Struggles of Generalized Anxiety Disorder (GAD)
GAD Generalized Anxiety Disorder
Generalized Anxiety Disorder is one of the most prevalently diagnosed disorders from the Diagnostic and Statistical Manual of Mental Disorders—fourth edition (DSM IV). Because this disorder is so widespread, it is perhaps the most important of the disorders to find an effective treatment. Presently, there are many different theories practiced and each of these theories offers its own treatments for Generalized Anxiety Disorder. Even though several theories exist, most of these theories agree that this disorder is often sporadic, often chronic, and difficult to treat. This hub will summarize what Generalized Anxiety Disorder is; explore Cognitive Behavioral Therapy techniques, analyze the success in treating Generalized Anxiety Disorder, examine other considerations for treatment, and sudden gains in treatment of Generalized Anxiety Disorder.
Generalized Anxiety Disorder
According to DSM IV, Generalized Anxiety Disorder is defined as excessive anxiety and worry that occurs more days than not and lasts for a period of at least six months. This is compounded by the individual finding it difficult to control the worry. It is characterized by restlessness, being easily fatigued, difficulty concentrating irritability, muscle tension, and disturbed sleep. This disorder is diagnosed slightly more in women than in men. Its prevalence is at 3% for a one year rate across the population and 5% lifetime. It appears that there is a familial association at least as a trait. DSM IV reports that, “In anxiety disorder clinics, up to a quarter of the individuals have Generalized Anxiety Disorder as a presenting or comorbid diagnosis.”
Cognitive Behavioral Therapy
Over the last few years, Cognitive Behavioral Therapy has been a popular form of therapy used in treating Generalized Anxiety Disorder. “Given the movement in the field favoring the expansion of cognitive-behavioral treatments,” it seems necessary to discuss its influence first (Dugas & Koerner 2005).
Dugas and Koerner have constructed a cognitive behavioral model and treatment for Generalized Anxiety Disorder. Their theory of Generalized Anxiety Disorder contains four main components: intolerance of uncertainty, positive beliefs about worry, negative problem orientation, and cognitive avoidance. In their article, they go through their treatment process which is built upon six core components: presentation of treatment rationale, worry awareness training, reevaluation of the usefulness of worrying, problem-solving training, cognitive exposure, and relapse prevention. They compared their results to applied relaxation and a wait-list control group. Their study results show that the treatment condition was statistically superior to their wait-list group on each of their study measures. They also show hope of integrative therapies with the ones they have already proposed. They suggest that, in regards to conceptualization and treatment of Generalized Anxiety Disorder, there is considerable room for improvement. However, even with these considerations, they find the future treatment of Generalized Anxiety Disorder through Cognitive Behavioral Therapy very hopeful.
Other theorists in this camp have recently tested the effectiveness of their treatments as well. Dugas, Freeston, Ladouceur, Leger, Langlois, Provencher, et al. did a study on Generalized Anxiety Disorder using group Cognitive Behavioral Therapy (2003). Their focus was positive beliefs about worry, problems solving training, and cognitive exposure. They conducted their experiment in groups of four to six people. They were curious if groups would make treatment time and cost beneficial with equal results. Their findings show that there was an improvement for the participants in groups. Furthermore, in a two year follow up, the individuals who participated in the groups showed continued positive results. There had already been evidence of the benefits in individual therapy and now they have the data to show that group therapy is also effective.
Dugas et al. found that both hypotheses held true. They found that there was significantly greater improvement in the group Cognitive Behavioral Therapy as compared to the control group, and that treatment gains were maintained up to twenty-four months. They recognize that some participants were still on medication and some were receiving follow up treatment at their twenty-four month testing period. Their conclusion is that group therapy for Generalized Anxiety Disorder is just as effective as individual therapy. However, one limitation they found was a greater drop out rate among participants in group settings versus individual therapy.
Rezvan, Baghban, Bahrami, and Abedi tested the effects of cognitive-behavioral therapy versus interpersonal therapy combined with cognitive therapy in treating Generalized Anxiety Disorder (2008). They conducted their experiment using three groups. The first group received only cognitive-behavioral therapy, the second group received combined interpersonal therapy and cognitive-behavioral therapy, and the third group was a control group and received no intervention. In the initial follow up they did not find any difference between the two primary groups. However, they did find that those who experienced both interventions had a decreased rate of short term relapse. This result shows that combined therapy of Cognitive Behavioral Therapy and Interpersonal Therapy has benefits over solely utilizing Cognitive Behavioral Therapy.
Mitte’s study was a meta-analysis of the difference between Cognitive Behavioral Therapy and pharmacotherapy (2005). She discovered in studies directly comparing both forms there were no significant differences in efficacy. She found that attrition rates were actually lower for patients treated with Cognitive Behavioral Therapy. Her conclusion is Cognitive Behavioral Therapy is a good form of therapy for treating Generalized Anxiety Disorder and equally as effective as pharmacologic methods.
With all of the positive findings, it seems that Cognitive Behavioral Therapy is taking the lead in finding treatment for Generalized Anxiety Disorder. Most of these studies are new so there is need for follow up studies to be done. However, Cognitive Behavioral Therapies have shown that they are effective treatments for Generalized Anxiety Disorder, at least in preliminary studies.
Other Considerations for Therapy
Katzman wrote an article on the current considerations in treating Generalized Anxiety Disorder. He contends, “GAD (Generalized Anxiety Disorder) is a serious and chronic condition that requires appropriate long-term treatment” (2009). His view is the short term goal is to treat symptoms and the long term goal is remission. The initial treatment for Generalized Anxiety Disorder is antidepressants but there are many limitations according to Katzman. He lists the limitations as: lack of response in many patients, lack of full remission, and risk of relapse. His claim is that through early clinical studies atypical antipsychotics may have a potential role in treating Generalized Anxiety Disorder. They can be used as a monotherapy or an augmentation to standard treatment. While he contends that this could be a beneficial treatment for persons suffering from Generalized Anxiety Disorder he also calls for further studies to be done to test the efficacy.
This seems to be a new wave of treatment now being suggested. There still needs to be a lot of research done on this method before it can be practiced in clinics.
Vassile, Brucce, Goisman, Pagno, Keller claim that “the past decade has brought major new development in the psychopharmacologic management of generalized anxiety disorder.” They conducted a longitudinal study. They examined the medication prescribing pattern for treatment of anxiety disorders over the last twelve years. They examined psychotropic medication use in 305 patients with Generalized Anxiety Disorder. They found that a significant number of the patients, followed in their study, continued to qualify for the diagnosis throughout the twelve years. Only one fourth of the patients being treated for Generalized Anxiety Disorder were no longer being treated with either selective serotonin reuptake inhibitors (SSRI), selective norepinephrine reuptake inhibitors (SNRI), or benzodiazepine.
This study was done to see if doctors were prescribing drugs even if their patients were no longer showing symptoms of their disorder. This study shows that patients who recovered were less likely to take medication. Although not reported, this study shows something different as well. These medications do not treat the disorder. They treat the symptoms of the disorder. Therefore, using these medications will never lead to a remission of symptoms or a cure of the disorder.
Sudden Gains in GAD
There may be a limitation in some of the studies presented to this point. As stated Generalized Anxiety Disorder is a sporadic disorder. The testing of it may not be sufficiently adequate to catch all of the nuances this disorder may present.
Present’s, Crits-Christoph’s, Gibbons’, Hearon’s, Ring-Kurtz’s, Worley’s, et al. experiment was to test sudden gains in patients using supportive expressive psychotherapy. They found sudden gains in 16% of the participants. 36% of these patients experienced reversal of these gains. The gains were not solidified. Their study is consistent with studies done on Major Depressive Disorder that found the similar results.
While their results were similar to other studies done on Major Depressive Disorder, they found that sudden gains did not predict an end-of-treatment outcome. This means that results could be affected by someone having a good or bad week, which could make results unreliable. They believe this is because Anxiety is so sporadic. They think that it would be good for the field to revamp the way they test anxiety because the disorder is so up and down. They suggest a longer outlook period to help improve testing. It seems that that Generalized Anxiety Disorder is hard to treat, but it is also difficult to measure individuals based on Present’s et al. findings.
Most all theories agree that Generalized Anxiety Disorder is often sporadic, often chronic, and difficult to treat. It is defined as excessive anxiety and worry, occurring more days than not. Although there is considerable room for improvement, it seems that future treatment through Cognitive Behavioral Therapy is very hopeful. Some of the findings were 1) greater improvements in group Cognitive Behavioral Therapy, 2) a combined therapy of Cognitive Behavioral Therapy and 3) Interpersonal Therapy has benefits, and it is equally as effective as pharmacologic methods in treating Generalized Anxiety Disorder.
Through early clinical studies it appears atypical antipsychotics may have a potential role in treating Generalized Anxiety Disorder. However, only one fourth of the patients being treated for Generalized Anxiety Disorder, with other medications, were no longer being treated after twelve years. These medications do not treat the disorder they treat the symptoms of the disorder. Therefore, using these medications will never lead to a remission of symptoms or a cure of the disorder.
The testing of Generalized Anxiety Disorder may not be sufficiently adequate. There are signs that sudden gains do not predict an end-of-treatment outcome. This seems to indicate Generalized Anxiety Disorder is difficult to measure and measurements may need reworking.
Many of these studies have proven their benefit in treating Generalized Anxiety Disorder. There is still room for improvement as a full remission of the disorder and symptoms continues to be a struggle.
Dugas, M., Freeston, M., Ladouceur, R., Leger, E., Langlois, F., Provencher, M., & Boisvert, J. (2003). Group cognitive-behavioral therapy for generalized anxiety disorder: Treatment outcome and long-term follow-up. Journal of Consulting and Clinical Psychology, 71(4), doi: 10.1037/0022-006X.71.4.821
Dugas, M., & Koerner, N. (2005). Cognitive-behavioral treatment for generalized anxiety disorder: current status and future direction. Journal of Cognitive Psychotherapy: An International Quarterly, 19(1), 61-81.
Katzman, M. (2009). Current considerations in the treatment of generalized anxiety disorder. CNS Drugs, 23(2), 103-120
Mitte, K. (2005). Meta-analysis of cognitive-behavioral treatments for generalized anxiety disorder: A comparison with pharmacotherapy. Psychological Bulletin, 131(5), doi: 10.1037/0033-2909.131.5.785
Present, J., Crits-Christoph P., Gibbons, M., Hearon, B., Ring-Kurtz, S., Worley, M., & Gallop, R. (2008). Sudden Gains in the Treatment of Generalized Anxiety Disorder. Journal of Clinical Psychology, 64(1), doi: 10.1002/jclp.20435
Rezvan, S., Baghban, I., Bahrami, F., & Abedi, M. (2008). A comparison of cognitive-behavior therapy with interpersonal and cognitive behavior therapy in the treatment of generalized anxiety disorder. Counselling Psychology Quarterly, 21(4), doi: 10.1080/09515070802602096
Vasile, R., Bruse, S., Goisman, R., Pagano, M., & Keller, M. (2005). Results of a naturalistic longitudinal study of benzodiazepine and ssri use in the treatment of generalized anxiety disorder and social phobia. Depression and Anxiety, 22, doi: 10.1002/da.20089