Practice Bulletin and Clinical Management Guidelines for health care providers. Educational grant provided by Women's Health and Education Center.
Anxiety disorders are common in women, and cause substantial impairment in all spheres of functioning. Many effective treatment modalities offer hope and help to most sufferers and by asking specific questions to determine whether an anxiety disorder is a possibility, physicians will be able to make the appropriate diagnosis. Women are particularly vulnerable to such disorders, experiencing them twice as frequently as men. Situations related to gender, such as childbirth and domestic violence may increase the frequency of these problems. Anxiety disorders cause substantial impairment in occupational and social functioning, but fewer than 50% of affected patients with anxiety disorders receive proper treatment (1).
The purpose of this document is to outline a general framework for healthcare providers to diagnose and treat various types of anxiety disorders in women.
Screening Questions for Anxiety Disorders
Risk factors for the development of an anxiety disorder include a personal or family history of a mood or anxiety disorder and major life stress, such as the birth of a baby, a serious medical diagnosis, and/or a loss financial or personal. Determining the likelihood of an anxiety disorder is possible observing following symptoms:
- Does the patient present with multiple physical and/or physiological symptoms that are not easily explained or that are disproportionate to the history or physical findings?
- How long have these symptoms been present? Did they start in childhood, adolescence, or adulthood?
- Do the symptoms date from a specific event? Does the patient present with a major life stress?
- Has the patient recently begun using a new medication?
- Has the patient recently used or discontinued recreational drug?
- Does the patient have a personal or family history of depression or anxiety?
- Does the patient have symptoms of depression or other psychiatric disorders?
- Does the patient have a substance abuse problem?
- Is she safe at home? Has she been physically or sexually abused/ traumatized?
- Does she have an undiagnosed, underlying medical problem?
Clinicians should first determine whether clinical features suggesting anxiety are present. The emotional component of anxiety manifests as excessive, uncontrollable worry that may be generalized or specific. Physical signs and symptoms of anxiety disorders are: anorexia, "butterflies in stomach", chest pain or tightness, diaphoresis, diarrhea, dry mouth, dyspnea, faintness, flushing, hyperventilation, lightheadedness, muscle tension, nausea, pallor, palpitations, paresthesias, sexual dysfunction, shortness of breath, stomach pain, tachycardia, tremulousness, urinary frequency and vomiting. Diagnosing the specific disorder requires following considerations:
- Does the patient have chronic, pervasive worry with periodic autonomic arousal (breathlessness, tachycardia, muscle tension, gastrointestinal upset (Generalized Anxiety Disorder)?
- Does the patient experience sudden, intense fear or discomfort accompanied by the abrupt onset of several physical and psychological symptoms (panic attacks)?
- Does the patient experience intense anxiety in social or performance situations (social anxiety)?
- Does the patient avoid places and/or situations in response to fear that a panic attack might occur and escape might be difficult (agoraphobia)?
- Does the patient have recurrent obsessive thoughts? Does the patient perform rituals to alleviate these thoughts (Obsessive Compulsive Disorder)?
- Does the patient have intrusive thoughts and/or nightmares, autonomic arousal, and avoidance in response to a trauma (Post Traumatic Stress Disorder)?
Many women with anxiety disorders have coexisting psychiatric conditions including major depression, substance abuse, eating disorders and other anxiety disorders. These conditions may produce or exacerbate anxiety (2).
- Generalized Anxiety Disorder (GAD): The prominent feature of GAD is persistent worry (more than 6 months) that is considered excessive and difficult to control. Worry is nonspecific or free-floating but severe and distressful, interfering with sleep, social and domestic behavior, and work. Emotional symptoms include: nervousness, tenseness, irritability, and difficulty concentrating. Physical symptoms are of three types motor/tension (tension headaches, restlessness, difficulty relaxing, easy fatigability), autonomic over-activity (gastrointestinal disturbances, palpitations, sweating, hot flashes, dizziness, frequent micturition), and hyperarousal (irritability, difficulty falling asleep, frequent awakenings, jumpiness). Symptoms are likely to be disproportionate to the physical signs, and they may worsen before the menses.
Onset of GAD often occurs during childhood or adolescence. Prevalence in the general population is 5% to 6%, but this proportion rises to approximately 25% in primary care clinic populations. Genetic factors may play a larger role than environmental factors in GAD development. This disorder is twice as common in women as in men. Also women are more likely to have comorbid dysthymia, which leads to a poorer prognosis and a decreased remission rate.
Treatment: the three main choices are Benzodiazepines (BZs), antidepressants and buspirone. BZs offer quick relief of symptoms, and are appropriate for short-term use. Response to BZs is rapid, sometimes as early as 1 week after starting treatment. After 6 to 8 weeks, the drug should be tapered, but not stopped abruptly. About 50% of patients will not relapse after a short BZ course. The Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line choice for GAD symptoms. They should be started at 50% of the starting dose for at least a week to avoid exacerbating anxiety. Buspirone also may be useful in treating GAD, especially in patients who do not tolerate SSRIs. Venlafaxine also has been approved for the treatment of GAD. Psychotherapy, use of cognitive-behavior therapy and applied relaxation together has been successful in GAD.
- Panic Disorder: This disorder is characterized by recurrent, unexplained attacks of sudden, overwhelming anxiety, fear, and panic, followed by at least 1 month of persistent concern about having another panic attack. A panic attack is a discrete period of intense fear or discomfort in the absence of real danger. Attacks are accompanied by at least 4 of 13 physical symptoms and it can sometimes coexists with agoraphobia, which is anxiety about being in places or situations where it may be difficult to escape or obtain help in the event of a panic attack. Both panic disorder and agoraphobia are more common in women than men. Among women with panic disorder, 50% have comorbid major depression.
Diagnostic and Statistical Manual -IV Criteria for Panic Attack (3):
- Palpitations, pounding heart, or tachycardia
- Trembling or shaking
- Sensation of shortness of breath or smothering
- Feeling of choking
- Chest pain or discomfort
- Nausea or abdominal distress
- Feeling of dizziness, unsteadiness, lightheadedness, or fainting
- Derealization or depersonalization
- Fear of losing control or "going crazy"
- Fear of dying
- Chills or hot flashes
Treatment: appropriate medication promotes a better response rate in proportion to the duration of treatment. For this reason patients with panic disorder are generally treated for 6-18 months. The SSRIs are the drugs of first choice. Although Tricyclic Antidepressants (TCAs) and Monoamine Oxidase Inhibitors (MAOIs) may be beneficial, they have limitations. Benzodiazepines (BZs) are good adjuvant for the patients with severe symptoms until stabilization with and antidepressant occur. However, they should be given on a scheduled basis rather than just as needed when a panic attack occurs. Psychotherapy, use of cognitive-behavior modification alone of with pharmacotherapy is extremely effective in treating panic disorder. It is likely to be most helpful for symptoms of agoraphobia.
- Social Anxiety Disorder: This disorder is also known as social phobia. It is marked by persistent fear of being observed and evaluated by others. It is most common anxiety disorder in both men and women. It is manifested by strong efforts to avoid social or performance situations in which embarrassment or humiliation may occur. Patients avoid public speaking, performing, social events, meeting new people and dating. This lead to low self-esteem and patients has decrease social and occupational functioning. Women are 2-3 times more likely than men to develop social anxiety disorder, but they are less likely to seek treatment. Women may be less motivated to discuss their symptoms with their physician, which increases the likelihood that the disorder will go unrecognized and untreated. Social anxiety disorder typically manifests with physical symptoms of blushing, stuttering, tremulousness, heart palpitations, "butterflies in the stomach", and/or excessive sweating of the hands or feet. It usually arises in childhood, but may simply be labeled as "shyness". Approximately 70% of patients with social anxiety disorder develop at least one other psychiatric illness.
Treatment: the SSRIs are the agents of choice in treating social phobia, although MAOIs and BZs are also effective. The TCAs are relatively unproven in this condition. Newer approaches include venlafaxine, nefazodone, and gabapentin. In specific social anxiety disorder, small doses of a beta-blocker before the phobic situations may help. Improvement usually occurs within 2 months, but some patients may need longer treatment to achieve full remission. In fact, an international consensus panel has recommended that treatment should last at least 1 year (4). Psychotherapy: use of cognitive-behavior therapy is effective in treating both the generalized and specific forms of social phobia. Social-effectiveness training can help patients who never acquired these skills secondary to social isolation. Self-help programs, such as Toastmasters, a national organization to improve public speaking skills, are also available.
- Obsessive-Compulsive Disorder (OCD): It is a chronic, disabling condition that often begins in childhood. It is characterized by recurrent, persistent obsessions, impulses, or images that are intrusive, inappropriate, and anxiety-provoking. Obsessions usually center on danger or risk of harm; typical examples include fear of contamination, obsession with order and symmetry, pathologic doubt, and recurrent horrific images. Patients often perform compulsive rituals to mitigate the anxiety resulting from these obsessions. Attempts to resist performing these rituals heighten the anxiety. An important diagnostic hallmark of OCD is the patient's acknowledgement that the rituals are unreasonable but irresistible. Common rituals such as hand-washings, counting, and checking may be performed for hours each day. Patients may try to conceal the rituals to avoid embarrassment. Women are twice more likely than men to develop OCD.
Treatment: the SSRIs have become the treatment of choice for OCD. Clomipramine is a good second choice if patients fail an SSRI trial. Onset of improvement is slow, often 10-12 weeks. Treatment should be prolonged (at least 1 to 2 years, possible indefinitely) to avoid relapse. Full remission is rare, and adjuvant agents may be needed. The BZs are not suitable for OCD; and exception is clonazepam, which has been useful as an adjuvant. For intractable symptoms, low-dose quetiapine may be useful. Psychotherapy, use of cognitive-behavior therapy alone or combination with pharmacotherapy, plays a crucial role in managing OCD.
- Post-Traumatic Stress Disorder (PTSD): It is in response to an experienced or witnessed life-threatening trauma. They suffer a triad of clinical features: reexperiencing the trauma through intrusive thoughts, nightmares, or flashbacks; autonomic arousal manifested by insomnia, hypervigilance, and an inability to relax; and avoidance of reminders of the trauma, with emotional numbing and social withdrawal. Onset may occur shortly after the traumatic event, or it may be delayed. In the acute form, symptoms remit within 1 month; in the chronic form, symptoms persist for more than 3 months.
Women are twice as likely as men to experience PTSD symptoms after a trauma (usually a physical or sexual assault). During the interview, it is important to ask about domestic violence as PTSD is common in battered women (5). As many women are ashamed to discuss their traumatic experiences and symptoms, PTSD can easily be missed in the clinical setting. To elicit such information, physicians must ask questions in a sensitive manner and then listen carefully to patients' responses.
Treatment: the SSRIs are the first-line drugs for PTSD, but TCAs, MAOIs, nefazodone, and mirtazapine have been shown to be beneficial. Buspirone and BZs such as clonazepam are useful in patients with hyperarousal. The antiseizure drugs carbamazepine and valproic acid also have been helpful. The antipsychotics olanzapine and risperidone have been useful in reducing PTSD symptoms as well. Various types of psychotherapy have helped patients with PTSD. Psychological debriefing, exposure therapy, cognitive-behavior therapy, and eye-movement desensitization and reprocessing have been helpful. Victims of domestic and/or sexual violence should be directed to support services.
Healthy life-style habits should be emphasized, and may be sole treatment necessary for mild to moderate symptoms. Patients should be encouraged to practice good sleep hygiene; adopt healthy eating habits; reduce or eliminate caffeine and nicotine; exercise regularly; and use relaxation techniques. If these measures are unsuccessful, then pharmacologic treatment should be considered. Therapy for anxiety disorders may be initiated in the primary care setting. If a patient's condition does not improve after two or more medication trials, especially when coupled with a trial of psychotherapy, referral to a psychiatrist of psychologist is appropriate.
- Psychotherapy: It plays an important role in the treatment of anxiety disorders, especially cognitive-behavioral therapy (CBT). Panic disorder with agoraphobia, OCD, specific phobias, and social anxiety disorder have all been shown to improve substantially with CBT. Relaxation therapy, meditation, and stress management are all useful adjuvant. Compared with pharmacotherapy, psychotherapy can provide lasting symptomatic improvement and increased protection against relapse. It is an appealing choice for pregnant and lactating women who wish to avoid medications. Disadvantages of psychotherapy include the substantial commitment of time and energy by patients, as well as the risk that they may not be able to tolerate periods of increased anxiety during treatment. Practitioners skilled in specific techniques may not be available in all geographic areas (6).
- Pharmacotherpy: Therapy for anxiety disorders may be initiated in the primary care setting. Most commonly used agents are (7):
- Benzodiazepines (BZs) - Although these agents can be used to treat all anxiety disorders except OCD, many physicians hesitate to prescribe them because of concerns about abuse, tolerance, and dependence. Short term (less than 8 weeks) BZ use may be appropriate for treating acute anxiety symptoms, and as initial treatment for GAD, panic disorder, and PTSD. Such use is unlikely to create physiologic dependence, and offers the quickest symptomatic relief. Potential side effects include sedation, lack of coordination, and short-term memory loss. Users must be cautioned about concurrent use of alcohol or other sedatives, and about avoiding operation of motor vehicles and heavy machinery.
- Selective Serotonin Reuptake Inhibitors (SSRIs) - Theses agents are the mainstay of treatment of all anxiety disorders. They are generally well tolerated, even in cases of overdose. Possible side effects include dry mouth, nausea, diarrhea, headache, sedation, insomnia, and anxiety. Patients are advised to take SSRIs in the morning with food to minimize nausea and insomnia. Sexual dysfunction, ranging from impaired desire to anorgasmia, is also a common adverse effect. The SSRI dosage should be low initially, and then increased gradually, if necessary, to lessen the likelihood of adverse events. Patients should understand that they may not derive full benefit from the drug for 4 to 6 weeks. Those who are refractory to or intolerant of one SSRI may do better with another, or they may be switched to an antidepressant from a different class; especially one with a more benign sexual side-effect profile.
- Tricyclic Antidepressants (TCAs) - Patients who have failed a trial of SSRIs may benefit from TCAs. Tricyclics have demonstrated efficacy in panic disorders, PTSD, and social anxiety disorder. Clomipramine is effective in OCD because it has SSRI-like properties. Possible side effects include dry mouth, constipation, sedation, weight gain, and dizziness. The main concern with TCAs is the potential for a lethal overdose. Still, they may be a suitable option for patients who cannot take SSRIs.
- Monoamine Oxidase Inhibitors (MAOIs) - These antidepressants are sometimes used to treat social anxiety disorder. However, their potential toxicity and restrictions on diet and use with other medications has greatly limited their use.
- Buspirone - This anxiolytic is a partial 5-HT1A agonist that has demonstrated efficacy in GAD treatment. It is well tolerated and does not cause dependence or respiratory depression. It may be a good choice for patients with a history of addiction or pulmonary conditions, or for those who are concurrently using central nervous system depressants. However, it may take weeks for buspirone to reach full efficacy, so it may not be helpful for patients seeking immediate relief of anxiety symptoms.
- Newer Agents - The antidepressants venlafaxine, nefazodone, and mirtazapine, and anticonvulsant gabapentin have shown promise in treating various anxiety conditions.
Primary care physicians are frequently required to evaluate and treat women with anxiety disorders. Many patients with anxiety disorders undergo expensive or even invasive testing for physical symptoms related to anxiety. As a result, these patients tend to overuse health care services and resources. The economic burden of anxiety disorders in 2007 was $42.3 billion, with non-psychiatric medical treatment accounting for $ 23 billion, psychiatric treatment $ 13 billion, lost productivity and other adverse functional consequences $ 4.2 billion, mortality related expenses 1.3 billion and pharmacotherapy accounted for about $ 840 million. Patients seen in a primary care practice will likely present with predominantly physical symptoms. Clinicians should suspect an anxiety disorder if patients cite multiple somatic and/or psychological complaints that do not appear to have a clear physiological cause, and that are interfering with social and/or occupational functioning.
Anxiety disorders are among the most prevalent form of mental illness in the United States. 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. This amounts to a lifetime prevalence of nearly 15%. Generalized anxiety disorder, panic disorders, social phobia, posttraumatic stress disorder, simple phobia and obsessive-compulsive disorder are currently all classified as anxiety disorders. The hallmark of these disorders is excessive worry, which may be sudden or episodic (panic attacks), continuous or situational triggered phobia. Women have higher predisposition toward anxiety disorders, with >13% meeting anxiety disorder criteria compared with 6% of men. The burden of negative consequences of anxiety disorders, are enormous, comparable to chronic somatic disorders. Anxiety disorders are associated with significant morbidity, chronicity, and often poor long-term prognosis. Over the past few years, significant changes in the way biomedical research is being conducted in the United States have included the migration of research from university and voluntary hospitals to proprietary clinical trial companies, larger reimbursements for study subjects, and greater transparency of study protocols and results (8). The scientific community should be optimistic that the domain of research that would permit proxy consent can be expanded beyond the narrow confines of minimal-risk studies.
- World Health Organization (WHO)
Prevention of Mental Disorders: Effective Interventions And Policy Options
- National Institutes of Health (NIH)
- Centers for Disease Control and Prevention (CDC)
Mental Health Work Group
- Olatunji BO, Cisler JM, Tolin DF. Quality of life in the anxiety disorders: a meta-analytic review. Clin Psychol Rev 2007;27(5):572--581.
- Ford JD, Adams ML, Dailey WF. Psychological and health problems in a geographically proximate population time-sampled continuously for three months after the September 11th, 2001 terrorist incidents. Anxiety, Stress, Coping 2007;20(2):129--146
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, Washington DC: American Psychiatric Publishing; 2000;417-423
- West AN, Weeks WB. Mental distress among younger veterans before, during, and after the invasion of Iraq. Psychiatr Serv 2006;57(2):244--248.
- Rickles K, Pollack MH et al. Efficacy of extended-release venlafaxine in non-depressed outpatients with generalized anxiety disorder. Am J Psychiatry 2000;15796:968-974
- Hammner MB, Faldowski RA, et al. Adjunctive risperiodone treatment in post-traumatic stress disorder: a preliminary controlled trial of effects on comorbid psychotic symptoms. Int Clin Psychopharmacol 2003;18(1):1-8
- Lee AM, Lam SK, Sze ML et al. Prevalence, course, and risk factors for antenatal anxiety and depression. Obstet Gynecol 2007;110:1102-1112
- Eth S, Leong GB. Toward revising the ethical boundaries of research with non-competent subjects. Am J Psychiatry 2009;166:131-134
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