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Anxiety during the menopausal transition: A systematic review
Journal of Affective Disorders 139 (2012) 141–148
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Journal of Affective Disorders j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j a d
Review
Anxiety during the menopausal transition: A systematic review Christina Bryant a,⁎, Fiona K. Judd b, Martha Hickey c a b c
Psychological Sciences, University of Melbourne and Royal, Women's Hospital, Parkville, Vic, 3052, Australia University of Melbourne Department of Psychiatry and Director, Centre for Women's Mental Health, Royal Women's Hospital, Parkville, Vic, 3052, Australia University of Melbourne and Royal Women's Hospital, Parkville, Vic, 3052, Australia
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Article history: Received 10 May 2011 Received in revised form 29 June 2011 Accepted 29 June 2011 Available online 23 July 2011 Keywords: Anxiety Menopause Midlife Vasomotor symptoms
Objective: There have been relatively few studies of the relationship between anxiety and menopause. Despite the paucity of clear evidence, some authors have suggested that the menopausal transition is a time of heightened risk for onset or exacerbation of anxiety symptoms. There is also controversy as to whether anxiety predates or is a consequence of hot flashes. The aim of this paper is to examine the evidence as to the relationship between menopause and anxiety, and between anxiety and hot flushes, one of the core symptoms of menopause. Method: A systematic review was undertaken based on literature published between 1960 and 2011, using the Medline, Web of Science and PsychINFO databases. The key terms ‘anxiety’, ‘anxiety symptoms’, ‘anxiety disorder’, ‘menopause’, ‘menopausal transition’, ‘midlife’, ‘hot flushes or flashes’ and ‘vasomotor symptoms’ were entered into the search. Studies were included if they reported original research using a clearly described measure of anxiety or investigated the relationship between anxiety and vasomotor symptoms. Results: Nine studies reporting the relationship between menopause and anxiety, two studies reporting the prevalence of panic disorder, and eight studies investigating the relationship between anxiety and vasomotor symptoms were identified. Overall, anxiety symptom levels were low throughout the menopausal transition, but the studies were characterised by poor measurement of both menopausal status and anxiety symptoms and relied heavily on the use of brief, largely nonvalidated measures of anxiety symptoms, which are of unknown clinical significance. In the studies that also measured factors such as attitude to menopause, and dispositional optimism or changes in family life these emerged as important predictors of vasomotor symptom severity. Conclusions: None of the available studies provides solid data on the prevalence of anxiety disorders that meet diagnostic criteria, and the present state of knowledge does not be no justify the inclusion of “menopausal anxiety” as a reproductive-related disorder. With respect to the relationship between hot flashes and anxiety, studies need to ensure that somatic and psychological symptoms are not confounded by the use of unsuitable anxiety measures, and that psychological variables are given serious consideration. © 2011 Elsevier B.V. All rights reserved.
Contents 1. 2. 3.
Introduction . . . . Method . . . . . . . Results . . . . . . . 3.1. The prevalence
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⁎ Corresponding author. E-mail addresses: [email protected] (C. Bryant), [email protected] (F.K. Judd), [email protected] (M. Hickey). 0165-0327/$ – see front matter © 2011 Elsevier B.V. All rights reserved. doi:10.1016/j.jad.2011.06.055
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3.2. The relationship 4. Discussion . . . . . . 5. Conclusions . . . . . Role of the funding source . Conflict of interest . . . . Acknowledgements . . . . References . . . . . . . .
C. Bryant et al. / Journal of Affective Disorders 139 (2012) 141–148
between anxiety and hot flashes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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1. Introduction One of the most consistent findings in psychiatry and psychology is that from menarche onwards females are at higher risk than males of developing both depressive and anxiety disorders (Bebbington et al., 1998). This sex difference remains robust throughout the lifespan, including old age, in the years beyond the reproductive period (Bebbington et al., 2003; Singleton et al., 2000). The widely reported association between puberty, the perinatal period, and menopause and higher levels of anxiety and depressive symptoms has led some authors to propose the construct of Reproductive Related Disorders (RRDs) (Halbreich, 2003). These disorders are said to comprise a group of diagnostic entities characterised by their link to reproductive processes and a maladaptive response by women described as being “genetically vulnerable” to normal hormonal changes (Halbreich, 2003). Others have questioned not only the validity of such a construct, but also, with respect to menopause, whether the marked cross cultural differences in menopausal symptoms support this hypothesis (Avis et al., 2001). The association between depression and menopause has been extensively explored, but the study of anxiety remains largely neglected (Maki, 2008; Soares, 2011). This is surprising, since symptoms of anxiety in the community are more common than those of depression (Singleton et al., 2000), and Generalised Anxiety Disorder (GAD) is the second most prevalent psychiatric disorder in the primary care setting (Maier et al., 2000). Natural menopause is thought to occur due to exhaustion of ovarian follicles and occurs at a mean age of 51 years in Western societies (Dratva et al., 2009). Menopause is defined retrospectively by the absence of menstruation for 12 months. With an ageing society, increasing numbers of women are living for decades following menopause. Around 80% of women experience vasomotor symptoms (hot flushes and night sweats, VMS) at menopause, of which around 20% find these symptoms sufficiently troublesome to require treatment (Hunter and Rendall, 2007). Menopause may also be associated with psychosocial adjustment to issues such as loss of fertility and changing family roles (Dennerstein et al., 1994; Hardy and Kuh, 2002). This systematic review provides a critical survey of the literature on the association between anxiety and menopause and examines the implications of this for future research and for clinical intervention. There are two prominent themes: first, the relationship between anxiety and menopause and secondly, the relationship between anxiety and vasomotor symptoms. This is of theoretical and clinical interest as it may highlight mechanisms by which the two may be related, and
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may also inform therapeutic interventions for menopausal symptoms (e.g., Hunter and Liao, 1996). 2. Method Published studies between 1960 and 2011, using the Medline, Web of Science and PsychINFO databases using the key terms ‘anxiety’, ‘anxiety symptoms’, ‘anxiety disorder’, ‘menopause’, ‘menopausal transition’, ‘midlife’, ‘hot flushes or flashes’ and ‘vasomotor symptoms’ were searched. Articles were also obtained by through publishers' email alerting services and manual searching of references identified in the articles obtained. One hundred and ninety-eight articles were sourced, but most were clinical studies of menopause symptom management. Included studies were in English, reported original research using a clearly described measure of anxiety, and investigated either the prevalence or severity of anxiety during both natural and induced menopause, or the relationship between anxiety and vasomotor symptoms. ‘Anxiety’ is a general term that can obscure the important distinction between anxiety symptoms and anxiety disorders. Anxiety encompasses diverse symptoms such as feeling on edge, worrying, specific fears, and physiological arousal, and these may be distressing to the individual in their own right. Anxiety disorders, however, are defined by reference to specific criteria, and have much lower prevalence than anxiety symptoms. The majority of the studies reviewed measured anxiety symptoms, rather than anxiety disorder. Nine studies reporting the relationship between menopause and anxiety symptoms, two studies reporting the prevalence of an anxiety disorder, namely panic disorder (PD), and eight studies investigating the relationship between anxiety symptoms and VMS were identified. 3. Results 3.1. The prevalence of anxiety during the menopausal transition Table 1 reports the findings from the studies of anxiety prevalence identified using the search strategy described above. A common feature of these nine studies is the widespread use of single-item or other non-validated measures of anxiety. Only four studies used validated measures of anxiety symptoms (Bauld and Brown, 2009; Calvaresi and Bryan, 2003; Li et al., 2008; Tangen and Mykletun, 2008), and no two used the same measure, thus making direct comparison impossible. Only the study by Li et al. (2008) used a validated measure, namely the Zung Anxiety Inventory (ZAI, Zung, 1971), and reported anxiety prevalence; two studies (Bauld and Brown, 2009), and Tangen and Mykletun (2008) using the DASS
Table 1 Studies measuring anxiety symptoms or disorder during the menopausal transition. Sample
Design
Anxiety measure
Findings
Avis et al. (2001)
14,906 aged 40–55 from five racial/ethnic groups
Cross-sectional questionnaire (SWAN Study)
51.9% of women reported feeling ‘tense or Caucasian women reported higher levels of nervous’, 51.6% reported feeling irritable. psychosomatic symptoms
Bauld and Brown (2009)
116 volunteers aged 34–55
Cross-sectional questionnaire
3 questions on feeling ‘tense or nervous’, ‘irritable or grouchy’ or ‘heart pounding’. DASS
Bromberger et al.(2001)
10,347 women experiencing natural pre-, peri- and postmenopause, aged 40–55 from five racial groups 766 women, aged 39–65; 451 men
Cross-sectional questionnaire (SWAN Study) at first data collection timepoint Cross-sectional populationbased questionnaire
Calvaresi and Bryan (2003) Freeman et al. (2005)
404 pre-menopausal women at baseline, population-based cohort
Li et al. (2008) Moilanen et al. (2010)
1280 women in Beijing, aged 45-59 1427 Finnish women aged 45–64
Rocca et al. (2008) Tangen and Mykletun (2008)
666 women aged b 45who had undergone BO 10,370 pre-,peri- and post menopausal women
Mean scores: anxiety= 2.85 (S.D., 3.36); stress= 5.46 (S.D., 4.24)
See Avis et al. (2001). Psychological distress defined as experiencing all 3 symptoms in the previous 2 weeks.
24.1% of women reported psychological distress.
STAI
Overall STAI scores not reported
Comments
Both these scores are in the normal range, but were positively correlated with attitude to menopause and worse menopausal symptoms. Rates of distress were highest in peri-menopausal group, and still held after accounting for VMS and sleep difficulties.
Compared with men, women reported higher levels of psychological symptoms but similar levels of somatic complaints. 24% of women reported ‘severe anxiety’ Self-assessed frequency and severity Prospective study with up Women with current depression excluded. of anxiety (rated 1–4) in the last to six follow-up points in the early MT, 19% in the premenopausal Perceived stress, history of PMS, and history of month (Penn Ovarian Aging Study) depression were strong predictors of anxiety. period and 16% in postmenopausal period (NS) Cross-sectional ZAI 10.2% prevalence of anxiety (defined as Anxiety was not related to menopausal stage, questionnaire standard score N 0.5) but hot flashes and history of PMDD increased risk. Very low levels of anxiety symptoms e.g., Authors conclude that ‘bothersome’ symptoms are Cross-sectional health survey, Home interview, self-administered common in mid-life irrespective of menopausal stage, community sample questionnaire that included 4 questions ‘nervousness’= 5.3% in pre-menopausal women, 6.6% in perimenopausal and 8.9% and strongly associated with lifestyle factors, such as on anxiety symptoms (nervousness, overweight, high alcohol use and sedentary lifestyles. in postmenopausal women irritability, trembling and heart palpitations) Longitudinal follow-up Anxiety symptom measures designed Risk of anxiety symptoms doubled in Anxiety not assessed with a validated measure. over 24 years for this study BO women (OR2.66; 95% CI, 1.04–2.26) These scores are all within the normal range. Cross sectional communityHADS Mean anxiety score =4.5 in dwelling sample pre-menopausal women, 5.0 in perimenopausal women and 4.8 in postmenopausal women.
C. Bryant et al. / Journal of Affective Disorders 139 (2012) 141–148
Authors
Notes : BO = bilateral oophorectomy; DASS = Depression, Anxiety and Stress Scales; HADS = Hospital Anxiety and Depression Scale; HAM-A = Hamilton Anxiety Rating Scale; MT = Menopausal transition; NS = Not significant; PMDD = Pre-menstrual dysphoric disorder; PMS = Premenstrual syndrome; SCL-90 = Symptom Check List; SCID = Structured Clinical Interview for DSM-IV-TR; STAI = Spielberger State-Trait Anxiety Inventory; SWAN = Study of women's Health Across the Nation; VMS = Vasomotor symptoms; ZAI = Zung Anxiety Index.
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(Lovibond and Lovibond, 1995) and the HADS (Zigmond and Snaith, 1983) respectively, reported levels of anxiety symptoms. Calvaresi and Bryan (2003) used a validated measure of anxiety, the STAI (State-Trait Anxiety Inventory, Spielberger et al., 1983) but did not report overall STAI scores, only their correlation with other variables. In all these studies, the anxiety symptom levels reported were in the normal range. The study by Tangen and Mykletun (2008) has a number of strengths, in that it used a widely-used measure of anxiety, the HADS, and a large population-based sample. The authors did find increased scores on the anxiety measure as women became perimenopausal, and decreased scores in the post-menopausal period, but it is noteworthy that these differences were neither statistically significant, nor did the scores ever reach a level suggestive of an anxiety disorder. One study reported the prevalence of a specific anxiety disorder (panic disorder) assessed with a diagnostic instrument, namely the SCID (Structured Interview for DSM-IV, First et al., 1996; Pacchierotti et al., 2004), and these authors highlight the overlap of the symptoms of panic disorder (PD) with vasomotor symptoms. This case–control study of panic disorder in a small sample (N = 45) of women attending a menopause clinic reported that 18% of the participants had PD, of whom 62% reported onset of PD at the commencement of menopause, and 38% reported worsening of symptoms at this time. The authors do not specify how commencement of menopause was defined, but it appears to have relied on the participants' recall, and no specific criteria were used. It is perhaps not surprising that in this self-selected group, a higher level of symptomatology was found than would be expected in menopausal women in general. A study by Smoller et al. (2007) used a very large community-based sample (N = 3369 post-menopausal women aged 51–83), but relied on a retrospective questionnaire of panic attacks in the last six months. Moreover, by choosing a post-menopausal sample, the authors missed periand early menopausal women, who have been thought by some authors to be at the greatest risk of developing anxiety symptoms (Freeman et al., 2005; Tangen and Mykletun, 2008). The authors reported a 10% prevalence of panic attacks across this very wide age spectrum, and found that women with panic attacks had an increased risk of coronary heart disease and stroke. It should be stressed, however, that experiencing panic attacks, whilst distressing, is not sufficient to meet criteria for panic disorder. The current literature is characterised by poor measurement of both menopausal status and anxiety symptoms. In summary, it relies heavily on the use of brief, largely nonvalidated measures of anxiety symptoms, which are of unknown clinical significance, and overall symptom levels are low. If anxiety symptoms during the menopausal transition are little different from population norms, it is highly unlikely that anxiety disorders, diagnosed with a validated measure or clinical interview, would be more prevalent during menopause than before or after. It is therefore not surprising that the findings of these studies are inconsistent when the studies reported use widely different populations and measures of both menopausal status and anxiety. Some studies report that levels of anxiety symptoms rise during the perimenopausal period, and then fall (Avis et al., 2001; Bromberger et al., 2001; Tangen and
Mykletun, 2008). Others report that anxiety was not related to menopausal stage (Li et al., 2008; Moilanen et al., 2010). All noted the importance of variables other than hormonal status: for example, Freeman et al. (2005) found that prior history of depression and perceived stress were strong predictors of anxiety, whilst Moilanen et al. (2010) emphasised the role of lifestyle factors, such as being overweight, being sedentary, and high alcohol consumption. General statements about the likelihood of anxiety at menopause, e.g. “women will encounter some other serious problems, such as depression and anxiety when they enter menopause” are not justified by the existing literature (Li et al., 2008, p 238, italics mine). A more nuanced understanding of anxiety during the menopausal transition is required in order to further explore this, and one factor that may hold the key to this is the association of anxiety symptoms with vasomotor symptoms.
3.2. The relationship between anxiety and hot flashes Hot flashes are a core symptom of menopause, together with night sweats, sleep disturbance and vaginal dryness. Around 74% of naturally menopausal women report experience hot flashes (von Muhlen et al., 1995). There is considerable variation within cultures and between cultures in the nature, severity and impact on quality of life of VMS. African American women report more severe VMS and Asian women less severe VMS than their Western counterparts, a difference that has been accounted for in a number of ways, including intrinsic racial differences (Avis et al., 2001), genetic differences (Rebbeck et al., 2010), as well as the contribution of cultural differences in the value attributed to ageing (Shea, 2006). There are physical similarities between anxiety symptoms, particularly panic attacks and VMS. These include rising sensations of heat through the chest and head, palpitations, and sweating associated with increased metabolic rate and noradrenergic dysregulation (Hanisch et al., 2008). It is not clear, however, whether sensations of anxiety precede VMS or vice versa. Studies examining the relationship between anxiety and VMS are summarised in Table 2. A number of methodological problems undermine the credibility of published studies: for example, the Zung Anxiety Index, used by Freeman at al. (2005) and Lermer et al. (2011) has a strong somatic focus which may skew reporting of anxiety in those with VMS (Soares, 2011). Measures that confound physical and psychological symptoms will not be able to distinguish the somatic aspects of anxiety from vasomotor symptoms. Whilst some studies do report an association between bothersome hot flashes and anxiety symptoms, these studies (e.g., Gold et al., 2006; Seritan et al., 2010) have used weak measures of anxiety. The study by Freeman et al. (2005) reported that women with high anxiety were five times more likely to report hot flashes than women with anxiety scores in the normal range. Measurement of hot flashes, however, was by means of menopause symptom checklist, and there was no corroboration of this self-report against an objective measure of vasomotor activity. When well validated measures of anxiety (e.g. the STAI) are combined with objective measures of VMS (skin conductance) (Thurston et al., 2005, 2006) a more complex picture emerges. For example, women with higher levels of anxiety are more likely to make false-
Table 2 Studies that examined the relationship between anxiety and vasomotor symptoms. Participants
Measures
Findings
Comments
Elavsky and N = 164; aged 42–58; McAuley (2009) women with low PA levels rectuited to a PA study Freeman et al. 436 pre- and peri(2005) menopausal women, aged 35–47
Random assignment to 4-month physical activity intervention or wait-list control Prospective study with up to eight follow-up points (Penn Ovarian Aging Study)
GCS, IPIP, LOT, STAI
Authors concluded that reporting of symptoms partially explained by factors such as personality and dispositional optimism, and may be amenable to physical activity interventions. Anxiety scores decreased over time, but authors do not report actual prevalence of anxiety in the sample.
Gold et al. (2006)
2784 women, age 42–52 at baseline, multi-racial from 7 sites in US
Prospective study (SWAN) with up to five follow-up points
Hardy and Kuh (2002)
N = 1572; aged 47–52; community sample
Limited relationship observed between psychological symptoms and menopausal symptoms. Higher levels of psychological symptom reporting in HRT users.
Assessment of psychological symptoms based on a scale containing only 4 items.
Lermer et al. (2011)
N = 80; aged 50–64; all postmenopausal; volunteer sample
MRC National Survey of Health and Development cohort study of people born in 1946; measures taken yearly for 6 years Observational study
Self-report of VMS; anxiety measured by the number of days in the past two weeks when symptoms (irritability, tense/nervous, racing heart, fearful for no reason) had been experienced Symptom checklist including items for anxiety, panic, fearfulness, hot flashes and night sweats
Correlations between optimism and VS at baseline. After intervention, increased physical activity associated predicted reduced VS. Anxiety significantly associated with hot flashes. Women with moderate anxiety scores three times more likely to report hot flashes, and those with high anxiety scores, five times more likely to report hot flashes Baseline anxietyb 4 in 23% of Whites, 24% in African Americans, 36% in Hispanics, 14% in Chinese, 13% in Japanese.
ZAI; 7-day hot flash diary
Higher scores on the somatic, but not on the affective, anxiety subscale predicted more severe and frequent VS.
Seritan et al. (2010)
N = 487; aged 40–64; pre, peri- or postmenopausal N = 42; aged 40–60; peri- or postmenopausal community volunteers.
Retrospective chart review of clinical sample Two days of sternal skin conductance monitoring, behavioural dairies 3× per hour, questionnaires
Anxiety assessed with yes/no response to: “I feel more anxious than usual”; reporting of VMS; NAMS STAI, BDI-II, ATM, DSI, SCL-90-R
N = 52 peri and postmenopausal women;; aged 40–60
Observational study of hot flashes and sleep disturbance using skin conductance monitor; self-report questionnaires
BDI-II, DSI, STAI, SWEL
Self-reported anxiety was 15% in premenopausal, 11% in perimenopausal and 6% in postmenopausal groups STAI scores within population norms, attitudes to menopause relatively neutral. Objective hot flashes were more likely after recording positive emotion (happiness and relaxation) and after physical exertion. No relationship between depression, trait anxiety or daily stress and hot flashes during sleep.
The anxiety scores only predicted 27.35% of the variance in VS. Authors suggest that relationships between anxiety and VS may be due to the overlap of somatic symptoms of anxiety and VS. Women reporting bothersome hot flashes more likely to report anxiety symptoms
Thurston et al. (2005)
Thurston et al. (2006)
Self-report measure of severity and frequency of hot flashes; Zung Anxiety Index
Scores ranged from 0 = no days to 4 = every day. Anxiety at baseline was strongly associated with VMS in all ethnic groups except Hispanics. VMS peaked in the late peri-menopausal period
Women with more positive attitudes to menopause had more hot flashes. Women with higher anxiety levels had higher false-negative reporting of hot flashes.
C. Bryant et al. / Journal of Affective Disorders 139 (2012) 141–148
Methodology
Sleep disturbance unrelated to sleep hot flashes, but psychological variables were related to self-reported sleep problems.
Note: ATM = Attitudes Towards Menopause; BDI-II = Beck Depression Inventory (2nd edition); DSI = Daily Stress Inventory; GCS = Green Climacteric Scale; IPIP = International Personality Item Pool; LOT = Life Orientation Test; PA = physical activity; NAMS = North American Menopause Society Menopause Health Questionnaire; STAI = Spielberger State-Trait anxiety Inventory; SCL-90-R = Hopkins Symptom Checklist, revised; SWEL = Sleep Wake Experience List; ZAI = Zung Anxiety Index.
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negative reports of hot flushes. There was no overall relationship between scores on the STAI and hot flashes. These inconsistent results question the existence of a direct relationship between the severity of vasomotor symptoms and anxiety symptoms. It also remains unclear whether anxiety symptoms predate or follow VMS. The perceived severity of VMS is affected by attitude to menopause, and dispositional optimism (Elavsky and McAuley, 2009) or changes in family life (Hardy and Kuh, 2002), suggesting that there are a number of psychological variables that are important in understanding the association between anxiety and hot flashes. It is likely that a conceptual model of hot flashes needs to incorporate a range of explanatory psychological variables, encompassing not only contextual factors such as stressful events, but also cognitive factors. 4. Discussion We aimed to review the association between anxiety and the menopausal transition, and to critically examine the role of anxiety in relation to hot flashes. The small number of studies identified confirms that the neglect of anxiety relative to disorders such as depression evident in other age groups (Bryant et al., 2008), also applies to women in midlife. The hypothesis that anxiety levels rise during the menopause transition and fall after menopause is widely proposed (Bromberger et al., 2001; Freeman et al., 2005). This hypothesis is not supported by the published literature. Studies of anxiety at menopause are largely limited by poor measurement of anxiety and/or vasomotor symptoms, and those studies that used validated measures of anxiety report anxiety scores that are within the normal range. Moreover, some measures of anxiety with a strong somatic component, for example the ZAI, as used by Li et al. (2004) and Freeman et al. (2005) may very well be tapping into symptoms attributable to hot flashes and scoring vasomotor symptoms as anxiety symptoms. There may be an increase in anxiety symptoms at menopause, but this has not yet been clearly demonstrated. Even less is known about the prevalence or severity of anxiety disorders during the menopause transition. The current literature based on large community based studies suggests that psychological symptoms during the menopause transition are associated with known risk factors for anxiety and depression, including stressful life events (Hardy and Kuh, 2002; Moilanen et al., 2010). It has been argued that there is a subgroup of women who may be at increased risk of psychological disorder during the menopause (e.g., Halbreich, 2003), but it seems premature to suggest that anxiety disorders would be candidates for inclusion in this. Moreover, other studies have questioned the association of psychological symptoms with the menopause per se. For example, Hardy and Kuh (2002) argued that psychological symptoms were not related to oestrogen level changes. These findings were based on an analysis of data from the UK 1946 cohort study, which suggested that psychological symptoms were more related to current life events and difficulties than menopausal status in a large sample (N =1572) of community dwelling women. A similar conclusion was reached by Moilanen et al. (2010) on the basis of findings from a community-based cohort in Finland. This highlights the complexity of the relationship between menopause and anxiety, which is further
demonstrated in the studies that have examined the relationship between anxiety and hot flashes. Hunter and Mann (2010) have proposed a cognitive model of hot flashes that integrates a number of biological, environmental and psychological variables. Whilst not ignoring menopausal status, Hunter and Mann propose that the experience of hot flashes is shaped by individual differences in symptom perception, cognitive appraisals of those symptoms, and beliefs about menopause. One aspect of symptom perception is anxiety sensitivity, which has been widely studied in relation to the aetiology and maintenance of a number of anxiety disorders. In light of the parallels between menstrual symptoms and panic attacks (dizziness, sweating and heart pounding), the construct has been applied to women with high levels of menstrual symptom distress. Sigmon et al. (2000) reported that women with higher levels of anxiety sensitivity reported higher levels of distress about menstrual symptoms, which then supports the role of beliefs and expectations in symptom experience. Anxiety sensitivity has not been examined in relation to hot flashes, but may have a role in explaining greater distress with regard to vasomotor symptoms. Another cognitive variable that may be relevant for understanding the relationship between anxiety and vasomotor symptoms is that of catastrophic thinking. It is well established that catastrophic thinking has an adverse effect on perceived symptom severity in chronic health conditions. Women who report more catastrophic thoughts also tended to report lower perceived control over their hot flashes Reynolds (2000). Whilst caution must be exercised in interpreting the results of a study with a relatively small sample of volunteers, it is supportive of the important role of cognition and symptom attribution in understanding the experience of hot flashes. These factors, and others, are considered in depth by Hanisch et al. (2008). These authors compared the symptomatology, neurobiology and biochemical mechanisms of hot flashes and panic attacks, in order to develop an integrative conceptual model of these two phenomena. They emphasised that hot flashes are a normal part of the menopausal transition, and most women neither desire nor require treatment for them. Similarly, not all individuals who experience one or two panic attacks will develop panic disorder. Whilst all hot flashes have certain shared physical symptom in common, it is the subjective interpretation of these symptoms that will influence whether they are associated with intense distress or anxiety. Their model incorporates both physical and psychological mechanisms, including factors such as anxiety sensitivity and symptom appraisal. This is consistent with the work of Thurston et al. (2005, 2006) which suggested that one of the important ways in which negative affect influenced hot flash experience was through a tendency to inaccurate interpretations of physical sensations. Models, such as those of Hunter and Mann (2010), or of Hanisch et al. (2008), sit within a broader literature that has sought to understand psychological aspects of physical symptoms. For example, Deary et al. (2007) proposed a model for understanding medically unexplained symptoms through the proposed roles of symptom perception, somatic focus and symptom attribution. Studies of pain also draw on
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psychologically complex models to understand the marked differences in individuals' responses to their pain and associated disability (e.g., Keefe et al., 2004). Given the complex interplay of psychological and physical symptoms during the menopausal transition, such models seem obvious candidates for helping us to move the field forwards, both clinically and in generating hypothesis-driven research. 5. Conclusions Published research on the relationship between anxiety and the menopausal transition has tended to use inadequate measures of anxiety, and to infer high levels of “anxiety” from the large number of women who endorse feeling “tense or stressed” during the preceding week or month. These results are open to serious misinterpretation. Future research should use well-validated, preferably diagnostic instruments. Given that none of the available studies provide solid data on the prevalence of anxiety disorders that meet diagnostic criteria, there can be no justification for the inclusion of “menopausal anxiety” as a reproductive-related disorder. With respect to the relationship between hot flashes and anxiety, studies need to use objective as well as subjective measures of VMS and ensure that somatic and psychological symptoms are not confounded by the use of unsuitable anxiety measures. Symptom attribution and cognitions about the meaning of symptoms are likely to influence perception of VMS. Studies of psycho-educational or cognitive-behavioural interventions for menopausal symptoms show promise. Some of these have used behavioural techniques, such as breathing training, temperature regulation, and cognitive coping strategies (Hunter and Liao, 1996). Further study is required to ascertain whether approaches geared to reducing anxiety sensitivity, and decatastrophising beliefs about the unpleasantness of hot flashes may also be beneficial. Role of the funding source The funding sources had no role in the content of this article. Conflict of interest The authors have no conflict of interest to declare. Acknowledgements The Centre for Women's Mental Health is supported by the Pratt Foundation. Martha Hickey is supported by an NHMRC Clinical Career Development Award.
References Avis, N., Stellato, R., Crawford, S., Bromberger, J., Ganz, P., Cain, V., KagawaSinger, M., 2001. Is there a menopausal syndrome? Menopausal status and symptoms across racial groups. Soc Sci Med 52, 345–356. Bauld, R., Brown, R., 2009. Stress, psychological distress, psychosocial factors, menopause symptoms and physical health in women. Maturitas 62, 160–165. Bebbington, P., Dunn, G., Jenkins, R., Lewis, G., Brugha, T., Farrell, M., Meltzer, H., 1998. The influence of age and sex on the prevalence of depressive conditions: reports from the National Survey of Psychiatric Morbidity. Psychol Med 28, 9–19. Bromberger, J., Meyer, P., Kravitz, H., Sommer, B., Cordal, A., Powell, L., Ganz, P., Sutton-Tyrell, K., 2001. Psychologic distress and natural menopause: a multi-ethnic community study. Am. J. Public Health 91, 1435–1442. Bryant, C., Jackson, H., Ames, D., 2008. The prevalence of anxiety in older adults: methodological issues and a review of the literature. J Affect Disord 109, 233–250. Calvaresi, E., Bryan, J., 2003. Symptom experience in Australian men and women in midlife. Maturitas 44, 225–236.
147
Deary, V., Chalder, T., Sharp, M., 2007. The cognitive-behavioural model of medically unexplained symptoms: a theoretical and empirical review. Clin. Psych. Rev. 27, 781–797. Dennerstein, L., Smith, A., Morse, C., 1994. Psychological well-being, midlife and the menopause. Maturitas 20, 1–11. Dratva, J., Real, F., Schindler, C., et al., 2009. Is age at menopause increasing across Europe? Results on age at menopause and determinants from two population-based studies. Menopause 16, 385–394. Elavsky, S., McAuley, E., 2009. Personality, menopausal symptoms, and physical activity outcomes in middle-aged women. Pers. Individ. Diff. 46, 123–128. First, M., Spitzer, R., Gibbon, M., Williams, J., 1996. Structured Clinical Interview for DSM-IV Axis I Disorders, Clinician Version (SCID-CV). American Psychiatric Press, Inc., Washington, D.C. Freeman, E., Sammel, M., Lin, H., Gracia, C., Kapoor, S., Ferdousi, T., 2005. The role of anxiety and hormonal changes in menopausal hot flashes. Menopause 12, 258–266. Gold, E., Colvin, A., Avis, N., Bromberger, J., Greendale, G., Powell, L., Sternfeld, B., Matthews, K., 2006. Longitudinal analysis of the association between vasomotor symptoms and race/ethnicity across the menopausal transition: study of Women's Health Across the Nation. Am. J. Public Health 96, 1226–1235. Halbreich, U., 2003. Anxiety disorders in women: a developmental and lifecycle perspective. Depress Anxiety 17, 107–110. Hanisch, L., Hantsoo, L., Freeman, E., Sullivan, G., Coyne, J., 2008. Hot flashes and panic attacks: a comparison of symptomatology, neurobiology, treatment and a role for cognition. Psychol Bull 134, 247–269. Hardy, R., Kuh, D., 2002. Change in psychological and vasomotor symptom reporting during the menopause. Soc Sci Med 55, 1975–1988. Hunter, M., Liao, K., 1996. Evaluation of a four-session cognitive-behavioural intervention for women suffering from menopausal symptoms following breast cancer treatment. Br J Health Psychol 1, 113–125. Hunter, M., Mann, E., 2010. A cognitive model of menopausal hot flushes and night sweats. J Psychosom Res 69, 491–501. Hunter, M., Rendall, M., 2007. Bio-psycho-social perspectives on menopause. Best Pract Res Clin Obstet Gynaecol 21, 261–274. Keefe, F., Rumble, M., Scipio, C., Giordano, L., Perri, L., 2004. Psychological aspects of persistent pain: current state of the science. J Pain 5, 195–211. Lermer, M., Morra, A., Moineddin, R., Manson, J., Blake, J., Tierney, M., 2011. Somatic and affective anxiety symptoms and menopausal hot flashes. Menopause 18. doi:10.1097/gme.0b013e3181ec58f8. Li, Y., Yu, Q., Ma, L., Sun, Z., Yang, X., 2008. Prevalence of depression and anxiety symptoms and their influence factors during menopausal transition and postmenopause in Beijing city. Maturitas 61, 238–242. Lovibond, P., Lovibond, S., 1995. The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav Res Ther 33, 334–353. Maier, W., Gansicke, M., Freyberger, H., 2000. Generalised anxiety disorder (ICD10) in primary care from a cross-cultural perspective: a valid diagnostic entity? Acta Psychiatr Scand 101, 29–36. Maki, P., 2008. Menopause and anxiety: immediate and long-term effects. Menopause 15, 1033–1035. Moilanen, J., Aalto, A.-A., Hemminki, E., Aro, A., Raitanen, J., Luoto, R., 2010. Prevalence of menopause symptoms and their association with lifestyle among Finnish middle-aged women. Maturitas 67, 358–374. Pacchierotti, C., Castrogiovanni, A., Cavicchioli, C., Luisi, S., Morgante, G., De Leo, V., Petraglia, F., Castrogiovanni, P., 2004. Panic disorder in menopause: a case control study. Maturitas 48, 147–154. Rebbeck, T., Su, H., Samuel, M., Lin, H., Tran, T., Gracia, C., Freeman, E., 2010. Effect of hormone metabolism genotypes on steroid hormone levels and menopausal symptoms in a prospective population-based cohort of women experiencing the menopausal transition. Menopause 17, 1026–1034. Reynolds, F., 2000. Relationship between catastrophic thoughts, perceived control and distress during menopausal hot flushes: exploring the correlates of a questionnaire measure. Maturitas 36, 113–122. Rocca, W., Grossardt, B., de Andrade, D., 2008. Long-term risk of depressive and anxiety symptoms following early bilateral oophorectomy. Menopause 15, 1050–1059. Seritan, A., Iosif, A.-M., Park, J., DeatherageHand, D., Sweet, R., Gold, E., 2010. Self-reported anxiety, depressive symptoms, and vasomotor symptoms: a study of perimenopausal women presenting to a specialized midlife assessment centre. Menopause 17, 410–415. Shea, J., 2006. Cross-cultural comparison of women's midlife symptom reporting: a china study. Cult. Med Psychiatry 30, 331–362. Sigmon, S., Dorhofer, D., Rohan, J., Boulard, N., 2000. The impact of anxiety sensitivity, bodily expectations, and cultural beliefs on menstrual symptom reporting: a test of the menstrual reactivity hypothesis. J. Anxiety Disord. 14, 615–633. Singleton, N., Bumpstead, R., O'Brien, M., Lee, A., Meltzer, H., 2000. Psychiatric Morbidity among Adults Living in Private Households, 2000. The Stationery Office, London.
148
C. Bryant et al. / Journal of Affective Disorders 139 (2012) 141–148
Smoller, J., Pollack, M., Wassertheil-Smoller, S., Jackson, R., Oberman, A., Wong, N., Sheps, D., 2007. Panic attacks and risk of incident cardiovascular events among postmenopausal women in the Women's Health Initiative Observational Study. Arch. Gen. Psychiatry 64, 1153–1160. Soares, C., 2011. In the heat of the moment: assessing anxiety and hot flashes in postmenopausal women. Menopause. doi:10.1097/gmcObO13e318206f103. Spielberger, C., Gorusch, R., Luschene, P., Vagg, P., Jacobs, A., 1983. Manual for the State-Trait Anxiety Inventory (Form Y). Consulting Psychologists' Press Inc., Palo Alto. Tangen, T., Mykletun, A., 2008. Depression and anxiety through the climacteric period: an epidemiological study (HUNT II). J Psychosom Obstet Gynaecol 29, 125–131.
Thurston, R., Blumenthal, Babyak, M., Sherwood, A., 2005. Emotional antecedents of hot flashes during daily life. Psychosom Med 67, 137–146. Thurston, R., Blumenthal, Babyak, M., Sherwood, A., 2006. Association between hot flashes, sleep complaints and psychological functioning in healthy menopausal women. Int J Behav Med 13, 163–172. Von Muhlen, D., Kritz-Silverstein, D., Barrett-Connor, E., 1995. A communitybased study of menopause symptoms and estrogen replacement in older women. Maturitas 22, 71–78. Zigmond, A., Snaith, R., 1983. The hospital anxiety and depression scale. Acta Psychiatr Scand 67, 361–370. Zung, W., 1971. A rating instrument for anxiety disorders. Psychosomatics 12, 371–379.
Contents lists available at ScienceDirect
Journal of Affective Disorders j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j a d
Review
Anxiety during the menopausal transition: A systematic review Christina Bryant a,⁎, Fiona K. Judd b, Martha Hickey c a b c
Psychological Sciences, University of Melbourne and Royal, Women's Hospital, Parkville, Vic, 3052, Australia University of Melbourne Department of Psychiatry and Director, Centre for Women's Mental Health, Royal Women's Hospital, Parkville, Vic, 3052, Australia University of Melbourne and Royal Women's Hospital, Parkville, Vic, 3052, Australia
a r t i c l e
i n f o
a b s t r a c t
Article history: Received 10 May 2011 Received in revised form 29 June 2011 Accepted 29 June 2011 Available online 23 July 2011 Keywords: Anxiety Menopause Midlife Vasomotor symptoms
Objective: There have been relatively few studies of the relationship between anxiety and menopause. Despite the paucity of clear evidence, some authors have suggested that the menopausal transition is a time of heightened risk for onset or exacerbation of anxiety symptoms. There is also controversy as to whether anxiety predates or is a consequence of hot flashes. The aim of this paper is to examine the evidence as to the relationship between menopause and anxiety, and between anxiety and hot flushes, one of the core symptoms of menopause. Method: A systematic review was undertaken based on literature published between 1960 and 2011, using the Medline, Web of Science and PsychINFO databases. The key terms ‘anxiety’, ‘anxiety symptoms’, ‘anxiety disorder’, ‘menopause’, ‘menopausal transition’, ‘midlife’, ‘hot flushes or flashes’ and ‘vasomotor symptoms’ were entered into the search. Studies were included if they reported original research using a clearly described measure of anxiety or investigated the relationship between anxiety and vasomotor symptoms. Results: Nine studies reporting the relationship between menopause and anxiety, two studies reporting the prevalence of panic disorder, and eight studies investigating the relationship between anxiety and vasomotor symptoms were identified. Overall, anxiety symptom levels were low throughout the menopausal transition, but the studies were characterised by poor measurement of both menopausal status and anxiety symptoms and relied heavily on the use of brief, largely nonvalidated measures of anxiety symptoms, which are of unknown clinical significance. In the studies that also measured factors such as attitude to menopause, and dispositional optimism or changes in family life these emerged as important predictors of vasomotor symptom severity. Conclusions: None of the available studies provides solid data on the prevalence of anxiety disorders that meet diagnostic criteria, and the present state of knowledge does not be no justify the inclusion of “menopausal anxiety” as a reproductive-related disorder. With respect to the relationship between hot flashes and anxiety, studies need to ensure that somatic and psychological symptoms are not confounded by the use of unsuitable anxiety measures, and that psychological variables are given serious consideration. © 2011 Elsevier B.V. All rights reserved.
Contents 1. 2. 3.
Introduction . . . . Method . . . . . . . Results . . . . . . . 3.1. The prevalence
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⁎ Corresponding author. E-mail addresses: [email protected] (C. Bryant), [email protected] (F.K. Judd), [email protected] (M. Hickey). 0165-0327/$ – see front matter © 2011 Elsevier B.V. All rights reserved. doi:10.1016/j.jad.2011.06.055
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3.2. The relationship 4. Discussion . . . . . . 5. Conclusions . . . . . Role of the funding source . Conflict of interest . . . . Acknowledgements . . . . References . . . . . . . .
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between anxiety and hot flashes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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1. Introduction One of the most consistent findings in psychiatry and psychology is that from menarche onwards females are at higher risk than males of developing both depressive and anxiety disorders (Bebbington et al., 1998). This sex difference remains robust throughout the lifespan, including old age, in the years beyond the reproductive period (Bebbington et al., 2003; Singleton et al., 2000). The widely reported association between puberty, the perinatal period, and menopause and higher levels of anxiety and depressive symptoms has led some authors to propose the construct of Reproductive Related Disorders (RRDs) (Halbreich, 2003). These disorders are said to comprise a group of diagnostic entities characterised by their link to reproductive processes and a maladaptive response by women described as being “genetically vulnerable” to normal hormonal changes (Halbreich, 2003). Others have questioned not only the validity of such a construct, but also, with respect to menopause, whether the marked cross cultural differences in menopausal symptoms support this hypothesis (Avis et al., 2001). The association between depression and menopause has been extensively explored, but the study of anxiety remains largely neglected (Maki, 2008; Soares, 2011). This is surprising, since symptoms of anxiety in the community are more common than those of depression (Singleton et al., 2000), and Generalised Anxiety Disorder (GAD) is the second most prevalent psychiatric disorder in the primary care setting (Maier et al., 2000). Natural menopause is thought to occur due to exhaustion of ovarian follicles and occurs at a mean age of 51 years in Western societies (Dratva et al., 2009). Menopause is defined retrospectively by the absence of menstruation for 12 months. With an ageing society, increasing numbers of women are living for decades following menopause. Around 80% of women experience vasomotor symptoms (hot flushes and night sweats, VMS) at menopause, of which around 20% find these symptoms sufficiently troublesome to require treatment (Hunter and Rendall, 2007). Menopause may also be associated with psychosocial adjustment to issues such as loss of fertility and changing family roles (Dennerstein et al., 1994; Hardy and Kuh, 2002). This systematic review provides a critical survey of the literature on the association between anxiety and menopause and examines the implications of this for future research and for clinical intervention. There are two prominent themes: first, the relationship between anxiety and menopause and secondly, the relationship between anxiety and vasomotor symptoms. This is of theoretical and clinical interest as it may highlight mechanisms by which the two may be related, and
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may also inform therapeutic interventions for menopausal symptoms (e.g., Hunter and Liao, 1996). 2. Method Published studies between 1960 and 2011, using the Medline, Web of Science and PsychINFO databases using the key terms ‘anxiety’, ‘anxiety symptoms’, ‘anxiety disorder’, ‘menopause’, ‘menopausal transition’, ‘midlife’, ‘hot flushes or flashes’ and ‘vasomotor symptoms’ were searched. Articles were also obtained by through publishers' email alerting services and manual searching of references identified in the articles obtained. One hundred and ninety-eight articles were sourced, but most were clinical studies of menopause symptom management. Included studies were in English, reported original research using a clearly described measure of anxiety, and investigated either the prevalence or severity of anxiety during both natural and induced menopause, or the relationship between anxiety and vasomotor symptoms. ‘Anxiety’ is a general term that can obscure the important distinction between anxiety symptoms and anxiety disorders. Anxiety encompasses diverse symptoms such as feeling on edge, worrying, specific fears, and physiological arousal, and these may be distressing to the individual in their own right. Anxiety disorders, however, are defined by reference to specific criteria, and have much lower prevalence than anxiety symptoms. The majority of the studies reviewed measured anxiety symptoms, rather than anxiety disorder. Nine studies reporting the relationship between menopause and anxiety symptoms, two studies reporting the prevalence of an anxiety disorder, namely panic disorder (PD), and eight studies investigating the relationship between anxiety symptoms and VMS were identified. 3. Results 3.1. The prevalence of anxiety during the menopausal transition Table 1 reports the findings from the studies of anxiety prevalence identified using the search strategy described above. A common feature of these nine studies is the widespread use of single-item or other non-validated measures of anxiety. Only four studies used validated measures of anxiety symptoms (Bauld and Brown, 2009; Calvaresi and Bryan, 2003; Li et al., 2008; Tangen and Mykletun, 2008), and no two used the same measure, thus making direct comparison impossible. Only the study by Li et al. (2008) used a validated measure, namely the Zung Anxiety Inventory (ZAI, Zung, 1971), and reported anxiety prevalence; two studies (Bauld and Brown, 2009), and Tangen and Mykletun (2008) using the DASS
Table 1 Studies measuring anxiety symptoms or disorder during the menopausal transition. Sample
Design
Anxiety measure
Findings
Avis et al. (2001)
14,906 aged 40–55 from five racial/ethnic groups
Cross-sectional questionnaire (SWAN Study)
51.9% of women reported feeling ‘tense or Caucasian women reported higher levels of nervous’, 51.6% reported feeling irritable. psychosomatic symptoms
Bauld and Brown (2009)
116 volunteers aged 34–55
Cross-sectional questionnaire
3 questions on feeling ‘tense or nervous’, ‘irritable or grouchy’ or ‘heart pounding’. DASS
Bromberger et al.(2001)
10,347 women experiencing natural pre-, peri- and postmenopause, aged 40–55 from five racial groups 766 women, aged 39–65; 451 men
Cross-sectional questionnaire (SWAN Study) at first data collection timepoint Cross-sectional populationbased questionnaire
Calvaresi and Bryan (2003) Freeman et al. (2005)
404 pre-menopausal women at baseline, population-based cohort
Li et al. (2008) Moilanen et al. (2010)
1280 women in Beijing, aged 45-59 1427 Finnish women aged 45–64
Rocca et al. (2008) Tangen and Mykletun (2008)
666 women aged b 45who had undergone BO 10,370 pre-,peri- and post menopausal women
Mean scores: anxiety= 2.85 (S.D., 3.36); stress= 5.46 (S.D., 4.24)
See Avis et al. (2001). Psychological distress defined as experiencing all 3 symptoms in the previous 2 weeks.
24.1% of women reported psychological distress.
STAI
Overall STAI scores not reported
Comments
Both these scores are in the normal range, but were positively correlated with attitude to menopause and worse menopausal symptoms. Rates of distress were highest in peri-menopausal group, and still held after accounting for VMS and sleep difficulties.
Compared with men, women reported higher levels of psychological symptoms but similar levels of somatic complaints. 24% of women reported ‘severe anxiety’ Self-assessed frequency and severity Prospective study with up Women with current depression excluded. of anxiety (rated 1–4) in the last to six follow-up points in the early MT, 19% in the premenopausal Perceived stress, history of PMS, and history of month (Penn Ovarian Aging Study) depression were strong predictors of anxiety. period and 16% in postmenopausal period (NS) Cross-sectional ZAI 10.2% prevalence of anxiety (defined as Anxiety was not related to menopausal stage, questionnaire standard score N 0.5) but hot flashes and history of PMDD increased risk. Very low levels of anxiety symptoms e.g., Authors conclude that ‘bothersome’ symptoms are Cross-sectional health survey, Home interview, self-administered common in mid-life irrespective of menopausal stage, community sample questionnaire that included 4 questions ‘nervousness’= 5.3% in pre-menopausal women, 6.6% in perimenopausal and 8.9% and strongly associated with lifestyle factors, such as on anxiety symptoms (nervousness, overweight, high alcohol use and sedentary lifestyles. in postmenopausal women irritability, trembling and heart palpitations) Longitudinal follow-up Anxiety symptom measures designed Risk of anxiety symptoms doubled in Anxiety not assessed with a validated measure. over 24 years for this study BO women (OR2.66; 95% CI, 1.04–2.26) These scores are all within the normal range. Cross sectional communityHADS Mean anxiety score =4.5 in dwelling sample pre-menopausal women, 5.0 in perimenopausal women and 4.8 in postmenopausal women.
C. Bryant et al. / Journal of Affective Disorders 139 (2012) 141–148
Authors
Notes : BO = bilateral oophorectomy; DASS = Depression, Anxiety and Stress Scales; HADS = Hospital Anxiety and Depression Scale; HAM-A = Hamilton Anxiety Rating Scale; MT = Menopausal transition; NS = Not significant; PMDD = Pre-menstrual dysphoric disorder; PMS = Premenstrual syndrome; SCL-90 = Symptom Check List; SCID = Structured Clinical Interview for DSM-IV-TR; STAI = Spielberger State-Trait Anxiety Inventory; SWAN = Study of women's Health Across the Nation; VMS = Vasomotor symptoms; ZAI = Zung Anxiety Index.
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(Lovibond and Lovibond, 1995) and the HADS (Zigmond and Snaith, 1983) respectively, reported levels of anxiety symptoms. Calvaresi and Bryan (2003) used a validated measure of anxiety, the STAI (State-Trait Anxiety Inventory, Spielberger et al., 1983) but did not report overall STAI scores, only their correlation with other variables. In all these studies, the anxiety symptom levels reported were in the normal range. The study by Tangen and Mykletun (2008) has a number of strengths, in that it used a widely-used measure of anxiety, the HADS, and a large population-based sample. The authors did find increased scores on the anxiety measure as women became perimenopausal, and decreased scores in the post-menopausal period, but it is noteworthy that these differences were neither statistically significant, nor did the scores ever reach a level suggestive of an anxiety disorder. One study reported the prevalence of a specific anxiety disorder (panic disorder) assessed with a diagnostic instrument, namely the SCID (Structured Interview for DSM-IV, First et al., 1996; Pacchierotti et al., 2004), and these authors highlight the overlap of the symptoms of panic disorder (PD) with vasomotor symptoms. This case–control study of panic disorder in a small sample (N = 45) of women attending a menopause clinic reported that 18% of the participants had PD, of whom 62% reported onset of PD at the commencement of menopause, and 38% reported worsening of symptoms at this time. The authors do not specify how commencement of menopause was defined, but it appears to have relied on the participants' recall, and no specific criteria were used. It is perhaps not surprising that in this self-selected group, a higher level of symptomatology was found than would be expected in menopausal women in general. A study by Smoller et al. (2007) used a very large community-based sample (N = 3369 post-menopausal women aged 51–83), but relied on a retrospective questionnaire of panic attacks in the last six months. Moreover, by choosing a post-menopausal sample, the authors missed periand early menopausal women, who have been thought by some authors to be at the greatest risk of developing anxiety symptoms (Freeman et al., 2005; Tangen and Mykletun, 2008). The authors reported a 10% prevalence of panic attacks across this very wide age spectrum, and found that women with panic attacks had an increased risk of coronary heart disease and stroke. It should be stressed, however, that experiencing panic attacks, whilst distressing, is not sufficient to meet criteria for panic disorder. The current literature is characterised by poor measurement of both menopausal status and anxiety symptoms. In summary, it relies heavily on the use of brief, largely nonvalidated measures of anxiety symptoms, which are of unknown clinical significance, and overall symptom levels are low. If anxiety symptoms during the menopausal transition are little different from population norms, it is highly unlikely that anxiety disorders, diagnosed with a validated measure or clinical interview, would be more prevalent during menopause than before or after. It is therefore not surprising that the findings of these studies are inconsistent when the studies reported use widely different populations and measures of both menopausal status and anxiety. Some studies report that levels of anxiety symptoms rise during the perimenopausal period, and then fall (Avis et al., 2001; Bromberger et al., 2001; Tangen and
Mykletun, 2008). Others report that anxiety was not related to menopausal stage (Li et al., 2008; Moilanen et al., 2010). All noted the importance of variables other than hormonal status: for example, Freeman et al. (2005) found that prior history of depression and perceived stress were strong predictors of anxiety, whilst Moilanen et al. (2010) emphasised the role of lifestyle factors, such as being overweight, being sedentary, and high alcohol consumption. General statements about the likelihood of anxiety at menopause, e.g. “women will encounter some other serious problems, such as depression and anxiety when they enter menopause” are not justified by the existing literature (Li et al., 2008, p 238, italics mine). A more nuanced understanding of anxiety during the menopausal transition is required in order to further explore this, and one factor that may hold the key to this is the association of anxiety symptoms with vasomotor symptoms.
3.2. The relationship between anxiety and hot flashes Hot flashes are a core symptom of menopause, together with night sweats, sleep disturbance and vaginal dryness. Around 74% of naturally menopausal women report experience hot flashes (von Muhlen et al., 1995). There is considerable variation within cultures and between cultures in the nature, severity and impact on quality of life of VMS. African American women report more severe VMS and Asian women less severe VMS than their Western counterparts, a difference that has been accounted for in a number of ways, including intrinsic racial differences (Avis et al., 2001), genetic differences (Rebbeck et al., 2010), as well as the contribution of cultural differences in the value attributed to ageing (Shea, 2006). There are physical similarities between anxiety symptoms, particularly panic attacks and VMS. These include rising sensations of heat through the chest and head, palpitations, and sweating associated with increased metabolic rate and noradrenergic dysregulation (Hanisch et al., 2008). It is not clear, however, whether sensations of anxiety precede VMS or vice versa. Studies examining the relationship between anxiety and VMS are summarised in Table 2. A number of methodological problems undermine the credibility of published studies: for example, the Zung Anxiety Index, used by Freeman at al. (2005) and Lermer et al. (2011) has a strong somatic focus which may skew reporting of anxiety in those with VMS (Soares, 2011). Measures that confound physical and psychological symptoms will not be able to distinguish the somatic aspects of anxiety from vasomotor symptoms. Whilst some studies do report an association between bothersome hot flashes and anxiety symptoms, these studies (e.g., Gold et al., 2006; Seritan et al., 2010) have used weak measures of anxiety. The study by Freeman et al. (2005) reported that women with high anxiety were five times more likely to report hot flashes than women with anxiety scores in the normal range. Measurement of hot flashes, however, was by means of menopause symptom checklist, and there was no corroboration of this self-report against an objective measure of vasomotor activity. When well validated measures of anxiety (e.g. the STAI) are combined with objective measures of VMS (skin conductance) (Thurston et al., 2005, 2006) a more complex picture emerges. For example, women with higher levels of anxiety are more likely to make false-
Table 2 Studies that examined the relationship between anxiety and vasomotor symptoms. Participants
Measures
Findings
Comments
Elavsky and N = 164; aged 42–58; McAuley (2009) women with low PA levels rectuited to a PA study Freeman et al. 436 pre- and peri(2005) menopausal women, aged 35–47
Random assignment to 4-month physical activity intervention or wait-list control Prospective study with up to eight follow-up points (Penn Ovarian Aging Study)
GCS, IPIP, LOT, STAI
Authors concluded that reporting of symptoms partially explained by factors such as personality and dispositional optimism, and may be amenable to physical activity interventions. Anxiety scores decreased over time, but authors do not report actual prevalence of anxiety in the sample.
Gold et al. (2006)
2784 women, age 42–52 at baseline, multi-racial from 7 sites in US
Prospective study (SWAN) with up to five follow-up points
Hardy and Kuh (2002)
N = 1572; aged 47–52; community sample
Limited relationship observed between psychological symptoms and menopausal symptoms. Higher levels of psychological symptom reporting in HRT users.
Assessment of psychological symptoms based on a scale containing only 4 items.
Lermer et al. (2011)
N = 80; aged 50–64; all postmenopausal; volunteer sample
MRC National Survey of Health and Development cohort study of people born in 1946; measures taken yearly for 6 years Observational study
Self-report of VMS; anxiety measured by the number of days in the past two weeks when symptoms (irritability, tense/nervous, racing heart, fearful for no reason) had been experienced Symptom checklist including items for anxiety, panic, fearfulness, hot flashes and night sweats
Correlations between optimism and VS at baseline. After intervention, increased physical activity associated predicted reduced VS. Anxiety significantly associated with hot flashes. Women with moderate anxiety scores three times more likely to report hot flashes, and those with high anxiety scores, five times more likely to report hot flashes Baseline anxietyb 4 in 23% of Whites, 24% in African Americans, 36% in Hispanics, 14% in Chinese, 13% in Japanese.
ZAI; 7-day hot flash diary
Higher scores on the somatic, but not on the affective, anxiety subscale predicted more severe and frequent VS.
Seritan et al. (2010)
N = 487; aged 40–64; pre, peri- or postmenopausal N = 42; aged 40–60; peri- or postmenopausal community volunteers.
Retrospective chart review of clinical sample Two days of sternal skin conductance monitoring, behavioural dairies 3× per hour, questionnaires
Anxiety assessed with yes/no response to: “I feel more anxious than usual”; reporting of VMS; NAMS STAI, BDI-II, ATM, DSI, SCL-90-R
N = 52 peri and postmenopausal women;; aged 40–60
Observational study of hot flashes and sleep disturbance using skin conductance monitor; self-report questionnaires
BDI-II, DSI, STAI, SWEL
Self-reported anxiety was 15% in premenopausal, 11% in perimenopausal and 6% in postmenopausal groups STAI scores within population norms, attitudes to menopause relatively neutral. Objective hot flashes were more likely after recording positive emotion (happiness and relaxation) and after physical exertion. No relationship between depression, trait anxiety or daily stress and hot flashes during sleep.
The anxiety scores only predicted 27.35% of the variance in VS. Authors suggest that relationships between anxiety and VS may be due to the overlap of somatic symptoms of anxiety and VS. Women reporting bothersome hot flashes more likely to report anxiety symptoms
Thurston et al. (2005)
Thurston et al. (2006)
Self-report measure of severity and frequency of hot flashes; Zung Anxiety Index
Scores ranged from 0 = no days to 4 = every day. Anxiety at baseline was strongly associated with VMS in all ethnic groups except Hispanics. VMS peaked in the late peri-menopausal period
Women with more positive attitudes to menopause had more hot flashes. Women with higher anxiety levels had higher false-negative reporting of hot flashes.
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Methodology
Sleep disturbance unrelated to sleep hot flashes, but psychological variables were related to self-reported sleep problems.
Note: ATM = Attitudes Towards Menopause; BDI-II = Beck Depression Inventory (2nd edition); DSI = Daily Stress Inventory; GCS = Green Climacteric Scale; IPIP = International Personality Item Pool; LOT = Life Orientation Test; PA = physical activity; NAMS = North American Menopause Society Menopause Health Questionnaire; STAI = Spielberger State-Trait anxiety Inventory; SCL-90-R = Hopkins Symptom Checklist, revised; SWEL = Sleep Wake Experience List; ZAI = Zung Anxiety Index.
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negative reports of hot flushes. There was no overall relationship between scores on the STAI and hot flashes. These inconsistent results question the existence of a direct relationship between the severity of vasomotor symptoms and anxiety symptoms. It also remains unclear whether anxiety symptoms predate or follow VMS. The perceived severity of VMS is affected by attitude to menopause, and dispositional optimism (Elavsky and McAuley, 2009) or changes in family life (Hardy and Kuh, 2002), suggesting that there are a number of psychological variables that are important in understanding the association between anxiety and hot flashes. It is likely that a conceptual model of hot flashes needs to incorporate a range of explanatory psychological variables, encompassing not only contextual factors such as stressful events, but also cognitive factors. 4. Discussion We aimed to review the association between anxiety and the menopausal transition, and to critically examine the role of anxiety in relation to hot flashes. The small number of studies identified confirms that the neglect of anxiety relative to disorders such as depression evident in other age groups (Bryant et al., 2008), also applies to women in midlife. The hypothesis that anxiety levels rise during the menopause transition and fall after menopause is widely proposed (Bromberger et al., 2001; Freeman et al., 2005). This hypothesis is not supported by the published literature. Studies of anxiety at menopause are largely limited by poor measurement of anxiety and/or vasomotor symptoms, and those studies that used validated measures of anxiety report anxiety scores that are within the normal range. Moreover, some measures of anxiety with a strong somatic component, for example the ZAI, as used by Li et al. (2004) and Freeman et al. (2005) may very well be tapping into symptoms attributable to hot flashes and scoring vasomotor symptoms as anxiety symptoms. There may be an increase in anxiety symptoms at menopause, but this has not yet been clearly demonstrated. Even less is known about the prevalence or severity of anxiety disorders during the menopause transition. The current literature based on large community based studies suggests that psychological symptoms during the menopause transition are associated with known risk factors for anxiety and depression, including stressful life events (Hardy and Kuh, 2002; Moilanen et al., 2010). It has been argued that there is a subgroup of women who may be at increased risk of psychological disorder during the menopause (e.g., Halbreich, 2003), but it seems premature to suggest that anxiety disorders would be candidates for inclusion in this. Moreover, other studies have questioned the association of psychological symptoms with the menopause per se. For example, Hardy and Kuh (2002) argued that psychological symptoms were not related to oestrogen level changes. These findings were based on an analysis of data from the UK 1946 cohort study, which suggested that psychological symptoms were more related to current life events and difficulties than menopausal status in a large sample (N =1572) of community dwelling women. A similar conclusion was reached by Moilanen et al. (2010) on the basis of findings from a community-based cohort in Finland. This highlights the complexity of the relationship between menopause and anxiety, which is further
demonstrated in the studies that have examined the relationship between anxiety and hot flashes. Hunter and Mann (2010) have proposed a cognitive model of hot flashes that integrates a number of biological, environmental and psychological variables. Whilst not ignoring menopausal status, Hunter and Mann propose that the experience of hot flashes is shaped by individual differences in symptom perception, cognitive appraisals of those symptoms, and beliefs about menopause. One aspect of symptom perception is anxiety sensitivity, which has been widely studied in relation to the aetiology and maintenance of a number of anxiety disorders. In light of the parallels between menstrual symptoms and panic attacks (dizziness, sweating and heart pounding), the construct has been applied to women with high levels of menstrual symptom distress. Sigmon et al. (2000) reported that women with higher levels of anxiety sensitivity reported higher levels of distress about menstrual symptoms, which then supports the role of beliefs and expectations in symptom experience. Anxiety sensitivity has not been examined in relation to hot flashes, but may have a role in explaining greater distress with regard to vasomotor symptoms. Another cognitive variable that may be relevant for understanding the relationship between anxiety and vasomotor symptoms is that of catastrophic thinking. It is well established that catastrophic thinking has an adverse effect on perceived symptom severity in chronic health conditions. Women who report more catastrophic thoughts also tended to report lower perceived control over their hot flashes Reynolds (2000). Whilst caution must be exercised in interpreting the results of a study with a relatively small sample of volunteers, it is supportive of the important role of cognition and symptom attribution in understanding the experience of hot flashes. These factors, and others, are considered in depth by Hanisch et al. (2008). These authors compared the symptomatology, neurobiology and biochemical mechanisms of hot flashes and panic attacks, in order to develop an integrative conceptual model of these two phenomena. They emphasised that hot flashes are a normal part of the menopausal transition, and most women neither desire nor require treatment for them. Similarly, not all individuals who experience one or two panic attacks will develop panic disorder. Whilst all hot flashes have certain shared physical symptom in common, it is the subjective interpretation of these symptoms that will influence whether they are associated with intense distress or anxiety. Their model incorporates both physical and psychological mechanisms, including factors such as anxiety sensitivity and symptom appraisal. This is consistent with the work of Thurston et al. (2005, 2006) which suggested that one of the important ways in which negative affect influenced hot flash experience was through a tendency to inaccurate interpretations of physical sensations. Models, such as those of Hunter and Mann (2010), or of Hanisch et al. (2008), sit within a broader literature that has sought to understand psychological aspects of physical symptoms. For example, Deary et al. (2007) proposed a model for understanding medically unexplained symptoms through the proposed roles of symptom perception, somatic focus and symptom attribution. Studies of pain also draw on
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psychologically complex models to understand the marked differences in individuals' responses to their pain and associated disability (e.g., Keefe et al., 2004). Given the complex interplay of psychological and physical symptoms during the menopausal transition, such models seem obvious candidates for helping us to move the field forwards, both clinically and in generating hypothesis-driven research. 5. Conclusions Published research on the relationship between anxiety and the menopausal transition has tended to use inadequate measures of anxiety, and to infer high levels of “anxiety” from the large number of women who endorse feeling “tense or stressed” during the preceding week or month. These results are open to serious misinterpretation. Future research should use well-validated, preferably diagnostic instruments. Given that none of the available studies provide solid data on the prevalence of anxiety disorders that meet diagnostic criteria, there can be no justification for the inclusion of “menopausal anxiety” as a reproductive-related disorder. With respect to the relationship between hot flashes and anxiety, studies need to use objective as well as subjective measures of VMS and ensure that somatic and psychological symptoms are not confounded by the use of unsuitable anxiety measures. Symptom attribution and cognitions about the meaning of symptoms are likely to influence perception of VMS. Studies of psycho-educational or cognitive-behavioural interventions for menopausal symptoms show promise. Some of these have used behavioural techniques, such as breathing training, temperature regulation, and cognitive coping strategies (Hunter and Liao, 1996). Further study is required to ascertain whether approaches geared to reducing anxiety sensitivity, and decatastrophising beliefs about the unpleasantness of hot flashes may also be beneficial. Role of the funding source The funding sources had no role in the content of this article. Conflict of interest The authors have no conflict of interest to declare. Acknowledgements The Centre for Women's Mental Health is supported by the Pratt Foundation. Martha Hickey is supported by an NHMRC Clinical Career Development Award.
References Avis, N., Stellato, R., Crawford, S., Bromberger, J., Ganz, P., Cain, V., KagawaSinger, M., 2001. Is there a menopausal syndrome? Menopausal status and symptoms across racial groups. Soc Sci Med 52, 345–356. Bauld, R., Brown, R., 2009. Stress, psychological distress, psychosocial factors, menopause symptoms and physical health in women. Maturitas 62, 160–165. Bebbington, P., Dunn, G., Jenkins, R., Lewis, G., Brugha, T., Farrell, M., Meltzer, H., 1998. The influence of age and sex on the prevalence of depressive conditions: reports from the National Survey of Psychiatric Morbidity. Psychol Med 28, 9–19. Bromberger, J., Meyer, P., Kravitz, H., Sommer, B., Cordal, A., Powell, L., Ganz, P., Sutton-Tyrell, K., 2001. Psychologic distress and natural menopause: a multi-ethnic community study. Am. J. Public Health 91, 1435–1442. Bryant, C., Jackson, H., Ames, D., 2008. The prevalence of anxiety in older adults: methodological issues and a review of the literature. J Affect Disord 109, 233–250. Calvaresi, E., Bryan, J., 2003. Symptom experience in Australian men and women in midlife. Maturitas 44, 225–236.
147
Deary, V., Chalder, T., Sharp, M., 2007. The cognitive-behavioural model of medically unexplained symptoms: a theoretical and empirical review. Clin. Psych. Rev. 27, 781–797. Dennerstein, L., Smith, A., Morse, C., 1994. Psychological well-being, midlife and the menopause. Maturitas 20, 1–11. Dratva, J., Real, F., Schindler, C., et al., 2009. Is age at menopause increasing across Europe? Results on age at menopause and determinants from two population-based studies. Menopause 16, 385–394. Elavsky, S., McAuley, E., 2009. Personality, menopausal symptoms, and physical activity outcomes in middle-aged women. Pers. Individ. Diff. 46, 123–128. First, M., Spitzer, R., Gibbon, M., Williams, J., 1996. Structured Clinical Interview for DSM-IV Axis I Disorders, Clinician Version (SCID-CV). American Psychiatric Press, Inc., Washington, D.C. Freeman, E., Sammel, M., Lin, H., Gracia, C., Kapoor, S., Ferdousi, T., 2005. The role of anxiety and hormonal changes in menopausal hot flashes. Menopause 12, 258–266. Gold, E., Colvin, A., Avis, N., Bromberger, J., Greendale, G., Powell, L., Sternfeld, B., Matthews, K., 2006. Longitudinal analysis of the association between vasomotor symptoms and race/ethnicity across the menopausal transition: study of Women's Health Across the Nation. Am. J. Public Health 96, 1226–1235. Halbreich, U., 2003. Anxiety disorders in women: a developmental and lifecycle perspective. Depress Anxiety 17, 107–110. Hanisch, L., Hantsoo, L., Freeman, E., Sullivan, G., Coyne, J., 2008. Hot flashes and panic attacks: a comparison of symptomatology, neurobiology, treatment and a role for cognition. Psychol Bull 134, 247–269. Hardy, R., Kuh, D., 2002. Change in psychological and vasomotor symptom reporting during the menopause. Soc Sci Med 55, 1975–1988. Hunter, M., Liao, K., 1996. Evaluation of a four-session cognitive-behavioural intervention for women suffering from menopausal symptoms following breast cancer treatment. Br J Health Psychol 1, 113–125. Hunter, M., Mann, E., 2010. A cognitive model of menopausal hot flushes and night sweats. J Psychosom Res 69, 491–501. Hunter, M., Rendall, M., 2007. Bio-psycho-social perspectives on menopause. Best Pract Res Clin Obstet Gynaecol 21, 261–274. Keefe, F., Rumble, M., Scipio, C., Giordano, L., Perri, L., 2004. Psychological aspects of persistent pain: current state of the science. J Pain 5, 195–211. Lermer, M., Morra, A., Moineddin, R., Manson, J., Blake, J., Tierney, M., 2011. Somatic and affective anxiety symptoms and menopausal hot flashes. Menopause 18. doi:10.1097/gme.0b013e3181ec58f8. Li, Y., Yu, Q., Ma, L., Sun, Z., Yang, X., 2008. Prevalence of depression and anxiety symptoms and their influence factors during menopausal transition and postmenopause in Beijing city. Maturitas 61, 238–242. Lovibond, P., Lovibond, S., 1995. The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav Res Ther 33, 334–353. Maier, W., Gansicke, M., Freyberger, H., 2000. Generalised anxiety disorder (ICD10) in primary care from a cross-cultural perspective: a valid diagnostic entity? Acta Psychiatr Scand 101, 29–36. Maki, P., 2008. Menopause and anxiety: immediate and long-term effects. Menopause 15, 1033–1035. Moilanen, J., Aalto, A.-A., Hemminki, E., Aro, A., Raitanen, J., Luoto, R., 2010. Prevalence of menopause symptoms and their association with lifestyle among Finnish middle-aged women. Maturitas 67, 358–374. Pacchierotti, C., Castrogiovanni, A., Cavicchioli, C., Luisi, S., Morgante, G., De Leo, V., Petraglia, F., Castrogiovanni, P., 2004. Panic disorder in menopause: a case control study. Maturitas 48, 147–154. Rebbeck, T., Su, H., Samuel, M., Lin, H., Tran, T., Gracia, C., Freeman, E., 2010. Effect of hormone metabolism genotypes on steroid hormone levels and menopausal symptoms in a prospective population-based cohort of women experiencing the menopausal transition. Menopause 17, 1026–1034. Reynolds, F., 2000. Relationship between catastrophic thoughts, perceived control and distress during menopausal hot flushes: exploring the correlates of a questionnaire measure. Maturitas 36, 113–122. Rocca, W., Grossardt, B., de Andrade, D., 2008. Long-term risk of depressive and anxiety symptoms following early bilateral oophorectomy. Menopause 15, 1050–1059. Seritan, A., Iosif, A.-M., Park, J., DeatherageHand, D., Sweet, R., Gold, E., 2010. Self-reported anxiety, depressive symptoms, and vasomotor symptoms: a study of perimenopausal women presenting to a specialized midlife assessment centre. Menopause 17, 410–415. Shea, J., 2006. Cross-cultural comparison of women's midlife symptom reporting: a china study. Cult. Med Psychiatry 30, 331–362. Sigmon, S., Dorhofer, D., Rohan, J., Boulard, N., 2000. The impact of anxiety sensitivity, bodily expectations, and cultural beliefs on menstrual symptom reporting: a test of the menstrual reactivity hypothesis. J. Anxiety Disord. 14, 615–633. Singleton, N., Bumpstead, R., O'Brien, M., Lee, A., Meltzer, H., 2000. Psychiatric Morbidity among Adults Living in Private Households, 2000. The Stationery Office, London.
148
C. Bryant et al. / Journal of Affective Disorders 139 (2012) 141–148
Smoller, J., Pollack, M., Wassertheil-Smoller, S., Jackson, R., Oberman, A., Wong, N., Sheps, D., 2007. Panic attacks and risk of incident cardiovascular events among postmenopausal women in the Women's Health Initiative Observational Study. Arch. Gen. Psychiatry 64, 1153–1160. Soares, C., 2011. In the heat of the moment: assessing anxiety and hot flashes in postmenopausal women. Menopause. doi:10.1097/gmcObO13e318206f103. Spielberger, C., Gorusch, R., Luschene, P., Vagg, P., Jacobs, A., 1983. Manual for the State-Trait Anxiety Inventory (Form Y). Consulting Psychologists' Press Inc., Palo Alto. Tangen, T., Mykletun, A., 2008. Depression and anxiety through the climacteric period: an epidemiological study (HUNT II). J Psychosom Obstet Gynaecol 29, 125–131.
Thurston, R., Blumenthal, Babyak, M., Sherwood, A., 2005. Emotional antecedents of hot flashes during daily life. Psychosom Med 67, 137–146. Thurston, R., Blumenthal, Babyak, M., Sherwood, A., 2006. Association between hot flashes, sleep complaints and psychological functioning in healthy menopausal women. Int J Behav Med 13, 163–172. Von Muhlen, D., Kritz-Silverstein, D., Barrett-Connor, E., 1995. A communitybased study of menopause symptoms and estrogen replacement in older women. Maturitas 22, 71–78. Zigmond, A., Snaith, R., 1983. The hospital anxiety and depression scale. Acta Psychiatr Scand 67, 361–370. Zung, W., 1971. A rating instrument for anxiety disorders. Psychosomatics 12, 371–379.