Her abdomen had swollen up like a pregnant woman’s and she looked like she could give birth any minute. But there was no baby.
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"You called me because of that case back in 1990, right?"
Yes, I confessed. Though it's been more than 25 years, Paul Paulman, a family practice physician and associate dean at the University of Nebraska College of Medicine, can still recall the details. A 30-year-old woman had come into the hospital where Paulman works. Her belly distended, she looked like she was very far along in her pregnancy and had come in to give birth. A routine case.
Before doing anything, the on duty resident performed an ultrasound to check on the baby. That's when he saw something no one had expected: The woman had no uterus. She had previously had a hysterectomy, so pregnancy would have been physically impossible. She knew she had the operation and yet her abdomen had swollen up like a pregnant woman's and she was convinced she was going to give birth at any minute. It was a false pregnancy, known in medical terms as pseudocyesis. Cases of false pregnancies are rare, only 80 cases showed up in the medical literature between 2000 and 2014. Paulman hasn't seen another case since.
Not all doctors are as prepared as Paulman and the residents he supervised. In North Carolina, in 2010, another false pregnancy presented at the emergency room. A pregnant looking woman came in with her husband, asking for a C-section. Doctors admitted her and tried to induce labor for two days before finally agreeing to the C-section. It was only when she was on the operating table and doctors started to perform the procedure that they discovered that there was no baby. There had never been a baby. The attending physician and the doctor who performed the C-section were reprimanded for failing to discover before the operation that there was nothing to operate on. The same thing happened in Rio de Janeiro in 2013, when a pregnant seeming woman came to a hospital there, saying she was in labor. Doctors checked for a heartbeat and, finding none, rushed her into an operating room for a C-section in an effort to save the baby. When they operated, they discovered there had never been a baby.
Cases of false pregnancy can be found in the medical literature dating back to antiquity. Hippocrates recorded treating 12 women presenting with false pregnancies around 300 B.C. In ancient China, cases of false pregnancy were referred to as "ghost fetuses," said to occur from the union of a woman with a ghost. Mary Tudor is often cited as a case of a false pregnancy, when the longed for child she thought she was carrying in her forties turned out not to be real.
Without modern medical testing, like ultrasounds, it's difficult to tell a real pregnancy from a false one. Women experiencing a false pregnancy have presented with every sign of pregnancy—from a distended belly, to swollen breasts, to cessation of menstruation. The only missing piece is an actual baby. Making the delusion seem even more credible is that most cases occur in women of childbearing age who are married, many of whom had been trying to conceive for years.
False pregnancies are officially classified as a somatoform disorder, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the diagnostic and classification text for psychiatrists and psychologists. What exactly causes the disorder is not known, though there are theories. The wish to be pregnant is extremely powerful, Paulman says. The disorder could occur because of hormonal changes that cause symptoms which are ascribed to pregnancy by especially susceptible women. Psychological longing could also cause the hormonal changes and physical symptoms to occur, says Catherine Birndorf, a reproductive psychiatrist and clinical associate professor of psychiatry at New York Presbyterian Hospital.
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Because of its rarity and the pejorative nature of the condition, there is very little research, Paulman says, mostly just case studies detailing individual experiences. Women who experience false pregnancies don't volunteer for studies, he says.
Lending credence to a physical origin to the condition are cases of false pregnancies in animals. Dogs in particular are very susceptible to experiencing false pregnancies, with female dogs that breed with castrated male dogs or female dogs that are neutered often displaying all the signs of pregnancy except the actual puppies after mating. False pregnancies in dogs are caused by high levels of reproductive hormones during estrus. Other animals, like goats, experience false pregnancies as well. A panda was recorded potentially experiencing a false pregnancy, though her keepers were never sure if it was a true false pregnancy or if she simply was so clever that she figured out that if she faked pregnancy symptoms she would get better treatment.
On the other hand, there is also evidence for a psychological origin to the hormonal shifts. False pregnancies are more common in developing nations where childbearing is seen as an integral part of a woman's role in society. Researchers believe the immense pressure put on women in the developing world to have children, especially sons, and the lack of other avenues for a fulfilling life, like careers, lead to higher instances of false pregnancies. Infertility in developing nations is also almost always blamed on women, (in reality, causes of infertility are evenly split between men and women), adding further pressure on women who are unable to conceive. Paulman describes the condition as a physical, emotional, and societal illness, much like anorexia nervosa.
While extremely rare, false pregnancies occur in men as well. Unlike with women, false pregnancies in men tend to happen in individuals with severe mental illness, explains Paulman. For example, a case study from 1995 in Virginia described a 43-year-old man with schizophrenia who suffered from persistent auditory and visual hallucinations and was in and out of psychiatric hospitals his whole life before developing a belief that he was pregnant.
But perfectly healthy men can experience symptoms adjacent to pregnancy, lending more weight to the idea that we don't have to be great yogis for our mind to have a profound impact on our body. While not suffering under any delusion that they are pregnant and totally conscious of the fact that men can't physically ever conceive, some men experience pregnancy symptoms during their partner's pregnancies out of sympathy for what their partner is going through. Symptoms tend to include those commonly associated with pregnancy, like back aches and weight gain. It is an overly emphatic response, Birndorf says.
As with any delusion, convincing someone who is so sure they are pregnant that it is all in their head is difficult. An ultrasound showing definitively that there is no baby in the uterus is often not enough. Some patients after an ultrasound will insist that the doctor looked in the wrong place and missed the baby, Paulman says. Therapy is recommended but most patients don't end up going as they are convinced there is nothing wrong with them. Breaking a delusion is extremely difficult—if you tell a patient who is convinced they are pregnant that it is not real, you will lose alliance with them and they will simply go to another doctor, Birndorf says.
More effective treatment protocols are unlikely anytime in the near future. It's an illness which is hard on patients who have it, but it is not life threatening, Paulman says. And no pharmaceutical company is going to fund research into treatment, he explains, because the burden of suffering might be great for the individual patient, but it is not that great for society.
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