BRITISH JOURNAL OF PSYCHIATRY (2000), 176, 83^85

Tokophobia: an unreasoning dread of tokophobia. They were not investigating an already-established illness pattern. Aseriesof26cases Direct questions were used to elucidate diagnoses of depressive episodes,anxiety disorders and post-traumatic stress disorder KRISTINA HOFBERG and IAN BROCKINGTON (PTSD) using ICD±10 (World Health Orga- nization,1992). Detailed enquiries were made about the obstetric history,including all ,contraceptive methods and sexual relationships. The relationship with each baby was examined. Questions about childhood sexual abuse and rape were Background Some women dread and Fear of parturition was described by Marce investigated. avoid childbirth despite desperately (1858) as follows: wanting a baby.This is called tokophobia. ``If they are primiparous, the expectation of un- known pain preoccupies them beyond all mea- RESULTSRESULTS sure, and throws them into a state of Aims Toclassify tokophobia for the first inexpressible anxiety. If they are already Twelve women were referred by obstetri- time inthe medicalliterature. mothers, they are terrified of the memory of cians,while 14 were new referrals to the thethepastandtheprospectofthefuture.'' past and the prospect of the future.'' MBU. One was contacted after her story MethodMethod Twenty-six womenwomennotedto noted to It is well known that may be a appeared in a magazine. Of the 26 women have an unreasoning dread of childbirth time of considerable anxiety,with symp- included in the study,24 women were were interviewed by the same toms escalating in the third trimester (Lu- married and 24 had had all their children psychiatrist, who was not the treating binbin et aletal,1975). Women in the 1990s still with the same partner. The average age at suffer from the fear of death during delivery the time of interview was 33 years (range doctor. A qualitative analysis oftheseof these (Fava(Fava et aletal,1990). When this specific anxi- 22±41). Twenty-five of the subjects had psychiatric interviews was performed. ety or fear of death during parturition pre- children with no evident disability. cedes pregnancy and is so intense that tokostokos ResultsResults Phobic avoidance of pregnancy (`childbirth') is avoided whenever possible, may date from adolescence (primary it is a phobic state called `tokophobia'. Primarytokophobia tokophobia), be secondary to a traumatic Eight women in the sample had a dread of delivery (secondary tokophobia) or be a METHOD childbirth that pre-dated pregnancy,that symptom of prenatal depression is,primary tokophobia. The dread of child- Subjects for the study were referred from birth started in adolescence. Sexual rela- (tokophobia as a symptom of depression). two sources,obstetricians in the West Mid- tionships were normal but contraceptive Pregnant women with tokophobia who lands and psychiatrists on the mother and use was scrupulous,some of these women were refused their choice of delivery baby unit (MBU) at the Queen Elizabeth using several methods of protection. Four method suffered higher rates of Psychiatric Hospital in Birmingham. of the eight women planned their pregnan- Twenty-seven women were referred for cies despite their intense fears. Two had an psychologicalmorbidity thanthose who the study,one declined to be interviewed. overwhelming desire to be a mother and achieved theirtheirdesired desired delivery method. The remaining 26 women were seen over saw that role as their raison d'ed'etreÃtre. These.These a two-year period in their homes by the feelings overpowered their avoidance but Conclusions Tokophobia is a specific same psychiatrist,who was not the treating did not allay their fear. and harrowing conditionconditionthat that needs doctor. No structured interview was used in One woman conceived only after she acknowledging. Close liaison between the this preliminary study. The authors devel- had arranged a lower segment Caesarean obstetrician and the psychiatristpsychiatristin in order oped an interview that combined narrative section (LSCS) for the delivery of her to assess the balance between surgical and histories with specific direct questions for first baby. Most women strongly desired obtaining information. The authors were ananelectiveLSCS.Maternalmorbidity elective LSCS. Maternal morbidity psychiatric morbidityisimperativemorbidity is imperative with investigating trends in presentation and was evident during these pregnancies tokophobia.tokophobia. past history that may identify women with (see Table 1).

Declaration of interest None.None.

Ta b l e 11Tab Events during pregnancy in eight women with primary tokophobia (number of women developing each event type)

Hyperemesis gravidarum AnxietyAnxietyPrenatal depressionDemanded LSCSAchieved elective LSCS

585 8444422

LSCS, lower segment .

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Outcome of primary tokophobia pregnancies Ta b l e 3 Events in subsequent pregnancy of13of 13 women with secondary tokophobia (number of women for Four women achieved their ideal delivery, each event type) bonded well with their babies and enjoyed excellent psychological health. Three Depression Hyperemesis gravidarum Desired LSCSArranged elective LSCS women endured vaginal deliveries against their will; all three suffered postnatal de- 555 5131311

pression,two suffered symptoms of PTSD LSCS, lower segment Caesarean section. and two had delayed bonding with their in- fants. One woman chose to deliver vagin- situation of tokostokos. Two women had not had no further episode of depression. The ally despite her intense fears (she was also obtained an operative delivery: one had second woman declined antidepressant terrified of needles,hospitals and doctors). had a successful vaginal delivery and good medication in pregnancy and was refused She had an emergency LSCS,and suffered psychological outcome,although she an LSCS. She described a traumatic vaginal postnatal depression. retained residual symptoms of PTSD from delivery,with continued depression post- her first delivery; the other suffered post- natally and a feeling of detachment from Secondarytokophobia natal depression,PTSD and a bonding dis- her baby.herbaby. order with her baby. One woman was Secondary tokophobia occurs after a trau- separated at birth from her baby,who matic or distressing delivery. Fourteen was ill. She suffered bonding delay. DISCUSSION women in the sample had developed a dread of childbirth after a previous deliv- Tokophobia and childhood sexual ery. Ten had experienced instrumental or TokophobiaTo k o p h o b i a asa s a symptoms ym p t o m o of f abuseabuse operative deliveries for foetal distress; two depression Five women from our sample described a others had suffered severe pain and perineal Four women developed a phobic dread and history of childhood sexual abuse and three tearing. Twelve stated that during the deliv- avoidance of tokostokos as a symptom of depres- a traumatic rape. A history of sexual assault ery they believed that they would die or sion in the prenatal period. In each woman may be associated with an aversion to rou- that the baby had already died. Maternal this was characterised by a recurrent intru- tine obstetric care associated with primary morbidity was evident and undetected for sive belief that she was unable to deliver her tokophobia or tokophobia as a symptom many months in ten women (see Table 2). baby and,if made to,would die. Of these of depression. The trauma of a vaginal de- One woman who accidentally conceived four women,the first two were primipar- livery may cause a resurgence of memories again organised a termination of pregnancy ous; both felt shocked at the realisation of of childhood sexual abuse and contribute rather than face another delivery. The di- pregnancy and both became depressed. to secondary tokophobia. lemma for these women was that the family One sought a termination of pregnancy felt incomplete but the women were terri- even though the pregnancy was planned. Tokophobia and termination of fied of a further delivery. The other began to exercise strenuously in pregnancy Nevertheless,13 of these women pro- the hope of inducing a miscarriage rather ceeded with further pregnancies. Eight were than endure a vaginal delivery. Both were Two women in the study terminated a preg- planned where a sibling was wanted for the treated psychologically and recovered spon- nancy because they could not face a deliv- first baby. Two women suffered miscar- taneously in the middle trimester of preg- ery. In both cases the baby was much riages (before going on to complete a preg- nancy. The second two women already wanted. Another woman described how nancy to term) and one had an ectopic had children; both had experienced vaginal she was offered a termination of pregnancy pregnancy; all three felt enormous relief deliveries that they perceived as untrau- when she had begged for an LSCS. A pro- when these pregnancies did not result in matic. Both of these subsequent pregnan- portion of termination of pregnancies may delivery. All 13 women were extremely cies were planned. In the context of be requested by women who suffer from anxious during their pregnancies with the relationship difficulties and depressive ill- tokophobia and want a baby but cannot recurrent,intrusive belief that they were ness both women failed to bond with their understand their own strong aversion to unable to deliver their babies (see Table 3). foetus and became adamant that they could parturition. In the absence of an empathic Eleven women were seen in the post- not deliver their babies. The care shown in professional listener or relevant medical lit- natal period; two were still pregnant but previous pregnancies was lacking. One erature,their only choice may be to termi- had arranged an LSCS (see Table 4). Nine woman responded well to antidepressants nate the pregnancy. of the postnatal women arranged an LSCS, in the prenatal period and arranged an all felt that they had avoided the fearful LSCS. She bonded well with her baby and Ta b l e 44Tab Postnatal events in11womenin 11women with secondary tokophobia (number of women for each TaTable b l e 2 Psychological morbidity inin14 14 postnatal women who developed secondary tokophobia after the event type) index pregnancy (number of women presenting each symptom) DelayedDelayed Postnatal PTSDPermanent Prenatal depressionPostnatal depressionPTSD symptomsReduced libidoBonding delay bonding depression contraception

090 99911226 232 3111010

PTSD, post-traumatic stress disorder. PTSD, post-traumatic stress disorder.

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Tokophobia and hyperemesis gravidarum CLINICAL IMPLICATIONS In this study,women with tokophobia had a high rate of hyperemesis gravidarum (5/8(5/8 && Tokophobia is a distressing psychological disorder that may be overlooked. of those with primary tokophobia,5/14 of && Tokophobia is associated with anxiety, depression, post-traumatic stress disorder those with secondary tokophobia). A psy- chological component to hyperemesis grav- and bonding disorders.

idarumidarum has been postulated. This may be && Recognition of tokophobia and close liaison with obstetricians may reduce the relevant to tokophobia,when rejection of morbidity associated with tokophobia. pregnancy,failure to bond with the foetus, attempts to obtain a termination of preg- LIMITATIONS nancy and terror at an impending delivery may occur.mayoccur. && Thesamplesizewassmall.The sample size was small.

&& All the women were Caucasian with English as their first language.They were all in Tokophobia and PTSD enduring relationships.They are not representative of the population.

PTSD is increasingly being recognised as a && No standardised questionnaire was used in this preliminary study. consequence of childbirth (Ryding et aletal,, 1997). Among subjects with tokophobia the incidence of PTSD was high,and was associated with traumatic delivery (second- ary tokophobia) and denial of the delivery KRISTINA HOFBERG, MRCPsych, Queen Elizabeth Psychiatric Hospital, Birmingham; I. F. BROCKINGTON, method of choice (primary tokophobia). FRCP,Department of Psychiatry,University of Birmingham

CorrespCorrespondence:ondence: Dr K.Hofberg,Department of PsychPsychiatry,Universityiatry,University of Birmingham,Queen Elizabeth Tokophobia and depression Psychiatric Hospital, Mindelsohn Way,Birmingham B15 2QZ; e-mail: kristina.hofberg@@virgin.net

In this sample depression was a frequent (First received 30 November 1998, final revision 15 June 1999, accepted 16 June 1999) cause and consequence of morbidity. Post- natal depression was associated with refu- sal of the delivery method of choice and with traumatic and distressing deliveries.

ACKNOWLEDGEMENTS Lubin, B., Gardiner, S. H. & Roth, A. (1975) MoodMood and somatic symptoms during pregnancy. Psychosomatic Tokophobia and sterilisation or MedicineMedicine,, 3737,136^146. vasectomy We thank Simon Jenkinson for his assistance, and the women in the study for their interest and confi- Ten women in the sample had completed a dences.dences. Marce, L.V.L.V.(1858) (1858) Traite de la Folie des Femmes sterilisation or were on a waiting list for Enceintes, des Nouvelles Accouchees et des Nourrices.. either sterilisation or vasectomy for their Paris: BaillieBailliere.© re. partner,this proportion of couples seeking permanent contraceptive methods shows REFERENCES that they are over-represented in this sam- Ryding, E. L.,Wijma, B. & Wijma, K. (1997) Post-Post- traumatic stress reactions after emergency cesarean ple. Ekblad (1961) addressed the issue of Ekblad, M. (1961) The prognosis after sterilization on section.section. Acta Obstetrica et Gynecologica Scandinavica,, 76,, `fear of pregnancy' as a reason for request- social^psychiatricsocial^ psychiatric grounds. A follow-up study on 225 856^861. women. Acta Psychiatrica Scandinavica,, 3737 (suppl. 161), ing sterilisation. Some childless women pre- 9^162. senting for sterilisation may be tokophobic Fava, G. A., Grandi, S., Michelacci, L., et aletal (19 9 0)0)(19 WorldHealthOrganization(1992)TheTenthThe Tenth Revision and respond to a psychological approach to Hypochondriacal ffearsears and beliefs in pregnancy. ActaActa of the International Classification of Diseases and Related dealing with the . Psychiatrica Scandinavica,, 8282, 70^72.,70^72. Health Problems (ICD ^10). Geneva: WHO.

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