False pregnancy

False pregnancy is the appearance of clinical or subclinical signs and symptoms associated with pregnancy although the individual is not physically carrying a baby.[1] The medical term for the condition, pseudocyesis, comes from the Greek word pseudes which means "false" and kyesis which means "pregnancy".[2] The false belief that one is pregnant includes signs and symptoms such as tender breasts with secretions, abdominal growth, delayed menstrual periods, and subjective feelings of a moving fetus.[1]

This article is about humans. For other mammals, see pseudopregnancy.

False pregnancy
Other names	Phantom pregnancy, hysterical pregnancy, pseudocyesis, delusional pregnancy
Specialty	Psychiatry

False pregnancy has a prominent psychiatric component as well as physical manifestations of pregnancy.[1] It can be caused by trauma (either physical or mental), a chemical imbalance of hormones,[1][3] and some medical conditions.[2] Contributing psychological factors include a strong desire for pregnancy or misinterpretation of objective bodily sensations.[1][3] Although rare,[2] men can experience false pregnancy symptoms,[1] called Couvade syndrome or "sympathetic pregnancy", which can occur when their significant other is pregnant and dealing with pregnancy symptoms.[3]

Examination, ultrasound, and pregnancy tests can be used to rule out false pregnancy. Psychotherapy, pharmacotherapy with antidepressants or antipsychotics, hormonal therapy, and uterine curettage are sometimes needed as treatment.[2]

While extremely rare in the United States because of the frequent use of medical imaging, in developing regions such as India and sub-Saharan Africa, the incidence of false pregnancy is higher.[1][3] Rural areas see more instances of false pregnancy because such women are less often examined by a health care professional or midwife during the duration of believed pregnancy.[1]

Classification

In the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), false pregnancy is a somatic symptom disorder; it is listed as "not elsewhere classified", meaning it is in a category by itself, different from other somatic symptom disorders (formerly known as conversion disorders) such as functional neurological symptom disorder.[1] The word pseudocyesis comes from the greek word pseudes which means "false" and kyesis which means "pregnancy".[2]

False pregnancy is sometimes referred to as "delusional pregnancy", but the distinction between the two conditions is inexact.[3] Delusional pregnancy is typically used when there are no physical signs of pregnancy, but false pregnancy can also be delusional.[4][5] Some authors consider the two conditions can be used interchangeably for research purposes.[3][5]

Signs and symptoms

The symptoms of pseudocyesis are similar to the symptoms of a true pregnancy.[2] Signs of false pregnancy include amenorrhea (missed periods), galactorrhea (flow of milk from breast), breast enlargement, weight gain, abdominal growth, sensations of fetal movement and contractions,[2] nausea and vomiting,[2] changes in uterus and cervix,[2] and frequent urination.[3]

Abdominal distention is the most common symptom.[1] In pseudocyetic abdominal swellings, the abdomen becomes uniformly swollen, and the navel stays inverted. The wall of the abdomen adopts a muscular, tympanic character.[1]

Duration of symptoms typically ranges from several weeks to nine months.[2]

Causes and mechanism

The exact mechanisms behind false pregnancy are not completely understood, but psychological and endocrine components may play a substantial role. Women who experience false pregnancy often experience related feelings of stress, fear, anticipation, and general emotional disturbance.[3] These strong emotions, along with dysfunctional changes in hormonal regulation, can significantly increase prolactin levels. High prolactin levels, or prolactinemia, can lead to many of the symptoms of true pregnancy, such as amenorrhea, galactorrhea, and tender breasts.[1][3] Heightened activity of the central nervous system may contribute to the abdominal swelling, sensations of fetal movement, and assumed contraction pains experienced by many women with false pregnancy.[1]

Endocrine changes observed in pseudocyesis include an increase in dopamine levels, nervous system activity, or dysfunction in the central nervous system.[2] These changes may be responsible for amenorrhea, galactorrhea, and hyperprolactinemia seen in falsely pregnant women.[1] Elevated sympathetic activity has been linked to the increased in abdominal size as well as the apparent feel of fetal movement and contractions.[1]

How abdominal distention develops is not fully understood and several causes have been proposed. A buildup in fat around the abdominal cavity, heavy constipation, habitual lordosis, and other causes may produce the appearance of a distended abdomen, and the resulting swelling can remain for months. After women with false pregnancy are placed under anesthesia, or are successfully persuaded that they are not pregnant, the distention promptly disappears, indicating that the proposed mechanisms are supplementary factors behind, but not the ultimate causes of, abdominal swelling.[1] Manipulation of abdominal wall muscles, such as the diaphragm, is the most likely contributor to abdominal distention. For example, continuously contracting the diaphragm may give the appearance of a distended abdomen while forcing the intestinal units downwards.[1] The sensations of fetal movement may also be related to contractions of the abdominal wall due to peristalsis, or movements of the gastrointestinal tract.[6]

Biological causes of false pregnancy are uterine or ovarian tumors, central nervous tumors, ovarian cysts, uterine fibroids, ectopic pregnancies[2] and gallstones.[5]

Psychiatric disorders, such as anxiety or mood disorders, personality disorders, and schizophrenia are common amongst women with false pregnancy, and may be linked to its development.[2] Some women with depression may gain weight due to decreased physical activity and poor eating habits.[2] Antipsychotics can induce pregnancy-like symptoms such as amenorrhea, galactorrhea, breast tenderness, and weight gain via raising prolactin levels.[3]

Risk factors

Psychological factors are associated with false pregnancy, including a strong desire for pregnancy; a misunderstanding of sensory changes in the body (for example, bloating or increased pressure on the pelvis); and depressive disorders that can lead to changes in the neuroendocrine system.[7] Other social factors impacting include low educational status, marital issues, unstable relationship patterns, history of partner abuse, social deprivation, poverty, lower socioeconomic status, and unemployment.[2] Other factors such as mental and physical trauma—like experiencing a miscarriage, infertility, loss of child, or sexual abuse— can manifest false pregnancy.[8] Symptoms may arise in women who are experiencing grief after loss in their reproductive abilities, rejecting the idea of motherhood and pregnancy, or facing challenges in gender identity.[2] Other psycyological factors include recurrent abortions, stress of imminent menopause, and hysterectomy (sterilization surgery).[2]

Diagnosis

Tests and physical examinations are required to confirm false pregnancies: a pelvic exam, urinalysis, and an ultrasound. A pelvic exam can show if conception has occurred, a urinalysis tests for hormones released in pregnancy, and ultrasound shows the presence of the fetus. An ultrasound can accurately distinguish between a false and true pregnancy.[8] There is no universal laboratory profile for women with false pregnancy; measured concentrations for prolactin, progesterone, follicle stimulating hormone, estrogen, and luteinizing hormone vary widely.[6][9]

In some cases, false pregnancy symptoms may mask underlying medical conditions such as abdominal tumors, central nervous tumors, ovarian cysts, or gallstones. Medical tests and imaging are recommended to rule out potentially life-threatening conditions.[5]

Differential

Delusional pregnancy is distinct from false pregnancy; although the distinction is "blurred",[3] physical signs of pregnancy are not present in delusional pregnancy,[10] while false pregnancy includes symptoms of true pregnancy.[4] According to Gogia et al. (2020), false pregnancy "involves a false belief that one is pregnant, but differs from delusional pregnancy in that it is a psychosomatic rather than psychotic or purely delusional belief".[5] In delusional pregnancy, schizophrenia accounts for more than a third of cases.[4]

The symptoms of false pregnancy can be misinterpreted by the individual as a true pregnancy when the symptoms are actually caused by diseases (like hormone-secreting tumors, alcoholic liver disease, cholecystitis, urinary tract infection, gallstones) or exposure to a substance (like a medication),[1] or other conditions like constipation.[2]

Management

False pregnancy can be ruled out with ultrasound,[2] but additional interventions such as psychotherapy and pharmacotherapy are sometimes needed.[2] Psychotherapy may be used when individuals have difficulty coming to terms with their false pregnancy, or remain symptomatic after knowing their false diagnosis. It allows patients to confront reality and accept the symptoms as illusions and provides an opportunity resolve other psychological stressors and trauma that may be implicated in manifestations of false pregnancy.[11]

There is no direct evidence for treating false pregnancy with pharmacotherapy, but medications may be used to restore hormonal and neurotransmitter imbalances which are implicated in physical manifestations of false pregnancy.[2] Reduction in catecholamine levels have been observed in people with symptoms such as hyperprolactinemia and abdominal distentions.[1] For most people, psychotherapy, pharmacotherapy (with antidepressants or antipsychotics), hormonal therapy, and uterine tissue removal is adequate to treat the condition.[2]

Antipsychotics have been shown to increase lactation and amenorrhea,[12] and can trigger delusions.[5] The delusion may be resolved with medication changes or adjustments.[5]

When underlying medical conditions are identified, surgical treatments may resolve the conditions along with the false pregnancy symptoms.[5]

Epidemiology

The rate of pseudocyesis in the United States has declined significantly since 1940. The rate in 1940 of one occurrence for approximately every 250 pregnancies had dropped by 2007 to between one and six occurrences for every 22,000 births.[2] In Nigeria, the frequency of false pregnancies was 1 in 344 true pregnancies, and in Sudan false pregnancies were reported to be 1 in 160.[2] There were about 550 cases documented in the literature as of 2016, with most cases in those between the ages of 20 and 44.[10]

Women of reproductive age comprise the majority of pseudocyesis occurrences.[3] About 80% of women who experience pseudocyesis are married.[3] False pregnancies are more common in societies with certain cultures and religions, particularly in areas where there is a high degree of pressure for women to have multiple children, and for those children to be male.[2]

Although rare, pseudocyesis occurs more commonly in developing countries. It is reported more frequently in countries that place heavy emphasis on fertility and childbearing; such pronatalist beliefs are often highly prominent in developing countries. In sub-Saharan Africa, a woman is allowed to share her husband's property only if she bears children. In these countries (and other developing nations), infertile women often experience abuse, blame, and discrimination. In Africa, it is reported to occur in 1 out of every 344 pregnancies. Societal factors enforce the importance of female fertility in these countries, thus possibly contributing to pseudocyesis rates.[3]

In addition to men, mothers of pregnant women may experience Couvade syndrome, and a woman can experience multiple episodes of pseudocyesis in her lifetime.[13]

History

The perception of false pregnancy has evolved over time. In the late 17th century, French obstetrician François Mauriceau believed that the enlarged abdomens of falsely pregnant patients were caused by bad air. Physicians slowly began to acknowledge other potential causes of pseudocyesis, including its origin in the mind and in the body. In 1877, a physician named Joshua Whittington Underhill observed that physical symptoms can convince a woman of pregnancy, or a “disordered brain” can convince her that ordinary abdominal pains or bowel movements are instead fetal movements. The idea that pseudocyesis could result from a woman's perception of herself led to investigation into the role of emotions in cases of pseudocyesis. An investigator in the early 20th century observed that strong emotions can dry a woman's milk supply. The investigator went on to infer that the opposite was also true, and it was believed that strong emotions could bring about its production in women who are not pregnant. Alternatively, some physicians questioned the legitimacy of pseudocyesis as a condition. For instance, French obstetrician Charles Pajot stated in the 19th century, “there are no false pregnancies, only false diagnoses.”[14][15]

Society and culture

In the mid-1960s, a woman who appeared to be in labor was not properly examined because delivery appeared imminent; it was thought that her water broke but the expelled liquid was urine.[16][17] In 2010, a woman in the United States who was suspected of being in labor was given a C-section but there was no fetus.[18]

Mary Tudor, also known as "Bloody Mary", had a false pregnancy. After coming to terms with it, she reportedly believed that God had not made her pregnant because she had not sufficiently punished heretics.[14][15]

Anna O, Sigmund Freud's most famous patient, experienced false pregnancy in the context of preexisting mental health problems. After being diagnosed with hysteria, she believed she was pregnant by Josef Breuer, her therapist. She even believed she was in labor as she was trying to have another session with Breuer.[19]

See also

• Denial of pregnancy

References

1. Tarín JJ, Hermenegildo C, García-Pérez MA, Cano A (May 2013). "Endocrinology and physiology of pseudocyesis". Reproductive Biology and Endocrinology (Review). 11: 39. doi:10.1186/1477-7827-11-39. PMC 3674939. PMID 23672289.
2. Azizi M, Elyasi F (September 2017). "Biopsychosocial view to pseudocyesis: A narrative review". International Journal of Reproductive Biomedicine (Review). 15 (9): 535–542. PMC 5894469. PMID 29662961.
3. Seeman MV (August 2014). "Pseudocyesis, delusional pregnancy, and psychosis: The birth of a delusion". World Journal of Clinical Cases (Review). 2 (8): 338–44. doi:10.12998/wjcc.v2.i8.338. PMC 4133423. PMID 25133144.
4. Bera SC, Sarkar S (2015). "Delusion of pregnancy: a systematic review of 84 cases in the literature". Indian J Psychol Med. 37 (2): 131–7. doi:10.4103/0253-7176.155609. PMC 4418242. PMID 25969595.
5. Gogia S, Grieb A, Jang A, Gordon MR, Coverdale J (June 2020). "Medical considerations in delusion of pregnancy: a systematic review". J Psychosom Obstet Gynaecol: 1–7. doi:10.1080/0167482X.2020.1779696. PMID 32597281.
6. Trivedi AN, Singh S (November 1998). "Pseudocyesis and its modern perspective". The Australian & New Zealand Journal of Obstetrics & Gynaecology (Case reports). 38 (4): 466–8. doi:10.1111/j.1479-828X.1998.tb03114.x. PMID 9890236.
7. Ibekwe PC, Achor JU (April 2008). "Psychosocial and cultural aspects of pseudocyesis". Indian Journal of Psychiatry (Case report). 50 (2): 112–6. doi:10.4103/0019-5545.42398. PMC 2738334. PMID 19742215.
8. "Pseudocyesis: what exactly is a false pregnancy?". American Pregnancy Association. Retrieved July 30, 2020.
9. Starkman MN, Marshall JC, La Ferla J, Kelch RP (1985). "Pseudocyesis: psychologic and neuroendocrine interrelationships". Psychosomatic Medicine (Case reports). 47 (1): 46–57. doi:10.1097/00006842-198501000-00005. PMID 3975327. S2CID 2029697.
10. Campos SJ, Link D (June 1, 2016). "Pseudocyesis". The Journal for Nurse Practitioners. 12 (6): 390–394. doi:10.1016/j.nurpra.2016.03.009.
11. Mortimer A, Banbery J (April 1988). "Pseudocyesis preceding psychosis". The British Journal of Psychiatry (Case reports). 152 (4): 562–5. doi:10.1192/bjp.152.4.562. PMID 3167413.
12. Babu GN, Desai G, Chandra PS (July 2015). "Antipsychotics in pregnancy and lactation". Indian Journal of Psychiatry (Review). 57 (Suppl 2): S303-7. doi:10.4103/0019-5545.161497. PMC 4539875. PMID 26330648.
13. Thippaiah SM, George V, Birur B, Pandurangi A (March 2018). "A case of concomitant pseudocyesis and Couvade syndrome variant". Psychopharmacology Bulletin (Case report). 48 (3): 29–32. PMC 5875365. PMID 29713103.
14. Rutherford RN (April 10, 1941). "Pseudocyesis". New England Journal of Medicine. 224 (15): 639–644. doi:10.1056/NEJM194104102241505. ISSN 0028-4793.
15. Daley MD (December 1946). "Pseudocyesis". Postgraduate Medical Journal. 22 (254): 395–9. doi:10.1136/pgmj.22.254.395. PMC 2478462. PMID 20287291.
16. Svoboda, Elizabeth (December 5, 2006). "All the signs of pregnancy except one: a baby". The New York Times. ISSN 0362-4331. Retrieved February 16, 2020.
17. Radebaugh, John F (Spring 2005). "House calls with John" (PDF). Dartmouth Medicine: 48–63.
18. James, Susan Donaldson (April 10, 2010). "Doctors perform C-Section and find no baby". ABC News. Retrieved February 16, 2020.
19. Hunter D (1983). "Hysteria, psychoanalysis, and feminism: the case of Anna O". Feminist Studies. 9 (3): 465–88. doi:10.2307/3177609. JSTOR 3177609. PMID 11620548.

Classification	D ICD-10: F45.8 ICD-9-CM: 300.11 MeSH: D011555 DiseasesDB: 29264