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ISSN: 2574 -1241
ISSN: 2574 -1241
Received: July 30, 2024; Published: August 07, 2024
*Corresponding author: Morales Miró Quesada Haydee, M.Sc. Biochemistry and Nutrition, master’s degree in Eating Disorders, Spain
DOI: 10.26717/BJSTR.2024.58.009097
Eating disorders (EDs) impact physical, emotional, and social health. The perinatal period, including pregnancy and the first postpartum year, is high-risk for EDs due to hormonal and psychosocial changes. However, symptom remission can also occur, influenced by hormonal factors, social support, and maternal motivations. This case study examines a woman diagnosed with Bulimia Nervosa (BN) who experienced remission during pregnancy. Semi-structured interviews identified protective factors: motivation for fetal well-being, self-care, and social support. The findings indicate that prenatal care and social support are crucial in reducing BN symptoms during pregnancy. A multidisciplinary approach involving medical, psychological, and nutritional support is essential for managing EDs in pregnant women. These results underscore the importance of targeted preventive and therapeutic strategies to improve maternal and fetal health.
Keywords: Eating Disorders; Case Report; Protective Factors; Psychosocial Factors; Bulimia Nervosa Symptoms; Bulimia Nervosa Remission
Abbreviations: ED: Eating Disorders; BN: Bulimia Nervosa; BED: Binge Eating Disorder; AN: Anorexia Nervosa; DSM-5: Diagnostic and Statistical Manual of Mental Disorders
Eating disorders (EDs) are severe mental illnesses characterized by dysfunctional eating behaviors and a distorted body image. They primarily affect women of reproductive age, suggesting an etiology linked to the female sex [1]. Over the past three decades, the prevalence of EDs has increased significantly, constituting a public health issue that requires global intervention and prevention efforts [2]. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) identifies three primary ED diagnoses: Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Binge Eating Disorder (BED). These disorders profoundly impact the physical, emotional, and social health of affected individuals and are associated with adverse consequences, including severe medical complications and social effects. The etiology of EDs is complex, encompassing biological predisposition, environmental and sociocultural factors, neurobiological influences, and psychological factors [3]. The perinatal period, which includes pregnancy and the first postpartum year, is particularly critical for women in terms of EDs. Expectations of rapidly regaining pre-pregnancy body shape can lead to significant body image dissatisfaction [4]. Additionally, hormonal, neurobiological, and psychosocial factors during this period may increase vulnerability to EDs or exacerbate existing symptoms. Conversely, some women may experience partial or complete remission of symptoms due to specific protective factors during the perinatal period.
This study focuses on identifying protective factors during the perinatal period that influence the remission of ED symptoms, specifically Bulimia Nervosa, and developing preventive measures to avoid symptom recurrence. Investigating this phenomenon can provide valuable information for developing therapeutic and preventive interventions targeted at women at risk during the perinatal period.
The patient, a 26-year-old pregnant female with a BMI of 17.5 diagnosed with Bulimia Nervosa, meeting the DSM-5 criteria, which include recurrent episodes of binge eating, feeling of lack of control over food intake during the episode, and recurrent inappropriate compensatory behaviors, occurring at least once a week for three months. The 26-year-old woman since the diagnosis at age 14, had received psychotherapeutic and psychiatric treatments, including hospitalizations in a private clinic for psychiatric disorders and addictions. The young woman, who had a long history of eating disorders, experienced intermittent periods of symptom improvement and deterioration. Complete remission was achieved only on two occasions: during a three-month hospitalization with continuous monitoring and during a voluntary admission to a religious community in Florida, USA. Throughout nearly thirteen years of treatment, the patient maintained a persistent focus on controlling food intake and body weight. At age 25, she became pregnant with a desired child and experienced a miscarriage before the 10-week mark, prompting her to consider the potential impact of her bulimic behaviors on the loss. Following this, she conceived again at age 26 and, notably, abstained from vomiting and compensatory behaviors throughout the remainder of the pregnancy. She successfully carried the pregnancy to term, delivering a 3.5-kilogram infant, whom she exclusively breastfed for five months. This case was selected for its relevance in studying protective factors for eating disorders during pregnancy.
To investigate the factors that may have influenced the remission of bulimic symptoms during the patient’s pregnancy, a series of semi-structured interviews and recall stimulation techniques were administered. These methods allowed for a detailed exploration of potential protective factors during the perinatal period. The interviews provided qualitative insights into the patient’s experiences and perceptions, while the recall stimulation techniques helped identify and analyze changes in behaviors and contextual factors associated with symptom remission.
Through interviews and memory-evocation techniques several factors were examined.
Body Dissatisfaction
Prior pregnancy patients reported significant dissatisfaction with their body, engaging in frequent self-checks and negative self-perception. In contrast during pregnancy self-perception improved; patients accepted weight gain as a natural part of pregnancy and felt positive about their pregnancy belly. During postpartum patient experienced increased comfort with her body and reduced self-checking behaviors, noticing changes but accepting them as part of motherhood. Eating Behaviors prior to pregnancy were characterized by restrictive eating, bingeing, and purging with associated guilt. During Pregnancy evident increase in enjoyment of food was experienced including indulgence in less nutritious options. Significant reduction in purging behaviors. During post-partum enjoyment of food was still present with less severe purging compared to pre-pregnancy. However, occasional purging resumed due to emotional stress. Psychosocial Support and Religiosity were also shown to play a role in the patient´s bulimic symptoms remission. Patient experienced strong support from her workplace and therapist but lost access to therapy post-pregnancy. Her husband’s support was crucial during pregnancy. Religiosity had been an influential factor for remission some years before when the patient lived in a religious community. Even though patients recognize the strength she found in her religious beliefs during pregnancy and postpartum periods, the role of religiosity in the perinatal period was less directly influential compared to other support forms. The concern for the fetus and maternal health prior pregnancy showed strong correlations since the patient expressed an important sense of guilt over a previous miscarriage, linking it to her bulimic behaviors. During the pregnancy months the patient experienced increased awareness and concern for the fetus what led to healthier behaviors and a reduction in bulimic symptoms. During the postpartum months patient maintained her focus on baby’s health, continuing with positive behaviors despite minor relapses in bulimic symptoms (Table 1).
Table 1: Coincidence of the categories identified in the instruments applied.
Eating disorders (EDs) are serious mental health conditions characterized by dysfunctional eating behaviors and distorted body image [5]. Bulimia Nervosa (BN) involves recurrent episodes of excessive food intake followed by inappropriate compensatory behaviors, such as self-induced vomiting, excessive use of laxatives, fasting, or excessive exercise [6]. BN significantly impacts the physical and mental health of women of childbearing age and managing it during pregnancy presents unique challenges. However, pregnancy can also offer an opportunity to improve eating patterns and even achieve remission due to protective factors [7,8]. Historical data shows that less than 50% of patients achieve full remission, with around 30% experiencing residual symptoms and 20% developing chronic illness [9]. Pregnancy naturally alters body shape and size, potentially altering body perception. For some women, these changes can reduce excessive concern about weight and shape, perceived as a normal part of pregnancy. This shift in body perception can decrease body dissatisfaction, a common trigger for bulimic episodes. Some women show increased self-compassion and acceptance of bodily changes during pregnancy, in contrast to their previous self-criticism. Studies suggest that body functionality and flexibility in body image can protect against disordered eating during pregnancy [10]. Additionally, focusing on the body’s role in nurturing new life may replace concerns about appearance, contributing to BN remission.
Pregnancy can enhance motivation for healthier behaviors due to concern for fetal well-being [11]. The responsibility of ensuring optimal fetal development may lead women to prioritize proper nutrition and avoid harmful behaviors like self-induced vomiting or laxative use [12]. This intrinsic motivation to protect the fetus can be crucial in BN remission [13]. In some cases, the guilt from a previous loss motivates to avoid bulimic behaviors, leading to an absence of binging and purging during the subsequent pregnancy. Social support is another significant protective factor during pregnancy. It plays a critical role in the recovery from EDs regardless of age [14]. Support from family and friends can influence ED behaviors and thoughts, offering emotional, tangible, and informational support that mitigates the negative impact of symptoms and aids recovery [15]. The given support from partner, workplace, and psychotherapists are crucial during the prenatal period. A multidisciplinary approach is essential for the remission and prevention of EDs during pregnancy, addressing psychological, social, and endocrinological factors [7,16]. This approach should include nutritional support, psychotherapeutic techniques, and, if necessary, psychotropic medication. Early intervention strategies are recommended for women with a prior ED diagnosis [17]. Additionally, religious involvement can offer emotional support and promote healthier lifestyle choices, reducing bulimic episodes [18]. Some patients can benefit from their religious community and support system, which helps avoid bulimic behaviors.
Psychosocial factors such as self-esteem, life satisfaction, and mood symptoms are significantly associated with BN during pregnancy [19]. Therapeutic interventions targeting these factors can be beneficial. Although literature describes both the potential exacerbation and remission of ED symptoms during pregnancy, relapse rates are notable. About 25% of patients who were in remission before becoming pregnant relapse within the first 20 weeks of pregnancy or the first 8 weeks postpartum [20]. It is observed that relapses often correlate with severe postpartum depression and hyperemesis gravidarum [20]. Self-compassion has emerged as a potentially influential factor in reducing BN symptoms [21]. It involves self-kindness and recognizing personal suffering as part of the human experience [22]. Patients exhibiting increased self-compassion during pregnancy and postpartum show reduced bulimic behaviors. Research supports the idea that self-compassion can enhance body image and reduce the severity of bulimic symptoms [23]. Pregnancy can be both a challenge and an opportunity for women with BN. Multidisciplinary care, including nutritional, psychological, and social support, plays a crucial role in managing and potentially remitting symptoms. Continued support and therapeutic interventions are essential for maintaining improvements and addressing any relapses that may occur.
This case study highlights the significant role of protective factors in the remission of Bulimia Nervosa during pregnancy. The findings emphasize that a combination of increased motivation for fetal well-being, improved self-care practices, and robust social support are crucial in mitigating ED symptoms. The experience of the patient underscores the importance of a multidisciplinary approach, integrating medical, psychological, and nutritional support, to effectively manage EDs during pregnancy. These insights can inform future preventive and therapeutic strategies, aiming to enhance maternal and fetal health while addressing the complexities of eating disorders in the perinatal period.
The authors declare that there are no conflicts of interest to disclose regarding the publication of this article.
Abstract
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