Are Women Prone to Worry?

How to cope when anxiety gets out of control

Jeanne L Alexander, MD Vivien Burt, MD, PhD

August, 2004

Do you worry excessively about your loved ones, your personal safety, or your performance on the job? Do you have the tendency to catastrophize and believe that the worst is about to happen? Do you spend nights lying awake, trying to avert potential problems? If so, you're not alone.

Anxiety is often thought of as a woman's issue because women are more than two to three times more likely to develop it than are men.[1] Five percent of all women suffer from anxiety at some point in their lives.[2] Some complain of generalized anxiety, a low-grade discomfort that never goes away. Others suffer from intermittent anxiety that waxes and wanes with no apparent cause.

Anxiety also includes more specific problems, such as phobias, post-traumatic stress disorder, and panic attacks.

Are women more sensitive to danger?

Evolution has always favored species that are more sensitive to danger. The fight-or-flight response of rushing adrenaline and accelerated heartbeat is our basic survival mechanism. The problem arises when this response becomes habitual or automatic and is no longer appropriate to the situation. (See The Devastating Effects of Chronic Stress.)

Some people are more sensitive to these cues from the environment. Others are so oblivious to risk that they often find themselves in hazardous situations. Most of us fall somewhere in the middle between these two extremes. Yet this variability in response gives humans an evolutionary advantage. The sensitive person alerts others to danger and the more risk-tolerant one holds the group in check and keeps others from reacting too quickly.

Women tend to be on the more sensitive end of the spectrum. There are many theories based on anthropological observations, role-related behaviors, and hormone shifts to explain this.

When is anxiety abnormal?

Abnormal anxiety is an exaggerated response to danger. "The person with an anxiety disorder sees a threat and reacts to a threat when no real threat exists."[3]

People who suffer from anxiety are perpetually consumed by worries and catastrophic thoughts. They are unable to tune out the natural worries of day-to-day life and continue to play them over and over again in their heads. This heightened anxiety impacts their body, their feelings, and behavior, as well as their thinking patterns. It is unclear whether this anxiety drives the misjudgments of danger, or the physiological arousal drives the anxious thoughts.

In either case, ongoing anxiety can be an incapacitating and uncomfortable problem. Its worst manifestation is the full-fledged panic attack.

The mental symptoms of ongoing anxiety range from fear and worry to difficulty concentrating, oversensitivity to slights or personal exchanges, general irritability, and catastrophic thinking. Physiological symptoms include palpitations or increased heart rate, sweating, gastrointestinal distress, sleep disturbances, muscle tension, dry mouth, clammy hands, a feeling of being constantly on alert or keyed up, and a general sense of fatigue. (For the standard diagnostic criteria for general anxiety, see http://www.behavenet.com/capsules/disorders/gad.htm.)

Anxiety and sleep

The anxious person may find it difficult to calm down and go to sleep. Some patients feel besieged by negative thoughts, and they say it's like having an internal committee so busy discussing the pro's and con's of every troublesome situation each night that they cannot rest.

Studies show that the sleep of an anxious person is not restorative and is generally too short. Such patients have more difficulty falling asleep (sleep latency), experience increased wake time throughout the night, and have reduced delta slow wave sleep, which is related to the body's ability to repair itself.

As a result, the anxious person is tired during the day, often has muscle aches and pains, has problems with thinking and memory, and feels generally irritable. These are all classic reactions to a reduction in quality sleep.

How does an anxiety disorder develop?

People with anxiety problems often have the first symptoms in childhood and adolescence. The symptoms may vary in severity depending on the situation and the amount of stress the individual faces, but at some point, the anxiety starts to interfere with day-to-day functioning. The patient may complain of performance anxiety, and problems with personal relationships and decision-making, or she may say that she just feels edgy and uncomfortable all the time.

Anxiety often affects the entire family. A woman may defend her anxious behavior by saying, "Everyone in my family thinks like I do." She may have picked up behavior patterns and ways of reacting to stressful situations from a parental role model. A genetic susceptibility to anxiety may reinforce her feelings and responses and make her discomfort seem "familiar."

There is some evidence that mothers and daughters have similar anxiety complaints, but a good clinician will consider the whole picture: the home environment, the behavior pattern of caregivers, and genetic susceptibility.

Anxiety and the brain

We have much to learn about the neurobiology of generalized anxiety. However, some studies have found a link between inherited and acquired vulnerabilities and abnormalities in the benzodiazepine receptor in the brain. (This receptor responds to sedatives, such as Valium® and alcohol, producing a feeling of relaxation.) Valium® and other benzodiazepines provide temporary relief, but they do not address the causes of anxiety or bring about a cure.

Antidepressants have proven effective in reducing symptoms of anxiety, as well.

Some researchers have found that anxiety-related sleep disturbances are related to abnormal regulation of serotonin levels.[7] This may be one of the ways that SSRI antidepressants help — by stabilizing sleep patterns in anxious individuals.

Anxious people may try to alleviate their symptoms with alcohol. While alcohol can give a momentary lift, the individual will feel worse, and mood will plummet as it leaves the system.

Anxiety and quality of life

Anxiety has a global effect on a person's life. Psychiatric researcher Ronald Kessler[8] found that anxious rated their mental health as "fair" or "poor" six times more often than healthy individuals. Thirty-five percent of those with severe anxiety problems considered themselves moderately to highly socially impaired. Anxiety can also affect job performance: 11 percent of those with an anxiety problem in this study reported missing six or more days of work in a given month.

A woman's anxiety response can also be heightened by premenstrual symptoms, childbirth, the perimenopausal transition, hot flashes, and certain hormone treatments.

We explore these factors below.

PMS and anxiety

Premenstrual irritability and mood changes can increase anxiety. These need not be significant enough to be considered a premenstrual dysphoric disorder (PMDD), a serious form of cyclical depression that occurs one week prior to menstruation.

While some patients may have a sub-clinical form of premenstrual dysphoric disorder, others simply experience a magnification of their anxiety symptoms the week prior to menstruation. These women often blame their problems on PMS when, in fact, the menses is simply intensifying a problem they have during the entire month.

Perimenopause

Women who have had intermittent but tolerable anxiety may also have increased emotional difficulties when they approach the "change of life." Ellen Freeman writes in a 2004 paper that perimenopausal women with a history of depression are twice as likely to have depressive symptoms at this time of life.[9] Perimenopausal women with hot flashes and night sweats are also four times more likely to suffer from depression compared to those without vasomotor symptoms; thus, hot flashes in and of themselves present a risk for mood problems.[10]

A combination of ongoing low-level anxiety, hot flashes, and related sleep disturbances may also increase emotional discomfort .[11] Women often complain that menopause causes their anxiety, yet a careful inspection of their history reveals that they have long suffered low-level anxiety that has blossomed under the biological stress of "the change."[12]

Not all women with low-grade anxiety experience this sudden flowering of symptoms, however. Further, the SWAN study (a large multi-site study designed to examine the health of women during their middle years) found that psychological symptoms are likely to be associated with estrogen and progesterone hormonal fluctuations in the early stages of menopause.

Hot flashes

It is important to distinguish between a hot flash and an anxiety attack. Hot flashes occur during the day as well as at night. They are associated with increased core body- temperature, a feeling of heat rising from the chest to the face, and profuse sweating.[12][13]
This change in core body temperature occurs with hormonal shifts and is related to neurotransmitters in the part of the brain called the hypothalamus.[14]

An anxiety attack is not associated with a change in body temperature, even though it produces sweaty and clammy hands and feet, accompanied by an increased heart rate. This anxiety response is triggered by neurotransmitters in the part of the brain responsible for cognition known as the locus coeruleus.

Hot flashes are linked to variable and declining estrogen levels that occur during the change of life.[15] Not all women suffer from hot flashes. Reports vary depending on culture, ethnicity, and diet.

In the U.S. approximately 20 percent of menopausal women complain of significant hot flashes.[16] At this time of life, the ovaries "sputter," monthly egg production decreases, and it finally shuts down altogether.

At this point, a woman may produce different levels of estrogen and progesterone from month to month. The constant change in hormones levels causes thermoregulation problems in some women, affecting the hypothalamus.

Hot flashes are also related to a woman's ability to manage stress and whether she has a history of anxiety or depression. It is important to note that depression and anxiety, as well as stress, can intensify hot flashes.[17] Hot flashes can also disturb one's sleep and make depression and anxiety worse.[18]

Progesterone

A small number of women have difficulty taking synthetic progesterones, and as a result, they become depressed.[19] (Progesterone affects a number of mechanisms in the brain that control serotonin levels.)

Others experience a "Valium®-like effect" when they take natural progesterones.[20] In fact, some feel as though they have just taken a sleeping pill.[21] This appears to be a result of the conversion of natural progesterone to "allopregnenolone," the brain's own natural sedative. Allopregnenolone works on the benzodiazepine receptors responsible for calming or exciting the brain. (Valium®, Xanax®, Ativan®, and Klonapin® are all benzodiazepines.)

Women who feel irritable on progesterone or find that it makes them anxious and depressed generally have difficulty tolerating hormone replacement or birth control pills that contain this substance.

A clinician will usually offer a natural progesterone as an alternative to a synthetic progesterone, such as Provera®. If the patient is still reactive, there are other options.

Progesterone-sensitive women may be able to tolerate a Mirena® IUD (a progesterone IUD), or a low-dose vaginal progesterone gel (4 percent). These choices have the advantage of limiting the brain's exposure to progesterone but require careful monitoring.

These solutions are suitable for those on hormone replacement therapy. The woman who is irritable or anxious on the birth control pill is often advised to try another form of birth control. (We will discuss the progesterone-sensitive woman in a future article —Ed.)

Post-partum anxiety

Post-partum anxiety (anxiety that persists for several weeks after delivering a baby) appears to be more common than depression.[22] Amy Wenzel reports that 30 percent of these women suffer from worry and generalized anxiety while only 12 percent were depressed. Other studies show anxiety in 18 percent to 20 percent[23] of the post-partum population.

The vulnerable woman who has had pre-existing problems with anxiety is more at risk for recurrence or worsening of her symptoms following childbirth. If a woman feels that the demands on her have mushroomed out of control, she is more likely to be anxious.[24] The post-partum period is a challenging time when women sleep less, have to
adjust to the needs of the child, must restructure the family environment, and cope with any financial stress associated with the baby's arrival.

The treatment of post-partum anxiety is important for the quality of life of the mother,[25] for the family, and the growing child.

Sometimes post-partum anxiety is confused with a post-partum thyroid condition. For this reason, a clinician should always check the thyroid when determining the nature of mood and or anxiety problems post-partum.

Treatments for anxiety

If you think you may have an anxiety problem, there are many successful treatments that will help you take control of the problem. Experts agree that mild-to-moderate mood and anxiety problems should be treated first with talk therapy.

Cognitive behavioral therapy (CBT), a short-term approach focusing on the management of negative thoughts, has proven especially effective. Here, you learn to identify and counter your fears and negative beliefs. Studies show that this approach is very helpful in decreasing long-held behavior patterns associated with anxiety (see links below).

If your anxiety is severe and does not respond to psychotherapy, medication may help your system stabilize. The most commonly prescribed medications are the serotonergic antidepressants (Prozac®, Zoloft®, Paxil®, Luvox®, Celexa®, and Lexapro®) and newer antidepressants that act on both the serotonergic and noradrenergic pathways (Effexor®). Your clinician will choose the one best suited to your individual needs.

Ideally, women of childbearing age should choose a psychiatrist who is familiar with the effects of medications on pregnancy and lactation. The American Academy of Pediatrics recommends Paxil® and Zoloft® for nursing mothers.

A reliable and well-respected patient resource on the interaction of drugs and lactation can be found at www.Motherisk.org — a counseling and research program associated with the University of Toronto.

Recommended resources

For more information on Cognitive Behavioral Therapy, consult this three-part series written by our managing editor, Valerie Andrews, for WebMDHealth.

Part I "Do Your Thoughts Drag You Down?"

Cognitive therapists say yes. Are they on to something?

http://my.webmd.com/content/article/11/1674_50428.htm

Part II "The Art of Self-Examination"

Cognitive Therapy Can Change Your Negative Thinking

http://my.webmd.com/content/article/11/1674_50565.htm

Part III "Fixing Common Thinking Errors"

Turn your distorted thinking around with these tips.

http://my.webmd.com/content/article/11/1674_50566.htm

For a cognitive behavioral therapist in your area, consult the Association for Advancement of Behavior Therapy, at http://www.aabt.org.

For general information on anxiety disorders, contact The Anxiety Disorders Association of America, http://www.aada.org,

Local and National Support Organizations

Anxiety Disorders Association of America 6000 Executive Blvd., Suite 513
Rockville, MD 20852
301-231-9350

National Institute of Mental Health (NIMH) Information Resources & Inquiry Branch
Room 15C-05
5600 Fishers Lane
Rockville, MD 20892
1-800-64-PANIC or (301) 443-4513

National Mental Health Association 1021 Prince Street
Alexandria, VA 22314-2971
1-800-969-6642

Self-Help Books

Bourne, E. J. (1995). Anxiety and Phobia Workbook. Oakland, CA: New Harbinger Press.

Copeland, ME. (1998). The Worry Control Workbook. New Harbinger Publications, Inc.

Craske, MG (1994). Mastery of Your Anxiety and Panic II. Graywind Publications

Foa, E. B., & Wilson, R. (1991). Stop Obsessing! How to overcome your obsessions and compulsions. New York, NY: Bantam.

Hanh, T. N. (1976). The Miracle of Mindfulness. Boston: Beacon Press.

Markway, B. G., Carmin, C. N., Pollard, C. A., & Flynn, T. (1992). Dying of embarrassment: Help for Social Anxiety and Phobia. Oakland, CA: New Harbinger Press.

Robins Eschelmann, E, McKay M (1995). The Relaxation & Stress Reduction Workbook. New Harbinger Publications, Inc.

Zuercher-White, Ph.D. (1995) The End of Panic: Breakthrough Techniques for Overcoming Panic Disorder. New Harbinger Publications, Inc.

Notes

1 Eaton et al. 1994; Robins et al. 1984; Yonkers et al. 1998.

2 Wittchen et al. 1994.

3 Freeman and diTommaso 2002, ch. 6.

4 American Psychiatric Association 2000.

5 Noyes et al. 1987; Kendler et al. 1992.

6 Torgersen 1983.

7 Hollander and Simeon 2005, p. 88-89.

8 Kessler et al. 1999.

9 Freeman et al. 2004.

10 Joffe et al. 2002.

11 Baker et al. 1997; Bromberger et al. 2001; Avis et al. 2001.

12 Feldman et al. 1985.

13 Freedman and Krell 1999.

14 Guthrie et al. 1996.

15 Dennerstein et al. 2000; Rannevik et al. 1995.

16 Dennerstein et al. 2000.

17 Freeman et al. 2001.

18 Baker et al. 1997.

19 Speroff et al. 2000.

20 Bjorn et al. 2000; Panay and Studd 1997; Smith et al. 1994.

21 Arafat et al. 1988.

22 Wenzel et al. 2003.

23 Wenzel et al. 2001.

24 Mineka and Kelly, 1989.

25 Schweizer 1995.

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