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Cognitive Behavioral Therapy Effectiveness for the Treatment of Generalised Anxiety Disorder

Abstract

According to the United States National Institute of Mental Health (2009), Generalized Anxiety Disorder (GAD) has been defined as “an anxiety disorder characterized by chronic anxiety, exaggerated worry, and tension, even when there is little or nothing to provoke it.” The prevalence of GAD, along with the associated incidence rate has also been explored, in addition to the symptoms manifested by the patients.

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The associated psychological conditions that accompany this illness have also been explored. The need for proper medical attention for Generalized Anxiety Disorder (GAD) has been examined. In addition, there are a number of different classes of medication, such as benzodiazepines (alprazolam) and antidepressants (venlafaxine) that have been applied to treat this mental disorder, and whose effectiveness has been felt during the period.

Apart from the named medications, a psychosocial treatment referred to as Cognitive-Behavioral Therapy (CBT) has also been used effectively and proved worth. This paper has therefore focused on the effectiveness of CBT in the treatment of GAD. In as much as the medication meant to treat GAD has proved beneficial, nevertheless, there are a number of side effects to the users, and these have been dwelt on, along with the option of therapeutic treatment, such as Cognitive-Behavioral Therapy (CBT), that seeks to minimize the side effects of popular medication for GAD.

Introduction

As an anxiety disorder, GAD is manifested by uncontrollable, excessive, and generally worry that is at best irrational, on the daily activities in a manner that is inconsistent with that which actually causes such a worry, in the first place. Such kind of excessive worry usually gets in the way of the day-to-day functioning of an individual, since they characteristically foresee disaster (Brown, O’Leary, & Barlow 2001), in addition to the fact that they tend to be excessively concerned over such daily matters as health issues, death, problems of the family, money, work difficulties and friend problems.

These individuals often manifest a multitude of physical symptoms that includes, but are not limited to, fidgeting, fatigue, nausea, headache, muscle aches, muscle tension, trembling, difficulty swallowing, irritability, insomnia, twitching, hot flashes, sweating, and rashes. So that a formal GAD diagnosis may be accomplished, such symptoms must be ongoing and consistent, persisting for 6 months (Brown et al 2001).

Like many other clinically significant syndromes, Generalized Anxiety Disorder (GAD) is a condition that calls for proper medical attention. Since its appearance in the Diagnostic and Statistical Manual of Mental Disorders in 1980, much has been done to bring it under control (Rygh & Sanderson 2004). This gave rise to different classes of medication including benzodiazepines (alprazolam) and antidepressants (venlafaxine) whose effectiveness has been felt during the period.

Apart from the named medications, a psychosocial treatment referred to as Cognitive-Behavioral Therapy (CBT) has also been used effectively and proved worth. This paper will therefore focus on the effectiveness of CBT in the treatment of GAD. It will identify the different components of the therapy and identify how successful it has been and what are the drawbacks the therapy has encountered. It will focus specifically on the researches that have been done by scholars concerning this field.

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Background

The cost of mental illness in the UK has been skyrocketing for the last ten years reports indicate. What is more, the cost is predicted to go even higher if the government fails to take appropriate action (O’Hara 2008). The sharp increase has been noted for a decade despite the increase in funding by the stakeholders.

In fact, unless preventive measures are taken promptly, the UK government might fail to meet the soaring demands in the future. Since 1999, the UK has seen a whopping 1.5 billion pounds get swallowed by the investments concerned with mental health (O’Hara 2008). However, this might not work unless a sustainable increase in funding is realized. This is caused by the increase in the number of cases as attributed to the ever-increasing number of the aged population. What disheartens most is the degree to which the cost is likely to increase in the next few years.

Estimates by the King’s Fund show that the British economy might experience a total increase of 83% on the overall cost of mental illness on the economy. This puts into consideration, the aging population, the increasing number of lost earnings, the rising cost of living, and the informal unpaid care. As a result, the rise might account for 88.4 billion pounds in the next 20 years. Within the same period, direct services that are offered by the Social Services and the NHS are expected to experience an increase from 22.5 billion pounds to 47.48 billion pounds.

What, therefore, is this generalized anxiety disorder that should cost the government such massive sums of money in the effort to combat it? The United States National Institute of Mental Health (2009) defines GAD as, “an anxiety disorder characterized by chronic anxiety, exaggerated worry, and tension, even when there is little or nothing to provoke it.”

People with this condition tend to give excessive worries concerning issues like family problems, difficulties in their workplaces, health issues, etc. as a matter of fact, GAD can be diagnosed when a person exhibits a consistent 6-month duration of intensive worrying about day to day problems. As a result, people with this medical condition are easily startled, cannot easily relax, and usually exhibit concentration difficulties. This condition is usually manifested in different levels like mild or severe. Mild levels of anxiety do not have dire consequences and can allow the patient to continue with his day-to-day chores. Problems come in when they experience severe conditions. This makes them fail to do even the simplest tasks in life.

In his research, Stein (2001) pointed out that GAD is a disorder that is prevalent and common in the general population. The noted prevalence in this condition is 3.1% to 3.8% in a year. According to the National Comorbidity Survey, as quoted by Stein, a pure form of GAD free from other psychiatric disorders makes up a simple one-third of the total prevalence. Many of the patients diagnosed with lifetime GAD had been found to possess another psychiatric condition. The most common comorbidities found were dysthymia and major depression which were closely followed by simple phobia, substance abuse, and social phobia.

In addition to this, GAD has been identified to possess the highest level of comorbidity as compared to any other form of anxiety disorder. Children and adolescents are the main social groups that are affected greatly by this medical condition followed by the elderly population. Several studies have also shown that GAD is closely linked to somatic disorders with other research purporting that GAD patients are the most likely to exhibit somatoform disorders as compared to any other form of anxiety disorder. What therefore are the symptoms that differentiate GAD from other psychiatric disorders?

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In DSM-IV-TR, several symptoms are outlined to identify GAD as opposed to other nonpathological worries (Rygh & Sanderson 2004). While there are several conditions that can provide closely similar symptoms, GAD has been distinguished specifically by the following symptoms:

  • This condition is identified by too much anxiety and worry for a period not less than six months.
  • Difficulty in controlling the worry.
  • Apart from worrying, the patient has physiological symptoms like being restless and edgy, easily getting tired, low level of concentration, sometimes the mind goes blank, the patient is easily irritated, muscles experience tension, and sleeping complications.
  • The focal point of the anxiety is not pinned by the characteristics of the Axis I disorder. This means that the anxiety is not concerned with panic disorder, compulsive disorder or being contaminated, anxiety disorder or distance from relatives and home, public embarrassment or social phobia, Anorexia Nervosa or weight gain, somatization disorder, and other physical complaints, and finally, the condition does not occur specifically during posttraumatic stress disorder.
  • Due to the different symptoms, the patient exhibits impairments in social, occupational, and other functional areas.
  • Finally, the disturbance is not a result of direct effects from a substance, general medical condition, disorder of the mood, psychotic disorder, or pervasive development disorder.

As mentioned earlier, all conditions always call for medical attention. Equally, GAD falls in the same category. There are several medications that are associated with GAD. The most common psychoactive medical prescriptions include benzodiazepines azapirons such as buspirone, selective serotonin-norepinephrine re-uptake inhibitors (SSRI) like venlafaxine and tricyclic antidepressants (TCA) like imipramine.

Finally, GAD patients also receive prescriptions of antipsychotic medications. With their ability to provide immediate relief, benzodiazepines tend to be the most prescribed of all these medications. In addition, most of these drugs are associated with great side effects that render them somehow inappropriate in the use against GAD. Again, benzodiazepines are considered the most favorable with comparatively less noxious side effects.

Most of the side effects associated with these drugs include fatigue that increases as the use also increases, on the other hand, when a patient withdraws abruptly, he is likely to experience conditions like an increase in the anxiety level, somatic disorders, headaches, tremor, agitation, nausea and in some rare cases seizures. Furthermore, an increased use with time was discovered to cause tolerance and dependence which led to recommendations against resorting to these groups of drugs as the premier agents in pharmacotherapy (Rygh & Sanderson 2004).

On the other hand, TCAs and SSRIs have never had a great usage due to their evident anticholinergic side effects. The side effects include constipation, weight gain, sexual dysfunction, urinary rention and dry mouth. In addition, they failed to attract much attention due to their delayed anxiolytic action, orthostatic hypotension and sedation.

Such drawbacks called for a better option that would help in minimizing these effects and also address the issue from its root cause which is the mind. This called for psychotherapy methods that would concentrate on ways to provide coping responses that would assist in the reduction of anxiety at any point of manifestation. this solution was found in Cognitive-Behavioral Therapy (CBT) which according to the Royal College of psychiatrists (2009) is the therapy concerned with self perception, perception of the world and perception of other people. This form of therapy has been greatly used in the treatment of GAD through four of its components, cognitive therapy, self monitoring, relaxation training and rehearsing the new cognitive and relaxation coping techniques and responses that one has learnt.

Self monitoring is the first step in the therapy. It involves teaching patients to clearly comprehend and develop an objective observation of their responses to anxiety and also the environmental cues that trigger this state. It is much easier for the patient to master all the learnt coping responses in time if he identifies the incipient anxiety in time. In relaxation training, patients are taught how to relax especially progressive relaxing of the muscles during sessions of treatment and are thus advised to do the same two times everyday so that they can learn how to respond to anxiety by quickly producing relaxation.

Due to GAD’s main symptom of threat perception in the near future, cognitive therapy plays an important role in the containing the condition. It is divided into four stages which are identification of the patient’s thought pattern about himself, the future and the world and the beliefs that have led to such perceptions, accuracy evaluation of the cognitions by considering their logic and evidences in the past, formulation of alternative interpretations and predictions that are more accurate and the application of the new perspectives in the event of an anxiety (Borkovec et al 2004).

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The final component which is the rehearsal of the coping responses involves frequent practicing of the coping responses that eventually and gradually leads to leads to change (gradual change as compared to mastery). In this process, patients are made to arouse anxiety feelings through imagination of the cues, and then they are made to apply their cognitive and relaxation skills for coping that they will have learnt.

Evidence of Success and drawbacks

As mentioned earlier, GAD was first identified as a clinically relevant condition in 1980. This triggered a host of researches with the first research appearing in 1984. After the first experiment, 16 more experiments have been carried out all of them concurring that traditional CBT as a form of treatment for GAD is efficient. These researches also enabled CBT to be listed as an empirically supported treatment for GAD by the Task Force for the Dissemination and Promotion of Empirically Supported Treatment. The most recent review was based on 13 studies that were out by that time. In this review, results for group comparisons and average effect sizes for the 16 investigation s were analyzed.

The two effect size types in this review included within-group effect-sizes which involved the posttherapy score less the pretherapy score divide by the standard deviation of the pretherapy and the between-group effect sizes which involved the posttherapy score of the CBT less posttherapy score for the condition of comparison divide by the standard deviation of the pooled posttherapy score. The scores were measured on the standard outcome measures used within the GAD treatment literature.

They are the Hamilton Anxiety Rating Scale, the Assessor Severity Rating and the State-Trait Anxiety Inventory. It also included a sample which involved women whose average age was 40 years who accounted for two thirds of it and had experienced GAD duration averaging 7 years with an average of 11 sessions of therapy (Borkovec et al 2004).

The above review pointed out that compared to other conditions before posttherapy and follow up, the largest improvement degree was generated by CBT treatment in the within –group effect sizes. CBT accounted for 2.50 average score while the other conditions had an average of 2.44. These results were based on 14 separate conditions of CBT. Conditions that played the role of controls for nonspecific effects generated effect sizes that were smaller as compared to these results.

They accounted for 2.9 and 2.0 respectively. Of the seven studies which involved a waiting list no-treatment conditions and which allowed the calculation of the effect size through providing of data and measures, four of them realized an almost no change status for the conditions accounting for about 0.01 from pretherapy to posttherapy.

Of the seven investigations that involved these control conditions, CBT assumed superiority over waiting-list no-treatment conditions in each investigation. An average of 1.09 was experienced by the between-group effect-sizes at posttherapy. In addition, CBT has witnessed an improvement level that was steady or better than the original score in the assessment of the follow ups within 6 to 12 months according to most of the investigations. 9 of the 11 conditions controlling for nonspecific factors have shown CBT commanding superiority with a further 7 out of 9 superiority of CBT over the rest during follow up.

The average score for between-group effect-sizes in the latter study was 0.71 and 0.30 for posttherapy and follow-up respectively. Comparing CBT with its component therapies has not shed too much light because CBT was found superior only in 2 of the 11 comparisons and 3 of the 8 comparisons for post therapy and follow-up respectively (Borkovec et al 2004).

The dropout rates of patients under treatment have been found to be very low in individual CBT as compared to other forms of treatment. During the experimental investigations, the drop out rate was averaged to less than 9%. For patients under medication, experiments concerned with the patient’s drug use have proved that the use of drugs reduces by the end of the psychotherapy. Use of CBT has also proved important in the treatment of depression as most of the experiments have shown that great improvements by the patients after CBT. Finally, the psychological disorders and other comorbid anxieties have been identified to reduce greatly after CBT (Borkovec et al 2004).

Due to it’s highly comorbid nature, GAD can be identified with other psychiatric disorders that are caused by structural complications of the brain. This had been thought to be a great challenge to psychological approach to treatment of such diseases. However, after thorough research, it has been identified that psychotherapy also has the ability to change the structure of the brain (Friedman 2002). According to Neurobiologist Eric Kandel’s study, learning has the ability to produce new proteins and hence change the model of the neurons. While carrying out a research on sea slugs, Kandel found out that those slugs exposed to learning conditions experienced a doubling of neural connections a phenomenon that was not realized on their non conditioned counterparts.

This study is important because psychotherapy can be taken to be a form of learning. When the therapists speak to patients, they make them change their brain function completely. As much as CBT has proved to be effective in the treatment of GAD, there are several drawbacks that are associated with the therapy. As the studies show, assessments of the clinically significant changes like endstate functioning, have proved that about only half of the number of those patients undergoing CBT as a result of GAD treatment go back to normal anxiety levels. This could be attributed to the complications associated with GAD. In some instances, GAD has been identified as one of the most difficult anxiety disorder conditions to be treated. This section will thus identify the complications associated with GAD that make CBT to be less effective as a means of combating it.

Interpersonal relationships associated with the patients suffering from GAD posses one of the greatest drawbacks in CBT treatment. Most of the investigations showed that more than half of all the patients of GAD were associated with one or even more comorbid Axis II diagnosis which offer rigidity and maladaptive interpersonal relationships characteristics. Furthermore, social phobia was also identified as the most common among the Axis I diagnoses in GAD patients.

The most identified worry topics for GAD patients was interpersonal fear. Indeed, a study that involved nine Axis I disorders found that GAD was strongly associated with spousal conflicts. Of the eight Inventory of Interpersonal Problems Circumplex Scales, GAD patients accounted for an average score that was higher than Horowitz’s clinical norms in the mixed diagnoses of the more than 200 psychiatric patients in five of them (Borkovec et al 2004).

This finding is very important in the process of CBT treatment of GAD because most of these patients are more focused on self protection from threats including other people that they fail to pay attention to other forms of information that concern their interpersonal impacts. As a result, they fail to realize that their behavior is not constructive to them or to the people around them. This makes them maintain their maladaptive character which implicates negatively on the treatment. The maladaptive patterns eventually become habitual and tackling them calls for ways that directly deal with the interpersonal problems (Borkovec et al 2004). Therefore, CBT fails to address interpersonal difficulties which are very necessary in the treatment of GAD.

Further studies have also pointed out that the emphasis laid by the CBT therapists is more on relationships and fails to address the major concern which is interpersonal situations. This was a drawback on the treatment of GAD because tackling the condition through emphasis on interpersonal relations has produced positive outcomes in most cases as compared to negative outcomes that have been associated with dealing with the issue from an emphasis on relationships.

Comparative process studies pointed out that psychodynamic treatment was positively related to emphasis on the interpersonal issues. This is therefore evident that CBT might not address fully the issue of interpersonal problems and that it lacks the basic techniques like those associated with the psychodynamic treatment and the interpersonal traditions. Without inclusion of the techniques used in the two processes named, the treatment of GAD by use of CBT might continue experiencing a high dropout rates and thus translate into failure of CBT (Borkovec et al 2004).

CBT has also been identified to contain some protocol that reinforces avoidant character in GAD patients instead of finding a way of alleviating the character. According to some of the researches, worrisome thinking might be as a response to cognitive avoidance that is meant to block some emotional processes. Worry as a form of avoidance has been proved in several studies. When control participants and GAD patients were asked of their reasons of worrying, the distinguishing factor between the two groups was the fact that GAD patients had one characteristic that was absent in the control participants.

GAD patients pointed out that they worry about the issues they worry about because they try to avoid worrying about other more emotional issues. This showed that GAD patients worry with a sole reason of avoiding other topics and their underlying primary affects (Borkovec et al 2004). Furthermore, GAD patients find it difficult to express the emotions which come up during treatment sessions and thus prefer directing “their attention to cognition.”

As a result, CBT therapists always fail to understand that emotions are supposed to be explored and deepened instead, they view emotions as phenomena that need to be controlled and reduced. This results into reinforcement of the avoidant characteristic of the GAD patients. The therapists of CBT fail to understand that higher levels of emotions whether negative or positive always result into positive outcomes.

On another review by the Cochrane library that was done by analyzing 25 researches carried out on 1,305 participants also pointed out that although 46% of GAD patients under CBT treatment showed improvements as compared to a mere 14% who showed improvement in the waiting list and usual treatment method after treatment, the therapy was marred by several drawbacks. One of the conspicuous finding was that the results found out in these studies were more mixed in comparison to supportive therapies.

This meant that the results could not be relied on squarely and that more comparative study had to be carried out to ascertain the cause of the mixed up results and identify on how CBT could be improved so as to come up with a more efficient treatment for GAD. In addition, the Cochrane review also found out that this therapy was much associated with high drop out levels especially in the instances where the therapy was carried out in group form. However, the lack of intensive reporting concerning dropout levels does not allow an interpretation that the dropout rate was directly related to less popularity of group therapy as compared to individual therapy which experienced a very small number of drop outs. This therefore leaves a lot of study to be carried out to bring out the clear picture (Ullman 2007).

Conclusion

From the evidence shown above, it is open that while CBT can be effective to the treatment of GAD, there are several drawbacks that need to be tackled to ensure that its efficacy is improved. The main issue in GAD has been identified to be cropping from interpersonal relationships, an issue that CBT fails to address squarely. In addition, the CBT protocol which reinforces the avoidant character in GAD patients should be tackled so that patients are taught to open up instead of closing up with their emotions. But before the proper reforms are made within CBT treatment, it is better for a psychopharmacological treatment is used.

This has shown great efficiency within researches that have been carried out. With a combination of the two, especially CBT and benzodiazepines whose side effects are less as compared to other medications, may be a better approach can be arrived at while more researches are done to improve on the CBT treatment.

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