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Women & anxiety disorders.

Vicky Marchand * was in her 20s when she had her first panic attack. Always a very religious person, she was in church when a woman wearing a deeply cut V-neck top approached her. "I noticed her cleavage, and that's when the panic attack hit, "said Ms. Marchand, who is now 47. "It felt like the worst kind of fight-or-flight feeling," she recalls. "As if a car were going to hit you and you feel like you have to escape."

Associating the attack with V-necks, Ms. Marchand spent the next two years afraid to look at people from the neck down. But her fears grew. She became so convinced that she had sinned in some way by looking at the woman's cleavage that she also tried to avoid any contact with people. "I wouldn't hug people, I would avoid anyone with revealing clothes in the chest area," she recalled. Eventually, she stopped speaking to men in her congregation, afraid she would inadvertently look at their genital area. She also started looking for ways to make herself feel "clean," including reading the Bible incessantly.

Amazingly, Ms. Marchand managed to function in her work as a health care professional, but her personal life became tortuous. At age 36, she tried to commit suicide and finally received a diagnosis: obsessive compulsive disorder (OCD), an anxiety disorder in which people suffer from unwanted, senseless, yet distressing intrusive thoughts called obsessions. They develop senseless behaviors called compulsions to control these thoughts, such as frequently washing their hands if they're obsessed with gems or repetitively checking locks if they're obsessed with safety. (1)

Obsessive compulsive disorder is just one of several anxiety disorder, including panic disorder, social anxiety disorder (SAD), general anxiety disorder (GAD) and posttraumatic stress disorder (PTSD). They affect more than 15 million people in the United States and, as with many mental health conditions, are twice as common in women as men. Overall, an estimated 13 percent of women have an anxiety disorder compared to 6 percent of men, and one in three women will experience an anxiety disorder in her lifetime. (2)

People with anxiety disorder are more likely to quit school, to be underemployed, to require health care services and to commit suicide than those without. (11) They are also more likely to suffer from depression and alcohol and drug abuse. (3)(8)

And yet, says Jerilyn Ross, LICSW, president and CEO of the Anxiety Disorder Association of America (ADAA), ''I think researchers and funders still think anxiety disorders are less worthy for studying. If mental illness is the stepchild of the health care system, then anxiety disorders are the stepchild of the stepchild."

Particularly in women. "Until recently, there was very little scientific information about anxiety disorders in women," she said. "Like most health issues, we assumed that whatever we knew about men was the same for women." To stimulate more research into anxiety disorders in women, the ADAA held a conference on the topic in 2005 and identified several areas for research: the gender gap in prevalence, risk factors, gender differences in symptoms and response to treatment, and barriers to therapy (9) Other topics for exploration include the influence of reproductive hormones on anxiety disorders and anxiety disorders in pregnancy and during the postpartum period. For instance, anxiety is not only common during and after pregnancy, but appears related to a higher rate of complications in the baby and may lead to premature birth. (10)

The gender disparity in anxiety disorders may be partly related to the fact that men are more likely than women to self-medicate their disorders with alcohol, said Sally Winston, PsyD, who codirects the Anxiety and Stress Disorders Institute of Maryland in Towson. "There's such a high comorbidity between alcoholism and anxiety that very frequently people are struggling with substance abuse of one kind or another," she said. In fact, some studies suggest that up to one-third of people in substance abuse treatment have a diagnosable anxiety disorder, while up to one-third of those in treatment for an anxiety disorder have a substance abuse problem.

Men may be more likely to try and drink away their anxiety because they have a harder time addressing health issues, she said. "It's easier to go into a bar and buy a drink than tell someone how they're feeling," she noted, adding, "In our culture, drinking is still not as socially acceptable for women."

But anxiety is. Worrying, shyness or fear is considered "normal" in women, the ADAA found during its conference. So, health care professionals may be less likely to diagnose an anxiety disorder in women. Meanwhile, women with anxiety disorders don't walk into the doctor's office wringing their hands and complaining they can't stop worrying. Instead, they're more likely to come in with headaches, irritable bowel syndrome, muscle tension or other stress-related symptoms that wax and wane, said Dr. Winston, They may also feel light-headed, as if they never get enough air, and experience tingling in their finger-tips, toes or face, an awareness of their heartbeat, and feel off balance.

Plus, women can be just as good as men at hiding their anxiety. Ms. Marchand spent nearly 20 years hiding hers. Another woman, Rita Clark, 65, had her first panic attack in the late 1960s; she spent the next 15 years rarely leaving her house because she feared another. Yet her husband and children viewed her as the "strong" one in the family.

"People try to hide their anxiety because they are so fearful of embarrassing themselves and losing control," said Ms. Ross.

A Normal Reaction Gone Awry

Jonathan S. Abramowitz, PhD, who directs the Anxiety and Stress Disorders Clinic at the University of North Carolina in Chapel Hill, thinks anxiety disorders are among the most common mental health conditions because anxiety itself is such a normal response to a stressful situation. But when it occurs apropos of nothing at a level far higher than what most people normally experience, its occurrence can be so disconcerting that people go to extremes to avoid a repeat.

"The thing that separates an anxiety disorder from normal anxiety is that a disorder is always irrational, and the person is aware that their anxiety is irrational," said Ms. Ross. Plus, a diagnosis requires that the condition disrupts the person's normal life and relationships.

Unfortunately, anxiety disorders are often misdiagnosed as depression, said Dr. Winston. One reason is that health care professionals may confuse the anxiety with the agitation seen in depression. "Anxiety is about something, there's a cognitive content to it, worrying about something, stewing over something," she said. Agitation is more a sense of being unable to concentrate, to sit still, to settle down, she said. Another important distinction between the two occurs with sleep patterns. "Anxiety usually interferes with falling asleep," said Dr. Winston, "but with agitation and depression you often wake up at 4 a.m. and can't fall back asleep."

The diagnosis can be even more confusing because the two often coexist. One of the largest studies ever to evaluate the prevalence of mental disorders in the United States found almost half of those who met the criteria for major depression also met the criteria for a coexisting anxiety disorder. (2) In fact, there's some evidence that the increased prevalence of anxiety disorders in women may play a role in their increased risk for depression. (11)

Still, there are clues that health care professionals should look for, said Ms. Ross. "Patients who come in for specific symptoms but when you ask if anything else is bothering them, they say their heart races for no reason, or they get the sweats and they're not menopausal, or they're having irrational thoughts or feelings. If you hear that, it's important to listen and probe deeper."

"Shaking and Trembling"

Rita Clark was playing cards with her husband and another couple when she started shaking, feeling as if she were having a heart attack. She ran to the bathroom and lay on the floor trembling. The next day she went to her doctor, who diagnosed her with low blood pressure. "I knew that wasn't true, but it sounded good to tell people," she recalled. "I knew in my heart that I was going crazy." This was the late 1960s, when mental illness was rarely discussed. Ms. Clark feared losing her children if she told anyone what was really going on.

That fear dictated her life for the next 15 years. Although she never had another panic attack as horrible as the first, she manipulated her life so she was always close to home, which she viewed as a safe place. She wouldn't go to the grocery store or visit family without her husband or children--"I felt I could do things socially as long as I had them there"--and if she felt any signs of a panic attack, she hightailed it home as quickly as possible. "I was convinced I was going to faint and make a fool out of myself and someone would find out that I wasn't in control," she recalled.

One afternoon 15 years after her first panic attack, she read a newspaper article about agoraphobia and panic disorder and recognized herself. "Oh my God," she thought. "They have a name for it. Maybe I'm not crazy." She ran out into the yard where her husband was sitting and showed him the article. "This isn't you," he said after reading it. "Yes, it is," she said. "This is what I've been like for 15 years."

She marks her recovery from that point, thanks to therapy and short-term medication. Today she works full time and travels the country speaking out about anxiety disorders.

The therapy that finally put Ms. Clark on the path to recovery is called cognitive behavioral therapy, or CBT. Studies find it works as well as medication for most anxiety disorders, with less chance of return in symptoms following discontinuation of treatment. (11) (12)

The National Association of Cognitive Behavioral Therapies defines CBT as therapy that is based on the idea that our thoughts cause our feelings and behaviors, not external things, like people, situations and events. Thus, you can learn to change the way you think to feel or act better even if the situation does not change.

"This type of therapy is very, very specific, and it works very, very well," said Dr. Winston. "It is a process of teaching patients not to be scared and of providing them with the facts about what's happening when they have a panic attack."

Finding a therapist trained in CBT, however, can be challenging, say Drs. Winston and Abramowitz. "Most therapists think in terms of psychodynamics, trying to figure out the root cause of a problem--what your mother did to you, what conflicts in your psyche need to be resolved," said Dr. Abramowitz. "In CBT, we only worry about things we can prove. We're only interested in the symptoms of the problem, not the psychic conflicts that may not even exist."

The only way to really know if a therapist is trained in using CBT to treat anxiety is to ask. Find out what percentage of their patients have anxiety disorders, the average length of time patients spend in therapy (CBT is a short-term form of therapy typically requiring a dozen or fewer session) and their success rate.

Medications may be used in conjunction with CBT, including antidepressants such as fluoxetine (Prozac), paroxetine (Paxil) and venlafaxine (Effexor); and buspirone (BuSpar). Benzodiazepines such as diazepam (Valium), alprazolam (Xanax) and lorazepam (Ativan), though potentially helpful in terms of reducing short-terms of reducing short-term distress, are typically not used along with CBT because they are sedating and can lead to perceived dependence, difficulty discontinuing and increased anxiety and panic attacks while discontinuing. (13)

The most important thing women should know, says Ms. Clark, is that treatment works. "Reach out for help," she advises. "You can get better. The fear of having a panic attack can go away."

Vicky Marchand knows that for a fact. After years of the wrong kind of therapy and another suicide attempt, she finally got the help she needed two years ago with a combination of CBT and the antidepressant fluvoxamine (Luvox), often used to treat OCD.

"If your mind can use your fears and insecurities to create your anxiety, than you can use the power of the mind to release your anxiety," she said. "I'm living proof it can be improved."

Resources

Anxiety Disorders Association of America 240-485-1001

www.adaa.org

Anxiety and Stress Disorders Clinic University of North Carolina Chapel Hill, NC

919-962-6906

www.unc.edu/depts/clinpsy/services/anxiety/

International Society for Traumatic

Stress Studies

847-480-9028

www.istss.org

National Association of Cognitive-Behavioral Therapists (NACBT)

www.nacbt.org

National Institute of Mental Health

www.nimh.nih.gov

New York State Psychiatric Institute/Columbia University Medical Center

Anxiety Disorders Clinic & EI Programa Hispano de Tratamiento

212-543-5367

nypisys.cpmc.columbia.edu

RELATED ARTICLE: Anxiety disorders defined.

In addition to obsessive compulsive disorder (OCD) defined on page 1, other common anxiety disorders (11) include:

Generalized anxiety disorder (GAD): Characterized by excessive worry about everyday life situations such as relationships, finances, work or school. Typically accompanied by physical symptoms such as headaches, nausea or trouble sleeping.

Panic attacks: Characterized by a rush of intense physical symptoms such as increased heart rate, sweating and dizziness that seems to come from "out of the blue" and peaks within a few minutes.

Panic disorder: The persistent fear that one will have a panic attack and fear about the consequences of such an attack.

Agoraphobia: Avoiding situations in which escape might be difficult or help may be hard to find, such as large crowds and being alone. Often accompanies panic disorder.

Social anxiety disorder: Characterized by painful anxiety in social situations or avoiding such situations altogether.

Posttraumatic stress disorder (PTSD): Condition in which people who experienced or witnessed a traumatic event reexperience these events in the form of flashbacks, nightmares or other intrusive memories. Also characterized by sleep disturbances, a heightened startle response, feeling detached from others and avoiding reminders of the trauma.

Specific phobia: Excessive fear of a certain object or situation, such as animals, storms, elevators, etc.

RELATED ARTILCE: Who's who?

The following health professionals help diagnose and treat anxiety disorders:

Primary health care providers: Includes family physicians, internists, pediatricians and obstetricians and gynecologists (primarily for screening and referral).

Licensed mental health professionals: Includes psychiatrists (MD or DO); psychologists (typically PhD, PsyD, or ScD), social workers and other therapists licensed by the state to provide evaluations, diagnosis and psychotherapy.

Nonlicensed professionals: Usually have a master's degree in the mental health or social work field. Check with your state's medical board regarding licensing requirements for mental health professionals.

References

(1) Anxiety and its disorders. Available at www.jabramowitz.com. Accessed Feb 22, 2008.

(2) Lepine JP. The epidemiology of anxiety disorders: prevalence and societal costs. J Clin Psychiatry. 2002;63 Suppl 14:4-8.

(3) Kessler RC, Berglund PA, Foster CL, Saunders WB, Stang PE, Walters EE. Social consequences of psychiatric disorders, II: Teenage parenthood. Am J Psychiatry. 1997;154(10):1405-1411.

(4) Sonne SC, Back SE, Diaz Zuniga C, Randall CL, Brady KT. Gender differences in individuals with comorbid alcohol dependence and posttraumatic stress disorder. Am J Addict. 2003;12(5):412-423.

(5) Rogers MP, White K, Warshaw MG, et al. Prevalence of medical illness in patients with anxiety disorders. Int J Psychiatry Med. 1994;24(1):83-96.

(6) Markowitz JS, Weissman MM, Ouellette R, Lish JD, Klerman GL. Quality of life in panic disorder. Arch Gen Psychiatry. 1989;46(11):984-992.

(7) Kessler RC, Walters EE, Forthofer MS. The social consequences of psychiatric disorders, III: Probability of marital stability. Am J Psychiatry. 1998;155(8):1092-1096.

(8) Kessler RC, Foster CL, Saunders WB, Stang PE. Social consequences of psychiatric disorders, I: Educational attainment. Am J Psychiatry. 1995;152(7):1026-1032.

(9) Anxiety Disorders in Women: Setting a Research Agenda. Anxiety Disorders Association of America. 2005. Available at www.adaa.org. Accessed Feb 1, 2008.

(10) Ross LE, McLean LM. Anxiety disorders during pregnancy and the postpartum period: A systematic review. J Clin Psychiatry. 2006; 67(8):1285-1298.

(11) Pigott TA. Anxiety disorders in women. Psychiatr Clin North Am. 2003; 26(3):621-672, vi-vii.

(12) Gorman JM. Treating generalized anxiety disorder. J Clin Psychiatry. 2003; 64 Suppl 2:24-29.

(13) Stevens JC, Pollack MH. Benzodiazepines in clinical practice: consideration of their long-term use and alternative agents. J Clin Psychiatry. 2005; 66 Suppl 2:21-27.
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