Mental health articles

Cognitive behavioural treatment

Behavioural treatments of generalized anxiety disorder initially involved exposure to feared situations combined with response prevention – much as in the treatment of phobias. In this, the individual is exposed to their feared situations, frequently in a graded manner starting with the least feared. On each occasion, they remain near the feared object until they are no longer anxious: that is, they are prevented from using their escape response. This was thought to extinguish the fear response as the individual learned the lack of association between the stimulus and its expected negative consequences. Unfortunately, while effective in the treatment of some other anxiety disorders, these methods proved of little value in the treatment of generalized anxiety disorder as the situations that threatened people with generalized anxiety disorder were so diffuse. Cognitive behavioural interventions did not prove effective in the treatment of generalized anxiety disorder until they incorporated three key strategies:

cognitive restructuring of anxiety-provoking thoughts relaxation training worry exposure assignments.

Cognitive restructuring involves identifying the cognitions leading to anxiety and challenging any inappropriate assumptions.

Strategies may be rehearsed in the therapy session before being used in the situation in which the client feels anxious.

Relaxation training involves a structured programme of learning to physically relax and to slow and control breathing at times of anxiety. Worry exposure follows an exposure and response prevention approach. Many people with generalized anxiety disorder attempt to mentally block or distract from negative or catastrophic thoughts. As a result, they fail to extinguish the associated anxiety, and continue to be worried by the thoughts in the long term. Worry exposure involves the individual focusing on their frightening or catastrophic thoughts or images for increasing periods of time, eventually up to between 25 and 50 minutes. Anxiety typically rises then falls, as the images are held and the individual habituates to them. This approach has proven relatively effective. One meta-analysis involving eight studies reported that 46 per cent of patients who received CBT made a clinically significant improvement. This compared to only 14 per cent in the treatment as usual comparison groups. Similar gains were achieved on measures of worry symptoms and overall quality of life.

A cognitive approach incorporating mindfulness and acceptance-based strategies has achieved outcomes matching those of the best second-wave CBT interventions (Roemer et al. 2008), albeit in a trial involving a very small number of participants. A small trial evaluating meta-cognitive therapy has also been reported, achieving a recovery rate at 12 months of 75 per cent. A second, albeit still relatively small, study of metacognitive therapy conducted by the same group (Wells et al. 2010) is reported in Research box 3. This study found metacognitive therapy to be more effective than applied relaxation, for up to one-year follow-up. The potential for these third-wave interventions still needs to be verified in larger, randomized controlled trials. Nevertheless, they have the potential to become the psychological treatment of choice for generalized anxiety disorder.

Psychoanalytic therapy

One study has examined the effectiveness of psychoanalytical therapy in the treatment of generalized anxiety disorder, comparing it with a cognitive intervention (Durham et al. 1994). Psychoanalytical therapy involved the exploration and understanding of the individual’s problems within the context of their current relationship, their developmental context, and in terms of the transference and resistance within the therapeutic relationship. The cognitive behavioural approach followed that described above. Levels of contact were similar across both interventions. Cognitive behavioural therapy proved signifi cantly more effective than psychoanalytical therapy, both immediately following therapy and at six-month follow-up. By this time, 76 per cent of those receiving CBT were ‘better’ or ‘very considerably’ improved; 42 per cent of those in psychoanalytic therapy achieved the same levels of success. Using a more conservative criterion of ‘return to normal functioning’, the results were less supportive of analytic therapy: 20 per cent of those receiving psychoanalytic therapy achieved this criterion in comparison with 66 per cent of those in the cognitive therapy condition. Drop-out from therapy was much lower in the cognitive therapy group than in the analytic therapy condition: 10 versus 24 per cent respectively.

Pharmacological therapy

Benzodiazepines have frequently been used in the treatment of generalized anxiety disorder, achieving an overall success rate of about 35 per cent. A further 40 per cent of people show moderate improvement but still have some symptoms. However, benzodiazepines bring a number of drawbacks, particularly when used in the long term, including impaired cognitive performance, lethargy, drug tolerance and dependence, depression, and relapse upon withdrawal, and are no longer considered the drug treatment of choice. For this reason, although the effectiveness of benzodiazepines is generally similar to that of antidepressants, the latter are usually the drug of choice. Both tricyclics and SSRIs appear equally effective, although the lower number of side-effects associated with SSRIs, and the greater levels of adherence to them, make them the pharmacological treatment of choice  Combining psychological and drug therapy may be of some benefi t, although the additional benefi ts occur after the cessation of drug therapy. Barlow et al., for example, found signifi cant gains on a measure of global improvement in 41 per cent of their study participants who received imipramine (a tricyclic) plus CBT 6 months after discontinuation of the drug. The same fi gure for those in the CBT alone group was 32 per cent, while only 20 per cent of those in the imipramine-alone group still evidenced signifi cant gains.

Tags: anxiety, disorder, generalized anxiety disorder, treatment