Motivation and emotion/Book/2017/Anxiety and gender

Overview
Individuals experience stress, anxiety and worry when under pressure. "Pull yourself together" is a common response, knowing once stressful situations have passed these feelings will subside. However, what if these feelings persisted at a greater intensity, being uncontrollable and significantly interfering with daily functioning? This is pathological anxiety.

Concerning figures demonstrate that anxiety is twice as prevalent in women than men (Donner & Lowry, 2013). Understanding how and why these differences exist has crucial implications for the severity and maintenance of anxiety and treatment efficacy.

This chapter explains how and why anxiety is experienced differently across genders, including gender differences in the development, maintenance and treatment of anxiety. Understanding reasons for anxiety-gender differences is crucial for providing greater understanding and more positive outlooks and improvement for anxiety prevention and treatment.


 * What is anxiety?
 * When does anxiety become abnormal?
 * Why do genders differ in their anxiety experience?
 * What are the implications of gender differences in anxiety, and how can they be managed?

What is anxiety?


Anxiety, a state of arousal following perceptions of a real or imagined threat, is characterised by feelings of unease, tension and worry and physiological, psychological and behavioural symptoms (Lankton, 2014). Anxiety usefully readies and motivates defensive behaviors against impending non-specific threats to well-being (Cisler, Olatunji, Feldner, & Forsyth, 2010). This future-oriented, self-focusing, "on-alert" emotion allows individuals to be adaptive, triggering anticipatory problem-solving, promoting survival (Amstadter, 2008).

Anxiety responses, however, can become disproportionate to the actual situation, being more persistent than required. This consumes attentional resources and can be debilitating and extremely distressing, causing withdrawal and interfering with social functioning (Amstadter, 2008).

Normal anxiety Normal anxiety is beneficial. In fact, it is necessary for survival (Lankton, 2014):
 * Anxiety, closely related to fear, anticipates potential threatening situations that may/may not occur in the future. Anxiety is normal when it serves to improve an individual's functioning and well-being, representing an adaptive attempt to prevent fear-provoking/threatening circumstances from occurring.
 * For example: Feeling anxious about an upcoming assessment deadline. These feelings vanish once the assessment is submitted, but are necessary at the time as they motivate an individual to take action, preparing them for serious, negative consequences.

Abnormal anxiety  Anxiety becomes abnormal when its duration, intensity and frequency are disproportionate to the actual or perceived threat. Abnormal anxiety is significantly distressing to an individual, disrupting general functioning and well-being (Jacofsky, Santos, Khemlani-Patel, & Neziroglu, 2013)
 * Becomes abnormal when it presents a debilitating issue, significantly affecting daily functioning, relationships and performance.

Anxiety disorders are the most common class of mental health disorders (Bekker & van Mens-Berhulst, 2007). They encompass excessive fear, apprehension, worry and nervousness, which is uncontrollable and characterises an individual's actions and functioning (American Psychiatric Association, 2013). Anxiety disorders are the most prevalent of mental health disorders, with an estimated worldwide prevalence of about 16% (Maeng & Milad, 2015).

Table 1

Summary of major anxiety and related disorders recognised in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Source: Adapted from the Diagnostic and Statistical Manual of Mental Disorders (5th ed.), (APA, 2013).

Comorbidity

A symptomatic feature of many psychiatric disorders, anxiety has high comorbidity with other subtypes of anxiety disorders, Major Depressive Disorder (Bekker & van Mens-Berhulst, 2007), personality disorders, eating disorders, ADHD and substance use disorders. This represents a key reason why anxiety disorders often go unrecognised or misdiagnosed (Hirschfeld, 2001), presenting significant consequences for prevention and treatment which is crucial for reducing mental health burden for individuals and societies.

McLean, Asnaani, Litz & Hofmann (2011) found gender differences in anxiety comorbidity, with women more likely to have comorbid diagnoses with other internalising disorders (MDD, Bulimia Nervosa, other anxiety disorders) and men more likely to have comorbid externalising disorders (ADHD, Intermittent Explosive Disorder and substance use disorders). Understanding these differences, and the reasons underlying them provide significant implications for improving both gender's odds against anxiety and other mental illness.

Want a crash course in anxiety disorders? Watch this YouTube video to gain a better understanding of the complexity of anxiety disorders! (CrashCourse, 2013) (11:31 minutes)

{What constitutes normal anxiety? - Causes significant distress. - It is disproportionate to the actual threat - Impaired daily functioning in social and occupational situations due to persistent worry/anxiety. + An adaptive emotion, improving an individual's well-being and safety, subsiding once stressful situations have passed.
 * type=""}

{What is the approximate worldwide prevalence of anxiety disorders? - 60% + 16% - 2% - 50%
 * type=""}

Gender differences in experiencing anxiety


The gender disparity in anxiety is a major worldwide challenge, with greater prevalence (nearly double the likelihood of diagnoses) and increased symptom severity in women (Donner & Lowry, 2013). These gender differences hold across the lifespan, emerging from age 6 (Lewinsohn, Gotlib, Lewinsohn, Seeley & Allen,1998). Ohannessian, Milan & Vannucci (2016) highlighted developmental trajectories of overall anxiety levels across genders, reporting that females initially have higher symptoms, with a slight linear decrease over the years, whereas males demonstrate a stable run across all symptoms.

Gender differences in anxiety have significant implications for diagnosis, treatment and other psychopathology; thus understanding the differences and how they arise can offer optimistic outlooks for future anxiety treatment.



Emotional expression and reactivity
Control over emotional expression (particularly negative ones) is consistently linked to reducing the intensity and duration of negative feelings which underlie anxiety and other psychopathology (Garner, Robertson, & Smith, 1997). Being limited or encouraged to express particular emotions contributes to a greater likelihood of negative socio-emotional functioning and psychopathological risk (Chaplin & Aldao, 2013).

Females are extensively viewed as the "more emotional sex", due to their greater tendencies and encouragement to express and dwell on their emotions, contributing to beliefs that this sex experiences more negative feelings and symptoms of anxiety than males (Nolen-Hoeksema, 2012). Women are believed to be more vulnerable to the effects of anxiety as a result and internalise negative emotions such as anxiety (Chaplin, 2015). Men have been portrayed as having restrictive emotionality, in which they tend to suppress or avoid internally experiencing and expressing emotions (Nolen-Hoeksema, 2012), as encouraged by society.

This greater likelihood for women to express, report and focus on their negative, anxious feelings, intensifying and extending the duration of the experience of anxiety is what relates to abnormal anxiety and other disorders. Girls are encouraged to freely express their feelings, resulting in expression of greater vulnerability, helplessness, anxiety and depression (Kring & Gordon, 1998).

However, despite these differences, the experience of anxiety and physiological arousal is similar across genders (Chaplin, 2015). While this should counter the gender-anxiety imbalance, Charbonneau and colleagues (2009) found that females have a higher emotional reactivity to stress, and thus greater negative emotional reactions to stress and anxiety than males do. Charbonneau et al. (2009) reported this may be the result of subjective appraisals, which may be more important than the level or frequency of stressful/threatening events in contributing to psychopathology, which puts them at greater risk of anxiety than males. Further, while males may be internally aroused, they tend to keep their emotions "locked in", so as not to jeopardise masculinity (Chaplin,2015).

Emotion regulation
Emotion regulation, the "process by which individuals influence which emotions they have, when they have them, and how they experience and express them" (Aldao, Sheppes & Gross, 2015), is increasingly found as central to psychopathology, particularly anxiety (Nolen-Hoeksema, 2012). The ability to regulate emotions is an essential component for understanding aetiology, maintenance and treatment of anxiety disorders (Cisler & Olatunji, 2012), and different gender emotion regulation strategies characterise different anxiety experiences.

Research finds maladaptive emotion regulation strategies (emotion dysregulation) within individuals with anxiety disorders (Cisler & Olatunji, 2012). Nolen-Hoeksema (2012) extended on findings that anxious individuals engage in regulation strategies which exacerbate anxious emotions. Women more often engage in rumination than men, which has been linked as a significant mediator of women's enhanced anxiety levels (Nolen-Hoeksema, 2012). Women seek to engage in and understand their emotions, and in utilising rumination they tend to get trapped analysing their emotions, blaming themselves and perceiving emotions and situations as uncontrollable (Nolen-Hoeksema, 2012), enhancing anxiety and other psychopathology risk.

Males tend to engage in suppression of emotions and unwanted thoughts in an attempt to regulate their anxious emotions (Nolen-Hoeksema,2012). This, however, has likewise been implicated with greater psychopathology, as chronic suppression of emotion enhances risk of a wide range of mental health disorders (Nolen-Hoeksema, 2012). When confronting anxiety, men also tend to engage in more problem-solving and reappraisal coping mechanisms, in efforts to control or change their situations. Males have the developmental experience to control and drive their emotions, and tend to engage in this process alone which can be linked to the lower likelihood of males with anxiety. However, in engaging in this type of coping behaviour, males are increasingly likely to abuse substances in efforts to avoid or cope with their "unmanly" emotions, which enhances prevalence of substance-use disorders (Nolen-Hoeksema,2012).

Gender difference theories
Linked to many theoretical underpinnings, gender differences in anxiety are most predominantly explained through biological, psychological and social frameworks. The bio-psycho-social model combines theories from these frameworks and is increasingly identified for its all-encompassing explanation of gender differences while addressing the complexity/variability of anxiety (Chaplin, 2015).

Bio-psycho-social model
This model suggests that gender differences in anxiety result from a combination of innate biological predispositions, psychological processes and social causes, with interaction between these factors enhancing vulnerability to anxiety across genders (Chaplin, 2015).

Biological theories
Different genetic predispositions and biological vulnerability factors have been identified for sexes relative to anxiety (Ohannessian, Milan & Vannucci, 2016). These biological factors increase anxiety susceptibility in girls and women in comparison to men, contributing to the preponderance of females experiencing anxiety (Lewinsohn et al., 1998).



Some of the most significant findings relating to biological differences in gendered experiences of anxiety relate to stress response circuitry, where it has been found that gonadal hormones can enhance or disrupt activity of the hypothalamic pituitary adrenal (HPA) axis, causing differing responses to anxiety and stress across genders (Christiansen, 2015; McHenry, Carrier, Hull & Kabbaj, 2014). One study found that female hormones (oestrogen and progesterone) significantly affect anxiety-related neurotransmitter systems, with hormone fluctuation during the female menstrual cycle affecting HPA axis reactivity (Christiansen, 2015; McHenry et al., 2014). This contributes to significant short- and long-term instability, enhancing stress reactivity and anxiety symptoms and severity in relation to frequent and major feminine hormonal fluctuations (e.g., puberty, pregnancy, menopause). Maeng & Milad (2015) highlight testosterone's protective benefits against anxiety for males, having an anxiolytic effect by inhibiting HPA axis activity and thus reducing male responsiveness to stress and reducing anxiety severity.

These sex difference findings have significant implications in accounting for part of the higher prevalence, severity vulnerability and anxiety sensitivity in females (Christiansen, 2015).

Psychological theories
The theory of Learned Helplessness suggests that a psychological lack of control or mastery presents a critical risk factor for anxiety (Zalta & Chambless, 2012). Chronic exposure to anxiety, and thus perceived uncontrollable situations, enhances expectations that an individual cannot control important events in their environment (Zalta & Chambless, 2012). Considering that females tend to ruminate over anxious or negative emotions, cognitive appraisals of a woman's experience with, and vulnerability to, anxiety promotes perceptions and behaviours reflecting helplessness, hopelessness and lack of control for the future (Madden, Feldman, Barret & Pietromonaco,2010). Rumination intensifies feelings of anxiety and helplessness and intensification of these emotions enhances a woman's lack of sense of mastery and control (Zalta & Chambless, 2012). Mastery, control and independence are instilled in males from a young age, giving them a sense of control over their lives and future environments (McLean & Hope, 2010).

Psychological theories suggest that the gender imbalance in anxiety may be a result of women's vulnerability and inequality/inexperience in social and economic realities. Women report lower instrumentality in comparison to males and thus lack a sense of control over their environments and emotions which significantly enhances their anxiety levels (Zalta & Chambless, 2012).

Women are also far more likely to overestimate the probability of threat, and are impacted by more adverse events than what men are resulting in appraisals that they deserve the negative emotions they are experiencing and that they lack the appropriate coping strategies to reduce their anxiety.

Social-developmental theories
Perhaps the most frequently applied theories to gender differences in anxiety are social theories.

Gender role theory (GRT) and socialisation


Gender roles constitute stereotypical sociocultural roles and expectations which influence the behaviour of each gender (Robinson, Wise, Gagnon, Fillingim & Price, 2004). Bem's (1981) GRT posits that boys and girls are socialised to develop gender consistent socially prescribed/reinforced behaviours, skills and interests (McLean & Anderson, 2009). Girls are taught to be more expressive: expressing their distress, avoiding feared objects and seeking social support; whereas instrumentality is reinforced in boys who are encouraged to suppress their fears/emotion and cope with anxiety, conforming to the masculine role of bravery, control and purposeful coping in anxiety-provoking scenarios (McLean & Anderson, 2009).

Differential reinforcement of gender roles is a common explanation for higher anxiety levels in women (Zalta & Chambless, 2012). This theory correlates with gender-anxiety prevalence, as the focus on less tolerated male anxiety encourages engagement in instrumental behaviours which equip men with the ability to cope with anxiety-related obstacles in life (Chaplin & Aldao,2013). Feminine gender roles, however, don't promote autonomy or mastery, rather emphasising dependency and protection through avoidance and social support (McLean & Anderson, 2009), which doesn't provide a buffer against symptoms of anxiety.

Gender role socialisation is consistent with many aspects of how each gender experiences emotion, particularly in relation to anxiety expressivity (Kring & Gordon,1998). In suppressing their emotions, men are 'prohibited' from expressing their emotions as freely as women do and frequently turn to substance abuse as a coping method as a result (Nolen-Hoeksema, 2012). Despite, in most cases, experiencing the same emotion and symptoms as women, men do not engage in avoidance behaviours to escape anxiety, as this is generally only accepted in females who are 'expected' to engage in this behaviour (Christiansen, 2015). Experience in concealing 'feminine' emotions, such as anxiety, enhances a male's chances at more adaptively handling anxiety, which may reflect the significant gender differences found.

Anxiety is subject to report bias, in that men under-report symptoms and experiences of anxiety (Christiansen, 2015), which has implications for anxiety and development of other psychopathology, as it goes untreated and increases the later burden placed on an individual and society. However, sex differences in anxiety are not just found to be the result of maintaining social desirability. McLean and Anderson (2009) demonstrated that socialisation resulted in actual sex differences in anxiety, with male confrontation of fears promoting exposure and extinction of anxiety responses.

Also, women are more vulnerable to anxiety as a result of gender inequality and division in social, economic settings. This enhances their perceived vulnerability and incapability, while enhancing the types of environmental stressors experienced (Christiansen, 2015).

Implications

 * Is anxiety is a gendered condition?
 * What are the implications of gender differences in anxiety?
 * Can these differences be reduced?

Gender differences in anxiety prevalence and experience present significant implications, concerning the maintenance (stigma), coping mechanisms and treatment efficacy of anxiety. Anxiety is highly comorbid and a symptomatic feature of many other mental health disorders, thus addressing etiological factors in gender differences is crucial to reducing personal and societal burden. Anxiety treatment remains largely indifferent to the evidence of gender differences in etiology and experience of anxiety (Donner & Lowry, 2013). This has significant implications because each gender utilises different strategies for coping with anxiety - which generally contribute to greater anxiety - and also differ in their thought process and self-beliefs about their capability and support network when dealing with anxiety.

Improving upon ineffective, gender-neutral treatments for anxiety is crucial to maintaining long-term recovery from anxiety. Gender differences in development, experience, sense of control and regulation of anxiety need to be addressed in treatment so as to promote healthy, long-term anxiety-free lives. Identifying gender differences in anxiety, and reasons underlying them, has implications for prevention opportunities. Understanding the interaction between biological, psychological and social factors predisposing an individual's vulnerability for anxiety can allow effective methods to be implemented early so as to reduce the chances of development. Such strategies would need to target parents because, as evident from social theories, gender role socialisation occurs from a young age, often by parents, and anxiety differences in gender are evident from the age of 4.

Further implications of understanding gender role differences in anxiety relate to the opportunity to emphasise and target the stigma men face when experiencing and addressing mental health. Most men refuse to seek out mental health services and treatment, even when significantly distressed, as a result of stigma and pressure to abide by masculine roles that men don't need help (Vogel, Wester, Hammer & Downing-Matibag, 2014). Vogel et al. (2014) emphasise the role stigma plays as a predictor of help-seeking in men, and response bias. Men are less likely to address issues, which can lead to untreated psychopathology and anxiety and significantly enhance the debilitating nature and level of distress and impaired functioning experienced by men with mental illness.

"Facing our mental struggles does not diminish our virility as men (or women). We must face our own anxiety. Our trauma does not taint our strength. Stop suffering in silence. Stop stigmatizing mental struggles. We must stop traumatizing the afflicted. Speak up if you are struggling. Get help from trained professionals. Being honest about how we feel does not make us weak, it makes us Human "(Delle, 2017).

Men and mental health

Males face greater mental health stigma than women in society which results in suppressing emotion and mental health issues, denying effective help-seeking (Ellis, 2012, pp.160). The following video (Delle, 2017) highlights mental health stigma men face and the importance of overcoming the discomfort of acknowledging and addressing mental health problems in a society uncomfortable with emotions: Sangu Delle - There's no shame in taking care of your mental health

Finally, identification of gender differences in anxiety has implications for the coping mechanisms adopted in response to anxiety and negative emotions. The majority of the coping strategies used by each gender play a more significant role in exacerbating anxiety or other psychopathology. Focusing on ridding maladaptive coping strategies and teaching adaptive ones is crucial for each gender to successfully live free from the debilitating nature of abnormal anxiety.

{Women most frequently engage in which emotion regulation strategy? - Suppression + Rumination - Drug Use - Exercise
 * type=""}

{Which gender is portrayed as having restrictive emotionality? - Women + Men
 * type=""}

{Which gonadal hormone has been found to have an anxiolytic effect, inhibiting HPA axis activity? - Oestrogen + Testosterone - Progesterone
 * type=""}

Conclusion
In conclusion, gender imbalance in anxiety prevalence requires identification of the gender differences in experiencing and susceptibility to the debilitating disease, through which implications regarding appropriate treatment and outlooks for psychopathology can be improved. Bio-psycho-social factors significantly predict gender differences in anxiety (in expression, reactivity and regulation of anxious emotions), enhancing the vulnerability of women and these differences hold significant implications for treatment efficacy and maintaining mental health stigma and psychopathology/anxiety prevalence worldwide. Addressing the extreme gender differences in anxiety will go a long way to improving the well-being of men and women across the lifespan.