Management Approaches to Generalised Anxiety Disorder

Generalised Anxiety Disorder (GAD) is a chronic and highly comorbid illness characterised by excessive and uncontrollable worry. There is a low probability of recovery (32% - 58%) and high recurrence (45% - 52%). Its severity and pervasiveness warrants effective treatment measures to be planned.

Treatment of GAD is split into 2 broad categories:
A) Psychotherapy
B) Pharmacotherapy

Psychotherapy Approach to GAD
1. Traditional Cognitive Behavioural Therapy (CBT)
2. Integrative Therapy
3. Psychodynamic Psychotherapy - Supportive Expressive Therapy (SET)

Cognitive Behavioural Therapy as The Best Modality for Treating GAD
CBT has currently being established as the best psychotherapy treatment for GAD. In the CBT framework, change in behaviour is promoted through: (Newman et al 2006)
i. identification of early anxiety triggers
ii. challenging and disrupting individual misconceptions and worries
iii. testing the validity of his erroneous beliefs
iv. reducing avoidance behaviours
v. improving skills for management of worry and anxiety
vi. developing adaptive ways of response to neutral and ambiguous situations

Initiation: psychoeducation on symptoms and treatment goals, engagement in self-monitoring and identification of maladaptive patterns, maintain present focus and develop cognitive, imagery, relaxation and behavioural intervention. Pt is given homework in between sessions.

Cognitive Restructuring: learning of association between thoughts and emotions, identifying cognitive errors and replacing with more accurate thoughts

Relaxation Technique: relaxation of muscles and breathing exercises

Self-Control Desensitisation: imagine encountering worry trigger then focus or relaxing away the stress response

CBT has significantly reduced anxiety symptoms posttreatment, with gains maintained for up to 2 years. (Borkovec and Ruscio 2001)

Integrative Therapy as Modification to CBT
Rationality: interpersonal and emotional processing deficits are noted in GAD patients. Pt may use worry not to avoid emotion but rather to brace themselves for a potential negative outcome.

Integrated treatment protocol incorporates CBT, interpersonal and emotional-based interventions to identify dysfunctional relationship patterns and enhancing emotional processing.

Acceptance and Commitment Therapy (ACT) helps to reduce reliance on emotional avoidance strategies as well as decrease individuals negative interpretation of thoughts, increase ability to enact behavioural changes that conforms to their values and to focus on here and now.

Supportive Expressive Therapy (SET) as Short Term Psychodynamic Psychotherapy
Delineation of core conflictual relatonship theme (CCRT) which comprises of:
1. wishes and needs of pt
2. response of others
3. subsequent response of pt

SET helps pt to identify CCRT across the areas of lives and understand its relation to the anxiety they are facing. Pt is able to learn improved ways of coping with feelings, expressing needs, and responding to others.

Treatment significantly reduced participants anxiety, worry andi nterpersonal problems (Crits Christopher et al 1996), but however 6-month follow up favoured CBT over SET, and CBT was superior to set on many measures. (Leichsenring et al 2009)

Pharmacotherapy Approach to GAD
1. Benzodiazepines
2. SSRI and SNRI
3. Pregabalin

Benzodiazepines as Short Term Control Measures
Alprazolam, diazepam and lorazepam are shown to be rapidly effective in short-term use. Thus they are most effective in treatment of acute anxiety symptoms.

Long term usage is controversial because of the adverse effects:
i. tolerance and dependence
ii. withdrawal
iii. sedative effect
iv. motor and cognitive impairment

SSRI and SNRI as First Line Pharmacological Treatment
SSRIs and SNRIs were efficacious in treatment of GAD.

Fluoxetine is best in terms of response and remission, while
Sertraline is best in terms of tolerability

TCA class imipramine in earlier studies (Rickels et al 1982) are also demonstrated to be effective in treating GAD but TCA prominent side effects and narrow therapeutic index has made it as second line treatment.

However while taking SSRIs, patient may experience side effects such as:
i. nervousness
ii. sexual dysfunction
iii. weight gain
iv. drowsiness
v. sleep disturbances

Conclusion
CBT and pharmacotherapy showed no significant differences in effectiveness for anxiety reduction, however CBT is better tolerated and more cost-saving than pharmacotherapy, making CBT the best modality for treatment.

In Child Adolescent Anxiety Multimodal Study, combination treatment of CBT plus sertraline had significant high rates of remission than other conditions, thus combination therapy may seem provide better outcomes for child and adolescent patients, and could be extrapolated to adults. There has not been any trials of combintion treatment in adults yet.