Delusion of Pregnancy: A Case Report and Literature Review

Abstract

Delusion of pregnancy is defined as a persistent belief that one is pregnant despite concrete evidence to the contrary. Despite being reported as an isolated event, delusion of pregnancy has been reported in many patients with underlying psychiatric conditions such as schizophrenia, bipolar disorder, psychotic depression, and other physiological disorders of mental function. This case study reports a case of a 44-year-old, drug-naïve female with delusion of pregnancy affected by paranoid schizophrenia. Pharmacological treatments are frequently insufficient in controlling this condition and are often supplemented with adjunctive psychotherapy.

Introduction

Delusion of pregnancy is defined as a persistent belief that one is pregnant despite concrete evidence to the contrary.^7,11 Despite being reported as an isolated event, delusion of pregnancy has been reported in many patients with underlying psychiatric conditions such as schizophrenia, bipolar disorder, psychotic depression, and other physiological disorders of mental function.^1,7,15 The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ( DSM5) describes delusion of pregnancy as a somatic type of delusional disorder when it occurs independently, within the spectrum of schizophrenia or other psychotic disorders. ²³ Previous studies have associated delusion of pregnancy with hyperprolactinemia resulting from the use of antipsychotic medication including haloperidol, olanzapine, and risperidone.^11,23 In patients with delusions of pregnancy and hyperprolactinemia, the pregnancy delusions were resolved by treating the hyperprolactinemia.^6,12 Other conditions have been associated with the delusion of pregnancy, including the false perception or interpretation of bodily sensations known as coenesthesia, ¹⁵ constipation in the elderly, ²⁵ urinary tract infections, Hashimoto thyroiditis, hyponatremia syndrome, metabolic syndrome, and polydipsia. As such, the delusion of pregnancy is associated with multiple conditions.^5,15,24

Delusion of pregnancy is applied when there are no obvious physical signs of pregnancy, a distinct feature used to differentiate it from pseudocyesis, a somatic condition of having all signs and symptoms of pregnancy in the absence of a fetus. This condition should also be differentiated from couvade syndrome, pseudopregnancy, and simulated pregnancy.^4,15,20 Delusion of pregnancy has been reported in women across all age ranges,^3,7,15,20 including postmenopausal women, ¹⁸ women who had a hysterectomy, and prepubertal girls. ¹⁰ However, the emergence of delusion of pregnancy in men has been strongly associated with impaired cerebral function, a history of male sexual abuse, and contact with pregnant women.

More cases have been reported on the delusion of pregnancy in developing countries as compared to developed countries.^3,20 Sociocultural factors play an important role in explaining this observed difference.^1,11,15,23 The desire of achieving pregnancy might be very high among women who live in cultures where motherhood is viewed as the ultimate goal of womanhood. In these cultures, the delusion of pregnancy has been reported in infertile couples where infertility is frequently blamed on women, leading to significant distress. ¹⁸ Thus, it is important to acknowledge the relationship between the delusion of pregnancy and chronic psychological stress. Other cases of delusion of pregnancy were reported in women who wanted pregnancy after the loss of their child in women experiencing acute loneliness or in those with ambivalent feelings about pregnancy.^5,15,24 In some cases delusion of pregnancy has been reported in association with other types of delusions such as delusion of infidelity, persecution, and erotomania.^7,24

Case Report

A 44-year-old married female patient presented to the clinic with suspiciousness toward others for the past 24 years and believes that she is pregnant and had delivered 15 children in the past 8 years.

The patient exhibited a long-term pattern of stubbornness and had a complicated obstetric history, which include an intrauterine fetal demise at 5 months gestational age, 2 Medical Termination of pregnancies (MTPs), and a voluntary hysterectomy in 2009. Her obstetric history at the time of presentation consisted of 0 term delivery, 0 preterm, 3 abortions, and no living child. The patient presented with delusions of reference, believing others are talking about her. Two months following the hysterectomy, the patient’s delusion of pregnancy started and reported that she is 3 to 5 months pregnant and also reported quickening. She was apprehensive that someone was trying to take the baby away from her and frequently asked her husband to return the baby to her. She used to visit several obstetricians to check the status of her baby and complained saying that the doctor had taken away the baby if confronted that she is not pregnant. Occasionally, she would complain of intermittent labor pain and would force her husband to take her to the hospital.

The patient at the time of admission showed very strong delusional tendencies and reasserted her delusions by stating that in the past, she had become pregnant 15 times, and believed her urine pregnancy test (UPT) and ultrasonography (USG) were done while she was asleep. She reported that her family members got away with all her medical reports and also delivered her babies while she was asleep. She claimed that “my clothes were soiled, no slippers to be found the next morning, and my abdomen was greatly distended.”

On the mental status exam, she was alert and attentive, with a cooperative attitude, fair hygiene, good eye contact, and no noted psychomotor agitation. Normal rate, volume, rhythm, and tone of speech were noted along with no latency and good articulation. Her language was fluent, the thought-form was coherent and linear with evidence of paranoid and persecutory delusions in her thought content. Anxious and depressed mood was noted while admission, along with below-average intellect, poor insight, limited judgment, and fair impulse control.

She endorsed a normal childhood and didn’t report any history of sexual or marital abuse, albeit admitted to feeling pressured for having babies as part of her duty as the woman of the house. The patient had gotten married to her husband at the age of 15 to 16 years of age and had completely lost touch with her maiden home to account for family history.

The patient was admitted with the above complaints and was administered lurasidone 120 mg per day and clozapine 150 mg per day for a period of 7 days. She developed akathisia with lurasidone, which was tapered and stopped. Clozapine trial failed i/v/o intolerability due to constipation and sedation. She was then observed on olanzapine 20 mg per day, however the pt. developed pain in the legs and restlessness. The patient eventually showed partial improvement with ECTS. Therapy was then focused on behavior and not psychotic symptoms. The husband explained the prognosis of her condition. Family therapy was advised. Her husband was asked to observe her behavior at home and to readmit her on a Si Opus Sit (SOS) basis for family therapy and treatment rationalization. The condition at discharge was only mildly improved.

On a follow-up after 1 month, she claimed that her husband was poisoning her food, giving her nightly injections to kill her, and because of the poison, a few babies had become disabled, and a few had died. The patient would explain that she could become pregnant despite hysterectomy through in vitro fertilization and sometimes through inserting an artificial uterus. On further investigation, poor drug adherence along with stressful marital conditions was suspected to potentially hinder improving her symptoms.

Discussion

Delusion of pregnancy is known to have a multifactorial etiology and is predominantly observed in developing countries. ²⁹ Albeit, the disorder is more common in females, multiple cases have been documented in men as shown in Table 1.^3,8 Although incidence has been reported across multiple age groups, according to a study by Bera and Sarkar, around 25% of the cases were observed in the age group of greater than 50 years with equal prevalence in males and females. The elderly in the non-reproductive age group have been more vulnerable to the delusion of pregnancy due to associated conditions such as senile dementia, metabolic syndrome, and frontotemporal lobar degeneration. Physician dismissal of symptoms in patients of this age group contributes to their vulnerability. ²⁶

Table 1.

Studies Reporting Delusion of Pregnancy.

Name of study, country; year	Type of Study	Associated Disorder	Intervention	Outcome
Grover and Dua 1 ; India	Case Report	• Severe depression with psychotic symptoms • Delusional disorder	• Antidepressant • Antipsychotic • electroconvulsive therapy (ECT)	The delusional belief continues to remain as such
Khasnobis et al 2 ; India	Case Report	Delusional disorder	• Antipsychotic • BZD	The delusional belief continued with decreased conviction
Gaikwad et al 3 ; India	Case report	Delusional disorder (Male patient)	Antipsychotic	Patient improved within 3 weeks of treatment with Trifluoperazine
Gupta et al 4 ; India	Case report	Paranoid Schizophrenia	Antipsychotics	60-65% Improvement
Goyal et al 5 ; India	Case report	• Paranoid Schizophrenia • Diabetes Mellitus • Cholelithiasis	• Antipsychotics • Psychoeducation	Patient improved
Ahuja et al 6 ; UK	Case report	BPD	• Valproate semi-sodium • Olanzapine	Patient improved after 2-4 weeks of admission and symptoms resolved completely. Valproate semi-sodium was continued, olanzapine dose was reduced
Tsai and Shen 7 ; Taiwan	Case report	• Psychotic mania	• Mood stabilizer • Antipsychotic	Delusion of pregnancy resolved on 16th day of hospitalization
Suresh Kumar et al 8 ; India	Case report	• Delusional disorder	• Antipsychotic • Benzodiazepines	Delusion completely resolved after 3 weeks of treatment
Onda et al 9 ; Japan	Case report	• Schizophrenia • Hyperprolactinemia	• Antipsychotics (Clozapine, Aripiprazole)	Improved after 6 months of hospitalization
Rush Ortegon et al 10 ; USA	Case report	Brief psychotic disorder	Antipsychotics (Chlorpromazine)	Delusions resolved after 2 months of treatment
Mascarenhas and Crasta 11 ; India	Case report	Paranoid Schizophrenia	Antipsychotics (Olanzapine)	Patient improved after starting treatment (Duration not specified)
Pang et al 12 ; Singapore	Case report	• Schizoaffective disorder • PCOS	Antipsychotics	Patient recovered completely in a few days after up titration of Olanzapine from 15 to 20 mg
Leal and Beito 13 ; USA	Case report	Hypothyroidism	• Levothyroxine • Olanzapine	Symptoms improved 1 month after admission and treatment
Penta and Lasalvia 14 ; Italy	Case report	• Paranoid schizophrenia • Hashimoto-related hyperprolactinemia	• L-thyroxine • Antipsychotics (aripiprazole) • Cognitive Behavioral Therapy( CBT)	Reduction in persecutory themes and remission of auditory hallucinations after 3 weeks of antipsychotic treatment. Delusion of pregnancy became less intense after 4 weeks.
AlZamil et al 15 ; Saudi Arabia	Case report	• Schizophrenia • Tuberous sclerosis	First and second generation Antipsychotics	Complete resolution after 18 days of inpatient treatment
Larner 16 ; UK	Case report	Frontotemporal dementia with Motorneuron disease (FTD/MND)	-	Patient died 18 months after diagnosis of FTD/MND
Lopes et al 17 ; Brazil	Case report	• Delusional disorder • Hypothyroidism • Anorexia Nervosa • Esophageal achalasia	• Levothyroxine • Hellere’s myotomy • Antipsychotics	Patients delusional disorder persists even after usage of antipsychotic
Sidana and Jain 18 ; India	Case report	Paranoid schizophrenia	Risperidone	Complete resolution of symptoms after 3 weeks of treatment
Vasudev and Sharma 19 ; Canada	Case series	Major depressive disroder with psychosis (1 year)	Olanzapine	Resolution of psychotic symptoms after 3 weeks of treatment, residual depression after 7 weeks of starting treatment
Kornischka and Schneider 20 ; Germany	Case report	• Schizophrenic psychosis • Capgras syndrome	Antipsychotics (Haloperidol/flupenthixol decanoate/ fluphenazine decanoate,g clozapine, risperidone, olanzapine, amisulpride, and quetiapine)	No resolution of symptoms for 25 years with over 4
Bhattacharya 21 ; India	Case report	Delusional disorder	• Risperidone • Electroconvulsive therapy • Flupenthixol • Pimozide	Improvement and complete resolution after 2 months only with Pimozide
Manoj et al 22 ; India	Case report	Delusional disroder (with history of sexual abuse)	• 6 ECTs • Symptomatic treatment	Patient gradually improved over time
Chatterjee et al 23 ; India	Case report	• subclinical hypothyroidism	• Risperidone • Iron and folic acid tablet • Levothyroxine ( Eltroxin)	Psychotic symptoms gradually decreased, and conviction of pregnancy became less after 2 weeks. By fourth week she agreed she may be wrong about the pregnancy, and she became almost free from symptoms after 45 days
Simon et al 24 ; Hungary	Case report	• schizoaffective psychosis	• mood stabilizer( lithium carbonate) • antipsychotics( haloperidol switched to olanzipine)	Psychotic symptoms gradually vanished and by fourth week she presumed fetus had been absorbed. Discontinued on medication after asymptomatic year but readmitted to psychiatric clinic with schizoaffective psychosis(without delusion of pregnancy)
Guilfoyle et al 25 ; Ireland	Case series	Case 1: Mixed Alzheimer’s disease/Vascular Dementia, dehydration, pneumonia, reduced mobility	Case 1:Prior medication (Escitalopram). On admission:fluids, antibiotics and laxatives	Case 1: The patient’s delusion was intermittent for 12 h and then disappeared
		Case 2: Delusion persisted for 3 days and delirium for 7 days. Unable to recall delusion afterward	Case 2: Prior medication (Oxycodone). On admission: Haloperidol, stool softeners and enemas	Case 2: Depression, delirium secondary to dehydration, acute renal impairment, constipation
		Case 3: Delusion of pregnancy persisted for 4 days and resolved about the same time as constipation.	Case 3: Prior medication (Trazodone, Tramadol). On admission: laxatives and enema	Case 3: Alzheimer’s disease, Parkinson’s disease, fecal incontinence
		Case 4: Delusion lasted several hours only	Case 4: Prior medication (Alprazolam, Escitalopram). On admission: stool softeners and enemas	Case 4: Vascular Dementia, Chronic depression, delirium, dehydration, acute renal impairment
			Case 5: osmotic and stimulant laxatives	Case 5: Delusion persisted for 4 days despite resolution of constipation, continued cognition improvement and gentle correction by staff. Delusion ceased spontaneously on day 10 of acute illness

In general, delusions can be explained by 2 models, and they often have 3 stages. The motivational model interprets delusions as a method of relief from distress and anxiety whereas the deficit model interprets delusion as a product of cognitive dysfunction and abnormalities in perception. ⁵ The development of delusion of pregnancy occurs in 3 stages. The first stage called “das trema,” is a general stage of apprehension, according to Conrad, and occurs after the loss of a loved one. The second stage involves the formation of a sensory perception related to weight gain, vaginal spotting or abdominal movements, and increased frequency of micturition. In this stage, the patient ends up searching for the significance behind these perceptions. The third stage involves attaching meaning to a neutral sensation to help deal with difficult situations (false belief of being pregnant to help deal with difficult situations such as losing a child or being diagnosed with infertility).^30,31

Biological and psychological factors have been put forth to explain the pathogenesis of delusion of pregnancy. Psychosocial factors such as real or imagined loss of pregnancy, loss of a loved person/object, and loneliness have been implicated in the development of delusion of pregnancy. In addition, sociocultural factors such as societal pressure to have children, social deprivation, belief in wizardry, and spiritual deities have also been known to cause delusion of pregnancy.^11,26 In some cases, low socioeconomic status and illiteracy were also associated with intensified belief. ² The loss of a loved one, perceived societal pressure and low socioeconomic status are the main contributors to the index patient’s delusions. Delusion of pregnancy in men can be psychodynamically interpreted as an expression of frustrated creativity, envy toward his wife’s ability to become pregnant, and expression of identification with their own mothers.^26-28

Delusions have also been attributed to being a response to chronic stressors. Stress-induced hyperprolactinemia is known to cause menstrual irregularities, breast engorgement, and mood changes which can be mistaken for pregnancy. There are multiple drugs such as sertraline, amitriptyline, fluoxetine, alpha-methyldopa, and verapamil which are also known to cause hyperprolactinemia. ³³

DSM-5 defines pseudocyesis as a false belief of being pregnant that is associated with objective signs and reported symptoms of pregnancy, which may include abdominal enlargement, reduced menstrual flow, amenorrhea, subjective sensation of fetal movement, nausea, breast engorgement and secretions, and labor pains at the expected date of delivery. There have been cases reported in the past of patients diagnosed with delusion of pregnancy presenting with physical symptoms such as abdominal distension, sensation of fetal movements, and shortness of breath. Although it is more common in pseudocyesis, a clear distinction cannot be made between the 2 conditions based on the presence or absence of signs and symptoms of pregnancy. ¹¹ The latter is considered a symptom of psychosis and when present independently is called somatic type delusional disorder according to DSM-5 within the realms of schizophrenia and other psychotic disorders. Although this index patient reports the sensation of fetal movements, there are no other signs or symptoms pointing toward a diagnosis of pseudocyesis.

Delusion of pregnancy is known to present more commonly with multi-thematic delusions (multiple delusions such as delusion of reference, the delusion of infidelity, the delusion of persecution) than monothematic delusions. In this index patient, there is a presence of delusion of reference and persecution associated with the delusion of pregnancy. ²⁹ There are no such associations present in pseudocyesis. There is also a history of chronic psychological stressors in the form of losing a fetus at 5 months of gestation, undergoing 2 MTPs, and a hysterectomy. The presentation of multi-thematic delusions, a history of chronic psychological stressors, and a lack of other physical symptoms favor a diagnosis of delusion of pregnancy over pseudocyesis.

Other conditions which imitate pregnancy and should be differentiated from the delusion of pregnancy are pseudopregnancy and couvade syndrome. Pseudopregnancy is a somatic state resembling pregnancy caused by organic factors. The physical symptoms here can be caused by endocrine tumors. ²³ Couvade syndrome is a somatic symptom disorder where in response to a female partner’s pregnancy, the male partner develops symptoms such as anxiety, weight gain, GI disturbances, and insomnia. The behavior will resemble that of a pregnant woman, but insight into not being pregnant is preserved here. ³²

Management of delusion of pregnancy must consider any associated underlying medical conditions to prevent life-threatening delays in diagnosis and treatment. In patients with antipsychotic-induced hyperprolactinemia, prolactin-sparing antipsychotics such as quetiapine, ziprasidone, and aripiprazole can be considered. Although they are known as prolactin-sparing antipsychotics, they are known to cause hyperprolactinemia and it is therefore recommended to monitor prolactin levels in such patients regularly. ECT has shown minimal and temporary improvement in this condition in the past. The index patient showed improvement with ECT. However, there is a lack of adequate literature to establish its long-term effectiveness. Delusion of pregnancy with underlying psychiatric conditions is known to be treatment-resistant and success with antipsychotics is not observed by their usage alone. Thus, cognitive and supportive psychotherapy should also be included with pharmacotherapy to achieve acceptable outcomes. Family therapy and psychoeducation about the condition can ensure the family members cope better with such diagnoses.^5,33

A huge tally of patients show minimal improvement with the above interventions. Since treatment modalities take different routes, further in-depth exploration and research is necessary to draw a clear distinction between the delusion of pregnancy and pseudocyesis to make sure the patient is better managed.

Conclusion

In conclusion, delusion of pregnancy is a broad condition that can manifest throughout a range of neuropsychiatric syndromes. Social, psychological, and biological factors can contribute to the development of delusion. Treatment should focus on pharmacotherapy along with cognitive and supportive psychotherapy.