Blood- and Injection Phobia in Pregnancy Epidemiological, Biological and Treatment Aspects

Bloodand injection phobia is an anxiety disorder with a prevalence of approximately 3-5% in the general population. The etiology is often a combination of genetic factors and a conditioning experience. The symptoms of bloodand injection phobia are dizziness, confusion, nausea, epigastria discomfort, anxiety and sometimes panic attacks when receiving injections, seeing blood or having a blood sample taken. Unique for this specific phobia is the high probability of fainting when the phobic situation is encountered if there is no possibility to escape or to avoid the stimuli. During pregnancy and labor, women with bloodand injection phobia are exposed to most of their fears and they therefore find themselves in anxiety-ridden situations. Stress and anxiety during pregnancy is known to be risk factors for adverse obstetric and neonatal outcomes. Studies have shown an altered hypothalamic-adrenal-pituitary axis in women with stress or/and anxiety during pregnancy and increased cortisol concentrations can imply negative consequences for the unborn child. Cognitive behavioral therapy (CBT) is known to be effective in treating specific phobias such as bloodand injection phobia. The prevalence, obstetric and neonatal consequences, impact on the hypothalamic adrenalpituitary axis and treatment aspects of bloodand injection phobia in a pregnant population have not been investigated before. The aims of this thesis were to study each of these phenomena. During 2005 a total of 1606 pregnant women were approached at their first visit in an antenatal care clinic in the southeast region in Sweden. They were asked to complete the “Injection Phobia Scale-Anxiety” questionnaire. All women who scored ≥ 20 on the “Injection Phobia Scale-Anxiety” questionnaire (n=347), were interviewed and either diagnosed for bloodand injection phobia or dismissed. In total, 110 women were diagnosed as having bloodand injection phobia. The prevalence of 7% shows that this condition is rather common among women in childbearing age. In a study based on the same population as above, a prospectively collected cohort of 110 women with bloodand injection phobia showed a higher rate of obesity (p<0.001), smoking (p=0.001), fear of childbirth (p<0.001), preeclampsia (p=0.01), preterm labor (p=0.028), elective cesarean section (p=0.032) and having a baby born small for gestational age (p=0.009) compared to a control group of 220 pregnant women without bloodand injection phobia. Samples of cortisol in the saliva were collected in the morning and evening in gestational week 25 and 36 in both groups of pregnant women. The women with bloodand injection phobia had increased cortisol concentrations in the saliva indicating an altered hypothalamicadrenal-pituitary axis during these weeks of pregnancy compared to the healthy controls (p=0.014). A treatment study was conducted using cognitive behavioral therapy in a group of pregnant woman with bloodand injection phobia. The results show that a two-session CBT in group for pregnant women with bloodand injection phobia is effective and stable for at least three months after partus (p<0.001). This therapy also reduces anxiety (p<0.001) and depressive (p<0.001) symptoms during pregnancy, which is beneficial for both mother and fetus/baby. To enhance psychological well being in pregnant women with bloodand injection phobia this method could be applied. List of original papers This thesis is based on the following papers, which are referred to by their Roman numerals I – IV: I. Lilliecreutz C, Josefsson A. Prevalence of bloodand injection phobia among pregnant women. Acta Obstet Gynecol Scand 2008; 87:1276-1279 II. Lilliecreutz C, Josefsson A, Sydsjö G. An open trial with cognitive behavioural therapy for bloodand injection phobia in pregnant women A group intervention program. Arch Womens Ment Health 2010; 13:259-65 III. Lilliecreutz C, Sydsjö G, Josefsson A. Obstetric and perinatal outcome among women with bloodand injection phobia during pregnancy. Accepted for publication in J Affect Disord Aug 2010 IV. Lilliecreutz C, Theodorsson E, Sydsjö G, Josefsson A. Salivary cortisol in pregnant women with bloodand injection phobia. Submitted to Arch Womens Ment Health