Treating Generalized Anxiety Disorder
Treating Generalized Anxiety Disorder
Treating Generalized Anxiety Disorder
CLINICAL PROBLEM
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184 II. ADULTS
worry as having positive utility for their coping. Assessment may be improved by
determining the focus of the worry for the individual as well as inquiry regarding
current and lifetime symptoms of depression.
PREVALENCE
GAD has been found to have an incidence of 5% in the general population. It has
a lifetime prevalence of 5% to 6.1%, 12-month prevalence of 3.1%, and a current
prevalence of about 2% to 3%. Projected lifetime prevalence at age 75 is 8.3%.
Current comorbidity for GAD has been reported to range from 8% to 22% for
dysthymia, 8.6% to 46% for major depression, 10.7% to 27% for social phobia,
and 11% to 36% for panic disorder—the four most common comorbid Axis I
diagnoses. Women are affected more than men with a ratio of 1:1.9 for lifetime
and 1:2.2 for 12-month prevalence; however, men show higher comorbidity with
substance abuse.
A recent review conducted by Turk and Mennin indicates that GAD is the least
researched of the anxiety disorders. GAD has also been found to be the most
resistant to treatment among the anxiety disorders, with remission rates of 0.38
at 5 years post treatment. Acute treatment of GAD targets reduction of symptoms
while long-term care focuses on full remission.
Cognitive behavior therapy (CBT) has been extensively researched for treatment
of GAD and found to be more effective compared to waitlist, pill placebo, placebo
treatment, and analytic psychotherapy. However, the success of this treatment
remains at 50% symptom reductions with high rates of relapse. CBT for GAD
is currently informed by four different conceptual models of GAD: Cognitive
Avoidance Theory, Metacognitive Model, Intolerance of Uncertainty Model, and
Emotional Dysregulation Model. These models overlap in that they view worry as
a persevering type of thought that occurs following a triggering thought, feeling, or
event. Furthermore, all of these models conceptualize worry as a means for coping
with future negative events that may arise.
The investigation of the impact of comorbidity on GAD treatment outcome has
yielded inconclusive results. A study conducted by Newman, Przeworski, Fisher,
and Borkovec has shown that comorbidity is associated with greater severity of
symptomatology at treatment entry. However, these comorbid clients show greater
change and thus, the efficacy of CBT for these individuals is not reduced. However,
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another study conducted by Provencher, Ladouceur, and Dugas found that CBT is
less effective for patients with a diagnosis of GAD and other comorbid diagnoses,
including panic disorder, at 6 months follow-up.
Medications for treatment of GAD may be used either alone or in adjunction with
psychotherapy. The use of antidepressants such as selective serotonin reuptake
inhibitors (SSRIs, such as sertraline, paroxetine, escitalopram) or serotonin–
norepinephrine reuptake inhibitors (SNRIs, such as venlafaxine or duloxetine) is
considered to be the first line of treatment. These have been shown to have limited
efficacy, with less than 40% remission rates, with a high risk of relapse and adverse
effects. Current research is exploring the effects of atypical antipsychotics, either as
monotherapy or as augmentation in the treatment of GAD.
Other empirically supported treatments include mindfulness, relaxation tech-
niques through the use of meditation, yoga, biofeedback, and exercise.
FUTURE RESEARCH
KEY REFERENCES
Borkovec, T. D., & Ruscio, A. M. (2001). Psychotherapy for generalized anxiety disorder. Journal of Clinical
Psychiatry, 62(Suppl. 11), 37–45.
Katzman, M. A. (2009). Current considerations in the treatment of generalized anxiety disorder. CNS Drugs,
23, 103–120.
Newman, M. G., & Llera, S. J. (2011). A novel theory of experiential avoidance in generalized anxiety disorder:
A review and synthesis of research supporting a contrast avoidance model of worry. Clinical Psychology
Review, 31(3), 371–382. doi: 10.1016/j.cpr.2011.01.008