Why Anxiety Disorders Affect Women More Than Men
Dr. Alvyda Pilkauskienė Psychiatric Day Hospital of the Mental Health Center at Dainava Department of Kaunas City Polyclinic
Introduction
Anxiety disorders (Table 1) are the most common of all mental illnesses, affecting approximately 13% of the population. The manifestation, symptoms, and treatment of anxiety disorders are significantly influenced by gender differences. Women are more likely to suffer from anxiety disorders than men (approximately 30.5–33% compared to 19–22%).
Increased anxiety (as a symptom) and a higher risk of developing anxiety disorders in girls typically emerge in mid-childhood. These gender differences tend to diminish after the age of 65. Anxiety disorders significantly impair patients’ quality of life and functioning, while also increasing morbidity, mortality, and treatment costs.
Affected individuals often have lower levels of education, fewer employment opportunities, are more prone to occupational injuries, and are more likely to depend on social benefits rather than independently earned income. Scientific medical literature also indicates that anxiety disorders are associated with higher rates of teenage pregnancy and early parenthood.
One possible explanation for the growing interest in gender differences in anxiety disorders is that, by examining the causes and characteristics of these disorders in both women and men — including phenotypic differences in the cytochrome P450 enzyme system in the liver — it may be possible to select more optimal and individualized treatment approaches.
Table 1. Classification of anxiety disorders according to ICD-10-AM*F40 – Phobic anxiety disorders
- F40.0 Agoraphobia
1.1 F40.00 Agoraphobia without panic disorder
1.2 F40.01 Agoraphobia with panic disorder - F40.1 Social phobias
- F40.2 Specific (isolated) phobias
- F40.8 Other specified phobic anxiety disorders
- F40.9 Phobic anxiety disorder, unspecified
F41 – Other anxiety disorders
6. F41.0 Panic disorder (episodic paroxysmal anxiety)
7. F41.1 Generalized anxiety disorder
8. F41.2 Mixed anxiety and depressive disorder
9. F41.3 Other mixed anxiety disorders
10. F41.8 Other specified anxiety disorders
11. F41.9 Anxiety disorder, unspecified
* Tenth revised and updated edition of the International Statistical Classification of Diseases and Related Health Problems, Australian Modification.
Generalized Anxiety Disorder
Generalized Anxiety Disorder (GAD) is characterized by persistent, excessive, and generalized anxiety that is not strongly linked to specific external circumstances. Patients often report constant worry, rapid fatigue, difficulty concentrating, ongoing irritability and nervousness, muscle tension, sweating, dizziness, palpitations, epigastric discomfort, and sleep disturbances.
A key feature of GAD is that anxiety is difficult to control and is present on most days for at least 6 months.
Typical anxiety symptoms in GAD include:
- excessive and uncontrollable worry;
- fatigue and reduced energy;
- impaired concentration;
- irritability and nervousness;
- muscle tension;
- autonomic symptoms such as sweating, dizziness, palpitations;
- gastrointestinal discomfort (e.g., epigastric pain);
- sleep disturbances.
Gender Differences
Generalized anxiety disorder is diagnosed in women approximately twice as often as in men (6.6% vs. 3.6%). From the age of 45, the prevalence of GAD increases in women, while remaining stable in men (10.3% vs. 3.6%).
During mid-adolescence, differences in symptom expression and disease course between genders become evident. Women more often present with somatic complaints, fatigue, and muscle tension. The abundance of somatic symptoms may be related to a greater tendency toward negative affect and neuroticism.
Men, on the other hand, more frequently experience interpersonal difficulties, particularly strained relationships with family members and friends due to anxiety.
Women tend to develop GAD at a younger age and experience remission later and less frequently. Partial recovery is more commonly observed in men.
Men are significantly more likely than women to have comorbid antisocial personality disorder, nicotine dependence, and alcohol or substance use disorders. In such cases, substances are often used as a means of coping with anxiety symptoms.
Women with GAD more frequently have comorbid mood disorders (excluding bipolar affective disorder) and other anxiety disorders (excluding social anxiety disorder). When taking a medical history, women more often report previous episodes of depression and the presence of disability among family members.
Research has confirmed that both genetic and environmental factors contribute to a higher risk of developing GAD in women. In addition, there is a strong genetic link between GAD and depression in women. The coexistence of GAD and depression significantly impairs functioning and increases the risk of suicide.
Data on the influence of the menstrual cycle on GAD are inconsistent. Some studies do not confirm any effect, while others report worsening of symptoms in up to 52% of patients during the premenstrual period.
During pregnancy, the prevalence of GAD increases to 8.5–10.8%. This is associated with several factors, including previous episodes of the disorder, lower levels of education and social support, and childhood experiences such as trauma or adverse environments. Symptoms are most pronounced during the first and third trimesters.
GAD in pregnant women is associated with a decrease in fetal brain neurotrophic factor levels. After childbirth, 4.4–10.8% of women experience GAD. Women diagnosed with GAD within the first 10 weeks postpartum more frequently report fear, avoidance of sexual contact, and negative perceptions of their physical attractiveness. They are also more likely to experience comorbid depression.
Selective serotonin reuptake inhibitors (SSRIs) may be less effective in women according to some data, although other studies show no significant difference in the effectiveness of sertraline between men and women.
It is also important to note that benzodiazepines (BZDs) are prescribed more frequently to women with GAD than to men. The likelihood of receiving these medications is significantly higher for women both during initial consultations and in follow-up visits.
Table 2. Most common anxiety symptoms
| Psychological anxiety symptoms | Somatic anxiety symptoms |
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Panic Disorder (PD)
Panic disorder (PD) is characterized by sudden, recurrent, and unpredictable (in terms of time and place) panic attacks (PAs) that are not related to specific circumstances. These attacks usually reach peak intensity within a few minutes and last approximately 10–20 minutes.
During an attack, a person may experience increased heart rate and breathing, chest pain, shortness of breath, dizziness, sweating, nausea, intense anxiety, fear of going crazy or dying, and a distorted sense of reality.
Between attacks, individuals often experience fear of recurrence, anticipatory anxiety, concern about possible consequences, and develop avoidance behavior.
Gender differences
Women are more likely than men to suffer from PD, and this difference becomes more pronounced with age. Prevalence rates show that in the 15–24 age group PD affects 2.5% of women and 1.3% of men, while in the 35–44 age group it affects 2.1% of women and 0.6% of men.
Recent data suggest that women tend to develop PD later than men. There is also an observed association between childhood sexual abuse and the development of PD in adult women.
Women experience panic attacks more frequently and report more severe panic and avoidance symptoms. They are more likely to rely on family support in stressful situations and often experience attacks when leaving home alone or using public transport.
Men with PD more often report general fatigue and decreased activity, while women report more pronounced physical exhaustion. During panic attacks, many patients experience respiratory symptoms such as shortness of breath and breathing difficulties.
Women are generally more sensitive to anxiety, particularly to physical sensations associated with panic, whereas men tend to fear the social consequences of anxiety more. Women with PD (with or without agoraphobia) have a higher risk of suicide and relapse.
Women with PD more frequently have comorbid mental disorders, including agoraphobia, generalized anxiety disorder (GAD), somatoform disorders, depression, and hypomanic episodes. They also have a higher risk of alcohol abuse or dependence compared to healthy individuals.
From adolescence, women are 2–3 times more likely to develop PD than men. Women with PD and agoraphobia more often avoid public transport and unfamiliar environments, prefer staying at home, and experience stronger catastrophic thoughts and physical symptoms. Men, in contrast, are more concerned about physical health and somatic consequences of panic attacks.
Female reproductive hormones significantly influence the course of PD. During the premenstrual period, anxiety may increase by up to 79%, panic attacks by 58%, and avoidance behavior by 47%.
During pregnancy, PD prevalence varies widely (0.2–5.7%). Among women with pre-existing PD, the condition remains unchanged in 40–45%, improves in 30–35%, and worsens in 20–30%.
After childbirth, the risk of developing PD or experiencing relapse increases, although some studies suggest symptoms may be less severe than during pregnancy. During menopause, PD may develop or worsen, while in postmenopause panic and avoidance symptoms generally decrease.
Hormonal fluctuations, particularly changes in estrogen levels, are believed to play a role in PD development.
Treatment responses may also differ: women showed greater improvement with sertraline on the Clinical Global Impression scale, while gabapentin appeared more effective in women with severe panic and agoraphobia symptoms.
Social Anxiety Disorder (SAD)
Social anxiety disorder (SAD), also known as social phobia, is characterized by a strong and persistent fear of social situations, particularly those involving possible scrutiny by others. Individuals fear acting in a way that may be embarrassing or humiliating and therefore tend to avoid such situations.
Gender differences
Gender differences appear before puberty. Women are about 1.5 times more likely to develop SAD than men (15.5% vs. 11.1%).
Women report more intense and numerous social fears, especially when interacting with authority figures, speaking in public, attending social events, working under observation, or being the center of attention. They are also more likely to fear eating or drinking in public or taking important exams.
Men more often report fear of using public restrooms or returning goods, and may avoid dating, which can contribute to social isolation.
Generalized SAD is more common in women (56% vs. 47%) and tends to have a more chronic course, with more severe symptoms and greater functional impairment. Specific SAD is more common in men.
Women with SAD are more likely to have comorbid mood and anxiety disorders, while men more often have antisocial personality disorder, gambling problems, and substance use disorders.
Childhood trauma, including parental conflict and sexual abuse, is a significant risk factor for SAD in women. Symptoms often worsen during the premenstrual period, and the disorder may increase the risk of postpartum depression.
Brain imaging studies have shown reduced amygdala and hippocampal volume in SAD patients, though significant differences were mainly observed in men.
Treatment response to SSRIs such as paroxetine and escitalopram does not appear to differ by gender.
Specific Phobias (SP)
Specific phobias are characterized by excessive and irrational fear triggered by a particular object or situation, such as animals, natural environments, enclosed spaces, or medical procedures.
Gender differences
Specific phobias typically begin early in life and occur twice as often in females (12–27%) as in males (6–12%).
Women more often fear animals and environmental situations, while men more commonly report fear of heights. Situational phobias tend to appear later and are more frequent in women.
Obsessive-Compulsive Disorder (OCD)
OCD is characterized by intrusive thoughts, images, or impulses (obsessions) and repetitive behaviors or rituals (compulsions) performed to reduce anxiety.
Gender differences
Prevalence data are inconsistent: some studies show no difference, while others suggest women are affected 1.5 times more often. However, in childhood OCD is more common in boys.
Men more often experience sexual or religious obsessions and symmetry-related compulsions, while women more frequently exhibit contamination fears and cleaning behaviors.
Women tend to have a more episodic and milder course, but are more likely to develop comorbid depression, panic disorder, PTSD, and eating disorders.
Hormonal factors also play a role: symptoms worsen premenstrually in about 42% of patients, and onset or worsening may occur during pregnancy or postpartum.
No significant gender differences were observed in response to treatment with clomipramine or fluoxetine.
Post-Traumatic Stress Disorder (PTSD)
PTSD is a delayed or prolonged reaction to severe trauma, characterized by intrusive memories, emotional numbness, avoidance, and increased arousal.
Gender differences
PTSD is twice as common in women as in men (12.5% vs. 6.2%).
Men чаще develop PTSD due to combat exposure, while women are more affected by sexual violence, abuse, or interpersonal trauma.
Women are more likely to experience avoidance, emotional numbness, and heightened arousal after trauma. Dissociative symptoms also increase PTSD risk more strongly in women.
PTSD may increase pregnancy-related complications. Treatment with SSRIs such as sertraline and fluoxetine appears more effective for symptoms commonly seen in women.
Summary
Anxiety disorders most commonly affect children, adolescents, and young adults, peaking in midlife and declining later. Women are about twice as likely as men to develop these disorders and often experience more severe symptoms, chronic courses, and comorbid conditions.
Although gender differences are clear, their exact causes remain uncertain. Further research is needed to better understand neurobiological, hormonal, genetic, and environmental influences and to develop more individualized treatment approaches.
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