Anxiety in women
Introduction
Many women operate in an ever-present state of low anxiety, also called generalized anxiety, that may blossom into episodes of full-blown panic attacks, phobia or anxiety disorders during times of psychological stress or biological change — like menopause.
A majority of patients with chronic anxiety are so accustomed to living with it — often since childhood — that they don’t even mention it until I ask or until they begin perimenopause and their anxiety symptoms worsen.
Anxiety is a knot of both emotions and physiology. Most early psychologists viewed anxiety as purely emotional: the outward sign of repressed negative feelings and inner conflict. But over 30 years of scientific research into severe anxiety disorders and panic attacks has established that all anxiety has a real, physiological cause that is just as important to treat — especially for relief of anxiety related to hormonal imbalance.
This is good news. It means that anxiety symptoms that were once dismissed as character flaws (think of the terms “worry wart”, “head case” and “control freak”) are not feelings you just have to live with or medicate when they get too severe for you to function. There’s a lot more to the story — and a lot that you can do to get that monkey of anxiety off your back.
What is anxiety?
Everyone experiences anxiety or feels panicky from time to time: the shaky knees and thudding heart, the shortness of breath, the mind going a million miles per hour. Part of what keeps us alive is our ability to feel fear. In fact, we are made with a kind of built-in alarm system that brings the full weight of our mental and physical prowess to bear in the face of danger — the “fight or flight” response.
The limbic system, the parts of the brain responsible for orchestrating our emotions, including the fight or flight response, relies on a complicated interplay between neurotransmitters and hormones to fuel the body and mind to deal with a perceived enemy.
What’s not natural is to feel afraid and upset most of the time without any tangible cause. Like our immune response, our fight or flight response is meant to click into action in the face of danger and then rest. But in our day and age, too many of us never get to relax: our minds are perpetually on high alert with the accompanying physical response.
It’s no exaggeration to say there is an epidemic of anxiety. Over 19 million American adults and millions of children have anxiety disorders ranging from mild to severe. And the statistics only count the people reporting their anxiety symptoms to doctors. There are many more people on the mild to moderate scale of anxiety who feel reluctant or even ashamed to admit their anxiety.
Our culture tells us that feelings of fear, vulnerability, and even shyness are signs of weakness — which makes anxiety the fault of the victim. Women are taught from childhood to “grin and bear it.” Let’s start by looking at the major types and symptoms of anxiety and then examine the real roots of anxiety. That’s where we’ll find solutions.
Severe anxiety disorders
Severe panic and anxiety disorders like obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), social phobias, and stress disorders affect only a small minority of anxiety sufferers. Severe anxiety disorders are highly treatable but require medical diagnosis. If you think you may be experiencing any of these disorders, contact your healthcare practitioner right away. Different approaches that include drugs and cognitive-behavioral therapies (such as exposure therapy) are proving to be very successful.
One hot topic of study is the connection between anxiety disorders and genetics, because anxiety disorders clearly run in families. Genes are a factor in some anxiety disorders, but generally not the most important factor. More often than not, anxious women grew up in anxious households. Anxiety is usually a learned behavior that can be unlearned — even when it’s severe. We’ll return to this topic after we explore generalized anxiety disorder, which affects many more women than the severe anxiety disorders.
Generalized anxiety disorder (GAD)
Mild to moderate anxiety is far more common but harder to identify than severe anxiety disorder. Called generalized anxiety disorder, or GAD, it’s characterized by compulsive worrying and physical symptoms of anxiety which persist for more than six months. Often these women were anxious — and medicated — as children, suffered some form of childhood trauma, or grew up in anxiety-ridden households.
More often than not, my patients are so used to their anxious feelings that they don’t mention them until I ask. That’s because while anxiety can be debilitating – and may grow increasingly so if left untreated – symptoms of mild to moderate anxiety may not obviously impact your ability to function.
In fact, quite the opposite may seem to be true. Often it is the high-achieving, seemingly “together” woman who finds it difficult to admit she has chronic anxiety. And frequently dynamic, non-stop women who rarely felt anxious in their younger lives get slammed with anxiety and panic attacks as they enter perimenopause.
These signs of anxiety can be misread at the PCP’s office precisely because these women appear to be such powerhouses. So let’s find out what the symptoms of anxiety really are.
Symptoms of anxiety and panic attack
While most of us will experience episodes in which we feel some or all of these symptoms, what differentiates healthy anxiety and/or panic from chronic anxiety and panic attacks is the trigger. If you think you hear a strange sound in the night, it’s natural to wake up with a start, your heart pounding and your muscles seizing. But it’s unhealthy to have these symptoms while sitting at a table in a restaurant.
One of my patients describes her chronic anxiety as a kind of internal grinding — an all-consuming revving up of energy that then has nowhere to go. Other symptoms of generalized anxiety and panic attacks include:
- Irrational fear or dread
- Muscle tension and headache
- Chest pain
- Elevated heart rate/palpitations
- Insomnia
- Diarrhea/GI distress/IBS
- Nausea
- A feeling of fullness or chest pressure/shortness of breath
- Jumpiness/irritability/shakiness
- Sudden changes in body temperature/hot flashes
- Tearfulness
- Depression – about 20–30% of people with anxiety disorders also suffer from depression.
Usually one of the things you don’t feel when you’re anxious is tired or hungry — until you eventually crash, feel more tired than ever, and then crave sugar to restore your mood.
How does a normal anxious feeling become chronic anxiety?
As we’ve said, anxiety is a knot of emotions and physiology. The root cause of the anxiety could arise on the emotional side or the physical side — or both.
The feeling of anxiety always begins with a trigger that initiates a survival response from the limbic system. At the first whiff of apparent danger, your brain chemistry, blood hormones and cellular metabolism all whirl into action.
When you have chronic anxiety, this response may lessen but it never gets turned off, even when there’s no palpable threat. Over time your anxiety symptoms may be triggered by less and less serious events because your limbic system has been sensitized to react in a highly anxious way.
For example, if you were constantly yelled at as a child, you may feel anxious later in life whenever there is potential for confrontation with an authority figure — and you may go to extremes to avoid that confrontation, even in a situation as seemingly benign as returning an article of clothing that doesn’t fit. By this point your conscious mind has lost track of the link between your current feeling and your past emotional experience — you no longer have any idea why you’re anxious about something that shouldn’t be a cause of anxiety.
The problem with anxiety is that it becomes so easily entrenched — it becomes your normal state. The links among your neurotransmitters, hormones and metabolism become tuned to an equilibrium in which anxiety is maintained. That’s why anxiety relief is all about changing the physical and emotional causes of your anxiety and creating a new, healthier equilibrium. But first let’s explore more deeply what causes anxiety.
Anxiety and emotional experience
Early emotional experience is the wellspring for anxiety. The experience may be a major childhood trauma (the death of a parent, divorce, child abuse or sexual abuse, etc.), emotional abuse (constant criticism, abandonment, deprivation), or emotional patterning (anxious parent, alcoholic parent). These adverse emotional experiences can set up a pattern of chronic anxiety.
Childhood is a time of little power and control. When terrible things happen to us as children, our coping mechanisms are not up to it. We can’t process what’s happened and move on in a healthy way. In a very real sense, that adverse childhood experience is trapped inside us. In adulthood, those hidden issues often surface as anxiety symptoms. It may be difficult to connect what is triggering your anxiety to what came before — but there is always a link.
The physical factors behind anxiety
Women have been taught for so long that anxiety is all in their heads that I’d like to spend a few moments talking about how anxiety is everywhere — in your brain, your pituitary gland, your adrenals, your GI system, your heart, and your ovaries too! And of course, they’re all interrelated.
1. Neurotransmitters and anxiety. A neurotransmitter imbalance can sensitize your brain to a fear response. Consistently high levels of excitatory neurotransmitters (for example, norepinephrine and epinephrine) and correspondingly low levels of the calming, inhibitory neurotransmitters (such as serotonin and gamma-aminobutyric acid, or GABA) actually modify your brain chemistry. At Women to Women, we run a neurotransmitter test on every patient with symptoms of anxiety. The test provides only a snapshot of these levels and is controversial, but it can be very useful in the hands of an experienced professional in guiding targeted neurotransmitter support.
Caffeine affects brain chemistry by raising levels of dopamine; in sufficient amounts, coffee and other caffeine-laden drinks can bring on panic attack symptoms. The jitteriness you feel from a shot of espresso comes from elevated dopamine. The neurotransmitter imbalances that cause anxiety are related to those in children with ADHD and ADD (conditions also associated with high dopamine); in fact, what may look like ADD in some children may actually be related to severe anxiety. The symptoms can be very similar.
Popular anti-anxiety medications like BuSpar, Ativan, Valium, and Xanax work on these neurotransmitters. Alcohol works in the same manner by raising levels of GABA. That’s why a drink helps you overcome your social discomfort and unwind, while more than a few causes slurred speech, slow reflexes, and a decrease in cognitive ability.
The fear-anxiety neural pathway is very easily influenced. This means that anti-anxiety medications (particularly benzodiazepines), caffeine, and alcohol are highly addictive. It makes sense that people who inherit or develop anxiety-sensitive brains also have a higher risk for addiction.
2. The HPA axis and anxiety. Along with your neurotransmitters, your hormones play a crucial role in mediating anxiety. The hypothalamic–pituitary–adrenal (HPA) axis is the hormonal system that influences mood. Imbalances along this system can bring on panic attacks and chronic anxiety.
As part of the cascade of hormones in the fight-or-flight response, your hypothalamus releases a hormone called corticotropin–releasing factor (CRF), which jolts you into action. CRF flows through your pituitary gland, where it stimulates adrenocorticotropic hormone (ACTH), which in turn tells your adrenal glands to release cortisol. Cortisol opens the gates for a rush of glucose, fat, and protein to give your cells the energy and alertness they need.
In a healthy system, the hormonal flood recedes once the threat is disabled. But different factors can disrupt this pathway, causing the gates to stay open and running the adrenals to exhaustion. Levels of ACTH and cortisol stay elevated, causing anxiety, weight gain, accelerated aging, and metabolic imbalances. (Click here for more information on adrenal fatigue.)
CRF also seems to be a factor in anxiety. People with high anxiety generally have high levels of CRF — which indicates that the HPA axis is always on. Researchers think that early emotional trauma may trigger elevated levels of CRF, which the body then maintains through adulthood.
3. Estrogen, progesterone, menopause and anxiety. Clearly, sex hormones like estrogen and progesterone play a critical role in anxiety. Women are more than twice as likely as men to feel anxiety, especially during the hormonal ups and downs of PMS, perimenopause, and menopause. Anxiety is often the first sign of perimenopause. Many women experience rampant anxiety symptoms when they first wean off HRT.
A recent study showed that anxious women are more likely to suffer uncomfortable hot flashes during perimenopause. In another study, baby rats of both sexes were deprived of maternal attention at birth. When they grew up, the female rats showed measurable signs of anxiety and stress when tested in a maze, whereas the male rats did not.
Estrogen is tied in to serotonin levels — as any woman who has ever suffered mood swings with her monthly cycles can attest. What you know instinctively, science is beginning to prove. Natural progesterone also has a soothing, calming effect on your system similar to and interdependent with neurotransmitters — when levels fall, so do our moods and energy levels. Estrogen and progesterone levels are directly influenced by the adrenals and cortisol overproduction. (For more information, see our article on adrenal exhaustion.)
Medications
Medication will not cure anxiety disorders, but it can keep them under control while the person receives psychotherapy. Medication must be prescribed by psychiatric practitioners, usually psychiatric practitioners, who can either offer psychotherapy themselves or work as a team with psychologists, social workers, or counselors who provide psychotherapy. The principal medications used for anxiety disorders are antidepressants, anti-anxiety drugs, and beta-blockers to control some of the physical symptoms. With proper treatment, many people with anxiety disorders can lead normal, fulfilling lives.
Antidepressants
Antidepressants were developed to treat depression but are also effective for anxiety disorders. Although these medications begin to alter brain chemistry after the very first dose, their full effect requires a series of changes to occur; it is usually about 4 to 6 weeks before symptoms start to fade. It is important to continue taking these medications long enough to let them work.
SSRIs
Some of the newest antidepressants are called selective serotonin reuptake inhibitors, or SSRIs. SSRIs alter the levels of the neurotransmitter serotonin in the brain, which, like other neurotransmitters, helps brain cells communicate with one another.
Fluoxetine (Prozac®), sertraline (Zoloft®), escitalopram (Lexapro®), paroxetine (Paxil®), and citalopram (Celexa®) are some of the SSRIs commonly prescribed for panic disorder, OCD, PTSD, and social phobia. SSRIs are also used to treat panic disorder when it occurs in combination with OCD, social phobia, or depression. Venlafaxine (Effexor®), a drug closely related to the SSRIs, is used to treat GAD. These medications are started at low doses and gradually increased until they have a beneficial effect.
SSRIs have fewer side effects than older antidepressants, but they sometimes produce slight nausea or jitters when people first start to take them. These symptoms fade with time. Some people also experience sexual dysfunction with SSRIs, which may be helped by adjusting the dosage or switching to another SSRI.
Anti-Anxiety Drugs
High-potency benzodiazepines combat anxiety and have few side effects other than drowsiness. Because people can get used to them and may need higher and higher doses to get the same effect, benzodiazepines are generally prescribed for short periods of time, especially for people who have abused drugs or alcohol and who become dependent on medication easily. One exception to this rule is people with panic disorder, who can take benzodiazepines for up to a year without harm.
Clonazepam (Klonopin®) is used for social phobia and GAD, lorazepam (Ativan®) is helpful for panic disorder, and alprazolam (Xanax®) is useful for both panic disorder and GAD.
Some people experience withdrawal symptoms if they stop taking benzodiazepines abruptly instead of tapering off, and anxiety can return once the medication is stopped. These potential problems have led some psychiatric practitioners to shy away from using these drugs or to use them in inadequate doses.
Buspirone (Buspar®), an azapirone, is a newer anti-anxiety medication used to treat GAD. Possible side effects include dizziness, headaches, and nausea. Unlike benzodiazepines, buspirone must be taken consistently for at least 2 weeks to achieve an anti-anxiety effect.
Beta-Blockers
Beta-blockers, such as propranolol (Inderal®), which is used to treat heart conditions, can prevent the physical symptoms that accompany certain anxiety disorders, particularly social phobia. When a feared situation can be predicted (such as giving a speech), a psychiatric practitioner may prescribe a beta-blocker to keep physical symptoms of anxiety under control.
Psychotherapy
Psychotherapy involves talking with a trained mental health professional, such as a psychiatric practitioner, psychologist, social worker, or counselor, to discover what caused an anxiety disorder and how to deal with its symptoms.
Cognitive-Behavioral Therapy
Cognitive-Behavioral Therapy Cognitive-behavioral therapy (CBT) is very useful in treating anxiety disorders. The cognitive part helps people change the thinking patterns that support their fears, and the behavioral part helps people change the way they react to anxiety-provoking situations.
Anxiety relief: natural treatments for anxiety
Relief from chronic anxiety comes from restoring your body’s natural, healthy equilibrium. You can do that through change in a number of factors: lifestyle, diet, allergies, exercise levels, hormonal balance, general physical health, and your emotional history.
Good nutrition is the foundation of natural treatment for anxiety. If you are serotonin-deficient you will crave sugar and simple carbohydrates. But those foods cause your insulin levels to spike and crash, further destabilizing your mood and creating that “bottoming out” feeling. Eat real whole foods, organic when possible, that will help maintain stable blood sugar levels. Avoid all processed, artificial products, trans fats, artificial additives, simple sugars and carbohydrates (or “white” food). Add multiple servings of fiber-rich vegetables or fruit to every meal and drink plenty of filtered water.
Take a medical–grade nutritional supplement to fill in any nutritional gaps. A daily supplement that includes essential fatty acids is an important part of supporting natural neurotransmitter balance and general good health.
Examine your diet for potential food allergies or sensitivities.
Physical activity is the single best anxiety medication I know. It’s just essential to hormonal balance. In one study, people who engaged in 30–60 minutes of moderate exercise every day reported less anxiety than a similar group on anti-anxiety meds who did not exercise. Start slow and build up to at least 30 minutes a day. Find a friend or a neighborhood group to exercise with – it’s more fun and you’ll be more likely to stick with it.
Get enough sunlight and fresh air. Fifteen minutes of sun exposure (without sunscreen) in the early morning and late afternoon stimulates the production of vitamin D in your body. Vitamin D deficiency is related to depression, SAD, and other mood disorders. Deep breathing helps calm the senses and relax the mind – so combine both!
Get enough sleep. Adequate sleep is paramount to brain health. Women should get 7–9 hours a night. If you have trouble sleeping, avoid all caffeine (including chocolate and green tea) and set a bedtime for yourself that you stick to. Practice a calming technique like meditation or deep breathing before bed.
Find a counselor to talk to about your emotional experience. Ask for a referral from a doctor, family member or friend. The local Y, religious institution, or grief counseling center may have a list of therapists they can offer. Interview several to make sure you find someone you really like and trust.
If you are paralyzed by catastrophic thoughts and debilitating physical symptoms of anxiety, talk to your healthcare professional about the usefulness of medication. If your doctor does not offer additional support techniques to help you in the long term, look around for an alternative or integrative medical practitioner.
