Anxiety is an innate human response to situations that cause fear, worry or concern. It is experienced cognitively, emotionally and somatically. Certain levels of anxiety are expected and typical when individuals experience major changes of circumstances in their personal or professional lives, and mild-to-moderate levels of anxiety can even be advantageous when channelled correctly, encouraging an individual to perform at their optimum level (Spielberger et al, 2017).
However, higher levels of anxiety can be an extreme response to perceived threats and can lead to faults in the thought process, which can in turn potentially become the reason for heightened levels of anxiety that disrupt and hinder everyday life. When this response to a perceived threat leads to the overestimation of the likelihood of negative occurrences, thereby interrupting day-to-day life and typical functioning, this is characterised as an anxiety disorder (Clark and Beck, 2011; Klein, 2018). Overall, anxiety affects a person's mental and physical health and can be experienced across a spectrum, spanning from mild to severe.
Anxiety is the general, umbrella term that includes numerous types of anxiety as categorised by the American Psychiatric Association (APA) (2013) and the World Health Organization (WHO) (2018). This includes, but is not limited to, generalised anxiety disorder (GAD), obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD) and social anxiety.
One such anxiety, health anxiety, was previously known as hypochondriasis, a dated, pejorative term that has carried a stigma since its initial discussion by Hippocrates (Starcevic and Lipsitt, 2001). Historically, hypochondriasis was perceived to be an illness without a specific cause and was deemed to be the male equivalent of hysteria, which was said to be experienced by women (Starcevic and Lipsitt, 2001).
In 2013 edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (APA, 2013), the clinical diagnosis of hypochondriasis was removed due to the stigma (Kenyon, 1965) and split into somatic symptom disorder (SSD) and illness anxiety disorder (IAD) (Bailer et al, 2016). The two disorders are often referred to as health anxiety (Fortes et al, 2018).
Health anxiety is typically defined as the perception of having an illness based on the misinterpretation of symptoms (Owens et al, 2004; Barsky, 2016). Symptoms of health anxiety can range anywhere from mild-to-moderate expressions of worry to clinically valid concerns. The diagnosis of health anxiety is thought to be flexible as opposed to conclusive (Barsky et al, 1986; Marcus et al, 2007), and health professionals should be aware that it should be approached as a continuum, rather than confined by strict clinical guidelines (Warwick and Salkovskis, 1990). This is because people who experience health anxiety can conduct themselves in a variety of ways. Health anxiety is challenging to diagnose, as anxiety and avoidance are typical evolutionary adaptive responses to threats, both real or perceived, and there can be a level of ambiguity in patients with mild-to-moderate symptoms (Kessler et al, 2009; Arnáez et al, 2019).
Previous research has shown that women are more likely to experience anxiety than men (McLean and Anderson, 2009; Saatchi et al, 2015). Other studies have found that women present with health anxiety symptoms, such as worrying and reassurance-seeking in reference to their health, at higher rates (MacSwain et al, 2009).
Pregnancy-specific anxiety
The idea that pregnancy is a time of contentment and the anticipation of becoming a parent, and that it is free of medical complications, is commonplace. However, when a woman is expecting a child, anxiety (often mild-to-moderate) can increase (Roesch et al, 2004; Brunton et al, 2018).
Previous research has shown pregnancy-specific anxiety to be an autonomous anxiety disorder (Da Costa et al, 1999; Ross and McLean, 2006; Stoll et al, 2018). Pregnancy-specific anxiety is defined as concerns and fears about being with child, childbirth itself, the future health of the child and potential parenting capabilities (Huizink et al, 2004; Prescott et al, 2018). Pregnancy can be an anxious time for a woman, due to the vast amount of changes that occur within such a short time span, and the prospect of raising a child. Literature shows that, although it is common practice for new mothers to be screened by health professionals for postnatal depression, pregnant women are three times as likely to develop and be diagnosed with anxiety or an anxiety-related disorder than postnatal depression (Stoll et al, 2018).
There are several measures available that either directly or indirectly assess a woman's level of anxiety during the perinatal period. The Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) measures a woman's fear of childbirth when pregnant. The measure is a self-report questionnaire composed of 33 items over six categories: loneliness, lack of self-efficacy, lack of positive anticipation, negative appraisal, fear, and concerns for the child (Garthus-Niegel et al, 2011).
Roesch et al (2004) explored the timing and occurrence of stress during critical stages of pregnancy and whether the severity of stress influenced gestational age. One measure they developed for the purpose of the study was the Pregnancy-Specific Anxiety (PSA), which consists of four items. Participants indicated on a Likert scale (1=not at all, 5=very much) how often they had felt afraid, concerned, anxious or panicky during the previous week, which was analysed in relation to their gravidity.
Although both measures concern wellbeing in the perinatal period, they focus on stress and fear of childbirth as opposed to anxiety alone. There are several measures available for this purpose, including the Manifest Anxiety Scale (Bendig, 1956), the Hamilton Anxiety Scale (Maier et al, 1988), the Beck Anxiety Inventory (Beck and Steer, 1990), and the Stait-Trait Anxiety Inventory (Speilberger and Sydeman, 1994). The National Institute for Health and Care Excellence (NICE) has recommended that health professionals use both the GAD-7 and GAD-2 (Spitzer et al, 2006) to assess women's levels of anxiety during pregnancy (Howard et al, 2014; Drake 2018).
Another measure, the Pregnancy-Related Anxiety Questionnaire–Revised (Huizink et al, 2004) has been psychometrically tested and is independent of general anxiety questionnaires (Reck et al, 2013; Huizink et al, 2016). One disadvantage of this 10-item measure is that it has been developed specifically for first-time mothers, with statements including ‘I am anxious about the delivery, because I have never experienced one before’. A more recent study altered this statement, to make it relevant to all pregnant women (Huizink et al, 2016). However, this measure still focuses on the general anxieties of pregnancy, for example: ‘I am worried about the fact that I shall not regain my figure after delivery’, ‘I am worried about my enormous weight gain’ and ‘I am worried about not being able to control myself during labour and fear that I will scream’.
Furthermore, some of the items relate to the health of the mother and baby post-birth, such as ‘I sometimes think that our child will be in poor health or will be prone to illnesses,’ and ‘I am afraid that our baby will suffer from a physical defect or worry that something will be physically wrong with the baby’. Although these are concerns that women may have during pregnancy, they cannot be determined until after the birth.
Although these measures are all relevant to assessing anxiety during pregnancy, they account for numerous general, pregnancy-specific anxiety triggers and are not specific to health anxiety alone.
Pregnancy-specific health anxiety
Pregnancy consists of multiple variables that can induce anxiety, such as financial and social instability, changing appearance, changes to familial and spousal dynamics, impending responsibility, doubts about parenting abilities and the overall general health of the mother and child.
During pregnancy, physical changes are experienced and can be anxiety-provoking. Regardless of parity, pregnancy is a subjective experience. Each change has the potential to induce pregnancy-specific health anxiety in the mother (Rubertsson et al, 2014). Anxiety can be detrimental to the psychological health of the mother, which subsequently affects physical health. Unless broken, the cycle of health anxiety during pregnancy can have a consistent, holistic, negative effect.
Pregnancy-specific health anxiety and illness anxiety disorder
IAD is a maladaptive fixation on the belief that one is experiencing or developing an illness (Coletti et al, 2016). For a patient to be diagnosed, they must present with these anxieties persistently for a period of more than 6 months, despite clinical investigation and assurance of health. IAD often originates from a misunderstanding of typical bodily functions such as bloating, sweating and awareness of one's own heartbeat (Reuman and Abramowitz, 2015).
General concern regarding the baby's health is expected during pregnancy (Huizink et al, 2004; Matthey and Souter, 2019), but excessive worry can become a psychological stressor that can affect both mother and child. Although IAD during pregnancy is not recognised, it is plausible that women could misconstrue somatic symptoms typical to pregnancy as something more concerning. For example, typical round ligament pain and light bleeding could easily be mistaken as the symptoms of a miscarriage.
For primigravid women, any symptom can cause concern. Each pregnancy is different; however, and so a woman may experience mild-to-moderate symptoms in a previous pregnancy and present with more serious symptoms in subsequent pregnancies, a cause of pregnancy-specific IAD.
Some of the most common signs and symptoms of pregnancy (a missed period, morning sickness, fatigue and excessive urination) (NHS, 2016) can vary from pregnancy to pregnancy. Morning sickness, for example, can be mistaken for hyperemesis gravidarum; while the increased urination experienced throughout pregnancy as a result of an increase in hormones may be perceived as a urinary tract infection or as a precursor to bladder or kidney infection (Williams and Davison, 2008; Beksac et al, 2017). Spotting is experienced by around 20% of pregnant women during the first trimester and is caused by implantation, but women may assume that this is an indication of an early miscarriage.
Given the abundance of bodily changes, pregnancy-specific IAD is feasible, regardless of how many times a woman has experienced pregnancy.
Pregnancy-specific health anxiety and somatic symptom disorder
SSD is a psychological illness that includes maladaptive anxieties related to health, leading to the onset of somatic symptoms. This can include general pain, loss of libido, gastrointestinal irregularities and neurological issues. Although these symptoms are real, they may or may not correlate with underlying medical conditions, mental illnesses or substance misuse. Irrespective of whether an underlying illness can be identified, patients who experience SSD experience somatic symptoms, which can be extremely distressing, especially when a diagnosis cannot be reached (Kurlansik and Maffei, 2016).
The APA defines SSD as a significant focus on a physical symptom (2013), often accompanied by maladaptive cognition and disproportionate anxiety. The preoccupation is based on a belief that the affliction is genuine (Skumin, 1991; Toussaint et al 2016). SSD is similar to the former disorder labelled hypochondriasis.
Women are more likely to experience SSD (APA, 2013); and there are many ways in which SSD may present in pregnant women. While women with IAD experience anxiety about the onset or presence of an illness via the misinterpretation of typical bodily functions, those with SSD experience valid somatic symptoms that may not always be attributable to an underlying disorder. If a woman with SSD presents with somatic symptoms and excessive anxiety but there is no medical explanation and mother and the baby appear healthy, a diagnosis will not be given. This can be extremely frustrating for the woman, as she sincerely believes herself to be ill and can get no definitive diagnosis.
Poor outcomes, such as complications, miscarriages or stillbirth in previous pregnancies could be a cause of SSD during later pregnancies. Research has shown that women who have suffered prenatal losses report significantly elevated levels of anxiety during subsequent pregnancies (Côté-Arsenault, 2003; Armstrong et al, 2009; Blackmore, 2011).
Although pregnancy is a time that may cause increased anxieties for a woman, symptoms of SSD may be inadvertently obscured, due to the increase in appointments with a multidisciplinary team of health professionals in which concerns can be voiced. The typical patient with SSD cannot receive a conclusive diagnosis until after they have presented with somatic symptoms to a clinician for more than 6 months. As gestation only spans 9 months and women may only discover they are pregnant 2-3 weeks after conception, a definitive diagnosis may be impossible. This could be frustrating and encourage a pregnant woman to seek health information from more unreliable sources (Prescott and Mackie 2017; Prescott et al, 2018).
Discussion
The diagnosis of health anxiety is increasing globally. It is considered a common mental health disorder, with some epidemiological studies reporting that 0.26-8.5% people in primary care alone meet the DSM criteria for diagnosis (Creed and Barsky, 2004). Numerous studies have explored the prevalence of anxiety and the optimum methods of treatment (Sundquist et al, 2015; Rollman et al 2017; James, 2019).
Given the importance of health during pregnancy and the possibility of heightened levels of anxiety, it could be suggested that there is a need for pregnancy-specific health anxiety to be categorised as a clinical condition of its own and investigated, considered and diagnosed separately to other forms of pregnancy-specific anxiety. There is no reference as to how many women experience pregnancy-specific health anxiety.
Health anxiety has become an increasing burden on healthcare providers and as pregnant women require extra appointments with a multidisciplinary team of professionals, this could further increase the strain. It is typical of patients with health anxiety to have a diminished quality of life, both psychologically and somatically (Rycroft, 1988; Lader, 2015). During pregnancy, this can be dangerous for both the mother and the child.
Women who suffer from pregnancy-specific health anxiety can become healthcare avoidant. This means that if they experience persistent symptoms and refuse to seek medical help, their general health could become endangered and eventually, more progressive health services will be required (Sirri et al, 2013). Avoidant patients are also more likely to self-medicate, which can lead to further complications (Cornally and McCarthy, 2011). Patients with health anxiety may inadvertently place strain on healthcare services by requesting repeat prescriptions, doubting diagnoses and monopolising health professionals' time.
Conclusion
Health professionals and pregnant women would both benefit from further research to allow for in-depth psychoeducation and a more extensive insight. The diagnosis of pregnancy-specific health anxiety could reduce both somatic and psychosomatic symptoms, increase general quality of life and inaugurate a more mediated gestation. However, pregnancy-specific health anxiety is extremely difficult to diagnose due to the rigid time constraints in which it would present, the ambiguity of symptoms, and the increase in atypical health appointments that are also pregnancy-specific.