Man, I Feel Like a Woman
Alexandra Romanov was a woman plagued by health issues. Headaches. Fatigue. Sciatica. Cardiac problems. As the stress in her life increased, so too did the quality and quantity of her ailments. I cannot say that the illnesses she endured were not real. In fact, I want to caution against making such an assumption. For centuries, we have treated the health of women differently from that of men. Despite their ability to endure pregnancy and delivery, the pain of women is often minimized. Even today, studies show that women are more likely to be prescribed sedatives than pain killers when compared to men with the same symptoms, and it takes longer for women to receive medication in emergency rooms. This bias is rooted in stereotypes about women that have persisted since Eve bit the apple. So I want to respectfully acknowledge Alexandra’s experience as a woman suffering from chronic pain and illness. But I would like to consider the possibility that her true suffering came not from the bodily discomfort she felt, but from the way in which she experienced it psychologically.
Pain, Pain, Go Away
Perhaps you’re familiar with the term hypochondriac. Often unsurprisingly directed toward women, it connotes a frail, sickly person who is terrified of illness and constantly convinced of their own bodily demise. This term has come to be so stigmatizing that our good friend the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) decided to give it a rebrand from “hypochondriasis” to “illness anxiety disorder” under the larger branch of somatic symptoms and related disorders. Diagnosis of somatic symptom disorder (SSD), the artist formerly known as “somatoform disorder” or just plain “hysteria”, was once characterized by complaints of physical ailments without an apparent medical explanation. Under the DSM-5 revisions, emphasis has shifted from the actual physical symptoms – commonly gastrointestinal, sexual, neurological, and cardiovascular problems and pain – to focus on the mental distress that they elicit. SSD patients have multiple physical (aka somatic) symptoms and are preoccupied with their health. Illness anxiety disorder is similar, but more exaggerated. These patients are completely focused on their ailments, which are often mild or nonexistent, are well versed in medical terms and concepts, are concerned about developing a serious illness, and have high levels of anxiety related to their health.
Somatic disorders affect women ten times as much as men, especially those with low socioeconomic status. Individuals with depression or anxiety, or certain diseases like irritable bowel syndrome or fibromyalgia are more at risk. Environmental factors like abuse, neglect, and life stress can also instigate onset, which can happen at any age.
From the illnesses that took her mother and siblings, to Alexei’s hemophilia which threatened the future of their family, to her own bouts of pain, sickness seemed to surround Alexandra. Additionally, hemophilia was not the only thing that ran in the family. Her mother’s sister, Princess Helena, was also accused of hypochondria, and became addicted to opium. Alexandra’s other aunt, Beatrice, was reported to have rheumatism. And her niece, Princess Alice of Battenberg (mother of Queen Elizabeth II’s husband, Prince Philip!), was committed to an institution with a diagnosis of schizophrenia. Her mother and grandmother were also known to be moody. Alexandra came from a long line of complicated and powerful women. While genetics are only estimated to contribute 7-21% of your risk for developing a somatic disorder, I think it’s worth considering how the illnesses of her loved ones may have shaped her.
I’m not going to debate whether or not Alexandra’s pain had a medical cause, and luckily the DSM-5 says I don’t have to. What I am arguing is that her anxiety about and preoccupation with health is consistent with SSD. Her diaries were filled with her careful notes, “chronicling her every-mutating neurotic and physical illnesses – sciatica, headaches, backaches, leg aches, angina, grading the gravity of her enlarged heart from Number One (slight) to Number Three (severe)” (Montefiore). This level of detail, attention, and habit suggest that a diagnosis of illness anxiety disorder could be warranted. Her close friend, Lili Dehn, recalled that “mental worry had increased her heart trouble,” consistent with studies illustrating the link between psychosocial factors and somatic disorders. Moreover, there is the fact that her lack of control led her to seek alternative help in healers like the controversial Rasputin when doctors failed to give her the answers she desired. One biographer reports that Alexandra’s physician diagnosed her with “progressive hysteria,” or hypochondria, cementing her dependence on alternative medicine (Erickson).
Even so, I found myself wanting to resist labeling Alexandra with a diagnosis that, despite the DSM’s best efforts, is so disparaging. But I think there’s one piece of historical evidence that makes the possibility that she suffered from a somatic disorder too hard to ignore. And that’s the mother of all somatic symptom and related disorders: the phantom pregnancy.
The first case of false or phantom pregnancy, known scientifically as pseudocyesis, was recorded by Hippocrates in 300 BC. While less common now due to modern pregnancy testing and reduced pressure on women to reproduce, it still occurs. Pseudocyesis is when a woman believes she is pregnant due to physical changes like amenorrhea (lack of menstruation), enlarged breasts, expansion of the abdomen, and nausea, but is not carrying a child. Diagnosis of pseudocyesis requires ruling out three other possibilities. First, the woman cannot believe she is pregnant in the absence of physical changes. That is actually a delusion associated with schizophrenia, and Alexandra was definitely not schizophrenic. Second, she cannot know she is not pregnant and claim to be so, which would be an intentional deception à la Mr. Schuester’s wife in “Glee.” Lastly, there can’t be a physical explanation, such as a uterine tumor, for the physical changes indicative of pregnancy. That’s what is known as false pseudocyesis (false false pregnancy).
Unlike the ancient perception of pseudocyesis as something afflicting infertile or menopausal women grieving the loss of their fertility, modern reviews show that the average patient is in their 20s or 30s, married, and already has children. That’s three checks for Alexandra. In addition, one study found a third of women who had false pregnancies were terrified of having a child, while the other two-thirds had a desperate desire for one. Given that pressure was mounting on Alexandra to give Russia a male heir, it seems she would fall into the latter category. Moreover, false pregnancy has been associated with grief, need for affection, and desperation to fulfill a partner’s desire for a child. These all sound like Alexandra to me.
In August 1902, Russia was expecting an imminent announcement of the birth of a new royal child, hopefully a boy. But their hopes were dashed when a statement was released indicating Alexandra suffered a miscarriage. Despite this story, the belief has persisted for over a century that Alexandra was never actually pregnant at all, she only believed she was. Private correspondence from her doctors to Nicholas says that when Alexandra underwent labor, she passed what they believed was a tumor formed from a non-viable embryo, known as a molar pregnancy. I’m not going to get into the nitty gritty about this diagnosis, but I have some doubts about its validity given Alexandra’s case doesn’t seem to be consistent with the normal symptoms. Moreover, Nicholas’ uncle wrote that the doctors said there was never a pregnancy, only symptoms of anemia resulting in her belief that she was carrying a child. One of Alexandra’s closest friends, Grand Duchess Xenia, also wrote in her memoir that it was indeed a phantom pregnancy. So I’m willing to consider that what Alexandra experienced was pseudocyesis, an extension of her existing somatic disorder. That being said, how is it possible that the body gives all the signs of pregnancy without the actual pregnancy part?
Maybe you’ve heard of the mind-body connection. Far more than some hand-wavey sentiment your yoga teacher might throw out, it’s an important framework for understanding how the body impacts the brain and vice versa. There’s nothing I can think of that illustrates this better than pseudocyesis.
Many of the symptoms of false pregnancy, like loss of period and breast growth, point directly to the pituitary gland: a pea-sized ball in your brain that acts as the master controller of all the hormones in your body. Modern studies of cases of pseudocyesis have confirmed that hormonal changes, including increased levels of prolactin and luteinizing hormone (LH), produce the physical changes consistent with pregnancy. Stick with me here as we review your 9th grade health class curriculum that you most certainly did not pay attention to.
Let’s start with the prolactin. This is the hormone that stimulates breast milk production, and during pregnancy causes the mammary glands to enlarge in anticipation of breast-feeding. Elevated levels in a nonpregnant woman could therefore lead to tender and swollen breasts, mimicking pregnancy. Then we have LH, which works in tandem with other hormones to drive the menstrual cycle forward. Without giving you the full rundown on how the female reproductive system works, the part that’s important to understand is that if LH levels remain high, as they do in patients with pseudocyesis, progesterone also stays high. When progesterone stays high, it signals to your body, “Don’t menstruate! You’re pregnant!” But, of course, in this case, you aren’t.
Okay, so your body is receiving the hormonal signals that you are pregnant and acting accordingly. But what’s causing the hormonal disruption in the first place? That’s where the brain really comes in. Interestingly, many of the women who have pseudocyesis are suffering from depression or chronic stress, much like Alexandra was. In both of these conditions, people have lower levels of neurotransmitters, the chemicals neurons use to communicate, called dopamine and norepinephrine. These have important roles in wakefulness, reward, pleasure, and more, explaining how they are involved in altered mood. But importantly, they also have key roles in modulating pituitary activity by inhibiting the release of hormones such as, you guessed it, prolactin and LH. This means that changes in the brain due to depression and stress cause increased LH and prolactin release, eventually producing physical changes consistent with pregnancy.
Interestingly, pseudocyesis happens often in dogs, perhaps for an evolutionary benefit, and researchers have found that giving dogs drugs to mimic dopamine signaling can reverse the false pregnancy, reinforcing the neuro-endocrine hypothesis. Additional support for this theory comes from observations that when a woman experiencing false pregnancy is put under anesthesia, her expanded abdomen immediately returns to normal, which could be explained by norepinephrine. While depression and stress decrease the levels of norepinephrine in the brain, they increase its presence in the rest of the body, leading to an increased “fight or flight” response through the sympathetic nervous system. The sympathetic nervous system controls muscles, including abdominal muscles and the diaphragm, which could produce the mystifying expanded abdomen in pseudocyesis. But, anesthesia alters sympathetic signaling, explaining why the abdomen immediately deflates when patients are sedated.
Together, these experimental findings give credence to the idea that the isolation, scrutiny, and anxiety that came along with being the Empress of Russia produced biochemical changes in Alexandra’s brain that in turn affected her hormones, ultimately resulting in a false pregnancy.
It’s All in Your Head
Back to the mind-body connection. We have seen that Alexandra’s life stress could have disrupted neurotransmitter levels, which in turn would lead to altered hormonal levels, leading to physical symptoms of pregnancy. But how do those physical changes in turn have an effect on the brain? Remarkably, pseudocyesis resolves itself immediately once the woman realizes she isn’t pregnant (typically from ultrasounds these days). As soon as they are confronted with the truth, their body responds to match that reality, suggesting that conscious awareness of and belief in pregnancy is needed to maintain the physiological roots of pseudocyesis. This beautifully illustrates how much our brains can affect our bodies, and how our bodies affect our brains in turn.
So to sum it all up, a combination of Alexandra’s temperament, background, and stressful lifestyle produced an abnormal preoccupation with her own health, characteristic of SSD, or illness anxiety disorder, depending on how far you’re willing to go. In addition, the intense pressure on her to produce a male heir led to a different manifestation of her illness, in which she genuinely believed she was pregnant in the absence of a baby.
From the beginning to the end, physical health ruled Alexandra’s life. The last Empress of Russia is often villainized, belittled, and loathed in the pages of history, and for the most part, I think she was misunderstood. However, I think there is something to the belief that she was a “hypochondriac.” Unfortunately, her health-related anxiety, the false pregnancy, and the dependence on Rasputin that they created had detrimental effects on popular opinion of the empirical family. Next week, Stefanie will tell us just how that all panned out.
For other historical references, see last week’s post, ”’Til Death Do Us Part”
Creed, F., & Barsky, A. (2004). A systematic review of the epidemiology of somatisation disorder and hypochondriasis. Journal of Psychosomatic Research, 56(4), 391–408. doi: 10.1016/s0022-3999(03)00622-6
Dehn, Lili. The Real Tsaritsa. Bob Atchinson, 2011. First published 1922 by Thornton Butterworth. http://www.alexanderpalace.org/realtsaritsa/.
D’Souza, R. D., & Wooten, W. M. (2019). Somatic Syndrome Disorders. In StatPearls. Treasure Island, FL: StatPearls Publishing.
Erickson, Carolly. Alexandra: The Last Tsarina. New York, NY: St. Martin’s Press, 2001.
Kenner, W. D., & Nicolson, S. E. (2015). Psychosomatic Disorders of Gravida Status: False and Denied Pregnancies. Psychosomatics, 56(2), 119–128. doi: 10.1016/j.psym.2014.09.004
Kiesel, L. (2017, October 7). Women and pain: Disparities in experience and treatment. Retrieved April 30, 2020, from https://www.health.harvard.edu/blog/women-and-pain-disparities-in-experience-and-treatment-2017100912562
Tarín, J. J., Hermenegildo, C., García-Pérez, M. A., & Cano, A. (2013). Endocrinology and physiology of pseudocyesis. Reproductive Biology and Endocrinology, 11(1). doi: 10.1186/1477-7827-11-39Winter, Adria O. (2018). Somatoform Disorders. In Rosen’s Emergency Medicine Concepts and Clinical Practice(9th ed., pp. 1358–1360). Eselvier.
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