Generalized Anxiety Disorder

The most common type of anxiety disorder that starts during the menopausal transition is generalized anxiety disorder (GAD). Be aware though that even if you have increased anxiety compared to your life before entering the menopausal transition, you may not meet the criteria for GAD. 

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is the standard classification of mental disorders used by health professionals in North America.[5]  The DSM-5 outlines the following criterion to make a diagnosis of Generalized Anxiety Disorder: 

1. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance) 
2. The individual finds it difficult to control the worry. 
3. The anxiety and worry are associated with three (or more) of the following six symptoms (With at least some symptoms having been present for more days than not for the past 6 months). 
   1. Restlessness or feeling keyed up or on edge.
   2. Being easily fatigued. 
   3. Difficulty concentrating or mind going blank. 
   4. Irritability. 
   5. Muscle tension.  
   6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)
4. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social occupational, or other important areas of functioning. 
5. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism). 
6. The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, a negative evaluation in social anxiety disorder, etc. 

If you are concerned that you may be experiencing generalized anxiety disorder, use this brief scale called the GAD-7 to assess your anxiety symptoms. If you score with moderate or severe anxiety, please see your healthcare provider to discuss treatment and management. [6] 

Panic Attacks vs Anxiety Attacks

Panic attacks can happen during the menopausal transition. Panic attacks come on suddenly, often with no warning, and typically last for 5 – 20 minutes. They may also occur in a series of episodes, one after another, for hours. [7]  In some cases, hot flashes are accompanied by feelings that mimic or even trigger a panic attack. [8] 

Symptoms of a panic attack include the following: 

• rapid heart rate
• chest pain
• dizziness or lightheadedness
• hot flashes or chills
• nausea
• numbness or tingling in the extremities
• shaking
• shortness of breath
• stomach pain
• sweating. 

During the panic attack itself, you may experience an overwhelming sense of losing control, sudden fear of dying, and a sense of being detached from the environment around you. Panic attacks are associated with a diagnosable panic disorder. 

Anxiety attacks are often mistaken for a panic attack, but they differ in several important ways. Unlike panic attacks, an anxiety attack happens after a bout of intense and prolonged anxiety or worry. Symptoms are usually less intense than panic attack symptoms, although still scary. They are not part of a diagnosable disorder, but they do often happen as part of a generalized anxiety disorder (GAD). Symptoms of an anxiety attack overlap with the symptoms of GAD, as follows:

• nervousness
• irritability
• increased heart rate
• rapid breathing
• trembling
• sweating
• a sense of impending danger
• difficulty concentrating
• sleep disturbances

[7]

Other Menopausal Transition Symptoms and Anxiety

Vasomotor symptoms (hot flashes) and anxiety are consistently associated with each other in multiple studies.  [9] Depression is also linked with both vasomotor symptoms and anxiety. It is unclear what the underlying factors are, but studies are continuing to explore this connection.  [1]

The relationship between anxiety and depression is not totally clear, but researchers do know that about 85% of patients with depression will also experience symptoms of anxiety. And it works in both directions – about 90% of patients with anxiety disorders also experience depression. This overlap of symptoms from anxiety and depression makes research and treatment challenging. Anxiety and depression can also be experienced separately. [10]

Insomnia is another common symptom of the menopausal transition, with 40-50% of women experiencing it.  Insomnia and difficulties sleeping are strongly associated with anxiety and depression. [7] One study looking at the relationship amongst anxiety, depression, and insomnia found that difficulty falling asleep is strongly associated with symptoms of anxiety, while the feeling that sleep was not refreshing or restorative is strongly correlated with depression.[11]

Therapy and Counselling

Cognitive behavioural therapy (CBT) is a type of psychotherapy based on the idea that your thought patterns affect your emotions, which can then affect your behaviors. CBT can teach people different ways of thinking, behaving, and reacting to situations to help reduce anxiety. For example, CBT recognizes that negative, worrying thoughts can lead to fearful, worrisome feelings and actions. Reframing your thoughts to be more positive can lead to more positive feelings and helpful behaviors. 

With a therapist using CBT, you will: 

• identify specific problems or issues in your daily life
• increase your awareness of negative thought patterns and how they can impact your life
• identify negative thinking and reframing it in a way that changes how you feel
• learn new behaviors and putting them into practice [13a]

Exposure therapy is a technique used in CBT that has patients confront the fears underlying their anxiety. This helps get individuals back doing activities that they have been avoiding due to anxiety. Relaxation techniques are used to help manage anxiety while doing the exposure therapy. [14]

Acceptance and commitment therapy (ACT) is another type of therapy that can be used specifically to treat anxiety. ACT teaches and uses strategies such as mindfulness to reduce anxiety. It is a newer form of therapy than CBT, so at this time, less information is available on its long-term effectiveness. [14]

Medication

Anti-anxiety medications work specifically to reduce the symptoms of anxiety including panic attacks and extreme worry and fear. Benzodiazepines are the most common class of anti-anxiety medications. They are very effective in helping to reduce anxiety, and they start working more quickly than most antidepressant medications. Benzodiazepines are the first-line treatment for generalized anxiety disorder. Unfortunately, it is easy to build up tolerance to benzodiazepines and start requiring higher and higher dosages to get the same calming effect. It is possible to become dependent on them and to experience withdrawal symptoms when the medication is stopped. Because of this, your health care provider will probably only prescribe benzodiazepines for a short period of time. If you are on benzodiazepines, your healthcare provider can work with you to safely decrease your dosages when you are ready to stop using them. [14] 

Antidepressants are helpful to treat anxiety as well as depression. Anxiety is closely linked to the neurotransmitter molecule serotonin. Taking Selective Serotonin Reuptake Inhibitors (SSRIs) can help anxiety by working to maintain high circulating levels of serotonin in the blood. The Science section provides more detail on serotonin, and how it works to help in the treatment of anxiety. [14] 

Beta-blockers are a medication usually used to treat high blood pressure. They are very useful to help relieve the physical symptoms of anxiety, including rapid heartbeat and shaking or trembling. They can also be used on an as-needed basis to help with episodes of acute anxiety, including some predictable forms of social anxiety such as public speaking or performing. [14]