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CASE REPORT
Psychodynamic and socio-cultural perspective of pseudocyesis in a noninfertile Indian woman: a case report
Makhal M, Majumder U, Bandyopadhyay GK
Department of Psychiatry, North Bengal Medical College, Sushruta Nagar,
Siliguri, Darjeeling, India, PIN 734012
Abstract
Pseudocyesis seen in non-psychotic woman without true gestation is a common
event in developing countries. Pseudocyesis results from multidimensional
factors. Our case was a 40 years, Hindu, married, illiterate, non-infertile woman
of lower socio-economic status, from rural part of Bengal, India. She presented
with amenorrhea, distended abdomen and breast engorgement. Gynecological
and radiological examination showed neither pregnancy nor postpartum state.
The women had three female children but no male child. There was excessive
pressure from husband to have a male child for generational continuity and
economic security in old age. Diagnosis of pseudocyesis was made and further
sessions with the husband were carried out. She was managed with supportive
psychotherapy and low dose of anxiolytic. Conclusion: This psychodynamic
change combined with the illiteracy, poverty, disturbed family dynamics, societal
pressure and cultural belief caused amenorrhea and all other body changes may
mimicking pregnancy.
Keywords: pathogenesis; psycho-socio-cultural factor; gender preference.
Introduction
Pseudocyesis was first described by Hippocrates1. John Mason Good coined the term
pseudocyesis from the Greek words pseudes (false) and kyesis (pregnancy)2. In pseudocyesis,
a non-psychotic woman believes herself to be pregnant and develops objective findings of
pregnancy which may include amenorrhea, abdominal enlargement, breast changes similar to
those in pregnancy, apparent fetal movements, softening of the cervix with signs of
congestion, nausea, vomiting and weight gain in the absence of true gestation3. Pseudocyesis
is quite different from ‘delusions of pregnancy’ found in schizophrenia and other psychotic
disorders4. The term ‘delusions of pregnancy’ rather than ‘pseudocyesis’ should be used in
cases that do not have any physical signs of pregnancy but have a false firm unshakable
belief of pregnancy5 . DSM IV TR categorizes it into somatoform disorders not otherwise
specified6, whereas ICD 10 classifies it as somatoform disorder, unspecified7. Pathological
ambivalence of pregnancy; conflict regarding gender, sexuality, or childbearing; a grief
reaction following a miscarriage, tubal ligation, or hysterectomy; disturbed family dynamics,
excessive societal pressure on women to have a large number of male children are
psychodynamic and socio-cultural factors for pseudocyesis8,9. The aim of this report is to
highlight the psycho-socio-cultural context of pseudocyesis.
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Case Report
A 40 years, Hindu, married, illiterate, woman of lower socio-economic status, from rural part
of Bengal, India reported to the G&O (Gynecology & Obstetrics) OPD of North Bengal
Medical College, India for antenatal checkup with the complaint of amenorrhea for 32 weeks,
distended abdomen, loss of appetite, nausea and vomiting, weight gain and breast
engorgement. The women felt foetal movement in last 2 months. Her past history showed that
she was having regular menstruation and was not on any drugs or oral contraceptives.
The woman was from a nuclear family. Her husband, a priest remained busy most of time in
religious activity which was their only source of income. They had three female children.
Their relationship was good after marriage which was gradually deteriorating after the birth
of female children that was perceived as a curse with economic and social liability. She was
blamed by her husband for giving birth of all three female children and not having a male
child for generational continuity and economic security in old age. The woman was
overburdened with household work and leading stressful life, wanted to attract attention and
sympathy of husband. She really had an immense desire to become pregnant to bring a male
child.
Gynecological examination showed soft, diffusely tympanetic, distended abdomen with an
inverted umbilicus. Neither fetal part was palpable nor the fetal movements felt. Pelvic
examination revealed a nongravid, empty, anteverted uterus with normal pelvic structures.
Breast was found to be engorged without pregnancy related changes. Urine for pregnancy test
was negative. Laboratory findings including complete haemogram, blood glucose, creatinine,
urea, lipid profile, uric acid, electrolytes, LFT, urinary routine examination, pituitary
hormones, thyroid profile, testosterone, estrogen and progesterone all were within normal
level. Ultra-sonography of whole abdomen was done. The scan showed a nongravid, empty,
anteverted uterus with normal pelvic structures. The patient displayed an intense emotional
outburst when she was informed of the negative obstetric findings regarding her being
pregnant.
At that period she was made referred to psychiatry OPD. Detailed history and mental status
examination revealed that she was neatly dressed, conscious, oriented, well communicated
and having anxious affect. She spoke coherently. Her thought content revealed a strong
belief of being pregnant, but this was considered as an overvalued idea rather than a delusion
because she argued that if "confirmatory testing" showed that she was not pregnant, she
would accept it. She did not have any hallucinations. The rest of the mental state examination
was unremarkable. There was no past and family history of mental illness. According to
DSM IV TR diagnostic criteria she was thought to have pseudocyesis based on above clinical
presentation.
The woman was reassured that she was experiencing a false pregnancy. She was explained
that this situation aroused as a result of her strong desire to become pregnant for a male child.
We advised her to take clonazepam (0.5mg) every night for 2 weeks to reduce anxiety and
also bring her husband in next visit. Subsequently, a supportive confrontation was done in
which the woman and her husband ware informed that she was not pregnant. The negative
results of urine for pregnancy test and ultrasound of the uterus were carefully interpreted to
convince the patient. Gentle exploration of her life situation was done. Reality–based,
problem-solving supportive psychotherapy was given. The husband was advised not to blame
her and to take extra care of his wife as well as their children. Then, the women attended for
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supportive psychotherapy on three occasions, together with her husband. The patient felt well
with this treatment. After two months of outpatient therapy, she resumed menses.
Discussion
Pseudocyesis is seen in woman with longstanding infertility who desperately wants to
become pregnant10. The intense desire for pregnancy and stress of infertility triggers the
pituitary gland to secrete elevated hormones, mimicking the hormonal changes of real
pregnancy8. The cultural attachment to childbirth and procreation among rural people of
some society have been explained as emanating from the multidimensional effects of having
children for generational continuity, economic security and social support in old age as well
as symbols of social status and achievement of the family and mother10. In India irrespective
of the caste, creed, religion and social status, the overall status of women is lower than men
and therefore a male child is preferred over a female child. A male child is considered a
blessing and his birth is celebrated as opposed to a female child where her birth is not
celebrated and is considered more of a burden11. In India women are still having a very low
status in their families, majority of them are illiterate and unaware of their rights. They
normally fall prey to traditional practices and beliefs11. A strong desire for male baby is seen
among 75% Indian women after two baby girls12. Birth of female child is perceived as a curse
with economic and social liability12. Desire for male child manifests so blatantly that parents
have no qualms about repeated, closely spaced pregnancies, premature deaths and even
terminating child before it is born12. Even at parity four and above, woman who had no living
sons did not want to terminate child bearing13. In our society, women always have the
apprehension that if they have no male child, her husband may bring a new bride for
procreation of male child for social prestige, continuity of generation and for social and
economic support in their old age11,14. In these remote parts of the country the low status of
women and the inability to negotiate with their family members leads to a lot of social
problem11. Majority of the women either go into depression or lead a stressful life.
This poor, illiterate, rural woman, mother of three female children, was having the lowest
status in family. She was always criticized by her husband for not having a male child. There
was economic burden but no social support. The leady was apprehensive and leading stressful
life in Patriarchal Societies. She really had a strong desire to become pregnant. The patient
believed that she was pregnant at that time and would bring a male child for continuation of
family name and economic insecurities.
Stress can really influence the regularity of an ovarian cycle; hence can suppress the
menstruation8. This woman was going through some stressful situation which combined with
other socio-cultural factors caused amenorrhea and all other body changes mimicking
pregnancy. Medication and Reality-based, problem-solving supportive psychotherapy
resolved the stressful situation.
Conclusion
Pseudocyesis results from multidimensional factors. More study is needed to explore the
Psycho-socio-cultural determinants of the illness.
References
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Corresponding author:
Dr. Manabendra Makhal
PO-Dehimondal Ghat,
PS- Shyampur, Dist- Howrah,
India, PIN- 711301.
Telephone: +919434199011
e-mail address: drmakhal@gmail.com