PSYCHOENDOCRINE RELATIONSHIPS IN PSEUDOCYESIS
ARTHUR STEINBERG, MAJOR, S N C , NATHAN PASTOR, M.D., E. B. WINHELD, CAPT., M.C.,
H. I. SEGAL, CAPT., M.C., F. R. SHECHTER, M.D., AND N. H. COLTON, CAPT., M.C.*
Pseudocyesis has always involved much medical
speculation. Bivins (1), in 1934, collected reports
of more than 400 cases from the medical literature
of the entire world, dating back to the time of
Hippocrates. Many synonyms for this clinical en-
tity have appeared in the literature; spurious preg-
nancy, false pregnancy, imaginary pregnancy, "gros-
sesse nerveuse," etc. The terms have often been
used rather loosely, and have covered a number of
conditions which cannot be considered as true cases
of pseudocyesis.
Dunbar (3) defines pseudocyesis as "a condition
in which a woman firmly believes herself to be
pregnant and develops objective pregnancy symp-
toms, in the absence of pregnancy." She differ-
entiates it from the following conditions: (1) hal-
lucinatory pregnancy, which occurs in the psy-
choses; (2) simulated pregnancy, where the patient
professes to be pregnant, knowing she is not;
(3) pseudopregnancy, caused by tumors which give
rise to endocrinological changes suggestive of
pregnancy (7, 15). Some authors (8, 9) state that
pseudocyesis occurs mostly in newlyweds and in
women near the menopause. Others (14, 16) feel
that its incidence is not so restricted. The etiology
has been paradoxically ascribed to a desire for
pregnancy and to a fear of pregnancy. The clas-
sical case history usually involves a woman of
neurotic tendencies, near the menopause, who has
had no children and strongly desires a child. Other
cases occur in younger women who have had illicit
intercourse, and fearing pregnancy, are convinced
that they are pregnant. These patients present all
the symptoms suggestive of pregnancy, including
morning nausea and vomiting, amenorrhea, enlarge-
ment and tingling of the breasts, milk secretion,
areolar pigmentation, and enlargement of the ab-
domen. The symptom complex is carried through
so convincingly that in many cases (5, 10) the
patient apparently comes to term and the error
is not realized until labor is unproductive.
There has been much speculation as to the
mechanism involved in the development of this
interesting condition. The subjective symptoms
are easily explained, but not so the objective signs.
In her excellent book on psychosomatic interrela-
1
Endocrine Research Institute of Philadelphia.
176
tionship, Dunbar (3) has pointed out that virtually
any group of symptoms and signs may develop
as a result of disturbances in the sphere of the
psyche. Even such organic illnesses as peptic ulcer,
colitis, cardiac disorders, etc., may arise as the
result of derangements in physiological processes
caused by emotional upsets.
The purpose here is not merely to report addi-
tional cases of pseudocyesis, but rather to present
evidence of the effect of the psyche on the endo-
crine system. The demonstration of marked altera-
tions in the excretion of gonadotropins and estro-
gens as a result of psychogenic influences offers a
more satisfactory explanation of the mechanism
involved in pseudocyesis. This mechanism may
operate in the production of menstrual disorders
(12, 13).
During the past three years, three cases of pseudo-
cyesis were encountered and studied. In addition
to a complete history and physical examination,
quantitative 24 hour urinary estimations of gonado-
tropins and estrogens as well as Friedman tests
were performed.
CASE REPORTS
Case 1. Mrs. E. M., age 23 years, white, was re-
ferred for a pregnancy test. She had been attending
a prenatal clinic for two months. Menarche oc-
curred at 14. There was a regular twenty-eight
to thirty day cycle. The flow lasted three or four
days and was painless. For the four months previ-
ous to her initial visit she had vaginal staining
lasting through part of one day at monthly in-
tervals. During these four months she had gained
21 pounds in weight. Her configuration was typi-
cal of a four to five months' pregnancy. The
abdomen protruded and a definite lordosis was
present. The patient had a characteristic waddling
gait and her appearance was so suggestive of preg-
nancy that she was discharged by her employer.
She herself was convinced that she was pregnant,
despite the doubt raised by her physician. At her
regular prenatal visits she complained of morning
nausea and vomiting. She stated that she "felt
life" two weeks after the initial visit. Her breasts
showed considerable enlargement, increased' areo-
lar pigmentation and Montgomery tubercles. A
colostrum-like fluid could be expressed from the
May 1946] PSYCHOENDOCRINE RELATIONSHIPS IN PSEUDOCYESIS
prominent nipples. Pelvic examination revealed a
soft cervix. The fundus could not be outlined be-
cause of the adiposity. The Friedman test per-
formed five months after the cessation of normal
menses was negative. However, the possibility of-
pregnancy was not dismissed. An occasional case
of pregnancy had been previously encountered, in
which the Friedman test had been negative as late
as the second trimester, in the presence of pituitary
hypofunction. It was probable in these cases that
the gonadotropins were not elaborated in sufficient
amount to give a positive Friedman test. It was
believed that this patient might fall into this cate-
gory. Accordingly, a 24 hour specimen of urine
was assayed (17) for gonadotropins and estro-
gens two weeks after the negative Friedman test.
Eighteen hundred rat units of gonadotropins and
3000 rat units of estrogens were excreted. On the
basis of the history and assay it was felt that she
was pregnant, and she was referred back to the
prenatal clinic. Two weeks later another pelvic
examination revealed' no further change. She con-
tinued to gain weight and stated that she continued
to feel "quick thumps" in her abdomen. She com-
plained of painful breast and severe muscular
cramps in the lower extremities. Her face, hands
and feet were edematous. Blood pressure and
urinalysis were normal. A roentgenogram of the
abdomen revealed no fetal structures. Another
assay, done four weeks after the first determination,
showed an excretion of 1200 rat units of gonado-
tropins and 200 rat units of estrogen per diem. A
pelvic examination done at this time revealed no
change. At this time the patient was informed that
she was definitely not pregnant. Although very
much upset and depressed, she resigned herself to
the situation. Within one week the subjective symp-
toms of pregnancy cleared up, and the objective
signs began to recede. One week later a hormone
assay showed 600 rat units of gonadotropins and
300 rat units of estrogen per 24 hours. She was
then treated as a case of hypopituitarism of the
Froehlich-type with an associated amenorrhea. The
patient was given 10,000 rat units of estradiol
benzoate twice weekly for four injections, intra-
muscularly, followed by 10 mgm. of progesterone
every other day for five injections. Slight vaginal
bleeding followed. After the cessation of bleeding,
daily injections of 300 international units of gonado-
tropic factor from pregnant mare serum and 500
international units of the gonad-stimulating hor-
mone from pregnancy urine were given during
the first half of the cycle for two cycles. She was
also placed on a weight-reduction regimen, and
177
given 60 gr. of enteric-coated ammonium chloride
daily, and 5 mgm. of benzedrine sulfate three times
a day, one hour before meals. During the following
month she menstruated and the flow lasted two
days. In the next eight months menstruation oc-
curred regularly every month with a three to four
day flow. She lost 24 pounds and her body resumed
a normal configuration.
Case 2. Mrs. C. R., aged 37 years, white, was
referred because of a possible pregnancy. During
each of the previous two cycles, there had been
one day of staining instead of her usual three-day
normal flow. For the past three weeks she had
experienced morning nausea. As a result, the pos-
sibility of pregnancy suggested itself to her. A
small, slender woman, always weighing about 75
pounds, she had gained 8 pounds with a con-
comitant breast and abdominal enlargement. Me-
narche occurred at 14 years of age. There was a
regular twenty-six to twenty-eight day cycle, with
a two to three day scanty, painless flow. There
had been one normal pregnancy twelve years previ-
ously. She was so firmly convinced of her preg-
nancy that she disregarded the fact that eleven
years previously, following a pelvic operation, she
had been told that she could never again conceive.
She refused to believe the pelvic findings of three
physicians, one of them a consultant obstetrician,
who informed her that she was not pregnant.
Physical examination of this patient also revealed
a configuration suggestive of pregnancy. Pelvic
examination showed a soft cervix; the uterus was
pulled to the right but was normal in size. The
adnexa was not palpable. A Friedman test was
negative. A twenty-four hour urine specimen col-
lected on the following day showed 35 rat units
of gonadotropins and 900 rat units of estrogens.
The patient had been told that these tests were
completely reliable. On the following day, she
menstruated for twenty-four hours. Three weeks
later a hormone assay revealed a titre of 35 rat
units of gonadotropins and 15 rat units of estrogens.
When seen two weeks after this, her abdomen was
noticeably flatter and her breasts were smaller. The
symptom of morning nausea had cleared up. In
the two years since, she has menstruated normally.
Case 3. Mrs. R. N., aged 20 years, white, was sure
she was pregnant because of amenorrhea of three
months' duration. She had been married seven
months. Menarche had occurred at the age of 14.
There was a twenty-eight day cycle and a flow of
five days' duration. Moderate dysmenorrhea and
pre-menstrual breast engorgement were present.
Physical examination revealed enlargement of the
 178 A. STEINBERG, N. PASTOR, E. B. WINHELD, H. I. SEGAL, F. R. SHECHTER, N. H. COLTON [Vol. 8

breasts with prominent Montgomery tubercles. Pel- Friedman test implies a minimum daily excretion of
vic examination showed a soft cervix and the fundus 1,500 rat units of chorionic gonadotropic hormone.
uteri slightly larger than normal. A Friedman test In all 3 cases the output of gonadotropins and
was negative. A hormone assay done three days estrogens was far above normal, but not enough to
later showed a urinary excretion of 600 rat units result in a positive Friedman test. In view of the
of gonadotropins and 200 rat units of estrogens. absence of pregnancy or abnormality of the pitui-
The patient was assured that she was not pregnant. tary or ovary, it appears that this increased hor-
She menstruated one week later, and has men- monal output must be attributed to the influence
struated regularly in the subsequent eight months. of the psyche on the endocrine system. Further
support of this hypothesis is given by the fact
that in each case, when the patient was told that
she was definitely not pregnant, prompt recession
When the initial case was seen, with a negative in physical signs took place, attended by a return to
Friedman test but with striking signs and symp- normal hormonal titers. In our patients it was noted
toms of pregnancy, it was decided to carry out that those designated as Cases 1 and 3 were re-
cently married; that Cases 1 and 2 strongly desired
a child. Case 2 had been told that she could never
\ again conceive, and yet as soon as a menstrual
\
change developed along with an increase in weight,
\ she felt that she was pregnant. In Case 1, as soon
1 as she developed hypomenorrhea and her con-
1
\ 1 figuration changed, the psyche began to exert its
1 influence so as to produce confirmatory evidence
of pregnancy, such as breast changes, nausea and
s
vomiting, etc. The relative difference in the en-
\ largement of the breasts and cervix compared to
• - '
the body of the uterus may be accounted for by dif-
\ ferences in tissue response to estrogens. Although
\ the hormone excretion titers were within the ranges
-— seen with an unexpelled dead fetus, the clinical
history in no case was compatible with such a
condition. In Case 2, a follicular cyst might have
FIG. 1. Mean urinary liters of gonadatropins and estrogens been suspected on the basis of the hormone titers
in rat units per diem excreted during normal gestation. alone, but this was offset by the clinical history and
negative pelvic examination.
quantitative urinary hormone assays. The decision
was based on the fact that in the past, an occasional The apparent close relationship between the
case of hypopituitarism with advanced pregnancy psyche and the endocrine system offers a more
was observed in which the Friedman test was nega- logical explanation for many cases of menstrual
tive. The subsequent cases were similarly studied disorders and their cure by psychotherapeutic mea-
to confirm the findings obtained in the first case. sures. For example, many physicians have seen
In a previous publication (17), the average values cases of amenorrhea where the patients feel certain
established for urinary gonadotropins and estrogens that they are pregnant, and when reassured, im-
excreted in twenty-four hours by normally men- mediately begin to menstruate. Similarly, many
struating women were found to range between cases of menorrhagia have been reported due to
40 and 60 rat units, and 60 to 90 rat units, re- psychic trauma which responded only to psycho-
spectively. During pregnancy the levels of both therapy (12, 13). Frank (6), in a recent discussion
on endocrine therapy, commented upon many spon-
gonadotropins and estrogens rise rapidly as illus-
taneous cures of amenorrhea of long duration, fol-
trated in figure 1. A positive Friedman test is based
lowing medical consultation, with no therapy.
on the demonstration of increased amount of
Repeated illustrations can be cited of this intimate
luteinizing hormone excreted in the urine. The
relationship between the psyche and the glands of
minimum value for a positive Friedman test is
internal secretion. The realization of this impor-
approximately 1 rat unit per c.c. of urine. Assum-
tant factor in functional endocrine disturbances
ing a daily urine excretion of 1,500 c.c, a positive
should lead us to evaluate the results of therapy
May 1946] PSYCHOENDOCRINE RELATIONSHIPS IN PSEUDOCYESIS 179

more critically. However, it does not follow that
a policy of therapeutic nihilism should therefore
be applied to all endocrinopathies. It is hoped that
other cases of pseudocyesis will be similarly studied
by other investigators.
We are indebted to Dr. Wm. H. Stoner of The Schering
Corporation, Bloomfield, N. J., who supplied the estradiol
benzoate (Progynon-B), gonadotropic factor from pregnant
mare's serum (Anteron), and gonad-stimulating hormone
from pregnancy urine (Pranturon), employed in this
investigation.
BIBLIOGRAPHY
1. BIVEN, G. D.: Spurious pregnancy, comprehensive re-
search study. Am. Med., 40:227, 1934.
2. BROOKHART, J. M., DEY, F. L., and RANSON, S. W.:
Failures o£ ovarian hormones to cause mating re-
actions in spayed guinea pigs with hypothalamic
lesions. Proc. of Soc. of Exp. Biol. and Med., 44:61,
1940.
3. DUNBAR, H. F.: Emotions and Bodily Changes. 2nd ed.
New York, Columbia University Press, 1938.
4. DEY, F. L., FISHER, C,-BERRY, C. W., and RANSON,
S. W.: Disturbances in reproductive functions caused
by hypothalamic lesions in female guinea pigs. Amer-
ican J. of Physiol., 129:39, 1940.
5. ERICKSON, C. W., and HASHINCER, E. H.: Case of
pseudocyesis associated with endocrine imbalance.
J. Kansas M. Soc, 35:395, 1934.
6. FRANK, R. T.: Sex hormones, their physiologic sig-
nificance and use in practice. J. A. M. A., 114:1504,
1940.
7. FRIEDLANDER, E., and MOSES, E.: Sekundare Schwanger-
schaftszeichen beim Chorionepitheliom des Mannes.
Wein. klin. Wchnschr.; 49:684, 1936.
8. GOLDBERG, A. T., and SHATZ, M. M.: Pseudocyesis.
Calif, and West. Med., 53:270, 1940.
9. JACOBS, J. B.: Pseudocyesis. Virginia Med. Mon., 57:
178, 1930.
10. JANA, A. P.: Case of pseudocyesis followed by true
pregnancy. Indian. M. Gaz., 69:445, 1934.
11. MILLER, J. A.: Psychogenic menorrhagia. M. J. and
Rec, 134:84, 1931.
12. NOVAK, J., and HARNIK, M.: Die psychogene Entsehung
dcr Menstrualkolik und deren Behandlung. Ztschr. f.
geburts. u. Gynak., 96:239, 1929.
13. NOVAK, J., and HARNIK, M.: Uterusblutungen psycho*
genen Ursprungs. Zentralbl. f. Gynak., 53:2976,
1929.
14. PADDOCK, R.: Spurious pregnancy. Am. J. Obst. and
Gynec, 16:845, 1928.
15. REEB: Amenorrhee avec symptomes de pseudo grossesse,
due a un corps jaune persistant ou a des kystes
luteiniques. Gynecologie, 32:65, 1933.
16. SCHEFF, P., and SIMON, R.: Delire de possession zoo-
pathique succedant a un delire de grossesses chez uns
obese postencephalitique. Ann. Med. Psychol., 9 1 :
612, 1933.
17. SEGAL, H. I., STEINBERG, A., SHECTER, F. R., COLTON,
N. H., and PASTOR, N.: Attempt at endocrine correla-
tion and therapy in 125 cases of menstrual disorders.
Am. J. Obst. and Gynec., 41:979, 1941.

TRAINING I N PSYCHOSOMATIC MEDICINE F O R T H E MEDICAL RESIDENT

A great many physicians, especially those returning from military service, have expressed
a desire for more training in psychosomatic medicine but wish to remain identified with
internal medicine. Correspondence with the American Board of Internal Medicine and the
Council on Medical Education and Hospitals of the American Medical Association has
established that training in psychosomatic medicine will be accepted as a part of the training
for certification in internal medicine.
Excerpts from the letters of D r . Werrell, Assistant Secretary-Treasurer of the American
Board of Internal Medicine, and Dr. Arestad, Assistant Secretary of the Council on Medical
Education and Hospitals of the American Medical Association, follow:
July 3, 1945, D r . Werrell: "The Board will recognize a limited amount of training in Psycho-
somatic Medicine incorporated with the regular residency in internal medicine in approved
hospitals, provided this subject is recognized and approved by the Council on Medical Educa-
tion and Hospitals."
December 27, 1945, Dr. Arestad: "The inclusion of this subject in the residency program in
medicine is, I am sure, an effective means of broadening the resident's experience in this
related field which occupies a large part of general medical practice."
We believe that such training will be a fundamental step in the development of psycho-
somatic medicine by producing a group who would be capable of cooperation in teaching and
research between the fields of medicine and psychiatry. It is hoped that approved hospitals,
especially those connected with medical schools, will avail themselves of this opportunity
to provide psychosomatic training for their medical residents.
EDWARD WEISS, M. D .