Lifetime prevalence of DSM-IV anxiety disorders in adult males and females
Abstract
Several studies have examined sex differences in different anxiety disorders. Females are repeatedly found to be more likely than males to suffer from anxiety in general and to be diagnosed with most anxiety disorders, including agoraphobia (AG), panic disorder (PD), separation anxiety (SA), specific phobia (SP), social anxiety disorder (SAD), generalised anxiety disorder (GAD), obsessive-compulsive disorder (OCD), and acute and posttraumatic stress disorder (ASD and PTSD), although the latter three are technically no longer categorised as anxiety disorders according to DSM-5. This chapter provides an overview of research on sex and gender differences in anxiety disorders ranging from the well-established female preponderance in prevalence and severity to possible sex differences in the risk and protective factors associated with anxiety, sex differences in the clinical presentation of anxiety disorders, and potential sex differences in the effectiveness of different treatments. The chapter contains suggestions for future research, including important questions that remain to be answered.Gender Disparities in Anxiety Disorders Essay.
Anxiety disorders are the most prevalent group of psychiatric disorders [1]. It is well-documented that females are more likely than males to develop an anxiety disorder with lifetime and past-year rates of anxiety disorders being 1.5–2 times higher among females than males [2]. The increased prevalence of anxiety disorders in females has persisted independently of changes in the diagnostic criteria from DSM-III-R to DSM-IV [3, 4]. Sex differences in different anxiety disorders do not emerge at the same time, but sex differences in general anxiety levels emerge before the age of 4, and by age 6, anxiety levels in girls are about twice as high as in boys [5]. Once they have emerged, sex differences in DSM-IV anxiety disorders generally remain stable across age groups ranging from 18 years to 60+ years [6].
In spite of a few studies failing to find significant sex differences in the prevalence of anxiety disorders, clinical and community studies have generally reported higher rates of panic disorder (PD), agoraphobia (AG), specific phobias (SP), generalised anxiety disorder (GAD), separation anxiety (SA), and both acute and posttraumatic stress disorder (ASD and PTSD) in females compared to males [2, 3, 7, 8]. Sex differences are less pronounced for social anxiety disorder (SAD) and obsessive-compulsive disorder (OCD), and sex differences in the prevalence rates of these two disorders are not always significant [7, 9]. As can be seen in Table 1, lifetime prevalence rates of DSM-IV anxiety disorders range from 1.1% AG to 11.1% SAD in males and from 1.6% AG to 15.8% SP in females [3]. The three most prevalent anxiety disorders in males are SAD followed by SP and GAD [3]. In comparison, the three top-ranging anxiety disorders in females are SP, SAD, and PTSD. In spite of these widely reported sex differences in the prevalence and severity of anxiety disorders, sex differences in anxiety have been largely neglected compared to depression [10].
In the most recent edition of the diagnostic and statistical manual of mental disorders (DSM-5) [12], some of the anxiety disorders were re-arranged. As a consequence, ASD, PTSD, and OCD are no longer characterised as anxiety disorders. ASD and PTSD were moved to the new category trauma- and stressor-related disorders and OCD was relocated to the newly created category of obsessive-compulsive and related disorders. However, because these changes are still relatively recent, a limited amount of research has been published based on these categories of disorders. Furthermore, as a substantial amount of research has been conducted on these disorders in combination with other traditional anxiety disorders, it was considered expedient to include ASD, PTSD, and OCD in this chapter. Gender Disparities in Anxiety Disorders Essay.
The inclusion of these three disorders further provides an opportunity to compare sex differences in ASD, PTSD, and OCD with sex differences in the disorders that have remained classified as anxiety disorders. Whereas ASD, PTSD, and OCD are no longer considered anxiety disorders, two new disorders have taken their place. In DSM-IV, selective mutism and SA were classified under the category of “Disorders usually first diagnosed in infancy, childhood, or adolescence” [13] but with the revisions carried out in the DSM-5, they were re-categorised as anxiety disorders [12]. Unfortunately, studies focusing specifically on sex differences in selective mutism are non-existing perhaps because the disorder is so rare that sex differences are rarely detected. Furthermore, this chapter will focus primarily on sex differences in adults, and research on selective mutism in adults is as hard to come by as research on sex differences. Thus, this chapter will examine the current status of research on sex differences in AG, ASD, GAD, OCD, PD, PTSD, SA, SAD, and SP.
| Diagnosis | Males %1 | Females %1 | F:M ratio2 | Classification3 |
| AG | 1.1 | 1.6 | 4:1 | Substantial |
| ASD | – | – | – | – |
| GAD | 4.2 | 7.1 | 3:1 | Moderate |
| OCD | – | – | 1:1 | Moderate |
| PD | 3.1 | 6.2 | 2:1 / 3:14 | Substantial |
| PTSD | 3.6 | 9.7 | 2:1 | Substantial |
| SA | – | – | OR = 1.45 | Substantial |
| SAD | 11.1 | 13.0 | 1:1 | Moderate |
| SP | 8.9 | 15.8 | 2:1 | Moderate |
| Any anxiety disorder | 22.4 | 32.4 | OR = 1.761 | – |
Table 1.
Notes: GAD: generalised anxiety disorder; SAD: social anxiety disorder; PD: panic disorder; AG: agoraphobia; SP: specific phobia; PTSD: posttraumatic stress disorder; ASD: acute stress disorder; SA: separation anxiety; OR: Odds ratio for sex differences, OD >1 reflects higher prevalence in females.
1DSM-IV prevalence rates (and OR for any anxiety disorder) based on the NCS-R and published by Gum et al. [3].
2DSM-IV-TR female-to-male ratios published by Bekker et al. [7] (except for SA and any anxiety disorder).
3Classifications presented by Mackinaw-Koons & Vasey [11].
Substantial differences: females exceed males by at least 100%
Moderate differences: females exceed males by 33–99%
4PD with AG/PD without AG
5Prevalence for males and females combined is 6.6%. Prevalence and OR published by Shear et al. [8].
1.1. Overview of relevant studies on sex differences in anxiety disorders since 2010
A search of studies on sex or gender differences in the different anxiety disorders published and indexed in PsycINFO and/or PubMed from 2010 until the end of 2014 was conducted. Search criteria can be seen in Table 2.
The literature search only included articles identified through the searches in PsycINFO and PubMed, even though articles published in the same period but not identified in these searches, may have been included in this chapter. The reasoning behind this is that the searches were intended to give an overview of the amount of sex/gender research published in relation to the different disorders over a period of 5 years. In addition, studies were excluded that did not focus primarily on anxiety disorders, focused on animals, focused primarily on children and younger adolescents, were not written in English, or were published as book chapters or dissertations. Articles were categorised as either relevant or not relevant based on whether their focus was on sex differences in the specific disorders. Furthermore, articles were classified as uniquely relevant to a specific anxiety disorder if that disorder was the sole focus of the article. Gender Disparities in Anxiety Disorders Essay. Because many studies report sex differences in the prevalence or severity of anxiety without mentioning this in the abstract, only studies that examined sex differences beyond this level (i.e., tried to explain these differences – or absence thereof – or examined moderation effects or sex differences in specific symptoms etc.) were categorised as relevant. In addition, studies that did not focus on specific anxiety disorders and studies that examined specific subsamples of limited general relevance (e.g., sex differences in anxiety in patients undergoing treatment for substance dependence) were not categorised as relevant. Finally, articles that did not present original research or conduct thorough reviews or meta-analyses were not included.
An overview of articles identified in the searches can be seen in Table 3. Several of the studies were indexed in both of the databases. Such overlap was taken into account, which reduced the number of total articles identified somewhat. As can be seen in Table 3, more studies have been published on sex differences in PTSD than in any other anxiety disorder within the past 5 years.
| Keywords | |
| Abstract | “General anxiety disorder” OR “generalised anxiety disorder” OR “generalized anxiety disorder” “Obsessive compulsive disorder” OR “obsessive-compulsive disorder” OR OCD “Specific phobia” “PTSD” OR “post-traumatic stress disorder” OR “posttraumatic stress disorder” “Acute stress disorder” “Panic disorder” “Agoraphobia” “Social phobia” OR “social anxiety disorder” “Separation anxiety” |
| Abstract | “Sex differences” OR “Gender differences” |
| Publication date | 2010–2014 |
Table 2.
Search criteria for sex/gender differences in anxiety studies published 2010–2015
Note: At least one keyword from each row had to be present in the title/abstract for articles to be identified in the search
Between 1 and 11 relevant studies were identified on sex differences in AG, GAD, OCD, PD, and SAD, whereas no relevant studies were identified on sex differences in ASD, SA, and PD. Quite a few of the studies published examined sex differences in several disorders, resulting in substantial overlap between the articles identified in the different searches. As a result of this, the number of unique articles identified in the searches of each disorder was substantially reduced for most of the disorders. The two exceptions to this were OCD where 5 of the 7 articles identified were unique and PTSD where a full 95.6% of the articles were unique. For the remaining diagnoses, between 0 and 5 articles were identified that were unique to each disorder. This overview of studies published within the past 5 years highlights the need for more research examining sex differences in anxiety. With the exception of PTSD, the number of published articles identified including sex or gender differences in the abstract is very low, and this number is reduced even further, when results are limited to those specifically focusing on sex or gender differences in relation to each disorder. The difference in numbers between the studies originally identified and the studies categorised as relevant suggests that future research on sex differences in anxiety should be much more focused. For this reason, the purpose of this chapter is to give an overview of what is presently known about sex differences in anxiety disorders and what still remains to be examined. Thus, this chapter may be read as a guide to research on sex and gender differences in anxiety disorders, summarising what is currently known and posing relevant questions for future research to answer. Gender Disparities in Anxiety Disorders Essay.
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| Diagnosis | PubMed total |
PsycINFO total |
Total | Relevant | Uniquely relevant |
| AG | 3 | 4 | 5 | 1 | 0 |
| ASD | 1 | 1 | 2 | 0 | 0 |
| GAD | 15 | 20 | 24 | 6 | 1 |
| OCD | 18 | 23 | 27 | 7 | 5 |
| PD | 23 | 21 | 27 | 9 | 4 |
| PTSD | 111 | 115 | 15 | 91 | 87 |
| SA | 6 | 6 | 9 | 0 | 0 |
| SAD | 23 | 28 | 21 | 11 | 5 |
| SP | 6 | 6 | 6 | 0 | 0 |
Table 3.
Results from literature search on sex/gender differences in the different anxiety disorders
Note: AG: agoraphobia; ASD: acute stress disorder; GAD: generalised anxiety disorder; OCD: obsessive-compulsive disorder; PD: panic disorder; PTSD: posttraumatic stress disorder; SA: separation anxiety; SAD: social anxiety disorder; SP: specific phobia
2.1. Sex differences in anxiety
A vast amount of research has documented sex differences in brain regions involved in cognition, memory, and affect [14]. In spite of important sex differences in the structure and function of the brain, most research on the brain’s involvement in learning, memory, fear conditioning, and fear extinction has been conducted on male populations, as less than 2% of studies in these areas have focused on females [14]. However, what little research has been conducted has uncovered both structural and functional sex differences in brain regions relevant to anxiety, including the prefrontal cortex, hippocampus, and the extended amygdala complex. For example, significant genetic differences between males and females with OCD have been reported, although findings are sometimes contradictory and replication is needed [15, 16]. Furthermore, blood pressure and pulse have been reported to be more reactive to anxiety in females compared to males [17]. As a result of such sex differences, females appear to be more easily conditioned than males [7, 18], and males and females have also been found to differ in fear extinction [18]. One way through which biological sex differences can affect anxiety disorders is through gonadal hormones. Gender Disparities in Anxiety Disorders Essay.
