PCOS and Anxiety

Individuals with PCOS are 3-7x more likely to experience anxiety,[1],[2] with particularly high rates amongst young women.[3] In this article, we explore the link between PCOS and Anxiety.

Anxiety disorders are a group of conditions that are characterized by fear and dread that makes it difficult to function and/or control your reactions.[4]

There are a variety of ways in which anxiety presents, including:[5],[6]

Generalized anxiety disorder (GAD): Fear, worry and constant feeling of overwhelm about everyday things such as work, relationships and health;
Agoraphobia: Intense fear of new experiences, places and people;
Panic disorder: Repeated unexpected panic attacks that do not related to another underlying health condition;
Specific phobia: Fear or anxiety about something specific (e.g., heights, spiders) that is so severe that it disrupts your life;
Social anxiety disorder (SAD): Persistent fear of being judged negatively and/or watched by others;
Separation anxiety disorder: Fear of being separated from a loved one (beyond the development stage of being a toddler);
Substance-induced anxiety disorder: Intense fear triggered due to ingesting drugs, taking medications, exposure to a toxic substance and/or withdrawal;
Condition-related anxiety disorder: intense panic caused by a specific health condition; and
Selective mutism: Not talking in some specific situations (usually in young children).

There are a number of conditions that share symptoms with anxiety including post-traumatic stress disorder (PTSD), acute stress disorder and obsessive-compulsive disorder (OCD).[7]

Anxiety symptoms can present in a variety of ways:[8]

Emotional changes which could range from fear, nervousness, worry and restlessness;
Changes to engagement in daily activities, such as problems concentrating and avoiding in things that trigger anxiety;
Fatigue, insomnia or feeling weak;
Experiencing gastrointestinal problems;
Trembling, sweating and/or breathing rapidly (hyperventilation); and
An impending sense of danger or doom.

Anxiety can significantly worsen existing health conditions such as depression or digestive problems and increase the risk of other chronic diseases including arthritis, chronic pain, cardiovascular disease, asthma and peptic ulcers.[9],[10] Likewise, individuals with chronic health conditions can develop anxiety as a result. Individuals with anxiety are more prone to develop substance use problems and withdraw from social interactions, further contributing to poor health.[11] These combined factors exacerbate the risk of suicide.

There are several pathways linking PCOS to increased risk for anxiety:

Androgen excess (in utero): PCOS is associated with elevated levels of hyperandrogenism, an excess level of androgens, a type of sex hormone.[12],[13] Individuals with PCOS are therefore often exposed to elevated androgens in utero, when they are developing in the womb. In-utero exposure to elevated androgens is believed to be linked to anxiety disorders in female offspring (and to a lesser extent male offspring).[14]
Insulin resistance: PCOS is associated with insulin resistance, whereby the cells in your muscles, fat and liver don’t respond well to insulin and can’t easily take up glucose from your blood.[15] Cells in the brain are also believed to develop insulin resistance, disrupting dopamine signaling, the hypothalamic-pituitary-adrenal (HPA) axis and linked to abnormal functioning of the Hippocampal and Anterior Cingulate Cortex (ACC).[16] Brain insulin resistance is believed to increase levels of lipid and protein oxidation (cell damage) in the striatum and nucleus accumbens (NAc),[17] areas of the brain involved in decision making and pleasure, reward and addiction respectively.[18],[19] It also leads to increased levels of monoamine oxidase A and B (MAO A and MAO B).[20] MAO A is a protein that oxidizes serotonin, a hormone influencing happiness and other body processes,[21] as well as norepinephrine and epinephrine,[22] hormones that control the “fight-or-flight” reflex by increasing blood flow in the body.[23],[24] MAO B is a protein that converts serotonin to ammonia (deaminates) serotonin.[25],[26]
Inflammation: PCOS is associated with increased inflammation linked to the reduced production of adiponectin.[27] Increased inflammation leads to increased permeability of the blood brain barrier, enabling inflammatory molecules to enter the central nervous system (CNS).[28] Increased inflammatory signals in the CNS leads to functional and structure changes, particularly in the hippocampus, the region of the brain involved in learning and memory.[29],[30]
Cortisol: PCOS is associated with significantly increased levels of cortisol, the “stress hormone”.[31] These elevated cortisol levels may be a combination of both disruption to the Hippocampus Pituitary Adrenal (HPA) axis[32] and an outcome of living with the burden of disease (see below). Elevated cortisol levels linked to a state of chronic stress is a risk factor for the development and severity of anxiety.[33]
Burden of disease: PCOS, its associated symptoms and health problems as well as poor experiences with the healthcare system can lead to withdrawal from social, professional and/or academic activities, a key risk factor for depression.[34]

Other risk factors for anxiety include:[35]

Certain personality traits such as neuroticism and low levels of extraversion;[36]
Experience of traumatic or stressful events;
Family history of anxiety disorders;
History of other mental health disorders;
Abuse of alcohol or illegal drugs; and
Experience of chronic or severe illness such as cardiovascular disease, hyperthyroidism and/or respiratory disorders.

Anxiety is diagnosed by a healthcare professional through a combination of tests, which can include:[37]

Physical exam and/or questions about your physical health to identify any underlying health problem;
Laboratory tests: blood tests for blood count and thyroid function; and
Psychiatric evaluation: questions about your thoughts, feelings and behavior.

There are a number of clinically-validated assessments that a healthcare professional can use to define the type and severity of anxiety, including:[38]

Hamilton Anxiety Rating Scale (HAM-A): a questionnaire administered by a healthcare professional consisting of 14 items scored on a 5-point scale;[39]
Generalized Anxiety Disorder Scale (GAD-7): a self-reported questionnaire consisting of 7 questions scored on a 4-point scale;
Beck Anxiety Inventory (BAI): a self-reported questionnaire consisting of 21 questions scored on a 4-point scale; and
Diagnostic and Statistical Manual of Mental Disorders (DSM-5): a diagnostic tool for clinicians to measure maladaptive personality traits across negative effect, detachment, antagonism, disinhibition and psychoticism.[40]

Treatment for anxiety often includes a combination of psychotherapy, medication and lifestyle modifications, which can include:[41],[42]

Cognitive behavioral therapy (CBT): CBT provides tools for people to challenge and change unhelpful thoughts and behaviors and can include mindfulness principles and target specific symptoms;
Exposure therapy: Exposure therapy provides the opportunity to confront fears within a safe environment or context and create new, more realistic beliefs or assumptions about the focus of those fears;
Anti-depressants: anti-depressants may be used to treat anxiety in some circumstances, including selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs) and tricyclic antidepressants;
Benzodiazepines: Benzodiazepines such as clonazepam, diazepam and lorazepam trigger the release of a neurotransmitter, gamma-aminobutyric acid (GABA), that slows the activity of the nervous system.[43] GABA has a variety of effects including blocking the formation of new memories and making you feel sleepy; for anxiety disorders it can have a settling effect;[44] and
Beta-blockers: Beta-blockers block the action of epinephrine and norepinephrine, neurotransmitters that trigger the body’s “fight or flight” response.[45] They therefore slow down your heart rate and relax the smooth muscle in blood vessels to treat some of the physical symptoms of anxiety such as rapid heartbeat and trembling.[46]

Neurostimulation, delivered via electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS) or vagus nerve stimulation (VNS) may offer relief for individuals with anxiety that is resistant to other forms of treatment.[47]

Reviewed by Dr. S, one of Neuraura's friends and trusted advisors

Sources

[39] chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://dcf.psychiatry.ufl.edu/files/2011/05/HAMILTON-ANXIETY.pdf

PCOS and Anxiety