Delusion of pregnancy and other pregnancy-mimicking conditions: Dissecting through differential diagnosis
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0975-2870.128986
The delusion of pregnancy is defined as the belief of being pregnant despite factual evidence to the contrary. Even being more common in a developing country, the literature about delusion of pregnancy from India is meager. The present article reports the case of delusion of pregnancy in an unmarried female associated with subclinical hypothyroidism and prominent sibling rivalry from psychological aspect. The literature in this field has addressed for the organic and psychodynamic, psychosocial aspect of this disorder and its difference from other disorders mimicking pregnancy and its relevance to the treatment plan. Keywords: Delusional disorder, delusion of pregnancy, hypothyroidism, pseudocyesis
Delusion of pregnancy (DP) is a Somatic Type of Delusional Disorder classified by the DSM-5 within Schizophrenia Spectrum and Other Psychotic Disorders. [1] It should be distinguished from four additional conditions imitating pregnancy:
DP is rare in developed countries due to recent advancement of more specific and accurate methods of detecting pregnancy. But it occurs more often in developing country. [4] The literature on DP in India is however scanty. [5] We hereby present a case of DP. The case needs to be differentiated from pseudocyesis. The case could present diagnostic impasse especially if other psychotic features are not fully manifested.
History Proper A 30-year old Hindu, unmarried female, educated up to class 12 from rural background, staying with her parents and elder sister complained of having occasional self-muttering and aggressive behavior toward her sister, started 5 years ago, when her sister passed in her graduation examination, but she couldn't. She started saying that it was not her sister but she passed the examination. Later on she used to say that she got a job in "Indian Police Lecturer," an imaginary organization, when her sister actually got a job. She explained that being envious, her parents and sister were conspirating against her. After 2 years during her elder sister's wedding she stayed 3 days in her neighbor's house and started demanding that it was her husband's property and began applying sankha and sindur (Hindu marriage symbol). Afterwards when her parents tried to get her married, she resisted vehemently divulging that she is already married to S.S who has no real existence. A year after her sister was reported to be pregnant she claimed that she has also conceived. For this she visited local doctor and performed USG which came negative but she declared that the report was wrong continued with her belief. The patient was able to maintain her self-care. Sleep, appetite, bladder bowel were normal. She informed having only had watery discharge, though her mother reported that she had regular menstrual history. During Interview During interview, she revealed a well-systematized delusion of pregnancy. In response to specific question about pregnancy, she stated that she had been pregnant with a son for last 12 months; she could feel the fetal movement, experience pain in abdomen, and complained of occasional shortness of breath due to gradual increasing fetal size. Mental Status Examination Mental status examination (MSE) revealed a middle-aged, medium built, well-kempt woman, with adequate eye contact, who was then agitated, suspicious, and hostile toward her parents and anyone who tried to contradict her view. Rapport established with effort. Affect was anxious, irritable, communicable and congruent to thought content. Speech was coherent, relevant, goal directed with normal reaction time. Thought content displayed somatic delusion, delusion of persecution, delusion of reference, delusion of misidentification. No formal thought disorder noted. On repeated interview throughout her stay in the hospital we failed to elicit any other psychotic features other than multiple delusions none of which were bizarre. Though history suggested self-muttering behavior, ward observation did not reveal any muttering or smiling behavior. The patient also gave valid explanation for her muttering (it was just grumble what she used to do when she feels irritated). The differential diagnosis considered were delusion of pregnancy and paranoid schizophrenia; and the patient was put on tab haloperidol 5 mg BD and tab clonazepam 1 mg BD. Laboratory Investigation TC, DC, ESR, platelet, urea, creatinine, and LFT revealed no abnormality except Hb 9 gm % and Eosinophil count 9%. Blood sugar level, kidney function test, complete hemogram, and ultrasound abdomen was within normal limits. Thyroid profile displayed normal FT4 and mildly elevated TSH 9.64 mIU/L. Her serum prolactin level was 26 ng/mL. A vitamin B12 estimation and MRI or CT imaging were necessary but could not be carried out due to financial constrain. Psychometric Assessment
Course After 3 days due to extrapyramidal side effects the patient was shifted to risperidone, which hiked up to 8 mg per day in next 7 days. For her medical comorbidity she was prescribed iron and folic acid tablet and Eltroxin 25 μg. Her psychotic symptoms gradually decreased; 2 weeks later, though she claimed to be pregnant with a male fetus though conviction became less. By the fourth week she started telling that as doctors are telling there is no pregnancy, so she may be wrong. Afterward she became almost free from the presenting symptoms and after 45 days of admission she was discharged on risperidone 2 mg daily, iron and folic acid and thyroxin 25 μg/day.
By definition, delusions are false firm ideas that cannot be corrected by reasoning and are out of keeping with patient's educational and cultural background. DP is etiologically heterogeneous phenomena. They can be triggered purely by organic factors or they can develop as an adaptation to stress induced by organic and/or psychological factors. Biologically DP has been described in schizophrenia, schizoaffective disorder, delusional disorder, mental retardation, senile dementia, psychotic depression, hyperprolactinemia, drug-induced lactation, [6] postpartum thyroiditis, metabolic syndrome, polydipsia, FTLD/MND. [7] Our patient described above had normal serum prolactin level and subclinical hypothyroidism. Her increased eosinophil count can be explained by intestinal parasite infestation as it is highly prevalent in rural India. It was not a consequence of antipsychotic treatment. Psychologically DP may be conceptualized as:
In this patient we noted multiple delusions (delusion of persecution, somatic delusion) which does not contradict the diagnosis of delusional disorder as DSM 5 includes "one (or more) delusion" in the diagnostic criteria. [1] And the central theme of all this delusion is the same. A strong sense of sibling rivalry has been operative since early childhood and which have a definite temporal relationship between events in life of patient's sister and her delusional content. It can be said that feeling of rejection, helplessness, and self-inadequacy are being manifested through these delusion. Moreover, low SES of the woman along with no social support exacerbates the problem. She had been continuously criticized and looked down upon. The delusion of having a male child can be attributed to obvious pressures of a patriarchal society and only a male child can bring relief by restoring her dignity and sense of adequacy. [8] Regarding her medical comorbidity, hypothyroidism is an established associated factor with psychiatric manifestation. Although mood and affective disorders are more common, studies have shown, however, that 5% to 15% of myxedematous patients have some form of psychosis. Although Asher's study of 14 patients and resulting description of "myxedema madness" has been often cited as a typical example of psychosis secondary to hypothyroidism; [9] subsequent case reports have revealed considerable variation in clinical psychotic presentations. [10],[11] Our finding of delusion of misidentification were also noted in a previous case report. [12] Psychosis typically emerges after the onset of physical symptoms, often after a period of years or months. [13] Disorders of thought may occur in patients with either clinical or subclinical hypothyroidism, which suggests that psychosis may be unrelated to the absolute degree of thyroid hormone deficit. [14] Cohen [15] described a case report similar to us but it rarely reported in India. Earlier studies also reported psychosis associated with anemia, specially vitamin B12 deficiency. Various psychiatric manifestations can occur in cobalamine deficiency. [16] Psychotic depression, paranoid schizophrenia, [17] and other mood changes have been commonly reported.
The case highlights the possibility of delusion of pregnancy (DP) if a patient presents with features suggestive of pseudocyesis. The obstetricians being more familiar with pseudocyesis might tend to overlook the other possibilities in such cases. This would be especially true if there are no associated clear-cut psychotic features. [18] The two conditions warrant a different line of management. Antipsychotics [19] play a key role in the DP along with the treatment of medical co-morbidities. [20] On the other hand they are of limited role in patients with pseudocyesis. [21] Psychodynamic and supportive psychotherapy could play a pivotal role in the management of later.
We acknowledge our gratitude toward all the colleagues and senior of our department for their help and support.
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