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All in your head?

Many women are told that HG is 'all in their head' and they just have to cheer up a bit and focus on something else and it will all go away. The following essay is an attempt to explain why healthcare professionals believe this, and why they are wrong. 


In 1979 Archie Cochrane famously awarded the “wooden spoon” to obstetrics as the least scientific of medical disciplines, mired as it was then in opinion based practice (King 2004). Much has, fortunately, changed in many aspects of obstetrics since then, but attitudes to HG treatment remain trapped in an early 20th century time warp. The theory proposed in the wake of psychoanalysis that hyperemesis gravidarum (HG) was caused by psychological disturbances, remains entrenched despite not only a notable paucity of evidence to support it, but a larger body of evidence which refutes it.


The popularity of psychoanalysis in the early 20th century led to the proposal that HG was psychogenic in origin, and various theories were proposed including neurotic tendencies, hysteria, an unconscious attempt at abortion, conflict between wanting and rejecting the baby, a rejection of feminity, sexual frigidity and psychological immaturity. (Munch 2002). Munch examines the empirical evidence for the psychogenic etiology of HG. She describes three studies from 1968, 1971 and 1988 which support it, one of which has been criticised for methodological weakness and gender-bias. She then describes five studies from 1955, 1946, 1959, 1997 and 1998 which find no support for a psychogenic cause of HG. None of these studies were constructed so as to be able to examine cause and effect ie they all studied women who were already suffering from HG. In other words, any psychological differences between HG sufferers and other pregnant women could be caused by HG, rather than having caused it. Poursharif et al report a 2001 study by Simpson et al in which women were assessed for conversion disorder during and after pregnancy. They found that during pregnancy women, with HG had higher scores, but after pregnancy they had no higher scores than women who did not suffer HG. Bozzo et al have conducted two studies in which cause and effect could be examined more convincingly by assessing women even before pregnancy. In 2006, women suffering from depression before pregnancy were compared with a control group of non-depressed women. The incidence of nausea and vomiting of pregnancy (NVP) in each group was not significantly different. (Bozzo 2006) In 2011, the same authors enrolled women with no prior history of depression who had contacted a helpline prior to becoming pregnant or at < 6 weeks of pregnancy, and also followed them up post partum. Standardised questionnaires were administered at several points in the pregnancy and post-partum to determine mental state.  Again, no association between pre-natal depressive symptoms and NVP was observed. (Bozzo 2011).


Research has found associations between depression and anxiety and HG (Swallow), but this will come as no surprise to sufferers. One minute you’re a healthy, active, economically useful person, excited about your new pregnancy. A few weeks later you are confined to bed, weak, starving, dehydrated, in pain from repeated vomiting and dehydration headache, unable to care for your children, do housework or go out to see friends, bored rigid from lying in bed doing nothing and in the grip of relentless, unending, gut wrenching, unbearable nausea. Consider this description by a study participant in Power et al. 2010


I felt that I was dying. I was completely dry, I couldn’t even sip water, I couldn’t even swallow. I had no saliva. I think the nausea and the vomiting gave me dehydration, and together made me … because of dehydration I couldn’t even stand up myself, 

I couldn’t do anything. I was simply feeling I was dying and the feeling of nausea, and nothing to come out, I was vomiting, but there was nothing to come out


Added to the overwhelming physical suffering, almost everyone around you, including healthcare professionals, is telling you that this is normal and there’s nothing you can take beyond ginger tea. That this situation causes you to be depressed does not require an explanation, it is self evident that this would reduce the mood of any sane human being. The fact that parts of the medical establishment seems to have come the conclusion that the only explanation for a woman suffering from HG to be depressed is that the depression caused the illness, does, however, require some explanation. 


Early researchers observed an association with depression and ambivalence towards the baby and jumped to the conclusion that this must be causing the disease. In other words, they attributed cause and effect without proper evidence that one thing was causing the other. This is a really basic scientific error, and you would hope that any such papers being put forward for publication today wouldn’t make it past the peer review process with this conclusion intact. 


Imagine if this error had been repeated with another pregnancy complaint - Symphisis Pubis Dysfunction (SPD). This is known to be caused by loosening of the ligaments in the pelvic girdle, causing bones to move in ways they are not supposed to, leading to intense and constant pain. Imagine for a moment though, that you did a study of women with SPD and you observe that they don't do much exercise. In fact they sit around a lot and try to keep any walking or other movement to an absolute minimum. We accept nowadays that this is because movement causes pain, but imagine that you are a bit misogynistic and you have a pre-existing belief that most medical problems are caused by lack of exercise. You write up your findings and conclude that as you have observed an association between lack of exercise and SPD, that lack of exercise causes SPD. You do no further research to test this hypothesis, for example examining women's lifestyles before they get SPD to see if more women who don't do exercise get SPD than women who do lots of exercise. This would be the rational, scientific approach. No, instead you just publish. Your conclusion proves to be very popular, nobody criticises it, or at least, if they do, everyone who likes your idea just ignores them. Your idea gets passed down into medical folklore, it makes it into textbooks and medical practice. For decades to come, women with SPD are advised to exercise. When they say they can't (because it effing hurts) they are told that they are just not making enough effort, it's implied that they're lazy, that they are the cause of their own problems because of their slothful habits. When they go weeping to their doctors asking for pain killers, they are told there is nothing they can take (despite decades of evidence showing the safety of several painkillers in pregnancy) and that they should think positively and focus on the baby. Does this sound absurd? I hope it does, because this is an exact analogy of what has happened with HG. 


But why would doctors not come to the seemingly glaringly obvious alternative hypothesis that being excessively ill can make a person depressed? Why did so many doctors accept a hypothesis which had no proof? Why the popularity for a psychological explanation when a physical one was far more likely?


Munch proposes the following explanation


Historically, medicine has had a tendency to adhere to a deterministic view that every effect has a cause and that the cause can be identified; and that ‘‘if there is a lack of 

bodily functioning there must be a specific cause, and this has to be identified before the patient’s complaint can be credited with any veracity.’’ (Hart & Grace, 2000, p. 199). This deterministic stance can lead to instances of blaming the victim, where patients are viewed as responsible for causing their medical condition (Marantz, 1990). Perhaps because science has been unable to establish the underlying pathophysiological mechanism of HG or a definitive treatment, many physicians and other HCPs tend to presume a psychosocial etiology, thereby placing greater responsibility for women’s control of the disorder. My review of the literature demonstrates that there is scant research, most of which has severe methodological limitations, to support or reject a theory of psychogenesis for HG. Not unlike other female medical conditions a medical folklore was socially constructed; the idea of psychogenesis was developed and embraced, and has essentially gone unchallenged (Tylden, 1968). (Munch 2002)



The question is, does belief about the etiology matter, does it impact on patient outcomes? The answer is that, unfortuately for women suffering from HG, it most certainly does. Historically, there was an immediate effect on inpatient treatment for HG sufferers. Swallow notes:



Take for example the quote from Atlee in 1934: 

 

My routine is as follows: From the moment the patient enters hospital she is denied the solace of the vomit bowl. She is told that, in the event of not being able to control herself, she is to vomit into the bed; and the nurse is instructed to be in no hurry about changing her. I try to see these patients as soon after admission as possible. I assure them very dogmatically that they are going to stop vomiting at once, and that they will leave the hospital perfectly well in a week. I tell them to eat whatever is put before them, and I instruct the nurse in their hearing to give them a fresh meal in 20 minutes if they do vomit. From the beginning they are put on full hospital diet, and their tray is in no way arranged to make them feel that they have digestive capacities other than normal. They are assured that the more they eat the quicker they will get better. (p. 757) (Swallow 2010)




It would be reassuring to think that this type of attitude is a thing of the past, however Swallow also notes


This punitive treatment regime persisted in some institutions until the 1990s (Parker, 1997). Indeed, Steve Lindow, a consultant who collaborated in my earlier research, relayed an incident from his medical training in the 1970s when he was based in an obstetrics and gynaecology ward. The consultant in charge insisted that women with hyperemesis gravidarum were not to be cared for, were to clean up their own vomit and have regular meals brought to them. (Swallow 2010)


As recently as 2010, Power et al reported results of a survey of women from inner city populations treated at a women’s teaching hospital in North West England. They found some appalling attitudes of staff towards women suffering from HG which resulted in a poor standard of care for some of them. The following are quotes from staff:

 

Most of it’s psychological anyway. The problem we have is communication, because most of them will not communicate with you. You know, they won’t tell you how they’re feeling and a lot, I don’t mean to generalise, but you get a blank look and you don’t get any response and that is really frustrating you know


They’re coming in to a ward with a bed occupancy of 110%, we need the beds, we’re thinking they’re not sick, we need to get that patient out, we need to get somebody who is a gynaecology urgency


Some women will actually starve themselves and induce a form of hyperemesis to get away from their home circumstances, and they are inappropriate referrals to the ward area. So, when they are there, they are noncompliant, because they see that if they get better they are going back to the same social circumstances and they don’t get looked into (Power 2010)


The following are quotes from patients


The nurses were quite nice; I think the doctor wasn’t too good to be honest. He was very harsh, he was just putting injections all over me, quite roughly and it was like he wouldn’t believe what I’m saying, that I’ve been sick and everything, literally. He was just, like, nothing’s wrong with you and I was … that day I was so bad, I couldn’t even talk properly, so I felt a bit terrible. (Power 2010)


Power notes that 


The predominant feeling among health care professionals was that often women with the condition were presenting a physical manifestation of underlying psychological or social difficulties. This manifestation might be conscious or unconscious and was most often suggested to be a result of social problems such as poor home circumstances. (Power 2010)


The idea that the problems of women admitted with the condition were often more psychosocial than physical appeared to lead to the conclusion that actual deception occurred, where patients faked their illness to garner sympathy and attention or a ‘‘rest’’ from home life: 


Some of these ladies actually believe the hospital is a five-star hotel, where you can just come and chill out and get taken care of and will have the nurses doing everything for them, get me this get me that. Too lazy, won’t stand up and get something from the cupboard. (Power)


The outcomes for the babies of women who suffer this kind of treatment are detailed by Pourshrif et al who examined reasons for terminating wanted pregnancies amongst women with HG:


What does appear striking is that women who terminated were more likely to report a negative attitude from their caregiver. As treatments and supportive care varied greatly among women, with at least a third reporting that they received little or no help from their health care providers, it is not surprising that most of these women (87%) expressed that one reason for their termination was that they had no hope for relief. (Poursharif et al., 2007)



The psychogenesis theory for HG has no evidential basis, even several decades after it was proposed, but many professionals on the ground have simply not caught up with current thinking about the condition and modern treatments. This would be understandable if there was a dearth of research into the condition, but there isn’t. A recent comprehensive review of NVP by Gadsby et al (Gadsby 2011) quotes 160 references. Using hyperemesis gravidarum as a search term in Pubmed yields 1418 references. The literature is replete with review papers and guidelines offering treatment algorithms for HG (Ebrahimi 2010, Arsenault et al., 2002 (SOCG guidelines), Lane 2007, Sheehan 2007, Verberg et al., 2005, Quinlan & Hili 2003, Jarvis & Nelson-Piercy 2011, Einarson et al., 2007, Ismail 2007, King, T.L., 2010, Sonkusare 2011). All of these articles reject the idea that psychological issues cause HG and all of them recommend treatment with antiemetics in primary care. Gadsby & Barnie-Adshead, however, in response to the publication of Jarvis & Nelson-Piercy 2011 note


In their clinical review of the management of nausea and vomiting in pregnancy Jarvis and Nelson-Piercy state that most women can be managed in primary care, and that various antiemetic drugs are safe during pregnancy.1 This message does not seem to be well accepted by prescribers. Many women with severe symptoms who contact our charity (Pregnancy Sickness Support) say that they feel their condition has been trivialised by their GP or midwife and that they have not been prescribed antiemetics. 

The number of admissions to hospital because of hyperemesis gravidarum is increasing each year and has gone from 8637 in 1989-90 to 25420 in 2006-7.2 One reason is probably that healthcare professionals are not offering safe effective treatment to women with severe symptoms. We hope that the message that antiemetics are safe in pregnancy, and that cyclizine 50mg three times daily should be considered as initial treatment, will receive widespread publicity and acceptance among prescribers.In this way, women who have severe symptoms of nausea and vomiting in pregnancy will receive the support and help they need from primary care. (Gadsby & Barnie-Adshead 2011)



All experts in the field of HG now confidently assert that HG has physiological causes and is not caused by psychological factors. Indeed, the notion that severe pregnancy sickness was caused by psychosis is absurd when looked at in relation to the fact that 80% of women suffer from pregnancy sickness (Gadsby & Barnie-Adshead 2010). This is considered normal, but past a certain point of severity, suddenly it must have a psychogenic cause? 


Consider this logic with another disease in which symptoms vary from minor illness to death - swine flu. Some swine flu sufferers have barely any symptoms, some have a mild flu, some quite severe flu and some end up on ventilators, a few of those dying. Imagine that patients up to the point of needing hospital admission are considered to be suffering from an acquired virus, which causes immune system reactions resulting in symptoms. They are treated sympathetically and offered antivirals and medications to relieve their symptoms. Now consider those admitted to hospital. Now, all of a sudden, it’s no longer caused by a virus, they are told that their symptoms are caused by psychological anxieties, perhaps related to inner conflicts about their sexuality or anxieties about their ability to breathe. They are treated as though they have caused their own illness and it is inferred by their caregivers that if they just pulled themselves together they could cure themselves. They are told, oh lots of people get flu, I had flu and I just took some lemsip and got on with it. They are asked have you tried holding your head over a bowl of hot water with eucalyptus leaves, that worked for my friend’s sister in law’s cousin when she had flu? I know you’ve said you can’t breathe but just try and breathe on your own. The patient is weak and ill so asks for help to get out of bed to go to the toilet and staff get annoyed at them and say, there’s nothing wrong with that patient’s lungs, she could breathe if she wanted to, she’s just here because she wants a break from her home life. The patient feels so immensely unwell that she would rather die than suffer any longer and when she expresses this, her caregivers just say oh it’s normal to feel like this with flu, buck up, you’ll be fine. No respiratory specialist would expect to be taken seriously with a theory like this, but this is exactly analagous to the narrative that we are expected to believe with the psychogenic etiology for HG. In summary, it is absurd, defies logic, defies biology and has no body of evidence to support it. So why does this belief persist?. Munch summarises:


In sum, my initial impression of the HG literature was that a linear trend toward very early conceptualizations of HG as a biological illness to be taken very seriously (e.g., because women died) shifted to the propensity to view HG as mostly psychogenic in etiology. Although this may hold true in the very early days of medicine, a more accurate interpretation appears to be that both biologic and psychogenic approaches to HG exist in parallel tracks throughout history with one surmounting the other in grabbing the imagination of clinicians and researchers depending on the zeitgeist of the times (e.g., post WWII fascination with psychoanalysis and Freud; various technological advancements in medicine). Still, the theory of psychogenesis was and remains today the overarching and predominant paradigm, despite controversy. Seemingly major shifts in HG paradigms perhaps may more accurately be portrayed as mild undercurrents of the debate with sociocultural factors (e.g., societal views about women) - rather than scientific evidence - playing a significant role in shaping the default paradigm of psychogenesis. Similarly, anecdotal accounts of HG remain unsettled. A female obstetric resident candidly and with some regret echoed the perceptions of her peers, ‘‘I have to admit most of us view them (HG patients) as whiners. There is not much we can do for them, like we can with a bleeder... HG cases are not technically exciting.’’ (personal communication, July 1998). A male obstetrician exclaimed, ‘‘I can’t believe anyone still thinks that HG is psychological... it’s a disorder of pregnancy.’’ (personal communication, November 2000). (Munch, 2002)


This discredited theory is still trotted out by people at the top of the obstetric profession. James Drife, emeritus professor of Obs/Gynae in Leeds as recently as January 2012 in a short opinion piece for the British Medical Journal about the HG suffered by Charlotte Bronte wrote



Today her hyperemesis would be treated with a routine drip, but sometimes cure can be elusive, particularly if the patient resents the pregnancy. (Drife 2012)


Prof Drife casually drops this in, effectively presenting it as fact, despite there being absolutely no evidence that the pregnancy being unwanted or otherwise affects the outcome of treatment. The reason that cure is elusive, is that medical science has not yet come up with a cure, all that can be done is to control the symptoms. The lack of a cure is because nobody knows what causes HG. This is also the case with other diseases, a notable pregnancy one being pre-eclampsia. Nobody knows what causes this, or how to cure it, the only cure for severe cases being delivery of the baby, but nobody suggests that this is because the mother resents the baby.


In their rapid response to Prof Drife’s comment, Fejzo and MacGibbon say


The cause of HG is unknown and over a century of unsubstantiated claims that it can be incurable for reasons such as the patient herself “resent(ing)” the pregnancy is exactly the abusive commentary that contributes to a poor patient-physician relationship and can lead the patient to elect termination. Suggesting the patient is somehow at fault for the severity of her physical symptoms when the fact is, we have no idea what causes nausea and vomiting in pregnancy is both unscientific and harmful to the patient (Fejzo and MacGibbon)


The psychogenic etiology of HG is often presented to women as received wisdom, not only by professor of obstetrics, but by midwives, GPs and even friends and family. In fact, though, it has never been universally accepted.


Opposition to the psychogenic explanation arose as early as 1929, when Peckham cautioned physicians to avoid assuming a neurotic element for fear of overlooking a potentially dangerous physiological condition. He concluded that it is difficult to conceive a neurotic etiology in patients who begin to vomit before a menstrual period has been missed, thereby being unaware of their pregnancy. (Munch, 2002)


Ian Donald, in the 1974 edition of his textbook Practical Obstetric Problems, wrote


It is safer to classify cases according to the severity of the vomiting than to use the old division into toxic and neurotic varieties. This is not only obsolete but dangerous too, as the diagnosis of neurosis may engender a regrettable complacency regarding the outcome of the condition. (Donald 1974)


So even at the time, the theory was rejected by experts. In the 21st century, in a modern hospital with trained medical staff, a woman should expect  evidence based medicine delivered in a professional manner. The psychogenic etiology of HG has no more validity than an urban myth and should be a consigned to history where it belongs. 


The truly disgraceful thing, is that to this day, women are being fobbed off by doctors, told they're being drama queens, that they  don't really want their babies, that they're anorexic, that it's all in their heads. For examples which have happened in the within the past 5 years, see the results of the Survey of Attitudes to HG here.


If you turned up to the labour ward and were forcibly shaved, given an enema, had your partner refused entry to the room and pinned to the couch with your legs in stirrups without asking what you wanted, you would suppose you had gone through some kind of time warp and fetched up in the mid 20th century. Yet this is about as modern as some HG treatments get in many hospitals in the UK today. A decades old, outdated, discredited theory is underpinning ‘care’ and affecting outcomes for women in the 21st century. That this is not a scandal and the source of considerable embarrassment for the obstetric community says much about the silence with which too many women endure this horrendous condition. 



Dr Margaret O'Hara, 2013




References


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