Approach to treating generalized anxiety disorder in adults
- Michelle Craske, PhD
Michelle Craske, PhD
- Director, Anxiety Research Center
- University of California, Los Angeles Department of Psychology
- Alexander Bystritsky, MD, PhD
Alexander Bystritsky, MD, PhD
- Professor of Psychiatry and Biobehavioral Sciences Director,
- Anxiety Disorders Program, David Geffen School of Medicine, University of California, Los Angeles
Generalized anxiety disorder (GAD) is characterized by excessive worry and anxiety that are difficult to control, cause significant distress and impairment, and occur on more days than not.
Generalized anxiety disorder is a relatively common disorder, most often with an adult onset and chronic course [1-4]. GAD can lead to significant impairments in role functioning, diminished quality of life, and high healthcare costs [5,6]. The disorder can be effectively treated with cognitive behavioral therapy (CBT), medication, or a combination of the two modalities .
This topic describes an approach to selecting among treatments for GAD. Information on the efficacy, dosing, and side effects of medications for GAD are described separately. Information on the components, efficacy, and administration of CBT for GAD is also described separately. The epidemiology, pathogenesis, clinical manifestations, course, and diagnosis of GAD are also described separately. (See "Pharmacotherapy for generalized anxiety disorder in adults" and "Psychotherapy for generalized anxiety disorder in adults" and "Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis".)
NEWLY DIAGNOSED PATIENTS
Patient need for treatment — Once a patient has been diagnosed with generalized anxiety disorder (GAD), the next step is to determine, based on clinical assessment of severity, extent of distress or impairment, and patient preference, whether treatment of the disorder is needed. Patients with a more mild subtype of GAD whose symptoms do not interfere significantly with functioning may reasonably elect to forgo treatment initially. Clinical follow-up with the patient every six months would be important to monitor the course of the disorder, and determine if symptoms were worsening and/or impeding functioning – indications that treatment may then be advisable. (See "Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis", section on 'Assessment'.)
Choosing between CBT and medication — For most patients with a new diagnosis of GAD in need of treatment, we recommend initial treatment with a serotonergic antidepressant, cognitive behavioral therapy (CBT), or both, rather than other interventions. Serotonergic antidepressants and CBT are the best-studied treatments found to be efficacious for GAD [8,9].
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- NEWLY DIAGNOSED PATIENTS
- Patient need for treatment
- Choosing between CBT and medication
- - Patients with co-occurring conditions
- - Patient preference for CBT
- - Patient preference for medication
- First-line medication
- No response to first SRI
- TREATMENT RESPONSE
- Response to CBT
- - Poor or partial response
- - Robust response
- Response to first-line medication
- - Partial response
- Second-line medication
- - Robust response
- - Agitation/insomnia
- OPTIONS FOR MEDICATION RESISTANCE
- Other antidepressants
- Antipsychotic medications
- Augmentation with CBT
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS