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Home , False pregnancy, Pseudopregnancy

Cent. Eur. J. Med. • 6(6) • 2011 • 720-722 DOI: 10.2478/s11536-011-0086-1

Central European Journal of Medicine

Pseudocyesis as a cause of abdomen enlargement in a female adolescent

Case Report Veselin Škrabić*1, Željka Vlastelica1, Zoran Vučinović2

1 Department of Pediatrics, Split University Hospital Centre, 21000 Split, Croatia

2 Department of Endocrinology, Split University Hospital Centre, 21000 Split, Croatia

Received 10 October 2010; Accepted 20 July 2011

Abstract: Pseudocyesis is a rare condition in the pediatric population characterized by all signs and symptoms of except the ex- istence of a [1]. In some patients it is associated with organic etiology, in others with mental disorders, also occurs in those without disorders in their medical history. Pseudocyesis occurs in both sexes, but more frequently in women. An effective treatment is a combination of and pharmacotherapy with and [2]. We present a 15,9-year old girl with pseudocyesis as a cause of abdomen enlargement, who comes from an ordinary family with a negative history of psychiat- ric illness. The organic etiology of her condition was excluded, and therefore she was treated with antidepressants which contributed to the resolution of her case. Keywords: Abdomen enlargement • Adolescent • Pseudocyesis © Versita Sp. z o.o.

(Münchausen syndrome). Modern 1. Introduction classification categorize it into somatoform disorders [1]. Pseudocyesis occurs in patients with confirmed or- Pseudocyesis is a condition in which a non-pregnant per- ganic cerebral or endocrinologic dysfunction, in patients son believes that they are pregnant, with the presence with chronic mental illnesses, as well as in patients of all objective signs of pregnancy except the existence without mental or organic illnesses [2]. of the fetus. It is a syndrome reported since Hippocrates’ Numerous mechanical factors can convince a times, who 300 B.C. described 12 women who ˝believed woman that she is pregnant, for example: retention they were pregnant ˝ [3]. The most famous person who of intestinal gases, urine retention, abdominal tumor, had this syndrome was Mary Tudor, daughter of Henry tumor of , ovarian tumor, hydatid mole, papillar VIII and Queen of England in the 16th century. renal carcinoma, inflammatory processes, as well as Pseudocyesis is also mentioned in literature under numerous causes of primary infertility [2]. the names pseudopregnancy or false pregnancy [4]. In patients with a false pregnancy, a wish for pre- The term ˝pseudocyesis˝ was introduced by John gnancy and fear of pregnancy are often present at the Mason Good in 1823. based on Greek words pseudes same time, and usually occurs in women at the begin- = pseudo (false), and kyesis = pregnancy [2]. Some ning of [2]. There are also several cases of authors classify it under psychosomatic disorders, pseudopregnancy in men described in literature. They others consider it a manifestation of , while all had an underlying psychotic and neuroendocrinolo- according to the third group it is a monosymptomatic gical disorders, incomprehension of society, social iso- lation, confusion of sexual identity. In some cases they

* E-mail: [email protected] 720 V. Škrabić et al.

can even simulate [2]. Pseudocyesis in men marijuana once, and was consuming alcohol on rare is often connected to ˝Couvade˝ syndrome, also known occasions. During the diagnostic procedure she under- as the ˝emphatic pregnancy˝, occurs in the husband or went gynecological ultrasound and examination, thyroid other close relatives of the pregnant women [2,3]. and abdominal ultrasound, MSCT of the abdomen In treatment of pseudopregnancy throughout history and pelvis with contrast; laboratory findings including there were used purgatives, baths, massages, curetta- hematological and biochemical tests, tumor markers, ge, surgical procedures, leeches, emetics, tonics and thyroid hormones analysis, cortisol and ACTH in rhythm, opiates. Nowadays a treatment that consists of psy- Synacten test, FSH, LH, , total and free testo- chotherapy, pharmacotherapy with antidepressants or sterone, SHBG, androstendione, DHEA-S and 17-OHP antipsychotics, hormonal therapy and uterine curettage were within the reference values. All the mentioned test is effective in almost all the patients. It is recommended results ruled out the existence of pregnancy. After the to analyse beta-HCG, thyroid gland hormones, to do the diagnostic procedure the girl herself believed she was ultrasound and tomografy of the pelvis and present the not pregnant, wanted to “lose” the belly and weight. After results to the patient in order to persuade her that there the psychiatric examination she began taking an antide- is no pregnancy [2]. In 5% of the cases false pregnan- pressant ˝sertraline hydrochloride˝. One month after the cy recidivates. It is important to point out the forensic discharge from the hospital the patient had contractions, meaning of the disorder due to possible accusation of „“ began to leak, and she was re-hospitali- infanticide [2]. zed. In the nineth month of pregnancy she went through simulated labour and the belly eventually withdrew. 2. Patient Report 3. Discussion A 15,9-year old female patient was admitted due to an of unknown cause. The patient is Pseudocyesis as a cause of abdomen enlargement is a from a family without a history of psychiatric illnesses. condition characterized by the presence of all the signs The mothers pregnancy and birth was normal and had and symptoms of pregnancy except the existence of the a normal psychomotoric development. In elementary fetus. Throughout history it was a relatively common school she was a very good student, with appropriate disorder, though its number has been significantly re- behavior, but at the end of primary education she started duced due to the development of prenatal care [1]. In to behave impulsively. his autobiographical book Freud described the case of a Eight months before admission to the hospital she woman with a false pregnancy in the final phase of psy- had her first and only with a 19-year- choanalysis. Similar cases were described by Groddeck -old boy. During the next three months she started to 1923rd, Briehl and Kulka 1935th, and Abram 1969th, have irregular menstrual bleeding, she noticed the interpreting them as a positive transfer from patients to growth of her abdomen and said to the friends that she the therapist, because of a separation due to the was pregnant. She had nausea with vomiting only one imminent termination of the treatment [2]. morning, two weeks after the intercourse. Psychological changes are caused by hypotha- One of the home pregnancy tests she made lamic-hypophysial-ovarian dysfunction and can be was positive. described as galactorrhoea--hyperprolac- Her appetite increased, and her breasts enlarged tinemia syndrome (GAHS). In this syndrome there is simultaneously with the abdominal distension. She had an abnormality in the growth hormone, prolactin, ACTH no galactorrhoea, and did not feel fetal movements. She and cortisol, and it is similar to a depressive disorder. did not have enhanced pigmentation on her abdomen and deficit is responsible (linea nigra) nor areolar hyperpigmentation. During the for hyperprolactinemia and gonadal dysfunction. Basal last 1.5 months before admission she gained 15 kg, and level of prolactin increases in pseudocyesis, similar to had a lumbar lordosis. Her body measurements at the hypothyroidism. High prolactin level leads to , day of admission were: body height: 165.5 cm, body we- prolongs the existence of the , and also ight: 74 kg, BMI 27.2 kg/m2 (+1.87 SDS). She had acne results in amenorrhea, which could explain some of on the forehead and back, and was a slightly hirsute the symptoms of pseudopregnancy. Corpus luteum is a (Ferriman-Gallwey score 9). During the conversation primary source of , a hormone responsible she was oriented and communicative, responding to for initiating and maintaining pregnancy in mammals [4]. all the questions without hesitation. Thus we found out Therefore pseudocyesis must be taken into con- she was smoking cigarettes for last five years, tried sideration as a differential diagnosis in secondary

721 Pseudocyesis in a female adolescent

amenorrhea. All the patients with described GAH syn- Demaret so described the pseudopregnancy in patients drome do not necessarily believe they are pregnant, with [2,6]. whereas in patients with pseudocyesis it is primary [1]. These features were not present in our patient, as All the symptoms of pseudocyesis (irregularity of her appetite increased, and she gained weight. During , amenorrhea, abdominal distension, the conversation our patient was showing no fantasies changes in breast size and shape, lactation, areolar hy- of pregnancy nor suicide tendencies, accepting her con- perpigmentation, medial linea nigra, inverted umbilicus, dition as it was with aspiration of resolving it. However, increased appetite and increased body weight, lumbar during simulated labor she believed in her pregnancy, lordosis, nausea and vomiting, insisting on pregnancy which lasted until after the ˝delivery˝ took place and the and feeling fetal movements) were seen in our patient belly withdrew. except , linea nigra, areolar hyperpigmenta- Ayakannu et al. described a case of a 16-year-old tion and feeling fetal movements. Laboratory and image girl with the most common symptoms of pseudocyesis findings were within the reference values, therefore exc- except abdominal enlargement, associated with taking luding hormonal changes as a cause of her condition. progestagens (Depo-Provera) for contraception [5]. In most cases the disorder is described in women Since our patient used no contraception, and all aged between 20 and 44, whereas in the pediatric po- the hormone values were within the reference ranges, pulation it is extremely rare and thus described in only the cause of her menstrual abnormalities was not few reports [1,2,5,7-9]. Selzer described the pseudo- determined. cyesis in a six-year-old girl who was mentally abused Silber described three cases of pseudocyesis in ado- by her promiscuous alcoholic mother and throughout lescents; their psychosocial evaluation showed it was a pregnancy she wanted to reduce the feeling of neglect conversion reaction in primary deprived and depressive and abandonment [8]. individuals. All of them were successfully treated with Growing up in a seemingly functional family with a psychotherapy [9]. As the psychiatric evaluation of our negative history of psychiatric illness, our patient sho- patient showed her condition being caused by under- wed no signs of mental neglection and abuse. lying depression she started to take an , An important role of separation conflict is also leading to a simulated labor after a month of therapy, described, in patients susceptible to separation, and a and thus resolving her condition. strong conversion reaction as a strong mechanism of Cases of recidivism every nine months during twenty defense, which can complicate the severe depression years were described, as well as false pregnancy of unu- leading to a suicide attempt when false pregnancy is sually long duration; De Pauw described monosympto- revealed [2,5]. matic of hypochondriac type which lasted 3000 Fantasies of pregnancy can lead to ambivalence, days (almost 10 years), and was successfully treated characterised by a wish to have a child and a fear from with pimozide [10]. pregnancy at the same time. The condition is manifested After successfully completed therapy, our patient with nausea and vomiting, similar to . had no recurrence yet.

References

[1] Marušić S, Karlović D, Zoričić Z, Martinac M, long-term contraception. J Obstet Gynaecol 2007; Jokanović Lj. Pseudocyesis: a case report. Acta 27: 322-35 Clin Croat 2005; 44: 291-5 [6] Demaret A. From pseudopregnancy to anorexia [2] Koić E, Mužinić L, Đorđević V, Vondraček S, nervosa. Acta Psychiatr Belg 1991; 91: 11-22 Molnar S. Pseudocyesis and Couvade syndrome. [7] Hendricks-Matthews MK, Hoy DM. Pseudocyesis Druš istraž Zagreb 2002; 6: 1031-47 in an adolescent incest survivor. J Fam Pract 1993; [3] Basil B, Mathews M. A Couvade Syndrome Variant? 36: 101-3 Psychosomatics 2006; 47: 363-4 [8] Selzer JG, Pseudocyesis in six-year-old girl, J Am [4] Tohei A, Taya K, Watanabe G, Voogt JL. Acad Child , 1968; 7: 693-720 Hypothyroidism increases prolactin secretion and [9] Silber TJ, Abdalla W. Pseudocyesis in adolescent decreases intromission threshold for induction of females. J Adolesc Health Care 1983; 4: 109-12 pseudopregnancy in adult female rats. Physiol [10] De Pauw KW. Three thousand days of pregnancy. Behav 2000; 69: 391-7 A case of monosymptomatic delusional pseudocy- [5] Ayakannu T, Wordsworth S, Smith R, Raghunandan esis responding to pimozide. Br J Psychiatry 1990; R, Vine S. Pseudocyesis in a teenager using 157: 924-8

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