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Blood-and Injection Phobia in Pregnancy: Epidemiological, Biological and Treatment aspects
Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Centre of Paediatrics and Gynecology and Obstetrics, Department of Gynecology and Obstetrics in Linköping. Linköping University, Department of Clinical and Experimental Medicine, Obstetrics and gynecology.
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Introduction: Blood- and 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 blood- and 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 blood- and 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 blood- and injection phobia.

Aim: The prevalence, obstetric and neonatal consequences, impact on the hypothalamic adrenal-pituitary axis and treatment aspects of blood- and injection phobia in a pregnant population have not been investigated before. The aims of this thesis were to study each of these phenomena.

Material and methods: 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 blood- and injection phobia or dismissed. In total, 110 women were diagnosed as having blood- and injection phobia. Among the women who scored <20 on the “Injection Phobia Scale-Anxiety” questionnaire, 220 women were randomly stratified for age and parity as a control group. The women in the study population answered questionnaires in gestational week 25, 36 and postpartum concerning symptoms of blood- and injection phobia, depression and anxiety. 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 medical records from the antenatal care visits, the delivery and postpartum check-up was used to collect data of importance. A treatment study was conducted using a two session cognitive behavioral therapy in a group of pregnant woman with blood- and injection phobia.

Results: The prevalence of blood- and injection phobia is 7 % in a pregnant population. Pregnant women with blood- and injection phobia stated more often a fear of childbirth (p<0.001) and were more frequently delivered by elective cesarean section (p=0.032). The incidence of having a baby diagnosed with a complication (p=0.001) was also higher among these women. The women with blood- and injection phobia had increased cortisol concentrations in the saliva compared to the healthy controls (p=0.014). A two-session CBT in group for pregnant women with blood- and injection phobia reduced phobic (p<0.001) anxiety (p<0.001) and depressive (p<0.001) symptoms during pregnancy.

Conclusions: Blood- and injection phobia during pregnancy is rather common. Pregnant women with blood- and injection phobia are more likely to be delivered by elective cesarean section and having a baby born with a complication compared to women not suffering from this specific phobia. Untreated blood- and injection phobia during pregnancy increases salivary cortisol concentrations indicating an altered hypothalamic-adrenal-pituitary axis during these weeks of pregnancy. To enhance psychological well being in pregnant women with blood- and injection phobia a two-session program providing CBT for groups of pregnant women is valuable and produces stable results for at least 3 months after delivery.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press , 2010. , 126 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1194
Keyword [en]
Blood-and injection phobia, pregnancy, prevalence, cortisol, outcome, cognitive behavioral therapy
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
URN: urn:nbn:se:liu:diva-59745ISBN: 978-91-7393-344-5 (print)OAI: oai:DiVA.org:liu-59745DiVA: diva2:353239
Public defence
2010-10-15, Berzeliussalen, Ingång 65,, Campus US, Linköpings Universitet, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2010-10-04 Created: 2010-09-24 Last updated: 2011-03-25Bibliographically approved
List of papers
1. Prevalence of blood and injection phobia among pregnant women
Open this publication in new window or tab >>Prevalence of blood and injection phobia among pregnant women
2008 (English)In: Acta Obstetricia et Gynecologica Scandinavica, ISSN 0001-6349, E-ISSN 1600-0412, Vol. 87, no 12, 1276-1279 p.Article in journal (Refereed) Published
Abstract [en]

Objective: The aim of the study was to investigate the prevalence of blood and injection phobia in an unselected pregnant population, in order to estimate the need for curative intervention programmes.

Design: A cross-sectional study. Setting. Antenatal care clinics in the southeast region of Sweden.

Sample: In total, 1,606 consecutively registered pregnant women attending their first visit with a midwife.

Methods: The women were asked to complete the Injection Phobia-Anxiety scale, measuring phobic symptoms. Women who scored 20 on the questionnaire were telephone-interviewed and then diagnosed or dismissed according to the DSM-IV criteria for blood and injection phobia. Main outcome measures. Prevalence of blood and injection phobia according to the DSM-IV.

Results: Of 1,529 women who chose to participate (92.5%), 110 women or 7.2% fulfilled the DSM-IV criteria for blood and injection phobia. The mean age of the women was 29.1 years.

Conclusions: Blood and injection phobia is hitherto unreported in the literature, but seems to be relatively common and needs to be recognized during pregnancy as it causes a great deal of discomfort and fear among pregnant women. The Injection Phobia-Anxiety scale is suitable as a screening tool in an antenatal care clinic setting.

Keyword
Blood-injection, phobia, pregnancy, prevalence
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-16232 (URN)10.1080/00016340802468324 (DOI)
Available from: 2009-01-12 Created: 2009-01-09 Last updated: 2010-10-04
2. An open trial with cognitive behavioral therapy for blood- and injection phobia in pregnant women-a group intervention program
Open this publication in new window or tab >>An open trial with cognitive behavioral therapy for blood- and injection phobia in pregnant women-a group intervention program
2010 (English)In: ARCHIVES OF WOMENS MENTAL HEALTH, ISSN 1434-1816, Vol. 13, no 3, 259-265 p.Article in journal (Refereed) Published
Abstract [en]

Around 7% of pregnant women suffer from blood- and injection phobia. The aim was to investigate if cognitive behavior group therapy (CBT) is effective in treating pregnant womens blood- and injection phobia. Thirty pregnant women with blood- and injection phobia according to DSM-IV took part in an open treatment intervention. A two-session cognitive behavior group therapy was conducted. As controls, 46 pregnant women with untreated blood- and injection phobia and 70 healthy pregnant women were used. Repeated measures ANOVA were performed. The scores for the CBT treatment group on the "Injection Phobia Scale-Anxiety" were reduced both after each treatment session and postpartum (p andlt; 0.001). Anxiety and depressive symptoms were also reduced (p andlt; 0.001). Cognitive-behavior group therapy for pregnant women with blood- and injection phobia is effective and stable up to at least 3 months postpartum. It seems also to reduce anxiety and depressive symptoms during pregnancy.

Place, publisher, year, edition, pages
Springer Science Business Media, 2010
Keyword
Anxiety, Blood- and injection phobia, Cognitive behavior group therapy, Depression, Pregnancy
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-56809 (URN)10.1007/s00737-009-0126-x (DOI)000277935600010 ()
Note
The original publication is available at www.springerlink.com: Caroline Lilliecreutz, Ann Josefsson and Gunilla Sydsjö, An open trial with cognitive behavioral therapy for blood- and injection phobia in pregnant women-a group intervention program, 2010, ARCHIVES OF WOMENS MENTAL HEALTH, (13), 3, 259-265. http://dx.doi.org/10.1007/s00737-009-0126-x Copyright: Springer Science Business Media http://www.springerlink.com/ Available from: 2010-06-04 Created: 2010-06-04 Last updated: 2010-10-04
3. Obstetric and perinatal outcomes among women with blood- and injection phobia during pregnancy
Open this publication in new window or tab >>Obstetric and perinatal outcomes among women with blood- and injection phobia during pregnancy
2011 (English)In: Journal of Affective Disorders, ISSN 0165-0327, E-ISSN 1573-2517, Vol. 129, no 1-3, 289-295 p.Article in journal (Refereed) Published
Abstract [en]

Backgroun: Little is known about how anxiety disorders affect pregnancy outcomes. Therefore we investigated the impact of one anxiety disorder, blood- and injection phobia, on obstetric and neonatal outcomes.

Method: From a population-based prospectively collected cohort we compared an index group of 110 women with blood- and injection phobia with a control group of 220 women. Standardized medical records were used to collect data. Obstetric and neonatal outcomes e.g. elective cesarean, prematurity, and small for gestational age were used as the main outcome measures.

Result: Women with blood- and injection phobia stated more often a fear of childbirth (p < 0.001) and were more frequently delivered by elective cesarean section (p = 0.032). The incidence of premature delivery (p = 0.028), neonatal morbidity (p = 0.001) and the risk of having a baby born small for gestational age (p = 0.009) was higher among women with blood- and injection phobia.

Limitation: The medical records, from which all information is drawn, despite standardization, sometimes may lack some information. However, this dilemma exists in both groups.

Conclusions: Women with an anxiety disorder such as blood- and injection phobia are at increased risk for adverse obstetric outcomes, premature delivery and for having a baby born with higher neonatal morbidity. It therefore seems important to identify and treat women with anxiety disorders without delay early during pregnancy in an effort to minimize risks of complications for the woman herself and the child.

Place, publisher, year, edition, pages
Elsevier, 2011
Keyword
Anxiety, blood-and injection phobia, premature, small for gestational age, cesarean
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:liu:diva-59743 (URN)10.1016/j.jad.2010.08.013 (DOI)000288293400038 ()20825998 (PubMedID)
Note
Original Publication: Caroline Lilliecreutz, Gunilla Sydsjö and Ann Josefsson, Obstetric and perinatal outcomes among women with blood- and injection phobia during pregnancy, 2011, Journal of Affective Disorders, (129), 1-3, 289-295. http://dx.doi.org/10.1016/j.jad.2010.08.013 Copyright: Elsevier Science B.V., Amsterdam. http://www.elsevier.com/ Available from: 2010-09-24 Created: 2010-09-24 Last updated: 2011-06-21Bibliographically approved
4. Salivary cortisol in pregnant women suffering from blood-and injection phobia
Open this publication in new window or tab >>Salivary cortisol in pregnant women suffering from blood-and injection phobia
2011 (English)In: Archives of Women's Mental Health, ISSN 1434-1816, E-ISSN 1435-1102, Vol. 14, no 5, 405-411 p.Article in journal (Refereed) Published
Abstract [en]

Purpose: Stress and/or anxiety during pregnancy affect maternal and fetal wellbeing and can cause premature delivery and postnatal pathology in the child. Women suffering from phobias related to blood and injections are prone to high levels of stress including anxiety and sometimes panic attacks during pregnancy. Cortisol is amongst the mediators through which the neurohormonal expressions of maternal psychological factors may be transduced to the fetus. The aim was to investigate if pregnant women suffering from blood- and injection phobia have raised cortisol levels or are characterized by unusual diurnal salivary cortisol profiles compared to healthy controls.

Methods: The sample consisted of 110 pregnant women with blood- and injection phobia and 110 pregnant healthy controls. Both groups provided morning and evening saliva samples in week 25 and 36 for the assay of cortisol. In gestational week 25 when blood was drawn for the mandatory blood testing extra blood was taken to analyze corticotrophin releasing  factor (CRF), adrenocorticotropic hormone (ACTH) and cortisol in serum.

Results: The expected diurnal decline in salivary cortisol was observed as well as increased cortisol levels during pregnancy. Pregnant women suffering from blood- and injection phobia had higher output of cortisol compared to women without the phobia (F=6.25 df=1 p=0.014) but no marked difference in the diurnal cortisol rhythm was found between the groups.

Conclusion: Our findings indicate that untreated blood- and injection phobia during pregnancy increases cortisol concentrations. Blood- and injection phobia is treatable and cognitive behavioral therapy can be used.

Place, publisher, year, edition, pages
Springer Berlin/Heidelberg, 2011
Keyword
Cortisol, anxiety, stress, pregnancy, blood- and injection phobia
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:liu:diva-59744 (URN)10.1007/s00737-011-0234-2 (DOI)000297847800005 ()
Available from: 2010-09-24 Created: 2010-09-24 Last updated: 2012-01-13

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