Anxiety disorders in women: A developmental and lifecycle perspective

Generalized anxiety disorder (GAD) is considered to be the second most frequent disorder in a primary care setting, after depression [Maier et al., 2000]. Gender dif ferences in the prevalence of GAD are quite well documented. The odds ratio (OR) of women to men has been reported to be 2.1 [Wittchen and Hoyer, 2001]. The National Comorbidity Survey (NCS) reported lifetime prevalence of GAD to be 3.6 % in men as compared to 6.6% in women [Wittchen et al., 1999]. It is of interest that the prevalence increases with age, from 1.5% in young men (15–24 yr) and 2.5% in young women to 3.6% in men over 45 years of age, and 10.3% in women over age 45. The rate is quite stable during reproductive age in both men and women. However, while it decreases in aging men, it substantially increases in women (Figure 1). The sex ratio is probably most prominent when both comorbidity of anxiety and depression and subthreshold disorders are considered [Angst et al., 1997; Preisig et al., 2001]. The German National Health Interview and Examination Survey, Mental Health Supplement (GHS) [Carter et al., 2001] showed that in women the increase in incidence of GAD occurs after age 35, while in men it occurred after age of 45 years. Higher prevalence in women as compared to men has been reported in most other anxiety disorders, including panic disorder, post-traumatic stress disorder (PTSD) and phobias which are twice as frequent in women [Bourdon et al., 1988; Breslau et al., 1991; Robins et al., 1984], and to a lesser degree obsessive– compulsive disorder (OCD), especially in women of reproductive age [Pigott, 1999], and social anxiety disorders [Kessler et al., 1998]. In most cases, gender dif ferences in first occurrences, life course, comorbidity, symptom cluster, and treatment response have been documented and/or suggested. No wonder that the epidemiological data set the stage to a longitudinal approach to the elucidation of sex differences in anxiety disorders. Such an approach should shed light on underlying mechanisms of anxiety disorders in men and women. They are addressed here mostly as they pertain to the papers included in this Special Issue. The impact of anxiety disorders starts even before birth, during in utero life. Anxiety disorders are quite prevalent during pregnancy. They are often associated with depression or anger, as a diagnostic comorbidity, or as a cluster of stress and anxiety symptoms [Field et al., 2003; Glover et al., 1999]. Maternal anxiety and stress have been reported to (a) reduce blood flow to the fetus by increasing uterine artery resistance [Teixeira et al., 1999], (b) increase fetal cortisol levels in parallel to their increase in the mother [Gitau et al., 1998], and (c) increase fetal activity. In utero stress may cause subsequent preterm delivery and impaired adaptation and behavior of babies 3–6 months post delivery [DiPietro et al., 1996; Wadhwa et al., 1998]. Field et al. [2003] note that fetuses of pregnant women with high anxiety levels were more active and had growth delays. Following birth, if the mother had high prenatal norepinephrine and low dopamine, her baby also had low dopamine as well as low serotonin levels. Such babies spent more time in deep sleep and less time in quiet and alert states. Their behavior was disturbed, their vagal tone was lower, and they had higher frontal EEG activities. Whether or not these babies would grow up to be anxious individuals is still a matter of speculation, but these data may support the notion of cumulative effect of genetics and in utero experiences. They may suggest that the prevention of anxiety, anger, and other dysphoric disorders may start with the pregnant mother. In extreme cases, stress during pregnancy may contribute to the risk factors for involuntary miscarriage. Neugebauer [2003] reports that dysphoric symptoms following miscarriage were higher for quite a while. Six to eight weeks following the event, 20.2% of women in that sample were still highly symptomatic, especially those in the younger age group. It is intriguing that the effect of miscarriage DEPRESSION AND ANXIETY 17:107–110 (2003)