General Anxiety Disorder (GAD)

Treatment

Treatment for GAD typically combines medication and psychotherapy.

Medication
GAD is treated with the following types of drugs:

• Antidepressants
• Benzodiazepines
• Beta-blockers
• Buspirone

Drug choice is determined by the patient's ability to tolerate side effects and by the drug's effectiveness in reducing symptoms.

Antidepressants
Paroxetine (Paxil®) and venlafaxin HCl (Effexor® XR) are the only antidepressants indicated for GAD, though it is generally believed that all antidepressant drugs significantly improve symptoms.

Benzodiazepines
Benzodiazepines are most commonly used in the treatment of GAD and include the following medications:

• Alprazolam (Xanax®)
• Chlordiazepoxide (Librium®)
• Clonazepam (Klonopin®)
• Diazepam (Valium®)
• Lorazepam (Ativan®)

Benzodiazepines increase the effectiveness of the neurotransmitter GABA, which reduces anxiety and stress and improves function, concentration, and the ability to manage an otherwise debilitating situation. They are generally thought of as calming drugs.

Side effects are often temporary and may dissipate after a couple of weeks. Common side effects include the following:

• Blurred vision
• Confusion
• Depression
• Dizziness
• Drowsiness
• Fatigue
• Headache
• Insomnia
• Light-headedness
• Muscle tremor
• Nasal congestion

Alprazolam (Xanax®) may be toxic when combined with nefazadone (Serzone®), which is used to treat depression. The physician reduces the dosage of alprazolam by half in these cases.

Pregnant women and nursing mothers should consult their physicians before using benzodiazepines, because they have been implicated in some cases of respiratory problems and withdrawal symptoms in newborns. Most of these drugs increase levels of oral contraceptives, which may present problems for some women.

Withdrawal symptoms occur in people who stop their dosage abruptly. Acute and intense anxiety lasting from 2 days to 2 weeks results from low levels of GABA. Medication is tapered off to prevent seizures, delirium, and death, which may occur with sudden discontinuation.

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Benzodiazepines that work quickly tend to be abused more often, or shared with friends and family as an on-the-spot remedy for stress. Alcoholics are at greater risk for benzodiazepine abuse, because the drugs effects similar to alcohol, including sedation and impaired physical and mental abilities. The two drugs should not be used together.

Beta-blockers
Beta-blockers that are used to treat cardiac conditions, also may be used in anxiety disorders to stop the physical symptoms of anxiety. Although the Food and Drug Administration (FDA) has not approved them for this use, psychiatrists may prescribe them. The drugs reduce nervous tension, sweating, panic, high blood pressure, and shakiness.

Their efficacy is limited to reducing these types of symptoms. Beta-blockers are not typically considered a first-line treatment for GAD.

Furthermore, beta-blockers have many side effects, including the following:

• Body ache
• Confusion
• Depression
• Dizziness
• Dry eyes
• Impotence (erectile dysfunction)
• Insomnia
• Low blood pressure and reduced pulse rate
• Memory loss
• Nausea, vomiting
• Rash

These drugs may cause problems for people with kidney or liver conditions. Also, they are excreted in breast milk, so nursing mothers should consult with their physicians before using them.

Medication may be used long-term or may be tapered and finally discontinued once severe anxiety is controlled or eliminated through psychotherapy.

Buspirone
This medication has been used for the treatment of GAD since 1986. It is not known how buspirone (BuSpar®) works in the body to reduce symptoms of anxiety. Its attributes include the following:

• Does not interact with alcohol
• Few or no withdrawal symptoms
• Lack of relaxant muscular effect
• Lack of sedative effect
• Works within 3 to 6 weeks and works effectively

Buspirone is usually prescribed for short-term relief of anxiety, providing the patient can tolerate its side effects, which include the following:

• Agitation, excitement
• Confusion
• Dizziness
• Drowsiness
• Fatigue, weakness
• Headaches
• Nausea
• Nervousness

Psychotherapy
The goal of dynamic psychotherapy is to identify and explore the causes of anxiety and what they mean to the patient. A therapist may work with the patient on a number of exercises, including stress evaluation and techniques to be practiced while the patient is on his or her own.

The goal of behavior therapy is to establish coping strategies for anxiety. Behavior and cognitive therapy overlap, because new behavior is only possible after a person is able to replace irrational, anxious thoughts with healthy ones. Methods include the following:

• Biofeedback
• Controlled exposure to anxiety-causing situations
• Meditation
• Planning relaxed events and relaxation training

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