Issues in Treating Anxiety Disorders in Pregnancy
Issues in Treating Anxiety Disorders in Pregnancy
Anxiety disorders are a frequent occurrence in pregnancy. While some worries and anxiety are experienced by more than 50% of pregnant women, a full-blown anxiety disorder involves risk to both mother and fetus and increases the risk of postpartum depression.1,2 The prevalence of antenatal generalized anxiety disorder (GAD) is highest (8.5% to 10.5%), followed by panic disorder (1.4% to 5.2%), obsessive-compulsive disorder (OCD; 1.2% to 5.2%), and PTSD (3%).3-7 The majority of these estimates are either higher than or comparable to rates seen in the general population.8
Antenatal vulnerability to anxiety
Although sex hormones are poised to have an anxiolytic effect (progesterone via γ-aminobutyric acid enhancement and attenuation of the noradrenergic response to stress, and estrogen via direct effect on the serotonergic system), anxiety symptoms may be exacerbated or precipitated by pregnancy.9-11 In addition to genetic susceptibility and increased vulnerability to hormonal flux in some women, role transitions and social expectations are key factors in the development of antenatal anxiety. They may awaken painful memories, even in women without a history of anxiety.12,13
Effects of maternal anxiety on the developing fetus
Untreated, significant, and ongoing antenatal anxiety exposes the fetus to excess glucocorticoids, which may influence the fetus’s susceptibility to enduring neuroendocrine changes.14 This fetal programming is believed to be mediated by cortisol binding to promoter regions of genes, which influences their expression.14,15 The effects on stress-related behavior, emotions, and cognitive abilities in adult life have been established by independent prospective studies.16 Other associated risks include preterm labor, low birth weight, and lower Apgar scores.17-19
Screening and treatment for antenatal anxiety can reduce these risks. The anxiety subscale of the Edinburgh Postnatal Depression Scale can be used for this purpose.
Presentation of anxiety disorders in pregnancy
Panic disorder. Normal pregnancy-related changes, such as increased heart rate, shortness of breath, heartburn, dizziness, and sweating, can easily be misinterpreted as harmful. Many women report onset of panic symptoms as these changes become more prominent between the 6th and 28th week of gestation.5 The combination of physical symptoms, cognitive factors (eg, catastrophic misappraisal), and maladaptive behavioral responses (eg, avoidance) can result in escalating physical symptoms of anxiety and panic.
Panic attacks developed when Jennifer was 7 months’ pregnant with her first child. Although she felt they were not triggered by a specific event, close examination revealed that they were usually precipitated by mild breathlessness when walking, climbing stairs, or performing household chores [physical]. This would trigger the thought: “What is happening to me? I might pass out” [cognitive].
Jennifer’s anxiety would rise, her heart would race, and her hands would tremble [physical]. She would ask her husband to come home from work [behavioral]. While waiting for him to arrive, she would scan her body for any further sensations [behavioral] and worry: “What if something is wrong with the baby?” [cognitive]. She would become dizzy and warm [physical], clutching the telephone in case of an emergency [behavioral], convinced that something was terribly wrong [cognitive].
• Clinicians have long known that anxiety is common during pregnancy, although only recently has research begun to better elucidate its etiology, prevalence, and treatment. The 2 most effective, evidence-based treatments for antenatal anxiety are cognitive-behavioral therapy (CBT) and psychopharmacology.
• This article discusses the specific risks of anxiety and its treatment during pregnancy and illustrates common presentations of the anxiety disorders in pregnant women. Key considerations for both CBT and psychopharmacological treatment are outlined, with specific recommendations for practitioners.
• The unique presentation of common anxiety disorders in pregnancy and their potential risks to both mother and fetus as well as confusing information about the safety of psychotropics in pregnant women pose a challenge to the treating physician. This article provides the most up-to-date information about the risks associated with anxiety, the use of common psychotropics, and general guidelines for treatment of anxiety during pregnancy.
Generalized anxiety disorder. In GAD, symptom expression is influenced by an intolerance of uncertainty and inaccurate beliefs about the utility of worry. Together, these result in the hallmark of GAD: worry about the future.
Millie was 6 months’ pregnant and consumed with worries about the impending arrival of her baby. “What if the baby isn’t healthy? What if I’m not a good mother? What if I can’t handle the pain? What if my marriage doesn’t survive?” Millie lay awake at night, her mind racing, and planned how she would deal with each of these imagined scenarios.
She spent much of her time poring over Internet discussion boards and parenting books. Although it never made her feel better, she believed that her worrying somehow prepared her for disappointment and prevented bad things from happening. When her husband tried to be reassuring, Millie became irritable and insisted that worrying is “what responsible mothers do.”
Obsessive-compulsive disorder. Pregnancy increases vulnerability to obsessive thoughts about the overwhelming responsibility for the baby’s well-being and safety.20 Obsessions tend to focus on possible harm to the baby, and compulsions often include washing and cleaning rituals and compulsive checking on and/or avoidance of the baby. While intrusive thoughts are common and normal among new mothers, avoidance, ritualizing, and attempts to control or suppress these thoughts reinforce and escalate anxiety.
Jillian had a history of subclinical OCD. Soon after she learned that she was pregnant, she experienced distressing intrusive thoughts and vivid images about abnormal fetal development and of having a miscarriage. The more she tried not to think about it, the more frequent and intense her thoughts became. She avoided contact with household chemicals and made everyone around her wash their hands thoroughly. She meticulously planned her diet, avoided many foods, and compulsively logged her daily intake of fruits, proteins, and vegetables. She only bought organic food, refused to eat out, and became socially isolated. She eventually stopped using the microwave and going to work because she feared the radiation from the computers there would harm her baby. Being told by the doctor that her baby was developing appropriately only reinforced her belief that her strategies were effective.
Childbirth-related specific phobia. Most women report some fear of delivery, but for a subset it can reach phobic proportions. Fear is learned through previous traumatic deliveries, negative information, or witnessing others’ fearful behavior. Extreme fear of childbirth can be associated with prolonged labor, increased perception of pain, and avoidance of labor in favor of cesarean birth.21-23
Since Carol learned she was pregnant, she has been very anxious about the delivery. She becomes distressed when pregnancy is discussed and pictures herself in excruciating pain during labor. At times, she seems to forget that she is pregnant and engages in unhealthy and unsafe behaviors. She often misses her prenatal care appointments and refuses to discuss or plan for delivery. She has admitted to wishing she were not pregnant and wants to be “knocked out” for the entire delivery.
PTSD. Aside from stress resulting from premature delivery, preeclampsia, pregnancy loss, or lack of emotional or social support, non–pregnancy-related traumatic events can negatively influence pregnancy and precipitate PTSD.24-28 A history of rape, childhood sexual abuse, and domestic violence are commonly endorsed by pregnant women with PTSD.29 These women often avoid health care providers and exhibit extreme sensitivity to bodily exposure as well as dissociation, flashbacks, or excessive need to control situations.