1. 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

2. Anxiety disorders and gender: State of the art & Future research Prevalence/ co-morbidity Theories Treatment (effects) Bekker & van Mens-Verhulst. 2007

3. 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) Bekker & van Mens-Verhulst. 2007

4. 12-month prevalence anxiety disorders European countries WomenMen Any anxiety disorder16.37.8 Panic Disorder 3.01.7 Agoraphobia 3.11.0 Social phobia 2.71.3 GAD 2.11.0 Specific phobias10.84.5 OCD 0.90.6 (adapted from Wittchen & Jacobi, 2005) Bekker & van Mens-Verhulst. 2007

5. 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? Bekker & van Mens-Verhulst. 2007

6. 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

7. Body female/male - higher premenstrual conditionability (r) - (5-HTTLPR) modulates the effects of early adversity in female (e; in macaques) - ??…. Gender femininity(ies)/ masculinity(ies) 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/?) Sex differences in prevalence of anxiety disorders (and other syndromes!) Bekker & van Mens-Verhulst. 2007

8. 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) Bekker & van Mens-Verhulst. 2007

9. 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! Bekker & van Mens-Verhulst. 2007

10. Anxiety disorders and gender: State of the art & Future research Prevalence/ co-morbidity Theories Treatment (effects) Bekker & van Mens-Verhulst. 2007

11. 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??? Bekker & van Mens-Verhulst. 2007

12. Body female/male - higher premenstrual conditionability (r) - (5-HTTLPR) modulates the effects of early adversity in female (e; in macaques) - ??…. Gender femininity(ies)/ masculinity(ies) 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) -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/?) Sex differences in prevalence of anxiety disorders Bekker & van Mens-Verhulst. 2007

13. 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 Bekker & van Mens-Verhulst. 2007

14. 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??? Bekker & van Mens-Verhulst. 2007

15. Body female/male - higher premenstrual conditionability (r) - (5-HTTLPR) modulates the effects of early adversity in female (e; in macaques) - ??…. Gender femininity(ies)/ masculinity(ies) 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/?) Sex differences in prevalence of anxiety disorders Bekker & van Mens-Verhulst. 2007

16. 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 Bekker & van Mens-Verhulst. 2007

17. 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 Bekker & van Mens-Verhulst. 2007

18. Body female/male - higher premenstrual conditionability (r) - (5-HTTLPR) modulates the effects of early adversity in female (e; in macaques) - ??…. Gender femininity(ies)/ masculinity(ies) 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/?) Sex differences in prevalence of anxiety disorders (and other syndromes) Bekker & van Mens-Verhulst. 2007

19. 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 ! Bekker & van Mens-Verhulst. 2007

20. Anxiety disorders and gender: State of the art & Future research Prevalence/ co-morbidity Theories Treatment (effects) Bekker & van Mens-Verhulst. 2007

21. 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 Bekker & van Mens-Verhulst. 2007

22. Body female/male - higher premenstrual conditionability (r) - (5-HTTLPR) modulates the effects of early adversity in female (e; in macaques) - ??…. Gender femininity(ies)/ masculinity(ies) 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/?) Sex differences in prevalence of anxiety disorders Bekker & van Mens-Verhulst. 2007

23. 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 Bekker & van Mens-Verhulst. 2007

24. 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! Bekker & van Mens-Verhulst. 2007

25. Thank you for your attention! Marrie H. J. Bekker and Janneke van Mens- Verhulst Maastricht, January 26-27 2007 Bekker & van Mens-Verhulst. 2007