Features

Anxiety Disorders in Women, Part 1: Prevalence, Trends, and Psychotherapy

Tracy L. Skaer, BPharm, PharmD; David A. Sclar, BPharm, PhD


Feature article

Anxiety disorders represent a major psychological, medical, and social burden in women, who now appear to have a gender-related predisposition. An awareness of this propensity— especially with regard to various disorder subtypes at different points in the life cycle—should guide health care providers to a heightened sensitivity and the need for comprehensive screening.

Anxiety disorders are among the most prevalent form of mental illness in the United States.1,2 Some 30 million Americans (25%) will fulfill the diagnostic criteria for at least one anxiety disorder in their lifetime, with 15.7 million affected annually.2,3 This amounts to a lifetime prevalence of nearly 15%.4-6 Generalized anxiety disorder (GAD), panic disorders, social phobia (SP), post-traumatic stress disorder (PTSD), simple phobia, and obsessive-compulsive disorder (OCD) are currently all classified as anxiety disorders.1 The hallmark of these disorders is excessive worry, which may be sudden or episodic (panic attacks), continuous (GAD), or situationally triggered (PTSD, phobia).

Women have a higher predisposition toward anxiety disorders,2,7-9 with > 13% meeting the diagnostic criteria compared with 6% of men.4-6 Moreover, women are approximately 2-fold more likely to meet lifetime criteria for panic disorder (5% versus 2%), agoraphobia (7% versus 3.5%), simple phobia (15.6% versus 6.7%), PTSD (11.3% versus 6%), GAD (6.6% versus 3.6%), SP (15.5% versus 11.1%), and OCD (3.1% versus 2%).2,10 Thus, risk factors associated with anxiety disorders include female gender, as well as lower income, less education, and living in the Northeast.11 The impact of gender is profound, increasing the likelihood of developing an anxiety disorder by 85% in women compared with men.11

The burden and negative consequences of anxiety disorders are enormous, comparable to chronic somatic disorders.12 Anxiety disorders are associated with significant morbidity, chronicity, and often poor long-term prognosis. They are frequently comorbid with other psychiatric disorders, especially major depressive disorder.13 The annual cost of anxiety disorders in this country is $42 billion (in 1990s dollars),7 with nonpsychiatric medical treatment accounting for $23 billion (54%); psychiatric treatment, $13 billion (31%); lost productivity and other adverse functional consequences, $4.2 billion (10%); mortality-related expenses, 1.3 billion (3%); and pharmacotherapy, $840 million (2%).14

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GENDER ISSUES

Gender plays a role in anxiety risk, co-morbidities, presentation, and treatment re-sponse.7-9,15 Women with PTSD may be at increased risk of substance abuse, and anxiety disorders have been shown to be more common in girls who drop out of school.15 Patient-specific data are lacking, but genetic factors, familial environment, and early-life adversity may be important determinants.16,17 Gender-related differences have been recognized in presentation, especially for panic disorder, which tends to be more severe, relapsing, and comorbid in women.7-9,18,19 Women who experience personal violence may be more vulnerable to PTSD, and the symptoms may be different in women (eg, numbing, avoidance) than in men (eg, irritability, poor impulse control).8,20

A single mechanism has not been identified to explain the gender differences in anxiety. Behavioral inhibition in infants and very young children has been linked with anxiety later in life, but studies do not strongly support a casual, gender-related role.21 Initially, OCD is more common in prepubertal boys, and generally does not emerge until adulthood in women.22 Separation anxiety disorder, negative affect, and new-onset panic attacks are more prevalent in girls, but the mechanisms for these differences remain unclear.22,23

The marked fluctuations in reproductive hormone levels during the female life cycle may modulate anxiety.18 Findings from smaller studies on PTSD, late luteal-phase anxiety, gestational/postpartum panic disorder, and lactation may provide an incentive for future research.20,24 Moreover, the relationship between anxiety disorders and menopause has yet to be explored.

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COMORBIDITY

There is consistent documentation of high rates of psychiatric comorbidity among patients with anxiety disorders.2,8,9,11,12,16,25,26 Clinical studies have shown that ≥ 50% of patients with a primary anxiety disorder have at least one additional anxiety or mood disorder27,28; 60% of patients with a principal anxiety or mood disorder have an additional axis I disorder, and 80% have a positive lifetime history.28,29 Reported comorbidity rates for specific anxiety and mood disorders are even higher. For instance, 65% and 88% of GAD patients have a current or lifetime comorbid anxiety or mood disorder, respectively, with PTSD patients at 92% and 100%.28,29 It is therefore important to screen patients for other psychiatric comorbidities at the time of anxiety disorder diagnosis.

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DIAGNOSIS

The American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders, fourth edition text revision (DSM-IV-TR) classifies anxiety disorders into several categories.1 The most common characteristic fea- tures of these illnesses are anxiety and avoidance behavior. For example, the diagnostic criteria for GAD require persistence of symptoms for at least 6 months with the essential feature of GAD being unrealistic or excessive anxiety and worry about a number of events or activities. For the specific DSM-IV-TR criteria for any given anxiety disorder, please refer to the following Web site: www.behavenet.com/capsules/disorders/ dsm4TRclassification.htm.

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PSYCHOTHERAPY

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CONCLUSION

Psychotherapy—particularly cognitive-behavior-al therapy (CBT)—can be very effective in the treatment of anxiety disorders.8,30,31 It focuses on correcting maladaptive thoughts and behaviors that initiate, perpetuate, or exacerbate anxiety symptoms.30,31 Through CBT, the patient learns to decrease the fear and avoidance of internal and external signals associated with panic attacks. The cognitive restructuring and graded exposure components of CBT target panic attacks and phobic-avoidance behavior.30 Indeed, CBT is frequently regarded as the treatment of choice for PTSD patients.32

Exposure therapy requires patients to confront phobic situations gradually, starting with the least-feared scenario. For patients who cannot or will not use antianxiety medications, CBT alone is certainly indicated. Therapy is associated with short-term im-provement in 66% of patients, and 6-month improvement in 75%.31 Social skills training, systematic desensitization or in vivo exposure, and CBT have also been demonstrated to be effective for social phobia, although it is unclear whether CBT or exposure therapy is better.32

Despite available data on the efficacy of pharmacotherapy and CBT for panic disorders, many patients are still treated with other, less reliable psychotherapies.32,33 One example is emotion-focused psychotherapy, which involves empathic listening and supportive strategies to help patients identify and manage painful emotions and life situations.33 With regard to panic disorder, this therapy assumes that unrecognized emotions trigger attacks and perpetuate the disorder.33 Thus, disavowing/avoiding the resulting fear, anger, guilt, or shame produces a vague sense of unease that is often misattributed to a physical condition. While emotion-focus psychotherapy appears credible, it has not performed as well as CBT or imipramine.33 Nonetheless, emotion-focused psychotherapy had a higher retention rate than CBT or imipramine. This may be due to therapistsÍ reluctance to switch to other modalities or try a combination of treatments. Thus, emotion-focused psychotherapy continues to be utilized, although its efficacy remains unproven.33

In 1989, eye-movement desensitization and reprocessing (EMDR) was introduced as a new treatment for psychological trauma. This is an information-processing therapy that uses an eight-phase approach, integrating elements of several effective psychotherapies with structured protocols designed to maximize treatment effects. These include psychodynamic, cognitive-behavioral, interpersonal, experiential, and body-centered therapies.34 There has been some question about EMDRÍs efficacy over the years, but it is now accepted as a treatment of choice by numerous mental health and trauma specialists.34-36 As of 2004, the APA and US Departments of Defense and Veterans Affairs have all recommended EMDR as first-line therapy for all anxiety/stress trauma cases.37 In addition, current guidelines from the International Society for Traumatic Stress Studies designate EMDR as an effective treatment for PTSD, listing it among the primary treatments for trauma victims.37

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CONCLUSION

Anxiety disorders are chronic, highly prevalent illnesses that frequently occur with other mental disorders, particularly in women. They can lead to significant impairment and disability, and recovery rates remain low despite the overall efficacy of available treatments. Psycho-therapy—particularly CBT and EMDR—is considered very efficacious in the treatment of anxiety disorders, and should be considered in the initial treatment plan together with pharmacotherapy.

The concluding article in this series, which will appear in an upcoming issue of The Female Patient, will focus on pharmacotherapy for anxiety disorders, including initial treatment, relapse/nonresponse, and pregnancy/lactation.

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Tracy L. Skaer, BPharm, PharmD, is professor of Health Policy and Administration, professor of Pharmaco-therapy, and associate director. David A. Sclar, BPharm, PhD, is Boeing Distinguished Professor of Health Policy and Administration, Boehringer Ingelheim Scholar in Pharmaceutical Economics, and director. Both are in the Pharmacoeconomics and Pharmaco-epidemiology Research Unit, College of Pharmacy, Washington State University, Pullman.


References

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