Psychosomatics 44:76-78, February 2003
© 2003 The Academy of Psychosomatic Medicine
Worsening of Symptoms of Bulimia Nervosa During Pregnancy
Rupert Conrad, M.D.,
Jörg Schablewski, M.D.,
Guntram Schilling, M.D., and
Reinhard Liedtke, M.D.
Received Jan. 4, 2002; revised May 20, 2002; accepted June 11, 2002. From the Department of Psychosomatic Medicine and Psychotherapy, University of Bonn. Address reprint requests to Dr. Conrad, Department of Psychosomatic Medicine and Psychotherapy, University of Bonn, Sigmund Freud Str. 25, 53105 Bonn, Germany; cr.bonn{at}t-online.de (e-mail).
Bulimia nervosa in pregnancy has been the subject of several studies.1–4 Most studies evaluating the course of eating disorder symptoms during pregnancy have reported a substantial improvement in bulimic symptoms and, in the majority of cases, a return to prepregnancy symptom levels or even a worsening of symptoms in the postpartum period.1,3–6 However, the reasons for improvement of bulimic symptoms during pregnancy are not fully understood. Morgan and colleagues3 reported on 94 women for whom phenomenological descriptions of pregnancy suggested an alleviation of a sense of responsibility for body weight and shape. Furthermore, physiological changes in the course of pregnancy, such as changes in taste and smell7 and changes in satiety associated with an altered leptin level,8 may have important influences on feeding behavior.
Even more important than understanding improvement of bulimic symptoms during pregnancy is the need for insight into the reasons for lack of improvement or even worsening of symptoms during pregnancy. Such research is important not only because of the health risk for the fetus9 but also because patients with bulimia seem to have a higher risk of affective disorders after delivery, including postnatal depression.1,3
This case report discusses a woman with worsening bulimic symptoms during her third pregnancy.
Case Report
Ms. A was a 37-year-old white, married woman with a 20-year history of DSM-IV bulimia nervosa, purging type. She was transferred to our inpatient eating disorders unit because of a dramatic worsening of eating problems that had occurred in the first trimester of her third pregnancy (gravida 3, para 2). She reported having had up to 10 episodes of bingeing and vomiting weekly before her pregnancy and having exercised three times a week. At the time of admission to the hospital in the 20th week of gestation, she had a stable pattern of persistent food restriction, more than 30 episodes of bingeing and self-induced vomiting weekly, and intense preoccupation with body shape. (Her body weight was 54 kg, and her body mass index was 20.3 kg/m2). Furthermore, she reported a pattern of excessive exercise, including jogging daily for at least 2 hours. Physical and laboratory examinations showed extensive dental caries and iron deficiency anemia. Further psychodiagnostic investigation unveiled a difficulty in communicating emotions (20-item Toronto Alexithymia Scale10 sum score=62). Ms. A had clinically relevant high scores on all subscales of the SCL-90-R11 (Table 1). Furthermore, she met the DSM-IV criteria for dependent personality disorder. In childhood and adolescence, these dependent traits were reflected in submissive and clinging behavior toward her mother, who was described as "authoritarian and overprotecting." Her medical history showed no eating disorders or other psychiatric disturbances in her family.
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TABLE 1. Scores on SCL-90-R Dimensions Before and After 6 Weeks of Inpatient Integrative Psychotherapeutic Treatment for a Patient With Worsening Symptoms of Bulimia Nervosa During Pregnancy
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According to her eating disorder history, onset of bulimia nervosa occurred at age 17. At that time, body shape became very important to her because she planned to become a dancer and compared herself with other women who were already active dancers. At the beginning, bingeing and vomiting took place twice a week. When she began her dancing studies, Ms. A reported having felt an even greater pressure to be slim, and gradually the cycles of bingeing and self-induced vomiting increased in frequency and severity to a maximum of 10 episodes per week. During this time she felt it extremely important for her self-esteem not to weigh more than 50 kg. Her actual weight varied between 49 and 52 kg (body mass index=18.5–19.6 kg/m2).
Her bulimic symptoms remained unchanged, except during two pregnancies at age 31 and age 33. During both pregnancies the patient completely stopped bingeing and vomiting. However, bulimic symptoms immediately returned after each delivery. Ms. A reported that she could easily accept a weight gain of about 10 kg during these pregnancies, although after each delivery she felt it was important to reduce her weight quickly. After each of the two pregnancies, her weight varied between 50 and 53 kg (body mass index=18.9–20.0 kg/m2).
After the second pregnancy, the eating disorder led to many partnership conflicts. Ms. A was very dissatisfied with her role as mother and housewife and planned to work again as a dance teacher. Her husband did not support this plan and instead held the view that another child could possibly stabilize the partnership and might have a favorable effect on the eating disorder. Although Ms. A was "highly ambivalent" about becoming pregnant again, she agreed to have another child.
Ms. A became pregnant for the third time. However, from the very beginning she reported being "overwhelmed with feelings of fear and guilt" and "being unable to cope with the situation." Furthermore, a sonogram taken at the beginning of the second trimester by her obstetrician revealed a possible malformation of the fetus. Ms. A reported feeling "intense fear" and disclosed her eating disorder to her gynecologist. She underwent further sonograms and an amniocentesis during the 17th week of gestation. It took another 2 weeks before the patient could be informed of the results of the amniocentesis, which showed no sign of a malformation.
In the 20th week of gestation, Ms. A was admitted to the specialized eating disorder unit, where she received 6 weeks of integrative psychotherapeutic treatment that included psychodynamic and cognitive behavior elements. Her husband declined to take part in planned couples psychotherapy sessions. He told his wife that he did not want to talk to strangers about their personal problems. Therefore, it was necessary to implement an individual psychotherapeutic approach. While undergoing individual cognitive behavior psychotherapy, Ms. A learned to recognize dysfunctional thoughts about self-esteem, body shape, and size. She also learned to alter these thoughts by cognitive restructuring techniques. Furthermore, she was taught to express her negative feelings to her husband and to other people more appropriately. In psychodynamic group psychotherapy, Ms. A was able, for the first time, to express her ambivalent feelings concerning pregnancy.
During her hospital treatment, there was frequent collaboration between psychological and obstetric professionals. A prenatal vitamin and ferrous sulfate were prescribed as a daily supplement to her diet. Ms. A was gradually able to increase her caloric intake and decrease purging behavior, and after 5 weeks of hospital treatment she stopped bingeing and vomiting. Posttreatment scores on the SCL-90-R showed clinically significant reductions in psychopathological symptoms, although some symptoms remained clinically significant. The SCL-90-R global severity index and scores on eight of the nine SCL-90-R subscales showed clinically significant decreases after treatment (greater than one standard deviation). Scores on only four of the nine SCL-90-R subscales revealed clinically significant symptoms after treatment. After discharge from the hospital, the patient continued individual cognitive behavior psychotherapy and demonstrated a slow, steady weight gain without further bulimic symptoms. At term she had a normal spontaneous vaginal delivery of a 3100-g male infant with an Apgar score of 9 at 1 and 5 minutes.
Discussion
This 37-year-old patient suffered a worsening of bulimic symptoms in the first trimester of her third pregnancy. She had an extensive history of bulimia nervosa since adolescence. However, at the beginning of her two previous pregnancies, her bulimic symptoms had improved.
Regarding the psychological factors contributing to the worsening of bulimic symptoms during pregnancy, it is noteworthy that the patient was "highly ambivalent" about a third pregnancy, but she agreed to have another child. Dependent personality traits were reflected in this behavior because she avoided telling her husband about her ambivalent feelings for fear of losing his support.
From a psychodynamic point of view, the case history showed a family environment that impinged adversely on self-esteem and self-efficacy. Ms. A described her mother as authoritarian and overprotective and lacking in affection and empathy. In this environment, it was difficult for Ms. A to become aware of her own emotions and needs. This familial pattern may lead to alexithymic personality features and may hamper the development of an autonomous identity.
During psychotherapy Ms. A became aware of the conflict between her desire to be dependent and her desire to have more autonomy. The more she learned to understand this conflict and the negative feelings associated with it, the more she felt "in control of the situation" and capable of coping with pregnancy.
Obviously, the worsening bulimia nervosa symptoms were provoked by marital conflicts. The literature provides a clear indication that the partner should be involved in psychotherapy for an eating disorder when the patient is pregnant.12 However, as we experienced in several cases, the partner often lacks the motivation or is unwilling to take part in therapy. In these cases, it is necessary to use an individual approach that also focuses on the marital conflicts and enables the patient to learn problem-solving skills. Role playing can be used to provide practice with realistic yet controlled situations tailored to the individual needs of the patient. Thus, in cognitive behavior therapy, Ms. A played the role of both partners in typical conflict situations. In this way she improved her ability to express her emotions and needs to her husband.
The individual psychotherapeutic approach combining cognitive behavior and psychodynamic elements proved to be beneficial in reducing the patient's binge-eating symptoms and improving her attitude toward weight and restrictive dieting. Furthermore, the treatment succeeded in reducing psychopathological symptoms such as depression. Thus, even if the bulimic symptoms during pregnancy are provoked by marital conflicts and the partner is unwilling to take part in couples psychotherapy, an individual psychotherapeutic approach can be successful. Systematic studies are needed to further improve the treatment of these patients.
Another clinical issue in this case is that the diagnosis of bulimia nervosa was overlooked at the beginning of the pregnancy, even though Ms. A had clearly identifiable risk factors, such as her profession as a dancer. As Morgan13 found, many gynecologists and obstetricians have deficiencies in their knowledge about the clinical features and physical manifestations of bulimia nervosa. Frequent collaboration between obstetricians and eating disorders specialists is necessary to improve the understanding of bulimia nervosa and to enable early diagnosis and therapy.
REFERENCES
- Blais MA, Becker AE, Burwell RA, Flores AT, Nussbaum KM, Greenwood DN, Ekeblad ER, Herzog DB: Pregnancy: outcome and impact on symptomatology in a cohort of eating-disordered women. Int J Eat Disord 2000; 27:140-149[CrossRef][Medline]
- Franko DL, Blais MA, Becker AE, Delinsky SS, Greenwood DN, Flores AT, Ekeblad ER, Eddy KT, Herzog DB: Pregnancy complications and neonatal outcomes in women with eating disorders. Am J Psychiatry 2001; 158:1461-1466[Abstract/Free Full Text]
- Morgan JF, Lacey JH, Sedgwick PM: Impact of pregnancy on bulimia nervosa. Br J Psychiatry 1999; 174:135-140[Abstract/Free Full Text]
- Abraham S: Sexuality and reproduction in bulimia nervosa patients over 10 years. J Psychosom Res 1998; 44:491-502[CrossRef][Medline]
- Lemberg R, Phillips J: The impact of pregnancy on anorexia nervosa and bulimia. Int J Eat Disord 1989; 8:285-295
- Mitchell JE, Seim HC, Glotter D: A retrospective study of pregnancy in bulimia nervosa. Int J Eat Disord 1991; 10:209-214
- Fairburn CG, Stein A, Jones R: Eating habits and eating disorders during pregnancy. Psychosom Med 1992; 54:665-672[Abstract/Free Full Text]
- Butte NF, Hopkinson JM, Nicolson MA: Leptin in human reproduction: serum leptin levels in pregnant and lactating women. J Clin Endocrinol Metab 1997; 82:585-589[Abstract/Free Full Text]
- Conti J, Abraham S, Taylor A: Eating behavior and pregnancy outcome. J Psychosom Res 1998; 44:465-477[CrossRef][Medline]
- Taylor GJ, Bagby RM, Parker JDA: The alexithymia construct: a potential paradigm for psychosomatic medicine. Psychosomatics 1991; 32:153-164[Abstract/Free Full Text]
- Franke G: SCL-90-R: Die Symptom-Checkliste von Derogatis. Göttingen, Germany, Beltz Test, 1995
- Van den Broucke S, Vandereycken W, Norre J: Eating Disorders and Marital Relationships. London, Routledge, 1997
- Morgan JF: Eating disorders and gynaecology—knowledge and attitudes among clinicians. Acta Obstet Gynecol Scand 1999, 78:233-239
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