Treatment for General Anxiety Disorder
The definition of general anxiety disorder, “GAD,” is an exaggerated state of persistent worrying that is uncontrollable and impairing, occurring more than 50% of the time over at least 6 months. It is often accompanied by distress, apprehension, mood irritability and even physical manifestations, such as fatigue and muscular tension.1
There is evidence that the biochemistry of the brain is heavily involved, including neurotransmitters.2,3
Treatment for GAD involves identifying and addressing the following:
- Genetic factors
- Neuropsychological factors
- Developmental and personality factors
Genetic factors are already done and can’t really be undone. However, identifying a family history will help identify other co-morbidities that will affect treatment. For example, if a major depression figures prominently in a parent, clues to the same, well-hidden before learning the family history, may become identifiable. Success in treating GAD may depend, for instance, in adequately treating major depression, diagnosed during GAD assessment.
Neuropsychological factors, such as variations in the brain’s glucose metabolism and receptor site (for neurotransmitters) density, can be addressed with diet, antidepressants, anti-anxiety agents, and benzodiazepines.
Developmental and personality factors, such as psychological deterioration from traumatic childhood experiences, can be addressed from a psychiatric approach, especially useful if there is a component of depression or panic disorder.
The nuts and bolts of treatment—CBT and medication
Cognitive Behavioral Therapy (CBT)
Cognitive and behavioral therapies are educational interventions that teach relaxation, coping skills, stress management, and assertiveness training.4 It is most successful when a patient is motivated. Skills are practiced during repeated exposure to stressors and stimuli, and repeated resolutions reinforce its success.
CBT is also helpful in depression, PTSD, panic disorder, OCD, and even medical conditions (smoking, over-eating, etc.), so it is doubly useful when someone suffering from GAD has one of these as a co-morbidity.
- Antidepressants. Antidepressants that affect serotonin (SRIs) or serotonin + norepinephrine (SNRIs) neurotransmitters are usually seen as a first choice before those below are considered. There are many SRIs and NSRIs on the market today. The other type of antidepressant, the tricyclic (clomipramine or imipramine), is usually bypassed in lieu of the SRIs and SNRIs because of consideration for side effects.
- SRIs. SRIs are “serotonin reuptake inhibitors,” which inhibit the metabolizing of serotonin so it hangs around longer in the nerve cells’ synapse. Serotonin is active in feelings of well-being.
- SNRIs are “serotonin and norepinephrine reuptake inhibitors,” which keep both serotonin and norepinephrine (noradrenaline) present longer. Both serotonin and norepinephrine contribute to mood stabilization and well-being.
Side effects of these include nausea, dry mouth, dizziness, headache, excessive sweating, fatigue, constipation, decreased libido, and insomnia.
- “Tranquilizers” (benzodiazepines). Also considered anti-anxiety (see below), benzodiazepines enhance the actions of the neurotransmitter gamma amino butyric acid (GABA). GABA slows things down (inhibits) and normally counteracts its counterpart, glutamate, which excites. Because chronic pain exhibits an imbalance between GABA and glutamate, the benzodiazepines have been used extensively in chronic pain management; however, this is no longer recommended due to the dangers of mixing these with other pain management drugs, such as narcotics and muscle relaxers.
Examples of the benzodiazepines:
Alprazolam (Xanax), clonazepam (Klonopin), clorazepate (Tranxene), chlordiazepoxide (Librium), diazepam (Valium), lorazepam (Ativan), oxazepam (Serax), temazepam (Restoril), and triazolam (Halcion).
Side effects include sleep disorders, diarrhea, nausea, and fatigue. They are not used in pregnancy (Category “D”). They have a high abuse potential, and sudden withdrawal can result in seizures and death, especially in those benzodiazepines with the fastest onset of action, such as alprazolam (Xanax). Although they are not recommended as part of a strategy for pain management, they often are begun after orthopedic surgery and then continued, combined with narcotics, which is an extremely hazardous situation.
- Pregabalin (Lyrica)
This is a drug which breaks down into gabapentin (which is the drug Neurontin). This is an anticonvulsant, thereby inhibitory to runaway nerve impulses.
Side effects are fatigue, dizziness, blurred vision, headache, dry mouth, and loss of balance.
- The antianxiety agent, buspirone (BusPar, Vanspar) can augment the benefits of antidepressants used in GAD. Unlike the tranquilizers above, it does not enhance the effects of GABA, which means it has a low abuse potential. It binds to the same receptors that serotonin does, yielding a similar effect (well-being).
Side effects include dizziness, headaches, nausea, nervousness, and “paresthesias” (misfiring of nerves, producing tactile sensations such as “pins and needles,” itching, etc.).
Combined CBT and medication
Recent studies have championed a combined approach of CBT plus medication (“augmentation of CBT”). Such treatment can result in an 80% resolution rate but this result takes years.
General anxiety disorder is a genetic, evolutionary, and biochemical impediment to the day-to-day goings-on for persons who suffer with it. It is important to address it, not only to improve the chance of eventually resolving it, but to identify other serious disorders that may be hiding within it, waiting for the right moment to erupt. Such “co-morbidities” require therapy in their own right, which is addressed in the next article.
- Dugas MJ, Marchand A, Ladouceur R. Further validation of a cognitive-behavioral model of generalized anxiety disorder: diagnostic and symptom specificity. J Anxiety Disord 2005; 19:329.
- Beck JS. Cognitive Behavior Therapy: Basics and Beyond, 2nd ed, Guilford Press, New York 2011. p.391.
- Wittchen HU, Zhao S, Kessler RC, Eaton WW. DSM-III-R generalized anxiety disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1994; 51:355.
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