INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY. VOL. 10: 107 1-1073 (1995)

SHORT REPORT

Pregnancy Delusions in Elderly Depressed Women: A Clinical Feature of Cotard’s Syndrome?

VINCENT CAMUS University Geriatric Psychiatry Service, Lausanne, Switzerland

LAURENT SCHMITT AND CHRISTINE FOULON University Psychiatry Service, Toulouse. France

C. A. DE MENDONCA LIMA AND J. WERTHEIMER University Geriatric Psychiatry Service, Lausanne, Switzerland

SUMMARY Five cases of delusions of pregnancy occurring in women over the age of 64 who had major depressive episodes with mood-congruent delusions are presented. The relation of such delusions to Cotard’s syndrome is discussed.

KEY worms-pregnancy delusions; elderly; melancholia; Cotard’s syndrome

Delusions of pregnancy were described by Esquirol in his treatise Des Maladies Mentales (1 838). They have been described in schizophrenia, erotomania and dementia and have no nosological specificity, but are often associated with affective disorder (Vie and Bobe, 1932; Bourgeois, 1980). Luque and Berrios (1 994) have reported Cotard’s syndrome to be frequent in the elderly. In a review of around 200 papers, they identified 100 cases of Cotard’s syndrome, 20 of which involved patients over 65 years of age. In order to evaluate the syndrome’s ‘completeness’, they constructed a ‘Cotard index’ by summing the number of: nihilistic delusions; delusions of hypochondriacal concern; immortality, guilt and damnation; other delusions; and hallucinations. We report five cases of delusions of pregnancy in elderly depressed women (6482 years old) suggesting that this kind of delusion, when occurring in a melancholic state, may be considered to be similar to Cotard’s syndrome.

Address for correspondence: Dr Vincent Camus, University Geriatric Psychiatry Service (SUPG), Route du Mont, 1008 Prilly, Lausanne, Switzerland.

CCC 0885-6230/95/121071-03 0 1995 by John Wiley & Sons, Ltd.

CASE 1

Mrs B, aged 64, was admitted in 1989 with a major depressive episode. She had a family history of bipolar affective disorder, and had presented in 1984 and 1988 with depressive pseudodementia. She had mood-congruent delusions of guilt, self- depreciation and worthlessness without cognitive impairment. She also described anxiety, a fear that she had cancer and delusions of persecution and pregnancy. She believed that she was pregnant with twins or triplets. Her descriptions included: ‘It’s moving in two or three different places’; ‘There is a man, a member of the medical staff, who comes every night to sleep with me, by order of the psychiatrist’; and ‘I’m pregnant, they will saw my legs off’.

CASE 2

Mrs R, aged 68, had a long history of recurrent depressive disorder, associated with alcohol abuse. On admission she was mildly euphoric with delusions of pregnancy. ‘I’m pregnant. I have several children, they are little elves, wearing

Received I February 1995 Accepted I6 March 1995

1072 PREGNANCY DELUSIONS AND COTARD’S SYNDROME

carnival dresses’. Subsequently, she exhibited depressive symptomatology with ideas of self- harm, incurability, hypochondriasis and dysmor- phophobic delusions. ‘I have a funnel and a hook in my tummy. I have plastic in my anus and in my tummy; moreover, I have plastic everywhere in the abdomen’.

CASE 3

Mrs B, aged 79, had a past history of several major depressive episodes. She presented following a suicide attempt by self-poisoning with petrol and by suffocation. Her mood was severely depressed; she exhibited psychomotor retardation, thoughts of ruination and prejudice, and also delusions of pregnancy and body alteration: ‘I am pregnant. I am burning inside, my tummy is burning’.

CASE 4

Mrs D, aged 80, had a 9-year history of major depressive episodes and delirium including admis- sion after attempted suicide by overdose of medication. In 1989 she was admitted with a depressive disorder following an attempt to drown herself. She exhibited mood-congruent pregnancy delusions; showing her abdomen, she said, ‘It’s growing here, it’s a child from my husband and he died 7 years ago. He has been here for 7 years and must be rotten after such a long time’.

CASE 5

Mrs R, aged 82, presented with a first major depressive episode in 1979, a year after the death of her husband. One of her brothers had been treated for bipolar affective disorder and her daughter had been treated for schizophrenia. In 1982 she presented with a melancholic state including delusions of guilt (thinking that she had poisoned her husband and that she had to be judged by a tribunal); of ruin; self-depreciation; and hypochondriacal preoccupations with cancer. She complained of burning feelings in her abdo- men with delusions of pregnancy: ‘I’m sure to be pregnant, I’ve been violated during the night’.

These five female patients presented with DSM- 111-R major depressive episodes with mood- congruent and non-mood-congruent delusions. In no case were the criteria for schizophrenia fulfilled

and all had a past history of unipolar or bipolar affective disorder. The delusions of pregnancy occurred in the absence of clouding of conscious- ness and did not appear to be a function of delirium; however, two cases had a past history of delirium, one of alcohol dependence and one of depressive pseudodementia. The delusions com- pletely resolved when the depressions were treated, one by antidepressant therapy, one by maprotiline and neuroleptics (butyrophenone and thio- xanthene) and the three others by electroconvul- sive therapy.

The first clear description of delusions of pregnancy is found in Esquirol’s treatise (1838) in the chapter titled ‘Demonomania’, a subgroup of ‘lypemania’ (psychotic depressive states) with delusions, mystic preoccupations and thoughts of possession by the devil. He described the case of a 3 1 -year-old depressed woman who was convinced she was pregnant, and who heard the child’s father’s voice telling her to prepare for the pains of the approaching delivery. In the chapter covering delusions (‘Des illusions chez les alitnts-Erreurs des sens’), other cases of melancholic states with hypochondriacal delusions and alterations of perception of intra-abdominal contents are des- cribed (‘devils in the abdomen’, ‘snakes in the uterus’). In an overview of pregnancy delusions, Vie and Bobe (1932) described a case, not considered by Luque and Berrios (1994), of a melancholic patient with pregnancy delusions related to nihilistic delusions: ‘I have dirtiness in the abdomen . . . I am gnawed by dogs . . . I have no more intestine, nor stomach’. Pregnancy delusions are also mentioned in another case report of Cotard’s syndrome (Bourgeois, 1980). This 60-year-old woman reported: ‘I am dead, completely dead . . . my legs don’t carry me any more . . . inside my body all is dirtiness . . . I am immortal, I am a pregnant corpse’. Then, speaking of herself in the third person: ‘She is 8 months pregnant, she had been pregnant for many years, and the child is dead, they will have to open the abdomen to get him out’.

When associated with delusions of foetal death or putrefaction, or to perceptions of burning or cutting off parts of the body, pregnancy delusions may be considered as nihilistic delusions. The monstrousness of organs Cotard (1880) described might correspond to disorders of perceived uterine contents.

Aetiologically, Luque and Berrios (1994) have argued that there is no clear evidence of a specific

V. CAMUS, L. SCHMITT. C. FOULON ET A L . 1073

parietal dysfunction in Cotard’s syndrome as proposed by Joseph and O’Leary (1986), while from a psychodynamic perspective, Bourgeois (1969) suggested that, for elderly patients, organ failure and proximity of death may be denied by misinterpretation of body function. It may be that a feature of such misinterpretation could be the conviction or perception of pregnancy. Pregnancy delusions in elderly melancholic states may be an associated clinical feature of Cotard’s syndrome. Although of interest, the prognostic value of such nihilistic delusions is unclear.

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