As an introduction to the psychological and social aspects of nausea and vomiting of pregnancy (NVP), I would like to present the case of a young patient who first stimulated my interest on the subject when I was a junior doctor working on a gynaecology ward in England.
She was an Italian girl, who at the time was 17 years of age and pregnant for the first time. The father was her then partner, an English boy of similar age, of whom her family disapproved. The disapproval was not only because of his age, but of his religion, or rather, lack of it. Neither of these factors accorded with the family's plans for their daughter. Both she and her partner lived with their respective parents, but had stated their intention to marry and move in together. The girl's parents vehemently opposed this and would discuss the issue with neither the boy nor his family.
She was admitted to hospital for the first time at 13 weeks' gestation; treated in the usual way, with intravenous fluids and metoclopramide and an ultrasound to check foetal well-being; and accommodated, as was, and remains, normal practice, on a general gynaecology ward, among women suffering from a variety of problems, including those awaiting or recovering from elective termination. She was not treated unsympathetically, but rather as a problem which should easily, perhaps rather boringly, be managed for a day or two and then discharged after normal test results were returned from the lab and the vomiting had settled.
She required five further admissions, all of which were instigated by her increasingly exasperated general practitioner, and all of which followed the same tired pattern, albeit the length of stay increased as time went by. During the later admissions it began to dawn on us that there was something about coming into hospital which somehow protected this girl from the family wrangling she was having to face at home and which appeared to be becoming increasingly serious as the pregnancy continued. On the one hand, she maintained her resolve to stay with her partner, despite intense family pressure to leave him, but on the other, she divulged during confidential conversations with nursing staff on the ward that her resolve was slipping and that she was becoming increasingly panicked about her predicament and unsure of what was best for her to do. The hospital seemed to be becoming a place of asylum for her.
Throughout the process, and despite all the undercurrents, both the couple and their respective families, who somehow contrived never to visit at the same time, maintained that her sickness must be resulting from some hormonal imbalance, that could and should be rectified by us, the staff. They importuned us with mounting intensity to do something to cure her.
At 22 weeks there was worsening anxiety all around, dehydration, failure to gain weight adequately and, ironically, a failure on my part to find any more veins in which to site an intravenous line. At this time her consultant, my boss, visited her for the first time. After a conversation which lasted barely a minute, he emerged from her bedside with instructions to arrange a therapeutic termination the next morning. This was met with a certain amount of relief by everyone. But amongst the staff there was definitely a feeling that somehow this was not an appropriate way to end the saga, particularly after all the work we had put into her management during the later stages of her illness. I think that the nurses felt betrayed by the consultant, who in one stroke instantly resolved the situation, but denied any of the meaning of her illness or the emotions that the nurses had begun to invest in her.
She went home the next day apparently cured, ostensibly grateful to the nursing staff, and indebted to the consultant. I never saw her or heard from her again.
As she received the obligatory box of chocolates from the patient, the ward sister later confided to me that she felt a fraud, as if she were being thanked for colluding with the consultant in minimizing the hours of effort put in by the staff to manage the suffering of the patient.
Mild and moderate NVP are probably statistically and psychologically normal.1 NVP occurs in 70% of pregnancies, typically starting by four to six weeks' gestation, peaking in incidence and severity by eight to twelve weeks, and commonly resolving spontaneously by the 20th week. When occurring later in pregnancy it is most likely because of a mechanical action by the enlarging uterine fundus on the diaphragm and cardiac and pyloric sphincters. Severe NVP represents a challenge because of its associations with pregnancy loss and intrauterine growth retardation.
There is a small but potentially engaging body of literature which suggests that the causation of severe NVP may involve pathological psychodynamic processes. More robust accounts exist of the impact of severe NVP on the social functioning of sufferers. Severe NVP could realistically trigger adjustment disorders, generalized anxiety, and even depressive episodes in an otherwise normal expectant mother, although this has not been confirmed in a study of such women. It is known that there is an association between time lost to paid work and the severity of NVP symptoms. Such a socioeconomic impact can likely affect the mental health of sufferers.
Dooley, in her psychoanalytic evaluation of Charlotte Bronte, identified the possibility of a psychological component to the aetiology of severe NVP.2 She wrote that Bronte had been "fearful, conflicted and reluctant to accept her future marriage and childbearing" and stated that "pernicious vomiting... always has psychogenic features." Furthermore, Rhodes again attributed Bronte's death to severe NVP, with the comment that "hyperemesis gravidarum only seems to be excessive in those who display neuroticism."3
Comments as to the cause of severe NVP have included that the woman who vomits is trying to purge herself of an unwanted pregnancy; is rejecting femininity; is sexually dysfunctional, etc. More recent studies and reports have attempted to substantiate such claims and variously found that women with severe NVP were more often unmarried when the child was born; had less frequently planned their pregnancies; and were more likely to admit that their pregnancies were unwelcome than women with moderate NVP. Social factors have also commonly been associated with severe NVP. Surveys have found high proportions of women with severe NVP live in overcrowded or unfamiliar circumstances. In the International Classification of Diseases, ICD-10 Classification of Mental and Behavioural Disorders of category F50.5 (vomiting associated with other psychological factors), the authors state that "in pregnancy... emotional factors may contribute to recurrent nausea and vomiting. "The category also includes "psychogenic hyperemesis gravidarum."
In all likelihood, there must exist a complex interaction between psychological and emotional causative factors and the bodily and mental responses of the expectant mother and her family to the disorder. Early studies and reviews report the issue of "conflict" caused by pregnancy, for example, the fear and anxiety of the future in terms of changing roles and responsibilities, as well as the possible adverse socioeconomic repercussions of the birth of a child. It has been proposed that such conflicts may manifest physically as nausea and vomiting of pregnancy. Experienced practitioners have also noted that patients' symptoms seem less severe when hospitalized: the concept of hospital as asylum.
In NVP there is a complex interaction between physiological and emotional causative factors and the bodily responses of the expectant mother. Treatment of NVP might therefore appropriately espouse both physical and psychological components, the latter preferentially comprising supportive psychotherapy as the first line. Mothers with NVP severe enough to cause personal distress or social or occupational disruption could be managed with a practical approach whereby they are provided with encouragement, explanation, reassurance and the opportunity to ventilate emotions. Simply having the patient maintain a record of her NVP and daily activities may assist in uncovering antecedents or exacerbating elements and consequences. These may be physical and/ or psychological. Psychodynamic psychotherapy could be used to uncover subconscious factors. Furthermore, inclusion of the expectant father or partner in this therapeutic modality may further assist the patient.
At this time there are no controlled studies of psychotherapy in NVP. While the above contentions may seem obvious to an enlightened audience, it is the author's experience that treatment strategies for severe NVP are rarely holistic in this sense and that there therefore exists a need to improve them.
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