Prise en charge de la tocophobie par thérapie cognitivo-comportementale : à propos d'un cas clinique

Tokophobia is a relatively unknown, although quite frequent, anxiety disorder. It is characterized by an excessive and persistent fear of childbirth, and accompanied by avoidance behaviors that may affect pregnancy, despite the patient's wish for a child, or childbirth. Tokophobia may explain some requests for abortions or elective Caesarean sections. The avoidance behaviors of the feared situation clearly distinguish tokophobia from a simple, and normal, fear of childbirth. Tokophobia is considered “primary” when it precedes the first conception, or “secondary” if it is consecutive to childbirth, for which the subjective experience was negative. It can also be associated with prenatal depression, of which it is a symptomatic component. This disorder can be associated with obstetric or postpartum complications. Despite its frequency and its disabling features, treatment has been the subject of little research, and most of the studies are more closely related to simple fear of childbirth rather than tokophobia. No study was identified using cognitive behavior therapy for tokophobia. The current article reports on the case of a 31-year-old patient suffering from primary tokophobia, that started in adolescence, and was characterized by symptoms of panic anxiety in various situations evoking pregnancy or childbirth. Fears led the patient to avoid pregnancy despite her desire for a child. There was no medical or other psychiatric history apart from a simple insect phobia; no sexual abuse was reported. Cognitive behavior therapy was carried out according to a protocol classically used in specific phobias; treatment was conducted in 20 sessions, over 10 months. Psychoeducation was conducted on the progression of childbirth as well as on phobic anxiety; cognitive restructuring was centered on biased representations and feelings of inability. Graded exposure to anxiety-provoking thoughts and images concerning the different stages of labour was also performed. These therapeutic tools were combined during the course of therapy given the evolution of the presenting clinical features. The results were clinically significant in reducing fears related to childbirth as shown by a 43% reduction of the total score on the adapted Traumatic Event Scale. Feelings of inability to carry out a pregnancy decreased from 9.5/10 before treatment to less than 2/10 at the end of therapy, allowing the patient to serenely consider this possibility. On the Clinical Global Impression scale, the severity of the illness decreased from 5 (“markedly ill”) to 2 (“borderline mentally ill”) and the improvement relative to baseline was rated as “very much improved”. This case report suggests that a cognitive behavior therapy protocol using conventional techniques employed in the treatment of specific phobias is both applicable and likely to induce significant clinical improvement in primary tokophobia. Further studies are needed to validate this approach.