As of this past December, I had not prayed the rosary in over a decade. It turns out, it takes a long time. Too long, in fact, if you’re about to throw up.
My husband and I were at a relative’s funeral. I was five weeks pregnant. My in-laws and I had just taken a three-hour ride from Denver to a small town in Nebraska where the service was being held. I’d anticipated morning sickness, of course, but this was something else. This was pregnancy vomiting of positively Dr. Seussian proportions: On the chair! On the floor! On your in-laws! By the door!
I thought that was the worst of it. But at the service, a few rosary Hail Marys in and I was nudging my husband in desperation, mouthing my urgent need to find a bathroom. That night, while my husband was out buying the Mike & Ikes and soda I requested (a very bad idea that sounded good at the time), I curled up with our dog in our hotel bed and wondered what the hell I was going to do if this continued.
It did. I lost 20 pounds over the first few months of pregnancy; no matter how much I ate, I rarely kept anything down. “It stops after eight weeks,” people (including my doctors) said at first. Then: “It’ll get better after the first trimester.” It didn’t. Finally, in the fourth, fifth, sixth month of this, people started responding wide-eyed, simply: “Still?” Yes. Still.
Hyperemesis gravidarum, or HG, is severe nausea and vomiting in pregnancy, which can sometimes cause extreme weight loss and dehydration. It affects up to 2 percent of pregnancies, and I was part of that unfortunate minority. I felt sick all the time, sick enough to cry (and I often did), the kind of sour-sick that makes its way into your aching muscles and your brain and your bones and regurgitates itself, regenerating again every time you try to eat or drink.
I counted the times I threw up each day: five, eight, sometimes into the double digits. Three times a week, I threw up in the grass outside the (bathroom-less) college classroom where I was about to teach, peering sideways to make sure no 18-year-olds witnessed me and decided to include this in their evaluations. I went to my prenatal appointments faithfully, and took the anti-nausea medications they prescribed, but nothing stuck until, at about six and a half months pregnant, I was finally so ravenous that my body seemed to give up its rebellion.
Jokes about “morning sickness” (a misnomer if ever there was one) are common and familiar to expecting moms. While they were funny, or at least harmless, at first, I grew to dread them. I started to resent the cavalier way they seemed to undercut the deep physical and emotional distress my condition was causing. We’re often expected to smile through pregnancy complications, given their happy reason for existing, but it doesn’t always work that way.
Pregnancy complications and mental health are tricky bedfellows. On one hand, if we're too straightforward about how they intersect, the material realities of your distress fade into the background of a really boring, predictable film called “Hysteria & Pathology, Vol. 310.” If we treat all pregnancy issues as purely physiological, and we risk missing out on the whole complex picture of what causes them.
It was originally posited that HG was a “conversion disorder,” or a neurological condition with no physiological origin or explanation. Some researchers have pushed back against this belief, arguing instead that HG is not a psychosomatic condition, but instead results from “a complex interaction of biological, psychological, and sociocultural factors.”
Still, there is evidence that the psychological component to HG is significant and real. A recent meta-analysis found that women with HG did tend to have higher rates of pre-existing mental illness (especially depression and anxiety). Pre-existing depression, anxiety, and personality disorders—namely, avoidant personality disorder and obsessive-compulsive personality disorder—are all risk factors for developing HG during pregnancy.
Perhaps most importantly, HG significantly increases a pregnant woman’s risk of developing depressive symptoms and even suicidal ideation during pregnancy, as well as postpartum depression after giving birth. Moreover, HG and anxiety can work as a sort of negative feedback loop, with each one exacerbating the other. “Anxiety affects the gastrointestinal tract and is often associated with nausea/vomiting in the non-pregnant population,” says Alison Reminick, a reproductive psychiatrist and director of the women’s reproductive mental health program at UC San Diego. “It would be reasonable to assume that anxiety increases susceptibility for HG. As well, physical symptoms of nausea and vomiting can trigger anxiety.”
We don’t yet have a specific, satisfactory explanation for what causes the onset of HG. Reminick agrees with this assessment, arguing that medical professionals might be tempted to conclude that HG is fundamentally a psychological problem, given our lack of an evidence-based explanation. “When a condition is puzzling, like HG, with no known cause or cure, medical professionals can feel helpless and discouraged that they cannot offer more to alleviate symptom burden and can ultimately dismiss the condition as purely psychogenic in nature,” she says. Treatment, as of right now, includes hydration and alternative methods like acupuncture.
Accordingly, many women with HG describe "not being believed" by physicians or as having their severe symptoms dismissed as signs of irrationality. If a pregnant woman experiences this in any capacity, “it’s time to find a new provider,” says Sherry A. Ross, OB/GYN and author of She-ology: The Definitive Guide to Women’s Intimate Health. “Women have to be their best advocate when it comes to any of their medical concerns," Ross says. "She must insist that her health care provider is listening and hearing her concerns.”
Indeed, the chicken-or-egg dilemma posed by hyperemesis gravidarum—do mental health symptoms cause it, are they catalyzed by it, or both?—is compounded by our societal tendency to dismiss women’s pain as psychological rather than physiological. Research has repeatedly shown that women who present to an emergency department with pain, for example, tend to wait longer for treatment than men who report the same level of pain, and are prescribed pain medication less often than men are for the same conditions. We tend to believe that women’s pain has an origin story, or, worse, that it’s “all in our head.”
If severe pregnancy vomiting, or any form of distress, is in fact caused in part by an underlying psychological issue—what’s the difference in terms of treatment or severity? The truth is, there’s a lot about pregnancy that we simply don’t know, and it’s often too easy to scapegoat another widely misunderstood category of complications—mental illness—and conflate the two, thus discrediting and dismissing the condition altogether.
I began to wonder if my own history of anxiety was somehow related to the severity of my symptoms. The intensity of the physical problems I was having didn’t match up with lighthearted media stereotypes and small-talk tropes about so-called morning sickness.
It’s important to remember that physical and psychological symptoms don’t cancel each other out; one doesn’t negate or lessen the other. Pain is certainly no less real because of its psychological origins, and in fact, is often more demonstrably intense if mental health issues are involved. The doubling of misconceptions about mental health issues and pregnancy alike serves to perpetuate the myth that conditions that originate “in our heads” can’t have material, and severe, consequences.
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