Adult Baby Syndrome and Gender Identity Disorder
Kristina Kise • Mathew Nguyen
Springer Science+Business Media, LLC 2011 Adult Baby Syndrome (ABS) has been reported now by several authors. Pate and Gabbard (2003) associated it with paraphilia and Croarkin,Nam,and Waldrep(2004) connected it to Obsessive–Compulsive Disorder (OCD). Evcimen and Gratz (2006) described a case that was associated with neither paraphilia nor OCD.Wepresent a case of ABS in a patient in which there did not seem to be a connection to either paraphilia or OCD,but, interestingly, the case was further complicated by gender identity issues.
Mr.B is a 38-year-old biological male who prefers to be identified as a female; therefore,Mr.Bwill further be referred to as Ms.B. She currently lives in a nursing home. She was first placed in a nursing home per her request after she was hospitalized with chest pain 2 years prior.She was referred for psychiatric treatment by her nursing home physician for evaluation of "delusions." Ms.B stated that she was born with both female and male reproductive organs, specifically,uterus, ovaries,andapenis,and claimed she was raised as a female. Her primary complaint during the evaluation was that the nursing home staff often addressed her as amale rather than a female.When this occurred, she became very upset and essentially had a temper tantrum,grabbing her chest,gasping for air, crying hysterically,yelling and cursing,and demanding to see a supervisor:" It takes an army of nurses to calm me down." Ms.Balso did not like male staff in her room because of a reported history of sexual abuse by an uncle at the age of 3. She also claimed physical abuse by a staff member in her previous nursing home who had allegedly hit, slapped, and punched her in the stomach.
Ms.B's other complaint was that she liked to be treated as a baby. The Certified Nurse Aide who accompanied her said she often regressed to an infant, particularly at night time.She used bottles, pacifiers, and baby-talk. She would rather have a crib than a bed.Ms.Bhad been engaging in these behaviors the last 2 years, but stated she had wanted to be a baby for the last 7 years. She said that the pacifier gaveher security.She wore a brief due to incontinence but insisted on calling it a diaper so she could be identified more as a baby. Ms.B stated she would like to be a baby because it relieved her of all her adult responsibilities. She felt she would not have to worry about anything as babies are innocent. She did not "want to growup." Often when asked a question, she prefaced her answer with "Well, as a baby" and then proceeded to answer the question.The patient stated,"For the record, I don't consider myself an adult. I would like to be treated as a baby, be re-taught,and be re-trained."She was very clear, however, that she knew she was not a baby.
Ms.B denied a history of depression.She reported as a teenager being placed on fluoxetine for 2 weeks but had not been on antidepressants since. However, her medical record indicated that she was currently on escitalopram 10mg daily.The patient denied taking any psychiatric medications and was very upset that this was on her medical record. She denied current depressive symptoms and suicidal ideation. Ms.Balso did not endorse any current subjective anxiety symptoms.She reported a history of sexual molestation and physical abuse; however, her symptomatology did not meet the level of Posttraumatic Stress Disorder. Other than this unusual desire to becomea baby, the patient did not endorse nor did she display other psychotic symptoms, such as auditory or visual hallucinations, paranoia, ideas of reference, thought broadcasting, thought insertion or disorganized behavior or speech. The patient reported being placed in a psychiatric hospital 8months prior because the nursing home did not want her anymore.She endorsed seeing an outpatient psychiatrist in 1994 for evaluation for gender reassignment surgery and was reportedly approved for surgery, but had yet to have the surgery for unclear reason. The patient reported having Guillain–Barre syndrome at the age of 13 that required a tracheotomy and left her paraplegic.
The patient reportedly graduated high school and then obtained amaster’s degree in architecture.She had been unemployed for 11 years.She stated that she quit working because of arthritis in her hands and was currently on disability for this.Both parents were deceased.Ms.B had never been married.She reported dating amale in high school, but her sexual orientation was not specified. Prior to living in a nursing home, she was living in a group home. She had only been in her current nursing home for the last 3 months.Prior to that, she was living out of state in another nursing home.
On mini-mental status testing,Ms.B scored a 25 out of 27. She could not spell "world." Her sentence was, "I am a baby. Girls." She appeared somewhat older than her stated age. She was alert and oriented. She sat in a wheelchair with her legs covered by a blanket. She was wearing feminine clothing and had chin-length hair,male facial features, and male body build with a deep voice and a notable tracheotomy scar. She had some abnormal movement of mouth and tongue consistent with tardive dyskinesia. She reported her mood as good, but her affect was somewhat bizarre.Her speech was of normal rate, rhythm, and volume. Her thought process was circumstantial. She was preoccupied with wanting to be a baby.
At the end of the initial visit, a diagnosis was not clear.She did not appear depressed or psychotic. There were noted inconsistencies at that time and collateral information was needed.We referred Ms.B for neuropsychological testing to aid in the diagnosis, specifically looking for cognitive functioning, effort, and psychosis.
After the initial appointment, records available from our psychiatric facility and the main hospital were reviewed. Many inconsistencies in the patient’s history and other pertinent data were discovered. Firstly, she was seen by Endocrinology in 2004 for gender reassignment. It is clearly stated that she is a biological male and changed her name to a female name in 2000.A recent ultrasound ordered by the nursing home physician clearly demonstrated only male anatomy.Furthermore, there were two psychiatric admissions in 2004 and 2006. She was admitted in 2004 for depression and, at that time, reported a past diagnosis of bipolar, 30 previous hospitalizations, and 28 previous suicide attempts. Her past psychiatric medications included Zyprexa, Lexapro, Paxil, and Prozac. She was discharged to a grouphome at her request.Her psychiatric admission in 2006 was again for depression. This time she reported a history of substance dependence for which she went to rehab at the ageof 24.She also endorsed sexual abuseby an uncle during this admission, but stated it was from the ages of 9–10 (rather than 3–4).The patient reported having only completed the 10th grade with special education on this admission. There was no mention on this or the previous admission of having a degree in architecture. She was living with a brother at this time and discharged home. It was noted during this admission that she was very demanding,manipulative, and attention seeking. The patient was admitted for chest pain in 2008 and, at her request,was only then admitted to a nursing home in 2008.
Ms.B was seen in our clinic for follow-up 4 weeks later.She had not yet had any neuropsychological testing. On this visit, she was focused on wanting to be taken off psychiatric medications and being allowed to assume the identity of a baby in the nursing home. She further clarified that she wanted to be a baby to escape reality when things go wrong or she has situations she doesn't know how to get out of. She was absolutely fixated on becoming an adult baby. She then reported a history of physical and sexual abuse by her parents,which she did not report at her last visit.Now, one may think she didn't feel comfortable discussing this in her first visit, yet she was comfortable discussing abuse by an uncle and a nursing home staff member in the previous visit.There were numerous inconsistencies.When presented with records demonstrating previous hospitalizations at our psychiatric hospital, a history of 28 suicide attempts, and the ultrasound results, she denied ever being admitted to the psychiatric hospital and was very angry, demanding to have copies of those records. She stated the ultrasound was wrong and that she did have female organs.Her story changed again and she stated she had been an adult baby since the teenage years. She also reported being raised as a baby until age 7.She denied ever having lived on her own, when, in fact, two discharge summaries clearly indicated that she did.She began requesting state hospital placement, implying that there she would be taken care of properly.During this appointment, it was also noted that there were no signs of lower extremity atrophy which would be consistent with paralysis. She also had poor eye contact throughout.At the end of the visit, she requested a 2 week appointment. It appeared she was interested inconvincing the interviewer it was acceptable to assume the identity of a baby in the nursing home.Again,we emphasized that we would like for her to obtain neuropsychological testing. She did not follow up despite attempts to call her nursing home.
Ms.B presents a diagnostic dilemmaina number of ways.Confounding the clinical picture may be issues of depression and anxiety. Her previous records of multiple psychiatric admissions and various psychoactive medications do hint to a past diagnosis of a mood disorder. Regarding her intense and persistent desire to be identified as a baby, the differential diagnoses may include Delusional Disorder,Dependent Personality Disorder, or even another personality disorder. The patient does not present with a fixed, false belief. She knows that she is not a baby, but would like to be treated as such. One could see how a past physician might have viewed her as psychotic and placed her on olanzapine given the intensity and bizarre nature of her desire to become a baby. Unfortunately, we did not have the records to review the context under which olanzapine was prescribed. Her changing stories and denial of past events, such as being in the psychiatric hospital multiple times, could suggest different personalities with different pasts.A further history would be needed to evaluate for dissociative symptoms. One would also need to consider pathological lying (pseudologia fantastica). This diagnosis would be favored over delusions, as the patient's story changed within a matter of minutes and weeks,whereas a delusion should be fixed. If we believed that the patient was lying, then malingering should also be considered. Malingering would be unlikely as it would be unclear what the patient's gain would be. Her wanting this level of nurturance could speak to a personality disorder (such as Dependent Personality Disorder); however, the focus on being treated as if she were a baby and acting as such (wearing a diaper, using a pacifier) is what is unusual, even in the context of depression and personality disorders. Perhaps desiring the identity of a baby is an entity all in itself, just like Major Depressive Disorder or Schizophrenia. Pate andGabbard (2003) suggested the name "Adult Baby Syndrome." It is also referred to as infantilism in the literature. This does not represent a new phenomenon, with some cases in the literature dating as far back as the 1960s. In some instances, ABS seems to represent a paraphilia.An online search reveals a number of websites regarding this, with those persons preferring to call themselves Diaper Lovers. It is often referred to as a diaper fetish in the scientific literature.Like paraphilia, it appears that most patients with ABS do not wish to change their behavior and therefore rarely seek psychiatric treatment. It does not appear, however, to be strictly a paraphilia for Ms. B. She specifically denied sexual pleasure, although we must admit she was an unreliable historian.Additionally, her primary intent seems to be one of gaining attention and additional care, freeing her from adult responsibilities.
Most cases of ABS present with identification of a desire to be a baby at a young age. Croarkin et al. (2004) reported a case of a 32-year-old male admitted for depression who had recurrent, intrusive, ego-dystonic thoughts and behaviors involving wearing diapers and becoming a baby. He also denied any sexual gratification related to these behaviors. They suggested it may be related to OCD.However, in the case of Ms.B, her thoughts and behaviors were ego-syntonic, which would go against a diagnosis of OCD.
Evcimen and Gratz (2006) described a 25-year-old male who wished to be a 10-year-old girl. Pettit and Barr (1980) described a case of 24-year-old man who began dressing in female clothes at the age of 10 and began to dress as a baby at the age of 15. Lehne and Money (2003) described a man with a changing fetish who ultimately considered himself an "adult baby" at the age of 45. His previous fetishes involved transvestic fetishism and pedophilia. Some noted similarities in these cases include a common past history of sexual abuse. Several share transgender issues and, notably, when dressing as a baby, they can dress in the opposite sex. However, few assumed a transgender identity whennot assuming a baby’s identity,which Ms.Bdid. Ms.B insisted on being addressed as a female, cross-dressed since childhood, took female hormones, and had requested gender reassignment surgery, suggesting a diagnosis of Gender Identity Disorder (GID). The gender issues seem to pre-date the ABS symptoms.Apsychodynamic explanation would be beyond the scope of this article; however,we may speculate the following: As few people in her life acknowledged her wish to assume a female identity, she may have suffered significant internal stress, which may have hampered her ability to psychologically develop appropriately. An inability to move through psychological developmental milestones may have led to this regression to ABS. Further investigation into the connection and potential co-morbidity between ABS and GID may lead to interesting findings. Clearly further information gathering and clarification would be needed to further understand Mr.B's presentation and pinpoint a diagnosis and/or etiology of this unusual behavior. Unfortunately, she did not show for her next two appointments and, to this date, has never followed up. |
