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Postpartum Depression: Diagnosis and Treatment
Postpartum Depression: Diagnosis and Treatment

Section 12
Maternal Eating Disorders and Postpartum Depression

CEU Question 12 | CEU Test | Table of Contents | Depression
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In the last section, we discussed Post-Traumatic Stress Disorder and Postpartum.  This included PTSD and pregnancy and childbirth and PTSD.

In this section, we will discuss Eating Disorders and Postpartum.  This will include pregnancy and the course of the eating disorder and the eating disorder and the baby. If you are already familiar with pregnancy and eating disorders, you might use the first part of this section as a review.

Eating disorders are nearly always marked by an almost fanatical degree of secretiveness.  Luckily, however, it appears that more women, especially those who have struggled successfully to conquer their illness, are now willing to speak about the problem in public.  Many of us, for example, are aware of the late princess Diana’s bingeing and purging, which became worse during pregnancy, and which also appears to have been associated with postpartum depression.

As you may know, bingeing and purging, or bulimia nervosa, is the most common of the three major eating disorders.  Anorexia nervosa is characterized by an extreme restriction of food consumption, to the point where the client can appear skeletal.  The clinical diagnosis of anorexia, in fact, depends upon the client’s having lost more than 15% of his or her body weight.

Both bulimia and anorexia appear to be associated with the client’s need to establish a degree of control in her life.  Because she believes that other aspects of her life are out of control, she seeks to find it in the one place she can, by controlling her food intake and body weight, except, of course, that this is a false sense of control, since in actuality, she has no control over the disease itself. 

If left untreated...anorexia can lead to severe nutritional deficiency, insomnia, loss of bone density, mood changes, fatigue, and even ultimately death as the body’s systems begin to break down from lack of nourishment.  Anorexia can also negatively impact upon fertility.  Bulimia, while not characterized by the same degree of emaciation as anorexia, is associated with serious dental, throat, and intestinal problems, including damage to the esophagus, lungs, and stomach, as well as kidney and heart complications. 

The third type of eating disorder, termed as "eating disorder not otherwise specified," involves periodic bingeing without compensatory purging and is both less prevalent and less physically dangerous than either bulimia or anorexia.

♦ Pregnancy and the Course of the Eating Disorder
First, let’s discuss pregnancy and the course of an eating disorder.  For many years we believed that, because they often stopped menstruating as a result of their extreme weight loss, women with anorexia could not conceive.  Today, however, we know that some women do ovulate, both while they are actively involved in anorexia and when they are in remission.  I have found, perhaps like you that many women who are diagnosed with major depression during pregnancy also have an eating disorder.

One question is whether pregnancy is likely to improve or worsen an existing eating disorder, and the answer to that seems to be that it can go either way. 

Felicia, age 24, is one for whom pregnancy was associated with relapse.  Felicia had begun to experience anorexia at the age of fourteen, but she was admitted to a treatment center and was eventually able to control her disease.  In fact, having qualified as a nurse counselor in private practice and earning a second degree in nutrition, Felicia herself became a specialist in treating patients with complex eating disorders.

When she became pregnant, however, Felicia began avoiding weighing herself at her prenatal classes.  When she occasionally did weigh herself, she either avoided looking at the number on the scale or stood on it backward.  When a nurse brought this behavior to the attention of Felicia’s obstetrician, he began to monitor her more closely until, in her second trimester, Felicia’s lack of weight gain prompted him to ask her point blank if she had been restricting her food intake.

At that point, Felicia became quite agitated and refused to pay any more prenatal visits to that particular doctor’s office.  Luckily, the nurse who had first noticed Felicia’s weighing behavior took it upon herself to make a visit to Felicia’s home.  With the nurse’s encouragement and at her husband’s insistence, Felicia went back into treatment and was able to begin eating normally again, gain weight appropriately, and give birth to a healthy baby, although she still needs to be monitored to be sure she doesn’t relapse postpartum.

♦ The Eating Disorder and the Baby
Second, let’s discuss the eating disorder and the baby.  Obviously, if a woman does not receive adequate nutrition during pregnancy, or if she is constantly purging, her behavior can have disastrous consequences for her baby.  But another serious concern is that women who severely restrict their own eating might also become restrictive of their baby’s.

In one such case... a public health nurse who was making a postpartum home visit noticed that her patient, Trina, was giving the baby her breast for no more than a minute before announcing "Now you're done."  After monitoring the situation for a period of time, the nurse found that the baby was rapidly losing weight.  At that point, the nurse became quite concerned and called the family doctor, who referred Trina to me.

As I learned during our sessions together, Trina had wanted to be sure that her baby, Serena, was adequately fed, but she was equally concerned that she not become fat.  Trina described herself to me as having been a chubby child who was constantly teased during elementary school. 

When Trina reached puberty she had learned to control her weight through vigorous exercise and extremely restricted eating.  Trina had joined the track team and was so good that she later competed internationally and, through her running, managed to shed two stigmas at once: her excess weight and the lack of respect she believed she’d received from her peers.

Trina’s pregnancy had been perfectly planned, the delivery went perfectly, and her baby was the perfect weight.  And yet she continued to have visions of Serena’s turning into a "fat little Trina."  The only way she could see to prevent this from happening was by making sure that the baby didn’t feel too hungry at the outset, as she recalled she had done as a child, and her mother had kept reminding her by telling her how much she’d eaten as a baby. 

What Trina simply didn’t realize was that by restricting Serena’s food intake she was actually jeopardizing her health.  Trina, based on her own past experience and feeling about herself, actually thought she was doing the right thing.

Do you have a Felicia or a Trina who might benefit from hearing this section in your next session? 

In this section, we have discussed Eating Disorders and Postpartum.  This has included pregnancy and the course of the eating disorder and the eating disorder and the baby.

In the next section, we will discuss Bipolar Disorder and Postpartum.  This will include postpartum psychosis and depression and bipolar disorder.

Peer-Reviewed Journal Article References:
Culbert, K. M., Breedlove, S. M., Sisk, C. L., Keel, P. K., Neale, M. C., Boker, S. M., Burt, S. A., & Klump, K. L. (2015). Age differences in prenatal testosterone’s protective effects on disordered eating symptoms: Developmental windows of expression? Behavioral Neuroscience, 129(1), 18–36. 

Hollifield, J., & Hobdy, J. (1990). The course of pregnancy complicated by bulimia. Psychotherapy: Theory, Research, Practice, Training, 27(2), 249–255.

Incollingo Rodriguez, A. C., Tomiyama, A. J., Guardino, C. M., & Dunkel Schetter, C. (2019). Association of weight discrimination during pregnancy and postpartum with maternal postpartum health. Health Psychology, 38(3), 226–237.

Lafarge, C., Usher, L., Mitchell, K., & Fox, P. (2020). The role of rumination in adjusting to termination of pregnancy for fetal abnormality: Rumination as a predictor and mediator of posttraumatic growth. Psychological Trauma: Theory, Research, Practice, and Policy, 12(1), 101–109.

Mitchell, A. M., Porter, K., & Christian, L. M. (2018). Examination of the role of obesity in the association between childhood trauma and inflammation during pregnancy. Health Psychology, 37(2), 114–124. 

Watson, H. J., Zerwas, S., Torgersen, L., Gustavson, K., Diemer, E. W., Knudsen, G. P., Reichborn-Kjennerud, T., & Bulik, C. M. (2017). Maternal eating disorders and perinatal outcomes: A three-generation study in the Norwegian Mother and Child Cohort Study. Journal of Abnormal Psychology, 126(5), 552–564. 

Online Continuing Education QUESTION 12
What need does an eating disorder often fill for a person? To select and enter your answer go to CEU Test.

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