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Negacion no psicotica del embarazo: Una comprension psicoanalitica.

Non-psychotic denial of pregnancy: A psychoanalytical comprension

Pregnancy involves some changes in social, physiological and psychological aspects, which affect not only the woman who is pregnant, but also the people around her. It could be defined as a period of great transition (Jenkins, Millar, & Robins, 2011). The way women experience these changes in their lives will affect the relationship with the newborn (Piccinini, Gomes, de Nardi, & Lopes, 2008). Pregnancy does not begin as a belief or a certainty; women start to think they are pregnant due to physical changes, but they will only know for sure about their condition by a physician or a pregnancy test confirmation. Therefore, physical changes is the starting for women to begin considering they are pregnant (Sjezer & Stewart, 2000). This process can be perceived as normal, but there is a specific phenomenon which refutes this idea. There are some women who cannot associate their bodily changes with a possible pregnancy; they misinterpret the common signs, and it is possible that they spend their whole pregnancy time without knowing about their condition. This phenomenon is called non-psychotic denial of pregnancy.

The non-psychotic denial of pregnancy phenomenon occurs when a woman is not aware that she is pregnant for a greater part of her pregnancy or until she goes into labor (Goncalves & Macedo, 2012a). Chaulet (2011) states that non-psychotic denial of pregnancy can be understood in two different ways: partial and total. When a woman finds out she is pregnant from the fifth month on, this is considered a partial form of non-psychotic denial of pregnancy. In this kind of situation, the assumption or the concealment of the pregnancy may occur to her family and friends' circle. On the other hand, when a woman finds out she has been pregnant only when she begins to deliver, it is considered a total form of the phenomenon (Goncalves & Macedo, 2012a).

The phenomenon of non-psychotic denial of pregnancy is not restricted to primiparous women, since it can occur in the second or third pregnancy. It may occur with single or married women of any social economic status (Bonnet, 1993). The situation can in fact happen with any woman, and it is difficult to predict who will develop it (Jenkins et al., 2011). Thus, as Jenkins et al. (2011) state, "women who deny pregnancy are a heterogeneous group, with no clear-cut identifying characteristics. Consequently, a risk score is almost impossible to construct" (p.287).

Non-psychotic denial of pregnancy belongs to a greater phenomenon called "denial of pregnancy". Denial of pregnancy can be understood in two different modalities: concealment of pregnancy and psychotic denial of pregnancy. Concealment of pregnancy is when a woman hides her condition out of fear of what it may represent in her circle of peers (Chaulet, 2011; Grangaud, 2001). In this form of pregnancy, though she is fully aware that she is pregnant, she knowingly conceals her bodily changes from others (Chaulet, 2011; Grangaud, 2001). Grangaud (2001) asserts that this phenomenon occurs in greater frequency amongst teenagers, and the most common way of disguising the physical changes is by wearing loose clothing and simulating menstruation to avoid suspicion. Psychotic denial of pregnancy refers to a denial of pregnancy related to a schizophrenic disorder. The bodily changes are visible, and the family does not take part in the denial. The fetal movements are perceived as delusional and interpreted as the presence of a "bug" living inside the stomach (Grangaud, 2001; Miller, 2003).

The phenomenon of non-psychotic denial of pregnancy cannot be considered a rare event (Bonnet, 1993; Chaulet, 2011; Grangaud, 2001; Marinoupoulos & Nisand, 2011; Spinelli, 2010; Wessel, Endrikat, & Buscher, 2002). Some studies support the fact that this phenomenon is not uncommon. Wessel et al. (2002) state that, in Germany, one non-psychotic denial of pregnancy phenomenon, in its total form, occurs in every 2455 births. In France, there is a frequency of one in every 1,000 (Pierronne, Delannoy, Florequin, & Libert, 2002). In a research conducted in Wales over a period of eleven years (1989-1999), Nirmal, Thijs, Bethel, and Bhal (2006) estimated the frequency of one in every 2,500 births. The total form, when compared to certain obstetrical situations, is more common in Germany than the birth of triplets, uterine rupture, or eclampsia.

It is important to highlight a specific and complete research conducted by Wessel and Buscher (2002) in Germany. In this research, the main goal was to know how many women experienced non-psychotic denial of pregnancy in a year. In order to accomplish this, the researchers contacted 24 hospitals and institutions in the Berlin Metropolitan Area, requesting the places to notify them if any case occurred. The study considered both partial and total forms of non-psychotic denial of pregnancy. The total amount of women who unconsciously denied their pregnancy was 62, including 12 deliveries in which the women were unaware that they were giving birth (Wessel & Buscher, 2002). Regarding the births, there were 69 deliveries in total, including four pairs of twins. Twelve births were premature, and the remaining were born within the regular gestation. There were 37 boys and 32 girls with weights ranging from 995 grams to 4,920 grams. Fifty-one of the babies stayed with their parents, while 13 were put up for adoption, being one eventually adopted. The total proportion found in this study was one in every 475 births in general (Wessel et al., 2002).

Besides not being rare, non-psychotic denial of pregnancy is not a current phenomenon either. The first professional to report this kind of situation was the gynecologist Franqois Mauriceau in 1681, when he stated that continuous bleeding throughout pregnancy could lead some women to ignore the fact that they were carrying a baby. He called this meconnaissance de la grossesse (ignorance of pregnancy), not studying the phenomenon further. Almost two centuries later, in 1858, the psychiatrist Louis-Victor Marce reported a case in which a woman, in a panic attack because she did not know she was pregnant, killed her own newborn baby. This case, presented by Louis-Victor Marce, already associated the nonrecognition of pregnancy and infanticide. After this case, specific literature concerning this phenomenon had few contributions, with a hiatus between 1900 and 1980, reappearing once again in 1980 in France with new studies (Chaulet, 2011; Grangaud, 2001; Guernalec-Levy, 2007; Marinoupoulos & Nisand, 2011). In France, the phenomenon is very much debated and studied. The Association Frangaise pour le reconnaissance du deni de grossesse was founded in 2003 in the city of Toulouse in order to disseminate the knowledge concerning this dangerous situation (Chaulet, 2011).

Being unaware of their own pregnancy implies a lot of psychological and physical issues for women. Since they do not know they are pregnant, no prenatal care is carried out. Thus, the newborn may have or may develop a condition that could be monitored and treated during the prenatal care. In some cases, these women continue drinking, smoking, or taking drugs, which can directly affect the newborn's health. The most dangerous consequence of non-psychotic denial of pregnancy is neonaticide. Resnick (1969; 1970) described this phenomenon as a situation in which one parent, or both, kill their baby in the first twenty-four hours of its life. Spinelli (2010), in her research of 16 cases of neonaticide, found that it was related to pregnancy denial.

Psychoanalysis: An essential tool to comprehend non-psychotic denial of pregnancy

This article finds support in psychoanalytical contributions, because of the comprehension of human phenomena, always prioritizing the listening and the singularity of each person (Dockhorn & Macedo, 2008; Dockhorn, 2010; Figueiredo & Minerbo, 2006), an essential resource when trying to explore the nuances of a complex phenomenon such as the non-psychotic denial of pregnancy. However, when considering the multitude of factors involved, as well as the lack of studies on the theme, the knowledge and investigations accumulated and published on the phenomenon of non-psychotic denial of pregnancy from other areas will not be discarded.

The nomenclature of this phenomenon, both in English and in French (Deni de grossesse), does not come from a psychoanalytical conception. Nevertheless, if we consider the psychoanalytical contributions, would the situation in which women are unaware that they are pregnant be only a denial? We only say denial as this defense mechanism does not portray the significance and complexity involved in the cases of women who go through most part, or the whole of gestation, without knowing they are carrying another human being. Some authors consider that the mechanisms of disavowal and splitting of the ego are involved in the non-psychotic denial of pregnancy (Chaulet, 2011; Grangaud, 2001; Marinopoulos & Nisand, 2011).

The theoretical path made by Freud to support the concept of disavowal of reality starts with the texts on castration theory (Laplanche & Pontalis, 1982). However, it is during the period between 1924 and 1928 that Freud starts to explore the process of this psychic mechanism named Verleugnung, in his text "An Outline of Psychoanalysis", in which he presents a more complete and deeper study of the process. Freud (1923/1974), in "The Infantile Genital Organization of the Libido", uses disavowal when referring to castration. A boy discovers the phallus is not present in every peer, since it is through experiences with the opposite sex that the boy perceives the absence of the penis, but he disavows (leugnen) this absence, and he sees a member. He reduces the contradiction between what he sees and what he expects, by the subterfuge that the member is small and will develop (Freud, 1923/1974). In "Some Psychological Consequences of the Anatomical Distinction between the Sexes", Freud (1925/1974) states that, in children, the disavowal in relation to the lack of a penis does not seem rare, nor too dangerous, but in adults, it would initiate a case of psychosis.

In "Fetishism", Freud (1927/1974) claims the fetish ends up being, facing castration, a defense mechanism in which the disavowal and the recognition of the feminine castration coexist and, therefore, the children could bristle a part of their narcissism (Safatle, 2010). This coexistence triggers a splitting of the ego into two parts, which do not influence each other, protecting the subject from the fear and the horror of castration, while maintaining the narcissistic integrity. Still, regarding the impact that the disavowal has and its participation in the splitting of the ego, both in fetishism and in psychosis, in "Splitting of the Ego in the Defensive Process", Freud (1938/1974) asserts that, before a situation in which children have an instinct request that they constantly satisfy and, when faced with an experience that says they cannot satisfy themselves the way they were doing, and which will result in a real and painful situation, children can take two different paths: either to refuse the instinct satisfaction, or to reject the reality and preserve the satisfaction. However, in some situations, children do not give up one of the possibilities, ending up taking both paths, and, with the help from certain mechanisms, they reject reality and refuse to accept any prohibition (Freud, 1938/1974). In other words, they recognize the danger of reality and assume the fear of this danger as a pathological symptom, trying, thus, to get rid of this fear. The parts in disagreement reach what is desired, even if this has a great consequence to the subject, as it opens a split in the ego.

Goncalves and Macedo (2011) understand the non-psychotic denial of pregnancy from the psychic disallow mechanism. This mechanism is proposed by the psychoanalyst Luis Claudio Figueiredo from Freud's psychic mechanism Verleugnung, to explain fetishism and psychosis (Laplanche & Pontalis, 1982). Figueiredo (2008) proposes the disallow mechanism to amplify its application, going beyond the pathologies first introduced by Freud and which have the mechanism of Verleugnung at its center.

The path developed by Figueiredo (2008) on this concept extends from his clinical experience with patients who have a fine capacity of observation, and who reveal quite peculiar characteristics in their mental functioning. Figueiredo (2008) perceived that these patients have a capacity of registering and storing important aspects of the external and internal realities in which they evolve; similarly, they can communicate clearly what they can capture in others and in themselves, along with different life situations they went through, especially in more complex, painful experiences (Figueiredo, 2008). Despite this condition, paradoxically, these patients tend not to consider the consequences of all these elements, and they are not able to link one into the other to form a more or less integrated and conclusive view of the external and of their own reality. This situation means these patients cannot, from these isolated scenes, build and relate the associative links, which would result in consistent reports, able to give a certain sense to their lives and their ailments.

The proposition of Figueiredo (2008), named disallow, is not linked to a diagnosis of psychosis or perversion, but, on the contrary, prioritizes the psychic condition involved in the non-establishment of transitive links generated by a perception. Thus, a psychic dynamic is demonstrated, which, when not authorizing the perception, prevents the associated links from elapsing, which would lead to the recognition of the effects of such consciousness.

In associating the non-psychotic denial of pregnancy phenomenon with the disallow mechanism, we perceive the disallow mechanism of the perceptive links related to the cases of women who are unaware that they are pregnant, not perceiving typical symptoms of pregnancy at the beginning of the gestation period. However, what would prevent the associative links to gather in order to form a greater thought that would then lead to the awareness of pregnancy?

Goncalves and Macedo (2012b) consider that, at the root of this phenomenon, lies a traumatic event, which would explain why women who experience non-psychotic denial of pregnancy cannot consciously accept the fact they are pregnant. Bonnet (1993) proposes the concept of "unthinkable pregnancy", which supports the idea of a traumatic condition. Bonnet (1993), a French pioneer, who has dedicated several years to the phenomenon of denial of pregnancy, interviewed several women who experienced this situation.

After conducting the interviews, the researcher left the room with the impression that the women had been talking about their pregnancies as though it were disconnected from sexual intercourse; in other words, these women de-potentiate the sexual act as possible fecundation. The denial of pregnancy is serving, in these cases, as a shield against a traumatic condition, as recognizing the sexual act would provoke an intense anxiety. Denial of pregnancy is followed by a denial of the potentiality and the possibility of fecundation. This condition is invoked by Bonnet (1993) as a childhood trauma, and the pregnancy would bring back this trauma to a woman's reality. The author notes that, in these women's lives, there was a sexual intrusion in their mental apparatus made by their parents when they were children, and also some paradoxical behavior related to sexuality made by their parents. Their parents might have shown an excessive exhibitionism and, at the same time, very strict parenting manners related to sexuality. In these family models, the author found many aspects which are similar to incestuous and violent family models, and 20% of the sample had suffered sexual abuse from their fathers. Some characteristics were evident: there was no possibility of talking about sex, as well as some confusion related to generational gap and sexual identity, and also negligence of physical needs of the children. When these women began their sexual life (genital), the traumatic experience of the past caused great damage, transforming their sexual experience and its developments--pregnancy, for example--into something unthinkable.

In his discussion of psychopathological structure, Chaulet (2011) considers that non-psychotic denial of pregnancy is related to the borderline issue. Goncalves and Macedo (2012b) propose some theoretical considerations on this denial of pregnancy and on borderline cases. Lerner (2009) states that borderline patients are characterized as people who regress very easily to the primary process. This characteristic may mislead some psychoanalysts to think that they are facing a psychosis disorder. The difference between borderline and psychotic patients is that borderline patients regress to primary process momentarily, and this use is somehow an answer to a situation in which the ego lives a traumatic situation and cannot run the content according to a secondary process because the symbolization is absent.

Rother Hornstein (2009) states that borderline patients struggle to recognize otherness, not only in the analytical setting, but also in their circle of peers: friends, family, etc. This deficit on otherness in situations of non-psychotic denial of pregnancy is proposed by Goncalves and Macedo (2012b), based on the concept described by Moraes and Macedo (2011), called "Indifference Experience". The indifference experience is based on Freudian contributions in the text "The project for a scientific psychology" (Freud, 1895/1974), concerning the concept of the experience of satisfaction. When a baby is born, they are purely instinct, which must cease, because it increases the excitation on the mental apparatus, resulting in displeasure, and when the mother, or someone who performs this function, carries out a specific action - breastfeeding the hungry baby, for example - this excitation is reduced. The reduction of excitation on the mental apparatus generates pleasure and records an experience of satisfaction onto it. The indifference experience is the opposite of the experience of satisfaction. In the latter there is an ineffective specific action; the mother does not recognize the other in its existence and its own difference. This experience will configure an indifference matrix, which will be reproduced by the subject in the relationship with other subjects (Moraes & Macedo, 2011).

Conclusions

Considering that non-psychotic denial of pregnancy is not a rare phenomenon; taking into account the important deficits that it produces in the physical and psychological health of these women; bearing in mind the complications to a baby's health as well as the consequences in the relationship and bond between a mothers and children, it is important to explore and to investigate the psychic dynamics through more psychoanalytical essays and papers in order to better understand this phenomenon. Furthermore, it is important to implement an appropriate and professional care for this kind of occurrence, in order to help mothers and babies in this sensitive situation (Jenkins et al., 2011). Psychoanalysis is an essential tool to understand this phenomenon because it does not consider an ailment with a linear causality and it always highlights the complexity of the human psychic.

Psychoanalysis provides, through its theoretical framework, possibilities of thinking a possible practice for the cases which women do not recognize their own pregnancy. A practice which covers non-psychotic denial of pregnancy is fundamental, once it enables both mothers' and babies' rescue from an ignorance and abandonment place.

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Accepted: 03/11/2014

Thomas Gomes Goncalves

Monica Medeiros Kother Macedo

Jaqueline Conz

Universidade Federal do Rio Grande do Sul, Brazil
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Author:Gomes Goncalves, Thomas; Kother Macedo, Monica Medeiros; Conz, Jaqueline
Publication:Revista Interamericana de Psicologia
Date:Jan 1, 2014
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