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Chapter: Essentials of Psychiatry: Anxiety Disorders: Generalized Anxiety Disorder

Generalized Anxiety Disorder: Nonpharmacological Treatments

Numerous studies have shown that psychological interventions are beneficial in the comprehensive management of anxiety disorders.

Nonpharmacological Treatments


Numerous studies have shown that psychological interventions are beneficial in the comprehensive management of anxiety dis-orders. However, data suggesting that specific psychotherapeutic techniques yield better results in the treatment of patients with GAD are inconclusive and more evidence is needed on the com-parative efficacy and long-term effects of different psychological treatments.


Cognitive–Behavioral Therapy


In recent years specific cognitive–behavioral therapy (CBT) in-terventions for the treatment of patients with anxiety disorders have been developed. Components of CBT include teaching pa-tients to identify and label irrational thoughts and to replace them with positive self-statements or modify them by chal-lenging their veracity. The cognitive modification approaches are combined with behavioral treatments such as exposure or relaxation training. There is currently evidence suggesting that CBT may be more effective in the treatment of GAD than other psychotherapeutic interventions, such as behavioral therapy alone or nonspecific supportive therapy (Chambless and Gil-lis, 1993). Six additional studies confirmed the efficacy of CBT compared with waiting list or pill placebo and patients tend to maintain improvement following CBT over 6 to 12 months of follow-up.


CBT targeting intolerance of uncertainty, erroneous be-liefs about worry, poor problem orientation and cognitive avoid-ance demonstrated effectiveness at post treatment (no change in the delayed treatment control group) 6- and 12-month follow-up, with 77% of the treatment group no longer having symptoms meeting criteria for a GAD diagnosis (Ladouceur et al., 2000). Cognitive therapy was also compared with analytic psychother-apy, and was found to be significantly more effective (Borkovec and Costello, 1993). Overall, two-thirds in the cognitive therapy group achieved clinically significant improvements and cognitive therapy was associated with significant reductions in medication usage.


A meta-analytic review of controlled trials examining CBT and pharmacotherapy for GAD, which included 35 studies, dem-onstrated the robustness of CBT in the treatment of GAD (Gould et al., 1997). Overall, both modalities offered clear efficacy to pa-tients, with the effect size for CBT not being statistically differ-ent from psychopharmacological approaches. CBT demonstrated greater effects in reducing depression and was associated with clear maintenance of treatment gains, whereas long-term efficacy of pharmacologic treatment was attenuated following medication discontinuation.


Barlow and colleagues (1986) developed a CBT approach to GAD which concentrates on the behavioral element of direct exposure to the contents of patients’ worry and apprehension (i.e., a deconditioning strategy) in addition to relaxation techniques (progressive muscle relaxation) and cognitive restructuring. The authors found that this technique is effective in reducing anxiety symptoms in patients with GAD.


Supportive Psychotherapy


Many patients with milder forms of GAD will benefit from simple psychological interventions such as supportive psycho-therapy. They may experience lessening of anxiety when given the opportunity to discuss their difficulties with a supportive cli-nician and to become better informed about their illness. Thus, basic supportive techniques such as reassurance, clarification of patient concerns, direct suggestions and advice are often effec-tive in reducing anxiety symptoms.


Relaxation and Biofeedback


Relaxation techniques such as progressive muscle relaxation and biofeedback have also been utilized in the treatment of patients with anxiety symptoms. Few controlled studies have examined their effectiveness. In a recent controlled study, Borkovec and Costello (1993) compared a comprehensive relaxation treatment and cognitive–behavioral therapy in the treatment of patients with DSM-III-R-defined GAD. The authors found that both treat-ments were equally effective and superior to a nonspecific sup-portive treatment intervention.


Psychodynamic Psychotherapy


Although there are no controlled studies evaluating the efficacy of psychodynamic psychotherapies in the treatment of patients with GAD, some of its important principles in understanding patients may be helpful. First, it is important to note that the psychoanalytic theories view anxiety as an indicator of certain unconscious conflicts, rather than as a primary target symptom to be alleviated. It is, therefore, the clinician’s task to use various techniques to help the patient uncover these unconscious conflicts. It is believed that the newly gained understanding of the underlying reasons for symptoms will have a therapeu-tic effect, thereby reducing anxiety. Through interpretation of previously unconscious conflicts and unconscious origins of anxiety, the patient will be able to utilize new insights and find more adaptive outlets or solutions to problems. In Harry Stack Sullivan’s theory, anxiety reflects the failure to develop secure interpersonal interactions, such as an emphatic and secure mother–infant relationship. He believed that the child learns to identify anxiety states in himself and significant others and develops protective defensive strategies which enable him to avoid experiencing anxiety. However, the defenses employed (termed security operations) are generally restrictive and may result in limiting the subject’s interpersonal interactions. Therefore, the task of the therapist, according to Sullivan’s model, is to trace the patterns of interpersonal interactions throughout the patient’s developmental stages (rather than to uncover the unconscious drives), thereby promoting a more ac-curate perception of self and others and subsequently better social adaptation.


Another therapeutic approach to the treatment of anxiety symptoms was offered by object relation and self-psychology theorists. They view anxiety as a result of the loss of or inad-equate emotional relationships with significant others. Therefore, the primary focus of therapy shifts to emphasize the importance of the relationship to the therapist, who functions as an empathic object providing emotionally corrective experiences. For exam-ple, the patient may learn that an important person may be imper-fect but still be trusted and nurturing.


Finally, most psychodynamically oriented therapists agree that the outcome of psychodynamic psychotherapy is determined by factors reflecting a patient’s maturity and strength. Specifi-cally factors such as the patient’s capacity for introspection, in-telligence, ability to relate to the therapist, and ability to bear painful feelings should be carefully evaluated.


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