“Mental health and somatization disorders”, regarding the delicate case of Garbiela Sevilla

Gabriela Sevilla was reported missing on Wednesday, October 19, after leaving alone for a private clinic in Lima because her water had broken and she had vaginal bleeding. After 36 hours, Gabriela was located, on the morning of Friday the 21st, with evidence of having been physically abused and without the baby, and she was immediately taken to the Military Hospital.

During the previous months, Gabriela had shared multiple photographs in which she was very happy, showing her pregnancy, giving the impression that it was going from strength to strength, celebrating even a baby shower. Her family shared the excitement.

surprising reports

Upon being examined, the authorities of the Institute of Legal Medicine of the Public Ministry announced a reportwhich concluded that due to “the absence of recent or past vaginal delivery” and that there were no “hormonal signs of pregnancy”. Gabriela Sevilla was not pregnant.

In this regard, obstetricians agree that a postpartum woman shows within the first 24 hours after delivery some elements that ensure that it occurred. Among them are the dilation of the cervix, through which the baby was expelled; an episiotomy wound (a cut made in the perineum or space between the vulva and the anus), traces of blood (lochia) in the vagina, and a large uterus that is beginning to shrink and will not reach its normal size in two to three weeks . Gabriela did not present any of these signs.

On the other hand, during pregnancy, the placenta produces large amounts of a hormone called human chorionic gonadotropin (HCG), the concentration of which is measured in thousands of international units (IU) during pregnancy. In the last weeks of pregnancy, for example, its concentration varies between 3,140 and 117,000 mIU/mL, a value that progressively decreases, taking three weeks to reach the normal value not indicative of pregnancy (0.5 mIU/mL). Gabriela’s test showed 0.5 mIU/mL.

With this evidence, it was concluded that, from the medical and scientific point of view, Gabriela Sevilla was never pregnant.

somatic symptoms

Diagnoses in psychiatry are guided by a periodic publication called “Diagnostic and Statistical Manual of Mental Disorders”, whose last edition was published in 2013 and revised in March 2022 (DSM-5-TR).

This latest revision has important changes related to the topic of this column. What until DSM-4 were called somatoform disorders are now called somatic symptoms and related disorders. But what does this mean?

The relationship between physical and mental health it is extraordinarily complex and very little understood. The word somatomorphy (‘somato’ = body, ‘morphos’ = form), indicates the mental health disorder characterized by the presence of symptoms that suggest a physical or bodily health disorder, but for which no demonstrable objective organic findings are found or known physiological mechanisms.

That definition suggested that the mind and the body were separate entities, and their collision caused symptoms impossible to explain with scientific methods.

In the new edition of the “Diagnostic and Statistical Manual of Mental Disorders” (DSM) the definition of somatomorphy is expanded, and it is replaced by somatic symptom disorder (SSD) and is the presence of somatic or bodily symptoms so distressing that they cause a significant interruption of the functioning of daily life, since those thoughts, feelings and behaviors are disproportionate and excessive for the clinical picture of the patient.

To be diagnosed with SSD, the individual must be persistently symptomatic (typically for at least 6 months).

The recent definition highlights that comprehensive evaluation of a patient requires recognition that psychiatric problems often occur in people with medical problems. While DSM-4 was centrally organized around the concept of medically unexplained symptoms, the DSM-5 criteria emphasize the degree to which a patient’s thoughts, feelings, and behaviors about their somatic symptoms are disproportionate or excessive.

pseudocyesis

With SSD defined, it is easier to understand the rare type of mental health disorder group called false pregnancy, phantom pregnancy, nervous pregnancy, or pseudocyesis.

Described by Hippocrates in 300 BC. C., who described 12 women “who imagine they are pregnant when seeing that the menses are suppressed and the wombs are swollen”, the term pseudocyesis (‘pseudes’ = false, ‘kyesis’ = pregnancy), was introduced by the writer John Mason Good in 1823.

Physiological manifestations of pregnancy occur in pseudocyesis: lack of menstruation, abdominal distension, sensation of perceiving fetal movements, changes in the size or shape of the breasts, secretion of milk, darkening of the areolas, weight gain, nausea, vomiting, and changes in the uterus and cervix. The duration of symptoms usually varies from a few weeks to 9 months.

In most cases, pseudocyesis occurred in infertile and perimenopausal women between the ages of 20 and 44, 80% married. Without an exact cause, it is possible that neuroendocrine, sociocultural factors, and psychological or psychiatric conditions are involved in the development of pseudocyesis.

If there is any lesson to be learned from this complex case, it is that – as it should happen in any person with a disorder of their mental health– A woman with pseudocyesis should not be the object of ridicule or derision, and should receive all the support and treatment necessary for her recovery.