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According to the Anxiety and Depression Association of America, generalized anxiety disorder (GAD) affects 6.8 million adults, or 3.1 percent of the U.S. population. So even though you might feel ashamed about your anxiety and like you’re the only one who’s struggling, you’re absolutely not alone.
It’s hard to live with excessive, uncontrollable, stubborn worry. Maybe it keeps you up at night. Maybe the worry arises first thing in the morning as you open your eyes. Maybe it feels like you’re rarely worry-free. In fact, people can worry anywhere from 3 to 10 hours a day.
However, this kind of crippling worry is highly treatable with psychotherapy and medication. For example, according to treatment guidelines from the Royal Australian and New Zealand College of Psychiatrists, for mild GAD, cognitive behavioral therapy (CBT) is best. For moderate GAD, CBT or a selective serotonin reuptake inhibitor (SSRI) or serotonin and norepinephrine reuptake inhibitors (SNRI) is recommended. For severe GAD, the most effective option is a combination of CBT and medication.
For most people who are newly diagnosed with GAD, UpToDate.com also recommends either an SSRI or SNRI, CBT, or both, because these are the best-studied treatments for effectively treating GAD.
Co-occurring conditions also are common with GAD—and will guide the specifics of your treatment. For instance, some individuals who have GAD and severe depression might not be able to fully participate in CBT. So they would start taking an SSRI and may or may not start CBT then, as well.
Both the National Institute for Health and Care Excellence (NICE) and Canadian treatment guidelines for anxiety disorders recommend psychological interventions (often CBT) as the first-line treatment, and an SSRI or SNRI for individuals who haven’t benefited from therapy (along with other medications as second-line options).
The first-line treatment and gold standard for treating generalized anxiety disorder (GAD) is cognitive behavioral therapy (CBT). CBT for GAD is a multimodal treatment, meaning that it includes various components that target the different symptoms of the illness: physical, cognitive, and behavioral.
Overall, CBT aims to help you reduce your anxiety and worrisome thoughts, effectively cope with stress, and calm your nervous system. You and your therapist will work together on creating a treatment plan that’s best for you. CBT typically consists of eight to 15 sessions (about 50 to 60 minutes per session). The number of sessions really depends on the severity of your symptoms, whether you have other co-occurring disorders, and the number of treatment components your therapist will be using. CBT includes homework outside of your therapy sessions, so your therapist will ask you to practice different strategies in your day to day, and report back.
In CBT, a therapist starts with educating you about GAD and how it manifests. You’ll also learn to observe and monitor your symptoms. Think of yourself as a scientist who’s studying your thoughts, feelings, and actions, or as a journalist gathering information and trying to identify patterns.
In CBT, you’ll also learn progressive muscle relaxation and other techniques to reduce the physical symptoms of GAD. You’ll challenge unhelpful thoughts that spark and exacerbate your anxiety. For instance, you might over-estimate that something terrible will happen, and under-estimate your ability to cope with a difficult situation. You’ll learn to change your worries into problems you can actually solve, and create actionable plans. You’ll gradually confront situations and activities that you tend to avoid, such as situations with an uncertain outcome (since avoidance only amplifies anxiety). Lastly, you and your therapist will come up with a relapse prevention plan. It’ll include the strategies you’ll continue to practice, along with a list of early warning signs and a plan to effectively navigate those signs. You’ll also identify future goals.
Typically, CBT is conducted face-to-face with a therapist. However, recent research has shown that therapist-supported internet cognitive behavioral therapy (ICBT) also is helpful. ICBT usually involves following a treatment program that’s available online while receiving support from a therapist via calls, text, or email.
The second-line treatment for GAD is acceptance and commitment therapy (ACT). In ACT, you learn to accept your thoughts without trying to alter or reduce them. One review article described it as: treating anxiety as you’d treat a child who’s screaming for a treat at the grocery store. ACT also helps you to focus on the present moment and your surroundings. And ACT helps you take action on your values, instead of letting your anxiety dictate your decisions and your days.
The first-line pharmacological treatment for generalized anxiety disorder (GAD) is a selective serotonin reuptake inhibitor (SSRI) or serotonin and norepinephrine reuptake inhibitor (SNRI). These medications are also highly effective for depression—which is important because depression commonly co-occurs with GAD. Which means that taking an SSRI or SNRI can decrease symptoms of both illnesses.
Your doctor will likely start with a low dose of an SSRI. While it varies by individual, you’ll begin to feel the benefits of the medication in 4 to 6 weeks. If you’re not showing much improvement, during that time, your doctor will likely increase the dose of the same medication. If that doesn’t seem to help, that medication will be tapered off, and your doctor will likely prescribe a different SSRI (or move on to an SNRI).
The SSRIs paroxetine (Paxil) and escitalopram (Lexapro) have been approved by the United States Food and Drug Administration (FDA) for treating GAD, along with the SNRIs venlafaxine XR (Effexor XR) and duloxetine (Cymbalta). Your doctor might prescribe a medication “off label,” which is still effective for treating GAD (even though it hasn’t been FDA approved). One example is the SSRI sertraline (Zoloft).
While the side effects of each SSRI vary, they commonly include nausea, diarrhea, weight gain, and sexual problems (e.g., decreased sex drive, delayed orgasm, or inability to achieve orgasm). The side effects of SNRIs include nausea, dizziness, sedation, sweating, constipation, and insomnia.
If you abruptly stop taking an SSRI or SNRI, or often even if you taper off slowly, these medications can produce discontinuation syndrome, which can include flu-like symptoms, dizziness, and insomnia.
When you start taking an SSRI, it tends to cause agitation and insomnia. If you’re unable to tolerate these adverse effects (and don’t have any issues with substances), your doctor might prescribe a low-dose benzodiazepine short term.
Benzodiazepines begin working within minutes or hours. Though they’re highly effective, benzodiazepines can cause tolerance and dependence, and can be abused. They also cause sedation and cognitive impairment. (In general, it’s best to avoid long-term use of benzodiazepines.)
If you struggle with substance abuse or have in the past, your doctor might instead prescribe the antihistamine hydroxyzine (Vistaril) or the anticonvulsant pregabalin (Lyrica), along with the SSRI or SNRI.
Many people with GAD don’t respond to the initial medications they try. The next treatment your doctor prescribes will depend on your specific symptoms, treatment history, and preference.
For instance, one option is the FDA-approved anti-anxiety drug buspirone (Buspar), which has similar efficacy as benzodiazepines. However, unlike benzodiazepines, buspirone doesn’t cause physiological dependence, and does take time to take effect—about 4 weeks. Side effects include dizziness, drowsiness, nausea, nervousness, restlessness, and trouble sleeping.
Another option for individuals who don’t respond to SSRIs or SNRIs are tricyclic antidepressants (TCAs) or monoamine oxidase inhibitors (MAOIs). For instance, the TCA imipramine (Tofranil) has shown efficacy in individuals with GAD (who don’t also have depression or panic disorder). TCAs also can cause discontinuation syndrome.
TCAs and MAOIs are prescribed less often because people can’t tolerate the side effects. TCAs also are dangerous in overdose with an increased risk of cardiotoxicity (damage to the heart muscle). Because of the potential of severe side effects, MAOIs require dietary restrictions, such as not eating aged cheeses, soy products, or smoked meats.
Atypical antipsychotic medication, such as risperidone, also might be prescribed—either by itself, or in conjunction with another medication to boost its effects. Side effects include sedation, weight gain, an increase in glucose and lipid levels, and extrapyramidal symptoms. The latter can include tremors, muscle spasms, slower movement, and uncontrollable facial movements (e.g., sticking out your tongue, repeatedly blinking).
Pregabalin is an effective treatment for GAD. While it’s better tolerated than benzodiazepines, tolerance, withdrawal, and dependence are possible, as well. Side effects include dizziness, drowsiness, fatigue, and swelling. Long-term use has been associated with weight gain in some individuals.
Hydroxyzine also seems to be an effective treatment. It might have more sedating effects than benzodiazepines and buspirone, making it a good option for treating GAD-related insomnia.
When we’re sitting at the doctor’s office, we often feel like we have to be “respectful,” and that being “respectful” means nodding our head, not asking any questions, and in general staying quiet. Instead, it’s vital to be your own advocate. Ask about potential side effects and strategies for minimizing them. Ask about discontinuation syndrome, and what you might expect. Ask when you’re supposed to feel better. In other words, bring up anything that concerns you. You deserve to speak up.
- Exercise is a significant stress reliever. The key is to participate in physical activities you enjoy, which might be different on different days. On some days, you might take a walk, while on other days, you might practice gentle, restorative yoga. Still, on other days, you might take a dance or boxing class.
- Get restful sleep. Sleep deprivation can trigger anxiety, and make us more sensitive to stressors. Focus on creating a bedtime routine that consists of the same three or four activities, which you do at the same time, and in the same sequence every night. These activities can be small—listening to a guided meditation, sipping tea, reading a few pages from a religious text. Also, make sure your bedroom is an inviting, soothing space with clean, cozy sheets, and clutter-free surfaces.
- Avoid caffeine and other trigging substances. Caffeine can exacerbate anxiety, so consider reducing or completely stopping drinking coffee, soda, and other caffeinated beverages. Consider quitting alcohol and tobacco, both of which also exacerbate and magnify anxiety.
- Read self-help books. There are many excellent books on anxiety from seasoned experts, which you can work through in conjunction with treatment. For instance, here’s a workbook based on cognitive behavioral therapy.
- Turn to what calms you. Maybe this is looking up at the sky, or being by the water. Maybe it’s painting or sitting on a park bench. Maybe it’s watching a funny film, or dancing to classical music. Maybe it’s visualizing a safe place. You can make a list of healthy, calming activities and strategies, and engage in them every day.