Podcast Transcript

Episode 47: Postpartum and Eating Disorder Recovery, Part 1

[Bouncy theme music plays.]

Sam: Hey, I’m Sam.

Ashley: Hi, I’m Ashley. And you’re listening to All Bodies. All Foods. presented by the Renfrew Center for Eating Disorders. We want to create a space for all bodies to come together authentically and purposefully to discuss various areas that impact us on a cultural and relational level.

Sam: We believe that all bodies and all foods are welcome. We would love for you to join us on this journey. Let’s learn together.

Ashley: Hi, everyone. Thank you for joining us for another episode of All Bodies. All Foods. I’m your host, Ashley, and I’m joined by my co-host, Sam, and a very special guest. Today’s episode is near and dear to my heart as we’re going to talk in depth about the postpartum period and how eating disorders, poor body image, and other mental health concerns can have a high potential to surface during this postpartum period. According to Postpartum International, it is estimated that 15% to 20% of birthing parents experience significantly heightened symptoms of depression and anxiety in the postpartum period. The Harvard Medical School Center for Women’s Mental Health reports that a third of pregnant women experience body image dissatisfaction and research indicates that body image dissatisfaction generally increases during the postpartum period, particularly among women with a history of an eating disorder. Furthermore, women with body image dissatisfaction during pregnancy or postpartum are four times more likely to develop depression compared to mothers who are satisfied with their body image. Additionally, current or past history of eating disorders have also been associated with increased depression and anxiety, both during and after pregnancy compared to women without a history of an eating disorder. This information is very telling and suggests that the perinatal and postpartum timeframes have the potential to be an incredibly vulnerable and tenuous period for parents. We are eager to understand how to better support our clients that fall into this category. And today we have invited Angela Kaloudis, licensed mental health counselor, and certified perinatal mental health provider to join us on the show today. Angela is a clinical training specialist for The Renfrew Center and maintains a private practice for individuals located in Massachusetts, Vermont, and New York. Angela provides expert supervision and training to affiliated Renfrew residential and outpatient facilities on evidence-based treatment promoting best practice and quality of care. She received her master’s degree in mental health counseling and behavioral medicine from Boston University School of Medicine, where she went on to become an adjunct clinical instructor. She has a passion for treating individuals with eating disorders, trauma, and birthing individuals with perinatal mood and anxiety disorders. Angela is a professional member of the International Association for Eating Disorder Professionals, Postpartum Support International, and the International Society for the Study of Trauma and Dissociation. Angela, thank you so much for being here.

Angela: I am so grateful and honored to be on this podcast and to spend time with you, Ashley and Sam, and talking about a topic that I can always talk about for hours and days. So it is, likewise, near and dear to my heart. So, I’m really grateful.

Ashley: Yeah. Well, I heard you present on this topic before and I told Sam, like, we have got to talk to you as someone, you know, that went through this a couple of years ago, having a baby. I think that this topic will just land with so many of our listeners. So first, I kind of just wanted to jump in and see if you could define the perinatal and postpartum timeframes for our listeners so they understand what exactly we’re talking about.

Angela: Yep, that’s a good question. And it’s important to clarify. So, when we say perinatal, because we’ll be throwing out these terms, right, like perinatal, postpartum. The perinatal period is actually the time of conception to depending on the research that you read, it says like a year post birth. So it accounts for the entire time from pregnancy into the postpartum period. When we say postpartum, we mean from the time of birth to 12 to again, some research does indicate it’s 18 months plus postpartum. But for the sake of just like what we’re going to be talking about, we’re talking about the year post birth. But just know, it could actually go on from junior than that.

Ashley: Okay, thank you so much.

Sam: Very helpful. So maybe we could kick off the episode with a little true and false. How does that sound?

Angela: Love it.

Sam: Okay, true or false, Angela, in the postpartum period, body image issues are uncommon because you’re focused on your child.

Angela: That is false, they are common.

Sam: False.

Angela: Yes.

Sam: Yes. Okay. Can you say more about body image after birth? So postpartum period is birth and on. What do we know about body image during that time?

Angela: Yeah. It’s a very vulnerable time. Transition to parenthood is like the number six of most stressful life events someone can go through. So when we think about stress and anxiety and transition, we think about how difficult it is to go through change. And what’s the number one thing that changes? Of course, there’s like, you know, you have to feed one or two multiple babies, but also like your body is changing for that care, the person who carried that birthing individual. And, you know, when we look at control, change, what is happening in our immediate environment, everything can feel so unknown. And so, the body becomes this main focus or can be. We can go through it more in depth, but I think social media doesn’t help. I think there’s just so many pressures for women, but birthing individuals in general around this pressure to bounce back.

Sam: Oh, absolutely, you see that. everywhere you see these influencers who just had a child and they’re like, look at me, I’m already doing the full workout I was doing before I was pregnant. And it’s, that can be so harmful because everyone is so different. I mean, that kind of pressure is really, really damaging.

Angela: I think that also, like healthcare doesn’t help. Because when we look at visits, like doctor visits postpartum, they significantly drop for the birthing individual, right? And it increases for the baby. But the focus on that person who carried is much, much less. And then the only time that sometimes they see their doctor, gynecologist, OB, midwife is six weeks. And at that six-week appointment, there are two things that get cleared. One, you can have sex again and two, again, this is for the carrying person with the vulva. You can have sex again, you’re healed and tqo, you can exercise. Like those are like what happens usually at those appointments. Um, so there’s this like, again, this pressure around like, Oh my gosh, that’s six weeks. Like, this is the time that I should be engaging in movement or like trying to look like I did pre-pregnancy.

Angela: And thank you so much also for bringing up, you know, obviously, there’s all kinds of physical changes that happen throughout pregnancy and the postpartum period. And we talk in the eating disorder field, we talk a lot about, you know, puberty being this major event that can trigger on an eating disorder. And we talk about that ad nauseam, you know, puberty, puberty. And it’s like, we’re not talking about the fact that postpartum is also a major physical change and menopause and we’re not talking enough about, you know, the physical changes that happen out, you know, beyond puberty.

Angela: Right. I mean, return of menses is a big one. Like, I mean, we think about like, menopause, which also doesn’t really talk about much. We talk about puberty. But again, there’s that like you said, Sam, like there’s this like middle piece that people are like, wait, am I supposed to navigate this on my own? Like, what is typical, what is normal, what is not normal, who do I go to, you know, so there’s a lot of questions, not a lot of answers.

Sam: Yeah, yeah. Okay, let’s move on to another true or false before we, you know, use the whole episode to just chat here. Okay, true or false, in the postpartum period, changing bodily functions such as hair loss and return of menses can cause severe distress.

Angela: True. Absolutely true. 100%. Actually, like, it’s so interesting that you’re asking this question because this surprises people. I would also add, like night sweats, too. Like body odor, hair loss. I mean, and when we think about these things, sometimes they happen immediately postpartum, like body odor or night sweats. But the hair loss doesn’t happen right away. The hair loss happens like months after giving birth, right? So and people are like, whoa, oh my gosh, I am shedding so much. And like, this is a personal anecdote. Like it surprised me. Like no one ever said anything about hair loss. And I am like, my hair was thinning. I was like, what is happening? I would go take a shower and there would be like clumps in the drain, not to get too graphic, but it would be really, really scary. Or like, you know, in that, in that period. And like, if you have a partner or people living in the home or your supports, they’re like, oh yeah, that’s just what happens, I guess. Or like, whoa, is everything okay? And we don’t know. So. Yes, it is absolutely true, and it scares people. People are like, I didn’t realize that this would be the trigger for me. And if the individual has an eating disorder or history of and they have lost their hair when they were malnourished or deep in their eating disorder, it can absolutely be like a resurgence of like memories or thoughts or urges, behaviors.

Sam: So these changes surprise people because they weren’t expecting it, they don’t know what’s causing it. It sounds like there’s just like not enough information and preparation about what to expect in the postpartum period.

Angela: Correct. I think also there’s this like idea when you’re pregnant, right, it’s like that pregnancy glow and not everyone has and I’m still convinced that is like a fib, but, you know, like there’s this like, oh, you’re glowing in pregnancy. And then like all of a sudden, like your hair becomes fuller and maybe it’s the prenatal vitamins that you might be taking, you know. And so like your nails become longer, you become like your skin is clearer. And then in postpartum, those same hormones, it’s a hormone drop. Right. That’s what that’s what they say, like related to hair loss, that it’s a hormone drop that causes the hair loss. The same hormones that increase during pregnancy that cause your hair to be fuller and that causes like glow. Um, but we praise the glow and the hair being full during pregnancy. And then all of a sudden in postpartum, when the person is like the most vulnerable in many cases, then all of a sudden they’re going through this bodily functions that might lead to them thinking that they’re unattractive. Again, this is all like, you know, we think about conventional women here, right? Like the attractiveness or like feeling fulfilled, being loved, like the things that, you know, make me even make them feel good.

Sam: Or like youthfulness. It’s sort of like, have I now that I had a child, is my youth gone? Because in this culture, we glamorize, you know, youth. I imagine that plays a role, too.

Angela: All of it plays a role.

Sam: Okay. Next question. True or false, exercise can be resumed after the first week of birth in the postpartum period, regardless of the birth story.

Angela: Oh my gosh, please, false.

Sam: I think our audience, they’re probably answering along. They’re like, no, that is not right.

Angela: No, despite popular belief. Despite popular belief, people do believe that is true, and that is so false. I can’t imagine exercising a week post-birth. I mean, your body has a lot of feeling to do, no matter what your birthing story is.

Sam: So Angela, if you had a client who was working on their relationship with exercise, how would you help manage their expectations around movement in the postpartum period? What would you want them to know?

Angela: Yeah, I mean, I think I typically just normalize how difficult it might be. And I tried to bring in as many supports as possible. When we think about like motivations to exercise, like what those are, because they’re going to be busy and sleep deprived and just remaining curious as to like, what is happening that you’re focusing in on movement? I mean, we can probably assume, but a week or two or even like six weeks postpartum is way too early for the body. That like, you know, we also want to just acknowledge a hustle culture and getting back to and doing the things as if you didn’t your body didn’t go through this major, if you have C-section major surgery, but you know, this birth and all the things that come along with it, milk comes in. I mean, there’s like beyond the birth, we think about like a complication of pregnancy. It’s the postpartum depression, perinatal mood and anxiety disorders. Whereas someone with an eating disorder or disorder relationship with movement can be at risk for. So really part of the education process is you might notice urges for this to increase. And so we want to remain curious. We want your supports to remain curious. And I want you to bring it up here to reduce that shame.

Sam: Absolutely. Okay. Next question. True or false? One may experience identity issues, loneliness, resentment towards their partner, and even intrusive thoughts during the postpartum period.

Angela: Absolutely true.

Sam: Yeah. Can you say more about it?

Angela: In fact, intrusive thoughts, I think some research shows some data is like up to 90% of birthing individuals will experience intrusive thoughts following birth.

Sam: Like what? Maybe we can normalize. I’m sure there might be some people out there that are horrified maybe at the type of thoughts that they’re having. So maybe we can just like normalize.

Angela: Yeah, yeah, yeah. Am I feeding my baby enough? Will I be a good enough parent? I mean, it could be things like, am I capable of doing this? Did I lock the freezer tight enough with breast milk? Oh gosh, did I sanitize that? So those are just some typical intrusive thoughts that people might have like, oh, is the baby breathing is a big one. Is like, how do I know the baby is breathing? Am I like, am I going to sleep through the baby crying? You know, is another one. So those are common. Am I feeding like a baby hungry right now? Am I feeding, especially if they’re breastfed or they don’t have, like they’re not pumping and that they can’t see the amount of ounces, like there could be a lot of issues of thoughts related to like, am I producing enough? How do I know it’s enough? How do I expect that?

Sam: Yeah. I hear a lot also sometimes, you know, after having a child, there’s this expectation that I should be immediately bonded with my child. Are there thoughts around that?

Angela: Very much so. I mean, I think there’s like a whole culture of being enamored with your baby and like what it means when you’re, it’s not like the best time of your life. Just a small anecdote if we have time, but I had a client once who came in and said, you know, it was a very interesting conversation. They went to the grocery store, and they were holding a screaming infant getting formula. And then they saw this like this person was right behind them on the checkout line. And then they said something well meaning, of course, it’s all coming from, I think a good place. But this individual behind them was like, oh, this is going to be the best time of your life. And you must be so in love with this time period as this person’s like holding a crying infant, hasn’t showered, like being like, this cannot be the best time of my life in this very moment. Like I am not feeling those things. So I think that like, again, the person in the checkout line did not, of course, mean to increase shame or guilt or anything like that. But I do think there is this notion that people should just be bonded quickly and in love with early parenthood or parenthood in general. That is not really the case.

Sam: Yeah, yeah. I think it’s so important to talk about that, that it’s okay if you’re not feeling that way. Okay, let’s move on to last question. True or false? Postpartum and postpartum depression are interchangeable terms.

Angela: False.

Sam: Yeah. But we hear people say this a lot, right?

Angela: Yes. I mean, it’s so interesting, because we’ll talk about I think we’ll talk about this too. But like, postpartum is that time period, right? But like postpartum depression isn’t the only perinatal mood and anxiety disorder that exists.

Sam: Yes, we have to dive in all of the different experiences that one might..

Ashley: So can we dive in, Angela? Could you kind of define like not only postpartum depression but like the perinatal and mood anxiety disorders and what we’re likely to see with somebody?

Angela: Yeah, yeah, yeah. Okay. So we’ll start with postpartum depression, which is a perinatal mood and anxiety disorder. And I guess like my biggest thing is like moving away from calling it postpartum depression, not to reduce like the, well, of course, to reduce stigma, but not to reduce like the amount of people who have postpartum depression, because it is most common and very prevalent. But again, it’s not the only diagnosis that exists for postpartum individuals. And I think that because of that, a lot of the other mood and anxiety disorders often get misdiagnosed or under screened or not really shown. So, we’ll start with postpartum depression because it is the most common, one of the most common. And this might look different depending on the person, but usually this is what people think about for that postpartum period when someone says, I have had postpartum issues, they usually think of postpartum depression. But symptoms can be like sad, crying a lot. Of course, there’s intrusive thoughts, but it could also be about rage. It could also be like intense anger, irritability. When we think about depression, like sometimes people are crying and blue, sad and blue. This is also, we’re talking about something that lasts more than two weeks. Because baby blues happen for like 85, 70 to 85% of individuals. Very common and it’s like the non-disorder. So when we talk about like perinatal mood and anxiety disorders, we’re talking about something that surpasses those first initial two weeks.

Sam: I see. So the baby blues will usually resolve after about two weeks.

Angela: Two-three weeks.

Ashley: And then perinatal mood and anxiety disorders could pick up… So we mentioned that like postpartum period could be like 12 to 18 months. How long can the perinatal mood and anxiety period be?

Angela: The same amount. Even actually, like I recently read, I was talking to another PMHC and we were looking at a research article and it can say up to 18 years. In fact, if it’s not properly managed and treated, which is interesting in terms of like, if the child goes away, things like that. But yeah, so if it surpasses like two to three weeks, then you look into perinatal mood and anxiety disorders. And if it’s postpartum depression, it might show up as irritability, anger, resentment, difficulty concentrating, sleep disturbance that is not influenced by the baby waking up. So it might be like, having a hard time falling asleep when there’s ability to fall asleep. When the baby is sleeping, having a hard time staying asleep or going to sleep themselves. Again, like there’s a lot of crossover with other perinatal mood and anxiety disorders. So that’s why proper screening and diagnostic tests are important. So, but I often see like difficulty concentrating, making decisions, feeling really overwhelmed by like tasks. So say someone’s going to the grocery store, we use that as an example, and they are just flooded with thoughts, like, does it even matter? And do I even, who even cares? Am I even a good parent? Should I even be a parent? Like maybe the baby would be better off with another mother, another parent. So these are like very common thoughts in postpartum depression. They’re often personalized, is how I describe it to my clients.

Ashley: Okay.

Sam: Personalized (inaudible) thoughts about how you are, your ability to be a good caretaker.

Angela: Yeah. And a bad mother, I can’t provide well. I should have never done this. Maybe my baby should be taken away. Maybe I’m just not capable. So those types of really dark, heavy thoughts.

Sam: Yeah.

Ashley: So what about postpartum anxiety. That’s another one we hear.

Angela: Yeah, yeah, so postpartum anxiety often can follow with postpartum depression, similar to how depression can show up even outside of that postpartum or perinatal period. But postpartum anxiety, these are more about like hypothetical future situations like, what if my baby is not getting enough food? What if like the doctor like doesn’t think that the baby’s growing like enough or I’m not doing a good enough job, what if like… they might be, they might be doing a lot of comparison around like, Oh, like my baby’s not hitting this milestone, but this person’s baby is like, what does that mean about me? Like, should I be doing something more? Right? So it’s like, it can be a lot of like those. It’s also just as common as postpartum depression. So those are the two most common perinatal mood and anxiety disorders that we’ll see. Again, I have my theories. Is it because they are screened most often? They’re known by most providers more. Whether or not they’re more prevalent than the other perinatal mood and anxiety disorders, I’m not totally convinced. I just think there’s much more awareness about them.

Sam: They’re just getting caught more frequently, but there’s maybe people suffering in silence with some of these lesser known issues.

Angela: Yeah, or like don’t fit what people think as depression or anxiety, you know? Which looks different in like minorities, people of color, LGBTQ, it just might look different. And like how people experience depression and anxiety, it may not be being sad or crying all the time. Right. It might be, you know, so like they get missed all more prevalent than other individuals.

Sam: Right. How does it present differently for some folks?

Angela: Yeah. I think it’s more like so reporting from some of my clients, it’s more like I just feel overwhelmed. Like I just feel like confused more or I feel like I can’t do this enough. So it’s a lot about like strength and like weaknesses rather than like looking down and sad and like are less likely to be upfront with their symptoms.

Sam: Yeah, that makes sense.

Ashley: And I think I read somewhere, or may have heard you say this, Angela, in one of your talks, that transgender parents are three times more likely to experience postpartum anxiety than non-transgender parents.

Angela: Yeah, so it’s trans and LGBTQIA, but specifically on trans parents. The three-fold statistic mostly comes from, like largely comes from, in comparison to like cisgender adults, they just have, they have more risk factors, right? So they’re less likely to take medication in that postpartum period, they’re less likely to have like a care, good care that’s non-discriminatory. They’re more likely to seek fertility treatments. So like that already places someone at risk for anxiety and depression. When we think about eating disorders and our LGBTQ community, they’re just at a higher risk for suicide in general. They’re more likely to be diagnosed with mental health struggles, which places someone at a higher risk for postpartum struggles. So, you know, when we think about like suicidal ideation attempts, suicidal attempts, like they’re the risk is already higher for our LGBTQ community. Plus, right, and our BIPOC communities. And so you know, the statistics that you read from PSI, they’re actually when we think about our BIPOC communities and our LGBTQ communities, they’re actually like twice as likely to be diagnosed with a perinatal anxiety disorder but trans individuals specifically are three times more likely for anxiety. Which is staggering when we think about that.

Ashley: Yeah, it really is. The thing on infertility or fertility treatments kind of got like that makes sense because just in and of itself, that is an anxious activity, right? Because you really have no idea how that’s going to turn out.

Angela: Exactly. And like who your fertility doctor is. I mean, we’re not even touching upon weight stigma. So if there’s an intersecting, like who’s willing to work with you, like what their knowledge is, like you’re putting yourself, you’re like, okay, in order to have a baby, do I just put up the discrimination? When we think about fertility treatments too, like you’re putting yourself at risk for more than one baby, right? And I say risk because you’re already high risk when you are carrying, triplets or twins, right? And so like you’re likely to have a C-section early. And I get, I said likely, you don’t, that’s not always the case, but more likely than not, you’re going through a major surgery like C-section and birth trauma can increase, especially if it’s an emergency C-section. So we really have to think about like all of the ways in which our community or the LGBT community is compromised and has like space and room for discrimination and oppression.

Sam: Absolutely, yeah.

Ashley: So you just mentioned birth trauma. Can you speak to postpartum PTSD?

Angela: Yes. So if we look at the amount of things that could happen in birth stories, so everything can be planned. You can go and be like, I would like this, and this in my birth. And babies do what babies do, right? And so like they might come early, you might have some complications in pregnancy that already puts you at high risk. So about an estimated like nine to 10% of individuals report having PTSD following birth. Wow. And this could be related to like prolapse cord,
pre-eclampsia or eclampsia. It could be due to like tears that weren’t taken care of, hypertension, things like that throughout pregnancy and into that birth. Emergency C-sections that were not properly given, like the person was not in charge of their decision. And I think that was the biggest key, is that like it could be actual or perceived, like loss of autonomy. So even if the individual is perceived to like not have choice, that person can experience postpartum PTSD. So it’s all about being in the know. And oftentimes like well-meaning, OBs, midwives, people, nurses, like will take action without giving all of the information to that birthing individual. And so that birthing individual is already going through a lot unknown. And then also like these medical interventions are done without them knowing. Or without being fully informed.

Ashley: Wow, that, I mean, that one sounds quite intense and sounds like something that could really come up for somebody at any point, you know? I’m thinking like immediately after birth, we’re so caught up in just like, like managing like how to, what do I do here, right? Do I get sleep… So I can imagine the PTSD might not set in until later, and then really start to disrupt. Yeah, their patterns.

Angela: It might actually even show up as like, postpartum panic attacks or anxiety. And like, until the dust settles, whatever that means to that individual. So after a certain time, they might experience flashbacks or nightmares, or they might not even know that they are experiencing PTSD until like, they’re thinking about another child, if that’s part of their plan, or not their plan, but part of their life, you know, so you know, they might be like, oh, I remember this, this I didn’t realize. And now I’m having so many flashbacks or intrusive memories, or even like outright avoidance. When we think about the diagnostic criteria for PTSD.

Ashley: Hey, Angela, I have a couple more, but I also want to like move into some other questions. Yeah, it’s so fascinating. I’m like, should we do two episodes on this? So the last two are postpartum OCD and postpartum psychosis. Can you speak to those?

Angela: Yes, OK. So I’m going to do postpartum OCD first because this one, I think you probably have heard me talk about it, but this one is so close, near and dear, because I’ve had so many clients come to me who are like, oh, I have postpartum depression, or I was told I have postpartum depression when really it’s postpartum OCD, or they have postpartum anxiety when really it’s postpartum OCD, or they’re so afraid of telling me their intrusive thoughts because of what will happen. And this goes into postpartum psychosis because, you know, some people have been hospitalized because a clinician got it wrong. They thought that it was postpartum psychosis when really it was postpartum OCD. So postpartum OCD is so misunderstood. And I think this is why I love it because I like all about educating. We have to understand what postpartum OCD is. And it’s misunderstood because people are like, what is it? Is it psychosis bipolar? Is it like, you know, just general anxiety? And then treatment often fails folks with postpartum OCD. But when we think about new parents and we, we talked about postpartum PTSD having a 9% to 10% prevalence rate, right? But postpartum OCD actually has, it’s an 11% prevalence rate of folks who have been diagnosed. Now again, this is leaving out a lot of people who fly under the radar.

Sam: Right. Or are getting misdiagnosed.

Angela: Again, misdiagnosed, right? Right. But we, they’re marked by obsessions. So like this is like intrusive recurrent. thoughts that we talked about earlier, and usually followed by compulsions, similar to like a general OCD without that postpartum focus. Obviously, it’s with the baby, and it can actually emerge for the first time during that postpartum period. So a lot of people may not have had OCD or like maybe they had it when they were like pediatric OCD and then they overcame it. Maybe they did some exposure. Maybe they didn’t. Maybe they just like moved on from the pediatric OCD and then the postpartum period really triggered it. But it’s followed by compulsions. Now this is where I think a lot of clinicians get tripped up because the compulsions aren’t always behavioral. Sometimes they are. Sometimes it’s like, I’m having intrusive thought that I need to clean the baby bottle more, more and more and more. And so they won’t sleep until they clean it like more times. Sorry, we talk about the germ focused type of OCD. But then you have mental compulsions, which I think. Most of the time, my clients come in with a lot of mental compulsions. So this is like today. Am I sure that I locked the front door? Did I close that window? And sometimes it follows a behavioral compulsion of like checking the window or checking the front door. But oftentimes it’s more like, let me check to see in my head if I did that. Am I still having that thought or like, you know, am I sure my baby loves me? Like, how do I know that I’m like bonded enough? Like, and like, you know, kind of mental reviewing and trying to neutralize the distress mentally. So that’s like a huge part of postpartum OCD that I think a lot of people get tripped up because they might have the thoughts, but they may not have like the behavior that was like really delaying. them leaving the house. It could also look like I’m going to be driving with my baby and then, but am I sure I like locked them tight enough in the car? So they might pull over and check and check. And so this is more of like the checking behavior. But sometimes it’s even like thinking back, like, what steps did I take? We also see a lot of avoidance in postpartum OCD. So I have a bunch of people who come in, they’re like, I won’t even take my baby out because what if I drop them? And so I’ll avoid driving with the baby in the car or like going near the laundry room is a big trigger for people. So like, what if I like accidentally like throw my baby in the washing machine or I give into this intrusive thought and so I’m not going to clean any clothes. I’m not going to cut food for my baby in front of them because what if like I stab them? That’s another big one. It’s like what if I stab my baby with this knife that I’m cutting food? So, you know, those are very, very common types of intrusive thoughts and types of convulsions that we might see, in which case exposure therapy would be what’s recommended or like inference-based types of stuff. Like how, what are you inferring by this, by your ability. Um, you know, because most of the time folks with postpartum OCD don’t follow through with their intrusive thoughts, you know, so they’re ego dystonic, which is what I like to say, which means that you can have the, they’re the person with OCD in that postpartum period knows they’re not comfortable with those thoughts. And if like for, for anyone listening to this, like that is the biggest difference between postpartum OCD and postpartum psychosis that like, my clients with postpartum OCD know that it is not a thought they want. It brings them great distress and they will do anything and everything to keep their supports and their baby safe. To the point that they like, you know, don’t do like basic living because they don’t want to hurt anyone. So it’s very debilitating.

Sam: Yeah, absolutely.

Ashley: And so the postpartum psychosis then, there might be that follow through with the intrusive thought.

Angela: Yes. So with postpartum psychosis, ego syntonic. So the person does not know that they are in unreality. It’s very rare, like much, much rarer than we think. It happens like one to two in every thousand births. It usually shows up in that early postpartum period but remember like the postpartum period is up to 12 to 18 months. So like sometimes we see symptoms increase, you know, six months, 10 months in. With postpartum psychosis, we usually see within the first one to two months, but you know, not everyone. But this is a medical emergency. There’s a high rate of suicide too. So like, it’s, you know, I think a lot of people are like, oh, postpartum psychosis, you’re definitely going to kill your kid. This is a huge misnomer. There is a risk of a fantasize for sure, which is why it’s a medical emergency if someone has postpartum psychosis. But it’s a medical emergency, not just because they might kill their child, but also they might kill themselves. So. there’s a high risk of suicide and a fantasized. So we just want to like, that’s why it’s important to kind of make sure you’re screening and that like we are getting that support that’s needed, which unfortunately not every state has services needed for perinatal mood and anxiety disorders. And, you know, I know we’re talking about psychosis, but if you have someone or if you yourself have postpartum depression, like, doesn’t mean that it’s going to turn into like, postpartum bipolar or postpartum psychosis. So I think there’s a lot of like misnomers there. And if I experience depression, then it’s going to be bipolar or it’s going to be psychosis. And that’s not always the case.

Sam: So Angela, switching gears a little bit, let’s talk eating disorders.

Angela: Yes.

Sam: Yes, so someone who is in recovery for an eating disorder, or maybe they’re just, you know, at elevated risk of developing an eating disorder. What are some of the challenges in this period, in the perinatal period? What are signs and symptoms? And what does care look like in this period?

Angela: So, well, It’s important to delineate a few things because there are some people who become pregnant, who have an active eating disorder. And then there are people who are in sustained recovery and become pregnant with a history of an eating disorder. So we’re kind of like we’re working with not two different camps. I know there are many people in the middle too with disorder eating or like you know, in a regular relationship with movement or food or disorder relationship. But, you know, for the most part, this is like, you know, if we were to put them in two categories, those are the categories that we’re kind of working with. So if someone is in sustained recovery, we just want to make sure that they are, you know, that the thoughts aren’t coming up for them. And this is like the perinatal in pregnancy, because they’re going to be seeing a doctor more often, we’ll assume, and this is a, like, I’m going to say normal pregnancy, because this is like the medical field. But if they are a high-risk pregnancy, which I believe everyone with a history of an eating disorder or with an active eating disorder is already a high-risk. But, you know, medical community doesn’t always agree. So if they are going through a normal pregnancy, they are just seeing their doctor more frequently up until like, it’s like once a month, and it’s every other week, we’ll say will follow just again, like a low-risk pregnancy and then after 35 weeks, they see their doctor or midwife weekly. Now, in that, if they are high risk, they’re seeing the doctor more frequently and they’re getting weighed more frequently. So even if someone is in sustained recovery, they might just be confronted, they will be actually confronted with a lot of the things that maybe have healed in the past for them, right, their body is changing, literally overnight, you know, and they’re just going through a lot of discomfort. So we want to just be careful about like how they might be what might be going on for them mentally, behaviorally, what a meal times look like, and that again, like this is the perinatal period, so we have pregnancy, but then also that postpartum period, like, you know, are the only feeding baby are the only concerned with the amount to feed baby? What does that look like for them? How are they nourishing themselves? Are they taking care of themselves? What are their thoughts like? Now it’s also important to remember that even if someone has struggled with recovery, maybe they had been diagnosed with eating disorder, maybe they have received treatment and they get pregnant, there’s a high likelihood that they’ll go into remission in pregnancy, right? And so, it’s like upwards of 70% will go into remission in pregnancy because they’re like, oh, look, I have to get healthy. I want to work on my relationships that way my child has a better future. So I don’t pass this on. I know there’s a genetic component, but also like environmental and like social. So we think about all of that. People are really motivated by being able to be like a healthy, nourished caretaker. And so, and usually like supports are on board, they’re like, okay, like, yes, we will help you out. This is like, you know, it’s like a community thing for the most part. In the postpartum period though, the people who, not everyone, but majority of folks who go into remission struggle in that postpartum period. So for clinicians or for individuals or loved ones who are supporting someone in that postpartum period, it’s important to like know the warning signs. So this might look like being overly concerned with body shape and size, regardless of diagnosis, avoidance of seeing people, avoidance of like pictures being taken. It might, you know, behaviors might switch, like diagnosis might fluctuate. So someone who maybe was like a binge and purge prior to pregnancy, went into remission, it might look like more like binges or restriction in that postpartum period and that, you know, we have to, we can’t as oftentimes pull praise. It’s like, oh, well, no longer using like, you know, methods of purging, whether it be by exercise, laxatives, or vomiting, but I’m, oh, but look, like I’m not eating as much and that might be missed. So, you know, some things kind of look out for. A big one too is increased obsession with breastfeeding or nursing or donating to milk banks. Every time I give my presentation, I get one to two clinicians who come up to me and talk about or loved ones or supports who come up to me and say, what if the person doesn’t want to stop donating milk because of the myth that breastfeeding leads to weight loss. Or breastfeeding can be pumping, it could be feeding by breast, but it could also be donating. You may not be feeding your own baby, but you might be giving the donations, like having a stash of milk. That’s a method for weight loss. No longer becomes the motivation, the values shift is what we often see and like it’s tricky because we want people, you know, to do what fulfills them and also the motivation, you know, we do have to assess what is going on, you know.

Sam: Of course. Yeah, we always want to dig in. What’s the intention behind the behavior? Is it the eating disorder driving it or your values? And that comes up so much in eating disorder care. And it’s really an important distinction.

Angela: Yeah. So that’s what I would say. are those like the things that we might see. Of course, like, you know, it might be talking a lot about body image. I mean, body image is huge. It’s actually like, when we think about relapse occurring from an eating disorder in that postpartum period, it is the body image, thoughts that are very prevalent related to that. So getting, again, we talked to just like, I guess, move back, right? We talked about like bouncing back, bounce back culture, getting your pre-baby body back, whatever that means. You can’t have a baby now, so there’s no pre-baby body. But it’s that intention of I need to look a certain way, I need to be loved, I need to be liked, be part of what I used to know. So the body image piece is huge and it has to be part of the conversation.

Ashley: Yeah. Angela, I’m curious. I’m going to spring this on you for a second. We are getting close to time. And we were curious if you would come back.

Angela: Yes, I know. I’m like, we have so much to talk about. I know. I’d love to come back.

Ashley: We do a second episode. Because I would really love to dive into this body image piece. I would love to dive into this bounce back kind of expectation piece. Even with the mental health, right? Or the physical health, like I’m thinking of folks that maybe had a medical condition, a C-section or had the, you know, a prolapse or something like that. And then we’d love to hear about like, how can the family and loved one, like how can the family system support, you know, our birthing parents, the person that’s experiencing this. So would you be willing to come back?

Angela: Oh my gosh, I would be honored.

Ashley: We need a part two. So everybody listening, put a pin in there. We’re going to bring you back.

Angela: Yay.

Sam: Yes. In the meantime, Angela, how can listeners get in touch with you, any resources that you could share?

Angela: So many resources. Well, first you can get in touch with me. You can feel free to email me, whether you’re a clinician, I offer consultation, or if you’re a client needing any resources, or like me to expand on anything that I talked about here, it’s at [email protected]. And yes, there’s so many resources. And I think that what might work best is if we link them. So we’ll link most of them. Just for like continued like learning around the things that we’ll talk about mostly in part two, but PSI, um, Ashley, you talked about Postpartum Support International. This is a really great hub for all things. They have support groups, which we’ll talk about a care team, hopefully in part two, but care team is really important in that postpartum period and support groups are a huge part of that. So finding community of like, of people going through something similar to bring to light, like other symptoms that you might be experiencing. Um, so PSI, um, there’s also some really great books, like Good Moms Have Scary Thoughts, which I love. There are some really great prompts in there. There’s also 2020 moms, which has recently changed their name to Policy Center for Maternal Mental Health. They actually like, so no matter where you’re listening from, what they do is they look at your state and they give the state a grade as to the resources available to you in your state. So it’s actually one of my most used resource in terms of like what’s available in terms of like mental health resources for postpartum individuals, perinatal individuals. So, I highly recommend those.

Ashley: Awesome. Thank you so much, Angela.

Angela: Yeah, of course. Thanks for having me.

Sam: Yes, we learned so much and I know our audience has too. And I am looking forward to part two.

Angela: Me too.

Ashley: See you soon. Thank you for listening with us today on All Bodies, All Foods, presented by the Renfrew Center for Eating Disorders.

Sam: We’re looking forward to you joining us next time as we continue these conversations.

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