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International Journal of Research and Review www.ijrrjournal.com E-ISSN: 2349-9788; P-ISSN: 2454-2237

Case Report

Delusion of in a Patient Treated with Atypical

Dr. Joylin Jovita Mascarenhas1, Dr. Gale Crasta2

1Assistant Professor, 2Post graduate Resident, Dept of , Father Muller Medical College, Mangalore

Corresponding Author: Dr. Joylin Jovita Mascarenhas

ABSTRACT

Delusion of Pregnancy (DP) is defined as the belief of being pregnant despite factual evidence to the contrary. Both pseudocyesis and delusional pregnancy are said to be common in developing countries but available evidence is scanty. A distinction has been made between the two syndromes, but the line of demarcation is blurred. Delusion of Pregnancy (DP) can occur as a primary psychiatric disorder or as a part of other medical disorders. induce hyperprolactinemia & metabolic syndrome can contribute or act as a maintaining factor in patients with DP.

Key words: Delusion of Pregnancy, Anti-psychotic induced, Heterogenous symptom

INTRODUCTION urination. The same sensory perception may False pregnancy or delusional have occurred many times before but, this pregnancy is the condition of believing one time around, as the person searches for what is pregnant despite factual evidence to the it might mean, it suddenly acquires contrary. (1) Delusion of pregnancy (DP) is extraordinary significance. This is the third an aetiologically heterogeneous stage, where meaning is attached to an phenomenon. Both biological and otherwise neutral sensation. How a person psychological factors have been implicated then deals with this momentous information in the causation of this symptom. (2) depends on personal factors (health, According to Conrad, the birth & education, reasoning ability, cognitive development of the delusion occurs in biases) and on situational factors (family, several stages. The first stage, “das trema” socioeconomics, culture, religion). (3,3) is a general feeling of non-specific The symptom can present as a part apprehension. This can be a result of of another disorder or can present in familial and societal pressures or personal isolation. When present independently, aspirations to become pregnant despite Delusion of Pregnancy is described as obstacles such as infertility, old age, somatic type of spinsterhood, ill health, poor marital according to Diagnostic and Statistical relationship, or inadequate socioeconomic Manual of Mental Disorders, Fifth Edition conditions. The general apprehension during (DSM-5), within the realms of this first stage may follow the loss of a spectrum and other psychotic child, or loss of status, or loss of a love disorders. (5) It should be distinguished from relationship. The second stage of delusion four additional conditions imitating formation is a sensory perception, such as pregnancy: weight gain, or vaginal spotting, or 1. Pseudocyesis: Development of the classic abdominal movement, or frequency of symptoms of pregnancy - ,

International Journal of Research & Review (www.ijrrjournal.com) 313 Vol.6; Issue: 7; July 2019 Joylin Jovita Mascarenhas et.al. Delusion of Pregnancy in a Patient Treated with Atypical Antipsychotics nausea, breast enlargement and family members to search for her lost child pigmentation, , and since 10months. On detailed evaluation, labour pains-occurs in a nonpregnant history taking & reviewing her past records, woman. we found that, the patient was diagnosed to 2. Pseudopregnancy: A somatic state have Paranoid schizophrenia (in view of 3rd resembling pregnancy. It is triggered by person auditory hallucinations, delusion of organic factors (e.g. physical symptoms persecution & reference) & was on caused by endocrine tumours). treatment with risperidone & olanzapine for 3. Simulated pregnancy: When a woman the same since the past 7 years (2012). admits to be pregnant, although she is aware Patient had attained complete remission, that she is not. (6) 2years back (2017) & the dosage of 4. Couvade syndrome: Where the father olanzapine was tapered (5mg) & risperidone develops a variety of somatic symptoms 8mg was continued. During this period, before, during, or after the birth of the child. patient was functioning adequately & got His behaviour can resemble that of pregnant married (March 2018). However, patient women although he knows that he is not had menstrual irregularities & weight gain pregnant. (7,8) on treatment. Post-wedding, drug Manjunatha et al, described compliance was questionable, though Delusional Procreation Syndrome (DPS) patient claimed to be adherent to treatment. that consists of sequential in every She also had the pressure to conceive soon possible stage of procreation such as having after her marriage (owing to her late age of spouse/partner, getting pregnant, having marriage). delivered a child (labour and ), General Physical & Systemic examination becoming parents/grand-parents and so on. were within normal limits (Per abdomen had (9) no evidence of striae). Investigations The most common diagnoses in including neuroimaging, electrocardiogram, patients with Delusion of pregnancy include haemogram, renal, liver, thyroid, lipid & schizophrenia (35.7%), bipolar disorders sugar profile were normal. Serum (16.7%) and (9.5%). (10) was also normal. Her menstrual cyles were Biologically DP has been described in regular. schizophrenia, , We admitted the patient for detailed delusional disorder, mental retardation, evaluation & management. Patient & her senile , psychotic depression, family members were interviewed. On hyperprolactinemia, drug-induced lactation, probing for further details, we found that, , metabolic syndrome, one month after her wedding (May 2018), polydipsia, FTLD/MND. (8) patient reported to her husband that she was Delusion of Pregnancy is said to be already five months pregnant. She disclosed more common in a , the to him that 5months back,2 strangers literature about delusion of pregnancy from entered her house during the night & she India is meager. (8) We hereby present a case was unable to remember the events that of DP which occurred during the remission occurred there by, as she was drowsy phase & on maintenance therapy, because of the medications. She also perpetuated by multiple factors. reported of amenorrhoea for a period of 7 months & nausea and vomiting, which was CASE ILLUSTRATION present throughout the pregnancy, but A 31 year old female, educated up to reduced after the third month. In addition to 5th Standard, married for 13months this, patient claimed she gained 5-6kgs of presented to the Psychiatry Out-patient weight & her abdominal girth was Department on 24th June, 2019, with a increasing. She also apprised her in-laws history of suspiciousness & demanding that she could feel the foetus move around

International Journal of Research & Review (www.ijrrjournal.com) 314 Vol.6; Issue: 7; July 2019 Joylin Jovita Mascarenhas et.al. Delusion of Pregnancy in a Patient Treated with Atypical Antipsychotics in her abdomen since the 5th month. She During the interview, patient held on started coercing her husband to take her to to this belief & when tried to reason, the hospital for her antenatal check-up. claimed that she had amenorrhea for Patient was seen by a obstetrician, who >9months, weight gain & abdominal conducted a & enlargement, when on treatment. These advised urine (UPT), both of were the signs of pregnancy. She would also which were negative for pregnancy. Hence, point on to a particular spot on her she was advised an Obstetric scan, which ultrasound report, claiming it to be her was normal & there was no evidence of a foetus & another scan done later without the gestational sac/foetal pole. Inspite of spot, indicative of delivery. evidence contrary to her claims, patient Patient was started on olanzapine & was continued to strongly believe that she was noticed to improve gradually both clinically pregnant. She complained of feeling as well as on the PANSS score. lethargic, attributing it to her pregnant state. She refused to perform most of her DISCUSSION household chores. In July 2018, patient also This is the first case report in which complained of pain & engorgement in her a patient in remission for >1year & on breasts & claiming that she has started maintenance treatment developed a producing breast milk which she would Delusion of Pregnancy. Patient express twice daily. She stopped the misinterpreted the side effect profile of the prescribed medications, claiming it to be medication as a sign of pregnancy. harmful to the foetus. In August 2018, in However, it could also be the part of the view of her persistent belief that she was primary disorder itself, suggestive of pregnant, she was taken to her treating relapse. Treatment with Aripiprazole, a psychiatrist. Repeat UPT was negative but prolactin sparing drug was also found to be Serum prolactin was found to be high. ineffective. This is in contrast with another Patient was started on aripiprazole, a study which showed that patients who had prolactin -sparing drug. She also erroneous ideas of being pregnant (four complained of severe back pain, which delusional and two non-delusional) increased in intensity & declared she is in temporally associated with labour. Ultrasound abdomen & pelvis hyperprolactinemia, resolved as prolactin showed? Pelvic Inflammatory disease (PID) levels returned to normal. (13) In our case, & was treated symptomatically in a local the delusion was precipitated by the side hospital. However, soon after the cessation effect profile of the drug & non-compliance of treatment, patient recounted that she lost on treatment, possible Pelvic inflammatory her consciousness due to the excruciating disease & pressure to conceive served as pain & during that period, she delivered a perpetuating factors. baby boy. She would claim that the baby In women suffering from , went missing immediately after birth and delusional pregnancy is not uncommon, she didn’t have the chance to even see the especially since the advent of antipsychotic baby. She would assert that her persecutors medications, which, by virtue of inhibiting have taken away the child & started secretion, raise prolactin levels to demanding family members to go in search produce amenorrhea, breast of the child. When family members & the swelling/tenderness, and -akin hospital staff tried to convince her that her to the somatic experience of pregnancy. (11) belief & assertion were untrue, patient Moreover, antipsychotic drugs are would be irritable. However, patient associated with considerable weight gain, continued the prescribed medications, but distending the abdomen and adding to a no improvement was seen & hence referred misperception of pregnancy. Even when to our tertiary care centre. there has been no prior sexual activity,

International Journal of Research & Review (www.ijrrjournal.com) 315 Vol.6; Issue: 7; July 2019 Joylin Jovita Mascarenhas et.al. Delusion of Pregnancy in a Patient Treated with Atypical Antipsychotics fantasy-prone women can find ways of maintaining factor. It is a heterogeneous convincing themselves that they are symptom with social, psychological and pregnant. They imagine the implantation biological determinants to its genesis. occurring by magic or through the wizardry Detailed evaluation & exclusion of the other of advanced reproductive technology. differential diagnoses is imperative. The Distinction has been drawn between treatment response can be considered good pseudocyesis, where signs of pregnancy are in about half of the patients, and demonstrably present (abdominal swelling, pharmacology remains the mainstay of menstrual disturbance, spotting, the report treatment. of quickening, breast tenderness and engorgement, weight gain, galactorrhea) and Declaration of Patient Consent delusions of pregnancy, where there may be The authors certify that they have obtained all cessation of menstrual periods and required patient consent forms. The patients abdominal distension, but no other outward understand that their names and initials will not be published and due efforts will be made to signs. (12) The first is said to be a conceal their identity, but anonymity cannot be somatoform disorder while the second is a guaranteed. symptom of psychosis. Delusions of pregnancy have been noticed to disappear REFERENCES soon after a change to a relatively prolactin- 1. Rosch DS, Sajatovic M, Sivec H. sparing antipsychotic. (13) Behavioral characteristics in delusional The psychological antecedents such pregnancy: A matched control group study. as ambivalence about pregnancy, Int J Psychiatry Med 2002;32:295-303. relationship issues, and loss are very 2. Chaturvedi SK. Delusions of pregnancy in frequently associated with men. Case report and review of the pseudocyesis/delusional pregnancy, literature. Br J Psychiatry 1989;154:716-8. 3. Mishara AL. Klaus Conrad (1905-1961): especially in a married couple who are delusional mood, psychosis, and beginning infertile and living in a pronatalist society. schizophrenia. Schizophr Bull. 2010;36:9– The infertility causes substantial distress 13. and discrimination. When antipsychotic 4. Schneider K. Clinical . medication were used to treat psychotic New York: Grune and Stratton; 1959. symptoms in these women, it led to high 5. American Psychiatric Association. prolactin levels and apparent manifestations Diagnostic and Statistical Manual of Mental of pregnancy, such as amenorrhea and Disorders. 5. Washington, DC: APA; 2013. galactorrhea, thus reinforcing a false 6. Dumont M. The unfortunate pregnancy of conviction of pregnancy. (10) the fi rst French feminist, Olympe de Though delusion of pregnancy can Gouges. Rev Fr Gynecol Obstet 1989; 84:63-6. be primary, it can appear in the context of 7. Mayer C, Kapfhammer HP. Couvade medical conditions that cause abdominal syndrome, a psychogenic illness in the distension such as fibroids, urinary transition to fatherhood. Fortschr Neurol retention, polydipsia, metabolic syndrome, Psychiatr 1993;61:354-60. tubal cyst or abdominal pain such as 8. Chatterjee SS, Nath N, Dasgupta G, . (11,14-18) Bhattacharyya K. Delusion of pregnancy and other pregnancy mimicking conditions: CONCLUSION Dissecting through differential diagnosis. The case highlights that delusion of Med ,J D Y Patil Univ 2014;7:369-72. pregnancy can emerge during the remission 9. Narayana Manjunatha, Shanivaram K. phase of the psychotic illness. Use of non- Reddy, N. R. Renuka Devi, Vikram Rawat, Somashekar Bijjal,Naveen C. Kumar, K. V. prolacting sparing antipsychotics (especially Kishrore Kumar, Jagadisha Thirthalli, B. N. risperidone) can significantly contribute in Gangadhar. Delusional Procreation its germination as well as act as a Syndrome: Report from TURUVECARE

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How to cite this article: Mascarenhas JJ, Crasta G. Delusion of pregnancy in a patient treated with atypical antipsychotics. International Journal of Research and Review. 2019; 6(7):313-317.

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International Journal of Research & Review (www.ijrrjournal.com) 317 Vol.6; Issue: 7; July 2019