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Illusion or Hallucination? Cholecystitis Presenting as Pseudopregnancy in Schizophrenia

Key Words: Schizophrenia Spectrum Disorder • Pseudopregnancy • Pseudocyesis

TO THE EDITOR: Pseudopregnancy as the presenting sign of a medical illness is a rarely reported psychiatric condition. However, it has been reported in association with alcohol-induced liver failure,¹ systemic lupus erythematosus,² abdominal neoplasia,³ persistent corpus luteum,⁴ pituitary tumor,⁵ and hyponatremia.⁶ There is only one reference to pseudopregnancy as the presenting symptom of abdominal surgery—in that case, the patient swallowed open safety pins.⁷ A nonpregnant woman presenting with a fixed, false belief that she is pregnant is often diagnosed with pseudocyesis. However, in these cases the disorder of thought content is limited strictly to the insistence on being pregnant despite medical evidence to the contrary. As this patient's disorder was likely an extension of her underlying schizophrenia, it would not correctly be categorized as pseudocyesis.⁸ I present here the case of a patient who presented with a false pregnancy and offer a discussion of the misinterpretation of physical symptoms by some psychiatric patients.

Case Report

Ms. W., a mildly obese African American woman in her late thirties, presented to the emergency room (ER) screaming with pain, stating she was 9 months pregnant and about to deliver. Both the ER physician and the obstetrics resident examined her. A quantitative B-HCG and an ultrasound were obtained. The results of both studies were negative. When Ms. W. was told she was not pregnant, she angrily cursed at the ER staff, claiming that they were colluding in a plot against her and her baby. On physical examination, she appeared of stated age with a significantly distended abdomen. Ms. W.'s umbilicus was inverted, and she had normal bowel sounds. No abdominal palpation was documented. Gynecologic exam revealed no other changes associated with pregnancy. The remainder of the physical examination was unremarkable. Psychiatry was consulted. Ms. W.'s medical records indicated a long history of schizophrenia treated with trifluoperazine (Stelazine), a typical antipsychotic. As she persisted in her belief of pregnancy, she was admitted to the inpatient psychiatry unit.

On further interview, Ms. W. persisted in her belief of being pregnant. She stated she had been pregnant 10 or more times and that "doctors from space" would somehow remove these children from her belly while she was asleep. Ms. W. did not know the name of her outpatient psychiatrist and did not know the last time she had taken her medication. Mental status exam revealed a neatly dressed and groomed woman who spoke with normal rate, volume, and prosody. She had very mild suppressible lip smacking, otherwise no abnormal psychomotor activity. Ms. W.'s thought processes were circumstantial and her thought content was dominated by the aforementioned delusion. She was without suicidal or homicidal ideation.

On intake physical examination, Ms. W. had a Murphy's sign (pain on inspiration during palpation of the right upper abdominal quadrant). A right upper quadrant (RUQ) ultrasound was ordered; however, the evening before the study Ms. W. experienced an episode of extreme abdominal pain and was returned to the emergency room. Once again, she believed these were labor pains. A RUQ ultrasound showed evidence of cholecystitis and several gallstones. Ms. W. was scheduled for cholecystectomy. When it was explained to her that she had an inflamed gallbladder as the cause of her pain, she did seem to finally accept that she was not pregnant. Ms. W. did, though, express that she hoped the surgeon would "look around inside just to make sure."

DISCUSSION

The most common physical signs present in women with false pregnancy include abdominal enlargement, menstrual disturbance, quickening, a history of infertility, breast changes, weight gain, galactorrhea, cervical softening, and uterine enlargement. The mechanism of abdominal distention in false pregnancy is unknown, but theories have included excess bowel gas, gaseous uterine distention, fecal impaction, bladder retention, or abdominal wall muscle spasm. In contrast to a normal pregnancy, the umbilicus remains inverted, in the abdominal distention of a false pregnancy (as in Ms. W.'s case).⁹

There is value in distinguishing hallucination from illusion, particularly in working with a chronically mentally ill population. Hallucinations are false sensory perceptions that have no basis in actual external stimuli. In other words, hallucinations are completely a construct of the patient's mind. For example, visual hallucinations do not disappear when these patients close their eyes—hallucinations are a creation of the mind, not of the eyes. Illusions, though, are misperceptions or misinterpretations of very real stimuli. Ms. W. suffered from severe pain secondary to an inflamed gallbladder. As do many patients with schizophrenia, her mind created an explanation that made sense to her. This involved incorporating her physical pain into a bizarre delusion. Ms. W. had abdominal pain, and pregnant women have abdominal pain, therefore she concluded that she was pregnant. It did not occur to Ms. W. that she had not missed any periods or not gained any weight in the past 9 months and that pregnancy was unlikely.

Psychiatric patients frequently suffer from medical conditions not detected on their first evaluation. Psychiatric inpatients have associated medical disorders on admission 24% to 60% of the time, and the referring providers fail to diagnose these ailments almost half the time. Schizophrenic patients, in particular, have concomitant medical illness up to 80% of the time.¹⁰ On review of 52 cases of false pregnancy, I found that only 2 of the cases specifically mentioned the examination of the RUQ (i.e., no hepatomegaly or Murphy's sign)—despite presentation to physicians with significant abdominal complaints. Given this information, physicians should consider creatively the possible etiologies of patients' fundamental complaints or their observed behavior.

Psychotic patients do their best to explain their symptoms given their limitations. In this case, Ms. W.'s pain was an illusion, a misperception of a very real condition. Future research in the perception and treatment of pain in schizophrenic patients is warranted. Functional imaging can be applied to see if schizophrenic patients process painful stimuli in the same anatomical areas as control subjects. A discrepancy might suggest deficits in specific processing pathways, like the dominant hemisphere lesions observed in some patients with conversion disorder or somatization disorder.¹¹ Clinicians should be wary of significant underlying medical illness in patients presenting with false pregnancy or any other state in which reality testing is impaired and should perform thorough physical examinations—particularly in light of any specific physical complaints.

The views expressed in this article are those of the author and do not reflect the official policy of the Department of Defense or any other department of the United States Government.

REFERENCES

1. Alfonso CA: Pseudocyesis with concomitant medical illness (letter). Gen Hosp Psychiatry 1990; 12:205–206[CrossRef][Medline]
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3. Echaviz A: Pseudopregnancy and gastric adenocarcinoma (letter). Medicina Clinica 1984; 83:307–308
4. Moulton R: Psychosomatic implication of pseudocyesis. Psychosom Med 1942; 4:376–389[Abstract/Free Full Text]
5. Chambers WR: Brain tumor simulating pregnancy. Am J Obstet Gynecol 1955; 70:212[Medline]
6. Shutty MS: Case report: Recurrent pseudocyesis in a male patient with psychosis, intermittent hyponatremia, and polydipsia. Psychosom Med 1993; 55:146–148[Abstract/Free Full Text]
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8. Dunbar HF: Emotions and Bodily Changes, 2nd Edition. New York, Columbia University Press, 1938
9. O'Grady JP, Rosenthal M: Pseudocyesis: A modern perspective on an old disorder. Obstet and Gynecol Survey 1989; 44:500–511
10. Kirch DG: Medical assessment in psychiatry, in Synopsis of Psychiatry, 7th Edition, edited by Kaplan HI, Sadock BJ, Grebb JA. Baltimore, MD, Williams and Wilkins, 1994, pp 298–299
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