Pseudocyesis, delusional pregnancy, and psychosis: The birth of a delusion

Delusion of pregnancy: Case series

Delusion of pregnancy is a relatively uncommon manifestation in psychotic patients. Differentiating it from closely related clinical entities like pseudocyesis/pseudopregnancy can be a challenge in clinical setting. Diagnosis of a psychotic illness with delusional pregnancy as the presenting feature in the absence of other florid symptoms of psychosis is a different challenge altogether. Currently, there is no consensus on the pharmacotherapy and psychotherapy of delusional pregnancy. We present a case series on delusional pregnancy with the intent to answer some of these gaps in the literature.

No Little Feet: Managing Pseudocyesis in a Homeless, Acutely Manic Patient with Schizoaffective Disorder, Bipolar Type

Pseudocyesis is a complex psychiatric manifestation of the physical symptoms of pregnancy. Although not pregnant, the pseudocyetic patient displays signs and symptoms consistent with pregnancy, such as abdominal distention, cramping, and/or sensations of fetal movement. Pseudocyesis is more common in developing countries than in the developed world, possibly due to the importance that traditional societies attach to childbearing and the low social status that these societies assign to women who are unable to produce children. Socioeconomically disadvantaged women in developed countries may also be at increased risk. Although the etiology, pathogenesis, diagnosis, and management of pseudocyesis are poorly understood, it manifests with real symptoms, which may complicate both the patient's perspective about her condition and the medical and psychiatric teams' approach to the patient. This case report is one of only a few in the literature to present an example of pseudocyesis developing in the context of acute mania. After describing the patient's clinical course, from her initial symptoms of pseudocyesis to their eventual resolution, this report will provide recommendations for the sensitive care of patients with this rare but significant condition.

Grappling with Issues of Motherhood for Women with Schizophrenia

Despite the fact that most persons with schizophrenia find steady employment difficult to sustain, many women with this diagnosis embrace and fulfill the most difficult task of all-motherhood. The aim of this paper is to specify the challenges of motherhood in this population and review the treatment strategies needed to keep mothers and children safe, protecting health and fostering growth. The review addresses concerns that had been brought to the author's earlier attention during her clinical involvement with an outpatient clinic for women with psychosis. It is, thus, a non-systematic, narrative review of topic areas subjectively assessed as essential to "good enough" mothering in the context of schizophrenia. Questions explored are the stigma against motherhood in this population, mothers' painful choices, issues of contraception, abortion, child custody, foster care and kin placement of children, the effects of antipsychotics, specific perinatal delusional syndromes, and, finally, the availability of parental support. This review is intended for clinicians. Recommendations are that care providers work collaboratively with mothers, take note of their strengths as well as their failings, offer a wide array of family services, monitor households closely for safety and for treatment adherence, appreciating the many challenges women with schizophrenia face daily.

Schizophrenia in Women: Clinical Considerations

Men and women, for biologic and sociocultural reasons, differ in the nature of their risks for schizophrenia and also in their care needs. Women with schizophrenia have several reproduction-associated risks and care needs that require special clinical consideration. They also have several specific risks related to antipsychotics and gender-associated needs not necessarily related to biology. These require clinicians' diagnostic acumen, treatment skills, cultural sensitivity, and advocacy know-how. Although this does not pertain to everyone, awareness on the part of clinicians is essential. This article addresses the current evidence for difference.

[Mother brain: Bayesian theory of maternal interoception during pregnancy and postpartum]

The perinatal period, including pregnancy and postpartum, causes major morphological, endocrinal, and thermal transitions in women. As the fetus grows, abdominal muscle fibers stretch, internal organs such as the bladder or colon move, and the uterine anatomy changes. Many of these changes involve interoception, the perception of internal body signals such as muscle and visceral sensations. Despite the importance of these interoceptive signals, few studies have explored perinatal interoception. We propose an innovative theory of maternal interoception based on recent findings in neuroscience. We show that interoceptive signals processing during pregnancy is crucial for understanding perinatal phenomenology and psychopathology, such as maternal perception of fetal movements, maternal-infant bonding, denial of pregnancy, phantom fetal movements after childbirth, pseudocyesis or even puerperal delusion. Knowing the importance of these interoceptive mechanisms, clinicians in obstetrics, gynecology and mental health should be particularly vigilant to maternal interoception during the perinatal period.

Delusion of Pregnancy: A Case Report and Literature Review

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.

Delusion of Pregnancy in Down Syndrome: Two Case Reports

Individuals with intellectual disability (ID) are more vulnerable to psychotic disorder and schizophrenia than the general population. However, psychotic symptoms have not been widely described in this population. Here, we deeply investigated the cases of two young women with ID and Down syndrome (DS) who developed a delusion of pregnancy, a rare condition defined as a fixed belief of being pregnant despite factual evidence to the contrary. The assessment included psychopathological and neuropsychological examination, as well as the evaluation of cognitive and adaptive functioning. In these cases, delusion manifested as a psychotic symptom of a cyclothymic disorder (case 1) or as an independent delusional disorder (case 2). However, some similarities emerged: both women exhibited good pre-morbid adaptive functioning and family history of psychiatric disorders; moreover, in both cases delusion emerged in association with an external trigger. Difficulties in verbally expressing one's thoughts and beliefs were found, as well as poor abstract reasoning skills that may have affected the ability to deeply conceptualize the delusional idea itself. These findings may provide crucial insights into the clinical manifestation of psychosis in individuals with DS and underscore the importance of a routine psychological and neuropsychological follow-up to provide prompt and adequate intervention.

Collaboration between Psychiatrists and Other Allied Medical Specialists for the Treatment of Delusional Disorders

Background: There is increasing evidence that individuals with psychosis are at increased risk for cardiovascular disease, diabetes, metabolic syndrome, and several other medical comorbidities. In delusional disorder (DD), this is particularly so because of the relatively late onset age. Aims: The aim of this narrative review is to synthesize the literature on the necessity for medical collaboration between psychiatrists and other specialists. Methods: A non-systematic narrative review was carried out of papers addressing referrals and cooperation among specialists in the care of DD patients. Results: Psychiatrists, the primary care providers for DD patients, depend on neurology to assess cognitive defects and rule out organic sources of delusions. Neurologists rely on psychiatry to help with patient adherence to treatment and the management of psychotropic drug side effects. Psychiatrists require ophthalmology/otolaryngology to treat sensory deficits that often precede delusions; reciprocally, psychiatric consults can help in instances of functional sensory impairment. Close collaboration with dermatologists is essential for treating delusional parasitosis and dysmorphophobia to ensure timely referrals to psychiatry. Conclusions: This review offers many other examples from the literature of the extent of overlap among medical specialties in the evaluation and effective treatment of DD. Optimal patient care requires close collaboration among specialties.

Delusion of pregnancy: Conception in brain

Delusional disorders are common psychiatric disorders, but a delusion of pregnancy is a rare condition. Four cases that presented at a single tertiary care psychiatry center with delusion of pregnancy as a part of different psychological disorders are illustrated here. These cases were seen over a period of 6 months and had varied presentations and associated psychopathologies. Three of the four patients showed rapid recovery to treatment, but one patient was lost to follow-up. The heterogeneity in the presentation, sociodemographic profile of the patients and even in the symptom profile and response to treatment in this condition is highlighted and discussed in this case series.

Delusional Disorder in Old Age: A Hypothesis-Driven Review of Recent Work Focusing on Epidemiology, Clinical Aspects, and Outcomes

The theme, strength, and duration of a delusion are considered important in distinguishing one psychosis of old age from another. Research results, however, are mostly based on studies conducted on one form of psychosis, namely schizophrenia. The aim of this hypothesis-driven narrative review is to gather clinically important information about the psychosis identified as delusional disorder (DD), as it affects persons of senior age. We hypothesized that DD becomes relatively prevalent in old age, especially in women; and that it is associated with demonstrable brain changes, which, in turn, are associated with cognitive defects and poor pharmacological response, thus increasing the risk of aggression and suicide. Computerized searches in PubMed and ClinicalTrials.gov were conducted using the following search terms: (delusional disorder) AND (elderly OR old OR aged OR psychogeriatrics). A total of 16 recent studies (including case reports) were reviewed. Our hypotheses could not be definitively confirmed because research evidence is lacking. In order to improve eventual outcomes, our literature search demonstrates the need for more targeted, well-designed studies.

Medical considerations in delusion of pregnancy: a systematic review

PURPOSE

Delusions of pregnancy are associated with functional impairment and psychological distress. Previous works have focused on characterizing their etiology and identifying contributory social and cultural factors. The purpose of this review is to give an overview of the literature on medical or surgical comorbidities associated with delusions of pregnancy.

METHODS

We searched Google Scholar, PubMed, and PsycInfo using the terms "pregnancy delusion," "delusional pregnancy," "pseudocyesis", and "false/pseudo/phantom/spurious pregnancy" to identify all published cases of delusional pregnancies. We included cases in which medical or surgical factors might have contributed to the delusion. We extracted the following information from selected case reports: patient age, psychiatric diagnoses, medications, medical comorbidities, somatic complaints, treatment, and outcome.

RESULTS

We found that 23 of 140 cases (16.4%) were potentially influenced by concomitant medical or surgical conditions including gallstones, abdominal tumors, hyperprolactinemia, constipation, a tubal cyst, and esophageal achalasia. Medical or surgical treatment was pursued in 15 of these 23 cases, followed by mitigation of the delusion in ten cases.

CONCLUSIONS

We emphasize the importance of a thorough workup including physical and gynecological examinations in patients presenting with a delusion of pregnancy. Clinicians should recognize and overcome potential barriers to undertaking comprehensive assessments in order to prevent delays in management and treatment of underlying medical or surgical conditions.

Pseudocyesis Leading to Folie-à-Deux

Pseudocyesis or false belief of pregnancy is the emergence of classical manifestations of pregnancy—nausea, breast enlargement and pigmentation, abdominal distention, amenorrhea, and labor pains—in a nonpregnant woman. It is a multifactorial disease and its development is influenced by many different elements such as neuroendocrine, social, psychodynamic, and cultural issues. “Folie-à-deux,” is shared psychotic disorder, describes a syndrome in which delusion is transferred to another person who is more susceptible. Both individuals are closely related or know each other for a long time and typically live together in relative social isolation. In its commonest form, the individual who first develops the delusion (the primary case) is often chronically ill and typically is the dominant member in a close relationship with a more suggestible person (the secondary case) who also develops the delusion. Treatment options should also be kept in mind as antipsychotics themselves can increase prolactin levels and can lead to amenorrhoea and galactorrhea and can further strengthen patient’s belief about her pregnancy. This case highlights that the most important therapeutic step in the treatment of folie-à-deux is separation of the inducer and the induced. Here we describe a case of folie-à-deux of a married couple in which the female had delusional pregnancy while the husband shared and supported her delusion against substantial medical evidence.

Addressing Delusions in Women and Men with Delusional Disorder: Key Points for Clinical Management

Delusional disorders (DD) are difficult conditions for health professionals to treat successfully. They are also difficult for family members to bear. The aim of this narrative review is to select from the clinical literature the psychosocial interventions that appear to work best for these conditions and to see whether similar strategies can be modeled or taught to family members so that tensions at home are reduced. Because the content of men's and women's delusions sometimes differ, it has been suggested that optimal interventions for the two sexes may also differ. This review explores three areas: (a) specific treatments for men and women; (b) recommended psychological approaches by health professionals, especially in early encounters with patients with DD; and (c) recommended psychoeducation for families. Findings are that there is no evidence for differentiated psychosocial treatment for men and women with delusional disorder. What is recommended in the literature is to empathically elicit the details of the content of delusions, to address the accompanying emotions rather than the logic of the presented argument, to teach self-soothing techniques, and to monitor behavior with respect to its safety. These recommendations have only been validated in individual patients and families. More rigorous clinical trials need to be conducted.

Men and women respond differently to antipsychotic drugs

BACKGROUND

Because women are often perceived as having better outcomes than men in psychotic illnesses such as schizophrenia - women are less often in hospital, have a lower suicide rate, are less often involved with the law, enjoy better relationships with family and friends - the question arises as to whether or not this apparent advantage is attributable to a gender difference in antipsychotic response.

OBJECTIVE

The aim of this paper is to critically review the quantitative and qualitative literature on gender difference in antipsychotic response sourced mainly from medical databases of the last ten years.

FINDINGS

There are theoretical reasons why women's effective doses of antipsychotics might need to be lower than guidelines recommend for men, especially as regards olanzapine and clozapine, but, because there are so many variables that impinge on antipsychotic response, it is difficult to provide definitive guidance. What is evident is that some antipsychotic side effects, weight gain for instance, are more worrisome for women than for men. It is also evident that, after menopause, women need an increase in their antipsychotic dose; other reproductive stages in women's lives require special prescribing considerations as well.

CONCLUSION

There is a science, and an art, to prescribing antipsychotics, which needs to take gender into account. This article is part of the issue entitled 'Special Issue on Antipsychotics'.

A 39-year-old man with schizophrenia and tuberous sclerosis with a delusion of being a pregnant woman-A case report

We present a case of a married man, known case of schizophrenia and tuberous sclerosis, who presented with delusion of pregnancy along with other psychotic symptoms. This type of delusion can be attributed to wish fulfillment as the patient has been married for seven years without being able to conceive.

Understanding the Delusion of Theft

The elderly with dementing illness often present with psychotic symptoms such as delusions, but the thematic content of delusions in the elderly differs from that of delusions expressed by younger individuals, and can be pathognomonic of early dementia. The aim of this paper is to review the recent literature on the delusion of theft, the most prevalent delusion in the elderly, in order to arrive at a deeper understanding of its sources and to identify successful therapeutic approaches. The literature from 2000 to the present was searched on the Google Scholar database using relevant search terms. Several older classical papers were also referenced. Understanding the origins of the delusion of theft - multiple losses, attempts at attributing such losses to an outside source, attempts at reliving a happier past - helps in devising responses that are comforting to the patient. The distress that often accompanies the delusion of having been robbed can be decreased by nursing home improvements in the handling of personal possessions, by the correction of sensory deficits, and by the provision of activities that distract from loneliness. Attention to stimuli that trigger the delusion helps to limit its occurrence. Medications may help, but can sometimes make matters worse. Understanding that delusional thinking can arise from sensory and cognitive deficits is critical to empathic caregiving and also to the lessening of caregiver burden.

Women who suffer from schizophrenia: Critical issues

Many brain diseases, including schizophrenia, affect men and women unequally - either more or less frequently, or at different times in the life cycle, or to varied degrees of severity. With updates from recent findings, this paper reviews the work of my research group over the last 40 years and underscores issues that remain critical to the optimal care of women with schizophrenia, issues that overlap with, but are not identical to, the cares and concerns of men with the same diagnosis. Clinicians need to be alert not only to the overarching needs of diagnostic groups, but also to the often unique needs of women and men.

Erotomania and Recommendations for Treatment

The aim of this paper is to help clinicians better understand how erotomania originates in order to facilitate treatment and make it more effective. Data sources are the narratives of six women who spoke in detail about the beginnings of their delusional beliefs and about the nature of the evidence that convinced them that their beliefs were well-founded. In every case, low self-esteem and emotional arousal preceded the emergence of the delusion. Misperceptions and misattributions appeared responsible for keeping the delusion alive. Despite external disconfirmation, social isolation protected the delusional beliefs from revision and extinction. The erotomanic delusion provided a sense of well-being that probably contributed to its maintenance. As well, a delusion-induced boost in well-being delayed help-seeking. Recommendations for treatment include staged interventions, first establishing a therapeutic alliance with a focus on understanding the psychological factors contributing to the origin and maintenance of the delusion. The next stage is the provision of social support and strategies directed at the restoration of self-esteem. The third stage is the gradual introduction of techniques to correct cognitive biases. Medication and risk management form an integral part of overall management. Objective evidence for the effectiveness of this approach is, however, not yet available.

Issues related to sex differences in antipsychotic treatment

PURPOSE OF REVIEW

The effectiveness, side-effect profiles, and numerous other characteristics of antipsychotic medications have been extensively studied. However, the majority of publications do not address the many potential sex differences in efficacy and doses of medications, as well as other sex-specific considerations.

RECENT FINDINGS

Of studies that exist, some suggest that female patients respond to lower doses of antipsychotic medications than males and that side-effect profiles vary between the sexes. However, the majority of preclinical trials use only male laboratory animals, and human clinical trials consist of too few women to analyze their response as a separate group.

SUMMARY

Although changes in hormone production occurring at multiple stages throughout a women's life (such as during pregnancy, breast feeding, menopause, and postmenopausal) are presented as too complex to deal with in clinical trials, they could instead be embraced as clinical dilemmas that require additional study and consideration. We suggest that a focus should be made to reanalyze data from existing major treatment trials of antipsychotics to determine what medications specifically provide the most efficacy for female patients and at what dose range. In addition, new prospective studies are needed to specifically address appropriate adjustments in psychopharmacologic treatment for female patients during pregnancy, and when postmenopausal. More studies of the effects of antipsychotics on male and female fetuses in utero and during breast feeding are also needed to better manage women with schizophrenia and their offspring on a long-term basis in the community. There is currently too little known about sex differences in neuropharmacology. With the new USA National Institutes of Health policy to include sex in all new proposals, the time has come to close this gap in knowledge.

Delusions of pregnancy in older women: a case series

BACKGROUND

Delusions of pregnancy have been reported in a wide variety of functional and organic psychiatric conditions but rarely with dementia. Most such delusions arise in women of child-bearing age. We report five cases in older women all of whom had severe constipation that probably precipitated this delusion.

CASE REPORTS

Of the five women (age 74-89 years), two had dementia, two had delirium and one had both. All patients had borne healthy children. Three women reported that they were in labour, and one was concerned that the baby was not moving. All had severe constipation on examination or imaging, and three had faecal impaction. All were treated with laxatives or enemas, and only one patient required brief antipsychotic therapy. The delusions lasted from a few hours to 5 days. In general, resolution of the delusion occurred in concert with improvement in bowel function, although in one case a large bowel movement was followed by the delusion that a baby had been born.

CONCLUSION

These cases suggest that misinterpretation of abdominal symptoms due to severe constipation in cognitively impaired women may trigger the delusion of being pregnant and that treatment of constipation often leads to resolution of the delusion.