Abdominal pain in expectant fathers

JESSE O. CAVENAR, JR., M.D. WILLIAM W. WEDDINGTON, JR., M.D.

Abdominal pain in expectant fathers ABSTRACT: Three case histories of patients experiencing

significant emotional difficulties while anticipating fatherhood are reported. Each man, during his wife's pregnancy, experienced abdominal pain for which no physical cause could be found. Contrary to previous findings, our experience indicates that such pain, called the couvade syndrome, usually requires psychiatric hospitalization. Husbands sometimes suffer pains during their wives' pregnancies or the postpartum period. The true incidence of this psychogenic disorder, called the couvade syndrome, is unknown because many cases are so mild and fleeting that the victims do not seek medical attention. The incidence in patients who do seek medical help is also unknown, because the diagnosis depends largely on how liberally the physician interprets the symptoms in the husband as being analogous to symptoms that the pregnant wife might suffer. Trethowan and Conlon' suggest that one in nine expectant fathers may experience psychogenic symptoms during his wife's pregnancy and parturition. The most common symptom they noted was toothache DECEMBER 1978' VOL 19· NO 12

(23%), followed by backache (22%), nausea (21 %), loss of appetite (20%), indigestion or abdominal pain (18%), followed by a host of less frequent symptoms. The authors report that most symptoms disappear spontaneously and that in most cases, definitive treatment is usually not required. "Couvade" is a derivative of the French verb "couver," meaning to brood or hatch. According to Hunter and Macalpine,2 observations on the couvade syndrome h~ve appeared over several centuries. They note that in 1627 Francis Bacon wrote: "There is an Opinion abroad (whether idle or no I cannot say) that loving and kinde husbands have a sense of their wives breeding childe by some accident in their owne body."

In 1865, Tylor 3 was the first to describe the ritual of couvade in primitive cultures, and to attempt to formulate the dynamics of the ritual. Essentially, it consists of the pregnant woman's husband taking to his bed during his wife's labor, simulating or experiencing labor pains, and receiving attention from persons in the environment that ordinarily would be given to a pregnant woman in labor. Tylor believed this to be an attempt by the father to establish paternity, and to ensure that the child would be accepted into the family.

Psychodynamics Other authors have attempted to explain the dynamics of the syndrome. Freud 4 felt that the ritual served to "contradict that doubt about paternity which is never quite to be overcome after the birth of the child." Reik s believed that dynamically the syndrome involved identification with the pregnant woman, and a marked ambivalence toward her. He suggested that a husband's hostility toward his wife would be increased at the 761

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time of delivery; strong defenses against pleasure from this hostility and her pain are present, and the impulses are therefore repressed. An attempt to deal with the ambivalence is made by identification, which leads to the ritual. Boehm 6 commented on the man's wish to bear a child. He believed this wish to be so common that he termed it "parturition envy." Klein? believed that the man's wish for a child makes him feel inferior to the mother, and that the man then overcompensates for this inferiority by the supposed superiority of possessing a penis. Brunswick8 wrote that the wish for a baby arises very early in the development of a child, is totally asexual, and is nothing but an identification with the mother who does possess that capacity. Evans 9 reported a psychoanalytic case in which a man had a simulated pregnancy during the course of the analysis. Interestingly, this man had previously suffered couvade syndrome during his wife's first pregnancy. Evans believed that the simulated pregnancy "was a most complete and dramatic expression of his identification with his mother. For him a woman's supreme claim to womanhood was in her possession of a baby, which he sought to acquire." Most authors have attempted to explain "parturition envy," the wish for a baby, and the couvade syndrome on the basis of an identification by the patient with the female. It has long been known that fathers-to-be may experience minor or major psychological turmoil during or after the wife's pregnancy.1O Zilboorg ll presented six cases, three with psychosis and three with severe neurosis, as a result of the birth of a child in the 762

family. He believed that an unconscious envy of the reproductive capacity of women was the cause of the depression. Towne and Afterman 12 reported 18 men who experienced a schizophrenic disorder in association with a birth in the family. They stressed the degree of parental deprivation and youthful trauma these men had experienced in their own lives. Jarvis '3 discussed four cases in which the fathers became disturbed during their wives' pregnancies or after childbirth. The disturbances ranged from symptomatic neuroses to overt psychoses. Jarvis could not

The patient ~ abdominal pain, depression, and delusion appeared to result from an unconscious wish to be in utero.

identify a particular dynamic, and felt each case had to be understood in terms of the totality of the father's premorbid personality and adjustment. Wainwright '4 discussed ten men who required hospitalization after becoming fathers. He described cases in which the increased responsibility of parenthood triggered latent homosexual conflicts, and cases in which fear of identification with the father was the causative factor. In others, a marked dependence on the wife was the significant dynamic leading to breakdown and subsequently to hospitalization. Cavenar and Butts lS described four men in whom sibling rivalry appeared to be the significant issue related to the birth of a child. Of these only one required hospital-

ization for severe obsessional neurosis; two were in psychoanalysis and were resistant to the idea of fathering children; and the fourth experienced severe anxiety attacks when told of his wife's pregnancyattacks based on unconscious hostility toward a sibling. Thus it appears that psychiatric disturbance in relation to fatherhood can be on many different dynamic levels, and that to understand the significance for an individual patient, one must entertain all of the above possibilities, and determine the father's premorbid personality. Our experience in this field is illustrated by the following three patients who had significant emotional difficulties surrounding fatherhood. The factor common to all three is that each, during his wife's pregnancy, experienced abdominal pain for which no physical cause could be found. While their disorders superficially appeared to be a variant of the relatively benign couvade syndrome, each was ultimately hospitalized for significant psychiatric disturbance. For each patient, we have attempted to relate couvade syndrome, postpartum psychiatric difficulties in fathers generally, and the significance of abdominal pain in these particular men during their wives' pregnancies. Case 1 A 22-year-old blue-collar worker was admitted to the forensic psychiatry unit for diagnostic evaluation after he had threatened to kill a major political leader. The mental status examination revealed a thin, passive, soft-spoken man who cried readily throughout the interview. He was depressed and had signs of psychomotor retardation. He appeared to have a thought disorder, PSYCHOSOMATICS

and admiUed to aUditory hallucinations of his father's voice saying that he was coming to visit the patient. Although acknowledging that he wrote the leUer to the political figure, the patient denied any harmful intent to the man. He wanted to indicate to everyone how important it was "for me to visit my own father." The history revealed that he was the youngest male and the third of four children. He had been a slow learner in school, finally leaving after the sixth grade to pursue odd jobs around his small hometown. His father was a truck driver who was embarrassed by his son's difficulty with school work, which led to a cold, emotionally distant relationship. His mother, a housewife, was very close to the patient, and he to her. During adolescence, the patient became involved in peer-inspired delinquency; this forced some attention from the father to "help me out of trouble." When the patient was 18, his parents separated. One year later, he married a local girl, but the father would not aUend the wedding. Shortly afterwards the father left the state and has had no further contact with the patient or the family. When the patient's wife announced her pregnancy, he felt excited, happy, and hopeful about the baby. As the wife became visibly pregnant, he began to experience, for the first time, a vague, generalized, nondescriptive pain in his abdomen. He consulted his family physician, who did a thorough physical and radiographic evaluation without finding a cause for the pain. The patient experienced liUte relief with various medications, and visited the family doctor so frequently with complaints of abdominal pain that he was finally referred to a psychiatrist. A diagnosis of hysterical pain was made, but IiUle relief was obtained. Except for the abdominal pain, both the patient and his wife did well throughout the pregnancy. Shortly after a son was born, the patient's abdominal pain ceased, but DECEMBER 1978 • VOL 19' NO 12

he began asking various family members for news of his father, requesting them to ask the father to visit both him and his new son. The father never responded. Six months after the birth of the son, the patient wrote the threatening leUer. In his psychotic reasoning, he chose to communicate the letter to "the father of the country," since his own father was not available. When arrested, he offered no resistance. Believing the patient to have a schizo-affective disorder, we treated him with antipsychotic and antidepressant drugs. The drugs

Abdominalpain in a man is a poor prognostic sign when it is associated with emotional upheaval during his wife's pregnancy. plus supportive psychotherapy effected a remission of his illness within six weeks. He expressed a desire to return home to his wife and son, but only if he could continue to receive outpatient psychotherapy. He stated, "I still need help, if not from my father, then from someone else." Dynamically, the man's abdominal pain represented an unconscious pregnancy fantasy. It was much more, however, than identification with his pregnant wife. It appeared to be an asexual regression to an early preoedipal level of development, an attempt to establish a caring, nurturing relationship such as a small baby might have in utero. It seemed that this unconscious fantasy and the abdominal pain were defenses against hostility toward both the mother and father for not meeting his dependency

needs. With the birth of the son, this defense no longer sufficed for his hostility and rage. In one sense, incorporation no longer defended the conflict; instead, projection took place, which led to the sending of the threatening letter. Projection was also evident in the onset of the auditory hallucinations. In spite of the fact that the patient talked about his difficulty with his father, we believe the conflict was on a deeper level, involving the mother to a much greater extent than was consciously realized. We wish to emphasize that, in this patient, the abdominal pain was a regressive somatic defense against becoming psychotic.

C. . 2 A 29-year-old business man came to the emergency room requesting psychiatric aid for the first time. He was tormented by increasingly severe anxiety, panic aUacks, and obsessive thoughts of killing his wife, son, and himself. These symptoms had been present for three months, and for the last three days he had been unable to function because of his anxiety. The mental status examination revealed an anxious, tearful, intelligent, and articulate man who appeared to be moderately depressed. There were no vegetative signs of psychotic depression, and no thought disorder. He was depressed enough to require inpatient care. His history revealed that he was the younger of two children with a sister three years his senior. He perceived his father, a business executive, as a taciturn, cold man with whom he had always had "almost a business-like relationship." He was close to his mother and sister, and recalled warmness in those relationships. At age 19, he had learned that his mother was dying of cancer, after four years of suffering. He recalled "having fallen apart" after her death and feeling 763

Expectant fathers alone and abandoned. He remembered his father as being particularly inaccessible after his mother's death, and was angered by the father's second marriage 10 months later. During his college years, shortly after his mother's death, he began to be bothered by intermittent abdominal pain. A thorough physical and radiographic workup revealed no cause for the pain. When his wife became pregnant, the abdominal pain was exacerbated. Another radiographic workup revealed no cause. The pain subsided soon after the son's delivery, only to be followed shortly afterward by the outbreak of anxiety, panic attacks, and obsessive thoughts. We discovered that three significant external events had combined to accentuate his anxiety: the tenth anniversary of his mother's death; the imminent anniversary of his son's birth; and a major promotion his father had received. Supportive therapy around these issues during a one-week hospitalization led to some symptomatic relief, and he was discharged with arrangements for him to undergo psychoanalytic therapy twice weekly. Over the course of two years in psychotherapy, it became clear that this man had not grieved for his lost mother. When he began grieving, however, the abdominal pain was again exacerbated; this cycle was noted at three different points in the therapy. It became clear from his dreams and other material that his abdominal pain represented a pregnancy fantasy and that the fantasy was on the regressive, infantile, preoedipal level. The fantasy served to reunite him and his mother and represented his wish to be in utero. As the grief was worked through, and could be acknowledged on a cognitive, verbal level, his abdominal pain ceased. Dynamically, with the death of DECEMBER 1978 • VOL 19· NO 12

his mother, the patient incorporated her in order to avoid her loss. This accounted for his inability to grieve at the time of her death. When he married, he chose a woman who was in many ways a mother substitute; interestingly, he had some conscious awareness of this, although it was intellectualized. When his wife became pregnant, he regressed again and the abdominal pain was accentuated. The pain was a pregnancy fantasy that reunited him with his mother through his identification with the child his wife was carrying in utero. Case 3

A 28-year-old financial manager was admitted to the psychiatric inpatient service because of severe depression, abdominal pain, and a delusion that "something, probably cancer, is growing inside my stomach." His history revealed that the patient was the only child of a prosperous family. He feared but admired his wealthy father, who was a self-made financial success; yet their emotional relationship had been distant. His mother, very protective of the patient, was the "boss" of the family as the patient grew up. She made plans for the patient while he was still a toddler to attend the "proper" schools and pursue a "proper" career. He did attend prep schools and later graduated from an Ivy League university after achieving All-American status in athletic competition. He had a very responsible position in the financial community and was married to a girl he knew since his teens. The marriage seemed good, and the couple decided to have a child. Although the patient professed happiness when his wife announced her pregnancy, he began coming home from work and going straight to bed, exhausted after a routine day. His withdrawal and apathy increased to the point where he could not get out of bed on weekends. His abdominal pain

was evaluated by the family physician, who found no physical cause. As his wife approached term, he began complaining that something was growing inside his stomach that he feared was cancer. One week prior to his wife's delivery, he was admitted for treatment of his depression. The patient's abdominal pain, depression, and delusion appeared to be the result of an unconscious attempt or wish to be in utero. He identified himself with the child in his wife's uterus, and his hostility toward tha't child, and therefore toward himself, contributed to his depression. When the patient responded very slowly to psychotherapy and antidepressant drugs, we considered electroconvulsive therapy, but he improved before we used it. After discharge from the hospital, he refused recommendations for outpatient psychotherapy; instead, he moved in with his mother and father. His mother resumed her nurturing attitude, but his wife filed for divorce. The patient has continued to reject his son financially and emotionally. Surprisingly, the patient's ego function appeared superficially to be intact in many areas before his wife became pregnant. Discussion In 1958, Bressler et a)l6 described seven women who had experienced abdominal pain for which no physical cause could be found; instead, the basis for their abdominal pain was an unconscious pregnancy fantasy. The authors point out that, even though the symptom appeared to be on an oedipal level, it was actually a more primitive, regressive, oral symptom. They hold that "somatically expressed pregnancy fantasies represent an essentially archaic ego's attempt to con767

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trol primItIve or'al sadistic hostility." They describe patients in whom the somatic defense (that is, the abdominal pain based on the unconscious pregnancy fantasy) is insufficient to contain the primitive hostility and ambivalence, and consequently psychosis supervenes. They stress that on a much more primitive level than identification, unconsciously a literal incorporation of the object takes place. By becoming "pregnant" the patient both incorporates and becomes her own mother. Simultaneously, by identifying with the "baby" she is carrying, she becomes her mother's child again, thus establishing a mother-child reunion in utero. Clearly, these fantasies are very primitive and archaic and if they become conscious, approach the psychotic spectrum. We believe these same psychodynamics are at work in the men

whom we descnbed. The parturition envy, birth envy, or wish to have a child appears to operate in men in the same manner as it does in women with unconscious pregnancy fantasies leading to symptom formation. This wish to have a child seems to be on a nonsexual, preoedipal level as described by Brunswick. s In the patients we described, it appears that the dynamic of primitive incorporation has occurred, leading to abdominal pain. Accordingly, we believe that abdominal pain in a man is a poor prognostic sign when it is associated with emotional upheaval during his wife's pregnancy. We question previous authors who suggest that couvade-type symptoms are benign, for in each man we have seen who suffered abdominal pain during his wife's pregnancy, hospitalization eventually became necessary. 0

Dr. Cavenar is associate professor of psychiatry at Duke University School of Medicine, and chief of the psychiatry service at Veterans Administration Hospital, Durham, N.C. Dr. Weddington is a resident in psychiatry at Duke University Medical Center and Veterans Administration Hospital, Durham. Reprint requests to Dr. Cavenar, Veterans Administration Hospital, 508 Fulton Street, Durham, NC 27705.

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