ABSTRACT: with the firm belief of being pregnant with

ABSTRACT:

Delusion of
pregnancy (DP) is a firm, fixed and false belief of being pregnant, occurring
in various psychiatric and organic disorders. Several cases on delusional
pregnancies have been reported with most of the them originating from the
developing countries. Although delusional pregnancy is more common in females, DP
can also be seen in men. The literature on multiple delusional pregnancies is
however, scanty. We hereby present the case of a 20-year-old female with the
firm belief of being pregnant with 22 fetuses (both intra- and extra-uterine), which
the patient states, are causing her pain in various parts of her body,
including her head, arms and legs.

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KEYWORDS: Delusion
of pregnancy, schizophrenia, hyperprolactinemia                       

INTRODUCTION:

Delusion of
pregnancy (DP) is a false belief of being pregnant despite factual evidence
pointing to the contrary. It is a type of somatic delusion which could occur in
schizophrenia, delusional disorder, mood disorder, epilepsy, dementia or other
organic brain disorders and may also present with drug induced lactation,
polydipsia and urinary tract infection1. Although more common in the
females, multiple cases of delusional pregnancy in men have also been reported2.

CASE REPORT:
We report the case of a
20-year-old Hindu female “U”, belonging to a lower socioeconomic status, is the
eldest of 4 siblings with no family history of psychiatric illnesses. She is
married but separated from her husband 5 years ago. Her husband physically and
verbally abused her and abandoned her after 8 months of marriage. She has never
been pregnant, as stated by her mother.

She
presented to the psychiatry ER department with complains of abdominal pain and
aggressive behavior. The patient was subsequently admitted, this being her 7th
admission. Total duration of illness was reported to be 5 years, which started
around the same time that her husband left her, when the patient was diagnosed
with schizophrenia. She was stable on olanzapine 10 mg and procyclidine 5 mg
for the last one year, however she didn’t take her prescribed medications for 3
days which seems to have precipitated this episode.

“U” believes
that she is pregnant since the last 5 years. Initially she thought she had 3
babies in her abdominal cavity and claimed that the abdominal pain is the
result of kicking movements of the babies. During most of the recent
hospitalization, “U” was convinced that there are a total of 22 different-sized
fetuses growing in different parts of her body, including her head, arms and
legs, which are producing physical symptoms of pain. She states that she can
see them and hear their voices that are telling her to “take them out”.
According to “U”, she has given birth twice prior to this, and her husband took
away both the babies to keep them away from the evil eye. She reported visual
and auditory hallucinations, of her husband and a religious figure both of whom
were calling her.

“U” was noted to have had menstrual irregularities with
hypomenorrhea and occasional vaginal spotting. She also complained of vomiting and
mild breast pain.

Interview
with the patient’s mother revealed that one year back, she drank disinfectant
solution(Dettol), which she claimed her husband commanded her to drink, “in
order to kill the germs in her body”, which she did and was taken to the ER
immediately where she was treated. The family attributed these symptoms to
“black magic” and took her to shrines of religious figures in hopes to get her
cured.

On
examination, the patient’s abdomen was mildly distended, which she claimed was
due to pregnancy. Mental status examination revealed a young female of average
height and weight, maintaining adequate eye contact and well oriented to time, place
and person.

Laboratory
investigations including CBC, PT/INR, urea, creatinine, electrolytes, LFTs and
blood glucose levels were within the reference ranges. Ultrasonography was
performed which revealed no abnormality with no signs of pregnancy. Her prolactin
level was elevated(58.5 ng/ml).

During her
hospital stay, patient was given Injection Haloperidol 5 mg, Tablet Olanzapine
10 mg and Tablet Procyclidine 5 mg, which were able to control the patient’s
aggressiveness, however, the delusions and hallucinations persisted. Patient
was started on monthly Intramuscular Fluphenazine Decanoate 25mg. The patient
continues to be monitored closely. The family members were educated regarding
the course of the disease and the importance of medicine compliance.

DISCUSSION:
Antipsychotics raise prolactin levels by D2 receptor blockade in
tuberoinfundibular region of the brain. Anti-psychotic associated
hyperprolactinemia was found to be the culprit in several reported cases of DP,
with symptoms improving as the prolactin levels normalize with the
discontinuation of drug3. The most commonly responsible
antipsychotic was risperidone3. Several studies suggest an association
between olanzapine use and raised prolactin levels4. Similarly, “U”
was taking olanzapine for 1 year which could be responsible for the higher than
normal prolactin levels observed.

Psychosocial
factors also play a vital role in development of DP. Shankar(1991) suggests
that the loss of love or a loved object may contribute to the emergence of DP,
a mechanism also noted in pseudocyesis5. Similarly, in this case,
the onset of delusion appears to have been precipitated by the patient’s
husband abandoning her, as both the events coincide with one another,
indicating a strong association.

Previous
studies have outlined the misperception of body sensations and physical changes
as signs and symptoms of pregnancy6. “U” also misinterpreted
abdominal pain, distension and vomiting as signs that she is pregnant.

CONCLUSION:

DP is a rare
occurrence in the psychiatric setting. Pharmacotherapy remains the mainstay of
treatment along with supportive psychotherapy.