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Two cases of pseudocyesis
Two cases of pseudocyesis ....
T\
J.Y.L • .J..J,
San Francisco, California
Two cases of pseudocyesis (grossesse nerveuse) are reported because of their particular motivation: both patients were motivated toward pregnancy by the desire to please the husband.
hospital nurseries, hoping someone would say, "Take this baby. We don't want it." Finally, she actually took a baby-kidnapped it-and took it home with her. At home, the arrival of the baby was greeted with much pleasure. Her husband had every= thing in readiness: crib, clothing, and all accessories. And she gave the baby good care: "I loved it like my own." Nine days later, the happiness in her home came to an end. Much newspaper publicity, a large-scale police hunt, and even a direct appeal to the kidnapper by the baby's father on television (which she saw), produced no result. But when a deputy sheriff became suspicious of her and questioned her, she was moved to go at once to a priest who helped return the baby. The patient was taken into custody on a charge of kidnapping, and later she was hospitalized because of "convulsions." These were actually muscle spasms of the extremities and were accompanied by deep breathing but no loss of consciousness. Her convulsions, like her pregnancy, seemed subject to volition. Thereafter, she returned to the hospital from jail five more times, because of swallowing objects, such as bits of rnetal frorn her bed, a straightened hairpin with curled ends, closed safety pins, broken glass, and finally opened safety pins. She liked it at the hospital and wanted to stay, she told one of our staff members, and that was why she swallowed these potentially dangerous objects. Eventually, an opened, straightened, safety pin failed to pass as did the other objects. It lodged in the cecum and had to be removed surgically. At operation, the appendix was found to have been removed, but the reproductive organs-uterus, tubes, and ovaries-were reported to be normal. While awaiting trial, she confided to a Courtappointed psychiatrist that she was the Virgin Mary and had been pregnant with the baby
Case 1. The first patient was a 27-year-old woman who had married for the second time a year prior to her admission to the hospital. After her marriage she gained weight rapidly. When her husband suggested that her weight gain could be due to pregnancy, she did not deny it. He was elated, bragged to his friends, and gave her showers and parties. She began to feel that she was pregnant but she knew that she could not be; she had continued to menstruate and she knew she was sterile. Ten years earlier, she had had a baby by cesarean section and her tubes were tied at that time.
Her enthusiastic husband took her to a physician who confirmed her "pregnancy." Two other physicians also thought she was pregnant. No biologic tests of pregnancy were performed. The patient knew they were wrong, but acquiesced in her assumed pregnancy. She was "living a lie," but she could not bring herself to tell her husband the truth. So, she continued to actand feel-pregnant. She had morning sickness, her abdomen enlarged, and at the sixth month, her menstruation actually ceased. Her expected date of confinement arrived and passed. People began to worry about her, because the baby was a month overdue. She became desperate. She went to the home of her mother in another city "to have the baby." She planned to tell her husband that the baby was stillborn, but she could not bring herself to do that. She came to San Francisco where she visited From the San Francisco General Hospital.
1865
1866
Dean
Jesus. The psychiatnst, convinced that sh<' was psychotic, recommended her immediate commitment to a state hospital. What he did not know was that her behavior in the presence of our staff, who were with her 24 hours a day, was entirely realistic. Also, he did not know that in an earlier admission, the bed adjoining the patient had been occupit>d by a young woman who had been hospitalized because of precisely this same delusion. That patient told everyone about ht>r delusion, and her mental illness was obvious. Those who knew our patient well thought that her psychosis was as spurious as her prPg-nancy. Our patient did go to a state hospital for a few months, but on an observational commitment for the Court. She was returned as fit for trial, and indeed, she seemed prepared to whatewr penance might be imposed upon her. She spent some months at the county jail and then was released on probation. Unfortunately, her travail had been in vain, for meanwhile her husband had divorced her. Case 2. The second patient was a 37-year-old woman who was admitted to the hospital because she believed herself to be pregnant and at term. Her menstruation had stopped ten months before, then her abdomen began to swell, and she thought that she felt fetal movements. A physical examination, including x-rays, showed no evidence of pregnancy. She was incredulous when informed of the results of the examination, and she seemed to persist in believing that she was pregnant. On psychiatric interview, she revealed that she wanted to have a baby in order to please her husband-actually, her common-law husband. He wanted a child, she said, and so did she. She already had a son by her first husband, but he was grown and independent. She went on to reveal that she was highly dependent on her common-law· husband, not only for companionship and affection, but also for support. Her circumstances were precarious, for her legal husband had abandoned her, and she could no longer work, because of an aggravation of an old traumatic arthritis of the left knee. Further, she had been denied public aid, possibly because of her unwillingness to file a complaint against her legal husband. As she became more confiding, she revealed that she had accepted the medical opinion of her "pregnancy." But she had not informed her common-law husband of the medical findings,
D~·cuntH'~ J -~- 19b:: Am . .T Ob.t. & ( :v1wc
and shL~ was anxwus that the llJ<'dira I ,,rat! no I tell him, becaust• "it would hurt him 11"' much ... In her presence>, I put a summarizin~ not<' in her hospital chart, and observing her interest, T read the note to her. She responded with much affirmative smiling and nodding. She noddPd vigorously when I read: "HPr desire that her common-law husband not be informed of her condition should be respected. She should he allowed to work out this problem with him in her own way." She nodded even more vigorously when I read: "She needs financial support.'' At the conclusion of this reading, she gave additional information to explain further her inability to obtain public aid: she wanted to avoid any embarrassment that a social service investigation might cause her common-law hus· band, for he was already supporting ,jx children by a previous marriage. This additional confidence seemed to indicate an increased trust as a result of my sharing my note vvith her.
Comment
Thus it appears that these 2 patients were motivated toward pregnancy mainly by the desire to please the husband. Possibly they saw pregnancy as a means of securing the husband's affection. They seemed to want his love and companionship as well as his support. One might suspect that their pregnancies were motivated solely by economic necessity. But such a harsh view does not seem warranted, because it is not in keeping with other qualities of their character. Both showed a fine regard for the feelings of their husbands, and both, at times, showed a nobility of attitude of high degree. Thus it seems proper simply to subsume their motivation under the heading of a desire to please the husband. This kind of motivation in cases of spurious pregnancy was previously noted by Fried and associates. 1 But the idea needs more emphasis, especially to psychiatrists who are prone to "intrapsychic" explanations of mental phenomena. Further, it is still a question whether these spurious pregnancies are simulated or hysterical-if such a distinction can be made. The question becomes important because of an implied moral judgment. One tends to regard what is merely simulated as
Volume 84 Number 12
malingering, that is, to secure a gain through feigning illness, and one therefore thinks it morally wrong. On the other hand, one tends to regard what is called hysteria as determined by unconscious rnotives, and one therefore thinks that it is not subject to moral judgment. Patients with hysteria have a similar attitude; they regard themselves as having an involuntary illness for which they bear no responsibility. But in pseudocyesis, as suggested by Baird, 2 the appearance of abdominal enlargement is contributed to, not merely by the accumulation of fat, but mainly by the assumption of a lordotic posture and the contraction and depression of the diaphragm, resulting in a uniformly rounded distention of the abdon1en. Tl1is distention disappears with relaxation, sleep, or anesthesia. It is possible that the difference between simulation and hysteria is merely verbal. For the only means by which hysteria can be distinguished from simulation is the admission by the patient--and this may occur only if the patient has an unusual degree of trust in the physician-that simulation, or malingering, was intended. Further, it seems that, if a condition is hysterical, then it can be simulated. If it cannot be simulated, then one should look for organic disease. Under this view, responsibility in hysteria is unimpaired. The hysteric is as responsible for a simulation that fulfills a trend of thought as is the malingerer for a simulation that yields an immediate gain, often financial in nature. And the only difference, perhaps, is that the hysteric has deceived himself. Yet, in pseudocyesis it is usual to find amenorrhea and sometimes galactorrhea, 1 conditions ordinarily not susceptible to simulation. Further, the work of Fried showed hormonal changes that could produce these findings. These hormonal changes were thought to result from pituitary stimulation, mental and neural, by way of the ·hypothalamus. The evidence for such a mechanism is brief-
Pseudocyesis 1867
iy summarized in Mazer and Israei's 3 lvfenstrual Disorders and Sterility. Possibly some degree of physiologic change can result from volition if the will to simu!ate is sufficiently strong, that is, if the condition to be simulated sufficiently dominates conscious awareness. It is known that hypnosis can produce such changes, as for instance the absence of bleeding on passing a large needle through the skin in an area of suggested anesthesia. (Perhaps the subjective appreciation of pain does influence the tendency to bleed.) Further, hypnosis has been used to produce and relieve amenorrhea and to control the menstrual cycle. (This is discussed in Dunbar's 4 Emotions and Bodily Changes.) But hypnosis itself seems to be a state that results from the desire to please another. White5 has said of hypnosis, " ... its most general goal being to behave like a hypnotized person as this is continuously defined by the operator and understood by the subject." Practitioners of magic do not like to have their magic exposed, and it is a rare hypnotist who can welcome the confession that is sometimes made by a subject who has accomplished a prodigious feat in a hypnotic trance, "I did it just to please you." (My own experience.) Not only hypnotists, but mankind at large, seems to hunger for magic, mystery, and miracle. So, in some cases of pseudocyesis, as in other neurotic disorders, the forces which produce the phenomenon are likely to be found in the interpersonal field. We may be moved to behave as we do because of the will of others. We need approval; and when we are conscious of disapproval, we feel guilty-or angry. Thus, in pseudocyesis, for similar reasons, one may encounter some women who, having a background that disposes them to such reactions, simulate pregnancy in order to please their husbands. REFERENCES
1. Fried, Paul H., et a!.: 1951.
J.
A. M. A. 145: 1329,
1868
Dean
2. 15airel, Uugalel: Combined Textbook of Obstetrics and Gynaecology, ed. 5, Baltimore, 1950, Williams & Wilkins Company, p. 228. 3. Israel, S. Leon: Mazer and Israel's Menstrual Disorders and Sterility, ed. 4, New York. 1959, Paul B. Roeber, pp. 223-225. 4. Dunbar, Flanders: Emotions and Bodily
Dec·.cmhc\ 1·~_ 19ti"2. .\m. ]. Oh~t. & Cylh"•~-
Changes. ed. :l, ."\ew ): ork, 19+ti, ( :olumbi;•
University Press, pp. :l:l3-335. '). White. Robert W.: In Tomkins, Silvan S .. Contemporary Psychopathology.. Cambridge, Mass .. 1943, Harvard University Press.
60 Rivoli St. San Francisco, Califomia
T\
J.Y.L • .J..J,
San Francisco, California
Two cases of pseudocyesis (grossesse nerveuse) are reported because of their particular motivation: both patients were motivated toward pregnancy by the desire to please the husband.
hospital nurseries, hoping someone would say, "Take this baby. We don't want it." Finally, she actually took a baby-kidnapped it-and took it home with her. At home, the arrival of the baby was greeted with much pleasure. Her husband had every= thing in readiness: crib, clothing, and all accessories. And she gave the baby good care: "I loved it like my own." Nine days later, the happiness in her home came to an end. Much newspaper publicity, a large-scale police hunt, and even a direct appeal to the kidnapper by the baby's father on television (which she saw), produced no result. But when a deputy sheriff became suspicious of her and questioned her, she was moved to go at once to a priest who helped return the baby. The patient was taken into custody on a charge of kidnapping, and later she was hospitalized because of "convulsions." These were actually muscle spasms of the extremities and were accompanied by deep breathing but no loss of consciousness. Her convulsions, like her pregnancy, seemed subject to volition. Thereafter, she returned to the hospital from jail five more times, because of swallowing objects, such as bits of rnetal frorn her bed, a straightened hairpin with curled ends, closed safety pins, broken glass, and finally opened safety pins. She liked it at the hospital and wanted to stay, she told one of our staff members, and that was why she swallowed these potentially dangerous objects. Eventually, an opened, straightened, safety pin failed to pass as did the other objects. It lodged in the cecum and had to be removed surgically. At operation, the appendix was found to have been removed, but the reproductive organs-uterus, tubes, and ovaries-were reported to be normal. While awaiting trial, she confided to a Courtappointed psychiatrist that she was the Virgin Mary and had been pregnant with the baby
Case 1. The first patient was a 27-year-old woman who had married for the second time a year prior to her admission to the hospital. After her marriage she gained weight rapidly. When her husband suggested that her weight gain could be due to pregnancy, she did not deny it. He was elated, bragged to his friends, and gave her showers and parties. She began to feel that she was pregnant but she knew that she could not be; she had continued to menstruate and she knew she was sterile. Ten years earlier, she had had a baby by cesarean section and her tubes were tied at that time.
Her enthusiastic husband took her to a physician who confirmed her "pregnancy." Two other physicians also thought she was pregnant. No biologic tests of pregnancy were performed. The patient knew they were wrong, but acquiesced in her assumed pregnancy. She was "living a lie," but she could not bring herself to tell her husband the truth. So, she continued to actand feel-pregnant. She had morning sickness, her abdomen enlarged, and at the sixth month, her menstruation actually ceased. Her expected date of confinement arrived and passed. People began to worry about her, because the baby was a month overdue. She became desperate. She went to the home of her mother in another city "to have the baby." She planned to tell her husband that the baby was stillborn, but she could not bring herself to do that. She came to San Francisco where she visited From the San Francisco General Hospital.
1865
1866
Dean
Jesus. The psychiatnst, convinced that sh<' was psychotic, recommended her immediate commitment to a state hospital. What he did not know was that her behavior in the presence of our staff, who were with her 24 hours a day, was entirely realistic. Also, he did not know that in an earlier admission, the bed adjoining the patient had been occupit>d by a young woman who had been hospitalized because of precisely this same delusion. That patient told everyone about ht>r delusion, and her mental illness was obvious. Those who knew our patient well thought that her psychosis was as spurious as her prPg-nancy. Our patient did go to a state hospital for a few months, but on an observational commitment for the Court. She was returned as fit for trial, and indeed, she seemed prepared to whatewr penance might be imposed upon her. She spent some months at the county jail and then was released on probation. Unfortunately, her travail had been in vain, for meanwhile her husband had divorced her. Case 2. The second patient was a 37-year-old woman who was admitted to the hospital because she believed herself to be pregnant and at term. Her menstruation had stopped ten months before, then her abdomen began to swell, and she thought that she felt fetal movements. A physical examination, including x-rays, showed no evidence of pregnancy. She was incredulous when informed of the results of the examination, and she seemed to persist in believing that she was pregnant. On psychiatric interview, she revealed that she wanted to have a baby in order to please her husband-actually, her common-law husband. He wanted a child, she said, and so did she. She already had a son by her first husband, but he was grown and independent. She went on to reveal that she was highly dependent on her common-law· husband, not only for companionship and affection, but also for support. Her circumstances were precarious, for her legal husband had abandoned her, and she could no longer work, because of an aggravation of an old traumatic arthritis of the left knee. Further, she had been denied public aid, possibly because of her unwillingness to file a complaint against her legal husband. As she became more confiding, she revealed that she had accepted the medical opinion of her "pregnancy." But she had not informed her common-law husband of the medical findings,
D~·cuntH'~ J -~- 19b:: Am . .T Ob.t. & ( :v1wc
and shL~ was anxwus that the llJ<'dira I ,,rat! no I tell him, becaust• "it would hurt him 11"' much ... In her presence>, I put a summarizin~ not<' in her hospital chart, and observing her interest, T read the note to her. She responded with much affirmative smiling and nodding. She noddPd vigorously when I read: "HPr desire that her common-law husband not be informed of her condition should be respected. She should he allowed to work out this problem with him in her own way." She nodded even more vigorously when I read: "She needs financial support.'' At the conclusion of this reading, she gave additional information to explain further her inability to obtain public aid: she wanted to avoid any embarrassment that a social service investigation might cause her common-law hus· band, for he was already supporting ,jx children by a previous marriage. This additional confidence seemed to indicate an increased trust as a result of my sharing my note vvith her.
Comment
Thus it appears that these 2 patients were motivated toward pregnancy mainly by the desire to please the husband. Possibly they saw pregnancy as a means of securing the husband's affection. They seemed to want his love and companionship as well as his support. One might suspect that their pregnancies were motivated solely by economic necessity. But such a harsh view does not seem warranted, because it is not in keeping with other qualities of their character. Both showed a fine regard for the feelings of their husbands, and both, at times, showed a nobility of attitude of high degree. Thus it seems proper simply to subsume their motivation under the heading of a desire to please the husband. This kind of motivation in cases of spurious pregnancy was previously noted by Fried and associates. 1 But the idea needs more emphasis, especially to psychiatrists who are prone to "intrapsychic" explanations of mental phenomena. Further, it is still a question whether these spurious pregnancies are simulated or hysterical-if such a distinction can be made. The question becomes important because of an implied moral judgment. One tends to regard what is merely simulated as
Volume 84 Number 12
malingering, that is, to secure a gain through feigning illness, and one therefore thinks it morally wrong. On the other hand, one tends to regard what is called hysteria as determined by unconscious rnotives, and one therefore thinks that it is not subject to moral judgment. Patients with hysteria have a similar attitude; they regard themselves as having an involuntary illness for which they bear no responsibility. But in pseudocyesis, as suggested by Baird, 2 the appearance of abdominal enlargement is contributed to, not merely by the accumulation of fat, but mainly by the assumption of a lordotic posture and the contraction and depression of the diaphragm, resulting in a uniformly rounded distention of the abdon1en. Tl1is distention disappears with relaxation, sleep, or anesthesia. It is possible that the difference between simulation and hysteria is merely verbal. For the only means by which hysteria can be distinguished from simulation is the admission by the patient--and this may occur only if the patient has an unusual degree of trust in the physician-that simulation, or malingering, was intended. Further, it seems that, if a condition is hysterical, then it can be simulated. If it cannot be simulated, then one should look for organic disease. Under this view, responsibility in hysteria is unimpaired. The hysteric is as responsible for a simulation that fulfills a trend of thought as is the malingerer for a simulation that yields an immediate gain, often financial in nature. And the only difference, perhaps, is that the hysteric has deceived himself. Yet, in pseudocyesis it is usual to find amenorrhea and sometimes galactorrhea, 1 conditions ordinarily not susceptible to simulation. Further, the work of Fried showed hormonal changes that could produce these findings. These hormonal changes were thought to result from pituitary stimulation, mental and neural, by way of the ·hypothalamus. The evidence for such a mechanism is brief-
Pseudocyesis 1867
iy summarized in Mazer and Israei's 3 lvfenstrual Disorders and Sterility. Possibly some degree of physiologic change can result from volition if the will to simu!ate is sufficiently strong, that is, if the condition to be simulated sufficiently dominates conscious awareness. It is known that hypnosis can produce such changes, as for instance the absence of bleeding on passing a large needle through the skin in an area of suggested anesthesia. (Perhaps the subjective appreciation of pain does influence the tendency to bleed.) Further, hypnosis has been used to produce and relieve amenorrhea and to control the menstrual cycle. (This is discussed in Dunbar's 4 Emotions and Bodily Changes.) But hypnosis itself seems to be a state that results from the desire to please another. White5 has said of hypnosis, " ... its most general goal being to behave like a hypnotized person as this is continuously defined by the operator and understood by the subject." Practitioners of magic do not like to have their magic exposed, and it is a rare hypnotist who can welcome the confession that is sometimes made by a subject who has accomplished a prodigious feat in a hypnotic trance, "I did it just to please you." (My own experience.) Not only hypnotists, but mankind at large, seems to hunger for magic, mystery, and miracle. So, in some cases of pseudocyesis, as in other neurotic disorders, the forces which produce the phenomenon are likely to be found in the interpersonal field. We may be moved to behave as we do because of the will of others. We need approval; and when we are conscious of disapproval, we feel guilty-or angry. Thus, in pseudocyesis, for similar reasons, one may encounter some women who, having a background that disposes them to such reactions, simulate pregnancy in order to please their husbands. REFERENCES
1. Fried, Paul H., et a!.: 1951.
J.
A. M. A. 145: 1329,
1868
Dean
2. 15airel, Uugalel: Combined Textbook of Obstetrics and Gynaecology, ed. 5, Baltimore, 1950, Williams & Wilkins Company, p. 228. 3. Israel, S. Leon: Mazer and Israel's Menstrual Disorders and Sterility, ed. 4, New York. 1959, Paul B. Roeber, pp. 223-225. 4. Dunbar, Flanders: Emotions and Bodily
Dec·.cmhc\ 1·~_ 19ti"2. .\m. ]. Oh~t. & Cylh"•~-
Changes. ed. :l, ."\ew ): ork, 19+ti, ( :olumbi;•
University Press, pp. :l:l3-335. '). White. Robert W.: In Tomkins, Silvan S .. Contemporary Psychopathology.. Cambridge, Mass .. 1943, Harvard University Press.
60 Rivoli St. San Francisco, Califomia