Pseudocyesis: Diagnosis and Treatment
Diagnostic Approach
Pseudocyesis is diagnosed by demonstrating a negative serum or urine β-hCG test combined with negative ultrasound findings in a patient who firmly believes she is pregnant and exhibits objective signs and symptoms of pregnancy. 1
Key Diagnostic Features
The patient presents with a false belief of pregnancy accompanied by objective physical signs such as abdominal enlargement, breast changes, nipple discharge, amenorrhea, and subjective sensation of fetal movement 1, 2
Laboratory confirmation requires negative β-hCG in both blood and urine to definitively exclude pregnancy 1
Pelvic ultrasound must demonstrate absence of intrauterine gestational sac, yolk sac, or embryo despite the patient's conviction of pregnancy 3, 1
Physical examination typically reveals findings inconsistent with actual pregnancy, such as non-distended abdomen, non-palpable uterus, and absence of true breast enlargement despite the patient's symptoms 1
Common Clinical Context
Most cases occur in patients with underlying psychiatric disorders, particularly major depressive disorder, psychotic disorders, or bipolar disorder with manic episodes 1, 4, 5
Risk factors include recent pregnancy loss, infertility, psychological naivete, social isolation, and membership in cultural groups emphasizing childbearing as central to female identity 2, 4
Depression is frequently an underlying or associated condition that may be overlooked in the initial evaluation 5
Treatment Algorithm
The primary treatment approach involves helping the patient recognize the illness through gentle confrontation with objective evidence, followed by psychiatric evaluation and treatment of underlying mental health conditions. 2, 4
Step 1: Initial Management
Present the negative pregnancy test and ultrasound results in a supportive, non-confrontational manner to help the patient accept reality 2, 6
Avoid dismissive or judgmental approaches, as these patients genuinely experience their symptoms and require empathetic care 2, 4
Provide education about the condition and reassure the patient that physical symptoms can occur without actual pregnancy 2, 6
Step 2: Psychiatric Evaluation and Treatment
Obtain immediate psychiatric consultation to assess for underlying psychiatric disorders including depression, psychotic disorders, and bipolar disorder 1, 4, 5
Initiate antidepressant therapy when depression is identified as the underlying problem, as this has been shown to effectively ameliorate pseudocyetic symptoms 5
For patients with psychotic features or bipolar disorder, use appropriate antipsychotic medications such as olanzapine, haloperidol, or risperidone as indicated by the underlying condition 1
Consider involuntary psychiatric commitment for patients with severe psychosis or inability to care for themselves 1
Step 3: Multidisciplinary Collaboration
Coordinate care between gynecology and psychiatry services, as this collaborative approach is essential for comprehensive management 4
Address psychosocial factors including infertility issues, recent losses, and cultural pressures that may contribute to the condition 2, 4
Provide ongoing counseling to address the psychological basis of the condition, particularly the patient's wish for pregnancy as essential to identity and self-esteem 4, 6
Important Clinical Considerations
The incidence of pseudocyesis has declined significantly over the past 50 years due to improved medical access and sociocultural changes 2
The etiology involves complex interactions between psychological, sociocultural, and endocrine factors, demonstrating the reciprocal interplay between mind and body 2, 4
Treatment success depends on recognizing and addressing the underlying psychiatric condition rather than focusing solely on the false pregnancy belief 4, 5
Patients without longstanding infertility can still develop pseudocyesis, making this diagnosis important to consider even in atypical presentations 6