Anxiety disorders: A gender test case within mental health (care) research Marrie H. J. Bekker and...

Anxiety disorders: A gender test case within mental

health (care) research Marrie H. J. Bekker and Janneke van Mens-

Verhulst

Maastricht, January 26-27 2007

Bekker & van Mens-Verhulst. 2007

http://www.nesda.nl/link.php?link=www.ggzbuitenamstel.nl

http://www.genderdiversiteit.unimaas.nl/pages/onderzoek_gbasic.htm

Anxiety disorders and gender:State of the art & Future research

• Prevalence/ co-morbidity

• Theories

• Treatment (effects)


Body female/male

Gender femininity(ies)/ masculinity(ies)

Differential diagnostics/statistics/treatment

Sex differences in exposure(daily life)

Person (m/f)-related vulnerability factors

-

Sex differences in prevalence of

anxiety disorders

Multi-Facet Gender and Anxiety Disorders Model, adapted from Bekker, 2003)


12-month prevalence anxiety disorders European countries

Women Men

Any anxiety disorder 16.3 7.8

Panic Disorder 3.0 1.7

Agoraphobia 3.1 1.0

Social phobia 2.7 1.3

GAD 2.1 1.0

Specific phobias 10.8 4.5

OCD 0.9 0.6(adapted from Wittchen

& Jacobi, 2005)


Prevalence W : M

• In general, higher prevalence in women (2:1)• Symptoms more severe in women

BUT• No data regarding non-Western ADs• Variation in sex-ratios across ethnic groups• Potential sex biases in prevalence figures

– Masculine underreport due to shame– Masculine coping by alcohol misuse > masking– Men’s socio-economic roles: less avoidance tolerated?


Co-morbidity with• “Women’s syndromes”:

– Other anxiety disorders– Depression– Histrionic (B) and Cluster C Personality Disorders

(dependent personality disorder)

• “Men’s syndromes”:– Substance abuse – (in case of OCD:) learning disorders, disruptive

behavior disorders, Tourette’s disorder, tics

Thus: sex-specific clusters?? Bekker & van Mens-Verhulst. 2007

Body female/male - higher premenstrual conditionability (r)- (5-HTTLPR) modulates the effects of early adversity in female (e; in macaques)- ??….


Differential diagnostics/statistics/treatment - masculine unwillingness to admit weak emotions (e) - men’s higher alcohol misuse (e)- higher social pressure on men toe have and keep employment outside the house (?)- sex X other diversity factors within population(s) (?)- sex-differential treatment effects (?)- ….?

Sex differences in exposure - sexual violence (e) - gendered meanings of feared situations (?) -sex-specific attachment experiences (?)- unemployment (?)- …..?

Person (m/f)-related vulnerability factors - conditionabilty fear responses (e)- rumination (e)- sense of control over the body (?)- trait anxiety (e)- lack of masculinity (+/-)- masculine gender role stress (+/-)- insecure attachment style (e; m/f??)-low autonomy-connectedness (e/?)


anxiety disorders(and other syndromes!)


Future prevalence research should • Use a multi-method approach (to avoid gender bias in

measurements)

• Examine temporal changes in distribution of anxiety disorders over the sexes

• Fill in white spots regarding– sex differences in disorder subtypes and severity of symptoms;– (gender-linked) prevalence of non-Western anxiety disorders;– prevalence of DSM-anxiety disorders in specific ethnic groups;– interaction gender x other diversity factors (e. g., ethnicity, SES,

employment status) (to get more insight into risk and protective factors)


Future prevalence research should • Focus on the, plausibly sex-specific, clusters of

anxiety disorders subtypes with co-morbid syndromes

• In other words, use the lumpers’ perspective!




• Theories



1. Learning theory

• Thousands of studies/ lots of evidence BUT:

• Why do more women than men acquire phobic fear responses and/ or phobic avoidance behaviour???






Person (m/f)-related vulnerability factors - conditionabilty fear responses (e)- rumination (e)- sense of control over the body (?)-trait anxiety (e)-high level of psychological and behavioral disruption after panic (but why??)- lack of masculinity (+/-)- masculine gender role stress (+/-)- insecure attachment style (e; m/f??)- low autonomy-connectedness (e/?)


anxiety disorders


Future research within the learning perspective should clarify

• Why more women than men acquire phobic fears and avoidant behaviours, and/ or

• why less men than women acquire these fears and behaviours

• The influence of gendered meaning of situations that are feared and avoided

• The role of (sexual) violence against women

• A possibly gendered pattern of reacting to one’s own bodily sensations


2. Sex role theory

• Some studies: some indication of a role for (lack of) masculinity, BUT

• Why do only a small minority of all women and men develop anxiety disorders???








anxiety disorders


Future research within sex/gender role perspectives should clarify

• The relations between anxiety disorders, stress anyhow, and stress resulting from gender roles

• Why only a small minority of women (and men) develop anxiety disorders whereas all women and men are exposed to existing gender roles

• If, how and with which results attention is paid to sex/gender roles within therapy


3. Attachment and Schema theory

• Almost all studies on attachment and anxiety: No attention paid to sex differences

• Clues for explaining the gender issue can be found in combining attachment theory with feminist, object-relational theory








anxiety disorders(and other syndromes)


Future research within attachment and schema theory should clarify:

• Gender aspects of autonomy-connectedness and attachment styles

• Sex-specific aspects of interaction patterns between care-givers and children resulting in anxiety disorders and their sex-unequal prevalences

• Predictive strength of these aspects for anxiety disorders

• The processes and mechanisms in between !




• Theories



Studies on (differential) treatment effects in men and

women• Are scarce! (Notice the dominance of CBT)

• We did not find gender-sensitive interventions!

• The scarce data do not yield much differences

• Meta-analytical studies (there are many of them!): No attention/ no differences








anxiety disorders


Future research should provide information about sex- and gender-

specific effects of treatments by:

• Including sex/gender-relevant aspects of therapy content and process

• Sex/gender-conscious sampling

• Using sex/gender sensitive measures

• Applying sex-stratification before analyzing

• Accounting for sex/gender in meta-analyses


General recommendations for future research on anxiety disorders (and

gender):

• Use sex differences as a source of knowledge!

• Implement the available gender-related knowledge into treatment, and examine effects

• Apply a gender-sensitive methodology!

• Use a lumper’s perspective!


Thank you for your attention!

Marrie H. J. Bekker and Janneke van Mens-Verhulst

Maastricht, January 26-27 2007


http://www.nesda.nl/link.php?link=www.ggzbuitenamstel.nl

http://www.genderdiversiteit.unimaas.nl/pages/onderzoek_gbasic.htm

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