Version May 2024
INTRODUCTION — Pseudocyesis (false pregnancy) has captured the imagination of both clinicians and nonclinicians for centuries, and has been featured in multiple books, movies, and television shows. In this rare clinical syndrome, a nonpregnant, nonpsychotic woman believes she is pregnant and exhibits signs and symptoms of pregnancy. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes pseudocyesis under Other Specified Somatic Symptom and Related Disorder [1].
This topic will provide an overview of pseudocyesis, including prevalence, epidemiology, risk factors, clinical presentation, diagnosis, and management.
In this topic, we use the term "woman/en" when referring to a person with pseudocyesis. However, when caring for such patients, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.
PREVALENCE AND EPIDEMIOLOGY — Pseudocyesis is a rare disorder that affects all ethnic, racial, and socioeconomic groups [2,3]. It is most common in women aged 20 to 39 years, but has been described in premenarchal and postmenopausal women. In a 1937 review of 444 cases dating back to the 17th and 18th centuries, most patients were married and at least 40 percent had given birth previously [3].
Although accurate prevalence figures are not available, pseudocyesis has been posited to occur more frequently in cultures where childbearing is the central role of women and fertility is a prerequisite for marriage or for a stable relationship. With trends toward smaller family size in many high- and middle-income countries, the prevalence of pseudocyesis tends to decrease [4], although immigrants may remain at risk [5-8].
CLINICAL PRESENTATION — The clinical presentation of pseudocyesis has both psychological and physiological aspects. Affected women are not pregnant but maintain a belief that they are pregnant even after pregnancy has been ruled out. Women with pseudocyesis also have one or more of the following signs or symptoms:
●Abdominal enlargement
●Menstrual irregularities
●Sensation of fetal movement
●Gastrointestinal symptoms
●Breast changes
●Abdominal pain
●Urinary frequency
The most common sign, abdominal enlargement, occurs without the typical effacement of the umbilicus observed in pregnancy [9]. Abdominal protrusion may be the result of gaseous distention, excess fat, pronounced lumbar lordosis, and/or fecal/urinary retention and often recedes with administration of general anesthesia [10,11]. Menstrual changes range from irregular cycles to amenorrhea. The subjective feeling of fetal movements tends to have an atypical pattern, intensity, and duration and may be related to contraction of the abdominal wall musculature or bowel peristalsis [12]. Nausea may present early and may be the initial reason that the woman suspects she is pregnant; vomiting may also occur. There may be weight gain. Breast changes can include engorgement, tenderness, areola and nipple pigmentation, and galactorrhea or nipple discharge [13]. Abdominal pain can be severe and usually occurs around the time the woman regards as her expected date of delivery. Some women also experience increased urinary frequency.
The initial presentation may be for routine prenatal care or for an acute pregnancy related problem (eg, pain, bleeding, labor, decreased fetal activity).
Laboratory — Endocrinologic changes can occur but are inconsistent; no single neuroendocrine profile is common to all women with pseudocyesis. Prolactin, estrogen, progesterone, follicle stimulating hormone, and luteinizing hormone concentrations vary widely [12,14].
NATURAL HISTORY AND PROGNOSIS — The natural history of pseudocyesis is not well described because of its low prevalence. Knowledge about pseudocyesis is derived from case reports and occasional case series.
Symptoms generally last from a few weeks to nine months or longer, even years [9]. Recovery may be spontaneous but is sometimes preceded by "labor" pain [3]. Women can experience a single episode or multiple episodes of pseudocyesis [15].
In an individual woman, prognosis is dependent, to a large extent, on resolution of the specific psychological and/or interpersonal factors that have been involved in the development of pseudocyesis in that patient. In some cases, pseudocyesis heralds the development of another psychiatric disorder, most often depression [16,17], but sometimes hypomania [18] or psychosis [19,20]. Some women with pseudocyesis attempt or die by suicide [21,22].
The prognosis of women misdiagnosed as pregnant should also be noted. Several cases of cesarean or near-cesarean delivery have been described in women with pseudocyesis who were mistakenly believed to be pregnant [23].
PATHOGENESIS AND RISK FACTORS — The etiology of pseudocyesis is unclear but appears to involve psychological and neuroendocrine mechanisms that affect each other in a reciprocal interplay between mind and body. There are three major hypotheses about the development of this disorder.
Psychosomatic hypothesis — Psychological factors, such as intense social pressure and anxiety, may alter the function of the hypothalamic-pituitary-ovarian axis, resulting in signs and symptoms of pregnancy, such as amenorrhea [24]. Such pressure may include an overwhelming desire to be pregnant for personal reasons, cultural considerations, or both. In these cases, a belief in pregnancy is thought to serve as a defense against confrontation with a difficult reality [25], often related to a loss [26]. The nature of triggering losses varies and can include loss of a loved one, loss of a prior pregnancy via miscarriage or stillbirth, or loss of a valued social role. In cultures in which a woman's social value is dependent on her ability to bear children, a woman who does not bear children may be subject to abuse, rejection, divorce, and/or economic distress [27]. This type of cultural context appears to contribute to risk of pseudocyesis.
Contributory psychological pressures include:
●Loss of reproductive capability (eg, infertility, sterilization, hysterectomy, menopause), loss of a pregnancy or a child [28].
●Interpersonal pressures (eg, an attempt to maintain a relationship, parity with other women, loneliness, or family pressure) [29].
●Fear of conceiving [5].
●Coping style characterized by somatization and denial, which sometimes occurs in the context of histrionic personality disorder [30].
●Cognitive style characterized by using less information before coming to conclusions, to be more certain of conclusions, and less likely to review them [31].
●Other contributory factors: emotional turmoil, childhood sexual abuse, troubled relationships with significant persons, and naivete about medical matters [6,7,32,33].
Somatopsychic hypothesis — Body changes can initiate a false belief of pregnancy in women who tend to misinterpret somatic stimuli [34]. In susceptible women, pseudocyesis has occurred in the context of hepatic failure [35], systemic lupus erythematosus [36], abdominal neoplasia [37], hyponatremia [38], cholecystitis [39], and other medical conditions [40]. It also occurs in some women whose antipsychotic medications cause, or are associated with, amenorrhea, weight gain, breast soreness, and/or galactorrhea due to high prolactin levels [41].
Psychophysiologic hypothesis — The psychophysiologic hypothesis is that major depressive disorder or stress, with their concomitant alterations in brain biogenic amines, may be an important initiating event in pseudocyesis, as biogenic amines are involved in the regulation of reproductive hormones [14,42].
DIAGNOSIS — The diagnosis of pseudocyesis is made in a nonpregnant, nonpsychotic woman who persists in believing she is pregnant after pregnancy has been ruled out and who exhibits signs and symptoms of pregnancy.
The Diagnostic and Statistical Manual of Mental Disorders includes pseudocyesis under Other Specified Somatic Symptom and Related Disorder [1].
An assessment for psychological contributory factors may confirm the diagnosis of pseudocyesis and identify problems amenable to treatment. The table summarizes aspects of the clinical history relevant to this assessment (table 1).
Differential diagnosis — Pseudocyesis should be distinguished from other conditions with similar presentations:
●Pregnancy – A positive urine or serum beta-human chorionic gonadotropin (hCG) test is diagnostic of pregnancy and is highly reliable. False positive and negative tests are rare. (See "Clinical manifestations and diagnosis of early pregnancy", section on 'Causes of a false-negative test' and "Clinical manifestations and diagnosis of early pregnancy", section on 'Causes of a false-positive test'.)
Abdominal ultrasound provides visual confirmation of the pregnancy and fetal status. (See "Clinical manifestations and diagnosis of early pregnancy", section on 'Ultrasound examination'.)
●Delusion of pregnancy – This is a false and fixed belief about being pregnant, despite factual evidence to the contrary. As compared with women with pseudocyesis, these women have a relative absence of physical signs suggestive of pregnancy [31]. Delusional pregnancy should be suspected in individuals with psychotic disorders. In some cases it is difficult to distinguish a delusional pregnancy (which is a psychotic disorder) from pseudocyesis (which is a somatic symptom disorder), since they may have similar psychological antecedents and may exist on a continuum [43]. For this reason, some authors opine that there should be no distinction [43].
Delusional pregnancies, with no physical signs suggestive of pregnancy, have also been reported in males [44-46]. Delusions of pregnancy, without accompanying somatic changes, have also been observed in women with various forms of dementia, including vascular, fronto-temporal, and Alzheimer's type [47].
●Medical conditions – Some medical conditions can produce signs or symptoms suggestive of pregnancy. For example, gestational trophoblastic disease (eg, hydatidiform mole) can be associated with all the signs and symptoms of pregnancy, but a normal fetus and placenta are not present; a persistent corpus luteum cyst can result in a missed period; and pituitary tumors can cause amenorrhea and galactorrhea. Pelvic tumors, Cushing syndrome, bezoars, bowel obstruction, constipation, inflammatory bowel disease, ascites, organomegaly, aerophagia, and other conditions can cause abdominal enlargement [11]. Stress, weight loss, polycystic ovary syndrome, or other factors may lead to missed menstrual periods that are misinterpreted as a sign of pregnancy. In a systematic review of cases of pseudocyesis and delusional pregnancy, 16 percent were potentially influenced by medical conditions [40].
●Feigned pregnancy – This refers to intentional feigning of pregnancy for some specific gain (eg, gaining attention, obtaining leave from work, avoiding punishment, or avoiding responsibility). This is classified as factitious disorder or malingering, the latter when there is a clear external motive, such as financial gain. In a consecutive case series of women with factitious disorder by proxy (women producing or feigning symptoms in their children), 19 percent had pseudocyesis [48].
●Couvade syndrome – Couvade syndrome, also known as "sympathetic pregnancy," refers to a condition in which someone close to a pregnant woman experiences pregnancy-related physical symptoms, usually toward the end of the pregnancy and during labor and delivery. In most cases, couvade syndrome is experienced by a male partner of a pregnant woman, but it can also be experienced by a woman, such as the mother of a pregnant woman [49].
MANAGEMENT — Controlled trials of treatments for pseudocyesis have not been performed. However, data from randomized trials have provided an evidence-based approach to treatment of somatoform disorders [50].
The following treatment recommendations are based on case reports and clinical experience.
Goals of treatment — The goals of treatment are to:
●Develop the woman's insight into her disorder when possible. However, insight may not be a realistic treatment goal for women who rely heavily on denial and somatization as coping skills [30].
●Reduce physical signs and symptoms suggestive of pregnancy.
●Alleviate any psychological, interpersonal, and/or sociocultural pressures that are fueling the woman's belief that she is pregnant.
●Develop the woman's engagement in other valued activities and goals.
●Improve social and occupational functioning.
●Reduce the risk of recurrence.
●Minimize unnecessary medical intervention, such as repetitive ultrasound examinations, unwarranted cesarean delivery, etc.
Once symptoms have remitted, some women employ "face-saving" explanations for why they are no longer pregnant. For example, a woman may maintain that she miscarried, that the baby "went to Heaven," or that witchcraft ended the pregnancy [51,52]. If she has shown functional improvement (for example, if she has learned to be more assertive with family members, thereby getting her needs met in ways other than by being pregnant), it is not essential to confront these face-saving solutions.
Conveying the diagnosis — A key intervention is to explain the diagnosis to the woman in a way that is therapeutic rather than damaging. In giving up the belief in pregnancy, she may be giving up a means of coping with intense emotions and/or of solving a difficult dilemma [53]. Having a strong, positive relationship with a clinician can help her face this loss, even if the clinical relationship is newly established and short-term [30].
Conveying the diagnosis empathically can promote acceptance of the diagnosis and can initiate conversations about underlying issues [30,54]. In some cases, this will be sufficient for the symptoms to remit, and follow-up may help prevent recurrence [53]. By comparison, delivering the diagnosis without empathy can lead to depression, agitation, psychosis, and/or "doctor shopping" [55-57].
Effective communication of the diagnosis of pseudocyesis includes [56]:
●Informing the woman about objective results (eg, physical examination and/or laboratory test negative for pregnancy).
●Conveying that you do not think she is pregnant, while empathically explaining that her belief in being pregnant is understandable due to physical signs (eg, menstrual irregularity) and emotional reasons (eg, pressure to become pregnant).
●Conveying that you want to continue to work with her to understand her condition further.
It is essential to make every effort to avoid an adversarial relationship and/or excessive confrontation. If the woman asserts that she is pregnant after being told she is not, it is important to accept that she is probably not ready to relinquish her belief. Usually the most therapeutic strategy is to refocus attention on arranging a follow-up visit, emphasizing a desire to understand what is happening, and showing interest in her well-being. If she returns with repeated or new complaints that she interprets as proof of pregnancy, the clinician should gently repeat the preceding points as often as necessary. This is when it becomes pseudocyesis.
While there is no need to perform unnecessary laboratory tests, ultrasound examinations can be both diagnostic and therapeutic, if well planned. The propensity of these women to distort reality interferes with the usefulness of sonography in convincing them that they are not pregnant [30]. Women with pseudocyesis can misinterpret ambiguous ultrasound images and believe they see fetal parts. In addition, if told nonspecifically that an ultrasound shows "everything is fine," a woman with pseudocyesis can interpret this to mean that the fetus is fine [22]. It can be helpful for a clinician to be present during the procedure to elicit the woman's observations and reactions directly, to address misperceptions, and to discuss pregnancy-linked fears and fantasies [30].
Counseling — Women with pseudocyesis rarely agree to formal psychotherapy. More often, they will agree to continue to see an obstetrician/gynecologist or midwife, and will accept informal counseling in that context. In such cases, the perinatal care provider can consult with a mental health provider for guidance [56].
Counseling for pseudocyesis is generally brief and episode-focused [30,51]. Women rarely agree to continue therapy once the acute symptoms and stressors have resolved, even if they are at risk for symptom recurrence or have not yet acquired more versatile coping skills.
The process of counseling for pseudocyesis can be summarized as follows:
●Establish and maintain an alliance with the woman.
●Identify internal and external factors that may be contributing to her belief that she is pregnant (table 1).
●Focus the content of sessions on specific, modifiable internal factors, not on the purported pregnancy. The table lists examples of frequently noted factors and strategies that can address them (table 2).
●When modifiable external factors are identified, invite significant family and friends to sessions to work on these factors, if appropriate (table 3).
Intervening with health care providers and health care systems — Treating pseudocyesis requires teamwork across health care disciplines and systems. A mental health professional, primary care provider, or obstetric provider can take the lead in forming a coordinated care plan, and communicating this plan to all health care professionals involved with the woman. This includes counseling ultrasound technicians, phlebotomists, clinic receptionists, nurses, and others who may encounter the woman, so that health care personnel do not inadvertently reinforce the false belief in pregnancy.
Psychotropic medication — There is no evidence that psychotropic medication directly treats pseudocyesis; however, when pseudocyesis is accompanied by symptoms of depression, mania, and/or psychosis, case reports suggest that treating comorbid psychiatric symptoms with antidepressants, mood stabilizers, and/or antipsychotic agents can alleviate pseudocyesis [57-59]. It is also important to note that some women with pseudocyesis may discontinue needed psychotropic medication due to a belief that they are protecting their fetuses from the risk of adverse effects [60]. (See "Unipolar major depression in adults: Choosing initial treatment" and "Bipolar mania and hypomania in adults: Choosing pharmacotherapy".)
In some cases, psychotropic medication may contribute to the development or maintenance of pseudocyesis by causing side effects that mimic pregnancy symptoms, such as nausea, weight gain, constipation, galactorrhea, and amenorrhea [31]. Switching to agents that do not cause these side effects can alleviate pseudocyesis in some women. (See "First-generation antipsychotic medications: Pharmacology, administration, and comparative side effects" and "Second-generation antipsychotic medications: Pharmacology, administration, and side effects".)
Restoring menstrual periods — In many cases of pseudocyesis, regular menstrual cycles spontaneously return with psychological acceptance of the nonpregnant state. In some cases, however, ongoing amenorrhea fosters an ongoing belief in pregnancy. Hormonal intervention to induce a withdrawal bleed can promote the woman's ability to relinquish a false belief in pregnancy. If hormonal intervention is done, we suggest that a gynecologist prescribe hormonal therapy to accompany rather than precede psychological intervention so vaginal bleeding is not interpreted as a miscarriage [56].
For women who are not hypoestrogenic, a progestin withdrawal test (ie, administration of medroxyprogesterone 10 mg daily for five days) will cause withdrawal bleeding. For women with marked hypoestrogenism and amenorrhea, estrogen may be needed to prime the endometrium before adding a progestational agent to cause withdrawal bleeding (eg, conjugated estrogen 0.625 mg or estradiol 2 mg daily for 21 days with 10 mg medroxyprogesterone acetate daily for the last 10 days). (See "Evaluation and management of secondary amenorrhea".)
If a woman with pseudocyesis is using a contraceptive agent that can cause amenorrhea (eg, depot medroxyprogesterone acetate injections, etonogestrel implant, levonorgestrel-releasing intrauterine device [IUD], extended or continuous use of estrogen-progestin contraceptives), we suggest switching to another method, such as cyclic estrogen-progestin contraceptives, a copper IUD, or nonhormonal methods, if feasible [61,62]. The woman is less likely to believe she is pregnant if she is having regular menstrual cycles.
Treating contributory medical conditions — Treating medical conditions that cause signs suggestive of pregnancy can help alleviate pseudocyesis [40], although this rarely suffices as a sole intervention. One example is prescribing laxatives to reduce abdominal distention from fecal impaction and bowel dilation [63].
Involving family and friends — Pseudocyesis is fundamentally a social condition [56]. Successful treatment often requires involving significant family members and friends, both to reduce pressures toward pseudocyesis and to help treat pseudocyesis [14,33,54,56,64]. The table lists examples of how family and friends can be involved (table 3). These individuals should be empathic, but not support the woman's belief that she is pregnant, and they should reduce any pressure to become pregnant that they are placing on her.
SUMMARY AND RECOMMENDATIONS
●Clinical relevance – Pseudocyesis is a somatoform disorder characterized by a false, but nondelusional, belief in being pregnant. (See 'Introduction' above.)
●Clinical presentation – Abdominal enlargement and other signs and symptoms associated with pregnancy are common in women with pseudocyesis. Symptoms generally last from a few weeks to nine months or longer. Recurrences may occur. (See 'Clinical presentation' above and 'Natural history and prognosis' above.)
●Prognosis – Prognosis is dependent, to a large extent, on resolution of the specific psychological and/or interpersonal factors that have been involved in the development of pseudocyesis in the patient. (See 'Natural history and prognosis' above.)
●Pathogenesis – The three major hypotheses about the development of pseudocyesis are the psychosomatic, somatopsychic and psychophysiologic hypotheses. Contributory factors can include psychological pressures, social pressures, and misinterpretations of bodily changes. (See 'Pathogenesis and risk factors' above.)
●Diagnosis – The diagnosis of pseudocyesis is made in a nonpsychotic woman who believes she is pregnant and exhibits signs and symptoms of pregnancy despite a negative pregnancy test. An assessment for psychological contributory factors may confirm the diagnosis (table 1). The Diagnostic and Statistical Manual of Mental Disorders includes pseudocyesis under Other Specified Somatic Symptom and Related Disorder. (See 'Diagnosis' above.)
●Differential diagnosis – Differential diagnosis includes pregnancy, delusional pregnancy, feigned pregnancy, couvade syndrome, and medical disorders that can produce some of the signs or symptoms of pregnancy. (See 'Differential diagnosis' above.)
●Management
•Treatment goals include reduced pressure to be pregnant, engagement in other valued goals and activities, reduction of physical signs and symptoms suggestive of pregnancy, improved insight, improved social and occupational functioning, and reduced risk of recurrence. (See 'Goals of treatment' above.)
•Effective communication of the diagnosis of pseudocyesis includes informing the woman about objective results, conveying empathically that you do not think she is pregnant, and conveying that you want to continue to work with her to understand her condition further. It is essential to avoid an adversarial relationship and/or excessive confrontation if the patient is not ready to give up her belief that she is pregnant. (See 'Conveying the diagnosis' above.)
•Other medical personnel and significant others should be advised regarding helpful ways to support the woman in relinquishing her false belief and refocusing on adaptive goals (table 2 and table 3). (See 'Intervening with health care providers and health care systems' above and 'Involving family and friends' above.)
•Hormonal restoration of menses is sometimes helpful, as is treatment of contributory medical conditions and psychopharmacologic treatment of comorbid psychiatric disorders. (See 'Psychotropic medication' above and 'Restoring menstrual periods' above.)
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