Bu I i m ia Associated with Repeated Spontaneous Abortion

Michael Ford, M. R. C. Psych. Bridget M. Dolan, Ph.D.

We report a case demonstrating a previously undescribed association between bu- limia and repeated spontaneous abortion. It is also the first report of bulimia in a British Sikh woman. Her history reveals features of multiimpulsivity and demon- strates an unusually early onset of bulimia associated with an organic condition, asthma.

CASE DESCRIPTION

Mrs. A., a 32-year-old Sikh woman, had binge eaten and vomited since the age of 6 until referral. She had developed asthma sufficiently severely to re- quire hospitalization for much of her childhood. She learned then that vomit- ing after meals relieved breathlessness. She soon started binge eating, particularly on chocolates and other “sweetners” brought to hospital by her family. At 18 she was overweight and began dieting, precipitating further binge eating. At 20 and 23 she described limited periods of loss of weight, phobia of normal body weight, and amenorrhea. Mrs. A.‘s history revealed many features of multiimpulsivity (Lacey & Evans, 1986). From 20 to 25 she had repeatedly taken overdoses and cut herself. From age 25 she started drink- ing heavily and became alcohol dependent. She also spent impulsively.

There were several familial and cultural stressors in her history. Born in Kenya of Asian, Sikh parents, her father, who was an alcoholic, died when she was 4. The family came to England when she was 6, and at this time her asthma began. Her mother remarried but she claims not to have been aware that this man was not her real father until age 11. She reports feeling rejected by her mother and stepfather, who had a stormy relationship. Because of her

Michael Ford, M. R. C. Psych., is Senior Registrar, Department of Psychiatry, Atkinson Morley’s Hos- pital, London. Bri&t Wan, Ph.D., is Research Psychologist and Hon. Therapist, St George‘s Hospital Medical School, London. Address reprint request to Ms. 8. Dolan, Bulimia Clinic Research Team, Ac- ademic Department of Psychiatry, St George’s Hospital Medical School, Tooting, London, SWl7 ORE England.

international journal of Eating Disorders, Vol. 8, No. 2, 243-245 (1989) Q 1989 by John Wiley & Sons, Inc. CCC 0276-3478/89/020243-03$04.00

244 Ford and Dolan

long hospitalizations Mrs. A. was cared for and educated by a succession of white hospital workers from 6 to 16. She gained five “A” levels, using studying as an excuse to avoid an arranged marriage. Mrs. A. became more distanced from her own culture, studying to become an accountant. Cultural disharmony was mirrored and exacerbated by her unhappy marriage to a Hindu, in which she was beaten. She was divorced at 29, and her ex-husband retained custody of their children. After subsequent relationships with both white and Muslim boyfriends she was rejected by her Sikh community.

Between 17 and 25 she became pregnant seven times. Persistant binge eating and vomiting was associated with four miscarriages between 3 and 5 months gestation. Amelioration of symptoms, in her fourth and seventh pregnancies, was associated with live births and in her sixth pregnancy with a still birth of 7 months gestation. All pregnancies antedated her alcohol abuse and were not associated with any drug abuse.

At interview she weighed 51 kg at 160 cm tall. She complained of feeling fat and was binge-eating and vomiting twice daily; she was not phobic of normal body weight. She appeared subdued and sad, describing depression and thoughts of self-harm, exacerbated premenstrually and in the evenings.

Treatment has been difficult. She has failed to persist with recent alcohol rehabilitation programs or to engage in inpatient treatment for her bulimia.

COMMENT

The patient had severe protracted bulimia with a previous history of anorexia nervosa. Features of multiimpulsivity, alcohol dependency, and frequent epi- sodes of self-harm suggest a personality disorder and a poor prognosis (Lacey & Evans, 1986). In the major clinical and epidemiological studies of bulimia in both the United States (Pyle et al., 1981) and the United Kingdom (Fairburn & Cooper, 1983), no black or Asian patients were described. Clinical cases of bulimia in black and Asian women are very rare (Lacey & Dolan, 1988). The absence of eating disorders in nonwhite women may reflect varying emphasis on slimness as desirable. Transformation of cultural values from white careers and rejection of and by her Sikh community may have contributed to the de- velopment of bulimia in our patient.

The demonstrated association of unremitted bulimia and recurrent abortion is particularly relevant in the light of a recent study on the impact of pregnancy on bulimic mothers and their babies (Lacey & Smith, 1987). Despite the fact that during pregnancy bulimic symptoms improved in all 20 mothers, the in- cidence of fetal abnormality, multiple pregnancies, and obstetric complications was higher than expected. Certain aspects of bulimia, particularly self-induced vomiting, major fluctations in calorific intake, and depression, could lead to difficulties during pregnancy. However, we are not aware of any other reports of fetal damage or spontaneous abortion in bulimic women.

We thank Dr J. Hubert Lacey for allowing us to report on his patient.

Bulimia and Spontaneous Abortion 245

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Lacey J. H., & Dolan B. M. (1988). Bulimia in black and Asian women: A catchment area study.

Lacey J. H., & Smith G. (1987). Bulimia nervosa: The impact of pregnancy on mother and baby.

Pyle R. L., Mitchell J. E., & Eckert E. D. (1981). Bulimia: A report of 34 cases:. 'ournal of Clinical

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