Therapy For Generalized Anxiety Disorder Research Articles

Generalized Anxiety Disorder Therapy, Associated with Pronounced Side Effects, and Prospects for the Use of Pharmacogenetic Testing: Case report

New generation antidepressants (AD) are widely used as first-line treatment for generalized anxiety disorder (GAD) and considered safely than tricyclics. Some side effects of AD are transient and may disappear after few weeks of treatment, but potentially severe may persist for a long time or occur later. Cardiovascular disorders (abnormal heart rhythm, QT prolongation, arterial hypertension, orthostatic hypotension) are especially dangerous side effects. Genetic polymorphisms of the enzymes involved in the metabolism of antidepressants may be one of the causes of side effects development. The objective of this case report is to demonstrate that timely assessment of the risk of side effects using pharmacogenetic testing (PGx) could have influenced choice of an antidepressant, timely dose adjustment, avoiding ineffective appointments. Use of the PGx can help to optimize GAD pharmacotherapy, its introduction into clinical practice requires further research.

Relationship between self‐worrying and self‐critical messages in clients with generalised anxiety engaging in emotion‐focused worry dialogues

AbstractEmotion‐focused therapy (EFT) has recently been adapted as a treatment for generalised anxiety disorder (GAD). One intervention used in this adaptation is a worry dialogue, in which the client enacts worry in one chair (“worrier”) and is facilitated to experience the impact of this worry in another chair (“experiencer”). Although not formally studied, anecdotal observations from therapists in the EFT for GAD treatment development study suggested that within worry dialogues there might be a link between client's self‐worrying and self‐critical messages. This study used data from 47 worry dialogues from fourteen study clients who received EFT for GAD. An observation based qualitative analysis of clients' self‐directed messages as present in in‐session worry dialogues was conducted using video/audio recordings of relevant sessions. Results indicate a relationship between self‐worrying and self‐critical messages. A total of 90 paired self‐worry and self‐critic messages across the 47 worry dialogues were logged. Six recurring clusters of themes/relationships were observed: (a) I need to be prepared for future negative events because… I'm weak and a failure; (b) I need to stop worrying… I'm flawed for being a worrier; (c) People will negatively judge me if I engage with them… because I'm not good enough; (d) If I don't worry, there will be negative consequences… and I will be responsible and will be unable to bear it; (e) I worry/ruminate that I cause(d) some damage… because I'm incompetent; and, (f) I must always be prepared against others taking advantage of me… because I'm weak. Given the observed close link between self‐critical and worry processes, it is important that therapists differentiate between these processes and remember to address both in therapy for GAD.

Evaluation of the effect of selective serotonin reuptake inhibitors on bone mineral density: an observational cross-sectional study

SummarySixty patients diagnosed with generalized anxiety disorder and treated with either paroxetine, sertraline, or citalopram for at least 12 months were enrolled in this study, and the bone mineral density (BMD) of the patients was compared with that of 40 healthy volunteers. Selective serotonin reuptake inhibitor (SSRI) therapy in generalized anxiety disorder was found to be related with decreased BMD values.IntroductionThe objectives of this study were to evaluate the effect of SSRI therapy on BMD in postmenopausal women diagnosed with generalized anxiety disorder (GAD) and to identify the effects of the duration of disease and treatment on risk factors for osteoporosis.MethodsSixty patients diagnosed with GAD and treated with paroxetine, sertraline, or citalopram from the SSRI group for at least 12 months were enrolled. Social demographic features, the Hamilton Anxiety Scale (HAS) results, and the Hamilton Depression Scale (HDS) scores of all the patients were assessed. The BMD of the patients was measured by dual-energy X-ray absorptiometry (DXA) at the femoral and lumbar regions. The patients were divided into three groups which are the paroxetine, sertraline, and citalopram groups. The BMD of the patients was compared with that of 40 healthy volunteers.ResultsThe L2–L4, total lumbar vertebrae, femoral intertrochanteric, total femoral Z-scores, and femoral Ward’s region T-scores of the treatment group were lower than the median T- and Z-scores of the control group (p < 0.05). Of the treatment groups, the femoral neck, trochanteric and intertrochanteric T- and Z-scores, total femoral T- and Z-scores, and femoral Ward’s T- and Z-scores of the sertraline group were significantly lower than the BMD values measured at the identical regions in the paroxetine and citalopram groups (p < 0.05).There was a significant negative correlation between the duration of treatment and the BMD values.ConclusionSSRI therapy in GAD was found to be related with decreased BMD values. Further randomized controlled studies are warranted to determine whether SSRI use is a risk factor for osteoporosis; such studies should investigate these factors by performing BMD assessments before treatment.

Pregabalin for the Treatment of Generalized Anxiety Disorder

To evaluate the efficacy and tolerability of pregabalin in the treatment of generalized anxiety disorder (GAD). A search of PubMed (1966-December 2011) and International Pharmaceutical Abstracts (1970-December 2011) was conducted using the MeSH and free-text terms pregabalin, anxiety disorders, and anxiety. All English-language articles identified through the search were evaluated for inclusion. Only randomized controlled trials involving the use of pregabalin for the treatment of GAD were included in the review. Eight published trials were identified through the search strategy. Successful treatment of GAD with pregabalin versus placebo and active comparators has been reported in clinical trials. Pregabalin lowered total Hamilton Rating Scale for Anxiety scores within 1 week and was effective against both somatic and psychic subcomponents. In 1 controlled clinical trial, pregabalin was found to be effective in patients aged 65 years and older. Another trial demonstrated improved relapse rates when pregabalin, compared with placebo, was used for up to 6 months. The most commonly experienced adverse events were somnolence, dizziness, headache, and dry mouth. Available evidence suggests that pregabalin is effective and well tolerated in the treatment of GAD. As somnolence and dizziness are common adverse effects, caution should be used in elderly patients. Pregabalin rapidly relieves anxiety, a benefit that it may have over many other currently available therapeutic options besides benzodiazepines. While not a first-line therapy in GAD, pregabalin offers another treatment option in patients who do not respond to or who suffer intolerable adverse effects from other agents.

Treatment of generalized anxiety disorder: a comprehensive review of the literature for psychopharmacologic alternatives to newer antidepressants and benzodiazepines.

Generalized anxiety disorder (GAD) is common, chronic, and debilitating. Treatment with benzodiazepines and newer antidepressants is often inadequate. This article reviews the effectiveness of alternative and augmenting medications, such as older antidepressants, antipsychotics, anticonvulsants, and β-blockers. A search using MEDLINE (1980 to week 4 of May 2010) with the key words generalized anxiety disorder or GAD and therapeutics or treatment was conducted. Articles included adult patients with a GAD diagnosis that established chronicity of illness. These included a small number of studies that used DSM-III criteria but added a chronicity of symptoms and included all studies that used DSM-III-R and DSM-IV criteria. Articles that did not include medications or that exclusively focused on newer antidepressants (selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, bupropion, and mirtazapine), buspirone, benzodiazepines, or herbal or investigational medications were excluded. Review articles and non-English-language articles were also excluded. Thirty-six studies were reviewed. All of the references were then analyzed, and key portions were extracted. Many studies were open trials. Double-blind, placebo-controlled studies with imipramine, risperidone, olanzapine, hydroxyzine, ondansetron, tiagabine, valproate, and pregabalin had been conducted. Imipramine, hydroxyzine, valproate, and pregabalin were the most effective, although risperidone, olanzapine, ziprasidone, and aripiprazole may also reduce symptoms. Several medication strategies can be considered as promising alternatives or augmenting to antidepressant or benzodiazepine therapy in GAD.

Understanding the relationships between health outcomes in generalized anxiety disorder clinical trials

The Wilson-Cleary health outcomes model is a hypothesized pathway linking traditional clinical variables to health-related quality of life (HRQL). This study tested the application of the Wilson-Cleary model to a patient population with generalized anxiety disorder (GAD) using longitudinal clinical trial data. These secondary analyses pooled data from three similar 8-week, placebo-controlled, double-blind, randomized, multicenter trials of quetiapine XR therapy in GAD. Relevant health assessments for the model concepts included the Clinical Global Impression-Severity of Illness, Hamilton Rating Scale for Anxiety, the Pittsburgh Sleep Quality Index and Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form. A lagged path model tested whether the hypothesized relationships at baseline and week 8 between the concepts of the adapted Wilson-Cleary model were consistent with the observed data. The resulting model fit the data (RMSEA = 0.077; CFI = 0.98; NFI = 0.96) and explained 56% of the variance in overall quality of life assessment at baseline and 69% of the variance in this assessment at week 8. Moderate to strong relationships between the adjacent hypothesized concepts support the specified model. This adapted Wilson-Cleary model for health outcomes validated in GAD should improve the understanding and usefulness of health status measurements in this condition and increase the applications of this model to other clinical trial data.

Management of Generalized Anxiety Disorder in Primary Care

Generalized anxiety disorder (GAD) is one of the most common psychiatric disorders in primary care, although it is often underrecognized and undertreated. GAD is chronic, disabling, and associated with other health problems. Treatment response is often unsatisfactory, but the clinical evidence base for new treatments has expanded substantially in the past decade and suggests a growing range of options for reducing the burden of GAD. The objective of this article was to review current literature on GAD and its management to provide an overview of the clinical importance of GAD in primary care and available treatments. Recent studies (ie, over the past decade) on the epidemiology and treatment of GAD were identified by searching Medline using the term generalized anxiety disorder only and in combination with the terms epidemiology and treatment and for each drug class (benzodiazepines, azapirones, antidepressants, antihistamines, alpha-2-delta ligands, and antipsychotics) and for named drugs (buspirone, venlafaxine, duloxetine, fluoxetine, escitalopram, olanzapine, paroxetine, pregabalin, quetiapine, and risperidone in addition to psychological therapies and cognitive-behavioral therapy. The literature search was conducted in August 2008 for the period 1987-2009. Studies were included if judged to be relevant to a review of the epidemiology and management of GAD. Articles were excluded if they were not written in English or were published more than 10 years before the literature search was conducted. A few older studies were included for which more recent research evidence was not available. Recent national and international guidelines for the management of GAD were also reviewed. Most currently available interventions have similar overall efficacy, and treatment choices should reflect the situation of individual patients. Important unmet needs exist for treatments (1) that work rapidly, with (2) broad spectrum benefits, (3) that can improve rates of remission and well-being, (4) are devoid of risk for withdrawal symptoms, and (5) have few if any adverse interactions with other drugs. Additional needs include (6) safer drugs for the elderly, (7) safe and effective drugs for children with GAD, (8) further evaluation of psychotherapy, and (9) understanding the appropriate circumstances for, and optimal choices of, drug combination. While the development of novel treatments evolves, current management approaches can focus on improving identification and defining optimal use of available therapies for GAD.

Therapist empathy and client anxiety reduction in motivational interviewing: “She carries with me, the experience”

In this article, we examine the use of motivational interviewing (MI) to treat generalized anxiety disorder (GAD) by means of case illustration that focuses on four categories drawn from the client's experience of the key ingredients in MI therapy. The case illustration, drawn from the York study on combining MI and cognitive behavior therapy in the treatment of GAD (uses the client's pre- and post-therapy narrative interviews) to arrive at categories representative of the client's experience of MI therapy. The results of the qualitative analysis highlight the key contributions to positive client outcomes and readiness for change in brief MI therapy for GAD.

Les sources du sentiment d’efficacité personnelle à la gestion du poids chez les personnes obèses et normo-pondérales

La combinaison des modèles de l’intolérance à l’incertitude (II) et de la régulation émotionnelle dysfonctionnelle (RÉD) pourrait améliorer l’efficacité du traitement cognitif-comportemental (TCC) du trouble d’anxiété généralisée (TAG). Cette étude préliminaire compare un TCC du TAG basé sur le modèle de l’II (TCC II) à un TCC du TAG basé sur la combinaison des modèles (TCC II + RÉD).Vingt participants ont complété le traitement. Des entretiens semi-structurés ont eu lieu deux semaines pré- et post-traitement. Des questionnaires ont été postés 3 et 6 mois post-traitement.Les analyses par modèles mixtes révèlent que les deux thérapies traitent efficacement le TAG (inquiétudes [F(3, 19,031) = 20,667, p < 0,001], sévérité du TAG [F(3, 29,567) = 20,567, p = < 0,001]). La régulation émotionnelle s’améliore dans les deux conditions (F[3,17,401] = 11,390, p < 0,001). Une différence intergroupe sur la régulation émotionnelle est identifiée par contraste entre le suivi 3 et 6 mois : les participants de la condition combinée s’améliorent davantage (t[15,678] = 2,133, p = 0,049, d de Cohen = 0,076).Un traitement du TAG intégrant la régulation émotionnelle pourrait entraîner une meilleure tolérance aux émotions.Generalized anxiety disorder (GAD) is characterised by excessive and incontrollable worry, and is associated with anxiety symptoms such as restlessness, insomnia, concentration difficulties and irritability. This condition has consequences in personal life, such as social withdrawal, and in societal life, such as absenteeism and an increased number of medical consultations. In addition, the evolution of GAD tends to be chronic without adequate treatment. Cognitive-behavioral therapy (CBT) successfully treats generalized anxiety disorder (GAD). More than 50% of individuals with GAD experience a complete remission or significant clinical change after CBT. However, a significant number of people still present GAD symptoms following CBT. Combining interventions from different theoretical GAD models could improve CBT efficacy. In this regard, theoretical links have been suggested between intolerance of uncertainty (IU ; Dugas et al., 1998) and emotion dysregulation (EDr ; Mennin et al., 2005) models (Ouellet, 2014; Riskind, 2005). The IU model posits that GAD development and maintenance is explained by a vulnerability to uncertainty. This vulnerability influences beliefs and attitudes towards worry as well as generates cognitive avoidance. The EDr model explains GAD by difficulties with emotion regulation. GAD individuals, in particular, have difficulties in understanding and react negatively to emotions. They also experience highly intense emotions and use inflexible emotion regulation strategies. Treatments based on these approaches are respectively considered efficient to treat this disorder in GAD literature. This preliminary study aims to compare CBT for GAD based on the IU model (CBT IU) to CBT for GAD based on the IU and EDr models (CBT IU + EDr).Twenty-one participants were randomly assigned to 12 sessions of CBT IU or CBT IU + EDr. The CBT IU included psychoeducation about GAD, exposition to situations of uncertainty, cognitive restructuring, problem-solving training and cognitive exposition. The CBT IU + EDr added psychoeducation, cognitive restructuring and exposure to emotions, as well as emotional awareness training. Twenty participants completed treatment. Evaluations, including the semi-structured Anxiety Disorders Interview Schedule (ADIS-IV) and self-administrated questionnaires, were carried out two weeks before and two weeks after GAD treatment. Follow-up questionnaires were sent by mail 3 and 6 months after therapy.Repeated measures mixed model analyses 2 (treatment conditions) × 4 (measurement time) were conducted and revealed that both treatments are efficacious for GAD symptoms (i.e., excessive worry [F(3, 19.031) = 20.667, P < 0.001], GAD severity [F(3, 29.567) = 20.567, P = < 0.001], anxiety [F(3, 19.375) = 9.176, P = 0.001], depression [F(3, 36.609) = 21.662, P < 0.001], intolerance of uncertainty [F(3, 35.053) = 28.837, P < 0.001]). Both conditions foster a change in emotion regulation (F[3,17.401] = 11.390, P < 0.001). Contrast analyses showed differences in emotion regulation among conditions between the 3-month follow-up and the 6-month follow-up. Participants in CBT IU + EDr seem to continue to improve emotion regulation capacity (t[15.678] = 2.133, P = 0.049, d de Cohen = 0.76), whereas participants in CBT IU seem to present a deterioration on this same variable (t[15.757] = −2.491, P = 0.024, d de Cohen = −0.56).Both treatments (i.e., CBT IU, CBT IU + EDr) are efficacious for GAD. The inclusion of an emotion regulation segment in GAD therapy seems, in a longer-term perspective, to be an advantage in improving emotion regulation in individuals presenting this disorder. The combined therapy (CBT IU + EDr) could cause greater tolerance to emotions or a generalisation effect on emotions. It seems relevant to continue studies on combining IU and EDr models in GAD treatment with a larger sample size and an in-depth therapy segment on emotion regulation.

Interactions between psychotherapy and drug therapy in generalized anxiety disorder

Given the availability of a wide range of proven pharmacological treatments for anxiety disorders and also the range of effective psychological interventions, the debate over drug therapy versus non-drug therapy, e.g. Cognitive Behavioural Therapy (CBT), has evolved into an appreciation of the importance of combining both approaches. The clinical trials of combination therapy in Generalized Anxiety Disorder (GAD) are still rare in comparison to those in Panic Disorder and OCD. A critical review of the few combination therapy studies in GAD revealed methodological limitations and variations in diagnostic criteria and in treatment–therapy combinations which gave inconsistent results, so rendering specific conclusions impossible, except that combination therapy may be of particular usefulness in severe cases of GAD. In general practice, not all patients require combination therapy and various criteria need to be addressed, e.g. What are the clinical indications, safety and efficacy of combined strategies? How does one adapt one treatment strategy to increase the efficacy of the other? Clinical findings have suggested that in particular anxiety states, drug therapy (especially the benzodiazepines) may inhibit the long term gains from psychotherapy. In order to show the differential long term effects of two anxiolytics (hydroxyzine and alprazolam) on ongoing psychosocial therapy in GAD, a controlled double-blind study was conducted concurrently in Mumbai and Paris. Copyright © 1999 John Wiley & Sons, Ltd.

Effects of psychotherapy on comorbid conditions in generalized anxiety disorder.

Comorbid diagnoses were examined in 55 principal generalized anxiety disorder (GAD) clients, and the effect of treatment for the principal disorder on those conditions was evaluated. High rates of comorbid diagnoses were present at pretherapy, with social and simple phobia being most common. The presence of additional diagnoses declined dramatically from pretherapy to follow-up and was significantly greater among clients for whom the GAD therapy had been successful than among clients for whom GAD outcome had been ambiguous. This was generally true regardless of whether clients reported at follow-up that they had received further therapy since the posttherapy assessment.