Many women with anxiety disorders have coexisting psychiatric conditions including major depression, substance abuse, eating disorders and other anxiety disorders. These conditions may produce or exacerbate anxiety ⁽²⁾.

1. Generalized Anxiety Disorder (GAD): The prominent feature of GAD is persistent worry (more than 6 months) that is considered excessive and difficult to control. Worry is nonspecific or free-floating but severe and distressful, interfering with sleep, social and domestic behavior, and work. Emotional symptoms include: nervousness, tenseness, irritability, and difficulty concentrating. Physical symptoms are of three types motor/tension (tension headaches, restlessness, difficulty relaxing, easy fatigability), autonomic over-activity (gastrointestinal disturbances, palpitations, sweating, hot flashes, dizziness, frequent micturition), and hyperarousal (irritability, difficulty falling asleep, frequent awakenings, jumpiness). Symptoms are likely to be disproportionate to the physical signs, and they may worsen before the menses.
   
   Onset of GAD often occurs during childhood or adolescence. Prevalence in the general population is 5% to 6%, but this proportion rises to approximately 25% in primary care clinic populations. Genetic factors may play a larger role than environmental factors in GAD development. This disorder is twice as common in women as in men. Also women are more likely to have comorbid dysthymia, which leads to a poorer prognosis and a decreased remission rate.
   
   Treatment: the three main choices are Benzodiazepines (BZs), antidepressants and buspirone. BZs offer quick relief of symptoms, and are appropriate for short-term use. Response to BZs is rapid, sometimes as early as 1 week after starting treatment. After 6 to 8 weeks, the drug should be tapered, but not stopped abruptly. About 50% of patients will not relapse after a short BZ course. The Selective Serotonin Reuptake Inhibitors (SSRIs) are the first-line choice for GAD symptoms. They should be started at 50% of the starting dose for at least a week to avoid exacerbating anxiety. Buspirone also may be useful in treating GAD, especially in patients who do not tolerate SSRIs. Venlafaxine also has been approved for the treatment of GAD. Psychotherapy, use of cognitive-behavior therapy and applied relaxation together has been successful in GAD.
   
   
2. Panic Disorder: This disorder is characterized by recurrent, unexplained attacks of sudden, overwhelming anxiety, fear, and panic, followed by at least 1 month of persistent concern about having another panic attack. A panic attack is a discrete period of intense fear or discomfort in the absence of real danger. Attacks are accompanied by at least 4 of 13 physical symptoms and it can sometimes coexists with agoraphobia, which is anxiety about being in places or situations where it may be difficult to escape or obtain help in the event of a panic attack. Both panic disorder and agoraphobia are more common in women than men. Among women with panic disorder, 50% have comorbid major depression.
   
   Diagnostic and Statistical Manual -IV Criteria for Panic Attack ⁽³⁾:
   1. Palpitations, pounding heart, or tachycardia
   2. Sweating
   3. Trembling or shaking
   4. Sensation of shortness of breath or smothering
   5. Feeling of choking
   6. Chest pain or discomfort
   7. Nausea or abdominal distress
   8. Feeling of dizziness, unsteadiness, lightheadedness, or fainting
   9. Derealization or depersonalization
   10. Fear of losing control or "going crazy"
   11. Fear of dying
   12. Paresthesias
   13. Chills or hot flashes
   
   
   Treatment: appropriate medication promotes a better response rate in proportion to the duration of treatment. For this reason patients with panic disorder are generally treated for 6-18 months. The SSRIs are the drugs of first choice. Although Tricyclic Antidepressants (TCAs) and Monoamine Oxidase Inhibitors (MAOIs) may be beneficial, they have limitations. Benzodiazepines (BZs) are good adjuvant for the patients with severe symptoms until stabilization with and antidepressant occur. However, they should be given on a scheduled basis rather than just as needed when a panic attack occurs. Psychotherapy, use of cognitive-behavior modification alone of with pharmacotherapy is extremely effective in treating panic disorder. It is likely to be most helpful for symptoms of agoraphobia.
   
   
3. Social Anxiety Disorder: This disorder is also known as social phobia. It is marked by persistent fear of being observed and evaluated by others. It is most common anxiety disorder in both men and women. It is manifested by strong efforts to avoid social or performance situations in which embarrassment or humiliation may occur. Patients avoid public speaking, performing, social events, meeting new people and dating. This lead to low self-esteem and patients has decrease social and occupational functioning. Women are 2-3 times more likely than men to develop social anxiety disorder, but they are less likely to seek treatment. Women may be less motivated to discuss their symptoms with their physician, which increases the likelihood that the disorder will go unrecognized and untreated. Social anxiety disorder typically manifests with physical symptoms of blushing, stuttering, tremulousness, heart palpitations, "butterflies in the stomach", and/or excessive sweating of the hands or feet. It usually arises in childhood, but may simply be labeled as "shyness". Approximately 70% of patients with social anxiety disorder develop at least one other psychiatric illness.
   
   Treatment: the SSRIs are the agents of choice in treating social phobia, although MAOIs and BZs are also effective. The TCAs are relatively unproven in this condition. Newer approaches include venlafaxine, nefazodone, and gabapentin. In specific social anxiety disorder, small doses of a beta-blocker before the phobic situations may help. Improvement usually occurs within 2 months, but some patients may need longer treatment to achieve full remission. In fact, an international consensus panel has recommended that treatment should last at least 1 year ⁽⁴⁾. Psychotherapy: use of cognitive-behavior therapy is effective in treating both the generalized and specific forms of social phobia. Social-effectiveness training can help patients who never acquired these skills secondary to social isolation. Self-help programs, such as Toastmasters, a national organization to improve public speaking skills, are also available.
   
   
4. Obsessive-Compulsive Disorder (OCD): It is a chronic, disabling condition that often begins in childhood. It is characterized by recurrent, persistent obsessions, impulses, or images that are intrusive, inappropriate, and anxiety-provoking. Obsessions usually center on danger or risk of harm; typical examples include fear of contamination, obsession with order and symmetry, pathologic doubt, and recurrent horrific images. Patients often perform compulsive rituals to mitigate the anxiety resulting from these obsessions. Attempts to resist performing these rituals heighten the anxiety. An important diagnostic hallmark of OCD is the patient's acknowledgement that the rituals are unreasonable but irresistible. Common rituals such as hand-washings, counting, and checking may be performed for hours each day. Patients may try to conceal the rituals to avoid embarrassment. Women are twice more likely than men to develop OCD.
   
   Treatment: the SSRIs have become the treatment of choice for OCD. Clomipramine is a good second choice if patients fail an SSRI trial. Onset of improvement is slow, often 10-12 weeks. Treatment should be prolonged (at least 1 to 2 years, possible indefinitely) to avoid relapse. Full remission is rare, and adjuvant agents may be needed. The BZs are not suitable for OCD; and exception is clonazepam, which has been useful as an adjuvant. For intractable symptoms, low-dose quetiapine may be useful. Psychotherapy, use of cognitive-behavior therapy alone or combination with pharmacotherapy, plays a crucial role in managing OCD.
   
   
5. Post-Traumatic Stress Disorder (PTSD): It is in response to an experienced or witnessed life-threatening trauma. They suffer a triad of clinical features: reexperiencing the trauma through intrusive thoughts, nightmares, or flashbacks; autonomic arousal manifested by insomnia, hypervigilance, and an inability to relax; and avoidance of reminders of the trauma, with emotional numbing and social withdrawal. Onset may occur shortly after the traumatic event, or it may be delayed. In the acute form, symptoms remit within 1 month; in the chronic form, symptoms persist for more than 3 months.
   
   Women are twice as likely as men to experience PTSD symptoms after a trauma (usually a physical or sexual assault). During the interview, it is important to ask about domestic violence as PTSD is common in battered women ⁽⁵⁾. As many women are ashamed to discuss their traumatic experiences and symptoms, PTSD can easily be missed in the clinical setting. To elicit such information, physicians must ask questions in a sensitive manner and then listen carefully to patients' responses.
   
   Treatment: the SSRIs are the first-line drugs for PTSD, but TCAs, MAOIs, nefazodone, and mirtazapine have been shown to be beneficial. Buspirone and BZs such as clonazepam are useful in patients with hyperarousal. The antiseizure drugs carbamazepine and valproic acid also have been helpful. The antipsychotics olanzapine and risperidone have been useful in reducing PTSD symptoms as well. Various types of psychotherapy have helped patients with PTSD. Psychological debriefing, exposure therapy, cognitive-behavior therapy, and eye-movement desensitization and reprocessing have been helpful. Victims of domestic and/or sexual violence should be directed to support services.