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

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.

Neuropsychological factors, such as variations in the brain’s glucose metabolism and receptor site 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.

Medication

• Antidepressants: Antidepressants that affect serotonin (SRIs) or serotonin + norepinephrine (SNRIs) neurotransmitters are usually seen as a first choice.

– 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.

Examples include: Fluoxetine (Prozac); citalopram (Celexa); escitalopram (Lexapro, Cipralex); paroxetine (Paxil); and sertraline (Zoloft).

– SNRIs: SNRIs are “serotonin and norepinephrine reuptake inhibitors,” which keep both serotonin and norepinephrine present longer. Both contribute to mood stabilization and well-being.

Examples include: Venlafaxine (Effexor); duloxetine (Cymbalta); and desvenlafaxine (Pristiq, Khedezla).

Side effects of these include nausea, dry mouth, dizziness, headache, excessive sweating, fatigue, constipation, decreased libido, and insomnia.

• “Tranquilizers” (benzodiazepines): Benzodiazepines enhance the actions of the neurotransmitter gamma amino butyric acid (GABA).

Examples: 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 have a high abuse potential, and sudden withdrawal can result in seizures and death.

• Pregabalin (Lyrica): A drug which breaks down into gabapentin (Neurontin), an anticonvulsant.

Side effects include fatigue, dizziness, blurred vision, headache, dry mouth, and loss of balance.

• The antianxiety agent, buspirone (BusPar, Vanspar) can augment the benefits of antidepressants. It binds to the same receptors that serotonin does.

Side effects include dizziness, headaches, nausea, nervousness, and “paresthesias.”

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.

Concluding

General anxiety disorder is a genetic, evolutionary, and biochemical impediment. Addressing it can improve the chance of resolving it and help identify other serious disorders that may be associated.

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Resources:

1. UpToDate.
2. 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.
3. Psychology Today.
4. Beck JS. Cognitive Behavior Therapy: Basics and Beyond, 2nd ed, Guilford Press, New York 2011. p.391.
5. Mayo Clinic
6. UpToDate
7. 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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