“DEVELOPMENT OF DELUSIONAL PREGNANCY IN A
MALE PATIENT”
TYPE
CASE REPORT
AUTHORS
1. DR VANI B KULHALLI
MUMBAI
2. DR PRATIMA MURTHY
ASSOCIATE PROFESSOR (At the time of reporting, which was around 2003-2004)
NIMHANS
BANGALORE
OBSERVED AT
NATIONAL INSTITUTE OF MENTAL HEALTH AND
NEUROSCIENCES,
(NIMHANS)
HOSUR ROAD,
BANGALORE,
INDIA,
560029.
KEY WORDS:
DELUSION, BIZARRE, SCHIZOPHRENIA, PREGNANCY, COUVADE, CANNABIS, PHENOMENOLOGY.
ABSTRACT
Delusion of
pregnancy in a male is a bizarre delusion reported previously in various
organic and psychiatric disorders. It has been reported secondary to phenomena
like somatic hallucinations, delusional misinterpretation, etc. We report a
case of delusion of pregnancy in a male patient with paranoid schizophrenia and
substance use to illustrate the evolution and possible contributory factors
focusing on this delusion. Diagnosis and management are also discussed.
CASE REPORT
S is a 28 year old married male, primary school educated electrician. His premorbid social adjustment was reported to be adequate and family history was unremarkable with respect to psychiatric disorders or substance use.
Patient presented with a ten month history of
abnormal behavior characterized by reporting odd beliefs, not working and disturbed
biological functions. He had history of cannabis use to the extent of
dependence of 6 years’ duration and occasional use of alcohol and inhalants.
His behavioral disturbances had started while he was using cannabis and
persisted 4 months after completely stopping drug use.
On examination he
had delusion of persecution, delusion of infidelity, delusion of reference,
delusion of pregnancy, delusion of being turned into a female, delusion of not
being able to use half his brain as it belonged to someone else. He believed he
had lost sexual potency due to excessive masturbation and use of cannabis. He
had a flat affect, third person auditory hallucinations, kinesthetic
hallucinations and delusional misinterpretation. Physical and laboratory
examination were within normal limits.
Further clarification revealed that delusion
of pregnancy developed soon after the birth of his first child. This was 7
months after onset of illness and 3 months after last use of any substance.
Patient reported that he used to hear the voices of his neighbours discussing
amongst themselves as well as telling him that there is a baby in his abdomen
(second and third person auditory hallucinations). He did not believe them, but
the voices persisted. One day he experienced pain on the right side of his
abdomen and he became convinced that he was pregnant (delusional
misinterpretation). The voices told him that he was impregnated when he had
intercourse with his wife in the superior position. They also told him that the
baby was his brother (who actually lived next door) and to ensure safe
delivery. Patient became concerned with the safety of his ‘baby’ and expressed
his beliefs to family members. He held this belief despite family members’
attempt to dispel it. About 2 weeks later the voices decreased in frequency and
intensity and other experiences became more prominent. Gradually he became less
and less worried about his pregnant state. The belief disappeared imperceptibly
as other psychopathology became more prominent.
During the period of onset and presence of the
delusion of pregnancy, patient refused to accept his baby as his own. However
with resolution of the delusion, he accepted the baby, even before other
psychopathology resolved totally.
He was diagnosed
as having paranoid schizophrenia and cannabis dependence with a differential
diagnosis of cannabis- induced psychosis and treated successfully with
Risperidone 8 mg started at the time of presentation.
DISCUSSION
Patient profile
Delusions of
pregnancy have been reported in patients of varying age groups and both in
males and females[1-6]. Likewise reports suggest a wide variation in the
intellectual abilities of patients
[1-5]. Our patient had a normal intelligence as reflected by his
education and adequate independent functioning.
Family history was
negative for psychiatric disorders. Previous authors have reported a positive
family history especially when the diagnosis was schizophrenia [4,5,7].
There was no
history of homosexual contact or of childhood abuse in the patient [5] as has
been reported before. Patient’s orientation was heterosexual as compared to
reports of bisexuality [8] in one case.
Phenomenological factors
Some authors have
cited this delusion as occurring secondary to misinterpretation of somatic sensations
[3,9] objective signs like galactorrhoea [4,9] and amenorrhoea [10] or as
occurring de novo. In this case compelling auditory hallucinations created a
background emotional state in which the patient interpreted sensation in the
abdomen as a definitive sign of pregnancy. Similar evolution was reported
by Bhate [2]. The auditory
hallucinations and the abdominal sensation had occurred while the patient was
off any drugs of abuse. The possibility of flashback phenomenon was ruled out
as patient did not report having similar experience anytime under the influence
of cannabis.
Male patients have
attributed their capacity to becoming pregnant as being due to ‘intersex’ state
[9], due to change of internal organs [7,9] or as being a real possibility for
all males [2,10]. Our patient did not give any such explanation. Reports have
also mentioned patients’ explanations about the mechanism of impregnation.
Patients reported being impregnated by kissing [10], by sexual contact with men
[5,10], artificial anal insemination [9] or by self [2,7]. Our patient reported
being impregnated by his own wife. This kind of highly bizarre explanation has
not been reported before.
Presence of
organic etiology has been previously reported [3,7]. But in this patient no
physical or laboratory abnormality could be demonstrated. Tests for presence of
cannabis at time of presentation were negative. Currently there is no
literature to suggest cannabis can cause structural changes although subtle
damage cannot be ruled out. Continuing effect of cannabis after it has been
metabolized is a matter of debate [11-14]. It is possible that the psychosis
was cannabis related while the delusion of pregnancy manifested later in the
course, when cannabis could not be detected. Inhalant use is well known for
causing brain damage, but in this case inhalant use was very infrequent and
probably non contributory. Hence organic causation in the form of structural
brain changes is unlikely in this case, but cannabis related pathology cannot
be completely ruled out.
Psychodynamic factors
The onset of the
delusion of pregnancy coincided with the birth of his child. Situational
influence of this kind where men developed the delusion of pregnancy during
wife’s pregnancy [15] or after coming in contact with pregnant ladies [8] has
been described and psychodynamic causes have been suggested.
Patient did not
express symptoms of pregnancy such as swollen abdomen, galactorrhoea, morning
sickness etc. as reported in other cases [8,10]. This patient had no symptoms
of pregnancy and firmly believed he was pregnant. Thus the current presentation
does not suggest the phenomenon of Couvade [16] in which a man develops
symptoms of pregnancy during the wife’s pregnancy but does not believe that he is
pregnant.
The patient was worried about loss of sexual
potency related to excessive masturbation and consumption of cannabis. In the
initial phase of psychosis, he was concerned about being turned into a female
by his enemies. He sought medical help for impotence which he believed had been
caused by the change of gender. In reality he was maintaining normal erectile
functioning at that time, as clarified by his wife. He made sexual overtures to
his wife in inappropriate social situations to the extent that family requested
help of police. He reported the belief of being pregnant soon after his wife
delivered. He refused to accept his baby
suspecting that his wife had been unfaithful. Throughout his illness duration
(including the substance use), this patient seemed to be concerned about sexual
matters. This indicates conflicts about sexuality. Previous reports have cited
psychodynamic origins of delusions of pregnancy [4]. In this case it is
possible that conflicts of sexuality may have manifested as delusion of
pregnancy
Diagnosis and management
Patient was diagnosed as having cannabis
dependence and paranoid schizophrenia. The psychotic phenomena had started
while patient was using cannabis. These phenomena continued to persist despite
4 months’ abstinence from cannabis. Although the literature does not provide
clear support for the occurrence of a chronic cannabis induced psychotic
disorder [17-19], the ICD-10 [20] does allow for such a diagnosis. Thus
cannabis- induced schizophrenia-like psychosis can be regarded as a
differential diagnosis. The commonest diagnosis reported previously is
schizophrenia [4,5,7,10,15]. Other diagnoses reported are delusional disorder
[9], post ictal psychosis [3], mania with psychotic symptoms [8,10] and
psychotic depression [21]. Delusion of pregnancy occurring in cannabis induced
psychosis has not been reported so far although alcohol abuse has been reported
[8,15].
The delusion
subsided when the hallucinations stopped. 6 weeks later patient was in clinical
remission. The delusion of pregnancy may have given way to other
psychopathology leading to its disappearance. It is also likely that the
delusion had resolved due to recovery as antipsychotic had already been
started. This kind of response to antipsychotic has been reported before
[1,2,9,15].
Conclusion
This case
illustrates the occurrence of a bizarre delusion of being pregnant in a male in
the context of psychosis which was possibility cannabis induced. It is
interesting to note the process of evolution and resolution, the effect of
substance use, psychosexual issues and the diagnostic possibilities of the
case.
References
- Jenkins S B, Revita D M and
Tousignant A: Delusions of Childbirth and labour in a bachelor. American
Journal of Psychiatry 1962; 118:1048- 1050.
- Bhate J M, Spear J C M and Robertson P E: Delusions of Pregnancy in Men. British Journal of Psychiatry 1989; 155: 423-424.
- Chaturvedi S K: Delusions of Pregnancy in Men. British Journal of Psychiatry 1989; 154: 716-718.
- Shankar R: Delusion of pregnancy in schizophrenia. British Journal of Psychiatry 1991; 159: 285- 286.
- Varma S L and Katsenos S: Delusion of Pregnancy. Australian and New Zealand Journal of Psychiatry 1999; 33: 118.
- Kornischka J and Schneider F: Delusion of pregnancy. A case report and review of literature. Psychopathology 2003; 36(5): 276-278.
- Chengappa K N R, Steingard S, Brar J S and Keshavan M S: Delusions of Pregnancy in Men. British Journal of Psychiatry 1989; 155: 422-424.
- Miller L J and Forcier K: Situational influence on development of delusions of pregnancy in a man. American Journal of Psychiatry 1992; 149: 140.
- Bitton G, Thibaut F, Lefevre-Lesage I: Delusions of Pregnancy in a man. American Journal of Psychiatry 1991; 148: 811-812.
- Michael A, Joseph A and Pallen A: Delusions of Pregnancy. British Journal of Psychiatry 1994; 164: 244-246.
- Adams I B and Martin B R: Cannabis: Pharmacology and toxicology in animals and humans. Addiction 1996; 91(11): 1585-1614.
- Deahl M: Cannabis and memory loss. British Journal of Addiction 1991; 86: 249- 252.
- Negrete J C: What’s happened to the cannabis debate? British Journal of Addiction 1988; 83: 359- 372.
- Rey J M and Tennant C C: Cannabis and Mental Health. British Medical Journal 2002; 325: 1183-1184.
- Thornicroft G: Cannabis and psychosis: Is there epidemiological evidence for an association? British Journal of Psychiatry 1990; 157: 25- 33.
- Hall W and Degenhardt L: Cannabis use and psychosis: A review of clinical and epidemiological literature. Australia and New Zealand Journal of Psychiatry 2000; 34(1): 26- 34.
- Arseneault L, Cannon M, Witton J and Murray R M: Causal association between cannabis and psychosis: examination of the evidence. British Journal Of Psychiatry 2004; 184: 110-117.
- Radhakrishnan R, Satheeshkumar G and Chaturvedi S K: Recurrent delusions of Pregnancy in a Male. Psychopathology 1999; 32: 1- 4.
- Enoch MD, Trethovan WH. Barker JC(eds): Some Uncommon Psychiatric Syndromes. Bristol, Wright. 1967.
- World Health Organisation: The ICD-10 Classification of Mental and Behavioral Disorders 1992.
- Bernardo M, Pintor L, Arrufat F, Salva J and Buisan E: Delusion of pregnancy in psychotic depression and ECT response. Convulsive Therapy 1996; 12(1): 39- 40.
