Pseudocyesis Preceding Delusional Disorder

Pseudocyesis Preceding Delusional Disorder

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  IOSR Journal ofDental and Medical Sciences (IOSR-JDMS) e-ISSN: 2279-0853, p-ISSN: 2279-0861.Volume 14, Issue 11 Ver. VIII (Nov. 2015), PP 01-03 www.iosrjournals.org DOI: 10.9790/0853-141180103 www.iosrjournals.org 1 | Page Pseudocyesis Preceding Delusional Disorder Dr. Dhrubajyoti Bhuyan1 , Dr. Sandipan Nayek2 1. Assistant Professor , Department of Psychiatry, Assam Medical College, Dibrugarh 2. Post Graduate Trainee, Department of Psychiatry, Assam Medical College, Dibrugarh Abstract: Background: Pseudocyesis is a clinical syndrome in which a non-pregnant woman manifests with a firm belief of being pregnant in association with the symptoms and signs that mimic the experience of being pregnant. Case Presentation: Here we are presenting a 45 year old lady presenting initially with pseudocyesis who after sometime following a gynaecological manoeuvre developed somatic delusion. The case was managed successfully with Tablet Risperidone Conclusion: Pseudocyesis is a rare condition and is often regarded as a neurotic disorder. However, its presence does warrant a detailed evaluation and long term follow up as in our case who later developed psychosis in the form of delusional disorder. I. Introduction Delusional disorder comprises a heterogeneous group of disorders of unknown aetiology whose hallmark and chief features are the presence of a single delusional system. Chief mode of presentation of somatic delusional disorder is ‘monosymptomatic hypochondrical psychosis’ which is characterised by delusion of infestations by insects, worms and foreign bodies, emitting a foul odour (halitosis) or of being ugly. [1] Pseudocyesis refers to a clinical syndrome in which a non-pregnant woman manifests with a firm belief of being pregnant in association with the symptoms and signs that mimic the experience of being pregnant.[2,3] The symptoms and signs of pseudocyesis include amenorrhea, abdominal enlargement, breast enlargement, and changes in the nipple and areola, enlargement of uterus and even feeling of the foetal movements by the patient, along with other symptoms like nausea, vomiting, weight gain, and reduced appetite.[3,4,5]Usually, most of the cases of pseudocyesis are seen among women aged 20-44 years, but it can occur at any age[4] 80% of the affected persons are married[6] The usual duration of these symptoms range from a few weeks to 9 months or longer. The diagnosis is based on the finding of a distended abdomen with a suggestive history along with the demonstration of absence of the foetus and placenta on abdominal ultrasound.[7] Pseudocyesis varies from malingering in which a non-pregnant woman consciously claims that she is pregnant with the knowledge that she is not to gain certain advantages. It is also different from the delusions of pregnancy found in schizophrenia and related psychotic disorders.[8] It should also be differentiated from pseudopregnancy in which ovarian tumors cause endocrinal changes suggestive of pregnancy .[9] II. Case Mrs. X, 45 years Hindu female from a rural and low socio-economic background, educated upto class V a tea garden worker, married since last 22 years and mother of 4 children attended psychiatry OPD of AMCH, Dibrugarh with the chief complaints of cessation of menstruation (Amenorrhoea) for last 2 years and a strong belief that there is some foreign material in the abdomen which was inserted by Gynaecologist for last 1 year. The patient also complains of pain abdomen for last 1 year which the patient attributed to be due to the foreign material. On further enquiry she revealed that15 years back i.e. after the delivery of her fourth child the she underwent sterilization by ligation operation. But she continued to have physical relation with husband as before. In Oct 2013, she had amenorrhoea for 7 months and pain abdomen for 3 months. At that time she started believing that she was pregnant and therefore she attended Obstetrics and Gynaecology (O &G) OPD at Jorhat Medical College. But in per abdominal examination the uterus was not palpable and per vagina the uterus was found to be normal in size. Urine test for HCG was Negative and USG whole abdomen had confirmed that there was no pregnancy. But the patient could not become assured as she used to feel the symptoms of the pregnancy known to her continuously like amenorrhoea, pain and distension of the abdomen, breast enlargement and tenderness and morning sickness and even she could get the sensation of foetal movement in her abdomen. So, she used to visit O&G OPD and private gynaecologist repeatedly at regular interval. The patient claimed that in April, 2014 during per vaginal examination the doctor had expelled her child with fingers and had inserted some foreign material. Following which she had started experiencing pain in the abdomen. She strongly believed that the pain abdomen was because of the foreign body which according to her the doctor had inserted during that time. But after repeated physical, gynaecological and radiological examination, no living issue or any foreign
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  Pseudocyesis Preceding DelusionalDisorder DOI: 10.9790/0853-141180103 www.iosrjournals.org 2 | Page material was found. So, she was referred to psychiatry Department for detailed evaluation. Accordingly she attended Psychiatry OPD at Department of Psychiatry, Assam Medical College and Hospital, Dibrugarh on18/03/15 vide Hospital no. 3054092. She was evaluated further there was no past and family history of any kind of psychiatric illness. Mental status examination revealed somatic delusion. She was diagnosed as a case of Delusional Disorder and was prescribed with Tab Risperidone 4 mg and subsequently increased to 6mg per day along with Tab Trihexyphenidyl 4mg. She has been followed up regularly at Department of Psychiatry on OPD basis and she had shown significant improvement with this treatment III. Discussion Many authors reported cases of pseudocyesis and somatic delusion or delusion of parasitosis separately in different journals over many a years. Pseudocyesis is reported among peoples of various age groups. Mendhekar D, Lohia D, Jiloha RC (2010) reported a case of Pseudocyesis in a prepubertal girl[10]. Del Pizzo J PoseyBahar L, Jimenez R (2011) reported a case of Pseudocyesis with bipolar disorder in a teenager patient[11]. . Perpetus C. Ibekwe, Justin U. Achor(2008) enlightened the cultural and Psychosocial aspects of pseudocyesis in a case of an 18-year-old lady with pseudocyesis[12].Our patient is also a middle aged(45 years) female patient from a developing country. Ouj U(2009) studied in a rural southeast Nigerian community on Pseudocyesis and found that pseudocyesis is more common among the African population than in developed countries [13]. It is notable that majority of the patients developing psychotic symptoms following pseudocyesis are of middle aged females as seen in our patient also. Grover S( et al 2013) reported a female patient presenting with strong delusional belief of being pregnant, which was associated with antipsychotic associated increase in prolactin levels and metabolic syndrome[14] Simon M (et al 2009) reported two cases with post partum delusion of pregnancy which can be regarded as a delusion with bizarre content[15]. Pseudocyesis was also reported in a previously schizophrenic patient following a medical condition. Yeh YW (et a 2012) reported a case of case of a middle aged female patient of schizophrenia who developed pseudocyesis following urinary tract infection complicated by acute urine retention. The patient accepted that she had pseudocyesis after the causative medical condition resolved [16]. The phenomenology associated with pseudocyesis is generally considered as neurotic rather than psychotic illness. Very few report till date has shown the association of pseudocyesis with psychotic disorder. B Craddock(et al 1990) reported a case of depressive psychosis following Pseudocyesis in a 38 year old lady[17]. G L Milner(et al 1990) reported a case of Pseudocyesis with folie a deux in a 27 years old lady and her 50 years old mother[18]. A Mortimer(et al 1988)reported a case of pseudocyesis preceding psychosis[19]. Here we are reporting a patient whose pseudocyesis took a different course leading to a delusional disorder(somatic delusion). IV. Conclusion Pseudocyesis is a rare condition which can be a symptom itself or may even be often associated with various psychiatric illnesses. Pseudocyesis per se is a neurotic condition but often reported as a symptom of various psychiatric illnesses including psychotic illnesses. Here we are reporting pseudocyesis preceding development of psychosis. Therefore clinicians including Obstetricians and Psychiatrists need to follow up the cases carefully and regularly as the clinical picture may change over time. References [1]. Munro A. Delusional disorders. Br J Psychiatry 1988;153:44–6. [2]. Sadock BJ, Sadock VA, Kaplan and Sadock’s synopsis of psychiatry. 9th ed. Philadelphia: Lippincott Williams and Wilkins; 2003. [3]. Brockington I. Obstetric and gynaecological conditions associated with psychiatric disorder. In: Gelder MG, Lopez-Ibor JJ, Andreasen N, editors.New Oxford Textbook of Psychiatry, vol 2. Oxford: Oxford University Press;2000. p. 1195-209. [4]. Barglow P, Brown E. Pseudocyesis. In: Howells JG, editor. Modern perspectives in psycho-obstetrics. Edinburgh: Oliver and Boyd; 1972. p.53-67. [5]. Small GW. Pseudocyesis: An overview. Can J Psychiatry 1986;143:452 -7 [6]. Paulman PM, Sadat A. Pseudocyesis. J Fam Pract 1990;30:575-82. [7]. Koic E, Muzinic L, Djordjevic V, Vondracek S, Molnar S. Pseudocyesis and couvade syndrome. Drustvena Istrazivanja 2002;11:1031-47. [8]. Mortimer A, Banberry J. Pseudocyesis preceding psychosis. Br J Psychiatry 1988;152:562-5. [9]. Hardwick PJ; Fitzpatric C ( 1981) Fear, Folie and Phantom Pregnancy: Pseudocyesis in a fifteen year old girl. British Journal of Psychiatry: 139:558-560. [10]. Mendhekar D, Lohia D, Jiloha RC.Pseudocyesis in a prepubertal girl. Indian J Pediatr. 2010 Feb;77(2):216-7. [11]. Del Pizzo J , PoseyBahar L, Jimenez R.Pseudocyesis in a teenager with bipolar disorder. Clin Pediatr (Phila). 2011 Feb;50(2):169- 71. [12]. Perpetus C. Ibekwe, Justin U. Achor. Psychosocial and cultural aspects of pseudocyesis. Indian J Psychiatry .Apr-Jun 2008; 50(2):112-116. [13]. Ouj U.Pseudocyesis in a rural southeast Nigerian community. J Obstet Gynaecol Res. 2009 Aug;35(4):660-5. [14]. Grover S , Sharma A, Ghormode D, Rajpal N. Pseudocyesis: A complication of antipsychotic induced increased prolactin levels and weight gain. J Pharmacol Pharmacother. 2013 Jul;4(3):214-6.
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  Pseudocyesis Preceding DelusionalDisorder DOI: 10.9790/0853-141180103 www.iosrjournals.org 3 | Page [15]. Simon M , Vörös V, Herold R, Fekete S, Tényi T.Postpartum delusion of pregnancy: an integrated view. Neuropsychopharmacol Hung. 2009 Jun;11(2):103-10. . [16]. Yeh YW , Kuo SC, Chen CY.Urinary tract infection complicated by urine retention presenting as pseudocyesis in a schizophrenic patient. Gen Hosp Psychiatry. 2012 JanFeb;34(1):101. [17]. Craddock B, Craddock N, Liebling. L I ; Pseudocyesis followed by depressive psychosis.The British Journal of Psychiatry .Oct 1990;157 (4): 624-625. [18]. Milner G L, Hayes G D .Pseudocyesis associated with folie a deux.The British Journal of Psychiatry. Mar 1990; 156 (3): 438-440. [19]. Mortimer A, Banbery J; .Pseudocyesis preceding psychosis.The British Journal of Psychiatry.Apr 1988;152 (4): 562-565.