J Neurol Psychiatry: first published as 10.1136/jnnp.6.1-2.17 on 1 January 1943. Downloaded from

THE PSYCHO-SOMATIC SYNDROME OF SPURIOUS AFTER THE MENOPAUSE

BY BETTY JACOBS Assistant Physician, Royal Edinburgh Hospitalfor Mental Disorders (RECEIVED 23RD OCTOBER, 1942) Spurious pregnancy ( or pseudo- satisfied in attributing it to wish fulfilment. The cyesis) constitutes a subject of considerable practical discrepancy, however, between the number of cases importance not only for the general practitioner and with a strong desire for pregnancy and those actually obstetrician but also for the psychiatrist, as it pre- presenting signs of pseudocyesis makes it clear that sents one of the most impressive examples of the wish fulfilment can result in the production of this influence of emotional mechanisms on physical particular psycho-somatic syndrome only under processes. certain conditions, still to be defined. The occurrence of this condition in and The following case represents a contribution to the animals has attracted attention throughout the ages, understanding of some of those conditions. one of the earliest descriptions being found in the writings of Hippocrates. Paddock, who in 1928 made Mrs. E. S. aet. 53 was admitted on 24th September a the 1941. Family history: The mother, to whom the patient survey of literature on that subject viewed from was unduly attached, is described as a quiet, sympathetic the obstetric aspect, quotes various authors, among with a deeply religious outlook. She was a mid- them James Y. Simpson and wife of repute. The father, who was 13 years older than

Montgomery (1863). copyright. The psychological significance of the syndrome, how- his wife, died when the patient was 7 years of age. No nervous or mental illness has been reported in the family. ever, has not received adequate attention. While Personal history: The patient was the only . She some authors maintain that pseudocyesis is found describes her early childhood as happy; but she was mainly in women of the 25-35 age period, Simpson always solitary and introspective. So strong was her and Montgomery emphasize its more attachment to her mother that she disliked leaving home frequent to go to school. She recalls scenes when she wept at the association with the climacteric period. Paddock very thought of leaving her mother and she found it maintains that most of the cases reported were young difficult to mix with other children, her contact with her women. He regards false pregnancy at the climac- schoolmates being entirely superficial. Occasionally teric as part of the general she suffered from " bilious turns," during which she http://jnnp.bmj.com/ menopausal syndrome. enjoyed a sense of pleasure and satisfaction because she Maranon (1929) supports Simpson and Montgomery could remain beside her mother and have her special in their view that the frequency of the condition is care and attention. She was obsessed with the idea that highest at the climacteric and classifies the condi- she was different from her friends and became progress- tion as a metabolic ively more dependent on her mother, the only person in disturbance originating from whom she could confide and from whom she could emotional causes. " In women whose desire to derive comfort and encouragement. The remain young makes them forget how old they are occurred at the age of 131; was irregular . . .it is striking to note how the suppression of the until the age of 18 when a normal cycle was established. menses coincides with a general increase in According to herself, she was small and under-developed on September 29, 2021 by guest. Protected the size until the age of 18, when she began to develop normally of the abdomen." He states that the condition may and her outlook became less solitary and dependent. be due to an unfulfilled desire to have children or to At the age of 191 she married, her husband being an effort at self-deception that sexual power may not 12 years older then herself. She says that because of his yet be lost. Schwarz age she was less afraid of him than of most other men and (1933) states that pseudocyesis that he gave her a feeling of protection akin to that tends to occur mainly in women with a premature which she had come to associate only with her mother. menopause. From the psychiatric point of view, That feeling of dependence remained a prominent feature Kehrer (1928) has recently surveyed the literature of her relationship to him. Her attitude towards the and reported on his own physical side of marriage was always immature * she was observations. He says that frigid and constantly harboured a fear of becoming preg- the supposition ofpregnancy may be the outstanding nant. This fear was fostered by her mother who thought delusion in a psychosis and that in many instances childbirth undesirable for her daughter because of her mental phenomena may be present in a marked delicate childhood. Consequently the patient sub- degree even in the absence of mitted to intercourse only infrequently, and then only bodily changes. The when- coitus interruptus was practised. Only in the most recent review of the literature has been con- 13th year of their marriage did normal intercourse take tributed by Moulton (1942). place on a few occasions and it was then that she became Those authors who have stressed the psycho- pregnant. Even now she complains that her husband pathological implications of the took advantage of her and that the pregnancy should condition have been never have occurred. Throughout the pregnancy she C 17 18 BETTY JACOBS J Neurol Psychiatry: first published as 10.1136/jnnp.6.1-2.17 on 1 January 1943. Downloaded from was unhappy and fearful, she had persistent hyperemesis, about her "pregnancy" and kept on asking other lost her appetite and on several occasions during the latter patients whether she would be all right. 3 months visited her doctor in a state of extreme agita- Phy sical Examination. Her abdomen was distended tion because she had ceased to feel life. She kept saying and firm, the swelling reaching the level of the umbilicus. that something dreadful was going to happen. Her In shape it was broader than that found in pregnancy, no physical condition was poor at the time of delivery, foetal parts could be felt and no foetal heart could be labour lasted for 2 days and was preceeded by 3 panic located. She could simulate foetal movements by con- attacks, during which she was very agitated and main- tracting and relaxing the abdominal muscles. No dull- tained that labour had commenced. Inertia persisted ness could be elicited on percussion, the note being throughout the labour and the patient was quite unco- hypertympanitic all over, suggesting the condition of operative. A forceps delivery was performed and the meteorism. The were full and enlarged and baby, a , was stillborn. The puerperium was cha- from the nipple a serous secretion could be expressed. racterized by apathy and lack of initiative and her Vaginal examination revealed no evidence of pregnancy. recovery was very gradual. Information received from a The was elongated and lacerated, the scar causing friend suggests that she had a melancholic at marked puckering of the edges. There was some laxity this time. She became more shy and secretive and the of the pelvic floor and the perineum was deficient. The doctor advised the husband that the patient should have , however, was in good position, quite mobile, and another child. She became pregnant 2 years later. of normal size. The appendages were palpable on both Though she had the same fears and apprehensions as in sides and the right was very slightly enlarged. The the first pregnancy, her physical condition was satis- Aschheim-Zondek Reaction was performed and the factory and hyperemesis much less persistent. The result was weakly positive. Two weeks later this was labour, like the first, was complicated by inertia but repeated with a negative result. delivery was spontaneous and this child, a , was alive. At first, repeated reassurances that she was not preg- She made a good recovery, took an interest in the child nant did not have the slightest effect. She was treated by and became very devoted to him. She remained as psychotherapy and although she was very unco-operative reticent as ever with strangers, but in the home she was less in the initial stages, she was later more readily influenced. quiet and secretive. Her whole life had obviously been She began to talk more freely about herself, said she had made much happier by the arrival of the baby. Four wanted to have another child, that she had never got over years later, however, when her husband developed the disappointment of the stillbirth, and that even the phthisis, she reverted to her former anxious state with its birth of her son had not compensated her for the loss of inhibitions and feelings of inadequacy. After his death the daughter. About six weeks after admission, she 6 months later, she made her home with her mother as admitted that she was not pregnant, and her depression she had done before her marriage. She made a good gave way to a state of comparative contentment. Never- adjustment to this life and was contented and happy until theless, the physical signs simulating pregnancy per- the death of her mother 2 years prior to admission. She sisted; but a week later the abdomen " deflated " became very depressed and felt that a part of herself had overnight, the secretion ceased and the Aschheim- died with her mother. She lost all initiative, took no Zondek Reaction gave a normal result. During this interest in anything, had no appetite, slept badly and remission, she was examined by Professor R. W. John- copyright. could see no hope for her son or herself. While she was stone, who recommended that a plastic operation be in this depressed condition, the incident occurred which, performed to repair the pelvic floor. This was done on according to her, was responsible for her " pregnancy." 22nd December, 1941, with a very good result. She was In March, 1941, an old schoolfriend, who was in the reassured about her pelvic condition at the time of the habit of visiting her home, " ravaged her in her grief." operation and she was quite convinced that there had The vague manner in which she recounts the story makes been no pregnancy whatsoever. At the same time, she it seem very doubtful whether that incident actually volunteered the information that her illness might have occurred. Previous to the alleged , her periods had been due to the great disappointment she had suffered become very irregular and they ceased altogether there- at the time of the stillbirth. She remained well until after. At that time her depression became more profound early March, when she again became depressed, saying http://jnnp.bmj.com/ and was aggravated still further by the fear of separation that the baby was almost due. This episode, however, from her son who had become eligible for military service. lasted for only two weeks and she was readily persuaded When no further periods occurred, she developed the idea that no pregnancy was present. At that time, the delu- that she was pregnant. She blamed herself for the sin she sion was associated with none of the symptoms or had committed and contemplated suicide. She rejected phvsical signs of pregnancy. After two months remission all the assurances from her doctor that no pregnancy she was found to have hidden a brick and a piece of rope existed and after a further six weeks she maintained that in a cupboard with suicidal intent. Her depression had she felt life. Her depression and agitation became so returned and she was obsessed with the idea that there marked that she had to be admitted to this hospital as a was a tumour in her abdomen. This delusion soon certified patient. reverted into the idea of pregnancy and impending labour on September 29, 2021 by guest. Protected without any of the previous physical manifestations. Coniditiont oni acldmiissioni. The patient was depressed The associated depression and agitation had also and agitated. Her first question was whether she could recurred. be taken to a maternity hospital lest the baby should 30th September, 1942. The patient has been given a arrive very soon. She was concerned about whether the course of electro-convulsant therapy, consisting of seven necessary facilities for childbirth were available here. treatments, during the past three weeks. After the Though she expressed the fear that she might die during second treatment, she lost the idea of pregnancy, but was labour, her main worry seemed to be concerned with still depressed. After the fourth treatment, the de- what the neighbours at home might say of her. In par- pression was replaced by a state of contentment and by ticular she was worried lest they might believe that her the end of the course, the patient had become slightly son was the father of the child. She gave a very sug- euphoric. The idea of pregnancy has not recurred- gestive history of her symptoms usually associated with April, 1943. The patient was discharged on 22nd March, pregnancy: morning sickness, frequency, pains in the 1943. She has completely recovered. breasts, discharge from the nipples, quickening at the 14th week, pain at the small of the back and discomfort when walking. She said that lately her abdomen had Summary been enlarging. . She was in a state of utter despair This is the case of a widow of 53 who, at the and repeatedly blamed herself for the disgrace she had time of the cessation of the brought upon herself and her son, saying that if her menstruation, expressed mother had been alive all this would never have hap- idea that she was pregnant, attributing conception pened. She slept badly, resisted feeding, talked only to an alleged rape. Her general mental condition PSYCHO-SOMATIC SYNDROME OF SPURIOUS PREGNANCY AFTER MENOPAUSE 19 J Neurol Psychiatry: first published as 10.1136/jnnp.6.1-2.17 on 1 January 1943. Downloaded from was that of an involutional depression which had first child during delivery. The development of a been precipitated by the death of her mother and her melancholic reaction after the stillbirth is of special whole emotional life was centred round the supposed interest in view of the results of a recent investigat on pregnancy. On admission she presented the typical into the ttiology of such psychoses carried out by the signs of pseudocyesis including positive hormonal author in this hospital. It has been shown that these reactions. These signs, however, disappeared in the conditions tend to be of the depressive type and that 8th month of the alleged pregnancy and have not strong aversion or ambivalence towards pregnancy recurred. The disappearance of these signs coin- can usually be demonstrated. It is probable that cided with a complete remission of her mental the conscious aversion which this patient had shown condition which was, however, only temporary. towards pregnancy in the past originated partly in With a subsequent relapse into her previous depres- her neurotic trends resulting in psychosexual imma- sion, the idea of pregnancy recurred. The previous turity, and partly in the fact that her mother, with personality was characterised by neurotic trends whom the patient had identified herself all her life, with features of and an unduly strong mother had discouraged her from having children. This fixation which the patient has never been able to latter circumstance must have had a profound effect resolve. She remained psychosexually immature, on the patient who had never succeeded in resolving was frigid and could never establish a normal her mother fixation. Her whole history bears out relationship to her husband. Her attitude towards the tendency to subordinate herself to her mother, her previous was that of fear and aver- and it is interesting to note that it was not until sion throughout her reproductive period. Her first after the mother's death, which coincided with theend pregnancy, occurring 13 years after marriage, of her own reproductive period, that the imaginary resulted in a stillbirth and was followed by an rape occurred. It is likely that her abnormal mother abnormal mental reaction, suggestive of a melan- fixation had been responsible for the sexual repres- cholic depression. Two years later, she gave birth sion which had characterized her life throughout the to a normal child. Both pregnancies were compli- active reproductive phase, and that the ideas of rape cated by hyperemesis and abnormal anxiety reac- and pregnancy were the products of a compensatory tions, while both labours were inert. When she was mechanism. It is characteristic not only of her widowed 4 years after the birth of her second child, personality type bUt also of the depressive condition she returned to her mother's home. The death of she presented that she reacted with a strong sense of her mother 2 years previous to admission was fol- guilt to those ideas. It is noteworthy that she copyright. lowed by a severe depressive reaction with melan- expressed a fear of being suspected of an incestuous cholic features. This depression persisted until the relationship with her son.-The complete psycho- delusion of pregnancy developed. The fear of somatic syndrome of pseudocyesis presented in this separation from her son constituted an additional case persisted only for the first 8 months of her illness source of apprehension. and thereafter physical signs have been absent even when the idea of pregnancy has recurred. The Comment appearance of those signs can be interpreted as a

This patient belongs to the group of cases de- last effort on the part of the reproductive system http://jnnp.bmj.com/ veloping false pregnancy during the climacteric while it is still capable of responding to stimulation. period ; the cessation of menstrual functions was From the psychiatric point of view it would not be certainly one of the precipitating factors in the reasonable to regard the disappearance of those development of the syndrome. The idea of preg- physical signs as the resolution of the condition of nancy occurred while she was still mourning the loss spurious pregnancy. It seems appropriate to of her mother and dreading the impending separa- describe false pregnancy as a psycho-somatic syn- tion from her son. The delusion developed on the drome which may be either complete or merely background of an involutional depression and her abortive. In some cases the physical symptoms are on September 29, 2021 by guest. Protected entire emotional life became absorbed in the idea of primitive nature only, while the full psychological of pregnancy. Her conscious attitude towards that syndrome is present ; in other cases, particularly pregnancy was one of fear and guilt, but it was in younger women, the emphasis is laid on physical evident that at the same time the pregnancy satisfied signs of the syndrome, while the mental components a strong subconscious desire. In one of her remis- remain more latent. sions when she had regained insight, the patient The following case shows the typical psychological explained her delusion on the basis of a compensa- syndrome of false pregnancy with only abortive tion for the disappointment she had suffered by the physical signs. stillbirth of her first child. It is noteworthy that the attitude of this patient towards pregnancy and Mrs. E. B. aet. 53, admitted on 13th July, 1942. childbirth during her active reproductive period had Family history was negative for nervous and mental ill- been characterized by aversion and ness. She had always been well exteriorized and there anxiety, and this was nothing unusual in her relationship to her parents. attitude was obviously responsible for the complica- She was married when she was 28, but she felt no real tions-hyperemesis, false labours, inertia, and puer- affection for her husband. She has always been frigid. peral depression. Further, it is not beyond possi- Of her 4 pregnancies, the first and third resulted in early bility that the inertia, which was miscarriages. Her first child died at the age of 3 and of obvious nervous the second child, a daughter, is alive and healthy. Her origin, may have contributed to the death of the family life was fairly happy until 10 years ago, when she 20 BETTY JACOBS J Neurol Psychiatry: first published as 10.1136/jnnp.6.1-2.17 on 1 January 1943. Downloaded from felt an increasing aversion to . Later syndrome can be found in the great majority of her husband became an alcoholic and he died from cases who the idea of after pneumonia in March 1942. During recent years she express being pregnant had become progressively more jealous and suspicious. the end of the reproductive period. It is note- Her menstrual periods had ceased suddenly at the age worthy that both patients had borne children, but of 35 for no known reason (the only abnormality to be in both cases " obstetric catastrophies" had acted found at that time was an extreme retroversion of the as mental traumata in the uterus). After the death of her husband, her increasing past. and paranoid attitude towards her environ- The previous historvof the second case had again ment made her admission to this hospital necessary. much in common with the histories of women who When she was examined for certification, she expressed are apt to develop abnormal mental reactions to real for the first time the belief that she was pregnant. the of those Condition on admission.-The patient was in a state of childbirth; psychosexual make-up mild elation, she was fully orientated and did not mind cases has been described by Zilboorg. This case being brought to hospital. The whole thought content too, suggests that it would be profitable to study all was taken up with her supposed pregnancy. She said mental changes with the content of thought centred that the film star Clark Gable had made her pregnant round as to one " through an automatic." She denied having had inter- reproduction belonging large course with him, said that she had met him before she group as far as the dominant complex is concerned. had met her husband and that he was in love with her but The psycho-somatic syndrome of spurious preg- that she was not in love with him, and that she had refused nancy would be one of that group; the other con- to marry him. Through the same " automatic " she in that context heard the voice of Clark Gable and she maintained that ditions to be studied would be through the medium of this same apparatus she was neurotic and psychotic reactions during pregnancy, examined regularly by an eminent obstetrician who came puerperium and ; certain hypochondriacal to reassure her about the wellbeing of the baby. She conditions occurring at the menopause and deriving was completely inaccessible to reason, maintaining that the same she was in the 8th month of her pregnancy and that she the content of thought from complex would could feel life. When it was pointed out that she pre- have to be included. It can be assumed that the sented no physical signs of such a condition she demon- idea of pregnancy in the climacteric period is, strated rhythmic contractions of the abdominal muscles psychogenetically, the antithesis of hypochondriacal which, according to her, were produced by the move- and ment of the child. Physical examination was completely ideas associated with that age period finding negative apart from those rhythmic movements described expression in complaints of hollowness, emptiness above. The hormonal reactions were negative. and sometimes amounting to nihilistic ideas. The existence of a psychological relationship between In this case the idea of pregnancy arose on the pregnancy and hypochondriacal complaints of this copyright. background of a paranoia developing in the climac- nature is borne out by the observation that such teric period. Death of the husband occurring pre- complaints frequently occur in the course of depres- vious to the appearance of that idea may have acted sive mental changes following childbirth. All as a precipitating factor. This patient, like the mental changes centred round the complex of repro- first one reported, had been frigid during the whole duction have it in common that they are not of the reproductive period and she, too, had never associated with a specific mental illness, and that recovered from the disappointment she had suffered they occur on the background of psychoses as well as

through previous miscarriages. The imaginary neuroses. http://jnnp.bmj.com/ pregnancy was attributed to a union with a fantasy It is clear that the observations of the two cases hero; even that delusional sexual relationship was presented in this article do not permit of any general characterized by frigidity and ambivalence. This conclusions regarding the aetiology of the psycho- patient showed no external physical signs, apart somatic syndrome of spurious pregnancy. How- from contractions of the abdominal muscles. The ever, it has been possible to demonstrate the com- lack of response on the part of the generative plexity of the physiological [and psychological system may be attributable to the fact that in this factors which were operative in the production of case, as distinct from the other, the idea of pregnancy that syndrome in the cases described. It may on September 29, 2021 by guest. Protected had occurred many years after the unusually early sometimes be difficult to trace the psychogenic cessation of the ovarian activity; it may also be factors in non-psychotic patients though the very due to the fact that in this case, the emotional coarse nature of that conversion symptom makes it reactions were less profound than in the first and unlikely that the underlying psychological mecha- that the patient in her delusions had completely nisms would remain completely hidden in the parted from reality ; the character of the psychosis unconscious. * which in this case formed the background of the idea of pregnancy makes it understandable that the delu- Conclusions the whole of the sion did not take possession of Two cases of spurious pregnancy occurring in psycho-somatic personality. However, physical women after the end of the reproductive period have signs were not entirely lacking and the rhythmic been described. In both cases the idea of pregnancy movements of the abdominal muscles may be formed the dominant content of thought in a regarded as an abortive expression of the physical part of the syndrome. Such movements were also * An interesting historic example of spurious pregnancy occurring towards the end of the reproductive period in a non-psychotic woman observed in the first case and both patients denied was Mary, Queen of England (1553-1557), the daughter of Henry VIII; in her case, the overwhelming environmental influences during child- that they produced them voluntarily. It can be hood and life, cooperating in the origin of the syndrome can be assumed that similar abortive physical signs of the easily traced (vide J. E. Neale, Queen Elizabeth, London, 1934). J Neurol Psychiatry: first published as 10.1136/jnnp.6.1-2.17 on 1 January 1943. Downloaded from PSYCHO-SOMATIC SYNDROME OF SPURIOUS PREGNANCY AFTER MENOPAUSE 21 psychosis which in the first case was of the involu- reactions following childbirth. It has been sug- tional melancholic, in the second case of the para- gested that the syndrome of spurious pregnancy noid type. The prepsychotic personalities were occurring after the end of the reproductive period characterized by psychosexual immaturity and there should be studied in the context of the whole group were histories of stillbirth and miscarriages which of mental changes associated with the functions of had acted as severe mental traumata. A variety of the reproductive system, including hypochondriacal environmental factors predisposing to the formation conditions following the menopause. of the idea of pregnancy could be demonstrated. I wish to thank Professor D. K. Henderson for his The first patient had had a depressive mental advice in the preparation of this paper. reaction of the melancholic type following still- birth. In that case physical signs and hormonal REFERENCES reactions suggestive of pregnancy were present for Jacobs, B. (1943). J. ment. Sci., 89, 242. some time ; in the second case physical signs were Kehrer, E. (1928). Handb. Biol. Path. Weibes, Wein- Leipzig; 6, 714. only abortive. Maranon, G. (1929). The Climacteric. London. Spurious pregnancy has to be regarded as a Montgomery, W. F. (1857). The of psycho-somatic syndrome, the completeness of Pregnancy, Blanchard and Lea, Philadelphia which depends on a variety of factors, the most (quoted by Paddock). important being the Moulton, R. (1942). Psychomat. Med., 4, 376. condition of the reproductive Paddock, R. (1928). Amer. J. Obstet. Gyntc., 16, 845. system and the extent to which the idea takes pos- Schwarz, 0. H. (1933). Obstetrics and Gynwcology. session of the whole personality. It has been London and Philadelphia. (Ed. by A. H. Curtis.) pointed out that the previous histories of the two 1, 675. cases Simpson, J. Y. (1863). Diseases of Women. Blanchard described had much in common with those and Lea, Philadelphia, (quoted by Paddock). found in women who develop abnormal mental Zilboorg, G. (1931). Amer. J. Psychiat., 10, 927. copyright. http://jnnp.bmj.com/ on September 29, 2021 by guest. Protected