Epidemiology Panic disorder without agoraphobia is twice as common in women as it is in men; panic disorder with agoraphobia is three times more common in women (149). Onset is generally in young adulthood, often following a stressful event. The lifetime prevalence is 1.5% to 3.5%; the 1-year prevalence is 1% to 2%. A substantial percentage of patients experience depressive episodes as well. Phobias are somewhat more common in women, depending on the object of the phobia. The 1-year prevalence is 9%, and the lifetime prevalence is 10% to 11%. Obsessive-compulsive disorder is equally common in women and men, with evidence of familial transmission. Prevalence is 2.5% for lifetime and 1.5% to 2.1% for 1 year. Posttraumatic stress disorder has a lifetime prevalence of 1% to 14%; victims of violence (including child abuse and wife battering) and war are at increased risk. Men and women differ in the types of violence to which they tend to be exposed. Rape, for example, poses a similarly high risk of PTSD in both men and women, but women are more often the victims of rape (149).
Assessment Given the relationship between anxiety disorders and traumatic experiences, the presence of signs and symptoms of anxiety disorders should trigger inquiries about abuse (146,147). Before making attempts to treat these disorders, it is important to know how long the patient has suffered from the disorder, what previous attempts were made to diagnose and treat it, and the effect it had on her psychological development, life choices, lifestyle, and relationships. In some cases, the entire family will have organized their schedules and activities around the patient’s symptoms and limitations; they may not volunteer this information.
Management Treatment should not be limited to antianxiety medications. Managing, even tolerating, patient anxiety is an anxiety-provoking process; anxiety is contagious and raises the specter of unlimited demands on the gynecologist’s time and energy. Prescribing medication is a familiar and comfortable, if not optimal, way to end a medical interview. Overprescribing benzodiazepines is a cause for medical and media concern. It is useful to defer the administration of anxiolytic medications until the impact of the physician’s support and interest can be assessed (150). Treatment should address the effects on the patient’s life and family and the signs and symptoms of the specific disease (151).
Benzodiazepines are most useful in acute situations (150). Use can quickly become chronic, with escalating dosages, diminishing therapeutic effects, and increasing demands on the physician. Women taking benzodiazepines may forget to include them in their medical history. When admitted to the hospital, they may suffer unrecognized withdrawal symptoms, complicating their treatment, or may continue to take medications from a personal supply without informing the medical staff (150).
There are many patients who could benefit from anxiolytics but who are inordinately worried about becoming dependent or addicted. A patient with no history of addictive behaviors is unlikely to get into trouble with a standard dose of medication (156,157). It is important to ascertain the source of anxiety or obsessive behavior. Many patients and their families are anxious because of misinformation or misunderstanding about a medical problem or treatment. Few patients can absorb all the information about significant gynecologic conditions at a single visit, but many feel that asking questions will burden the physician or make the patient appear stupid. Patients suffer anxiety when there is disagreement among family members or medical staff about the diagnosis or recommended treatment. Many patients dread certain aspects of care, sometimes on the basis of past experience or outdated information (157). A simple explanation or alteration in procedure can alleviate the anxiety. For example, a reassuring family member or friend can be allowed to stay with the patient during a diagnostic test, sedation can be administered orally or by inhalation before an intravenous line is inserted, or the patient can be allowed control over her own analgesia.