By Linda Shanti McCabe, PsyD, USA
Pregnancy and early motherhood can be a minefield for women recovering from eating disorders. The hormone changes, body changes, mood changes, sleep changes, and learning curve of early motherhood may be triggers for relapse, even for women who desperately want a glowing experience.
Years ago, when I worked in an eating disorder treatment program, a client made a collage image of her stomach. In contained an exploding solar system to represent her bulimia: painful explosions literally were bursting out of her stomach. Right under that, in her womb, she placed babies, “because I want to have children someday.” She wanted to recover, and knew she couldn’t have or care for children if she continued with the bulimia that was destroying her.
An incentive to recover?
Though previously thought to be the case, anorexia and other eating disorders do not necessarily damage fertility (Hoffman, Zerwas, and Bulik, 2011). However, many medical complications are associated with eating disordered behaviors during pregnancy, such as: preterm delivery, low birthweight, intrauterine growth restriction, Caesarean birth, and low Apgar scores (James, 2001). These potential complications can actually be an incentive for a woman to not engage in disordered eating behaviors during pregnancy. However, if she is not engaging in the eating disorder behaviors, she is required to tolerate the distress of dramatic changes in hormones, weight, body shape, and mood. These changes can often be overwhelming.
One of the first things that happen for a newly pregnant woman is that she is weighed in at her appointment with the obstetrician/gynecologist (ObGyn). For a woman recovering from an eating disorder, the scale can take on God-like power. In an eating disorder, the scale becomes an entity that determines what she feels, how (she thinks) others feel about her, and her core worth as a human being. The slightest change can send her into a day of self-loathing anxiety, depression, or food-obsession that make it hard to function.
For women who have freed themselves of this obsession prior to pregnancy, it can feel traumatic to suddenly be weighed – and to be gaining weight – every time she comes to her ObGyn appointments. Due to shame, women often don’t report to their ObGyn that they have or had an eating disorder. And yet this lack of disclosure can prevent accessing the psychological, emotional, and physical support that could be essential for her recovery.
A call to action
An ObGyn, who was monitoring a client I see in therapy, seemed to think there was “no problem” with her gaining such a low amount of weight during her pregnancy, because the baby was healthy. Meanwhile my client was obsessively weighing herself multiple times per day, over-exercising, restricting her food, and suffering with perinatal anxiety. This is an example where collaboration is essential between providers. ObGyns are often not trained in eating disorders, and therefore often miss screening for them and providing treatment resources.
During pregnancy and postpartum, a woman with an eating disorder will interact with the healthcare system extensively: perhaps more than any other time in her life. Thus the opportunity for intervention is great. ObGyns, midwives, and doulas should have basic training in assessing for eating disorders. These same professionals need to be collaborating with therapists and psychiatrist who specialize in eating disorder (and preferably also perinatal mood disorder) treatment. Referral resources such as therapists and psychiatrist should be provided if an ObGyn assesses there is a history of or current eating disorder.
When looking good does not equal feeling good
Many women who have or have had eating disorders are practiced at “looking good.” Looking good (hiding or stuffing uncomfortable feelings in order to please others) is often a skill they have mastered in their family of origin. This “looking good” aspect of the eating disorder becomes a way to mask uncomfortable feelings of inadequacy, anxiety, anger, or depression.
Sometimes eating disorders are referred to as “undiagnosed mood disorders,” due to the very common comorbidity of anxiety or depression. One recovering mother I worked with, who was struggling with almost debilitating postpartum anxiety, received compliments frequently on how quickly she lost the baby weight and how “glowing” she looked. The “glow” was a mixture of sleep deprivation and almost overwhelmingly debilitating anxiety. Thankfully, because she knew she was at risk for eating disorder relapse due to her history, she sought professional support. Because of this, she did not relapse into her eating disorder, and recovered fully from her perinatal anxiety.
One in seven (and some statistics say one in five) mothers suffer with postpartum depression (Postpartum International, 2013). Recent research shows that both too much and too little weight gain during pregnancy are correlated with a higher risk of Major Depressive Disorder. (Cline, Decker, 2012).
If most women recovering from an eating disorder also have a mood disorder, you can imagine how common it is for a woman with an eating disorder to develop perinatal depression or anxiety.
Perinatal Mood Disorders (PMAD’s)
Though tearfulness is commonly thought to be the main “face” of postpartum depression, there are many other symptoms that many new mothers and family members do not recognize as a mood disorder. Some of the many symptoms of a perinatal mood disorder can include:
- Irritability or anger
- Hyper vigilance
- Losing the baby weight – and then some- too rapidly
- Binge eating or loss of appetite
- Not sleeping, even when the baby sleeps
- Feeling a sense of numbness/apathy/”not like myself”
- Lack of interest in the baby
- Feelings of guilt, shame, or hopelessness
Perfectionism is not a helpful trait for early motherhood
Women recovering from disordered eating often have temperamental risks toward internalizing stress, being over-achieving and perfectionistic, caring toward others (often at the expense of themselves), and obsessing about food as a way to resolve complex life problems. When you mix these temperament factors with cognitive distortions such as “I should know how to do this motherhood thing,” and “Motherhood should come naturally and easily,” you have an environment ripe for failure.
Babies and early motherhood are messy. Giving birth is messy. The Postpartum period is messy. Sleep can be inconsistent, diapers are messy, and feeding is messy, regardless of if you are breast or bottle-feeding. In addition, giving birth and breast-feeding can be re-traumatizing for many mothers with histories of sexual abuse (Simkin and Klaus, 2005). All these factors make it challenging for a woman who may have an idealized vision of what she “should” be feeling and experiencing.
For the new mother: there is hope
Recovery is possible. It is always possible to enter, or re-enter, recovery from an eating disorder. Ideally, you will have some solid recovery before pregnancy, but it is always possible to get into recovery. What does it take and what helps? Here are a few staring points:
Support is the best thing you can do for yourself (and your baby). Find a therapist that specializes in eating disorder recovery. You may also need a dietician and psychiatrist to help you navigate the food and mood changes during the perinatal period. If you are experiencing intrusive thoughts or thoughts of harming yourself or your baby, you will need immediate attention. (Call your local hospital or emergency line [911 in the US] for immediate attention or check Postpartum Support International’s website for additional resources). The best treatments for eating disorder and perinatal mood disorder recovery usually include a combination of: therapy, social support, and/or medication. Seek and get the support you need. Enlist the support of your loved one(s)
2. Throw out your scale
You will NEVER find peace there. You will never, ever find what you are looking for there. It’s not in there. Throw it out! Smash it, throw it in the garbage, bring it to your therapist and have a breaking-up session. Allow the grief, anxiety, or other uncomfortable emotions you have been avoiding to come, and be released.
3. Lower the bar
A mom-friend of mine and I call each other weekly to check in. This is basically the message we repeat to each other every week. Lower the bar. If recovering from perfectionism as a mom, you have to let some of that go. Ideally, you will let go of all of it. Realistically, let go of some of it.
A wish for new moms
World Eating Disorder Action day is June 2. My wish for recovering mothers is they begin to treat themselves, with tenderness, like newborn mothers. My hope for you, new mom, is to give yourself lots of support and don’t expect yourself to know things with which you have no experience. Surround yourself with loving personal and professional support for your “newborn mom” self. Trust doing one small, tiny thing per day is enough. You are enough; you are good enough. Lower the bar. Recovery is possible, you can recover, and you are not alone.
About Dr Linda
Linda Shanti McCabe, PsyD, is a licensed clinical psychologist and recovered mom in San Francisco. She helps women recover from disordered eating and perinatal mood disorders. To read more about her work, go to www.DrLindaShanti.com or her blog at www.Recoverymama.com.
* This blog is not intended to provide psychological treatment. Seek a treatment professional in your geographic location for eating disorder or perinatal therapy.
Join Linda in supporting World Eating Disorders Action Day. Be sure to follow along on Twitter @WorldEDDay and hashtag #WeDoAct, #WorldEDActionDay, @WorldEatingDisordersAction on Instagram and World Eating Disorders Action Day on Facebook.