In this Cyberounds^®, we are pleased to have as our guest, Dr. Kathryn Zerbe, Jack Aron Professor in Psychiatric Education and Women's Mental Health, The Menninger Clinic, Topeka, Kansas. Not only is Kassy a distinguished psychiatric educator, but she is also the critically acclaimed author of Women's Mental Health in Primary Care, who has written widely about today's subject, anxiety.(1),(2)

Stewart

As Kassy discussed in another Cyberounds^®, anxiety disorders are the most prevalent psychiatric disorder. They seem to be more frequent, by a factor of two to three, in women than in men. Therefore, we want to focus this Cyberounds^® on the special issues and concerns that we need to be aware of when we treat the anxious female patient.

Let's start with some definitions. What are the most common anxiety disorders?

Zerbe

There are several. I've summarized them in Table 1.

Based on the American Psychiatric Association Diagnostic and Statistical Manual, DSMIV, 1994, Washington, DC, American Psychiatric Press.

Stewart

Why do you think there are more women than men affected by anxiety disorders?

Zerbe

In our society, one of the strongest precipitants for the differential incidence is that women tend to be highly critical of themselves, much more so than men. Maybe this is a legacy of all the years when men were the economic providers and women stayed home and raised children, that is, were viewed as taking care of less "important" activities. The self-criticism can make a women believe that she is bad or incompetent because of a single mistake. It's an exaggerated response that men don't, in general, experience.

Stewart

Do you think excessive self-criticism will evaporate as the current generation of working women finds its rightful economic place in the society?

Zerbe

I hope so, but there's disconcerting evidence that women, despite their newfound economic roles, still continue to shoulder most of the homemaking and childcare responsibilities. I recommend to our readers, The Second Shift, that explores this paradox. The first shift is her job, then she comes home for another 8-hour day taking care of the family.

Stewart

So a woman cannot really count on support from men for her traditional role? Is this the precipitant for the excess anxiety we see among women?

Zerbe

A number of factors may contribute to a woman's experience of anxiety, including disappointments and frustrations in personal and professional life, struggles with autonomy, low self-esteem. They are often the aftereffects of unsatisfying adult relationships, bereavement or anticipated bereavement.(3) As The Second Shift describes, women are responsible for the physical and emotional care of family members, particularly parents and children. They are expected to be the nurturers at home and tough at the office. And that's not always the easiest of roles to harmonize.

Stewart

Do you think that this "schizophrenic" set of expectations is what gives women so much stress and anxiety?

Zerbe

It certainly factors in. Symptoms of anxiety are a leading cause of women's disproportionate consumption of minor tranquilizers and other psychotropic agents.(4),(5),(6)

We don't know much about the underlying genetic, neurobehavioral and psychosocial mechanisms that appear to uniquely affect women. Genetics does seem to have an influence,(7),(8),(9),(10) but my suspicion is that the cause of anxiety is multi-factorial, a mix of nature and nurture, rather than one or the other.

Stewart

In terms of treatment, are there any special considerations for women patients?

Zerbe

With respect to pharmacological treatment, we have to factor in a woman's smaller weight and body size, menstrual cycle and interactions with contraceptives. Because of the extra societal burdens and responsibilities placed on women, the therapist has to always keep in mind these stressors.

Stewart

Given that women are the nurturers, more attuned to emotional issues in others, is it possible to take advantage of this in the treatment?

Strategies and Tips to Help Women Patients

Zerbe

Each of the anxiety disorders is characterized by the need to worry excessively. The health care provider can deflect this worry somewhat by praising the patient for being highly attuned to the needs of others, especially loved ones.

We know from other Cyberounds^® conferences that reactions to stress can be protective, evolutionarily adaptive. The health care provider needs to emphasize how this super-responsive "warning system" may be necessary to preserve their own lives and the lives of their young. In other words, tell the concerned woman patient, that anxiety can be useful but we have to find a way to not let it get out of control.

Stewart

What's the differential diagnosis of anxiety in women? I am thinking that underlying medical conditions can manifest as anxiety or create anxiety? What should physicians look for?

Diagnostic Considerations

Zerbe

Yes, anxiety can be very prominent with heart disease. Angina pectoris, dysrythmias, valvular disease -- especially mitral valve prolapse -- and congestive heart failure are frequently accompanied by dread and apprehension. As you've written, coronary disease is underdiagnosed in women.(11),(12) It is important to distinguish between cardiac symptomatology and the acute anxiety of panic disorder.(13)

Women have a higher incidence of some diseases -- systemic lupus, hyperthyroidism, anemia -- and these have to be ruled out. Other diseases, particularly those affecting the respiratory system, such as asthma, chronic obstructive pulmonary disease and pneumonia may cause acute anxiety symptoms. Don't forget that even teenage women who smoke a lot of cigarettes may develop pulmonary pathology and associated anxiety symptoms.

Stewart

My experience as an internist is that it takes work to ease out from women patients information about all the medications they take. Is this something we need to underline for our audience?

Zerbe

The same is true among my patients. We have to make an extra effort to get a complete medication history, especially since there are many drugs which can precipitate anxiety. The health care provider needs to ask about and record all medications -- OTC and prescription. In particular, women taking NSAIDs, steroids, psychostimulants for dieting and pseudoephedrine compounds for allergies or upper respiratory infections may present with a subthreshold or full-blown anxiety attack because of medication side effects.

Stewart

Diet is also important, right?

Zerbe

Definitely. Caffeinated beverages (e.g., coffee, tea, sodas) and foods (e.g., chocolate), even in small amounts, can exaggerate anxiety in some at-risk women.

Stewart

I want to underline your point about caffeine. I always specifically ask my patients how much coffee or soda they drink. It's very useful information, particularly with some GI disorders. Women, especially for weight control, drink a lot of diet soda.

Zerbe

Same is true with respect to assessing anxiety. Caffeine is a frequent cause of "the jitters" and we physicians get so busy we forget to ask, or don't realize, that even a small amount of caffeine can precipitate an anxiety attack on a predisposed (subclinical) anxiety disorder patient.

Stewart

I agree. Kassy, can you tell our audience what other special risk factors affect women?

Risk Factors Special to Women

Zerbe

Addiction

About 15% of patients with an anxiety disorder also suffer from a substance abuse disorder.(14) More common is the substance-abusing patient who also has an anxiety disorder. As previously stated, anxiety disorders are a leading cause of women's disproportionate consumption of benzodiazepines and other psychotropic agents.

Unrecognized substance abuse is a major problem among women. Health care providers need to remember that women can be addicts. Not only prominent women -- political wives Betty Ford, Kitty Dukakis and Joan Kennedy come to mind -- but regular, middle class women can be substance abusers. These are life-threatening challenges that must be treated even before the anxiety disorder.(15)

Suicidal Behavior

Among those with anxiety disorders, women are more likely than men to attempt suicide. This is especially true among single, divorced, or widowed women.(16),(17) In many cases, the suicidal patient may need to be first hospitalized before treatment for the anxiety disorder can begin.

Stewart

Aside from the benefits of evolutionarily enhanced vigilance to protect the young, how effective, emotionally, is a mother with anxiety disorder?

Zerbe

Some studies have found that women with anxiety disorders are less warm and emotionally available to their children.(18), Obviously, this will have a consequence for the emotional development of their children. It's going to be difficult for a child to get close to a mother troubled by an anxious temperament or severe anxiety symptoms. Sometimes, we see that the mother's anxiety is manifested as agoraphobia. She's afraid to go outside the home, have sustaining adult relationships and, in her anxiety, turns to her child to deal with her separation anxiety. The child, in turn, may suffer, by modeling its behavior after the mother, refusing to go to school (school phobia) or play with peers.(19),(18),(10)

Stewart

One of the particularly female problems made worse, perhaps, by our society's emphasis on youth and beauty and appearance, is a preoccupation with her body. How does this preoccupation play into the anxiety?

Zerbe

Anxious patients focus on their bodies. They worry about becoming ill, sometimes obsessing on their symptoms. This can produce a somatization disorder that usually begins in younger women and tends to be chronic. The somatizing patient is often dissatisfied with her physician, in contrast to anxious patients, who seek out supportive and reassuring health care providers.

Stewart

Women still remain reluctant, more so than men, to express their anger. Does this reluctance have anything to do with the etiology of anxiety disorder?

Episodes of Anger

Zerbe

Once again, we see there's a conflict between the nurturing role and what women believe they are allowed to feel or express. Mothers, especially, are upset by their anger, concerned that it may have a harmful effect on their children. Recent psychiatric literature reports that anger attacks and anxiety are correlated. These attacks occur in patients with generalized anxiety disorder, panic disorder, posttraumatic stress disorder and depression.(20) Hypothesized to represent a variant of panic disorder, anger attacks are accompanied by rapid onset of overwhelming emotion and autonomic arousal. These symptoms respond to antidepressants. If a female patient complains of increased anger or irritability, be sure to rule out anxiety, depression or a mixed anxiety-depression syndrome.

Stewart

Among my medical patients, few are willing to talk about the possible psychological components of their illness. The idea that their own mental functioning may play a role in their medical problem makes many patients feel ashamed, as if they've failed, in terms of self-reliance. Is that your experience?

Shame in Seeking Help

Zerbe

There's definitely much shame associated with a psychological disorder or "weakness" of any kind -- especially among women. Female obsessive-compulsives will, for example, often carry out their rituals in private. The socially phobic would rather turn down a promotion so they can avoid making a speech or even talking to colleagues for "fear of humiliation."(21)

Stewart

From another Cyberounds^® on PTSD, we know that women have a greater experience with trauma. Is this one of the reasons for the increased frequency of anxiety disorder among women?

Zerbe

Murrey et al.(22) found that 48.5% of women with an anxiety disorder in their sample had a history of childhood sexual abuse. Although sexual abuse has most frequently been linked with posttraumatic stress disorder, these investigators were surprised to find high rates of panic disorder, obsessive-compulsive disorder and depression in this group. Moreover, samples of battered women(23) also had an increased incidence of anxiety.

Consistent, perhaps, with the nurturing role women carry out, some women experience acute loss as a traumatic separation. The elderly are particularly prone to anxiety and depression after the death of a spouse with whom they have spent most of their lives. Women who must deal with a medical catastrophe in their own lives or with a loved one are also prone to experience premonitions of anxiety.

Stewart

Let's talk about childbearing. We all know that this is a particularly stressful moment, emotionally and physiologically, for women. How do you manage the anxious pregnant or postpartum patient?

Reproduction and Childbearing

Zerbe

New mothers naturally experience a host of concerns about the well being and care of their babies. Many worries abound, ranging from the overall care and safety of the infant to obsessional preoccupation with the baby.

Researchers have focused on postpartum depression but less attention has been paid to postpartum anxiety. It goes without saying that the postpartum period is a high-risk time for the onset of psychiatric illness. A recent series of case reports has described a range of anxiety syndromes that occur during pregnancy, particularly the first and last trimesters.(24)

Panic disorder, obsessive-compulsive disorder and generalized anxiety disorder have been reported in the postpartum period.(25) Because their patients responded well to an SSRI, investigators have speculated that an interaction between rapidly changing reproductive hormonal levels (decline of estrogen and progesterone) and a predisposition to psychiatric disorders, rather than an individual's adjustment to motherhood, may underlie obsessive-compulsive thoughts and actions in the puerperium.

With respect to panic disorder, some studies show a consistent improvement during pregnancy and a worsening postpartum.(26),(6) Many women with panic attacks complain of concomitant premenstrual worsening. Progesterone elevation during the later luteal phase of the cycle causes chronic hyperventilation, which may lead to panic in vulnerable groups.(27)

Stewart

Given our concerns about the fetus, is there anything special you have to do to treat the pregnant patient?

The Pregnant Patient

Zerbe

In the childbearing age, the first-line treatments for anxiety disorders are nonpharmacological. However, most of the medicines for anxiety confer low teratogenic risk. Medications are much less of a risk than a high level of maternal anxiety or the risk of symptoms from medication withdrawal for an anxious patient.

I recommend the lowest possible dose of medication and increasing talk therapy, especially during the first trimester. If there's a definite need for pharmacological treatment, the preferred medications are fluoxetine or tricyclics. Large numbers of case follow-ups over time suggest that untoward effects appear minimal. Oral cleft palate has been associated with in utero exposure to benzodiazepines, but an absolute increase in risk has not been proven.

By the second half of pregnancy, when increased intravascular volume leads to decreased absorption and/or enhanced capacity of metabolism, higher doses of medication may be needed.

During labor and delivery, antidepressants may be continued to minimize risk of relapse. Benzodiazepine dosage should be reduced to prevent fetal intoxication or withdrawal. Treating anxiety disorders in pregnancy may require specialty consultation because new options are likely to quickly evolve and influence standards of care.

Stewart

What about premenstrual tension and contraceptives? How do they relate to anxiety disorders?

Contraceptive Use and Premenstrual Anxiety

Zerbe

It's been suggested that anxiety disorders (e.g., panic attacks) may actually worsen premenstrually.(6) The clinician must, therefore, be aware of potentially iatrogenically induced (e.g., contraceptive) or menstrually related syndromes when evaluating women with anxiety.

The menstrual cycle and contraceptives create some important drug-drug interactions that we should be aware of. Psychotropic drugs may affect the efficacy of oral contraception.(28) Drug levels may vary over the course of the menstrual cycle and the drugs themselves may interact with contraceptives. A few case reports have linked Norplant^® with the onset of major depression and panic disorder.(29)

Stewart

Kassy, can you summarize for our audience the take away points on anxiety disorder?

Summary

Zerbe

Anxiety disorders are the most prevalent psychiatric disorders and they occur two to three times more frequently in women than in men.

Though emphasis must be placed on the accurate evaluation of the anxious patient and ruling out medical conditions that mimic anxiety, many patients do not seek help because they are ashamed and otherwise don't recognize they're suffering from anxiety disorder.

Health care providers need to consider that women patients may also be suffering from depression, substance abuse and physical diseases (cardiac, respiratory, autoimmune). Women are more likely than men to be preoccupied with physical disease and have a higher incidence of suicidal behavior. The postpartum period may be a high-risk time for the onset of an anxiety disorder that has to be carefully monitored.

A multidimensional treatment approach that considers a woman's multiple roles as a mother, wife, nurturer and worker must be the basis of the therapy and support. In this way, we can help the majority of women not only to find relief from anxiety but also to attain an enhanced sense of well being and competency in their lives.

Stewart

Thank you, Kassy, for a most illuminating Cyberounds^®.