Asian Journal of Psychiatry 29 (2017) 89–90
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Short communication Obsession of pregnancy: Does it exist?
Sir, A 47 years old lady presented with repetitive/ruminative thoughts of being pregnant leading to distress, anxiety, constant preoccupation about ‘what will people say’ and associated sadness & anhedonia. 12 years back there was an event of tear in the condom during sexual-intercourse. She started having fear that ‘she will get pregnant’ and later that ‘she is pregnant’ when missed her menstrual period on due date. She immediately consulted a gynecologist who conﬁrmed that there was no pregnancy. But patient insisted for further evaluation including ultrasonography (USG) which also did not reveal any pregnancy. She continued to think that she is pregnant and started imagining and feeling symptoms of pregnancy like nausea, giddiness, increased frequency of urination, fullness in lower-abdomen imagining to the level of feeling of fetal-movements. She kept on consulting various gynecologists and getting investigated for around 9 years (ultrasonography – 8 times). One of the gynecologists realized the repetitive nature of concerns and referred her to psychiatrist. With thought of pregnancy she would get anxious, check her abdomen repeatedly for fetal movements and look herself in mirror for abdominal distention. This was the only topic in her discussions though her thoughts could be shaken for short periods. She knew that her thoughts were wrong but could not stop them and in a ﬂow they keep-on going to further level. Sometimes when the thoughts of pregnancy are going-on, they would reach to the level of labor or delivery and she would experience labor pain in that period and needed to be admitted in hospital just to relieve her distress. Thought of being pregnant would lead to avoid sexual-contact with husband. She had reduced interaction with family members, decreased concentration and frequent mistakes in daily chores. She had regular menstrual periods, never used other contraceptive methods (except protective methods by husband) and not operated for tubal ligation. Her mental status revealed anxious mood and aﬀect, preoccupation of thoughts of being pregnant, ideas of helplessness with intact concept, judgment & memory and had full insight. These clinical features point toward the presence of obsession and compulsion along with signiﬁcant impairment of socio-occupational functioning. She satisﬁed diagnostic criteria for obsessive compulsive disorder (OCD) as per the International Classiﬁcation Of Diseases, 10th version (ICD-10) with depressive symptoms. The Y-BOCS (Yale-Brown Obsessive Compulsive Scale) score was 24 (severe range) and HDRS (Hamilton Depression Rating Scale) score was 20 suggestive of moderately severe depression. Oral ﬂuoxetine was started, gradually increased to 60 mg/day and clomipramine 50 mg was added later-on with supportive psychotherapy. She improved and stopped treatment after 3 years. She had relapse of symptoms 5 months later with increased severity and was restarted on ﬂuoxetine 20 mg daily but suﬀered severe gastritis. Hence shifted to Escitalopram 10 mg, later increased to 20 mg along with clonazepam 0.5 mg. Clomipramine was added increasing to 50 mg. She was given cognitive behavioral therapy (CBT). Initially her cognitive distortions were challenged and in subsequent sessions she was exposed to the repetitive thoughts through imagination in relaxed state and prevented from compulsively checking for pregnancy signs. After 6 sessions of CBT her symptoms remitted and her Y-BOCS score came down to 6 (in subclinical range) and HDRS score to 4 (normal range). Same medications were continued thereafter and her visits to gynecologists stopped completely. 1. Discussion This patient's obsession of pregnancy can be “pathological doubt” yielding to the compulsion of “checking” for the signs of pregnancy. Presence of severe anxiety, constant preoccupation, repetitive checking for pregnancy signs and full insight supported the obsessive nature of the condition and checking for fetal movements, abdominal distension and repetitive visits of gynecologists suggest the compulsive component. This reﬂects a obsessive compulsive phenomenon leading to consideration of obsession of pregnancy as a diagnosis. The close diﬀerential of pseudocyesis, delusion of pregnancy and simulated pregnancy were considered (Radhakrishnan et al., 1999; American Psychiatric Association, 2013; Dumont, 1989). In pseudocyesis the physical signs/symptoms of pregnancy are evident (Tarín et al., 2013) and as the days of gestation progress the patient gets corresponding signs but marked anxiety or preoccupation with same repetitive thoughts may not be present as in this case. In delusion of pregnancy, belief is unshakable with lack of insight and patient is usually not ready for psychiatric help. The lifetime prevalence of OCD is 1–3% (Karno et al., 1988; Ruscio et al., 2010). The obsessions can be wide and variable in nature with content varying from rare situations to common natural conditions like pregnancy. Such conditions if present, can be a challenge to the treating gynecologist or physician but a careful evaluation can lead to correct diagnosis. Literature suggests that combination of pharmacotherapy and CBT can lead to signiﬁcant improvement in OCD (Jenike, 2004) which was seen in this case. Thus it is interesting to analyze the rare phenomenon of obsession of being pregnant and the role of CBT in addition to pharmacotherapy. References American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders: DSM-5, 5th ed. American Psychiatric Association, Washington. Dumont, M., 1989. The unfortunate pregnancy of the ﬁrst French feminist, Olympe de Gouges. Rev. Fr. Gynecol. Obstet. 84, 63–66. http://dx.doi.org/10.1016/j.ajp.2017.03.042 Received 20 January 2017; Received in revised form 30 March 2017; Accepted 30 March 2017 1876-2018/ © 2017 Elsevier B.V. All rights reserved.
Asian Journal of Psychiatry 29 (2017) 89–90
Jenike, M.A., 2004. Clinical practice. Obsessive-compulsive disorder. N. Engl. J. Med. 350, 259–265. Karno, M., Golding, J.M., Sorensen, S.B., Burnam, M.A., 1988. The prevalence of obsessive-compulsive disorder in ﬁve US communities. Arch. Gen. Psychiatry 45, 1094–1099. Radhakrishnan, R., Satheeshkumar, G., Chaturvedi, S.K., 1999. Recurrent delusions of pregnancy in a male. Psychopathology 32, 1–4. Ruscio, A.M., Stein, D.J., Chiu, W.T., Kessler, R.C., 2010. The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Mol. Psychiatry 15 (1), 53–63. Tarín, J.J., Hermenegildo, C., García-Pérez, M.A., Cano, A., 2013. Endocrinology and physiology of pseudocyesis. Reprod. Biol. Endocrinol. 11, 39. ⁎
Abhijeet Faye , Vivek Kirpekar, Rahul Tadke, Sushil Gawande, Sudhir Bhave Dept of Psychiatry, NKP Salve Institute of Medical Sciences and Lata Mangeshkar Hospital, Nagpur, Maharashtra 440019, India E-mail address: [email protected]
⁎ Corresponding author at: Dept of Psychiatry (OPD-10), NKP Salve Institute of Medical Sciences and Lata Mangeshkar Hospital, 2nd ﬂoor, OPD Building, Digdoh Hills, Hingna Road, Nagpur, Maharashtra 440019, India.