Out of mind

"I'm pregnant," said Gail defiantly to the young psychiatrist, her black ponytail bobbing behind an overweight face. "It doesn't matter what the scan says, I can feel him moving." "But," her consultant said, "we've repeatedly given you pregnancy tests, you've seen the scan." Gail burst into tears, rubbing them away with her sleeve. "The scan can't be sensitive enough. I am going to have a baby."

Gail, 35 and single, suffered from a mild learning disability, possibly compounded by a psychotic illness. Her elder sister had married and delivered four healthy children; the last was born three months previously, making it hard for her to visit Gail. Their mother was a midwife and worked full time. Gail's "pregnancy" began soon after she heard that her sister was pregnant again, and had now lasted almost ten months. She didn't have a boyfriend and denied any sexual encounters. "I got pregnant from the toilet seat in McDonald's. The man hadn't cleaned it."

Initially Gail's GP thought she just might be pregnant. She had all the signs—a missed period, sore swollen breasts, nausea and vomiting, tiredness. But when the tests proved negative, he suggested that the community mental health team should become involved; since then she had refused to see him. After several months of short home visits by community psychiatric nurses (she wouldn't see a psychiatrist), it became clear that Gail was either not taking the medication they left for her or it wasn't working. She began to tell the nurses that she could feel the flutter of movement in her tummy. They also discovered that she was spending most of her giro in Mothercare—leaving bills and rent unpaid. To avoid the confrontation of a section, Gail's consultant (an older and also childless woman) came up with a compromise: Gail would agree to come into the all-female psychiatric ward for treatment, but in return they would give her a scan.



Now, as Gail once again left her medical team feeling defeated, the young psychiatrist perceived something heroic in this dogged reassertion of a ten month gestation. Second-line psychotropics hadn't touched her, and the scan had perhaps made things worse—she had taken a liking to the antenatal clinic. Moreover, Gail's delusions seemed to be infectious. Three other patients on the ward now claimed to be pregnant. A fourth was complaining of abdominal pains. Bizarrely, all this was happening while the young psychiatrist's wife was six months pregnant with their first child.

Many psychiatric states have been linked with claims of pregnancy. Josef Breuer's patient Anna O famously developed a hysterical pregnancy and labour in response to finding out that the physician's wife was about to give birth. What Freud later interpreted as an erotic transference so alarmed Breuer that he cut off treatment and never worked with hysterics again. Delusions of pregnancy, sometimes in the context of an illness like schizophrenia, are not uncommon. And while a delusion can be broadly defined as a fixed false belief, a delusion of pregnancy can be further complicated by the somatic syndrome of pseudocyesis—or false pregnancy. The most famous historical case of pseudocyesis was Bloody Mary, who developed the condition while in need of an heir for the English throne. The physical symptoms can be surprisingly dramatic: in some cases there's a full term swelling that disappears under anaesthetic only to reappear on waking up.

Textbooks describe a few cases of delusions of pregnancy in men, but it is much more common for men to develop psychiatric symptoms when their partners are expecting. This is known as Couvade syndrome (from the French "to hatch"), and reportedly affects up to 36 per cent of expectant fathers in the US. Constipation, diarrhoea and stomach cramps are common—even nosebleeds and headaches. But Couvade syndrome can also involve the expectant father going into labour and being attended on in much the same way as his wife. The condition has often been dismissed as mere anxiety, but it has recently been suggested that hormonal changes may play a part. Now the young psychiatrist felt his own stomach groan. This was ridiculous—he couldn't have Couvade.

Yet something was causing a minor epidemic of pregnancy on the ward. Were antipsychotic drugs to blame? One common side-effect of blocking dopamine (as antipsychotics do) is to raise the blood levels of the hormone prolactin—something that occurs naturally in pregnancy. Equally, certain non-dominant female wolves are known to develop false pregnancies in response to more dominant females giving birth. Their milk becomes an important resource for the hungry group. Could Gail, through her assertiveness, be affecting the other patients in some biological or psychological way? There was no doubt that "pregnancy" had brought Gail attention from the ward team. Was this a case of competition within an all-female psychiatric hierarchy?

The young psychiatrist again caught his mind wandering. It was five o'clock and he needed the toilet. He looked over to his consultant to excuse himself, before noticing that she too was staring out of the window. And her hand was resting lightly on her lower abdomen.