Anxiety disorder is characterized by an apprehension of unknown danger and dread accompanied autonomic symptoms without an apparent object, threat or cause. Being pregnant is considered by some to be a cause of specific anxiety disorder, which not only affect the health of a woman, also the social future of a new mother. A pregnant woman concern over the well-being of the baby, outcome of the pregnancy and birth or parenting, may present as predominant feature. Those who have a history of mental illness or substance use, poor social support, exposed to violence or abuse, unplanned pregnancy, previous negative experience of pregnancy, having first baby, expecting a male baby, lower self-esteem are more vulnerable to have the anxiety disorders. During the 1st and 3rd trimester, reported a prevalence rate of anxiety disorder is varying from 10% to 16%. Nearly 54% of the women experienced anxiety at the some point of pregnancy. The elevated and prolonged anxiety disorder has been associated with negative consequences on mother and development of child and also related to postnatal depression and posttraumatic stress disorder. Controversies are there regarding the use of medications during pregnancy. Hence, pregnant women with an anxiety disorder require assessment and intervention-free from side effects from a specialized mental health professional. It is striking that relatively little research efforts have been put in developing and testing the interventions that have the potential to reduce or alleviate anxiety, free from side effect, and easy to apply. Even, the NICE guideline proposed the low-intensity psychological interventions which may benefit pregnant women with the symptoms of mild-moderate anxiety. Although Biofeedback is one of the emerging promising treatment modalities, but no effort has been put by scientific groups.
The available limited data from Western countries showed that Bio-feedback is an acceptable, effective, and usable self-help intervention. However, there are no data available from developing countries such as India.
The index case presented with anxiety spectrum symptoms and panic disorder during the first-trimester pregnancy and was managed with Biofeedback therapy and delivered a healthy baby without any prenatal or postnatal complications. To the best of knowledge, this is the first case report from India to report the biofeedback as a treatment modality for the anxiety disorder.
An 27-year-old pregnant woman presented with complaints of a recurrent panic attack and other anxiety symptoms. On evaluation, it was revealed that she was a known case of panic disorder, and getting paroxetine 25 mg/day and clonazepam 0.25–0.5 mg sos. She continued the treatment for 1½ year. After that, planned for a baby and stopped the medication with the advice of the therapist. In the first trimester, started having anxiety about the health of the baby and the outcome of the pregnancy. She would remain to preoccupy that “how she will cope with labor and childbirth” and would have “baichani” and palpitation which would persist most of the day. Gradually, she started having recurrent episode of panic attacks, 1–2 times/week. She consulted an obstetrician, clinical examination and blood investigations, including thyroid profile, ultrasound, electrocardiogramand vitals, including blood pressure, were within normal limit. Following which, visited psychiatry outpatient department. On exploration, it was found that whenever the patient would not take Paroxetine, would have relapse of anxiety symptoms. After clinical evaluation and assessed on generalized anxiety disorder-7 (GAD-7-scored 13 out of 21) scored a moderate level of anxiety. Pharmacological and nonpharmacological therapy were offered and explained the pros and cons of the drugs.
Patient and family member opted for the Biofeedback therapy and breathing exercise. Biofeedback therapy sessions were started with regular monitoring of severity of symptoms on GAD-7 and clinically. Initially, 2–3 session/week, 30–45 min, were given for 3 weeks and had 60%–70% (GAD-7 score came down from 13 to 7) improvement. Gradually, frequency of session reduced to 1/week and had complete improvement in 2 months (GAD Score was 3). Thereafter, she would visit 1–2 times/month and delivered a normal baby at the full term by normal vaginal delivery without any adverse consequences.
Biofeedback therapy demonstrates a mind-body connection and trained the individual to modify their physiological parameters to improve the overall physical and mental health. Although Biofeedback procedures are highly effective in ameliorating a variety of psychiatric as well as a medical symptom such as chronic pain, still, it is rarely used in India. In a systemic review of six studies and in one randomized controlled trial, found that biofeedback is an effective and acceptable treatment for the anxiety disorder in pregnancy. From India, a single case report has been found on the effectiveness of the Biofeedback on somatic complaints. It is based on the principle of the operant conditioning of various autonomic functioning could be achieved, which means the acquisition of the self-regulation of the reflexes of the physical function of the body. Biofeedback provides experimental and visual evidence of the connection of mind-body interaction. In the index study, we used the biofeedback machine, which has a monitor used to display the changes in the parameters of the body. There were electrodes (acts as a sensor) which were placed on the fingers, abdomen to measure the heart rate, blood pressure, respiratory rate, or galvanic skin response. The therapist was guiding the patient through a relaxation technique. The session would last for 30–45 min. As reported in the literature that as the therapy progresses, the patients understand that changes in thoughts and emotions may result in changes in body functioning. Similarly, the index patient also perceived the changes and improvement in the anxiety symptoms.
This study strengthens the evidence that Biofeedback therapy can be safely used during pregnancy without any prominent side effects. This case report can be a springboard for future research to find the effectiveness of the therapy.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
1. World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research. 1993 Geneva World Health Organization
2. Evans K, Spiby H, Morrell JC. Non-pharmacological interventions to reduce the symptoms of mild to moderate anxiety in pregnant women. A systematic review and narrative synthesis of women's views on the acceptability of and satisfaction with interventions Arch Womens Ment Health. 2020;23:11–28
3. Lee AM, Lam SK, Sze Mun Lau SM, Chong CS, Chui HW, Fong DY. Prevalence, course, and risk factors for antenatal anxiety and depression Obstet Gynecol. 2007;110:1102–12
4. Glover V. Maternal depression, anxiety and stress during pregnancy
and child outcome; what needs to be done Best Pract Res Clin Obstet Gynaecol. 2014;28:25–35
5. Coelho HF, Murray L, Royal-Lawson M, Cooper PJ. Antenatal anxiety disorder as a predictor of postnatal depression: A longitudinal study J Affect Disord. 2011;129:348–53
6. Cornsweet Barber C, Clark M, Williams S, Isler R. Relaxation and mindfulness to manage computerised self-help programme MIDIRS Midwifery Dig. 2013;23:449–54
7. Zafeiri E, Kandylaki A, Zyga S, Zarogiannis I, Panoutsopoulos GI. The contribution of biofeedback brain boy method to the treatment of anxiety disorders Mater Sociomed. 2019;31:105–9
8. Marc I, Toureche N, Ernst E, Hodnett ED, Blanchet C, Dodin S, et al Mind-body interventions during pregnancy
for preventing or treating women's anxiety Cochrane Database Syst Rev. 2011;6:CD007559
9. van der Zwan JE, Huizink AC, Lehrer PM, Koot HM, de Vente W. The effect of heart rate variability biofeedback training on mental health of pregnant and non-pregnant women: A randomized controlled trial Int J Environ Res Public Health. 2019;16:1051
10. Mehra A, Souhan A, Kumari V. Is biofeedback the last resort for fibromyalgia: A case report and review of Literature Int J Psychol Sci. 2019;1:6–8