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A Pregnant Woman's Fear of Her Baby

Received November 10, 1999; revised March 16, 2000; accepted May 31, 2000. From the Department of Public Health Sciences, Wake Forest University School of Medicine; Department of Psychiatry and Behavioral Medicine, University of South Florida. Address correspondence and reprint requests to Dr. Brenes. Wake Forest University School of Medicine, Department of Psychiatry & Behavioral MedicineMedical Center Blvd, Winston-Salem, NC 27157; e-mail: gbrenes{at}wfubmc.edu

Key Words: Phobic Disorders • Pregnancy

It is not uncommon for women to experience pregnancy-related anxiety,^1–3 especially with respect to fear of the delivery, worry about death, and maternal separation. An often overlooked source of anxiety during pregnancy is fear of medical procedures, including blood draws and needle sticks, which are a standard part of prenatal care. Although fears of medical procedures are relatively common and such phobias may lead to decreased medical care,⁴ the effect of medical-procedures phobias on prenatal care has not been examined. We describe the successful treatment of a pregnant woman with numerous anxieties related to her pregnancy and prenatal care, including a fear of medical procedures and needles as well as emotional distress related to having a fetus living within her body.

Case Report

Mrs. D., a 23-year-old married White woman, presented for psychological treatment at a university-based outpatient psychiatry and behavioral medicine clinic because of her fear of needles and medical procedures. Mrs. D. sought treatment at this time because she was 29 weeks pregnant, and the routine prenatal medical procedures (e.g., ultrasounds, blood tests, etc.) and physician visits were increasing in frequency, resulting in a significant increase in her anxiety level. Although her pregnancy was unplanned, Mrs. D. reported that she and her husband wanted to have children. However, because of her extreme fear and aversion of pregnancy, they had planned to adopt children.

By the 29th week of her pregnancy, Mrs. D. had tolerated two blood tests as part of her routine prenatal care because she was too "embarrassed" to refuse. However, she had refused all optional tests. Mrs. D. stated that she became extremely anxious when she was thinking about or was reminded of her pregnancy (e.g., attending doctors appointments, feeling the baby kick, or thinking of the delivery) and had hyperventilated multiple times. Furthermore, she reported having nightmares before undergoing any medical procedure. Mrs. D. expressed a strong desire to have a cesarean section under general anesthesia so that she would not be aware of the birthing process. In addition to her fear of the medical aspects of pregnancy, Mrs. D. expressed intense anxiety related to carrying the fetus within her body. She stated that she felt "weird" about having a baby living inside her, and her anxiety increased whenever she felt the fetus move, saw the heartbeat of the fetus on the ultrasound, or was otherwise reminded of her pregnancy.

Mrs. D. reported that she had been afraid of needles since the age of 9 when a physician attempted to give her an injection during a routine visit. She reported that neither she nor her parents could identify any precipitants related to her intense anxiety and behavioral reaction. Although 33%ndash;50% of individuals with blood, injury, and injection phobias have a positive family history,^5,6 Mrs. D. denied having a family history of specific phobias. Furthermore, there was no known history of pregnancy-related anxiety or ambivalence in her family or close acquaintances. Thus, there was no evidence that genetic or modeling factors contributed to the etiology of her problem. Mrs. D. was unable to recall when her fear of pregnancy developed, but she had discussed this fear with her husband on multiple occasions before her pregnancy. Otherwise, she reported no history of psychiatric problems. She acknowledged having a family history of alcoholism in her mother, but no personal history of substance abuse.

Assessment and Diagnosis

Mrs. D. presented as a well-groomed pregnant woman. Her affect was pleasant, but she became very anxious and tearful when discussing her dislike of needles and her pregnancy. Mrs. D.'s complaints were consistent with a diagnosis of specific phobia, blood-injection-injury type, based on DSM-IV criteria.⁷ She had a consistent and excessive fear of needles and medical procedures (Criterion A) since the age of 9 years and experienced an immediate anxiety response when exposed to these stimuli (Criterion B). Although Mrs. D. recognized that her reaction was excessive (Criterion C), her fear was interfering with her daily life and her prenatal care (Criterion E). She refused optional medical procedures and experienced intense anxiety reactions when she was unable to avoid needles, medical procedures, or physician appointments (Criterion D). Her symptoms included subjective feelings of anxiety, hyperventilation, nightmares, and avoidance of recommended but optional medical procedures. Mrs. D.'s presentation did not fulfill the criteria for any other anxiety disorder, including posttraumatic stress disorder (because her fears did not follow a life-threatening event), obsessive compulsive disorder (because her thoughts were simply excessive worries about a real-life problem), or generalized anxiety disorder or panic disorder (because her anxiety was specific to needles and medical procedures).⁷

Findings on psychological tests administered during her first visit supported this diagnosis (see Table 1). On the State-Trait Anxiety Inventory,⁸ Mrs. D. scored extremely high and well within the clinically significant range on measures of current anxiety and propensity toward anxiety. She produced a profile on the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) that was exaggerated but valid according to commonly accepted standards.⁹ Of the 10 clinical scales, 8 were elevated to a clinically significant level consistent with high levels of emotional distress. Her MMPI-2 profile was indicative of individuals who are anxious, nervous, tense, high-strung, tend to overreact, and have anxiety and/or depressive disorders.⁹ An analysis of relevant MMPI-2 item responses revealed that she acknowledged the following anxiety symptoms: nervousness, irritability, difficulty concentrating, indecisiveness, sleep disruption, and other physiological symptoms of anxiety (e.g., palpitations, tremor).

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TABLE 1. Pre- and posttreatment T-scores on the MMPI-2 and STAI

Course of Treatment

Mrs. D. was seen for 11 one-hour-long sessions of outpatient individual psychotherapy over the course of 10 weeks until her baby was born. A cognitive and behavioral treatment approach was employed, with the goals of decreasing her anxiety about being pregnant and decreasing her avoidance of recommended medical procedures. She was taught relaxation techniques including diaphragmatic breathing,¹⁰ progressive muscle relaxation,¹¹ and imagery¹² to help her learn to control both her emotional and her physical responses (e.g., hyperventilation) to distressing thoughts and situations. Diaphragmatic breathing was especially effective, as it eliminated her hyperventilation and quickly facilitated a sense of self-control. Progressive muscle relaxation and imagery were moderately successful in reducing her anxiety, but the fetus' movements disrupted her ability to concentrate sufficiently when practicing these techniques. Cognitive techniques such as thought stopping¹³ and cognitive restructuring¹⁴ were also used to help Mrs. D. cope with distressing ideation. Cognitive restructuring helped her to conceptualize movements of the fetus, which greatly distressed her, as those of a child moving outside of her body rather than those of a living being within her body. Finally, Mrs. D. was taught communication and assertiveness skills to increase her ability to communicate her concerns to medical personnel and her family. She learned to assertively communicate her desire to avoid discussing her pregnancy, as such reminders of her condition increased her anxiety. Mrs. D. was taught to express her fears and her preferences to her husband and to medical professionals so that they could better assist her in managing her anxiety during office visits and her hospitalization for childbirth.

Frequent collaboration between the psychological professionals and obstetric professionals involved in Mrs. D.'s care was necessary and somewhat beneficial. Outpatient and hospital staff were advised of her phobias, and a consensus was reached regarding the need for anxiolytic medication at the time of delivery and, possibly, psychiatric consultation during her hospital stay. Mrs. D. took no medications other than prenatal vitamins during her pregnancy. She complied with all procedures ordered but continued to decline any optional medical procedures. From a medical standpoint, her pregnancy went well with the exception of failure to gain weight because of nausea and vomiting during the first trimester.

Mrs. D. gave birth 2 weeks after her due date. She attempted vaginal delivery, as requested by her obstetrician, but this was unsuccessful and resulted in hyperventilation. Because of insufficient dilation and suspected cephalopelvic disproportion, she underwent a cesarean section. She refused both epidural and regional anesthesia and was given general anesthesia during the delivery. After the birth of a 10-pound baby boy, her observed anxiety abated. Observations by nursing and social work staff indicated that Mrs. D. had bonded and interacted appropriately with her baby. A follow-up psychological evaluation conducted 10 weeks later also revealed reduced anxiety and observations of appropriate bonding with the baby. As illustrated by Table 1, Mrs. D. continued to report high levels of anxiety, but her propensity toward anxiety, as measured by the State-Trait Anxiety Inventory, had significantly decreased following her treatment and childbirth. Her MMPI-2 posttreatment results revealed clinically significant elevations on 5 of the 8 scales that were elevated pretreatment, and significant decreases (greater than 1 standard deviation) on scales measuring exaggeration of psychological distress and susceptibility to react to stress with physiological symptoms.⁹

Discussion

It is not uncommon for pregnant women to experience anxiety.^1,15 Yet, surprisingly, little research has systematically examined specific fears and more intense anxiety reactions among pregnant women. Existing research suggests that some women experience specific fears related to the delivery, dying, the baby's health, and maternal separation anxiety.^1–3 More extreme anxiety was described by Sved-Williams,¹⁶ who reported that 9 postpartum women experienced "phobic avoidance of the baby." However, no studies could be identified in the literature that have described women reporting fear or disgust of having a fetus growing within their body.

Cognitive-behavioral therapy, which has been proven to be successful in the treatment of anxiety disorders including phobias,¹⁷ was used to treat Mrs. D.'s multiple medical and pregnancy-related phobias. Commonly used treatment techniques, such as relaxation and cognitive restructuring, were successful in reducing, though not eliminating, her anxiety. With additional cognitive-behavioral treatment, Mrs. D. was able to comply with instructions from medical professionals and to communicate her preferences to them.

One of the most widely used cognitive-behavioral treatments for anxiety disorders, exposure with response prevention, was specifically avoided in this case. Although this is efficacious in reducing anxiety,¹⁸ it is associated with initial increases in anxiety. Therefore, this treatment was contraindicated in light of the large body of literature demonstrating a relationship between anxiety and negative outcomes in pregnancy, including complicated deliveries,¹⁹ emergency cesarean sections,²⁰ lower infant birth weight,²¹ and shortened gestation.²¹ In addition, there was a case report of placental abruption that was attributed to a panic attack.²² Furthermore, pregnancy is a time-limited circumstance and Mrs. D. was in her last trimester when she sought psychological treatment. Thus, there was minimal concern about establishing a pattern of avoidance behavior that would interfere with her future functioning. As an alternative to using exposure to pregnancy-related stimuli with response prevention, Mrs. D. was taught to reframe her physiological symptoms (e.g., fetal movement) into more acceptable images—a technique sometimes used with medical patients for pain and symptom management.²³

There are several reasons for concluding that Mrs. D.'s reduction in anxiety was related to the cognitive-behavioral treatment. First, her anxiety had been increasing consistently before treatment but decreased significantly after the second session of relaxation training. Most notably, her hyperventilation resolved immediately after training in diaphragmatic breathing (with the exception of one episode following a difficulty and unsuccessful attempt at vaginal delivery). Second, anxiety disorders may improve or worsen during pregnancy,²⁴ but for women in general, anxiety typically rises during the third trimester as the delivery becomes more eminent.^15,19 Mrs. D.'s psychological treatment occurred during her third trimester when anxiety would be expected to increase rather than decrease. Third, it is unlikely that natural exposure to the feared stimuli (e.g., increased movement of the fetus, increased frequency of required medical appointments, and procedures) without the opportunity for avoidance caused the decrease in her anxiety. In fact, before psychological treatment, Mrs. D.'s anxiety was increasing rather than decreasing as her exposure to medical and pregnancy-related stimuli increased. Fourth, there was little reason to believe that Mrs. D.'s decreased anxiety was because of changes in her obstetrical care. Despite collaboration with several of her obstetric physicians and nurses via telephone and letters, Mrs. D. sometimes was seen by other professionals in the same practice who were unaware of her specific fears. Attempts to further allay some of her anxiety by increasing the continuity of her obstetrical care (including being seen by the same physician at the same office location) through consultation-liaison psychiatrists were only partially successful because of the large size of the practice.

Although some of Mrs. D.'s obstetricians and nurses correctly identified her anxiety early in her pregnancy, they were unaware of the severity of her phobias and her intense negative reaction related to having a fetus within her body because Mrs. D. was embarrassed to divulge this information. Obstetricians may wish to question their patients more thoroughly regarding their fears and feelings about the fetus and, if indicated, refer patients for psychological and/or psychiatric treatment.

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Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Email this article to a Colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via Google Scholar Articles by Brenes, G. A. Articles by Milo, K. M. Search for Related Content PubMed Citation Articles by Brenes, G. A. Articles by Milo, K. M. Phobic Disorders

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