Right now, an estimated 18.1 percent of adults in the U.S. suffer from some form of anxiety disorder — going off of the most recent population count, that’s more than 58 million Americans over the age of 18 who spend their days feeling constantly on edge, or living in fear of far-fetched health problems or other people, or waiting for the next panic attack to strike, or battling a constant, all-encompassing sense of worry.
One of those people is Wall Street Journal writer Andrea Petersen, whose new book, On Edge: A Journey Through Anxiety, details her struggle to stop her anxiety from taking over her life. The more she learned about the disorder, Petersen explains, the more complicated it revealed itself to be: Anxiety is a mysterious cocktail of different risk factors — among other things, personality, family history of mental illness, past trauma, and stressful life circumstances can all play a role. But amid all the complexity, one thing has made itself clear: “There is no greater risk factor for anxiety disorders,” Petersen notes, “than being born female.”
“Women are about twice as likely as men to develop [an anxiety disorder], and women’s illnesses generally last longer, have more severe symptoms, and are more disabling,” she writes. “Anxious women are also more likely to develop an additional anxiety disorder, an eating disorder, or depression. In general, women ruminate more than men.”
All of which, she continues, raises the question: “Are women born anxious, or are we raised to be that way?” Science of Us recently talked to Petersen about the answer to that question, and the differences, both learned and innate, that contribute to the gender discrepancy in anxiety. Below is a lightly edited and condensed version of our conversation.
You talk in the book about how girls absorb messages early on in life that can make them more anxious than boys. What does that process look like?
There’s a pretty striking statistic that women have double the risk for anxiety disorders than men do. That’s something that I wanted to try to get at — why is that? There are several hypotheses — there’s some evidence that hormonal factors come into play, that women’s fluctuating levels of estrogen may contribute — but the most interesting and most robust science is looking at the social factors, how little boys and little girls are raised and the differences there, and how those contribute to the greater risk for women to later develop anxiety disorders. So there’s a whole body of dispiriting research showing how boys are much more likely to be encouraged to be independent, to be assertive, where girls are much more likely to be dissuaded from that behavior.
There’s a researcher in Canada who was looking at the injury rates between boys and girls — boys, by toddlerhood, are two to four times more likely to be injured than girls are, and their injuries tend to be more serious, and she was trying to uncover what was behind that. She was actually on maternity leave with her oldest son and spent a lot of time on playgrounds, and what she saw was this really striking difference in how boys and girls are encouraged, or not encouraged, to deal with risk. So she did a series of studies with little boys and girls on a playground, and she had parents teach their kids to slide down a pole like you’d see at a firehouse. And what she found is that boys were much more likely to be encouraged to be independent, while girls were much more likely to be cautioned about safety, about danger. Even though boys and girls had the same skill level — both boys and girls were equally adept at actually using the equipment — the way parents treated them was very different, to the point where even when boys actually asked for help, parents said no. A couple of boys tumbled to the ground off this fire-station pole because they couldn’t do it without assistance, and they were left on their own.
So while this kind of parenting may help protect girls physically, the research suggests that it also contributes to this feeling of vulnerability, that the world is a dangerous place. Because the message that sends to girls — encouraging them to be very cautious and always highlighting safety and danger — is that the world is a dangerous place, and that they can’t cope on their own. And that feeling of vulnerability of course is a core belief of anxiety as well.
[Another] study had young children who were told to make a world out of these sand toys with their parents. And what they found is, parents were much more likely to praise their sons when they were being assertive or independent, when they were telling their parents where to put a toy or directing the play. But when girls did that, parents were much more likely to talk over their children, ignore them, or dissuade what they were saying. So the message that sends is that you don’t have control over your experience, over your world.
In the book, you mentioned that boys are more anxious in infancy. When does that begin to flip?
This was from a book that [psychology professor] Michelle Craske at UCLA did looking into this research. With newborns, boys actually are more fussy and irritable, and what Craske hypothesized is that this sort of irritability may protect them from developing anxiety later on. Several studies have shown that mothers are more in sync with their newborn boys than they are with girls, in that they’re more likely to actually match their sons’ facial expressions, the direction that the babies are looking. And the thinking is that because these newborn boys are more irritable, they’re better able to attract the attention of the mother. And that synchronicity, that harmony, she conjectures, may actually give boys a stronger sense of security that their world is predictable, and that they may have more control over their environment.
This irritability tends to even out between boys and girls at a few months old. And then it flips, where by about age 2, girls are starting to show negative affect — they tend to be more fearful and acting more inhibited, or reacting more strongly, negatively, to novelty. Researchers say this is also the time when kids are beginning to exhibit more gender-role behavior, and also parents are more likely to encourage their daughters more than their sons to share toys with other kids, to be empathetic, to consider other kids’ points of view. And there’s some thought that instilling that empathy may have a downside, that girls might see threatening expressions on other people’s faces and internalize that.
Does that mean girls are also more likely to be affected by other people’s anxiety?
There’s some research showing that girls are better able to identify facial expressions. This is all conjecture, but the scientists conjecture that when girls see a frightened expression on someone’s face, they may be more likely to internalize the fear that they’re seeing. There was some research where mothers presented two toys, a rubber snake and a spider, to their toddlers; and in part of the study, mothers were told to describe the toy as scary or yucky and make frightened faces; and in other parts of the study, they were told to describe the toy as cute and fun and make positive, joyful expressions. And what they found is that boys and girls were both obviously more likely to respond to the toys in a fearful way when their mothers made the fearful expressions, but girls generally acted more afraid and were more likely to avoid the toys than boys were. So what they were trying to get at was, when you model behavior that you see from your parents, how might there be gender differences in this? And how might that then relate to development of anxiety?
You mentioned that socialization was just one factor that researchers are looking into. What are some of the other things that might play a role in the gender discrepancy?
Going back to some research that Michelle Craske cites in an earlier book, she conjectures that one reason why women might face a greater risk of anxiety is because of the kinds of trauma that they’re more likely to face. Research has shown that men generally have more traumatic experiences in their lives — things like serious accidents, experiencing or witnessing violence — but women are much more likely to be victims of sexual assault and abuse. Craske conjectures that because that kind of bad experience is so uncontrollable and unpredictable, it may be more likely to lead to the development of anxiety disorders or PTSD.
There are also some people doing some really interesting things with sex hormones and how they influence anxiety. There’s some research looking at how sex hormones influence fear conditioning and extinction. Fear conditioning is a kind of paradigm of how people develop fear. The way the research is generally done is, something like a shock is paired with another kind of stimulus. There’s one study that I cite where a picture of a lamp was paired with a shock to the hand. So then if you have several rounds of that, people develop this fear where essentially if they see the picture of the lamp, they’ll have a fear response to the picture, even when it’s not followed by the shock. And then extinction is when there’ll be several trials of seeing the picture of the lamp followed by no shock, so eventually their levels of fear response tend to go down. And these researchers found that women with a higher level of estradiol, which is a form of estrogen, had a stronger extinction recall, meaning that they maintained a lower level of fear than women with lower levels of estradiol. So looking at how sex hormones could influence how people catch and retain fear.
One thing that’s sort of interesting is that with levels of stress hormones, like epinephrine and norepinephrine, men’s physiological reactions to stressful events tend to be stronger than women’s. So this fight-or-flight response seems to be more pronounced in men. And scientists conjecture that this makes evolutionary sense — that obviously a sensitive fight-or-flight response would make a lot of sense if you’re hunting or you’re fighting adversaries. And women tend to have a more muted fight-or-flight response, some scientists have dubbed “tend and befriend.” Women tend to respond to stress by producing more oxytocin, a hormone that’s thought to promote attachment, and it spurs women to tend to their young and fuels more relationship formation with other members of the group. You could see why this would maybe be evolutionarily advantageous — if the group is being threatened, you tend to be worried about your kids and making sure they’re okay — but one of the disadvantages of this response is, it could reinforce worry and avoiding threats: “Where are my kids? Are they okay? Let’s get out of here.” Which could reinforce this idea that you can’t cope on your own, or a pattern of avoidance, when we know that avoiding situations that make you anxious tends to reinforce anxiety.
With kids especially, though, it seems like it’d be hard to know when to make them confront whatever it is they’re avoiding, and when to let them stay safe in their comfort. How do you decide where to draw that line?
It’s all about impairment — obviously, having a shy, socially reticent child is not a disorder. Being introverted is not a problem. What we’re talking about is impairment, when it’s preventing a child from doing things that are age-appropriate, or doing the things they want to do when they want to do them. [For example], a child really wants to join in at a party, but can’t get themselves to do it. The way that the professionals do it is, they have parents create a fear hierarchy with their kids, so there’s a certain goal. Say your goal is to have your child attend a birthday party and not cling to your leg the whole time, but actually engage in the activity. That wouldn’t be the first thing you would do — you wouldn’t throw them in the deep end of the pool. You would start with maybe having them wave to another kid from right by your side, and then eventually say hello, and then eventually say their name or ask a question.
This is all principled from cognitive behavioral therapy, which is one of the most evidence-based treatments for anxiety disorder. It’s all based on sort of gradually exposing yourself to situations that you fear. The main active ingredient in CBT is exposure therapy, so [this is] taking that and using that as kind of a preventive thing.
You have a daughter of your own. Have there been any situations where what you learned writing your book has influenced your parenting?
There is some evidence that controlling and rejecting parenting can fuel anxiety in children. I think what researchers have come to see is that if your child is temperamentally anxious, if that’s how your child is wired, what parents will often do is respond to the children by helping them avoid the situations. We all love our kids and we don’t like to see them in distress, so a natural reaction is to help them avoid that distress and maybe skip that sleepover they’re worried about, or not continue with that soccer program. Or even speaking for their children if their children are too afraid to talk to a teacher or talk to another child. But that just ends up reinforcing that anxiety because that sends a message that the kids can’t do it on their own. And at the same time, they’re not developing those skills. They’re not actually learning that yes, they can do it.
So there are some really interesting programs that are now cropping up to help anxiety disorders in young children. And obviously, my daughter has a genetic predisposition to anxiety, which I try not to see sort of every personality quirk as a nascent psychiatric disorder. I don’t want to do that to her, but I walk a fine line. I don’t have a son, so in terms of the gender differences, I can’t see in vivo how I may be treating her differently. But it’s strange — I don’t tend to be that parent who hovers in the playground. I’m more likely to give her a longer leash than my husband is. That’s actually something I try to pull him back on, because he’s the more anxious parent in terms of her physical safety. Which is sort of ironic, I think.