Generalized Anxiety Disorder Treatment

John M. Grohol, Psy.D.
24-Jun-2004

Introduction

Since all anxiety disorders can have medical cause or component, it is important for individuals to be thoroughly medically checked out before consulting psychological or psychiatric care. For instance, individuals who drink a lot of caffeine can present with many similar symptoms of anxiety, and even panic attacks. A good medical examination will rule out this and other biological or environmental causes and possibilities.

Anxiety is often a component found within many other mental disorders as well. The most common mental disorder which presents with anxiety is depression. Clinicians generally regard such anxiety as a good sign, because it means that the individual hasn't simply accepted their depressed mood as they would a free meal... They are depressed and they are anxious because they are concerned about the ego dystonic nature of their depressed mood. A thorough initial evaluation is rudimentary to ruling out other possible and more appropriate diagnoses.

Treatment for generalized anxiety disorder (also known as GAD) is varied and a number of approaches work equally well. Typically the most effective treatment will be an approach which incorporates both psychological and psychopharmacologic approaches. Medications, while usually helpful in treating the bodily symptoms of acute anxiety (e.g., panic attacks), are best used for this disorder as a short-term treatment only (a few months). Clinicians should be especially watchful of the individual becoming psychologically or physiologically addicted to certain anti-anxiety medications, such as Xanax.


Psychotherapy

Psychotherapy for GAD should be oriented toward combatting the individual's low-level, ever-present anxiety. Such anxiety is often accompanied by poor planning skills, high stress levels, and difficulty in relaxing. This last point is important because it the easiest one in which the therapist can play an especially effective teaching role.

Relaxation skills can be taught either alone or with the use of biofeedback. Education about relaxation and simple relaxation exercises, such as deep breathing, are excellent places to begin therapy. While biofeedback (the ability to allow the patient to hear or see feedback of their body's physiological state) is beneficial, it is not required for effective relaxation to be taught to most people. Progressive muscle relaxation and more general imagery techniques can be used as therapy progresses. Teaching an individual how to relax, and the ability to do it in any place or situation is vital to reducing the low-level anxiety levels. Individuals who learn these skills, which can be taught in a brief-therapy framework, go on to lead productive, generally anxiety-free lives once therapy is complete. A common reason for failure to make any gains with relaxation skills is simply because the client does not practice them outside of the therapy session. From the onset of therapy, the individual who suffers from GAD should be encouraged to set a regular schedule in which to practice relaxation skills learned in session, at least twice a day for a minimum of 20 minutes (although more often and for longer periods of time is better). Lack of treatment progress can often be traced to a failure to follow through with homework assignments of practicing relaxation.

Reducing stress and increasing overall coping skills may also be beneficial in helping the client. Many people who have GAD also lead very active (some would say, "hectic") lives. Helping the individual find a better balance in their lives between self-enrichment, family, significant other, and work may be important. People who have GAD have lived with their anxiety for such a long time they may not recognize a life without constant worrying and activity. Helping the individual realize that life doesn't have to boring just because one isn't always worrying or doing things may also help.

Individual therapy is usually the recommended treatment modality. Many times people who present with GAD feel a bit awkward discussing their anxiety in front of others, especially if they are less than accepting. A clear distinction should be made at the onset of the evaluation to differentiate GAD from social phobia, however, and the appropriate diagnosis should be made. It would be unwise to recommend group therapy to someone who had social phobia or GAD early on, because of the social component to either disorder. Placing a person into a group setting without minimal interpersonal and relaxation skills being taught first in individual therapy is a recipe for disaster and early treatment termination.

Non-specific factors in therapy are important to these patients, as they will make the most beneficial gains in a supportive and accepting therapeutic environment. Simply listening to the individual and offering objective feedback about their experiences is likely helpful. Examining stressors in the client's life and helping the individual find better ways of handling these stressors is likely to be beneficial. Modeling techniques of appropriate social behaviors within therapy session may help. Clinicians should not confuse GAD with specific phobias, which have much more acute and traumatic symptoms. In the same respect, treatments for specific phobias generally are not appropriate nor effective with GAD. Some clinicians easily confuse this important distinction.

Hypnotherapy is also an appropriate treatment modality for those individuals who are highly suggestible. Often hypnotherapy is combined with other relaxation techniques.

If an individual finds themselves hyperventilating then they are breathing in too much oxygen. One of the correct things to do is to direct them to breath into a paper bag. This does increase the percent of C02 in the inhalation, which thereby helps keep the 02/C02 balance. While this technique is valid, the better technique is to slow down respiration rate and volume with slow deep breaths (without the paper bag).

Robert Fried, Ph. D. (psychologist) has a couple books out on respiration you might want to check out. One of his books is "The Hyperventilation Syndrome," Baltimore, Johns Hopkins Univ. Press, 1987.


Medications

Medication should be prescribed if the anxiety symptoms are serious and interfering with normal daily functioning. Psychotherapy and relaxation techniques can't be worked on effectively if the individual is overwhelmed by anxiety or cannot concentrate.

The most commonly prescribed anti-anxiety agent for this disorder has historically been benzodiazepines, despite a dearth of clinical research that shows this particular class of drugs is any more effective than others. Diazepam (Valium) and lorazepam (Ativan) are the two most prescribed benzodiazepines. Lorazepam will produce a more lengthy sedating effect than diazepam, although it will take longer to appear. Individuals on these medications should always be advised about the medications' side effects, especially their sedative properties and impairment on performance.

Tricyclic antidepressants often are an effective treatment alternative to benzodiazepines and may be a better choice over a longer treatment period.

Medication for this disorder should only be used to treat acute symptoms of anxiety. Medication should be tapered off when it is discontinued.

Phillip W. Long, M.D. also notes:

"Buspirone, a new nonbenzodiazepine antianxiety drug, is non-addictive and does not impair mechanical performance such as driving. Response to buspirone occurs approximately in two weeks, as compared to the more rapid onset associated with benzodiazepines. Schwiezer et al. (1986) studied patients who previously had taken benzodiazepines for the treatment of anxiety and who were later placed on buspirone. These patients were found to have a poor response to buspirone."


Self-Help

Self-help methods for the treatment of this disorder are often overlooked by the medical profession because very few professionals are involved in them. Many support groups exist within communities throughout the world which are devoted to helping individuals with this disorder share their commons experiences and feelings of anxiety. Individuals should first be able to tolerate and effectively handle a social group interaction. Pushing an individual into a group setting, whether it be self-help or a regular group therapy experience, is counterproductive and may lead to a worsening of symptoms.

Symptoms


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Last reviewed: By John M. Grohol, Psy.D. on 9 Oct 2013
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