Consistent with previous epidemiological research, we found a preponderance of women among almost all anxiety disorders examined. One in three women met criteria for an anxiety disorder during her lifetime, compared to 22% of men. Overall, the lifetime and past year rates were approximately 1.5 to 2 times as common among women, with the greatest differences in PTSD, GAD, and PD. The pattern of gender differences across the anxiety disorders is consistent with data from the NCS survey of DSM-III-R disorders (Kessler et al., 1994
), with some variation in the prevalence rates for certain disorders.
The lifetime prevalence of PTSD (8.5% for women vs. 3.4% for men) was slightly lower than the NCS rates (10.4% vs. 5%; Kessler et al., 1995
) and lower than rates reported in the Detroit Area Study (17.7% vs. 9.8%; Breslau et al., 2004
). The lower prevalence of PTSD in our study is somewhat surprising given evidence that DSM-IV criteria tend to yield higher estimates than DSM-III-R criteria, which were used in the comparison studies (Breslau & Kessler, 2001
). The lifetime prevalence of PD (7.1% for women vs. 4% for men) was higher than reported in the NCS (5% vs. 2%) and the NESARC (6.7% vs. 3.3%; Grant et al., 2006
), possibly due to the oversampling in CPES of ethnic minority populations who are known to endorse panic disorder in higher rates (Asnaani, Gutner, Hinton, & Hofmann, 2009
). The lifetime prevalence of AG (3.1% for women vs. 1.7% for men) is considerably lower than rates reported by the NCS (7% vs. 3.5%), although the NCS data likely overestimated rates of AG by misclassifying individuals with specific phobia (Wittchen et al., 1998
). Alternately, the lower rates found in the present study could reflect the use of updated methodologies. Indeed, the prevalence of AG was more in line with European epidemiological research (1.1% vs. 0.6%; Alonso et al., 2004
) that also used DSM-IV criteria and the renewed version of the CIDI.
SAD was the only anxiety disorder that did not show significant gender differences in the lifetime rates. The prevalence rates for SAD in this study (10.3% for women vs. 8.7% for men) were lower than in previous reports (15.5% vs. 11.1%; Kessler et al., 1994
), but the pattern of gender differences is similar. The past-year prevalence rate of SAD was significantly greater among women than men; these rates (6.5% for women vs. 4.8% for men) were also lower than previous reports (9.1% vs. 6.6%; Kessler et al., 1994
). The lower rates found in the present study may be due to sample composition of the CPES, in that European Americans more often report anxiety symptoms than individuals from minority groups (e.g., Asnaani et al., 2010
We found no gender effects in the mean age of onset for any of the DSM-IV anxiety disorders examined. This is consistent with previous epidemiological research on PD (Kessler, Chui et al., 2006
), GAD (Angst et al., 2009
; Vesga-López et al., 2008
), AG, specific phobia, and SAD (Bourdon et al, 1988
), but inconsistent with some clinical studies reporting an earlier onset of GAD in women than in men (Simon et al., 2006
; Steiner et al., 2005
; Yonkers et al., 2003
). GAD may have a more continuous course among treatment seeking samples than among individuals in the community, who may have fewer comorbid disorders or lower symptom severity on average. In our data, the hazard rate ratio for anxiety disorders in men and women did not differ significantly with age, suggesting that women are at greater risk for developing an anxiety disorder across the lifespan. From a developmental perspective, therefore, men and women appear to follow a similar trajectory in terms of the onset of anxiety disorders, but women assume this trajectory at a significantly greater rate.
The persistence of anxiety disorders also did not differ across genders. This has been a relatively neglected question in the epidemiologic literature on gender and anxiety even though gender role theories strongly imply that the maintenance of anxiety disorders should be greater for women than men (see Craske, 1999
; McLean & Anderson, 2009
). In PTSD, the available data suggest that women have a more chronic course than men (Breslau et al, 1998
; Kessler et al., 1995
). Epidemiological data on gender effects in the course of other anxiety disorders is not available, and data from clinical samples is mixed. For example, some studies showed that relapse rates for PD are higher in women than men (Yonkers et al., 1998
; Yonkers et al, 2003
), but other research has found no evidence that gender impacts the onset or remission of GAD, PD, or SAD (Yonkers et al, 2003
). In this study, persistence was examined by comparing rates of past year disorder among those with a lifetime incidence of that disorder. The cross-sectional design of the CPES is not ideal for examining chronicity or age of onset and further consideration through longitudinal approaches is needed.
Regarding comorbid diagnoses, women with a lifetime diagnosis of an anxiety disorder were significantly more likely than men to be diagnosed with another anxiety disorder, BN, and MDD, all of which are disorders known to predominately affect women. High levels of comorbidity between anxiety and depressive disorders have been supported consistently in previous studies (e.g., Kessler et al., 1996
, Kessler et al., 2005
). The preponderance of women with both anxiety and depressive disorders hints at possible gender effects in higher-order risk factors such as negative affectivity, which is strongly linked to both disorders (Norton et al., 2005
) and is more often observed among girls (Steiner et al., 2002
) and adult women across cultures (Lynn & Martin, 1997
; Costa et al., 2001
). Furthermore, several studies have found that a similar risk factor, neuroticism, is more closely linked to anxiety and depression in women than men (Jardine et al., 1984
; King et al., 1991
). This suggests that latent gender-dimorphic temperamental factors play a key role in consequent gender differences both in anxiety and depression. Temperamental factors are thought to be further moderated by gender socialization processes that prescribe gender-specific expectations for the expression of anxiety and the acceptable means of coping with anxiety (see McLean & Anderson, 2009
). In other words, genetic vulnerabilities gradually evolve into fully articulated traits through complex, bidirectional interactions with environmental factors. The nature of this genetic diathesis, including how gender affects heritability and expression, is not well understood (see Neale & Kendler, 1995
, Roy et al., 1995
In contrast to the pattern of comorbid internalizing disorders, men with a lifetime diagnosis of an anxiety disorder were significantly more likely to be diagnosed with comorbid ADHD, IED, and all of the substance use disorders. Previous reports have documented that IED and ADHD are each highly comorbid with anxiety disorders and more prevalent in men than women (IED: Kessler, Coccaro et al., 2006
; ADHD: Gershon, 2002
). Gender effects in substance use among individuals with anxiety disorders have been documented in previous epidemiological (Bolton et al., 2006
; Robinson et al., 2009
) and clinical studies (PD: Cox et al., 1993
; PTSD: Tarrier & Sommerfield, 2003
). Hallam (1978)
proposed a self-medication hypothesis in which men cope with anxiety through substance use, whereas women cope through agoraphobic avoidance. This hypothesis has been supported by research showing that men are more likely to view alcohol as an effective strategy for coping with anxiety (Cox et al., 1993
). Studies examining comorbidity either within episodes or across the lifetime should take into account the large gender effects in base-rates. Future research should move beyond documenting differential patterns of comorbidity across genders to examine how gender affects the sequential relationships between anxiety and co-occurring disorders.
Our findings support the conclusion that anxiety disorders represent a significant source of disability, especially for women. Anxiety disorders were associated with more missed work days in the past month for women, but not men. This could be due to greater comorbidity of anxiety disorders among women, greater social acceptability of work absenteeism for women, or a combination of both. Both men and women with an anxiety disorder were more frequent users of all health care services assessed compared to those without an anxiety disorder. This is consistent with previous work demonstrating that anxiety disorders are associated with disproportionately high rates of medical health care service use (Wang et al., 2005
). In fact, an analysis by Greenberg et al. (1999)
showed that more than half of the cost linked to anxiety disorders is attributable to nonpsychiatric medical expenditures. The results of this study indicated that the majority of these costs are related to the morbidity of anxiety disorders in women.
Men, but not women, were more likely to visit a professional for either an emotional or substance use issue in the past year if they had an anxiety disorder, possibly due to differential access to appropriate services. In an analysis of the NCS-R data, Wang et al. (2005)
found that although women with a DSM-IV disorder were more likely than men to seek health care treatment, among those who did seek treatment, women were less likely than men to receive mental health care services. As the authors suggested, primary care physicians may be more willing to manage women’s mental health problems themselves, and are more inclined to refer men to a mental health specialist. Alternatively, it may be that an anxiety disorder motivates men to seek mental health care more so than women (Albizu-Garcia et al., 2001
), possibly due to the relatively greater consistency of anxiety with a feminine gender role than a traditional masculine gender role (Bem, 1981
; for a discussion see McLean & Anderson, 2009
The results of this ethnically diverse epidemiological study showed that the preponderance of women with anxiety compared to men is relatively consistent across racial groups. However, race/ethnicity did affect the pattern of gender differences in a small number parameters examined, especially the burden of illness. The finding that anxious individuals endorsed greater dysfunction and greater service use than non-anxious individuals was only true European American men (number of ER/medical visits per month), European American women (all three indices of burden), and Hispanic women (number of ER/medical visits per month). Thus, the association between anxiety disorders and greater dysfunction and health care utilization is only true for certain groups, particularly European American women. These findings are consistent with a previous work showing that European Americans are more likely to seek treatment for an anxiety disorder that African Americans, even when controlling for SES-related variables and disorder severity (Keyes, et al., 2008
). However, a unique contribution of our study is the finding that anxiety disorder status is related to burden of illness differently across men and women from different racial groups, with anxious European American women representing a particularly dysfunctional and high health care service-utilizing group.
In sum, the present study provides an overview of the gender effects in DSM-IV anxiety disorders from the largest, most ethnically representative survey of the U.S. population to date. Women were more likely than men to meet criteria for all anxiety disorders examined, with the exception of SAD, which was equally prevalent across genders. There were no differences between men and women with regard to the age of onset and the estimated chronicity of anxiety disorders. Significant gender effects were observed in the patterns of comorbidity and in the dysfunction associated with having an anxiety disorder, which together underscore the importance of gender to the epidemiology of anxiety.
Limitations of this study include the cross-sectional design which precludes causal analysis of reported associations, and the reliance on retrospective assessment which may be error-prone due to recall bias. Our analysis has assumed that the WMH-CIDI criteria capture endorsement of the disorders studied with similar accuracy in men and women. However, reporting biases may not be equally distributed across genders; the experimental evidence that men tend to underreport anxiety relative to women is mixed (Egloff & Schmukle, 2004
; McLean & Hope, 2010
; Pierce & Kirkpatrick, 1992
). However, we cannot rule out the possibility that the observed differences between men and women are somewhat influenced by gender-related differences in the conceptualization and reporting of symptoms. Finally, we did not assess whether professional treatment was sought for anxiety or for some other mental health problem, and we did not examine the type of treatment sought. We recommend for future research to explore strategies aimed at reducing the gender-linked economic costs and to examine the reasons why race/ethnicity moderate the association between gender and anxiety disorders.