Examining sex differences in CBT effectiveness for anxiety disorders, and explaining and tackling their high prevalence in women: A meta-analysis, and a systematic review focused on gender, “vulnerability in affiliation”, and implementation options

Anxiety disorders are, together with mood disorders, the most prevalent and costly mental disorders in The Netherlands [1, 2]. Approximately twice as many women than men develop an anxiety disorder, a difference that most likely occurs due to a sex-related (i.e., mainly biological) factors, with gender-related (i.e., mainly social and psychological including cognitive) factors [15]. Moreover, in many cases, anxiety disorders precede depressive disorders, that also occur twice as often in women than in men, also due to sex- as well as gender-related factors. Particularly the gender-related factors seem suitable for being addressed in psychological treatments. Fortunately, many gender relevant aspects of anxiety disorders have been discussed in the literature, by other authors [15], but also by ourselves [7, 35, 36] in several scientific papers and recently also in fact sheets for educating and training mental health care professionals. However, an updated comprehensive overview is lacking. Also, current knowledge is rather fragmented and lacks a coherent, synthesizing perspective. Moreover, the most recent review, from 2009 [15], did not offer concrete suggestions for gender sensitive treatment options in men and women. More in general, little or none attempts have been undertaken to integrate gender sensitive knowledge into existing anxiety disorder treatments, such as cognitive behavioral therapy (CBT), the ‘golden standard’ treatment, and/or in prevention and early detection for decreasing chronicity and/or relapse. This is remarkable, especially because current treatment effects are far from optimal [5]. In addition, no meta-analyses have yet been carried out to investigate whether men and women have comparable treatment outcomes. As is known from other fields, incorporating gender sensitive knowledge into treatment and therewith making treatment more gender sensitive likely increases effectivity. In sum, concerning the, especially for women, highly prevalent and invalidating psychopathology category of anxiety disorders, there is a world to win. To get this world within reach, necessary steps are optimizing the current gender relevant knowledge by updating and synthesizing the now fragmented knowledge into a coherent framework - while identifying the knowledge gaps; and evaluating to what degree available gender related knowledge seems suitable for integration into prevention and treatment. In order to work towards this goal, we aim to carry out 1) a meta-analysis, investigating sex differences in CBT outcomes for anxiety disorders, and 2) a systematic review on gender-related factors explaining the sex differences in prevalence and other relevant aspects of anxiety disorders, as targets for (early) intervention. Within our review we will pay special attention to what we consider a particularly promising factor: “vulnerability in affiliation”, which we, tentatively, circumscribe as a so strong orientation toward fulfilling others’ needs that own needs are ignored. Many studies have shown that, on average, women tend to be more involved with and seek more closeness to others, possibly contributing to more internalizing disorders among women. A high need for affiliation may be associated with problematic anger regulation (i.e., silencing the self, [24, 25]), autonomy problems [26], lower self-esteem [12], anxious attachment, and emotion focused coping [28]. These tendencies - which seems more characteristic for women than for men, but particularly for female clinical populations - may have adverse effects on mental health. Aside from gender aspects we will, particularly in our review, also take other diversity factors into consideration, such as ethnic diversity and social-economic background. The resulting papers will highly contribute to the current state-of-the-art scientific literature on sex differences in anxiety disorders, as our overview on gender related factors will provide not only an update of the current literature but also a coherent framework – that is currently lacking. In the review we will also delineate gaps in the current scientific literature, and offer concrete starting points for future studies, such as on gender sensitive treatment for anxiety disorders. Through our obtained gender expertise, we believe vulnerability in affiliation to be a key component of what establishes sex differences in psychopathology, particularly in anxiety disorders. Moreover, as – astonishingly - sex differences in anxiety disorder treatment have not been meta-analyzed yet, and as little efforts have been undertaken to translate the wealth of gender relevant literature on anxiety disorders to concrete treatment strategies, our work will contribute to more gender sensitive, and, more in general, more diversity-sensitive prevention and treatment of anxiety disorders and therewith most probably to increased effectiveness.