Now You See Me, Now You Don’t: The Mysterious Phenomenon of Phantom Pregnancy
Editors’ Note: This article uses female-gendered language to refer to pregnant people and those who menstruate. This choice was made because cited literature on the subject focuses on only female-identifying patients. The editors wish to recognize that pregnancy and menstruation are independent of gender identity.
Kalina Rashkov, Sudiksha Miglani
Illustrations by Elsie McKendry
On September 3rd, 1554, news that Queen Mary I was expecting a child swept through Britain [1]. England would finally have an heir to the throne, prompting celebrations throughout the country. For quite some time, Mary had been experiencing symptoms of pregnancy: her stomach was swollen and expanded, she experienced morning sickness, and even reported feeling the baby moving beneath her abdomen. However, the royal infant never appeared. Several years after this incident, Mary believed she was expecting yet again. However, this was not the case, leaving physicians baffled by her inexplicable condition for a second time. While medical practitioners in the Tudor Era could not determine the cause of the monarch’s suffering, historians consider Queen Mary I to be the first recorded case of pseudocyesis, also known as phantom or hysterical pregnancy [1].
The Tangible Symptoms of Pseudocyesis
Pseudocyesis occurs when a woman believes she is pregnant and shows physical signs of pregnancy despite not carrying a child [2]. Among the most common physical symptoms in women who experience pseudocyesis are irregular menstruation and changes in breast size and shape; other reported symptoms include abdominal swelling, the sensation of fetal movement, lactation, weight gain, nausea, and vomiting [3]. Queen Mary’s experience with these symptoms is not as uncommon as we might predict; medical literature has recorded around 550 cases of pseudocyesis in individuals whose ages ranged from 6 to 79, with a frequency of around 1 in 10,000 pregnancies in the Western world [4].
In pseudocyesis, a woman’s intense psychological desire for a child accompanies these physical symptoms. In many cases, women experiencing pseudocyesis want children and have a history of infertility or miscarriages. Clinicians have proposed that the psychological and social pressure to have children can influence physical changes in the body [3, 5]. Because of this psychological component, pseudocyesis is commonly confused with delusional pregnancy, when women falsely believe they are pregnant without physical symptoms [6]. Physical symptoms that mimic pregnancy distinguish pseudocyesis from delusional pregnancy, which is entirely psychological [6]. As such, pseudocyesis is most easily recognized by characteristics like morning sickness, lactation, and irregular periods [6]. Although scientists are still unsure of the root causes of pseudocyesis, the effort to uncover the biological and psychological underpinnings of this debilitating illness is ongoing [7].
How the Body Prepares for a Phantom Baby
Patients who experience pseudocyesis do not fall under one specific medical profile and may exhibit a wide range of hormonal interactions [8]. However, many of the first physical signs of pseudocyesis are related to the imbalance of essential hormones associated with pregnancy and the regulation of the ovulatory cycle [3]. Hormones are chemical messengers secreted by glands to communicate with cells throughout the body. Critical hormones involved in pregnancy are released and regulated by a gland at the base of the brain called the anterior pituitary gland. These hormones bind to receptors, causing physical changes in regions of the body associated with pregnancy, such as the breasts, ovaries, and uterus [9].
Estrogen and progesterone are hormones involved in initiating and sustaining pregnancy through every trimester [10]. During pregnancy, estrogen and progesterone are responsible for building and maintaining the lining of the uterus so that the developing embryo is supported in its growth period [10]. The ovaries and other glands produce these crucial hormones. The ovaries produce estrogen in response to signals mediated by the anterior pituitary gland. Clinicians have frequently observed high levels of estrogen and progesterone in women with pseudocyesis [11]. These high hormonal levels often lead to symptoms that can be confused with pregnancy in women who are not pregnant, such as irregular periods, tender breasts, mood swings, bloating of the stomach, and symptoms of morning sickness, including nausea and vomiting. The abdominal growth commonly associated with pseudocyesis is due to the presence of estrogen and progesterone, which promotes the development of uterine tissue and increases blood flow to the uterus [11].
Another pregnancy hormone involved in pseudocyesis is prolactin, produced by the anterior pituitary gland [12]. In pregnant and breastfeeding women, high levels of prolactin aid in breast milk production and lactation. The hormone travels through the bloodstream to stimulate the mammary glands’ growth, which activates the synthesis and release of breast milk [13]. High prolactin levels have been observed in several cases of pseudocyesis [12]. They are recognized as the cause of some pregnancy-like symptoms, such as enlarged breasts, in women who are not pregnant [12]. These high prolactin concentrations signal to the body that a baby is on the way, stimulating breast milk production. The breasts of individuals with pseudocyesis subsequently swell and can produce milk like those with a typical pregnancy [3, 5]. These individuals often have high prolactin levels due to the dysregulation of the anterior pituitary, as well as a variety of biological and psychological factors [12]. The imbalances in estrogen, progesterone, and prolactin concentrations mimic the physical conditions of pregnancy, essentially tricking the body into believing it is pregnant [8, 14].
Factors that dysregulate the anterior pituitary, causing hormonal imbalances, vary from case to case. But they are often caused by specific medications and the patient’s mental state [8]. Antipsychotic medications, typically prescribed to treat certain mental illnesses, can dysregulate the anterior pituitary, causing the overproduction of prolactin in the body [15]. A specific mental illness typically treated with antipsychotics is schizophrenia, a psychotic disorder [16]. Individuals diagnosed with schizophrenia maintained normal levels of prolactin before receiving antipsychotic drugs to treat the disorder. After treatment, they showed five times the normal levels of prolactin [16]. Schizophrenic patients with pseudocyesis are also prone to experiencing illusions and hallucinations involving children [4]. Mental illness, like schizophrenia, coalescing with medication-induced hormonal imbalances can create the perfect storm for pseudocyesis.
While there is a clear correlation between the ability of antipsychotic medications to alter the anterior pituitary gland and the production of prolactin, it is important to consider that the known causes of pseudocyesis are complex. A dysregulated anterior pituitary gland and pseudocyesis are not always a reaction to antipsychotic medications, and the effects of antipsychotics on hormone levels and the body are highly variable based on factors including age, menopause, and stress levels [17]. Not every woman who takes antipsychotics experiences pseudocyesis, and not every woman with pseudocyesis takes antipsychotics; the interaction between the psychological state of wanting to be pregnant and bodily changes caused by hormones causes pseudocyesis. The power of a person’s psychological state on their physical response cannot be understated [18]. When you are anxious about taking an exam, your body releases stress hormones to physically prepare you for a dangerous situation [19]. Your breath quickens, and your heart beats faster to prepare your body to run away from something frightening, even though there is nothing inherently dangerous about your situation. The same concept applies to pseudocyesis; psychological stress can cause physical changes in your body, like the pregnancy symptoms we see in women with pseudocyesis [18]. The ability of psychological stress to physically influence the body is a common explanation for why pseudocyesis seems to have a higher chance of occurring in certain populations [7].
When Life Intervenes
While it is known that neuroendocrine changes are involved in pseudocyesis, it is crucial to consider the importance of certain sociocultural factors that make women more likely to initially experience these hormone changes and psychological stressors [8]. The link between sociocultural factors and the manifestation of pseudocyesis is not entirely understood; however, women with fewer socioeconomic opportunities are more likely to develop pseudocyesis [3]. In these cases, children may be considered necessary to these women, as they could support the struggling household when they are older [7]. Other factors that increase the likelihood of women experiencing this phenomenon include relationship instability and recurrent partner abuse [3].
Women whose cultures value childbearing and emphasize the need to have children to continue certain traditions or preserve the family line can be more vulnerable to experiencing pseudocyesis [7]. The cultural pressure to have children and continue the lineage can be an environmental stressor triggering physical changes in women [7]. Women’s psychological stress due to the social expectation to bear children occurs in several reported cases of pseudocyesis, including Mary I of England [1]. As the Queen, Mary was under immense pressure to produce an heir to the throne. It was seen as a duty to Great Britain, and her failure to have a child would paint her as an unsuccessful monarch in the eyes of her subjects [20]. Like many other women, Queen Mary had previously struggled with fertility issues and miscarriages [1]. This previous struggle could increase the stress she felt to become pregnant and contribute to her case of pseudocyesis.
Due to sociocultural influences disparately impacting the development of pseudocyesis, women in distinct regions are affected differently. Pseudocyesis is more common in countries with less access to prenatal testing throughout pregnancy [8]. This pattern is primarily attributable to the psychological aspect of the disorder; women with pseudocyesis often convince themselves they are pregnant, and in some cases, the most effective treatment is to provide the individual with irrefutable evidence that they are not [21]. This evidence usually comes in the form of an ultrasound. When women have access to ultrasounds, they can see no evidence of a fetus in their womb, which generally resolves pregnancy-related hormone imbalances and related pregnancy symptoms [21]. With the assistance of these technological advancements, those who may be at risk for pseudocyesis, and even those experiencing mild symptoms, may resolve their case before their symptoms give cause for concern [8]. However, even after absence of pregnancy is confirmed by an ultrasound or blood test, some individuals continue to experience the physical and psychological symptoms of pseudocyesis [5]. Since the exact hormonal and psychosocial causes of pseudocyesis remain unknown, a blanket treatment plan for these cases is still unavailable [8]. Some patients receive hormone therapy to correct imbalances in hormone levels, while others are treated with behavioral therapy focused on problem solving to challenge false beliefs of pregnancy [3]. This psychologically-focused approach harnesses the intense mind-body connection that was a key factor in the development of the symptoms in the first place [3]. On the other hand, not all individuals have access to these treatment options, and pseudocyesis may resolve itself without their aid [3]. Regardless of treatment options, access to a robust support system is vital for complex and effective care both before and after the individual is able to accept the absence of a pregnancy [22]. While addressing the symptoms of pseudocyesis and supporting those affected by the disorder is important, understanding the interplay between the psychological, biological, and sociocultural components is crucial in treating the root cause [3].
References
Medvei, V. C. (1987). The illness and death of Mary Tudor. Journal of the Royal Society of Medicine, 80(12), 766–770. doi: 10.1177/014107688708001214
Small, G. W. (1986). Pseudocyesis: An overview. Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie, 31(5), 452–457. doi: 10.1177/070674378603100514
Azizi, M., & Elyasi, F. (2017). Biopsychosocial view to pseudocyesis: A narrative review. International Journal of Reproductive Biomedicine, 15(9), 535–542. PMID: 29662961
Campos, S. J., Link D. (2016). Pseudocyesis. The Journal for Nurse Practitioners. 12, 390–394. doi: 10.1016/j.nurpra.2016.03.009
Dubravko, H. (2010). Pseudocyesis in peri- and postmenopausal women. Open Medicine, 5(3). doi: 10.2478/s11536-009-0084-8
Seeman, M. V. (2014). Pseudocyesis, delusional pregnancy, and psychosis: The birth of a delusion. World Journal of Clinical Cases, 2(8), 338. doi: 10.12998/wjcc.v2.i8.338
Ibekwe, P., & Achor, J. (2008). Psychosocial and cultural aspects of pseudocyesis. Indian Journal of Psychiatry, 50(2), 112. doi: 10.4103/0019-5545.42398
Tarín, J. J., Hermenegildo, C., García-Pérez, M. A., & Cano, A. (2013). Endocrinology and physiology of Pseudocyesis. Reproductive Biology and Endocrinology, 11(1), 39. doi: 10.1186/1477-7827-11-39
Rawindraraj, A. D., Basit, H., & Jialal, I. (2020). Physiology, anterior pituitary. StatPearls Publishing. PMID: 29763073
Ozturk, S., & Demir, R. (2010). Particular functions of estrogen and progesterone in establishment of uterine receptivity and embryo implantation. Histology and Histopathology, 25(9), 1215–1228. doi: 10.14670/HH-25.1215
Pascual, Z. N., & Langaker, M. D. (2020). Physiology, pregnancy. StatPearls Publishing. PMID: 32644730
Grover, S., Sharma, A., Ghormode, D., & Rajpal, N. (2013). Pseudocyesis: A complication of antipsychotic-induced increased prolactin levels and weight gain. Journal of pharmacology & pharmacotherapeutics, 4(3), 214–216. doi: 10.4103/0976-500X.114610
Freeman, M. E., Kanyicska, B., Lerant, A., & Nagy, G. (2000). Prolactin: Structure, function, and regulation of secretion. Physiological Reviews, 80(4), 1523–1631. doi: 10.1152/physrev.2000.80.4.1523
Bazer, F.W. (Ed.). (1998). Endocrinology of pregnancy. Humana Press Inc. doi: 10.1007/978-1-4612-1804-3
Bargiota, S. I., Bonotis, K. S., Messinis, I. E., & Angelopoulos, N. V. (2013). The effects of antipsychotics on prolactin levels and women’s menstruation. Schizophrenia Research and Treatment, 2013, 1–10. doi: 10.1155/2013/502697
Maguire, G. (2002). Prolactin elevation with antipsychotic medications: Mechanisms of action and clinical consequences. Journal of Clinical Psychiatry. PMID: 11913677
Majumdar, A., & Mangal, N. S. (2013). Hyperprolactinemia. Journal of human reproductive sciences, 6(3), 168–175. doi: 10.4103/0974-1208.121400
Salleh, M. R. (2008). Life events, stress and illness. Malays J Med Sci, 10(4), 9-18. doi: 10.1016/j.nurpra.2016.03.009
Aguilera, G. (1998). Corticotropin releasing hormone, receptor regulation and the stress response. Trends in Endocrinology & Metabolism, 9(8), 329–336. doi: 10.1016/s1043-2760(98)00079-4
Froude, J. A. (1924). The reign of Mary Tudor. Dent.
Ouj, U. (2009). Pseudocyesis in a rural southeast Nigerian community. The journal of obstetrics and gynecology research, 35(4), 660–665. doi: 10.1111/j.1447-0756.2008.00997.x
Reblin, M., & Uchino, B. N. (2008). Social and emotional support and its implication for health. Current opinion in psychiatry, 21(2), 201–205. doi: 10.1097/YCO.0b013e3282f3ad89