Pseudocyesis in a Transgender Woman

Prim Care Companion CNS Disord 2023;25(2):22cr03343
To cite: Mian T, Obrzydowski J, Mulinix J, et al. Pseudocyesis in a transgender woman. Prim Care Companion CNS Disord. 2023;25(2):22cr03343.
To share: https://doi.org/10.4088/PCC.22cr03343
© 2023 Physicians Postgraduate Press, Inc.

^aCommunity Hospital North, Indianapolis, Indiana
*Corresponding author: Jacob Mulinix, DO, Community Hospital North, 1147 Fletcher Ave, Indianapolis, IN 46203 ([email protected]).

Pseudocyesis is a psychiatric disorder that mimics gestation without objective evidence of pregnancy; one falsely believes they are pregnant when they are not. Though similar to delusional pregnancy, a major difference is the experience of physical symptoms in pseudocyesis, which reinforce the perception of pregnancy.¹ Existing research focuses on cisgender individuals. Our case is novel, as it presents a case of pseudocyesis in a transgender woman.

Case Report

A 28-year-old homeless transgender Black woman (assigned male at birth) with a history of schizoaffective disorder, bipolar type, and pseudocyesis presented in an acute manic episode with psychosis. She exhibited symptoms of mania such as rapid, pressured speech; grandiosity; disorganized thoughts; and psychotic symptoms of auditory hallucinations with behavior centered on the belief that she was pregnant with twins. Along with psychiatric symptoms, she endorsed physical symptoms of pregnancy, notably breast tenderness, abdominal distention, cramping, and nausea. The patient had not undergone gender affirmative surgeries in the past and denied using hormonal medications at the time of her initial presentation. Prior to admission, she had multiple prior emergency department visits and pursued extensive workup regarding her pregnancy, such as abdominal ultrasound, abdominal computed tomography, and pregnancy tests. The patient was admitted to the unit of the hospital for severely mentally ill patients.

Laboratory study results (prolactin, thyroid-stimulating hormone, complete blood count, comprehensive metabolic panel) were within normal limits. Physical examination results were unrevealing. Psychosis and mania were stabilized with an antipsychotic medication treatment regimen of aripiprazole titrated to 400 mg long-acting injectable to be given every 4 weeks and lithium 600 mg twice/d with blood level stabilized in therapeutic range (0.5–1.2 mEq/L). Despite improvement in a majority of the psychiatric symptoms, the patient’s pseudocyesis was resistant to medication management and multiple psychotherapeutic strategies including supportive therapy, gentle confrontation, cognitive-behavioral therapy, and group therapy during 7 days of inpatient admission.

Discussion

Many theories exist about the development of pseudocyesis. One theory is that pseudocyesis developed as a psychological defense mechanism to serve an individual who has experienced extreme insecurities.² Literature highlights this condition to be primarily associated with cisgender women in cultures that strongly value the role of the female as a childbearing member of society.^3,4 From a psychodynamic perspective, delusions arise to protect the patient’s ego and thus play a defensive role. It is possible that for some transgender women, and with our case in particular, having childbearing capacity could be innately important, and this dissonance may potentially lead to the development of pseudocyesis. Numerous biologic etiologies exist, which include D₂ blockade from antipsychotics resulting in hyperprolactinemia, disturbances in the hypothalamic-pituitary-ovarian axis, depression, recurrent abortions, uterine or ovarian tumors, and morbid obesity.⁵ Our team refrained from treatment with full D₂ antagonists in favor of a D₂ partial agonist (aripiprazole) to minimize the potential for physical symptoms that could occur from hyperprolactinemia and potentially reinforce false beliefs.

This case presents a unique situation in which it can be challenging for the clinician to treat a delusion that is intrinsic to the patient’s gender identity but not compatible with their assigned sex at birth. Most literature suggests empathetic communication with patients who have objective evidence of not being pregnant as an initial step of management.⁶ Antipsychotic medications can be utilized to treat delusions, and a variety of psychotherapeutic techniques have been suggested, including supportive, cognitive, behavioral, and psychoanalytic psychotherapies.^5,7 Treatment strategies in our case were extrapolated from literature pertaining to cisgender individuals; however, no literature was found involving transgender patients. We believe that with increased awareness, openness, and access to care for the transgender population in the United States, pseudocyesis will become more apparent across various health care settings. More biological and psychosocial etiologies must be investigated in the transgender population to provide effective treatment for transgender women with pseudocyesis.

Published online: April 13, 2023.
Relevant financial relationships: None.
Funding/support: None.
Patient consent: Consent was obtained from the patient to publish the case report, and information has been de-identified to protect anonymity.