DELUSION OF PREGNANCY IN A MALE PATIENT

 

“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.

 Organic etiology

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.

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