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The couvade syndrome—some further observations
Journal
of Psychosomatic
Research.
Vol.
12. pp. 107 to 115.
Pergamon
Press
1968.
THE COUVADE SYNDROME-SOME OBSERVATIONS
Printed
in Northern
Ireland
FURTHER
W. H. TRETHOWAN* THE Couvade
syndrome is of interest in that it may be regarded as an elegant example of a psychosomatic disorder though not one, as a general rule, which gives rise to a physical lesion. Couvade symptoms, by definition, only occur in men during their Following child-birth and sometimes wives’ pregnancies or at the time of parturition. possibly even before this event they disappear though may recur in chronological Each subject, therefore, being free of Couvade relationship to future pregnancies. symptoms in between times can be regarded as his own control. As a starting point it is proposed to reconsider the main conclusions derived from a large-scale controlled study completed three years ago [I]. This investigation was carried out by a questionnaire given to 327 expectant fathers at or about the time their wives gave birth, by which means inquiry was made into the state of health of the A midwife immediately scanned each subjects during the previous nine months. questionnaire to check whether it had been properly completed. A similar though somewhat shorter questionnaire was given to 221 men of comparable age and socioeconomic status whose wives were not pregnant and had not been so during the previous year. The main differences which emerged between the two groups were as follows : 1. A significantly greater number of expectant fathers were affected by symptoms than were the controls (x” = 6.61, p = 0.01). 2. Whereas the difference between the number of those in either group having a single symptom only was statistically insignificant, expectant fathers differed very greatly from the controls in the number of those having two or more listed symptoms (x2 = 20.77, p < 0.0001). 3. Of all the symptoms subject to inquiry, those from which expectant fathers were found to suffer significantly more often were: loss of appetite (x2 = 1532 p < O-0005), toothache (x2 = 14.69, p < 0.0005) and nausea and sickness (x2 = 11.29, p < 0~001). 4. All other symptoms with the exception of backache, of which the incidence was identical in the two groups, were commoner in expectant fathers. Although differences in the incidence of these other symptoms when considered separately did not attain statistical significance they did so collectively. 5. It was observed that the incidence of symptoms in expectant fathers reached a peak at the beginning of the third month of pregnancy. Thereafter the incidence diminished but rose again, somewhat, during the ninth month or at the commencement of labour. 6. A significant relationship between the occurrence of somatic and certain minor psychiatric symptoms, e.g. depression, tension, insomnia, irritability, etc., * University of Birmingham, Edgbaston 15, Birmingham. 107
108
W. H. TRETHOWAN
was observed (x2 = 9.484, p < 0*005). A similar and even more significant correlation between somatic symptoms and anxiety by the subjects about their wives’ pregnancies was apparent (x2 = 16.77, p < 0*0005). However it was also observed that the relationship between anxiety and physical symptoms often went quite unperceived by the sufferer. 7. It was concluded that about 1 in 9 (11 per cent) of all expectant fathers in this survey suffered from Couvade symptoms i.e. somatic symptoms of psychogenic origin occurring in direct relationship and in some way due to their wives’ pregnancies. It is not proposed to reconsider the many fascinating historical references which have been made to this strange disorder. Nor will very much be said of the several psychodynamic hypotheses which have been advanced to explain both the Couvade syndrome and the ritual Couvade which appear to stand in analogous relationship to one another. These are aspects which have been dealt with in length elsewhere [l-4]. Instead it is proposed to re-examine some of the initial conclusions together with new material derived both from original and from fresh sources, which have since come to light. Firstly consider the question of incidence. It was originally suggested that about 1 in 9 of all expectant fathers might be affected by Couvade symptoms. This conclusion was, without doubt, largely determined by the nature of the inquiry and the choice of symptoms in which interest was shown. These, in the first place, were selected in a somewhat arbitrary fashion, though with reference to a study carried out by Curtis [5] who observed the occurrence of gastro-intestinal symptoms in 22 or 55 expectant fathers. Our questionnaire was, therefore, directed towards eliciting the presence or absence of the following : Indigestion, colic, nausea and sickness, increased or decreased appetite, diarrhoea, constipation, toothache and backache-in that order. Although asked to record other unnamed physical symptoms this invitation did not produce very many positive answers. However, it has since become apparent that the range of Couvade symptoms, though commonly related to the alimentary system and often mimicking the discomforts of pregnancy, may be much wider than at first thought. Inman [6] for example, observed that styes and tarsal cysts were prone to occur in husbands during their wives’ pregnancies or at or about the time of child-birth. Boils and certain skin conditions have also been thought to occur in special relationship to pregnancy. In one instance it is recorded that herpes labialis occurred after child-birth and apparently in relationship to the patient’s wife suckling her new-born. Lay people, too, who are aware of the Couvade phenomenon are also liable to ascribe, rightly or wrongly, a fairly wide variety of symptoms to this cause. Thus ten letters written by different husbands and wives contained the following catalogue of complaints: dental abscesses and whitlows, styes, toothache, nose-bleeding, facial neuralgia (two attacks 10 years apart and occurring only during pregnancy), abdominal bloating (very uncommon), heartburn, stomach cramps and so-called ‘sympathy’ pains. Although this and much of the other evidence tends to be anecdotal it almost seems feasible to consider that any symptom whatsoever which occurs in close chronological relationship to pregnancy and parturition and not on other occasions may be a manifestation of the Couvade syndrome. Obviously, however, other explanations must be carefully ruled out. One patient may also suffer from many symptoms and not always from the same
The Couvade syndrome-Some further observations
109
ones when pregnancy recurs. The following is a list of somatic and psychiatric symptoms suffered by one normally quite physically healthy man during his wife’s six pregnancies. They included anorexia, toothache (together with demands for multiple extractions), morning sickness, several kinds of abdominal pain-variously described as indigestion, cramps in the upper and lower abdomen and colicky attacks during labour-also chest pain. In addition he recalled frequency of micturition, dermatitis on one thigh (on one occasion and then for a short time only), headaches, insomnia, poor concentration and certain oddities of behaviour including snipping a roll of wire into tiny pieces during his wife’s labour and, on another occasion, just prior to delivery, incubating and assisting in the hatching out of a clutch of bantam’s eggs [4]. Despite all this and some awareness that his symptoms occurred only in chronological relationship to his wife’s pregnancies he seemed to have no insight into their likely cause. A study currently being carried out by Dr. Gerald Dickens [7] of the incidence of pica, cravings and other perversions of appetite in pregnant women has also thrown light on the range and frequency of Couvade symptoms in their husbands for he has made further enquiry into this. Although the findings await detailed analysis they are nonetheless of considerable interest. According to information provided by their wives 31 of the husbands of the 63 women so far interviewed appear to have suffered from some Couvade symptoms. In one other case the woman’s father appears to have been affected. In all instances the symptoms appeared in chronological relationship to pregnancy and disappeared within a few hours of delivery. This strongly suggests that they were in fact Couvade symptoms and of psychogenic origin. In addition it was observed that all the women interviewed seemed not only to be aware of the Couvade phenomenon but readily acknowledged this as the cause of their husbands’ symptoms. This is remarkable. Could it be that these women, in some way, suggested to their husbands that they ought to have symptoms? The finding in this study that almost fifty-per cent of husbands were affected shows that the Couvade syndrome may be very much commoner than was originally thought. The investigator believes that the fact that all his subjects are primipara may have something to do with it. Having a first-born child, it is generally thought, is attended by greater anxiety than subsequent ones. This, however, needs confirmation. However, in the much larger survey originally referred to, those with wives bearing their first child seemed to be no more liable to symptoms than those having one or more. It has to be remembered of course that among the expectant father group in the original survey over half (56.9 per cent) actually had symptoms. But so indeed did 457 per cent of the controls. Although this difference has been shown to be statistically significant (x2 = 6.61, p = 0.01) the fact that so many of the controls suffered in at least some of the same ways as did the expectant-father group indicates that in a considerable proportion of the latter group the symptoms they experienced may well have had nothing to do with their wives’ pregnancies, but were due to all too common gastro-intestinal upsets and things of that kind. This poses the question, how liable is a pregnant woman to ascribe any odd minor symptoms from which her husband may suffer to her pregnancy which, were she not pregnant, she would not otherwise do? At the same time we have to reckon with a number of cases in which symptoms occur in husbands and in which there is very little doubt that pregnancy and parturition play a significant part. This event may also be commoner than our original a
W. H. TRETHOWAN
110
estimate of 1 in 9. If so the real incidence of Couvade symptoms may be being obscured by what virtually amounts to a conspiracy of silence. The finding that many expectant fathers seem often to be prepared to tolerate quite unpleasant symptoms without complaint or consulting the doctor on this account without (whatever their wives may think), ascribing their symptoms to anxiety over pregnancy is of great interest. This suffering-in-silence although by no means invariable, seems to fit in with certain of the psychodynamic mechanisms which, it has been suggested, underlie the syndrome. The range of symptoms uncovered by Dr. Dickens’ investigation is also fairly wide and includes most of those already catalogued. Between them these 31 husbands reported approximately double that number of symptoms. The commonest in order of frequency were some kind of abdominal pain, nausea, vomiting, toothache, backache and disorders of appetite (Table 1). It is of interest that the last category TABLE 1. SYMPTOMSIN 31 HUSBANDS (DICKENS 171) Abdominal pains (various) Nausea Vomiting Toothache Backache Disorders of appetite Skin conditions Miscellaneous
10 10 10 8 7 7 4 5 61
includes
two
instance
for
chocolate,
husbands fried
who,
eggs
doughnuts
and
like fried
and chips.
their bread
wives, together
suffered with
from
cravings-in
ice cream;
In both cases other Couvade
in the
symptoms
the
first
other
for
were also
present. As this survey is not yet complete and there are more cases yet to be added and analysed no final conclusions can be drawn in regard to any possible relationship between the occurrence of symptoms both in wives and husbands. However Dr. Dickens states that in the case of those husbands suffering from Couvade symptoms there would appear, among their wives, to be a greater tendency for nausea and vomiting and both qualitative and quantitative changes of appetite to occur; also a higher incidence of difficulties in labour. These findings, however, do not attain statistical significance, though possibly may do as the total number of women interviewed increases. In view of these new observations it was decided to take a fresh look at the original material, bearing in mind that data derived from a questionnaire has considerable limitations and must not be overworked. The 327 expectant fathers were, therefore, subdivided into four groups, these subdivisions depending on the degree to which they resembled or differed from the control group and on how closely the pattern of their complaints fulfilled criteria which might reasonably lead to a supposition that they were likely to be due to the Couvade reaction. Group A consists of 145 subjects (44.5 per cent). These did not record as positive any of the given check-list of symptoms although under the heading ‘Other’ 41 listed symptoms which, in 28 instances, were classified as psychiatric and, in 13 others as miscellaneous, which category includes some symptoms which were possibly of physical origin and some others of a more ambiguous nature.
The Couvade syndrom+Some
further observations
111
Group B consists of 57 subjects (17.5 per cent) who recorded only one of the listed symptoms, though 25 recorded additional psychiatric and 8 miscellaneous symptoms. It may be recalled that the reporting of a single symptom only was an occurrence equally common in the control as in the expectant-father group. Group C consists of 78 subjects (24 per cent) who recorded as positive two or more of the listed symptoms of which only one was considered to be a key symptom (i.e. loss of appetite, nausea and/or sickness and toothache) all of which were found to occur significantly more often in expectant fathers than in the controls. Where more than one key symptom was recorded subjects were placed in this group (rather than in Group D) only when the time relationship between the occurrence and resolution of symptoms and the march of pregnancy and parturition did not seem to coincide satisfactorily. Group D, the group most disparate from the control group, consisted of 47 men (14 per cent) having a pattern of symptoms which appeared to fulfil the main criteria of the Couvade syndrome. They reported at least two of the three most significant symptoms, these occurring in fairly clear-cut chronological relationship to their wives’ pregnancies or to parturition, i.e. not occurring before the beginning of the third month and resolving almost immediately after childbirth. Dividing the subjects up in this way makes the incidence of Couvade symptoms higher than that originally suggested-one in seven as against one in nine. What differences or similarities may be observed between these four groups? Neither husbands or wives in any group differed in average age. No difference can be observed in the number of those expecting a first child and those already having one or more. Rather more of the wives in Groups A, B and C had had previous miscarriages than those in Group D (22.1, 16.3 and 18.0 per cent as against 14.6 per cent) but these differences do not attain statistical significance. A somewhat, though once again, not a significantly higher proportion of Group D patients were absent from work for some period during their wives’ pregnancies owing to symptoms. But this does not tell us very much other than that they comprised those who were among the most severely affected and rated themselves as such (See Table 2). Similarly apart from TABLE 2. SELF-RATING ACCORDING SEVERITY OF SYMPTOMS GROUP
Severe Not Severe Total
TO
B
C
D
6 51 57
12 66 78
17 30 47
x* = 9.15,n = 2,p = 0.01.
reporting a larger incidence of the more significant symptoms (loss of appetite, nausea and/or vomiting, toothache) Group D also reported a larger total number of symptoms (167 in 47 subjects, av. 3.5 per head) than did Group C (209 in 78 subjects, av. 2.7 per head). This difference, again, is no more than a measure of severity though does not attain significance. Some difference could be perceived in social-occupational class this tending to fall progressively from Group A to D. (See Table 3). Despite this trend the difference is not significant statistically. Furthermore information about social-occupational class
W. H. TRETHOWAN
112
of quite a number of the subjects is lacking. But if as is likely there is some degree of correlation between social-occupational class and intelligence then it may not be surprising that the less intelligent seem more prone to be affected. However the Couvade syndrome is no respecter of persons. Bardham [8] states: “Socio-economic status has no relation to the onset; the clinical features may, however, vary according to the level of intelligence and education”. TABLE3. SOCIAL-OCCUPATIONAL CLASS
Group I, II III IV, v Unemployed
10.0 63.0 23.5 3.5
11.5 61.5 25.0 2.0
5.5 66.0 26.1 2.5
4.5 57.5 35.5 2.5
(Differences not significant).
It is when we come to consider the relationship between overt anxiety and the incidence of somatic symptoms that rather more striking differences between the groups begin to emerge. Whereas in Group A only 69 men (48 per cent) admitted to any feelings of anxiety over their wives’ pregnancies (these being those who did not record as positive any of the listed somatic symptoms) the proportions in Groups B, C and D were 62, 74 and 72 per cent respectively. These differences are significant (x2 = 19.87, it = 3, p < 0.0005) and point to a clear relationship between anxiety and the occurrence of Couvade symptoms. But this is no simple matter. The relationship though perhaps obvious to the onlooker is by no means always apparent to the victim. Indeed while 130 of 186 men with physical symptoms (70 per cent) admitted anxiety over their wives, about onethird (56 or 30 per cent) did not. Conversely nearly one-half (67 of 141 or 48 per cent) of those without physical symptoms were overtly anxious nonetheless. The reasons given for being anxious are not strictly comparable but an impression was gained that what may be called pseudo-obstetrical reasons for anxiety (“It’s her first” “I can’t bear to see her suffer”) were commoner in ascending order from one group to the next (A-18 %, B-25 %, C-30 %, D-34 %). A similar pattern emerges when the relationship between the occurrence of Couvade and other psychiatric symptoms is considered. Once again the association is patently obvious to the observer. While 26 per cent of the total expectant-father group reported accessory psychiatric symptoms the proportion rose steadily through the four groups from 19 to 36.2 per cent (see Table 4). This difference is fairly significant (x2 = 9.31, /z = 3, p < 0.05 > 0.025) but becomes even more so when all accessory symptoms including those of miscellaneous or ambiguous nature (i.e. those in which there is uncertainty whether they are of physical or psychiatric origin) are taken into account (see Table 5). (x2 = 14.04, II = 3, p < 0.005 > 0.001). What does all this amount to? The finding that those with Couvade symptoms also exhibit more anxiety and other psychiatric symptoms, together with a larger number of more nebulous complaints, strongly suggests a higher incidence of neuroticism in this group, which conclusion might have been anticipated. But anxiety about what? In very few instances does there seem to have been any real basis for anxiety, i.e. an actual obstetric reason. Also, as has already been shown, many expectant
The Couvade syndrome-Some TABLE
4.
113
further observations
ACCESSORY PSYCHIATRIC SYMPTOMS
Group
A
B
C
D
With Without Total
28 (19 %) 117 (81%) 145
17 (27.8 %) 40 (70.2 %) 57
24 (30.8 %) 54 (69.2 %) 78
17 (36.2 %) 30 (73.8 %) 47
x2 = 9.31, n = 3, p < 0.05 > 0.025. TABLE 5. ACCESSORY AND OTHER (AMBIGUOUS) SYMPTOMS
Group
A
B
C
D
With Without Total
41 (28.2%) 104 (71.8%) 145
25 (43.9 %) 32 (561%) 57
37 (47.4%) 41 (52.6%) 78
30 (64.3 %) 17 (35.7 %) 47
x2 = 14.04,
n =
3, p < 0.005 > 0.001.
fathers appear to be anxious or at least to experience somatic anxiety symptoms, without any insight into why these symptoms should occur. This avoidance of conflict -a deliberate turning-away (the classical concept of repression seems too feebly passive to account for such a powerful defence mechanism) removes many Couvade cases from the relatively simple class of somatically expressed anxiety states into the category of conversion reactions, in which denial of the basic cause for anxiety looms large and appears, indeed, to be a prime factor. In conclusion further consideration will be given to toothache-one of the odder manifestations of the Couvade syndrome. It is perhaps fairly easy to understand how, by a process of identification perhaps, anxious men may suffer, like their pregnant wives, from nausea, morning sickness, perversions of appetite and other mimetic symptoms, even perhaps-and very rarely-from abdominal bloating. But toothache is more difficult to explain. Nevertheless, and as several studies have shown, it is among the commonest discomforts of expectant fatherhood. Awareness of toothache as a Couvade symptom goes far back into history. It has found a place in folklore, for example in the popular belief among the miners of Fife that, at the beginning of pregnancy, a husband may develop a toothache which may persist until the birth of his child [9]. Similar ideas have been recorded from Yorkshire, Cheshire, Oxfordshire, East Anglia and no doubt from elsewhere also. Almost inevitably the notion tickled the fancy of the Elizabethan dramatists giving rise to references in several plays by different playwrights to expectant fathers who, it is said “breed” their wives’ children in their teeth. What has also to be considered is what, in this context, is meant by toothache. This, like headache, may be a vague term. It can mean several different things. In many cases the toothache from which expectant fathers suffer is of a familiar kind though treatment, even extraction, of the supposedly offending tooth (or teeth) does not, it seems, necessarily bring relief. In other cases the pain is not so much a toothache but some form of neuralgia located in the face or jaw. Transitions can also occur. Here is an example: A 24-year old, slightly effeminate mild-mannered man, a slaughterman by trade, developed toothache about half-way through his wife’s first pregnancy. This occurred when she was found to have glycosuria and was admitted to hospital for investigation
114
W. H. TRETHOWAN
on this account. Two weeks later, when she was discharged his toothache immediately resolved. It returned, though less severely, when she was admitted in labour and disappeared once again, after the birth of their child. At the time that it started he consulted his dentist who could find little to account for it. Beginning as an ache in one tooth the pain soon migrated to others, then spread to his gums and finally to the roof of his mouth whereupon, he said, it became much more painful and took on a neuralgia-like quality. Whereas the pain tended to last all day it did not trouble him at night. Aspirin relieved it very little. During the early months of her pregnancy his wife suffered much from sickness. At 12 weeks she threatened abortion which caused her husband some worry. Later, except for glycosuria all went well. She had no trouble with her teeth during pregnancy, having one routine filling only. Her husband stated that although he himself did not have very good teeth, he had always sought regular dental attention. Apart from his father likewise. Indeed he recounted how, this he admitted to being a worrier; on the day he himself was born, his father lost his speech on that day only-an attack of hysterical aphonia perhaps. Further recourse to our original material throws very little light on the origin of ‘Couvade-toothache’. Although so many more expectant fathers were affected than were those in the control group, few-only 5 of 76-saw this as being in some way related. Three gave other reasons; the other 68 none at all. In only 3 instances was toothache present before the third month of pregnancy. In 7, just when it began was not at all clear. In the remainder the incidence was highest during the third to the fifth month, when over half (46 or 60 per cent) were affected. Without regard to when it started toothache persisted in 42 cases (55 per cent) until a short time after delivery. The average duration of ‘Couvade-toothache’ is difficult to determine, but having regard to the fact that the range is very wide-from a few days to almost the whole duration of pregnancy-it seems, in this series of cases, to have been about 12 weeks. Long or short, it does not appear to have been particularly severe or disabling-other symptoms when they occurred were often more troublesome, though seldom excessively so. Of several theories which have been advanced to ‘explain’ this odd phenomenon, that which invokes the mechanism of identification and the notion of sympathetic Reduced to the simplest terms this hypothesis magic may be the most credible. states that expectant fathers develop toothache as a magical act in order to protect the teeth of their pregnant wives from damage. This notion rests upon the old sawfor every child a tooth, an old wives’ tale which some still believe. The idea is, it is said, quite without foundation. Whereas given poor enough nutrition a pregnant woman’s bones may decalcify, her teeth escape this hazard. She may develop gingivitis, even caries, but these, it is said, are risks not special to pregnancy. Even so the belief that pregnancy damages teeth seems to be widespread as the following rather crude survey suggests. One-hundred subjects, chosen more or less at random, were given a short questionnaire containing 10 statements pertaining to some everyday matters of health. Included “Pregnancy commonly damages a woman’s among them was the statement: teeth”. All that was required was a “Yes” or “No” answer. The 100 subjects included 70 who might be thought of as semi-sophisticated medically in that they consisted
The Couvade syndrome-Some
further observations
115
of 43 male medical students and 27 females including a number of nurses. The remainder consisted of a heterogenous group of administrative, technical and secretarial staff together with a few non-psychiatric patients. 17 of these were female and 13 male. It turned out (Table 6) that 55 of the subjects to whom the questionnaire was TABLE
6.
PREGNANCY COMMONLY DAMAGES A WOMAN’S TEETH?
(100 replies)
Medical students and nurses Other (including domestic, secretarial staff and some patients) Total
Total by sex
True?
False?
!I$
3
x F
M F
55
45
True
False
26 (46 %) 29 (66%)
30 (54 %) 15 (34%)
believed that the statement was true. A greater proportion of women (66 per cent) believed it than did men (46 per cent). Of the more medically sophisticated group only slightly more did so than did not. Among the others nearly twice as many did so. While the exact figures matter very little it is quite apparent that the idea is one to which many people still subscribe. And yet, so the dental experts insist, this is a belief which has absolutely no foundation. The people included in this survey were all but a handful, unmarried, but there is no evidence to suggest that there is any substantial alteration in the belief after marriage has taken place. given
REFERENCES 1. TRETHOWAN W. H. and CONLON M. F. Br. J. Psych&. 111, 57 (1965). 2. TRETHOWAN W. H. Discovery 26, 30 (1965). 3. TRETHOWAN W. H. Mother di Child Care 1, 53 (1965). 4. ENOCH M. D., TRETHOWAN W. H. and BARKER J. C. Some Uncommon Psychiatric
John Wright, Bristol (1967). 5. CURTIS J. L. U.S. Arm. Forces Med. J. 6, 937 (1955). 6. INMAN W. S. Br. J. Med. Psychol. 19, 37 (1941). DICKENS G. Personal communication (1967). 8. BARDHAM P. N. US. Arm. Forces Med. J. 20, 200 9. ROLLESTONJ. D. Br. Dent. J. 78, 225, 227 (1945).
7.
(1964).
Syndromes,
of Psychosomatic
Research.
Vol.
12. pp. 107 to 115.
Pergamon
Press
1968.
THE COUVADE SYNDROME-SOME OBSERVATIONS
Printed
in Northern
Ireland
FURTHER
W. H. TRETHOWAN* THE Couvade
syndrome is of interest in that it may be regarded as an elegant example of a psychosomatic disorder though not one, as a general rule, which gives rise to a physical lesion. Couvade symptoms, by definition, only occur in men during their Following child-birth and sometimes wives’ pregnancies or at the time of parturition. possibly even before this event they disappear though may recur in chronological Each subject, therefore, being free of Couvade relationship to future pregnancies. symptoms in between times can be regarded as his own control. As a starting point it is proposed to reconsider the main conclusions derived from a large-scale controlled study completed three years ago [I]. This investigation was carried out by a questionnaire given to 327 expectant fathers at or about the time their wives gave birth, by which means inquiry was made into the state of health of the A midwife immediately scanned each subjects during the previous nine months. questionnaire to check whether it had been properly completed. A similar though somewhat shorter questionnaire was given to 221 men of comparable age and socioeconomic status whose wives were not pregnant and had not been so during the previous year. The main differences which emerged between the two groups were as follows : 1. A significantly greater number of expectant fathers were affected by symptoms than were the controls (x” = 6.61, p = 0.01). 2. Whereas the difference between the number of those in either group having a single symptom only was statistically insignificant, expectant fathers differed very greatly from the controls in the number of those having two or more listed symptoms (x2 = 20.77, p < 0.0001). 3. Of all the symptoms subject to inquiry, those from which expectant fathers were found to suffer significantly more often were: loss of appetite (x2 = 1532 p < O-0005), toothache (x2 = 14.69, p < 0.0005) and nausea and sickness (x2 = 11.29, p < 0~001). 4. All other symptoms with the exception of backache, of which the incidence was identical in the two groups, were commoner in expectant fathers. Although differences in the incidence of these other symptoms when considered separately did not attain statistical significance they did so collectively. 5. It was observed that the incidence of symptoms in expectant fathers reached a peak at the beginning of the third month of pregnancy. Thereafter the incidence diminished but rose again, somewhat, during the ninth month or at the commencement of labour. 6. A significant relationship between the occurrence of somatic and certain minor psychiatric symptoms, e.g. depression, tension, insomnia, irritability, etc., * University of Birmingham, Edgbaston 15, Birmingham. 107
108
W. H. TRETHOWAN
was observed (x2 = 9.484, p < 0*005). A similar and even more significant correlation between somatic symptoms and anxiety by the subjects about their wives’ pregnancies was apparent (x2 = 16.77, p < 0*0005). However it was also observed that the relationship between anxiety and physical symptoms often went quite unperceived by the sufferer. 7. It was concluded that about 1 in 9 (11 per cent) of all expectant fathers in this survey suffered from Couvade symptoms i.e. somatic symptoms of psychogenic origin occurring in direct relationship and in some way due to their wives’ pregnancies. It is not proposed to reconsider the many fascinating historical references which have been made to this strange disorder. Nor will very much be said of the several psychodynamic hypotheses which have been advanced to explain both the Couvade syndrome and the ritual Couvade which appear to stand in analogous relationship to one another. These are aspects which have been dealt with in length elsewhere [l-4]. Instead it is proposed to re-examine some of the initial conclusions together with new material derived both from original and from fresh sources, which have since come to light. Firstly consider the question of incidence. It was originally suggested that about 1 in 9 of all expectant fathers might be affected by Couvade symptoms. This conclusion was, without doubt, largely determined by the nature of the inquiry and the choice of symptoms in which interest was shown. These, in the first place, were selected in a somewhat arbitrary fashion, though with reference to a study carried out by Curtis [5] who observed the occurrence of gastro-intestinal symptoms in 22 or 55 expectant fathers. Our questionnaire was, therefore, directed towards eliciting the presence or absence of the following : Indigestion, colic, nausea and sickness, increased or decreased appetite, diarrhoea, constipation, toothache and backache-in that order. Although asked to record other unnamed physical symptoms this invitation did not produce very many positive answers. However, it has since become apparent that the range of Couvade symptoms, though commonly related to the alimentary system and often mimicking the discomforts of pregnancy, may be much wider than at first thought. Inman [6] for example, observed that styes and tarsal cysts were prone to occur in husbands during their wives’ pregnancies or at or about the time of child-birth. Boils and certain skin conditions have also been thought to occur in special relationship to pregnancy. In one instance it is recorded that herpes labialis occurred after child-birth and apparently in relationship to the patient’s wife suckling her new-born. Lay people, too, who are aware of the Couvade phenomenon are also liable to ascribe, rightly or wrongly, a fairly wide variety of symptoms to this cause. Thus ten letters written by different husbands and wives contained the following catalogue of complaints: dental abscesses and whitlows, styes, toothache, nose-bleeding, facial neuralgia (two attacks 10 years apart and occurring only during pregnancy), abdominal bloating (very uncommon), heartburn, stomach cramps and so-called ‘sympathy’ pains. Although this and much of the other evidence tends to be anecdotal it almost seems feasible to consider that any symptom whatsoever which occurs in close chronological relationship to pregnancy and parturition and not on other occasions may be a manifestation of the Couvade syndrome. Obviously, however, other explanations must be carefully ruled out. One patient may also suffer from many symptoms and not always from the same
The Couvade syndrome-Some further observations
109
ones when pregnancy recurs. The following is a list of somatic and psychiatric symptoms suffered by one normally quite physically healthy man during his wife’s six pregnancies. They included anorexia, toothache (together with demands for multiple extractions), morning sickness, several kinds of abdominal pain-variously described as indigestion, cramps in the upper and lower abdomen and colicky attacks during labour-also chest pain. In addition he recalled frequency of micturition, dermatitis on one thigh (on one occasion and then for a short time only), headaches, insomnia, poor concentration and certain oddities of behaviour including snipping a roll of wire into tiny pieces during his wife’s labour and, on another occasion, just prior to delivery, incubating and assisting in the hatching out of a clutch of bantam’s eggs [4]. Despite all this and some awareness that his symptoms occurred only in chronological relationship to his wife’s pregnancies he seemed to have no insight into their likely cause. A study currently being carried out by Dr. Gerald Dickens [7] of the incidence of pica, cravings and other perversions of appetite in pregnant women has also thrown light on the range and frequency of Couvade symptoms in their husbands for he has made further enquiry into this. Although the findings await detailed analysis they are nonetheless of considerable interest. According to information provided by their wives 31 of the husbands of the 63 women so far interviewed appear to have suffered from some Couvade symptoms. In one other case the woman’s father appears to have been affected. In all instances the symptoms appeared in chronological relationship to pregnancy and disappeared within a few hours of delivery. This strongly suggests that they were in fact Couvade symptoms and of psychogenic origin. In addition it was observed that all the women interviewed seemed not only to be aware of the Couvade phenomenon but readily acknowledged this as the cause of their husbands’ symptoms. This is remarkable. Could it be that these women, in some way, suggested to their husbands that they ought to have symptoms? The finding in this study that almost fifty-per cent of husbands were affected shows that the Couvade syndrome may be very much commoner than was originally thought. The investigator believes that the fact that all his subjects are primipara may have something to do with it. Having a first-born child, it is generally thought, is attended by greater anxiety than subsequent ones. This, however, needs confirmation. However, in the much larger survey originally referred to, those with wives bearing their first child seemed to be no more liable to symptoms than those having one or more. It has to be remembered of course that among the expectant father group in the original survey over half (56.9 per cent) actually had symptoms. But so indeed did 457 per cent of the controls. Although this difference has been shown to be statistically significant (x2 = 6.61, p = 0.01) the fact that so many of the controls suffered in at least some of the same ways as did the expectant-father group indicates that in a considerable proportion of the latter group the symptoms they experienced may well have had nothing to do with their wives’ pregnancies, but were due to all too common gastro-intestinal upsets and things of that kind. This poses the question, how liable is a pregnant woman to ascribe any odd minor symptoms from which her husband may suffer to her pregnancy which, were she not pregnant, she would not otherwise do? At the same time we have to reckon with a number of cases in which symptoms occur in husbands and in which there is very little doubt that pregnancy and parturition play a significant part. This event may also be commoner than our original a
W. H. TRETHOWAN
110
estimate of 1 in 9. If so the real incidence of Couvade symptoms may be being obscured by what virtually amounts to a conspiracy of silence. The finding that many expectant fathers seem often to be prepared to tolerate quite unpleasant symptoms without complaint or consulting the doctor on this account without (whatever their wives may think), ascribing their symptoms to anxiety over pregnancy is of great interest. This suffering-in-silence although by no means invariable, seems to fit in with certain of the psychodynamic mechanisms which, it has been suggested, underlie the syndrome. The range of symptoms uncovered by Dr. Dickens’ investigation is also fairly wide and includes most of those already catalogued. Between them these 31 husbands reported approximately double that number of symptoms. The commonest in order of frequency were some kind of abdominal pain, nausea, vomiting, toothache, backache and disorders of appetite (Table 1). It is of interest that the last category TABLE 1. SYMPTOMSIN 31 HUSBANDS (DICKENS 171) Abdominal pains (various) Nausea Vomiting Toothache Backache Disorders of appetite Skin conditions Miscellaneous
10 10 10 8 7 7 4 5 61
includes
two
instance
for
chocolate,
husbands fried
who,
eggs
doughnuts
and
like fried
and chips.
their bread
wives, together
suffered with
from
cravings-in
ice cream;
In both cases other Couvade
in the
symptoms
the
first
other
for
were also
present. As this survey is not yet complete and there are more cases yet to be added and analysed no final conclusions can be drawn in regard to any possible relationship between the occurrence of symptoms both in wives and husbands. However Dr. Dickens states that in the case of those husbands suffering from Couvade symptoms there would appear, among their wives, to be a greater tendency for nausea and vomiting and both qualitative and quantitative changes of appetite to occur; also a higher incidence of difficulties in labour. These findings, however, do not attain statistical significance, though possibly may do as the total number of women interviewed increases. In view of these new observations it was decided to take a fresh look at the original material, bearing in mind that data derived from a questionnaire has considerable limitations and must not be overworked. The 327 expectant fathers were, therefore, subdivided into four groups, these subdivisions depending on the degree to which they resembled or differed from the control group and on how closely the pattern of their complaints fulfilled criteria which might reasonably lead to a supposition that they were likely to be due to the Couvade reaction. Group A consists of 145 subjects (44.5 per cent). These did not record as positive any of the given check-list of symptoms although under the heading ‘Other’ 41 listed symptoms which, in 28 instances, were classified as psychiatric and, in 13 others as miscellaneous, which category includes some symptoms which were possibly of physical origin and some others of a more ambiguous nature.
The Couvade syndrom+Some
further observations
111
Group B consists of 57 subjects (17.5 per cent) who recorded only one of the listed symptoms, though 25 recorded additional psychiatric and 8 miscellaneous symptoms. It may be recalled that the reporting of a single symptom only was an occurrence equally common in the control as in the expectant-father group. Group C consists of 78 subjects (24 per cent) who recorded as positive two or more of the listed symptoms of which only one was considered to be a key symptom (i.e. loss of appetite, nausea and/or sickness and toothache) all of which were found to occur significantly more often in expectant fathers than in the controls. Where more than one key symptom was recorded subjects were placed in this group (rather than in Group D) only when the time relationship between the occurrence and resolution of symptoms and the march of pregnancy and parturition did not seem to coincide satisfactorily. Group D, the group most disparate from the control group, consisted of 47 men (14 per cent) having a pattern of symptoms which appeared to fulfil the main criteria of the Couvade syndrome. They reported at least two of the three most significant symptoms, these occurring in fairly clear-cut chronological relationship to their wives’ pregnancies or to parturition, i.e. not occurring before the beginning of the third month and resolving almost immediately after childbirth. Dividing the subjects up in this way makes the incidence of Couvade symptoms higher than that originally suggested-one in seven as against one in nine. What differences or similarities may be observed between these four groups? Neither husbands or wives in any group differed in average age. No difference can be observed in the number of those expecting a first child and those already having one or more. Rather more of the wives in Groups A, B and C had had previous miscarriages than those in Group D (22.1, 16.3 and 18.0 per cent as against 14.6 per cent) but these differences do not attain statistical significance. A somewhat, though once again, not a significantly higher proportion of Group D patients were absent from work for some period during their wives’ pregnancies owing to symptoms. But this does not tell us very much other than that they comprised those who were among the most severely affected and rated themselves as such (See Table 2). Similarly apart from TABLE 2. SELF-RATING ACCORDING SEVERITY OF SYMPTOMS GROUP
Severe Not Severe Total
TO
B
C
D
6 51 57
12 66 78
17 30 47
x* = 9.15,n = 2,p = 0.01.
reporting a larger incidence of the more significant symptoms (loss of appetite, nausea and/or vomiting, toothache) Group D also reported a larger total number of symptoms (167 in 47 subjects, av. 3.5 per head) than did Group C (209 in 78 subjects, av. 2.7 per head). This difference, again, is no more than a measure of severity though does not attain significance. Some difference could be perceived in social-occupational class this tending to fall progressively from Group A to D. (See Table 3). Despite this trend the difference is not significant statistically. Furthermore information about social-occupational class
W. H. TRETHOWAN
112
of quite a number of the subjects is lacking. But if as is likely there is some degree of correlation between social-occupational class and intelligence then it may not be surprising that the less intelligent seem more prone to be affected. However the Couvade syndrome is no respecter of persons. Bardham [8] states: “Socio-economic status has no relation to the onset; the clinical features may, however, vary according to the level of intelligence and education”. TABLE3. SOCIAL-OCCUPATIONAL CLASS
Group I, II III IV, v Unemployed
10.0 63.0 23.5 3.5
11.5 61.5 25.0 2.0
5.5 66.0 26.1 2.5
4.5 57.5 35.5 2.5
(Differences not significant).
It is when we come to consider the relationship between overt anxiety and the incidence of somatic symptoms that rather more striking differences between the groups begin to emerge. Whereas in Group A only 69 men (48 per cent) admitted to any feelings of anxiety over their wives’ pregnancies (these being those who did not record as positive any of the listed somatic symptoms) the proportions in Groups B, C and D were 62, 74 and 72 per cent respectively. These differences are significant (x2 = 19.87, it = 3, p < 0.0005) and point to a clear relationship between anxiety and the occurrence of Couvade symptoms. But this is no simple matter. The relationship though perhaps obvious to the onlooker is by no means always apparent to the victim. Indeed while 130 of 186 men with physical symptoms (70 per cent) admitted anxiety over their wives, about onethird (56 or 30 per cent) did not. Conversely nearly one-half (67 of 141 or 48 per cent) of those without physical symptoms were overtly anxious nonetheless. The reasons given for being anxious are not strictly comparable but an impression was gained that what may be called pseudo-obstetrical reasons for anxiety (“It’s her first” “I can’t bear to see her suffer”) were commoner in ascending order from one group to the next (A-18 %, B-25 %, C-30 %, D-34 %). A similar pattern emerges when the relationship between the occurrence of Couvade and other psychiatric symptoms is considered. Once again the association is patently obvious to the observer. While 26 per cent of the total expectant-father group reported accessory psychiatric symptoms the proportion rose steadily through the four groups from 19 to 36.2 per cent (see Table 4). This difference is fairly significant (x2 = 9.31, /z = 3, p < 0.05 > 0.025) but becomes even more so when all accessory symptoms including those of miscellaneous or ambiguous nature (i.e. those in which there is uncertainty whether they are of physical or psychiatric origin) are taken into account (see Table 5). (x2 = 14.04, II = 3, p < 0.005 > 0.001). What does all this amount to? The finding that those with Couvade symptoms also exhibit more anxiety and other psychiatric symptoms, together with a larger number of more nebulous complaints, strongly suggests a higher incidence of neuroticism in this group, which conclusion might have been anticipated. But anxiety about what? In very few instances does there seem to have been any real basis for anxiety, i.e. an actual obstetric reason. Also, as has already been shown, many expectant
The Couvade syndrome-Some TABLE
4.
113
further observations
ACCESSORY PSYCHIATRIC SYMPTOMS
Group
A
B
C
D
With Without Total
28 (19 %) 117 (81%) 145
17 (27.8 %) 40 (70.2 %) 57
24 (30.8 %) 54 (69.2 %) 78
17 (36.2 %) 30 (73.8 %) 47
x2 = 9.31, n = 3, p < 0.05 > 0.025. TABLE 5. ACCESSORY AND OTHER (AMBIGUOUS) SYMPTOMS
Group
A
B
C
D
With Without Total
41 (28.2%) 104 (71.8%) 145
25 (43.9 %) 32 (561%) 57
37 (47.4%) 41 (52.6%) 78
30 (64.3 %) 17 (35.7 %) 47
x2 = 14.04,
n =
3, p < 0.005 > 0.001.
fathers appear to be anxious or at least to experience somatic anxiety symptoms, without any insight into why these symptoms should occur. This avoidance of conflict -a deliberate turning-away (the classical concept of repression seems too feebly passive to account for such a powerful defence mechanism) removes many Couvade cases from the relatively simple class of somatically expressed anxiety states into the category of conversion reactions, in which denial of the basic cause for anxiety looms large and appears, indeed, to be a prime factor. In conclusion further consideration will be given to toothache-one of the odder manifestations of the Couvade syndrome. It is perhaps fairly easy to understand how, by a process of identification perhaps, anxious men may suffer, like their pregnant wives, from nausea, morning sickness, perversions of appetite and other mimetic symptoms, even perhaps-and very rarely-from abdominal bloating. But toothache is more difficult to explain. Nevertheless, and as several studies have shown, it is among the commonest discomforts of expectant fatherhood. Awareness of toothache as a Couvade symptom goes far back into history. It has found a place in folklore, for example in the popular belief among the miners of Fife that, at the beginning of pregnancy, a husband may develop a toothache which may persist until the birth of his child [9]. Similar ideas have been recorded from Yorkshire, Cheshire, Oxfordshire, East Anglia and no doubt from elsewhere also. Almost inevitably the notion tickled the fancy of the Elizabethan dramatists giving rise to references in several plays by different playwrights to expectant fathers who, it is said “breed” their wives’ children in their teeth. What has also to be considered is what, in this context, is meant by toothache. This, like headache, may be a vague term. It can mean several different things. In many cases the toothache from which expectant fathers suffer is of a familiar kind though treatment, even extraction, of the supposedly offending tooth (or teeth) does not, it seems, necessarily bring relief. In other cases the pain is not so much a toothache but some form of neuralgia located in the face or jaw. Transitions can also occur. Here is an example: A 24-year old, slightly effeminate mild-mannered man, a slaughterman by trade, developed toothache about half-way through his wife’s first pregnancy. This occurred when she was found to have glycosuria and was admitted to hospital for investigation
114
W. H. TRETHOWAN
on this account. Two weeks later, when she was discharged his toothache immediately resolved. It returned, though less severely, when she was admitted in labour and disappeared once again, after the birth of their child. At the time that it started he consulted his dentist who could find little to account for it. Beginning as an ache in one tooth the pain soon migrated to others, then spread to his gums and finally to the roof of his mouth whereupon, he said, it became much more painful and took on a neuralgia-like quality. Whereas the pain tended to last all day it did not trouble him at night. Aspirin relieved it very little. During the early months of her pregnancy his wife suffered much from sickness. At 12 weeks she threatened abortion which caused her husband some worry. Later, except for glycosuria all went well. She had no trouble with her teeth during pregnancy, having one routine filling only. Her husband stated that although he himself did not have very good teeth, he had always sought regular dental attention. Apart from his father likewise. Indeed he recounted how, this he admitted to being a worrier; on the day he himself was born, his father lost his speech on that day only-an attack of hysterical aphonia perhaps. Further recourse to our original material throws very little light on the origin of ‘Couvade-toothache’. Although so many more expectant fathers were affected than were those in the control group, few-only 5 of 76-saw this as being in some way related. Three gave other reasons; the other 68 none at all. In only 3 instances was toothache present before the third month of pregnancy. In 7, just when it began was not at all clear. In the remainder the incidence was highest during the third to the fifth month, when over half (46 or 60 per cent) were affected. Without regard to when it started toothache persisted in 42 cases (55 per cent) until a short time after delivery. The average duration of ‘Couvade-toothache’ is difficult to determine, but having regard to the fact that the range is very wide-from a few days to almost the whole duration of pregnancy-it seems, in this series of cases, to have been about 12 weeks. Long or short, it does not appear to have been particularly severe or disabling-other symptoms when they occurred were often more troublesome, though seldom excessively so. Of several theories which have been advanced to ‘explain’ this odd phenomenon, that which invokes the mechanism of identification and the notion of sympathetic Reduced to the simplest terms this hypothesis magic may be the most credible. states that expectant fathers develop toothache as a magical act in order to protect the teeth of their pregnant wives from damage. This notion rests upon the old sawfor every child a tooth, an old wives’ tale which some still believe. The idea is, it is said, quite without foundation. Whereas given poor enough nutrition a pregnant woman’s bones may decalcify, her teeth escape this hazard. She may develop gingivitis, even caries, but these, it is said, are risks not special to pregnancy. Even so the belief that pregnancy damages teeth seems to be widespread as the following rather crude survey suggests. One-hundred subjects, chosen more or less at random, were given a short questionnaire containing 10 statements pertaining to some everyday matters of health. Included “Pregnancy commonly damages a woman’s among them was the statement: teeth”. All that was required was a “Yes” or “No” answer. The 100 subjects included 70 who might be thought of as semi-sophisticated medically in that they consisted
The Couvade syndrome-Some
further observations
115
of 43 male medical students and 27 females including a number of nurses. The remainder consisted of a heterogenous group of administrative, technical and secretarial staff together with a few non-psychiatric patients. 17 of these were female and 13 male. It turned out (Table 6) that 55 of the subjects to whom the questionnaire was TABLE
6.
PREGNANCY COMMONLY DAMAGES A WOMAN’S TEETH?
(100 replies)
Medical students and nurses Other (including domestic, secretarial staff and some patients) Total
Total by sex
True?
False?
!I$
3
x F
M F
55
45
True
False
26 (46 %) 29 (66%)
30 (54 %) 15 (34%)
believed that the statement was true. A greater proportion of women (66 per cent) believed it than did men (46 per cent). Of the more medically sophisticated group only slightly more did so than did not. Among the others nearly twice as many did so. While the exact figures matter very little it is quite apparent that the idea is one to which many people still subscribe. And yet, so the dental experts insist, this is a belief which has absolutely no foundation. The people included in this survey were all but a handful, unmarried, but there is no evidence to suggest that there is any substantial alteration in the belief after marriage has taken place. given
REFERENCES 1. TRETHOWAN W. H. and CONLON M. F. Br. J. Psych&. 111, 57 (1965). 2. TRETHOWAN W. H. Discovery 26, 30 (1965). 3. TRETHOWAN W. H. Mother di Child Care 1, 53 (1965). 4. ENOCH M. D., TRETHOWAN W. H. and BARKER J. C. Some Uncommon Psychiatric
John Wright, Bristol (1967). 5. CURTIS J. L. U.S. Arm. Forces Med. J. 6, 937 (1955). 6. INMAN W. S. Br. J. Med. Psychol. 19, 37 (1941). DICKENS G. Personal communication (1967). 8. BARDHAM P. N. US. Arm. Forces Med. J. 20, 200 9. ROLLESTONJ. D. Br. Dent. J. 78, 225, 227 (1945).
7.
(1964).
Syndromes,