones, the hypothalamus
can be inuenced by higher centers in the brain. So
emotional upsets can encourage or depress pituitary and
therefore ovarian and menstrual functions. Disturbances
of the hypothalamus cause amenorrhoea by interfering
with production of GnRH.
5
Stress can really inuence the regularity of an
ovarian cycle; hence can suppress the menstruation.
Upadhyay. Pseudocyesis
JNMA I VOL 47 I NO. 3 I ISSUE 171 I JUL-SEP, 2008
150
Amenorrhoea is also considered to be a common
feature of depressive mental disorders.
Emotional
upsets and stresses for example nervous shock, change
of work or environment, travel abroad, love affair and
marriage etc. can also lead to menstrual disorders even
amenorrhoea. The effect of nervous tensions is seen
not only in causing amenorrhoea but in curing it also.
5
This amenorrhoea during the early years of marriage
might have lead this woman to think of pregnancy and
she developed her mental picture of a pregnant woman
leading to all changes in her body.
As this woman was going through some stressful
situation, it would have been better for her to change the
environment, that’s why mother-in-law was suggested
to ask her son to take his wife along with him to India.
REFERENCES
1. Marybeth K. Hendricks-Matthews, Pseudocyesis in an
adolescent incest survivor – pseudopregnancy, Journal of
Family Practice, Jan.1993: Available from: URL: http://
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13381476
2. Small G. Pseudocyesis: an overview. Can J Psychiatry
1986;31:452-7.
3. Cristiane de Oliveira, Empty crib. Whole Woman: the
phenomena of Pseudocyesis. Published on Serendip’s
exchange created 2006=12-16 23:11. Available from: URL:
http://serendip.brynmawar.edu/exchange
4. Paul M. Paulman, Pseudocyesis, Journal of Family Practice,
May 1990. Available from: URL: http://www.ndarticle.
com/p/articles/mi_m0689/is_n5_v30/ai_9147671
5. Tindall VR. Jeffcoate’s Principles of Gynaecology. 5th ed.
London 1987.
Upadhyay. Pseudocyesis
... Although perceived infertility is not always at the heart of delusional pregnancy [61] , it contributes, more so in some social contexts than in others [62] . Infertility can cause extreme levels of distress [63,64] , especially in developing countries where childlessness is never an acceptable option for married women, and where infertility treatments are often not available. ...
... Adoptions are also forbidden in most interpretations of Islamic law [66] because preservation of hereditary lineage is important. Infertility, though often caused by the male partner, is attributed, almost always in developing countries, to the woman [61] . A childless woman is viewed as a failure and is rejected by her husband and his family, as described in ethnographic studies carried out in the countries where pseudocyesis appears to be relatively commonplace [67][68][69][70] . ...
... Infertility can be just cause for divorce or, in polygamous societies, justification for the husband taking another, more fertile wife [55,61] . The paradox is that infertility is relatively common in these same countries because of the prevalence of genital infection spread by unprotected sexual contact and because of unsanitary obstetric practices. ...
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Article
Per DSM-V, pseudocyesis is included under the category "other specified somatic symptom and related disorder" and is defined as a false belief of being pregnant that is associated with objective signs and reported symptoms of pregnancy. The male counterpart of pseudocyesis is Couvade syndrome, also called "sympathetic pregnancy" where a man experiences symptoms of pregnancy when his female partner is pregnant. There are extensive reports on pseudocyesis and Couvade syndrome in psychiatric literature but none with features of both, in a single case. Here we present a unique case of a fifty-eight-year-old mother who presented with symptoms of concomitant pseudocyesis and Couvade syndrome concurrently when her daughter was pregnant. This case report discusses the epidemiology, course of symptoms and common comorbidities associated with this interesting diagnosis.
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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.
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PTSD (Posttraumatic Stress Disorder) is a type of anxiety disorder, resulting from a traumatic experience which presents a number of pathological symptoms, disrupting everyday life and causing severe psychological suffering. A case of 24-year old woman with pseudocyesis - a rare disorder characterised by existance of gestation's sings despite its' absence, is presented. The patient developed typical symptoms of pregnancy in the course of the PTSD, after previous miscarriage. For 13 months the patient remained amenorrheic, with inhibited ovulation, had morning sickness, maintained weight as during pregnancy and had abdominal pain. All these symptoms were accompanied by numerous symptoms of anxiety and depression. The hormone therapy that was used did not avail the desired effect, which further testified that the symptoms were psychogenic. After undergoing psychotherapy, the disorder subsided.
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It is obvious that Dr Tindall, a professor of obstetrics and gynecology at the University of Manchester, revised Professor Jeffcoate's textbook with loving care. Dr Tindall trained under Professor Jeffcoate in Liverpool, and he has endeavored to retain some of the verve and vigor that was breathed into the original book by a renowned and opinionated professor. The original text was written by Professor Jeffcoate in 1957, and he stated plainly in the first edition that he had not "played it safe by stating only generally accepted views, but had attempted to reach a conclusion that satisfied himself as being as rational as present knowledge allowed." Professor Jeffcoate, who is revered by British obstetricians and gynecologists in much the same way that Sir William Osler has been lionized among American internists, has emphasized the clinical approach to gynecology throughout the text. The first chapter bears that exact title: "The Clinical
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The author reviews the medical literature on pseudocyesis, the condition where a nonpregnant woman believes she is pregnant and has objective signs of pregnancy. The disorder involves both psychological and neuroendocrine mechanisms and is related to other conditions varying in severity from fleeting fears and wishes in healthy women to pathological changes in neuroendocrine functions in others. The notion that the condition is a heterogeneous one, closely related to other more common disorders, is emphasized.
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This case is an example of pseudocyesis in an incest survivor. Symptoms of pregnancy were unconsciously created by the patient to shield her from the memory of her incest and at the same time confront the reality of her abuse. Her symptoms allowed her entrance into the medical system. Once in the system, it was just a matter of time before she was referred for psychological evaluation. The authors recommend that family physicians consider incest when evaluating patients who present with pseudocyesis.
Available from: URL: http
  • M Paul
  • Pseudocyesis Paulman
Paul M. Paulman, Pseudocyesis, Journal of Family Practice, May 1990. Available from: URL: http://www.findarticle. com/p/articles/mi_m0689/is_n5_v30/ai_9147671
Empty crib Whole Woman: the phenomena of Pseudocyesis. Published on Serendip's exchange created 2006=12-16 23:11. Available from: URL: http://serendip.brynmawar
  • Oliveira Cristiane De
Cristiane de Oliveira, Empty crib. Whole Woman: the phenomena of Pseudocyesis. Published on Serendip's exchange created 2006=12-16 23:11. Available from: URL: http://serendip.brynmawar.edu/exchange
Pseudocyesis in an adolescent incest survivor – pseudopregnancy Available from: URL: http
  • K Marybeth
  • Hendricks-Matthews
Marybeth K. Hendricks-Matthews, Pseudocyesis in an adolescent incest survivor – pseudopregnancy, Journal of Family Practice, Jan.1993: Available from: URL: http:// www.findarticle.com/p/articles/mi_m0689/is_n1_v36/ai_ 13381476
Whole Woman: the phenomena of Pseudocyesis
  • Cristiane De Oliveira
Cristiane de Oliveira, Empty crib. Whole Woman: the phenomena of Pseudocyesis. Published on Serendip's exchange created 2006=12-16 23:11. Available from: URL: http://serendip.brynmawar.edu/exchange
  • Paul M Paulman
Paul M. Paulman, Pseudocyesis, Journal of Family Practice, May 1990. Available from: URL: http://www.findarticle. com/p/articles/mi_m0689/is_n5_v30/ai_9147671
Jeffcoate's Principles of Gynaecology
  • V R Tindall
Tindall VR. Jeffcoate's Principles of Gynaecology. 5th ed. London 1987.