AN OVERVIEW ON PSEUDOCYESIS

ADEYEYE, MARY MOFIYINFOLUWA

DOKITA Editorial Board Member

KEYWORDS:
PREGNANCY
LABOUR
PSEUDOCYESIS

Introduction

The term “Pseudocyesis” was established from two Greek words; Pseudo means false and Kyesis means pregnancy in 1923 by John Mason Good (1). It can be broadly defined as the neuroendocrinological, pathophysiological and psychosocial clinical syndrome in which a non-psychotic woman firmly believes herself to be pregnant while manifesting symptoms and signs of pregnancy and labour pains in the absence of true gestation (2). It is also known as false pregnancy, pseudopregnancy or phantom pregnancy.

It is a rare condition with characteristic somatic features commonly in women with long standing infertility who desperately want to become pregnant and their wish for pregnancy is essential to their identity and self-esteem. Pseudocyesis is the manifestation of a woman’s fears and need of pregnancy. It should also be noted that one of the most common findings in women with pseudocyesis is depression.

 An important differential diagnosis of pseudocyesis is delusion of pregnancy.  Delusion of pregnancy is a similar to pseudocyesis, however, there is a difference between the two. The clinical distinction between pseudocyesis and delusion of pregnancy is primarily based on the presence or absence of physical manifestations of pregnancy (3). In delusion of pregnancy, there is a false and fixed belief of being pregnant despite the absence of physical signs suggestive of pregnancy. It is usually experienced by psychotic women and men (4).

 The aim of this presentation is to provide an overview to the term ‘pseudocyesis’, briefly discussing its epidemiology, clinical presentations, differential diagnosis and possible treatment of pseudocyesis.

EPIDEMIOLOGY

Pseudocyesis affects all ethnic, racial and socioeconomic groups. The frequency of occurrence in Nigeria was reported to be 1 in 344 pregnancies (6), 1 to 6 per 22,000 births in the United States (7) and 1 out of 160 women treated for infertility in Sudan (8). The condition has been observed to be predominant in African countries, most especially in cultures that place great value on child bearing and motherhood and also in cultures where childbearing is the central role of women.

 The vast majority of cases of pseudocyesis occur in infertile and perimenopausal women usually between the ages of 20 and 44 years. The average age of a woman experiencing this condition is 33 years. The incidence of pseudocyesis in postmenopausal women and children has been observed to be rare. 80% of women with pseudocyesis are married, 14.6% are unmarried and 2.3% are widowed (7).

 Cases of pseudocyesis have been reported to be frequent in developing countries where women are usually not examined by a Physician until they are in labour or seek medical aid (9). Women can experience single or multiple episodes of pseudocyesis.

AETIOLOGY

There is currently no exact cause of pseudocyesis despite the considerable medical interest and speculations. Studies have shown that there are some factors and conditions that are involved in the development of pseudocyesis with emphasis on interaction between these factors and the reproductive system. These have been summed up into 3 theories. They are:

  1. Conflict Theory

This is an intense desire for or fear of pregnancy which creates an internal conflict and causes endocrine changes through a complex neuroendocrine mechanism. It is believed that these desires trigger the pituitary gland to secrete elevated hormones mimicking the hormone changes of real pregnancy (10). An example of these hormones is prolactin.

Hyperprolactinaemia (elevated prolactin level) has been suggested as a cause of many signs of pseudocyesis. These signs include: menstrual irregularities, apparent foetal movements and labour pains (11). Hyperprolactinaemia can result from psychological stress or use of drugs like oestrogens, antidepressants, antihypertensives, opiates, dopamine, and beta blockers (8).

In regard to these neuroendocrinological changes, women who have history of infertility, lost an object of love (like a favourite job, an aim or purpose), experienced recurrent abortions, in their second marriages or forced marriage, have history of childhood abuse etc., are usually individuals susceptible to pseudocyesis.

  1. Wish-fulfilment Theory

This occurs when minor changes in the body initiate the false belief of being pregnant, especially in the presence of abdominal distention or pressure on the pelvic structures. This is seen in women with history of miscarriages and infertility.

  1. Depression Theory

 Pseudocyesis may be initiated by some chemical changes in the nervous system that are related to depressive disorders. Chemical changes like a deficiency in brain dopamine and norepinephrine in depressive disorders increase sympathetic nervous system activity, dysfunction of CNS and steroid feedback inhibition of gonadotrophin-releasing hormone.  All these changes have been assumed to be a shared endocrine trait between major depression and pseudocyesis (12,13).

CLINICAL PRESENTATIONS

The clinical presentation of pseudocyesis has both psychological and physiological aspects. It has been observed that depression is a common finding in pseudocyetic women. Most of these women suffer from major depression, anxiety and/or emotional stress (6,11).

The physiological aspects include: abdominal enlargement/distension which is the most common sign. This has been thought be due to excess fat, flatus or faecal and/or urinary retention and an exaggerated lumbar lordosis, causing forward displacement of the abdominal viscera (14).

 Also, there are usually changes in the breast which include enlargement, tenderness, darkening of areolar tissue, nipple discharge (6). Gastrointestinal symptoms such as nausea, vomiting, reduced appetite and weight gain may be present. There is usually subjective sensing of foetal movements, which may be due to contraction of abdominal muscle or bowel peristalsis. Menstrual irregularities, increased urinary frequency, labour pain usually around the time the women regard as their expected date of delivery (15,16). The duration of these symptoms usually ranges from few weeks to 9 months.

DIAGNOSIS AND ITS DIFFERENTIALS

To determine whether a non-psychotic woman is experiencing pseudocyesis, the physician must: evaluate her symptoms, perform a pelvic examination, do a blood or urine pregnancy test and do an abdominal ultrasound (17,18). In pseudocyesis, no foetus is seen on the ultrasound and heartbeat is also absent. Urine pregnancy test is negative, with exceptions in some underlying medical conditions like cancer that produce hormones similar to pregnancy. The most accurate method to diagnose pseudocyesis is use of an ultrasound.

Differential diagnosis of pseudocyesis include delusion of pregnancy, deceptive pregnancy and erroneous pseudocyesis. Deceptive pregnancy is seen in women who consciously acknowledge being pregnant while knowing she is not. It is done for sympathy and attention. Erroneous pseudocyesis is seen in women who mistakenly misinterpret symptoms of pregnancy like menstrual irregularities and/or abdominal enlargement.

MANAGEMENT

There is no specific management or recommended medications for treating patients with pseudocyesis. Studies have shown that the resolution of the condition is entirely dependent on the patient when they are confronted with the reality of not being pregnant.    

But a multidimensional treatment involving the Gynaecologist, Psychiatrist, family and friends is usually advised and has been found effective (19). Usually, an ultrasound is done to show the patient that she is not pregnant. But since depression is a common symptom seen in most pseudocyetic patients, antidepressant drugs are prescribed to treat any underlying depression, combined with hormonal psychotherapy and supportive psychotherapy. Support from friends and family are also vital.       

CONCLUSION

Pseudocyesis is a rare condition which can easily be misdiagnosed as some health workers are still not fully aware of the condition. It is an important condition that needs to be discussed more especially with health workers and women who are in their reproductive age.

Women are encouraged and advised to go for antenatal as this condition can be prevented with the use of antenatal services. Parents, most especially the mothers in-law in developing countries, are also advised to stop putting pressure on their children for offspring.

References

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  2. Brown E, Barglow P. Pseudocyesis: A paradigm for psychophysiological  interactions.  Arch  Gen  Psychiatry. 1971.
  3. Hardwick PJ, Fitzpatrick C. Fear, folie and phantom pregnancy. Pseudocyesis in a fifteen year old girl. Br J Psychiatry. 1981.
  4. Adityanjee AM. Delusion of pregnancy in males: a case report and literature review. Psychopathology.1995.
  5. Cohen LM. A current perspective of pseudocyesis. Am J Psychiatr 1982.
  6. Small G: Pseudocyesis: an overview. Can J Psychiatry. 1986.
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  16. Brooks JG. Pseudocyesis in a 6-year-old girl: follow-up report at 23. J Am Acad Child Psychiatry.1985.
  17. Ahmad MF, Abu MA, Chew KT, Sheng KL, Zakaria MA. “A positive urine pregnancy test (UPT) with adnexal mass; ectopic pregnancy is not the ultimate diagnosis”. 2018.
  18. Li X, Zhang C, Li Y, Yuan J, Lu Q, Wang Y. “Predictive values of the ratio of beta-human chorionic gonadotropin for failure of salpingostomy in ectopic pregnancy”. 2019
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