Generalized Anxiety Disorder Treatment - Research Paper Example

? Generalized anxiety disorder Generalized Anxiety Disorder and Anxiety Generalized anxiety disorder is different from normal anxiety or nervousness. If untreated, generalized anxiety disorder can cause people to avoid situations that set off or worsen their anxiety. Individuals with generalized anxiety disorder are likely to experience depression, and can abuse alcohol or other drugs in an attempt to gain relief from anxiety. The individual’s tasks such as school, work or performance, can be significantly affected by anxiety disorders (Evans et al. 2008). The main difference between generalized anxiety disorder and anxiety is the stressor. Whereas normal anxiety occurs because of a stressor, such as an interview, exam, a new job or a disagreement, generalized anxiety disorder occurs almost all the time even in the absence of stressors. This implies that an individual with generalized anxiety disorder can have problems through the day and even small responsibilities can make them anxious. Generalized anxiety disorder also produces more intense and longer anxiety periods contrasted to normal anxiety. Even when an individual with generalized anxiety disorder is reacting to a stressor the reaction is often disproportionate to the stressor. Antidepressants that Normal anxiety is proportionate to the intensity of the situation causing the anxiety, people with generalized anxiety disorder are likely to be more anxious (Campbell & Brown, 2002). Normal anxiety is brief while generalized anxiety disorder is ongoing and can last for several weeks. Another difference between the two types of anxiety is that while the symptoms of normal anxiety are mild and at times unnoticeable, generalized anxiety disorder is followed by manifestation of other symptoms such as light-headedness, headaches, dizziness, trembling, nausea, heart pounding, and sweating. Generalized anxiety disorder also affects the individual’s quality of life and impairs the proper functioning of the individual in the end. Avoidance is the main effect of the anxiety disorder and results in the avoidance of activities, which cause anxiety. Normal anxiety results only from things that are related to the situation warranting the anxiety but people with generalized anxiety disorder tends to worry about everything. Moreover, people can control normal anxiety using a variety of coping techniques, but it is difficult for people with generalized anxiety disorders to cope on their own. Symptoms Several symptoms that indicate generalized anxiety disorder exist, and these symptoms vary from one individual to another. Not all individuals with generalized anxiety disorder show the same symptoms and the intensity of the symptoms varies. Although stress does not necessarily cause generalized anxiety, disorder it can intensify the symptoms of the condition. The symptoms are not similar, but people can experience a combination of symptoms including emotional, physical, and behavioral symptoms. The basic emotional symptoms of the disorder include continuous worries, feelings of uncontrollable anxiety, intrusive thoughts concerning the causes of the anxiety, inability to stand uncertainty, and a persistent feeling of apprehension. Behavioral symptoms, on the other hand, include failure to relax and have peaceful times, poor concentration or lack of focus, procrastinating due to the feelings that make the individual overwhelmed and avoiding situations that make the individual anxious. Physical symptoms that indicate generalized anxiety disorder include feelings of tension and tense muscles, difficulty in sleeping or remaining awake, restlessness, jumpiness and stomach problems such as nausea and diarrhea (Borkovec, Alcaine & Behar, 2004). Individuals with generalized anxiety disorder cannot appear to address their concerns, although they often comprehend that they are more anxious than the situation requires. Generalized anxiety disorder develops gradually and often begins during the early stages of life. The symptoms of GAD may improve or worsen during some stages but are always worse during stressful times. The symptoms may not fully manifest in individuals with mild generalized anxiety disorder and these individuals can function normally in society, however, they may face difficulties in undertaking simple tasks. Diagnosis If the symptoms related to GAD are present, then the physician will conduct an evaluation by posing questions regarding the individual’s medical history and performs a physical examination. There are no laboratory tests to diagnose GAD, but physical illnesses can cause symptoms similar to those of GAD and; therefore, it is necessary to rule out these options. The diagnosis of GAD is based on reports of the duration and the intensity of symptoms of the disorder. The diagnosis also includes problems functioning problems associated with the disorder. Determination of the presence of GAD takes into consideration the symptoms the dysfunction associated. Positive diagnosis of GAD involves the presence of anxiety on more days of a period of at least six months and the symptoms must interfere with normal functioning of the individual. There are two standards in the diagnosis of GAD. These standards are the DSM-IV-TR criteria and the ICD-10 criteria (Hoehn-Saric Borkovec & Belzer, 2007). DSM-IV-TR criteria This criterion follows excessive worry and anxiety or anxious expectations occurring for more days within the 6 months period and affects a number of activities. The criteria also look at the difficulty the individual faces in controlling worry. The worry must be associated with at least three other factors or one factor in the case of children and these factors must have occurred for more rather than fewer days within a period of six months. These factors are being easily fatigued, irritability, tension, restlessness, trouble concentrating and sleep disturbance. The center of worry or anxiety must not result from other disorders. The criterion also requires that the worry or anxiety should result in significant distress or impairment in the social functioning of the individual. Furthermore, the anxiety must not have resulted from the use of substances and must not occur only during the presence of other disorders (Borkovec & Ruscio, 2001). ICD-10 criteria This criterion requires a period of not less than six months where the individual experienced outstanding tension, feelings of nervousness and worry concerning usual problems and events. For diagnosis using this criterion at least four factors must be identified with at least one autonomic arousal symptom identified. Autonomic arousal symptoms foreseeable using this criterion includes palpitations, sweating, dry mouth and shaking or trembling. At least one of these symptoms must be identified to diagnose GAD using this criterion. Other symptoms that are likely are symptoms relating to the chest and abdomen, and these include chest pain or discomfort, difficulty in breathing, abdominal distress or nausea and a feeling of choking. Symptoms relating to the brain and the mind include dizziness, lightheadedness, de realization, and fear for uncertain things. Other general symptoms associated with this criterion include cold chills or hot flushes and tingling sensations or numbness. There are also symptoms that relate to tension such as muscle tension, restlessness, mental tension and difficulties in swallowing. Other nonspecific symptoms are inflated responses to small surprises, problems in concentrating, irritability and sleep related issues. Additionally the disorder should not satisfy panic disorder criteria and should not result from a physical disorder or a disorder related to psychoactive substances (Gorman, 2001). Comorbidity GAD and depression A large proportion of individuals diagnosed with depression is likely to have an anxiety disorder, the rate of comorbidity of these patients with GAD are high as well as those with panic disorders. Individuals with diagnosed cases of anxiety also show elevated levels of comorbid depression and include patients suffering from social phobia, agoraphobia, and panic disorders. Additionally individuals with anxiety and comorbid depression have a lower treatment response and a high illness severity compared to patients with only a single disorder. Social functioning and the quality of life of individuals with these disorders are greatly harmed by the condition. For most individuals, symptoms of depression as well as that of anxiety are not severe enough to require primary diagnosis of anxiety or major depressive disorder. Nevertheless, dysthymia is a major common comorbid diagnosis of GAD patients (Roemer & Orsillo, 2002). GAD and substance abuse Individuals with GAD have a comorbidity incidence of between 30 to 35% with abuse of alcohol and alcohol dependency and between 25 to 30% for substance abuse and dependence. Individuals suffering from both substance abuse and GAD also have increased prevalence for other comorbidities. Other comorbidities Apart from the coexisting depression, GAD can also coexist with cases connected to stress such as stress and irritable bowel syndrome. Patients with GAD can also present symptoms like headaches and insomnia. Moreover suffering from attention deficit hyperactivity disorder can have comorbid disorders related to anxiety with GAD being more prevalent. Causes Hereditary GAD can be hereditary and show some form of familial aggregation. The individual’s genetics play a role in the cause of GAD. Individuals with genetic predispositions are likely to develop GAD often as a response to a stressor. Substance induced Prolonged use of some drugs such as benzodiazepines can aggravate underlying anxiety conditions. Reducing benzodiazepines can significantly reduce the symptoms related to anxiety. Similarly, prolonged use of alcohol is also related to anxiety disorders and abstinence can reduce anxiety related symptoms. Nevertheless, it can take more than 2 years for anxiety assume the baseline position in individuals recovering from alcoholism. A significant proportion of individuals with GAD are determined to be as a result of either alcohol or benzodiazepine. The symptoms of GAD worsen initially during withdrawal but eventually disappear with continued abstinence (Dugas, 2002). In patients with GAD, anxiety symptoms, while deterioration initially during the withdrawal stages; vanish with abstinence from alcohol or benzodiazepines. Recovery from these substances can take long, but individuals are often able to return to normal. Tobacco is also a risk factor in the development of anxiety related disorders. Additionally caffeine can worsen a preexisting condition of anxiety. People with GAD are often sensitive to caffeine and eliminating caffeine can largely eradicate GAD. However, withdrawal from caffeine can increase anxiety at the early stages. Neurology GAD can also result from a disruption of the functionality of the amygdalas and processing of fear and anxiety. Sensory information get into the amygdalas is processed and passed through the basolateral complex, which processes fear memories related to senses and communicates the importance of the threat to sensory processing and memory parts of the brain. Another section close to the nucleus of the amygdalas is responsible for controlling species’ specific fear in connection to other areas of the brain. In people with generalized anxiety disorder, the associations functionally appear to be less separate, and the central nucleus has greater gray matter (Davidson et al. 1999). Other causes Other factors that influence the development of GAD include regular sadness, unsafe political conditions, and traumatic childhood experiences, suffering personal loss, physical illnesses, life changes, and situations with high levels of stress. Treatment Psychological treatments Psychological approaches to treating GAD should be attempted first before trying pharmacologic approaches. This modality of treatment best fits individuals with mild anxiety, and it addresses three categories of GAD symptoms. Biofeedback and relaxation techniques are essential in decreasing arousal. The cognitive therapy approach assists the patient to reduce distortions by providing a perspective that enables them assess their worries more realistically thus enabling them to develop better plans to manage anxiety. Patients are taught to identify their worries and provide evidence that support or contradict their concerns. The approach also assists patients realize that worrying about their worry increases anxiety and that procrastination and avoidance are not effective solutions to their problems. Research has indicated that, among the psychological modalities to the treatment of GAD, cognitive therapy seems more successful than psychodynamic psychotherapy, behavior therapy, or pharmacotherapy. Patients with severe social stressors, personality disorders and those who expect little from psychological interventions dot not respond positively to psychotherapeutic techniques, and they require both psychotherapy and pharmacotherapy techniques (Waters & Craske, 2005). Cognitive behavioral therapy The cognitive behavioral therapy is a technique of treating GAD that involves the patient working with a therapist to understand how feelings and thought affect behavior. The objective of therapy is to alter negative thought models that result in the patient’s anxiety and replacing them with realistic patterns. The elements of this therapy include exposure to allow the patient confront anxieties and feel at ease with anxiety aggravating conditions and also assist is practicing skills learned. This approach can be used alone or in conjunction with drugs. Cognitive behavior theory has been shown to be more effective in the treatment of GAD compared to pharmacologic treatments in the long run. Although both techniques are effective, the cognitive approach is more effective in reducing depression (Spitzer et al. 2006). GAD is based on components that are mainly psychological. These components include positive worry beliefs, unsuccessful problem-solving, interpersonal issues, previous trauma, and intolerance of uncertainty, cognitive evasion, and negative problem direction, and emotional hyper arousal, negative, cognitive responses to emotions, maladaptive emotion organization, poor interpretation of emotions, restrictive behavior and avoidance of experiments. In order to fight these emotional and cognitive aspects associated with GAD, psychologists embrace some treatment components in intervention. These components include relaxation methods, self-monitoring, stimulus control, cognitive reform, problem solving, training on emotional skills, experiential experience, socialization, self-control, mindfulness, acceptance exercises and psycho education. The initial step in this process is psycho education, and it involves providing information to the individual about the disorder. This enhances the patient’s motivation for treatment and increases the patient’s compliance to treatment by developing realistic treatment expectations. The aim of psycho education is to offer relief, destigmatize the disorder, and improve incentive for treatment. The next step is self-monitoring, and this requires monitoring their levels of anxiety and the events that provoke anxiety. Self-monitoring is meant to recognize signals that stimulate anxiety. Stimulus control intervention, on the other hand, implies the reduction of conditions that culminate to worrying. This intervention may require patients to postpone worrying to a certain time of the day where the individual will only focus on the worries and problem solving. Cognitive behavior therapy involves the use of Socratic questioning to make the patient reflect on their worries and realize that alternative feelings and interpretations are more accurate. The process engages behavioral experiments that test the viability of negative and substitute thoughts (Newman, 2000). Acceptance and commitment therapy Another psychological treatment for GAD is the acceptance and commitment therapy. This approach is a behavioral treatment that is based on acceptance models. The modality is aimed at targeting three therapeutic objectives which are reduction of the use of avoidance strategies to avoid feelings, reducing personal responses to thoughts and increasing the individual’s ability to remain committed to changing behavior. This approach attains it objectives by changing the individual’s efforts to control events into changing their behavior and aim on valuable directions. The technique advocates mindfulness and acceptance in responding to unmanageable events and manifests behavior that enacts personal values. The approach works best when combined with pharmacology treatment (Wells, 2005). Intolerance of uncertainty therapy The intolerance of uncertainty therapy implies a regular negative reaction to ambiguous and uncertain occurrences irrespective of the likelihood of its occurrence. This approach is employed as a standalone intervention to treatment of patients with GAD. The approach focuses on assisting patients develop tolerance to uncertainty and reduction of anxiety. The approach is founded on psychological aspects of psycho education, problem solving, awareness of worry, acknowledgment of uncertainty, and behavioral experience. This approach is effective in patients with GAD and shows continued improvement in follow up sessions (Fricchione, 2004). Motivational interviewing Another intervention for people with GAD is the use of motivational interviewing. Recent use of this approach has also included a combination with cognitive behavior therapy to improve treatment rates. Motivational interviewing centers on the patients desire to increase intrinsic motivation and reduce ambivalence regarding change resulting from treatment. Motivational interviewing involves for essential elements. These elements are an expression of empathy, increase conflict between undesired behavior and values not in line with these behaviors, moving with resistance, as opposed to confrontation and encouraging self-efficacy. The approach uses open-ended questions and careful listening of the patient’s answers to identify talk related to changes. A combination of the motivational interviewing therapy and the cognitive behavior therapy is more successful than using the later alone (Newman, 2000). PHARMACOLOGIC TREATMENT Benzodiazepines Pharmacologic therapy is advisable for patients whose daily functioning is affected by anxiety. Benzodiazepines are anxiolytics, which are most often used to treat GAD. These drugs do not reduce worrying but act reduce anxiety by reducing vigilance and eliminating other symptoms such as tension. Benzodiazepine therapy in the treatment of GAD can commence with 2 mg and the dosage can be increased daily up to a maximum of 40 mg. the use of benzodiazepines in remedial dosages does not result in abuse or addiction. However all interventions involving benzodiazepine can result in dependence and withdrawal symptoms occur once the drug is discontinued. The possibility of dependence increases with the prolonged use of the drug and can result even where the appropriate doses are administered. Additionally these drugs carry some risks, which include impairment of motor and cognitive functioning and the physical and psychological reliance makes it hard for patients to discontinue the drugs. These shortcomings reduce the use of this drug and, therefore, the drug can only be effective in the short run (Evans et al. 2008). Buspirone Other medical interventions to the treat GAD is the use of Buspirone, which is often used in individuals with chronic anxiety and individuals who relapse after using Benzodiazepines. Buspirone is also employed in individuals with a history of substance abuse. The use of Buspirone is effective just like Benzodiazepines, but there is no risk of tolerance or dependence on the drug. Unlike Benzodiazepines, which offer immediate relief of symptoms of anxiety, Buspirone does not take effect until after two to three weeks. Buspirone provides an opposite effect to the effect of Benzodiazepines in that it cures the worry associated with GAD. However, the drug can be ineffective in individuals who have used Benzodiazepines within 30 days of treatment. The initial doses of Buspirone start at 5 mg and increase to a maximum of 20 mg. SSRIs Other drugs that are effective against GAD are selective serotonin reuptake inhibitors. These antidepressants alter brain chemistry and inhibit the absorption of serotonin to the brain. Although they are commonly used to treat clinical depression, they are also effective in the treatment of anxiety including GAD. The side effects of these drugs include headaches, sexual dysfunction, diarrhea, and constipation (Rowa, & Antony, 2008). Pregabalin Pregabalin can also be used in the treatment of GAD and acts by reducing the release of neurotransmitters such as substance P, noradrenaline and glutamate. The therapeutic effects of the drug appear after a week and relieve somatic and psychic symptoms of anxiety. Continued use of the drug provides relieve to anxiety without the risk of tolerance and does not alter sleep patterns or provide psychomotor impairment. Pregabalin also has a lower potential for dependency and abuse and is preferred as contrasted to benzodiazepines for these reasons. Anxiolytic effects of the drug appear immediately after administration, and this gives it an advantage over other drugs (Rowa, & Antony, 2008). Reference list Borkovec, T. D., & Ruscio, A. M. (2001). Psychotherapy for generalized anxiety disorder. Journal of Clinical Psychiatry, 62, 37-45. Borkovec, T. D., Alcaine, O., & Behar, E. (2004). Avoidance theory of worry and generalized anxiety disorder. Generalized anxiety disorder: Advances in research and practice, 2004. Campbell, L., & Brown, T. A. (2002). Generalized anxiety disorder. Handbook of assessment and treatment planning for psychological disorders, 147-181. Davidson, J. R., DuPont, R. L., Hedges, D., & Haskins, J. T. (1999). Efficacy, safety, and tolerability of venlafaxine extended release and buspirone in outpatients with generalized anxiety disorder. Journal of Clinical Psychiatry. Dugas, M. J. (2002). Generalized anxiety disorder. Evans, S., Ferrando, S., Findler, M., Stowell, C., Smart, C., & Haglin, D. (2008). Mindfulness-based cognitive therapy for generalized anxiety disorder. Journal of anxiety disorders, 22(4), 716-721. Fricchione, G. (2004). Generalized anxiety disorder. New England Journal of Medicine, 351(7), 675-682. Gorman, J. M. (2001). Generalized anxiety disorder. Clinical cornerstone, 3(3), 37-43. Hoehn-Saric, R., Borkovec, T., & Belzer, K. (2007). Generalized anxiety disorder. In Gabbard's Treatments of Psychiatric Disorders, 4th Edition. American Psychiatric Publishing, Inc. Newman, M. G. (2000). Generalized anxiety disorder. Effective brief therapies: A clinician’s guide, 157-178. Roemer, L., & Orsillo, S. M. (2002). Expanding our conceptualization of and treatment for generalized anxiety disorder: Integrating mindfulness/acceptance?based approaches with existing cognitive?behavioral models. Clinical Psychology: Science and Practice, 9(1), 54-68. ROWA, K., & ANTONY, M. M. (2008). Generalized anxiety disorder. Psychopathology: History, Diagnosis, and Empirical Foundations, 78. Spitzer, R. L., Kroenke, K., Williams, J. B., & Lowe, B. (2006). A brief measure for assessing generalized anxiety disorder: the GAD-7. Archives of internal medicine, 166(10), 1092. Waters, A. M., & Craske, M. G. (2005). Generalized anxiety disorder. Improving outcomes and preventing relapse in cognitive behavioral therapy. New York: Guilford, 77-127. Wells, A. (2005). Generalized anxiety disorder. In Encyclopedia of cognitive behavior therapy (pp. 195-198). Springer US. Read More