Women & Mental Illness
The Facts
• Despite being common, mental illnesses are
under-diagnosed or mis-diagnosed
• Less than half of those who meet diagnostic
criteria for psychological disorders are
identified by doctors
Gender Specific Risk Factors
• Gender specific risk factors for common mental
disorders that disproportionately affect women
include:
–
–
–
–
–
gender based violence,
socioeconomic disadvantage,
low income and income inequality,
low or subordinate social status and rank
and unremitting responsibility for the care of others
(World Health Organization)
Examples of Disorders Specific to Women
• Premenstrual Dysphoric Disorder
• Major Depression during
conception and pregnancy
• Postpartum Depression
• Depression during the transition to
menopause
Mood Disorders
Depression
• Depression in women is often more severe than in
men; affects twice as many women as men
• Many factors influence depression. In women these
may include:
• biological factors
– differences in brain functioning between women and men
– women’s unique hormones and reproductive functions
• psychological factors
– ways in which women are socialized as “women” – how
they learn to think, feel and act
Unipolar/Major Depression
Marked by:
• Extreme lethargy
• Disturbed sleep, early waking, difficulty getting to
sleep and waking up tired
• Permanent sense of anxiety
• Sensation of utter despair, hopelessness or
uselessness
• Irritability and physical exhaustion
• The disturbance is not due to the direct
physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical
condition
Associated Features:
• Lack of concentration
Lack of sexual drive
Irrational fears such as fear of death, thoughts of
suicide, or fear of committing suicide
(American Psychiatric Association)
Unipolar/Major Depression
• Many of the same symptoms as hypothyroidism;
hypothyroidism can also trigger depression
• Unipolar depression, predicted to be the second leading cause
of global disability burden by 2020, is twice as common in
women (World Health Organization)
Seasonal Affective Disorder (SAD)
• The symptoms of SAD differ from clinical depression and
include:
– Low mood, reduced interest in normally pleasurable activities,
decreased concentration
– Oversleeping (often an increase of 4 hours or more each day)
– Low energy and fatigue
– Weight gain and carbohydrate/sweets craving
– Withdrawal from social contacts
– Depression
(Mood Disorders Society of Canada)
Seasonal Affective Disorder con’t ...
• Most people with SAD have unipolar depression, but as many
as 20% may have or go on to develop a bipolar disorder
• women are eight times more likely to suffer from SAD than
men
(Mood Disorders Society of Canada)
Adolescence
• Before adolescence, there is little difference
in the rate of depression in boys and girls
• Between the ages of 11 and 13 there is a rise
in depression rates for girls
• By the age of 15, females are twice as likely to
have experienced a major depressive episode
as males
– Females have significantly higher rates of
depression, anxiety disorders, eating
disorders, and adjustment disorders; males
have higher rates of disruptive behaviour
disorders
(National Institute of Mental Health)
Adulthood: Relationships & Work
• Stress in general can contribute to depression in
persons biologically vulnerable to the illness
• The higher incidence of depression in women is
not due to greater vulnerability, but to the
particular stresses that many women face
– e.g., responsibilities at home and work, single
parenthood, and caring for children and aging
parents
• Lack of an intimate, confiding relationship, as well
as marital disputes, are often related to
depression in women
– rates of depression are highest among unhappily
married women
(National Institute of Mental Health)
Adulthood: Reproductive Events
• Reproductive events include: menstrual cycle,
pregnancy, the post-pregnancy period,
infertility, menopause, and sometimes, the
decision not to have children
• Many women experience certain behavioural
and physical changes associated with phases of
their menstrual cycles
– in some women, these changes are severe,
occur regularly, and include depressed
feelings, irritability, and other emotional
and physical changes (i.e, premenstrual
syndrome [PMS] or premenstrual dysphoric
disorder [PMDD])
• Postpartum mood changes can range from
transient "blues" immediately following
childbirth to an episode of major depression to
severe, incapacitating, psychotic depression
Adulthood: Reproductive Events con’t ...
• Pregnancy itself seldom contributes to
depression, and having an abortion does not
appear to lead to a higher incidence of
depression
– Women with infertility problems may be
subject to extreme anxiety or sadness,
though it is unclear if this contributes to a
higher rate of depressive illness
– Motherhood may be a time of heightened
risk for depression because of the stress
and demands it imposes
• Menopause, in general, is not associated
with an increased risk of depression
– women more vulnerable to change-of-life
depression are those with a history of past
depressive episodes
(National Institute of Mental Health)
Abuse & Depression
• women molested as children are more likely to have clinical
depression at some time in their lives than those with no such
history
• a higher incidence of depression among women who have
been raped as adolescents or adults
• women who experience other commonly occurring forms of
abuse, such as physical abuse and sexual harassment on the
job, also may experience higher rates of depression
• abuse may lead to depression by fostering low self-esteem, a
sense of helplessness, self-blame, and social isolation
• there may be biological and environmental risk factors for
depression resulting from growing up in a dysfunctional family
(National Institute of Mental Health)
Poverty
• Women and children represent seventy-five
percent of the North American population
considered “poor”
• Low economic status brings with it many
stresses, including isolation, uncertainty,
frequent negative events, and poor access to
helpful resources
• Sadness and low morale are more common
among persons with low incomes and those
lacking social supports
(National Institute of Mental Health)
Later Adulthood
• At one time, it was commonly thought that women were
particularly vulnerable to depression when their children left
home and they were confronted with "empty nest syndrome"
and experienced a profound loss of purpose and identity
– most studies show no increase in depressive illness among
women at this stage of life
• However, more elderly women than men suffer from
depressive illness
– being unmarried (which includes widowhood) is a risk
factor for depression
(National Institute of Mental Health)
Suicide
• Four times as many men as women die by suicide; however,
women attempt suicide two to three times as often as men
(National Institute of Mental Health)
Suicide con’t ...
• Suicides and attempted suicides are very rare in the absence
of current major psychiatric disorders
• More than 90% of suicide victims and attempters have at least
one current Axis I (mainly untreated) major disorder, most
frequently major depressive episode (56-87%), substance use
disorders (26-55%) and schizophrenia (6-13%).
• Comorbid anxiety and personality disorders as well as serious
medical disorders are also frequently present, but they are
quite rare as principal (or only) diagnoses
(Rihmer, 2007)
Suicide
(data from Harvard University and the World Mental Health Survey)
• Risk factors for suicidal thoughts, plans and attempts are consistent
across countries, and include having a mental disorder and being
female, younger, less educated, and unmarried
• The risk of suicidal thoughts increased sharply during adolescence
and young adulthood in every country studied
• The strongest risk factor associated with suicidal thoughts and
behaviours were mood disorders in high income countries and
impulse control disorders in low- and middle-income countries
• The risk of making an attempt was highest among those with
substance abuse and impulse-control disorders
(17 countries: Nigeria, South Africa, Colombia, Mexico, USA, Japan,
New Zealand, China, Belgium, France, Germany, Italy, the Netherlands,
Spain, Ukraine, Israel, and Lebanon)
Anxiety Disorders
Post-traumatic Stress Disorder
• Violent personal assault, such as rape or mugging, car or
plane accidents, military combat, industrial accidents and
natural disasters, such as earthquakes and hurricanes, are
stressors which have caused people to suffer from PTSD
• In some cases, seeing another person harmed or killed, or
learning that a close friend or family member is in serious
danger has caused the disorder.
(Canadian Mental Health Association)
Post-traumatic Stress Disorder
• The high prevalence of
sexual violence to which
women are exposed and
the correspondingly high
rate of Post Traumatic
Stress Disorder (PTSD)
following such violence,
renders women the
largest single group of
people affected by this
disorder
Posttraumatic Stress Disorder
• The essential feature of posttraumatic stress disorder
(PTSD) is the development of characteristic symptoms
following exposure to a traumatic event that arouses
"intense fear, helplessness, or horror," or in children,
"disorganized or agitated behaviour" (American
Psychiatric Association 1994, p. 428)
• A host of stressors, both natural and manmade, can be
traumatizing.
• Naturally occurring stressors include natural disasters and
medical illnesses.
• Man-made events include accidents and acts of violence
(e.g., rape, war)
Posttraumatic Stress Disorder
A. The person has been exposed to a traumatic event in
which both of the following were present:
(1) the person experienced, witnessed, or was confronted
with an event or events that involved actual or
threatened death or serious injury, or a threat to the
physical integrity of self or others
(2) the person's response involved intense fear, helplessness,
or horror. Note: In children, this may be expressed
instead by disorganized or agitated behaviour
Posttraumatic Stress Disorder
B. The traumatic event is persistently re-experienced in one (or more)
of the following ways:
(1) recurrent and intrusive distressing recollections of the event,
including images, thoughts, or perceptions. Note: In young
children, repetitive play may occur in which themes or aspects of
the trauma are expressed.
(2) recurrent distressing dreams of the event. Note: In children, there
may be frightening dreams without recognizable content.
(3) acting or feeling as if the traumatic event were recurring (includes
a sense of reliving the experience, illusions, hallucinations, and
dissociative flashback episodes, including those that occur on
awakening or when intoxicated). Note: In young children, traumaspecific reenactment may occur.
(4) intense psychological distress at exposure to internal or external
cues that symbolize or resemble an aspect of the traumatic event
(5) physiological reactivity on exposure to internal or external cues
that symbolize or resemble an aspect of the traumatic event
Posttraumatic Stress Disorder
C. Persistent avoidance of stimuli associated with the
trauma and numbing of general responsiveness (not
present before the trauma), as indicated by three (or
more) of the following:
(1) efforts to avoid thoughts, feelings, or conversations associated with the
trauma
(2) efforts to avoid activities, places, or people that arouse recollections of the
trauma
(3) inability to recall an important aspect of the trauma
(4) markedly diminished interest or participation in significant activities
(5) feeling of detachment or estrangement from others
(6) restricted range of affect (e.g., unable to have loving feelings)
(7) sense of a foreshortened future (e.g., does not expect to have a career,
marriage, children, or a normal life span)
Posttraumatic Stress Disorder
D. Persistent symptoms of increased arousal (not present before the
trauma), as indicated by two (or more) of the following:
(1) difficulty falling or staying asleep
(2) irritability or outbursts of anger
(3) difficulty concentrating
(4) hyper-vigilance
(5) exaggerated startle response
E. Duration of the disturbance (symptoms in Criteria B, C, and D) is
more than 1 month.
F. The disturbance causes clinically significant distress or impairment
in social, occupational, or other important areas of functioning.
Other Anxiety Disorders
• Generalized Anxiety Disorder  55-60% of sufferers
are women
• Panic Disorder  approximately two thirds of those
who seek treatment are women
• Specific Phobias 
– 75 to 90% of individuals with animal, natural environment,
and situational types of specific phobias are women
– 55 to 70% of individuals with fear of heights and bloodinjection-injury phobias are women
(Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition)
Generalized Anxiety Disorder
A. 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).
B. The person finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the
following six symptoms (with at least some symptoms present for more
days than not for the past 6 months). Note: Only one item is required in
children.
(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)
• The anxiety, worry, or physical symptoms cause clinically significant
distress or impairment in social, occupational, or other important areas
of functioning.
Panic Disorder
(with or without Agoraphobia)
A. Both (1) and (2):
(1) recurrent unexpected Panic Attacks
(2) at least one of the attacks has been
followed by 1 month (or more) of one (or
more) of the following:
(a) persistent concern about having additional
attacks
(b) worry about the implications of the attack
or its consequences (e.g., losing control,
having a heart attack, "going crazy")
(c) a significant change in behaviour related
to the attacks
B. The presence or absence of Agoraphobia.
Phobias
A. Marked and persistent fear that is excessive or
unreasonable, cued by the presence or anticipation
of a specific object or situation (e.g., flying,
heights, animals, receiving an injection, seeing
blood).
B. Exposure to the phobic stimulus almost invariably
provokes an immediate anxiety response, which
may take the form of a situationally bound or
situationally predisposed Panic Attack.
Note: In children, the anxiety may be expressed by
crying, tantrums, freezing, or clinging.
C. The person recognizes that the fear is excessive or
unreasonable.
Note: In children, this feature may be absent.
D. The phobic situation(s) is avoided or else is endured
with intense anxiety or distress.
Phobias
E. The avoidance, anxious anticipation, or distress in
the feared situation(s) interferes significantly with
the person's normal routine, occupational (or
academic) functioning, or social activities or
relationships, or there is marked distress about
having the phobia.
F. In individuals under age 18 years, the duration is at
least 6 months.
Specify type:
Animal Type; Natural Environment Type (e.g., heights,
storms, water);
Blood-Injection-Injury Type ; Situational Type (e.g.,
airplanes, elevators, enclosed places);
Other Type (e.g., phobic avoidance of situations that
may lead to choking, vomiting, or contracting an
illness; in children, avoidance of loud sounds or
costumed characters)
Personality Disorders
Borderline Personality
• Girl, Interrupted
• Fatal Attraction
Borderline Personality Disorder
• One in every 33 women, compared with
one in every 100 men, are diagnosed with
Borderline Personality Disorder
• 75% of those diagnosed are women
• 75% have been physically or sexually
abused
(National Institute for Mental Health)
Borderline Personality Disorder
• Still a controversial diagnosis
• Has been one of the most diagnosed and most researched of
the personality disorders
• The main feature of borderline personality disorder is a
pervasive pattern of instability in interpersonal relationships,
self-image, and emotions
• The road to recovery is long
• Often comorbid with other disorders
(The Psychiatric Times)
From: www.thelastpsychiatrist.com
• First, borderline is a heuristic of countertransference: if the psychiatrist
feels frustrated, or exasperated, then the patient is borderline.
• Second, borderline is meant as a synonym for any of the following: needy,
argumentative, touchy/hypersensitive.
• Third, it is generally reserved for the following four types:
1. Very attractive female, who comes for problems the psychiatrist considers
ordinary: men, work/school, problems with parents, etc. It is diagnosed here most
often by female psychiatrists, and carries the connotation: "Grow up.“
2. Overweight, typically white, female, who needs/wants benzos, especially
Klonopin. The implications are lack of self-control, and reliance on external
supports.
3. Thin female with a lot of anger. By example, the woman who comes for treatment
of "depression" but describes most life events in terms of attacks, sleights, harm,
etc.-- i.e., power differentials.
4. Gay man.
Borderline Personality Disorder
Diagnostic Features:
Borderline Personality Disorder is a condition characterized by
impulsive actions,
rapidly shifting moods,
and chaotic
relationships.
The individual usually goes from one emotional crisis to another. Often
there is dependency, separation anxiety, unstable self-image, chronic
feelings of emptiness, and threats of self-harm (suicide or selfmutilation). This disorder is only diagnosed when these behaviours
become persistent and very disabling/distressing.
Borderline Personality Disorder
Complications:
Completed suicide occurs in 8%-10% of individuals with this
disorder, and self-mutilative acts (e.g., cutting or burning) and
suicide threats and attempts are very common. Recurrent job
losses, interrupted education, and broken marriages are common.
Comorbidity:
Very stressful or chaotic childhoods are commonly reported (e.g.,
physical and sexual abuse, neglect, hostile conflict, and early
parental loss or separation). Mood disorders, Substance-Related
Disorders, Eating Disorders (usually Bulimia), Posttraumatic Stress
Disorder, Attention-Deficit/Hyperactivity Disorder, and other
Personality Disorders frequently co-occur with this disorder.
Eating Disorders
Eating Disorders
• Eating disorders affect far more women than
men, however, the numbers for men are
increasing with more gay men than
heterosexual men suffering from the disorders
(International Journal of Eating Disorders)
• Ratio of women to men suffering from
anorexia nervosa is estimated at 20:1
• most commonly begins during puberty
Axorexia Nervosa
• Symptoms include:
• Losing a lot of weight.
• An inability to maintain a weight that is
normal for one’s age and height
• An obsessive desire to be thinner
• Fear of gaining weight or becoming "fat”
• Distorted perception of one’s own body
• Allowing weight and shape to overly
influence how one feels about
themselves
• A powerful desire to take control of
one’s life and feel competent
(National Eating Disorder Information Centre)
Bulimia Nervosa
• Ratio of women to men suffering from
anorexia nervosa is estimated at 20:1
• Symptoms include:
• Eating large amounts of food frequently and
in one sitting
• Feeling out of control and unable to stop
eating
• Eating quickly and in secret
• Feeling uncomfortably full after eating
• Feeling guilty and ashamed of the binges
(National Eating Disorder Information Centre)
Pro-ana (pro-anorexia) and Pro-mia (pro-bulimia)
• Fading Obsession
– 57 Reasons
– Thinspiration
– Includes an extensive Tips & Tricks section, including:
• Distractions (i.e., things you can do instead of eating)
• Fasting
• Purging
• Secrecy (i.e., how to keep people from being
suspicious)
1. General feedback: Midterm projects
2. Discussion: Monster/Violence Against
Women
3. Disorders: continued
4. Sexuality
Somatoform Disorders
Somatoform Disorders
• Shared characteristics of somatoform
disorders:
– physical symptoms or complaints
for which there is no organic basis
– symptoms may include sensory or
motor disability, hypersensitivity,
and pain
Somatization Disorder
•
•
•
•
four pain symptoms
two gastrointestinal symptoms
one sexual symptom
one psuedo-neurological symptom
Conversion Disorder
• Physical, emotional, or sexual abuse can be
a contributing cause
• Women diagnosed with conversion disorder
outnumber men by a 2:1 to 10:1 ratio
• Risk of addictions may be high in
somatoform disorders because of
medications used to manage physical pain
History of “Hysteria”
• Hysteria comes from the Greek
word, hystera, meaning womb
• Originally designated a link
between certain nervous disorders
and diseases of the female sexual
and reproductive organs
• Therefore, hysteria was thought of
as something to which women
were exclusively susceptible
• Hippocrates’ theory on the wandering womb had a
great impact on feelings about the female body and
sexuality
Hippocrates
• Hippocrates, as well as generations of medical
thinkers after him, viewed the womb as an
independent creature
• Because female bodies were thought to crave
warmth and moisture, frequent sexual activity was
needed to stabilize the uterus
• It was thought that unnatural behaviour, such as
celibacy or an excess of “male activities,” would drive
the uterus to distraction and cause it to wander
freely throughout the body
• There were various consequences to these travels
depending on how far the uterus wandered and
where it chose to attach itself, but when the roving
organ ultimately came to rest next to the brain, it
caused hysteria
(Phillips, 2006)
The Victorian Era
• Estimated that a quarter of all women
suffered from hysteria (not surprising since
the list of symptoms was 75 pages long)
• In the 19th century, female sexual arousal
did not have a name, it had a diagnosis
• Genital massage was the treatment for
hysteria
• the vibrator was developed to automate a
function that doctors had been performing
for their female patients
– the relief of physical, emotional and sexual
tension through external pelvic massage,
culminating in orgasm
Further Prevalence Stats
from the
American Psychiatric Association
Prevalence
• Depressive disorders account for close to 41.9% of the
disability from neuropsychiatric disorders among women
compared to 29.3% among men
• Leading mental health problems of the elderly are depression,
organic brain syndromes and dementias—a majority are
women
• An estimated 80% of 50 million people affected by violent
conflicts, civil wars, disasters, and displacement are women
(and children)
• Lifetime prevalence rate of violence against women ranges
from 16% to 50%
• At least one in five women suffer rape or attempted rape in
their lifetime
Prevalence
• 1 in 5 women will experience an episode of major
depression during her lifetime
• 1 in 3 will experience an anxiety disorder
• Anxiety/panic disorder occurs more often in women
than men
• 85-95 % of people with anorexia or bulimia are women
• The risk of PTSD following traumatic experiences is
two-fold higher in women than men
• Four times as many men as women die by suicide;
women attempt suicide 2-3 times more often as men
(American Psychiatric Association)
The Politics of Diagnosis
• Labelling a cluster of symptoms will affect how the
individual views the problem
– e.g., if a person is told that they are suffering from
depression they may ignore other factors that could be
contributing to exhaustion, such a lack of sleep, poor
exercise and dietary habits
• Diagnostic categories are also influenced by
stereotypes
– Men predominate in aggressive and antisocial disorders;
women are most often diagnosed with depression and
anxiety (involving passivity and helplessness)
The Politics of Diagnosis
• Stereotyped descriptions were given to psychologists
and psychiatrists who were asked to provide
diagnoses (they were also told that the cases might
be ‘normal’)
–
–
–
–
Lower-class men: antisocial
Married, middle-class woman: dependent
Single, middle-class woman: histrionic/hysterical
Married, upper-class man: normal
*both male and female therapists were influenced by
the stereotypes about gender and class
The Politics of Diagnosis: PMDD
• Premenstrual Dysphoric Disorder
• The woman experiences 5 symptoms during the
prementrual phase:
– depressed and hopeless feelings, marked anxiety and
tension, tendency toward sudden sadness and crying,
persistent anger or irritability, lethargy, decreased interest
in activities, appetite changes, insomnia, a sense of being
out of control, and physical symptoms (e.g., bloating,
headache)
• APA Committee on Women unanimously opposed
the inclusion of PMDD in the DSM, as did more than
6 million others (evidenced by letters, petitions)