Donna E. Stewart

Anorexia nervosa, bulimia, and pregnancy.

Of 74 women previously treated for anorexia nervosa or bulimia, 15 had conceived 23 pregnancies when assessed at follow-up. The status of the eating disorder, course of pregnancy and delivery, infant health, and postpartum adjustment are described. Women in whom eating disorders were in remission at conception had greater maternal weight gain and babies with higher birth weights and 5-minute Apgar scores than women who conceived while they still had symptoms of restricting anorexia nervosa or bulimia. Women who had symptoms of eating disorders at conception also had continuance or worsening of these symptoms during pregnancy and the postpartum year. We recommend delay of pregnancy until the eating disorder is truly in remission.

Psychologic distress during menopause: associations across the reproductive life cycle

Objective: To determine if women with high psychologic distress attending a menopause clinic report more previous psychiatric disorders (especially depression), or psychologic distress associated with oral contraceptive use and reproductive cycle events than women with low psychologic distress attending the clinic. Method: Consecutive women attending a university hospital menopause clinic were administered the Brief Symptom Inventory (BSI). Women with high psychologic distress (who met case severity on the BSI general severity index) were compared to a similar number of the lowest scoring clinic women on their reports of previous psychiatric diagnoses and treatment, and depression or distress related to oral contraceptive use, the premenstrual period, or associated with pregnancy. Results: The forty-four women with high psychologic distress were significantly more likely than the forty-two menopause clinic patients with low psychologic distress to report a past psychiatric diagnosis (usually depression) (p = 0.001), requiring anti-depressant treatment (p = 0.002), oral contraceptive dysphoria (p = 0.004), dysphoric premenstrual syndrome (p = 0.000), postnatal blues (p = 0.02) and postpartum depression (p = 0.004). Conclusions: Although the halo effect of current distress or retrospective reporting may have biased these results, the similarity of ratings in the two groups on physical symptoms in menopause and psychologic symptoms during pregnancy makes this less likely. These findings corroborate other recent studies showing that women who suffer from affective disorders following one reproductive event are more vulnerable to recurrences associated with others. Clinicians should inquire about possible relationships between previous depression or psychologic distress and reproductive cycle events as it may help predict women who are vulnerable to affective disorders and psychological distress at these critical times.

Infertility and eating disorders

Sixty-six consecutive infertility clinic patients were prospectively screened with the 26-item Eating Attitudes Test and a study questionnaire. Women identified as being at high risk for an eating disorder were then interviewed to confirm or refute the diagnosis. A total of 7.6% of infertility clinic women were found to suffer from anorexia nervosa or bulimia nervosa. If eating disorders not otherwise specified were included, a total of 16.7% of infertility patients were found to suffer from an eating disorder. Among infertile women with amenorrhea or oligomenorrhea 58% had eating disorders. Because women often fail to disclose eating disorders to their gynecologists and may appear to be of normal weight, it is recommended that a nutritional and eating disorder history be taken in infertility patients, particularly those with menstrual abnormalities. It has previously been shown that disorder eating and nutrition can affect menstruation, fertility, maternal weight gain, and fetal well-being.

Reproductive Functions in Eating Disorders

This article reviews current knowledge about the effects of anorexia nervosa, bulimia nervosa and partial syndromes on ovulation, menstruation, sexuality, fertility, pregnancy and fetal-infant health. Eating disorders may result in failure to ovulate, oligomenorrhea, amenorrhea, reduced sex drive, infertility, hyperemesis gravidarum, low maternal weight gain in pregnancy, small babies for gestational date, low birth weight infants, increased neonatal morbidity and problems in infant feeding. The available information suggests that clinicians should inquire about nutritional intake, a history of eating disorders and weight reducing behaviours as part of the routine assessment of patients with the disorders of reproductive function listed above. If an eating disorder is discovered before conception, the woman should be encouraged to delay pregnancy until the eating disorder is treated and effectively under control. If the woman is pregnant, early diagnosis and treatment are essential to reduce maternal and fetal complications. The infants of eating-disordered women should be carefully followed to ensure adequate nutritional intake. Problems in reproductive function related to eating disorders offer rich opportunities for multispecialty collaboration in primary and secondary prevention programmes directed toward both mother and infant.

A Prospective Study of the Effectiveness of Brief Professionally-Led Support Groups for Infertility Patients

Objective: This study prospectively evaluates the effectiveness and patient acceptability of professionally-led support groups in alleviating psychologic distress in infertility patients. Method: Sixty-four consecutive patients in a university hospital infertility program were administered a battery of psychologic tests before and after attendance at an 8 weekly session support group. The comparison group consisted of 35 consecutive infertility referrals to the same unit who were not initially offered the support group and were similarly tested over an 8 week period. Results: Support group patients had significantly greater (p ≤ 0.01) entry than exit scores on several measures of psychologic distress and depression (the Beck Depression Inventory, the Hamilton Rating Scale for Depression, and the Global Severity Index, Anxiety, Depression, Hostility and Obsessive Compulsive Subscales of the Brief Symptom Inventory). The Avoidance Coping Style on the Moos Coping Responses Inventory was correlated with a higher Global Severity Index (p ≤ 0.01). Comparison group patients had similar psychometric scores to the support group patients at entry but showed no change over 8 weeks. Attenders expressed a high rate of satisfaction with the support group. Conclusions: Professionally-led support groups are a highly acceptable and effective intervention in self-referred patients in alleviating psychological distress related to infertility.

The rational use of psychotropic drugs in pregnancy and postpartum.

When a pregnant woman or nursing mother requires psychotropic medication, one must consider the effect of such medications on the fetus or baby. The authors review the evidence for teratogenic effects of such drugs given during pregnancy, toxic or withdrawal effects in the newborn and dangers to the breast-fed baby. Suggestions are made for judicious use of psychotropic drugs in pregnant or nursing women.

Replantations surgery following self-inflicted amputation

Four cases of self-inflicted amputation of the upper limb which were surgically replanted are described. Three of the four patients are psychiatrically well, employed and pleased with the surgical result. The fourth patient committed suicide. The literature on self-mutilation and replantation surgery is reviewed and psychological factors and the role of the psychiatrist in replantation surgery are discussed.

Motivation for Motherhood and the Experience of Pregnancy

It is frequently assumed that becoming a mother is an essential step in the development of female identity. Although female hormones may increase a womans readiness to care for an infant, there is no clear cut evidence of a hormonal basis for maternal feelings. A womans desire to have and raise children is affected by cultural expectations and opportunities. Current analytical thinking, while viewing reproductive choice as being an important component of feminine identity, does not emphasize the necessity of having a child to feel feminine. Once pregnant, the woman works through issues related to body image, relationship with mother and husband, concerns for the fetus, fears about the future and her new vision of herself.

Infertility by choice or by nature.

Sexually active women have only recently had the ability to make a conscious decision to delay or refrain from bearing children. This is not only the result of the availability of effective contraceptive methods but also due to attitudinal changes in society and individuals. These reproductive choices may result, for some women, in conflict over the use of contraceptives, and the decision or timing of pregnancy. However, infertility imposed by nature in the form of inability to conceive, miscarriage or stillbirth removes the womans sense of control over this important aspect of her life and frequently results in severe distress. The psychological issues surrounding these reproductive choices and events are reviewed and discussed.

Psychiatric assessment of competency to care for a new-born

General hospital consultation psychiatrists are sometimes asked to assess the ability of a recently delivered mother to safely care for her new-born at home. There are surprisingly few papers in the literature that deal with this problem. The authors review their experience with 56 women referred by a maternity unit over a 10 year period and discuss the demographic characteristics, diagnosis, management, and outcome of their intervention. They discuss how such an assessment should be carried out and review the literature. Some conclusions are drawn about high risk factors, and the need for early identification of these mother-infant pairs as part of primary prevention. They point out the need to take decisive action when the infants safety appears to be seriously at risk and note that the mothers and infants in their group have done fairly well during the follow-up period with appropriate treatment, teaching and supervision.