case study of someone with generalized anxiety disorder

Cognitive-Behavioral Therapy for Generalized Anxiety Disorder: Case Formulation and Evidence-Based Treatment Strategies

• First Online: 19 July 2023

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• Nicole J. LeBlanc 5 ,
• Anna Bartuska 6 ,
• Lillian Blanchard 7 &
• Luana Marques 5  

Part of the book series: Current Clinical Psychiatry ((CCPSY))

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Generalized anxiety disorder (GAD) is a prevalent chronic disorder that is associated with significant psychosocial impairment. The hallmark feature of GAD is excessive and uncontrollable worry that occurs across multiple domains of life. Cognitive-behavioral therapy (CBT) is the most widely studied psychotherapy for GAD and has received strong empirical support in randomized controlled trials. Most CBT models conceptualize worry as an ineffective emotion regulation strategy that individuals use to cope with fear and anxiety. CBT for GAD therefore involves teaching patients to notice their habitual responses to fear and anxiety and utilize more helpful emotion regulation strategies when feeling these emotions. Common treatment strategies include psychoeducation, self-monitoring of worry episodes, applied relaxation, mindfulness exercises, cognitive reappraisal, behavioral experiments, imaginal exposure, and valued actions. In this chapter, we describe the goals and evidence base for these treatment strategies and demonstrate their use with a case vignette.

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LeBlanc, N.J., Bartuska, A., Blanchard, L., Marques, L. (2023). Cognitive-Behavioral Therapy for Generalized Anxiety Disorder: Case Formulation and Evidence-Based Treatment Strategies. In: Sprich, S.E., Petersen, T., Wilhelm, S. (eds) The Massachusetts General Hospital Handbook of Cognitive Behavioral Therapy. Current Clinical Psychiatry. Humana, Cham. https://doi.org/10.1007/978-3-031-29368-9_6

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Do you often find yourself worrying about everyday issues for no obvious reason? Are you always waiting for disaster to strike or excessively worried about things such as health, money, family, work, or school?

If so, you may have a type of anxiety disorder called generalized anxiety disorder (GAD). GAD can make daily life feel like a constant state of worry, fear, and dread. The good news is GAD is treatable. Learn more about the symptoms of GAD and how to find help.

What is generalized anxiety disorder?

Occasional anxiety is a normal part of life. Many people may worry about things such as health, money, or family problems. But people with GAD feel extremely worried or nervous more frequently about these and other things—even when there is little or no reason to worry about them. GAD usually involves a persistent feeling of anxiety or dread that interferes with how you live your life. It is not the same as occasionally worrying about things or experiencing anxiety due to stressful life events. People living with GAD experience frequent anxiety for months, if not years.

GAD develops slowly. It often starts around age 30, although it can occur in childhood. The disorder is more common in women than in men.

What are the signs and symptoms of generalized anxiety disorder?

People with GAD may:

• Worry excessively about everyday things
• Have trouble controlling their worries or feelings of nervousness
• Know that they worry much more than they should
• Feel restless and have trouble relaxing
• Have a hard time concentrating
• Startle easily
• Have trouble falling asleep or staying asleep
• Tire easily or feel tired all the time
• Have headaches, muscle aches, stomachaches, or unexplained pains
• Have a hard time swallowing
• Tremble or twitch
• Feel irritable or "on edge"
• Sweat a lot, feel lightheaded, or feel out of breath
• Have to go to the bathroom frequently

Children and teens with GAD often worry excessively about:

• Their performance in activities such as school or sports
• Catastrophes, such as earthquakes or war
• The health of others, such as family members

Adults with GAD are often highly nervous about everyday circumstances, such as:

• Job security or performance
• The health and well-being of their children or other family members
• Completing household chores and other responsibilities

Both children and adults with GAD may experience physical symptoms such as pain, fatigue, or shortness of breath that make it hard to function and that interfere with daily life.

Symptoms may fluctuate over time and are often worse during times of stress—for example—with a physical illness, during school exams, or during a family or relationship conflict.

What causes generalized anxiety disorder?

Risk for GAD can run in families. Several parts of the brain and biological processes play a key role in fear and anxiety. By learning more about how the brain and body function in people with anxiety disorders, researchers may be able to develop better treatments. Researchers have also found that external causes, such as experiencing a traumatic event or being in a stressful environment, may put you at higher risk for developing GAD.

How is generalized anxiety disorder treated?

If you think you’re experiencing symptoms of GAD, talk to a health care provider. After discussing your history, a health care provider may conduct a physical exam to ensure that an unrelated physical problem is not causing your symptoms. A health care provider may refer you to a mental health professional, such as a psychiatrist, psychologist, or clinical social worker. The first step to effective treatment is to get a diagnosis, usually from a mental health professional.

GAD is generally treated with psychotherapy (sometimes called “talk therapy”), medication, or both. Speak with a health care provider about the best treatment for you.

Psychotherapy

Cognitive behavioral therapy (CBT), a research-supported type of psychotherapy, is commonly used to treat GAD. CBT teaches you different ways of thinking, behaving, and reacting to situations that help you feel less anxious and worried. CBT has been well studied and is the gold standard for psychotherapy.

Another treatment option for GAD is acceptance and commitment therapy (ACT). ACT takes a different approach than CBT to negative thoughts and uses strategies such as mindfulness and goal setting to reduce your discomfort and anxiety. Compared to CBT, ACT is a newer form of psychotherapy treatment, so less data are available on its effectiveness. However, different therapies work for different types of people, so it can be helpful to discuss what form of therapy may be right for you with a mental health professional.

For more information on psychotherapy, visit the National Institute of Mental Health (NIMH) psychotherapies webpage .

Health care providers may prescribe medication to treat GAD. Different types of medication can be effective, including:

• Antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs)
• Anti-anxiety medications, such as benzodiazepines

SSRI and SNRI antidepressants are commonly used to treat depression, but they also can help treat the symptoms of GAD. They may take several weeks to start working. These medications also may cause side effects, such as headaches, nausea, or difficulty sleeping. These side effects are usually not severe for most people, especially if the dose starts off low and is increased slowly over time. Talk to your health care provider about any side effects that you may experience.

Benzodiazepines, which are anti-anxiety sedative medications, also can be used to manage severe forms of GAD. These medications can be very effective in rapidly decreasing anxiety, but some people build up a tolerance to them and need higher and higher doses to get the same effect. Some people even become dependent on them. Therefore, a health care provider may prescribe them only for brief periods of time if you need them.

Buspirone is another anti-anxiety medication that can be helpful in treating GAD. Unlike benzodiazepines, buspirone is not a sedative and has less potential to be addictive. Buspirone needs to be taken for 3–4 weeks for it to be fully effective.

Both psychotherapy and medication can take some time to work. Many people try more than one medication before finding the best one for them. A health care provider can work with you to find the best medication, dose, and duration of treatment for you.

For basic information about these and other mental health medications, visit NIMH’s Mental Health Medications webpage . Visit the U.S. Food and Drug Administration (FDA) website  for the latest warnings, patient medication guides, and information on newly approved medications. 

Support Groups

Some people with anxiety disorders might benefit from joining a self-help or support group and sharing their problems and achievements with others. Support groups are available both in person and online. However, any advice you receive from a support group member should be used cautiously and does not replace treatment recommendations from a health care provider.

Healthy Habits

Practicing a healthy lifestyle also can help combat anxiety, although this alone cannot replace treatment. Researchers have found that implementing certain healthy choices in daily life—such as reducing caffeine intake and getting enough sleep—can reduce anxiety symptoms when paired with standard care—such as psychotherapy and medication.

Stress management techniques, such as exercise, mindfulness, and meditation, also can reduce anxiety symptoms and enhance the effects of psychotherapy. You can learn more about how these techniques benefit your treatment by talking with a health care provider.

To learn more ways to take care of your mental health, visit NIMH’s Caring for Your Mental Health webpage .

How can I support myself and others with generalized anxiety disorder?

Educate yourself.

A good way to help yourself or a loved one who may be struggling with GAD is to seek information. Research the warning signs, learn about treatment options, and keep up to date with current research.

Communicate

If you are experiencing GAD symptoms, have an honest conversation about how you’re feeling with someone you trust. If you think that a friend or family member may be struggling with GAD, set aside a time to talk with them to express your concern and reassure them of your support.

Know When to Seek Help

If your anxiety, or the anxiety of a loved one, starts to cause problems in everyday life—such as at school, at work, or with friends and family — it’s time to seek professional help. Talk to a health care provider about your mental health.

Are there clinical trials studying generalized anxiety disorder?

NIMH supports a wide range of research, including clinical trials that look at new ways to prevent, detect, or treat diseases and conditions—including GAD. Although individuals may benefit from being part of a clinical trial, participants should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others may be better helped in the future.

Researchers at NIMH and around the country conduct clinical trials with patients and healthy volunteers. Talk to a health care provider about clinical trials, their benefits and risks, and whether one is right for you. For more information, visit NIMH's clinical trials webpage .

Finding Help

Behavioral health treatment services locator.

This online resource, provided by the Substance Abuse and Mental Health Services Administration (SAMHSA), helps you locate mental health treatment facilities and programs. Find a facility in your state by searching SAMHSA’s online Behavioral Health Treatment Services Locator  . For additional resources, visit NIMH's Help for Mental Illnesses webpage .

Talking to a Health Care Provider About Your Mental Health

Communicating well with a health care provider can improve your care and help you both make good choices about your health. Find tips to help prepare for and get the most out of your visit at Taking Control of Your Mental Health: Tips for Talking With Your Health Care Provider . For additional resources, including questions to ask a provider, visit the Agency for Healthcare Research and Quality website  .

If you or someone you know is in immediate distress or is thinking about hurting themselves, call the National Suicide Prevention Lifeline toll-free at 1-800-273-TALK (8255). You also can text the Crisis Text Line (HELLO to 741741) or use the Lifeline Chat on the National Suicide Prevention Lifeline website   .

The information in this publication is in the public domain and may be reused or copied without permission. However, you may not reuse or copy images. Please cite the National Institute of Mental Health as the source. Read our copyright policy to learn more about our guidelines for reusing NIMH content.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health NIH Publication No. 22-MH-8090 Revised 2022

AMY B. LOCKE, MD, FAAFP, NELL KIRST, MD, AND CAMERON G. SHULTZ, PhD, MSW

A more recent article on  generalized anxiety disorder and panic disorder in adults  is available.

Am Fam Physician. 2015;91(9):617-624

Patient information : See related handout on anxiety and panic disorders , written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Generalized anxiety disorder (GAD) and panic disorder (PD) are among the most common mental disorders in the United States, and they can negatively impact a patient's quality of life and disrupt important activities of daily living. Evidence suggests that the rates of missed diagnoses and misdiagnosis of GAD and PD are high, with symptoms often ascribed to physical causes. Diagnosing GAD and PD requires a broad differential and caution to identify confounding variables and comorbid conditions. Screening and monitoring tools can be used to help make the diagnosis and monitor response to therapy. The GAD-7 and the Severity Measure for Panic Disorder are free diagnostic tools. Successful outcomes may require a combination of treatment modalities tailored to the individual patient. Treatment often includes medications such as selective serotonin reuptake inhibitors and/or psychotherapy, both of which are highly effective. Among psychotherapeutic treatments, cognitive behavior therapy has been studied widely and has an extensive evidence base. Benzodiazepines are effective in reducing anxiety symptoms, but their use is limited by risk of abuse and adverse effect profiles. Physical activity can reduce symptoms of GAD and PD. A number of complementary and alternative treatments are often used; however, evidence is limited for most. Several common botanicals and supplements can potentiate serotonin syndrome when used in combination with antidepressants. Medication should be continued for 12 months before tapering to prevent relapse.

Generalized anxiety disorder (GAD) and panic disorder (PD) are among the most common mental disorders in the United States and are often encountered by primary care physicians. The hallmark of GAD is excessive, out-of-control worry, and PD is characterized by recurrent and unexpected panic attacks. Both conditions can negatively impact a patient's quality of life and disrupt important activities of daily living. The rates of missed diagnoses and misdiagnosis of GAD and PD are high, with symptoms often ascribed to physical causes.

This article reviews the diagnosis and management of GAD and PD in adults. Diagnosis and care of children and adolescents with these conditions require special considerations that are beyond the scope of this review.

Epidemiology, Etiology, and Pathophysiology

The 12-month prevalence for GAD and PD among U.S. adults 18 to 64 years of age is 2.9% and 3.1%, respectively. In this population, the lifetime prevalence is 7.7% in women and 4.6% in men for GAD, and is 7.0% in women and 3.3% in men for PD. 1

The etiology of GAD is not well understood. There are several theoretical models, each with varying degrees of empirical support. An underlying theme to several models is the dysregulation of worry. Emerging evidence suggests that patients with GAD may experience persistent activation of areas of the brain associated with mental activity and introspective thinking following worry-inducing stimuli. 2 Twin studies suggest that environmental and genetic factors are likely involved. 3

The etiology of PD is also not well understood. The neuroanatomical hypothesis suggests that a genetic-environment interaction is likely responsible. Patients with PD may exhibit irregularities in specific brain structures, altered neuronal processes, and dysfunctional corticolimbic interaction during emotional processing. 4

Typical Presentation and Diagnostic Criteria

Generalized anxiety disorder.

Patients with GAD typically present with excessive anxiety about ordinary, day-today situations. The anxiety is intrusive, causes distress or functional impairment, and often encompasses multiple domains (e.g., finances, work, health). The anxiety is often associated with physical symptoms, such as sleep disturbance, restlessness, muscle tension, gastrointestinal symptoms, and chronic headaches. 5 Diagnostic and Statistical Manual of Mental Disorders , 5th ed, (DSM-5) diagnostic criteria for GAD are listed in Table 1 . 5 Some factors associated with GAD include female sex, unmarried status, lower education level, poor health, and presence of life stressors. 6 The age of onset is variable, with a median age of 30 years. 1

A number of scales are available to establish diagnosis and assess severity. The GAD-7 ( Table 2 7 ) has been validated as a diagnostic tool and a severity assessment scale, with a score of 10 or more having good diagnostic sensitivity and specificity. 8 Greater GAD-7 scores correlate with more functional impairment. 8 The scale was developed and validated based on DSM-IV criteria, but it remains clinically useful after publication of the DSM-5 because the differences in GAD diagnostic criteria are minimal. The PRO-MIS Emotional Distress–Anxiety–Short Form for adults and the Severity Measure for Generalized Anxiety Disorder–Adult, available from the American Psychiatric Association at http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures , are intended to aid clinical evaluation of GAD and monitor treatment effectiveness.

PANIC DISORDER

PD is characterized by episodic, unexpected panic attacks that occur without a clear trigger. 5 Panic attacks are defined by the rapid onset of intense fear (typically peaking within about 10 minutes) with at least four of the physical and psychological symptoms in the DSM-5 diagnostic criteria ( Table 3 ) . 5 Another requirement for the diagnosis of PD is that the patient worries about further attacks or modifies his or her behavior in maladaptive ways to avoid them. The most common physical symptom accompanying panic attacks is palpitations. 9 Although unexpected panic attacks are required for the diagnosis, many patients with PD also have expected panic attacks, occurring in response to a known trigger. 9 The Severity Measure for Panic Disorder–Adult ( http://www.psychiatry.org/File%20Library/Practice/DSM/DSM-5/SeverityMeasureForPanicDisorderAdult.pdf ) is an assessment scale that can complement the clinical assessment of patients with PD.

Differential Diagnosis and Comorbidity

When evaluating a patient for a suspected anxiety disorder, it is important to exclude medical conditions with similar presentations (e.g., endocrine conditions such as hyperthyroidism, pheochromocytoma, or hyperparathyroidism; cardiopulmonary conditions such as arrhythmia or obstructive pulmonary diseases; neurologic diseases such as temporal lobe epilepsy or transient ischemic attacks). Other psychiatric disorders (e.g., other anxiety disorders, major depressive disorder, bipolar disorder); use of substances such as caffeine, albuterol, levothyroxine, or decongestants; or substance withdrawal may also present with similar symptoms and should be ruled out. 5

Complicating the diagnosis of GAD and PD is that many conditions in the differential diagnosis are also common comorbidities. Additionally, many patients with GAD or PD meet criteria for other psychiatric disorders, including major depressive disorder and social phobia. Evidence suggests that GAD and PD usually occur with at least one other psychiatric disorder, such as mood, anxiety, or substance use disorders. 10 When anxiety disorders occur with other conditions, historic, physical, and laboratory findings may be helpful in distinguishing each diagnosis and developing appropriate treatment plans.

Some studies evaluating anxiety treatments assess non-specific anxiety-related symptoms rather than the set of symptoms that characterize GAD or PD. When possible, the treatments described in this section will differentiate between GAD and PD; otherwise, treatments refer to anxiety-related symptoms in general.

Medication or psychotherapy is a reasonable initial treatment option for GAD and PD. 11 Some studies suggest that combining medication and psychotherapy may be more effective for patients with moderate to severe symptoms. 12 The National Institute for Health and Care Excellence (NICE) guidelines on GAD and PD in adults are a useful review of available evidence; however, information about self-help and group therapies may have less utility in the United States because of their relative lack of availability. 11

Compassionate listening and education are an important foundation in the treatment of anxiety disorders. 11 Patient education itself can help reduce anxiety, particularly in PD. 13 The establishment of a therapeutic alliance between the patient and physician is important to allay fears of interventions and to progress toward treatment.

Common lifestyle recommendations that may reduce anxiety-related symptoms include identifying and removing possible triggers (e.g., caffeine, stimulants, nicotine, dietary triggers, stress), and improving sleep quality/quantity and physical activity.

Caffeine can trigger PD and other types of anxiety. Those with PD may be more sensitive to caffeine than the general population because of genetic polymorphisms in adenosine receptors. 14 Smoking cessation leads to improved anxiety scores, with relapse leading to increased anxiety. Many studies show an association between disordered sleep and anxiety, but causality is unclear. 15 In addition to decreased depression and anxiety, physical activity is associated with improved physical health, life satisfaction, cognitive functioning, and psychological well-being. Physical activity is a cost-effective approach in the treatment of GAD and PD. 16 , 17 Exercising at 60% to 90% of maximal heart rate for 20 minutes three times weekly has been shown to decrease anxiety 16 ; yoga is also effective. 18

First-Line Therapies . A number of medications are available for treating anxiety ( Table 4 ) . Selective serotonin reuptake inhibitors (SSRIs) are generally considered first-line therapy for GAD and PD. 19 – 22 Tricyclic antidepressants (TCAs) are better studied for PD, but are thought to be effective for both GAD and PD. 19 , 20 In the treatment of PD, TCAs are as effective as SSRIs, but adverse effects may limit the use of TCAs in some patients. 23 Venlafaxine, extended release, is effective and well tolerated for GAD and PD, whereas duloxetine (Cymbalta) has been adequately evaluated only for GAD. 24 Azapirones, such as buspirone (Buspar), are better than placebo for GAD 25 but do not appear to be effective for PD. 26 Mixed evidence suggests bupropion (Wellbutrin) may have anxiogenic effects for some patients, thus warranting close monitoring if used for treatment of comorbid depression, seasonal affective disorder, or smoking cessation. 27 Bupropion is not approved for the treatment of GAD or PD.

Medications should be titrated slowly to decrease the initial activation. Because of the typical delay in onset of action, medications should not be considered ineffective until they are titrated to the high end of the dose range and continued for at least four weeks. Once symptoms have improved, medications should be used for 12 months before tapering to limit relapse. 11 Some patients will require longer treatment.

Benzodiazepines are effective in reducing anxiety, but there is a dose-response relationship associated with tolerance, sedation, confusion, and increased mortality. 28 When used in combination with antidepressants, benzodiazepines may speed recovery from anxiety-related symptoms but do not improve longer-term outcomes. The higher risk of dependence and adverse outcomes complicates the use of benzodiazepines. 29 NICE guidelines recommend only short-term use during crises. 11 Benzodiazepines with an intermediate to long onset of action (such as clonazepam [Klonopin]) may have less potential for abuse and less risk of rebound. 30

Second-Line Therapies . Second-line therapies for GAD include pregabalin (Lyrica) and quetiapine (Seroquel), although neither has been evaluated for PD. Pregabalin is more effective than placebo but not as effective as lorazepam (Ativan) for GAD. Weight gain is a common adverse effect of pregabalin. There is limited evidence for the use of antipsychotics to treat anxiety disorders. Although quetiapine seems to be effective for GAD, the adverse effect profile is significant, including weight gain, diabetes mellitus, and hyperlipidemia. 31 Hydroxyzine is considered a second-line treatment for GAD, 32 but there are minimal data for its use in PD. Its rapid onset can be appealing for patients needing immediate relief, and it may be a more appropriate alternative if benzodiazepines are contraindicated (e.g., in patients with a history of substance abuse). Based on clinical experience, gabapentin (Neurontin) is sometimes prescribed by psychiatrists to treat anxiety on an as-needed basis when benzodiazepines are contraindicated. Of note, the placebo response for medications used to treat GAD and PD is high. 13

PSYCHOTHERAPY AND RELAXATION THERAPIES

Psychotherapy includes many different approaches, such as cognitive behavior therapy (CBT) and applied relaxation ( Table 5 ) . 33 , 34 CBT may use applied relaxation, exposure therapy, breathing, cognitive restructuring, or education. Psychotherapy is as effective as medication for GAD and PD. 11 Although existing evidence is insufficient to draw conclusions about many psychotherapeutic interventions, structured CBT interventions have consistently proven effective for the treatment of anxiety in the primary care setting. 34 – 36 Psychotherapy may be used alone or combined with medication as first-line treatment for PD 37 and GAD, 11 based on patient preference. Psychotherapy should be performed weekly for at least eight weeks to assess its effect.

Mindfulness has similar effectiveness to traditional CBT or other behavior therapies, 38 particularly mindfulness-based stress reduction. 39 A meta-analysis of 36 randomized controlled trials on meditation showed that meditative therapies reduce anxiety symptoms, but most studies looked at anxiety symptoms rather than anxiety disorders. 40 Transcendental meditation has similar effectiveness to other relaxation therapies. 41

After a treatment course, rebound symptoms may occur less often with psychotherapy than with medications. Successful treatment requires tailoring options to individuals and may often include a combination of modalities. 11 , 37 , 42 Combined treatment with medications and psychotherapy reduces relapse even at two years. 43

COMPLEMENTARY AND ALTERNATIVE MEDICINE THERAPIES

Although a number of complementary and alternative products have evidence for treating depression, most lack sufficient evidence for the treatment of anxiety. Botanicals and supplements sometimes used to treat GAD and PD are listed in Table 6 . Kava extract is an effective treatment for anxiety 44 ; however, case reports of hepatotoxicity have decreased its use. 45 St. John's wort, tryptophan, 5-Hydroxytryptophan, and S-adenosyl-l-methionine should be used with caution in combination with SSRIs because of the increased risk of serotonin syndrome. 46

Evidence indicates that music therapy, aromatherapy, acupuncture, and massage are helpful for anxiety associated with specific disease states, but none have been evaluated specifically for GAD or PD.

Referral and Prevention

For patients with GAD or PD, psychiatric referral may be indicated if there is poor response to treatment, atypical presentation, or concern for significant comorbid psychiatric illness. There is insufficient evidence to support a concise recommendation on the prevention of PD and GAD in adults.

Data Sources : We searched Essential Evidence Plus, PubMed, and Ovid Medline using the keywords generalized anxiety disorder, panic disorder, diagnosis, treatment, medication, epidemiology, etiology, pathophysiology, differential diagnosis, and complementary and alternative medicine. We searched professional and authoritative organizations on the topic of anxiety disorders, including the American Psychological Association, the National Institute of Mental Health, the National Institute for Health and Care Excellence, and the Cochrane Collaboration. Search dates: May to July 2014.

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Generalized Anxiety Disorder Case Study: James

A paper on case studies.

If you are seeking help in this area, please let one of our therapists know. Theravive has thousands of licensed counselors available to help you right away. The following article may have multiple collaborators and thus, parts of it may not represent the official positions of Theravive.

Generalized anxiety disorder, (GAD) is a traumatic illness, and is hard to understand unless you are experiencing it yourself. While specific anxiety disorders are complicated by panic attacks or other features of the disorder, GAD has no specific focus. (Durand, 2007 p.130). The person constantly worries about everyday life; not being able to figure out what to do with their worries. All the while making themselves and everyone around them miserable. (p.130). The worries seem to take over control of one's life, almost to the point of not being able to function at all.

It seems that GAD tends to run in families based on studies conducted, and seems to happen more to women than men. (Durand, 2007 p.132). And evidence shows that GAD may be proved to be just as heritable, the same as other anxiety disorders. (p.133). The textbook states that this disorder originated in 1980, however therapists were working with patients with anxiety way before the criteria was developed. (p.133). For many years, clinicians believed that people who were generally anxious just didn't seem to have anything specific to focus on, thus calling it the 'free floating' disorder. (p.133).

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) has specific criteria that characterized GAD. As stated in our textbook, the features are:

• Excessive anxiety and worry for 6 months or more about a number of events or activities. • Difficulty in controlling the worry. • At least three of these symptoms: (1) restlessness of feeling all keyed up; (2) becoming fatigues easily; (3) difficulty concentrating; (4) irritability; (5) muscle tension; (6) sleep disturbance. • Significant distress or impairment. • Anxiety is not limited to one specific issue. (Durand, 2007 p.131).

Generalized anxiety disorder has been studied using various criteria. The National Comorbidity Survey (NCS) focused on noninstitutionalized American civilians ages 15 to 54. The results were reported and found there was a clear predominance of women with GAD, with a 2:1 female/male ratio. It was lowest among the younger age group but increased with age. (NA, 1997). 'There was a significant regional difference in GAD as well, with a higher lifetime prevalence in the Northeast than in other parts of the country.' (1997). Studies have shown that many people could not really pinpoint a clear age of onset of GAD or an onset dating back to childhood. (Barlow, 1993 p.156). There have also been twin studies which conclude that GAD is somewhat greater for identical female twins than for non-identical twins, but only if one twin already had generalized anxiety disorder. (Durand, 2007 p.132). But later researched showed that what seemed to be inherited was the ability to become anxious rather than GAD itself. (p.132). It's amazing to know that people with GAD seem to show less responsiveness on most physiological measures, such as heart rate, blood pressure, skin conductance and respiration rate than do people with other anxiety disorders. (p.133).

Although it seems to prove that GAD is quite common, I am amazed that more people don't have this disorder. I think that many people have general anxieties on a daily basis, but most people are able to handle them successfully. I did not realize that most people with GAD have usually had symptoms of anxiety or feelings of being worried throughout life, but just didn't know when it all started. The criterion has changed over the years as well as doctors have become more knowledgeable about this disorder. I first had knowledge of this disease in 1997 when I noticed strange things happening.

He was not really watching as he stared directly at the television set. I would notice that he had no expressions at all; nothing during the humorous scenes, or the dramatic ones. He once told me that it was as if he was someone else, watching himself try to crawl out of his own skin. That was 10 years ago when I was married to this man who was suffering from generalized anxiety disorder. I didn't understand and I really didn't want to. I thought he was just being lazy and unmotivated. Although this disorder seems to be simple to others, it is quite alarming to the person who is suffering from it, and the onset is rather quick, whereas, treatments are difficult. Everyone experiences anxiety, but in most people, it does not last for months at a time.

The case study I am choosing is about James who is a doctor suffering from generalized anxiety disorder. At 31 years of age and living in New York, he is unemployed because of his constant anxiety, even at the thought of working. He now lives with his parents off a small trust fund set up for him by an uncle. Although he was an overachiever throughout his academic career, James is having a hard time keeping it together, while his parents are somewhat supportive but disappointed with his medical career. Let's see what we can learn about this horrible and crippling disorder. 'Generalized anxiety disorder is associated with irregular neurotransmitters in the brain. Neurotransmitters are chemicals that carry signals across nerve endings. Neurotransmitters that seem to involve anxiety include norepinephrine, GABA (gamma-aminobutyric acid), and serotonin.' (na, 2001). So it was thought that reduced levels of GABA initiated excessive anxiety, although neurotransmitters are much to complex to be interpreted that simply. (Durand, 2007 p.45).

The brain is a very fascinating and intricate part of who we are and if the brain is not functioning properly, then our reactions to certain situations are not in balance. This is why some people still believe that undeniable psychological disorders are said to be caused by biochemical imbalances. (Durand, 2007 p.50). So in James' case, his brain was not functioning right and he was experiencing an unnatural balance of change within his various neurotransmitters, causing him to become anxious, easily irritated, distracted and quite tense. He also complained of headaches, body aches and pains and always feeling tired.

Genetics does play a major role is determining whether a person will or will not have a psychological disorder. The textbook states that the research is beginning to acknowledge genes that relate to some psychological disorders. (Durand, 2007 p.70). I feel that genetics does contribute to some disorders, but I also think that the environment and society can cause debilitating stress to induce certain disorders, such as anxiety. If the gene linked to the disorder is dormant, a stress related incident can bring it to the surface, thus bringing on the disorder. My research has shown that there are brain abnormalities indicated with generalized anxiety disorder. A study of 30 patients displayed that compared to 20 healthy volunteers, 11 patients had significant brain abnormalities mainly in the right temporal lobe. (Nutt, 2003 p.209). The temporal lobe controls the processes of recognizing various sights and sounds and long term memory storage. (Durand, 2007 p.48). However there are two temporal lobes on each side of the brain, located at the level of the ears. The lobes help a person distinguish one sound from another as well as one smell from the other. The right lobe controls visual memory while the left lobe controls verbal memory. (Johnson, 2006) So this would explain why James kept making mistakes because he was probably having a hard time remembering simple procedures.

The first thing James would need to do would be to seek professional help and see if he has this disorder, although being a medical doctor, he may have self diagnosed himself, however he should see a psychiatrist. There are no laboratory tests that can determine if a person has anxiety or a mental illness, but a doctor will perform a battery of tests to weed out other illnesses, such as an overactive thyroid gland, which can produce anxiety and its symptoms. (NA, 2007 WebMD). James' next plan of attack would be to discuss the different types of medications that are available for providing relief from this disorder. Since James has generalized anxiety disorder, which has been called a 'free-floating' disorder because of his constant worrying and nervousness, as stated earlier, he would need a medication that treats low levels of GABA. (Roberts, ch.17 p.6). The textbook states that the drub benzodiazepine (minor tranquilizers) is the most frequently prescribed. (Durnad, 2007 p.134). The drug is used for short-term relief and can be hard to stop taking because of dependence issues. One such drug in particular is called Xanax, which is shown to enhance the function of GABA in the brain. It also slows down the central nervous system. This drug is extremely addicting; it's the drug my ex-husband did not want to give up, so we got a divorce.

There is also evidence that antidepressants can be used for GAD and may be a better choice. (p.134) The most common antidepressants are prozac and zoloft. 'These drugs are shown to affect the concentration and activity of the neurotransmitter serotonin, a chemical in the brain thought to be linked to anxiety disorders.' (na, 2004). Some of these drugs that I have researched for GAD, are also used for treating migraines, because I was prescribed some for headaches. No wonder I was always in a good mood, even though it felt like my head was about to explode.

Because the drugs prescribed for this disorder are recommended to be taken for short periods of time, therapy should be initialized as well. The side effects of these drugs are: Xanax (benzodiazepines): drowsiness, fatigue, decreased concentration, confusion, blurred vision, pounding or irregular heartbeat, impaired coordination, short term memory problems, dizziness. (Smith et al, 2006).

Prozac (Selective Serotonin reuptake inhibitors): nausea, insomnia, headaches, decreased sex drive, dizziness, weight gain or loss, nervousness, sweating, drowsiness/fatigue, dry mouth, diarrhea or constipation, skin rashes. (Smith et al, 2006) These medications offer so many side effects, it's a wonder anyone wants to take them at all. But I guess for the person who is suffering from anxiety attacks or generalized anxiety disorder, the side effects may be a welcomed relief There are also natural remedies to help with GAD such as valerian root and kava kava, which has been treating anxiety for years, but the results are not well documented. (Smith et al, 2006) Some natural remedies can actually make anxiety worse and taking supplements may interact with the prescription anxiety medications, so it's a good idea to discuss this with a doctor.

Another approach to treatment is to help James with therapy sessions to try to figure out why he is experiencing all this anxiety and worry. One session may include showing James pictures of things that may make him anxious and then teaching him how to relax deeply to fight his tension. It's called cognitive behavioral treatment, developed in the early 1990s, and is quite successful; however we need both medications and therapy to treat GAD. (Durand, 2007 p.134).

Acupuncture, which is one medical treatment that does no harm to the body, only releases energy and gets it moving in the system; (NA, 2007) biofeedback, which is the ability to allow the patient hear or see feedback of their body's physiological state while relaxing;(Grohol, 2004) and hypnotherapy shown as an appropriate treatment modality for those individuals who are highly suggestible, have also been used to treat anxiety. (Grohol, 2004).

So which treatments work the best? That is hard to say because everyone is different and will react differently to each treatment. As stated in the textbook, a combined treatment of therapy and medications suggested there were no advantages for both, and that people did better in the long run when having psychological treatments only. (Durand, 2007 p.144). So it's suggested to start with psychological treatment first and then followed by drug treatments for the patients who are not responding to therapy. (p.144).

How does environment influence our behavior? Do we imitate what we see around us? Are we simply looking for acceptance, thereby, acting or saying what we think society expects? Who decides what acceptable behavior is? Although the environment may affect a person's behavior, there are many other elements to explore that influence the way we are.

James is coping with generalized anxiety disorder, as was stated earlier. At 31, he is allowing this disorder to control his life which is leading to being emotionally and physically drained. Although he realizes that he is an intelligent and capable person, he knows to avoid any situation that may exacerbate the anxieties that he is experiencing. With minimal support from his family and friends, James feels that he is dealing with this all alone and just wants to lead a normal life. Perhaps the stress and strain of becoming a doctor led to James' anxiety disorder as it may have been dormant within his genetic makeup, and is now just surfacing.

Many people develop generalized anxiety disorder (GAD) during adolescence, but do not seek professional help until they are adults. (NA, 2001). When they do finally get help, they claim they have been anxious and nervous all their lives. (2001). These people cannot just 'get over it' but society seems to not grasp that concept. Some of the environmental influences that could lead to general anxiety are: • Work. This would affect James immensely because his whole life has been based around his becoming a doctor. Even his father wanted him to follow in his footsteps and have a prestigious career. • School. Although James did not experience anxieties until after he graduated from medical school, I'm sure he still felt anxious with tests and schoolwork. • Relationships. This would be dealing with James' parents as they are somewhat supportive but disappointed that his career has not been progressing. He also lost his relationship with his girlfriend of three years because of the stress. • Health. Because James is dealing with this disorder, his health is rapidly declining. He is having headaches, body aches and pains and is always tired. His emotional health is affected as well with feelings of laziness and worthlessness. • Financial. James is realizing that if he cannot work, he cannot earn a paycheck. He is living off a small trust fund set up for him by his great uncle, but that won't last forever. All of these things are considered threats and can cause James to worry excessively which is interfering with his life.

Is the environment to blame for James' anxiety or is it more biological? I think that genetics and the environment work together to produce this disorder. I feel that if a person is genetically prone to have anxiety and fear; if the person never leaves the house, then what does he/she have to worry about? The environment has to play a role in the mobility of this disorder. If James were to isolate himself from the world, he would still have anxiety; however he would not be able to face his fears, thus restricting his life. His thought process would be 'what if this happened, or what if that happened?' He would always be having threatening thoughts and images playing over and over in his mind. (Alloy, 2006 p.189).

Our textbook states that GAD generally runs in families, which I mentioned earlier. (Durand, 2007 p.132). With all the research and studies that are performed, it will show that generalized anxiety disorder is inherited. So genetics and biology has to be the most important because people who aren't suffering from anxiety will react more favorable to a stressful situation, than someone who is suffering from GAD. It seems that we all have to face the same environmental influences, but the threat of each situation interacts with the biological aspect of a person, thus bringing on the symptoms of the disorder. (p.133).

James needs to be treated by a psychiatrist, not a family physician. He needs to be seen by someone who deals with psychological disorders daily and is educated with the treatments available. Psychological treatments work better in the long run and work just as well as prescription medication. Our textbook states that, 'as we learn more about generalized anxiety, we may find that helping people with this disorder to focus on what is actually threatening is useful.' (Durand, 2007 p.134).

Research has indicated that psychological treatments work very well for children who suffer from GAD. (Durand, 2007 p.135). But I feel that unless a child is diagnosed early in life, the treatments won't be as effective. I'm sure that James was experiencing some form of anxiety as a child, but children are difficult to diagnose, and if the parents don't know what to look for, they won't know the child needs help. But children respond to cognitive-behavioral treatments along with family therapy. (p.135).

I feel that psychosocial treatments would be the best way to start with a patient. In James' case, I think he should start with therapy for at least three months. He needs to confront the fear, phobias and anxieties head on to figure out what's making him feel emotionally and physically drained. I would also suggest to James that he should educate and read everything he can on this disorder. Having this knowledge will benefit him so he may get the most out of his treatments. If I had a disorder, I would want to know everything about it. And I would be asking a million questions. Sometimes I feel that everyone in society could use some form of therapy to deal with the stressors of life.

Next, I would try medications in addition to therapy to help James with possible other symptoms of GAD, such as depression. (Smith et al, 2006). The medication, however, would only be used on a temporary basis, as addiction can occur. My ex-husband was on medication for his GAD, but he was not seeing anyone for therapy. I think that was the biggest problem. He was increasing his dosage without telling his doctor, thus becoming extremely dependent on the drugs. As a doctor, James should know that some of the medications used for GAD are very addictive and hopefully would only be used as directed.

There are certain beliefs about thoughts and thought processes that are included in cognitive forms. (Papageorgiou, 2004 p.228). 'There are two types of worries; Type 1 and Type 2. Type 1 worries deal with external daily events such as the welfare of a partner, and non-cognitive internal events such as concerns about bodily sensations. Type 2 worries are focused on the nature and occurrence of thoughts themselves such as worrying that worry will lead to insanity. It's basically worry about worry.' (Wells, 1997 p.202). The cognitive model claims that the varieties of worry are typically type 2 worries in which the patients negatively appraise the activity of worrying. (p 202). I feel that the cognitive psychological model best applies to understanding and treating this disorder. I believe that by using cognitive therapies and similar research studies, we can begin to know what it takes to treat the people who are suffering with better results now and in the future. There are new medications that can help people with GAD, but there are side effects that may be too harsh or severe. I believe that more psychosocial therapies may need to be developed in order to help these people, so they can live a normal life without medications, because of the problems they present to the body.

I believe that James could once again become a successful doctor if and when he gets his generalized anxiety disorder under control. The treatments are available; all he has to do is seek them out. I feel that with therapy coupled with medications would benefit James tremendously. Eventually he will be able to stop taking the medications and perhaps enjoy a fairly normal life. The good news is that only 4% of the population meets the criteria for GAD during a given one-year period. However it is still one of the most common anxiety disorders. (Durand, 2007 p.132). . My research for this paper has helped me so far in understanding what a person is going through with crippling anxiety. It's not something that a person can just 'get over' and I know I wanted to tell my ex-husband that many, many times. However, he became addicted to the prescriptions drugs, and became a drug addict in about two weeks. Because of my first hand experience with this disorder, I chose to do my projects on it.

References N.A. (1997) Retrieved Oct. 20, 2007 from The Natural History of Generalized Anxiety Disorder website: www.medscape.com N.A. (2001). Retrieved Sept. 16, 2007 from General Anxiety Disorder website: http://www.mentalhealthchannel.net N.A. (2004). Retrieved Sept. 13, 2007 from Anxiety Disorders Association of America website: http://www.adaa.org N.A. (2007) Retrieved Sept. 17, 2007 from Anxiety Panic Guide website: http://www.webmd.com N.A. (2007). Retrieved Oct. 21, 2007 from Acupuncture for Generalized Anxiety Disorder website: www.revelutionhealth.com Barlow, D. (1993) Clinical Handbook of Psychological Disorders: A step-by-step treatment Manual 3rd ed. Guilford Press Retrieved Oct. 20, 2007 from libsys.uah.edu. Durand, V. & Barlow, D. (2007) Essentials of Abnormal Psychology: Mason, OH. Thomson/Wadsworth Publishing. Grohol, J. (2004) Retrieved Oct. 20, 2007 from generalized anxiety disorder treatment website: www.psychentral.com/disorders Johnson, G. (2006) Retrieved Sept. 15, 2007 from A Guide to Brain Anatomy website: http://www.waiting.com/brainanatomy Nutt, D. & Ballenger, J. (2003). Anxiety Disorders. Malden, Ma: Blackwell Publishers Retrieved Sept. 18, 2007 from Net library search: libsys.uah.edu Papageorgiou, C. & Wells, A. (2004). Depressive Rumination Nature, Theory and Treatment. Hoboken, NJ: John Wiley & Sons, LTD. Roberts, M. (nd). Introductory Guide to Psychology Kaplan University Class SS-124 Alloy, L. & Riskind, J. (2006). Cognitive Vulnerability to Emotional Disorders. Mahwah, NJ: Lawrence Erlbaum Associates Inc. Smith, M., Kemp, G., Larson, H., Jaffe, J., Segal, J. (2006). Retrieved Oct.8, 2007 from Anxiety Attacks and Disorders website: http://www.helpguide.org Wells, A. (1997). Cognitive therapy of Anxiety Disorders: A practice manual and conceptual guide. Chichester, NY: John Wiley & Sons, LTD.

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• Generalized anxiety disorder

It's normal to feel anxious from time to time, especially if your life is stressful. However, excessive, ongoing anxiety and worry that are difficult to control and interfere with day-to-day activities may be a sign of generalized anxiety disorder.

It's possible to develop generalized anxiety disorder as a child or an adult. Generalized anxiety disorder has symptoms that are similar to panic disorder, obsessive-compulsive disorder and other types of anxiety, but they're all different conditions.

Living with generalized anxiety disorder can be a long-term challenge. In many cases, it occurs along with other anxiety or mood disorders. In most cases, generalized anxiety disorder improves with psychotherapy or medications. Making lifestyle changes, learning coping skills and using relaxation techniques also can help.

Generalized anxiety disorder care at Mayo Clinic

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Generalized anxiety disorder symptoms can vary. They may include:

• Persistent worrying or anxiety about a number of areas that are out of proportion to the impact of the events
• Overthinking plans and solutions to all possible worst-case outcomes
• Perceiving situations and events as threatening, even when they aren't
• Difficulty handling uncertainty
• Indecisiveness and fear of making the wrong decision
• Inability to set aside or let go of a worry
• Inability to relax, feeling restless, and feeling keyed up or on edge
• Difficulty concentrating, or the feeling that your mind "goes blank"

Physical signs and symptoms may include:

• Trouble sleeping
• Muscle tension or muscle aches
• Trembling, feeling twitchy
• Nervousness or being easily startled
• Nausea, diarrhea or irritable bowel syndrome
• Irritability

There may be times when your worries don't completely consume you, but you still feel anxious even when there's no apparent reason. For example, you may feel intense worry about your safety or that of your loved ones, or you may have a general sense that something bad is about to happen.

Your anxiety, worry or physical symptoms cause you significant distress in social, work or other areas of your life. Worries can shift from one concern to another and may change with time and age.

Symptoms in children and teenagers

Children and teenagers may have similar worries to adults, but also may have excessive worries about:

• Performance at school or sporting events
• Family members' safety
• Being on time (punctuality)
• Earthquakes, nuclear war or other catastrophic events

A child or teen with excessive worry may:

• Feel overly anxious to fit in
• Be a perfectionist
• Redo tasks because they aren't perfect the first time
• Spend excessive time doing homework
• Lack confidence
• Strive for approval
• Require a lot of reassurance about performance
• Have frequent stomachaches or other physical complaints
• Avoid going to school or avoid social situations

When to see a doctor

Some anxiety is normal, but see your doctor if:

• You feel like you're worrying too much, and it's interfering with your work, relationships or other parts of your life
• You feel depressed or irritable, have trouble with drinking or drugs, or you have other mental health concerns along with anxiety
• You have suicidal thoughts or behaviors — seek emergency treatment immediately

Your worries are unlikely to simply go away on their own, and they may actually get worse over time. Try to seek professional help before your anxiety becomes severe — it may be easier to treat early on.

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As with many mental health conditions, the cause of generalized anxiety disorder likely arises from a complex interaction of biological and environmental factors, which may include:

• Differences in brain chemistry and function
• Differences in the way threats are perceived
• Development and personality

Risk factors

Women are diagnosed with generalized anxiety disorder somewhat more often than men are. The following factors may increase the risk of developing generalized anxiety disorder:

• Personality. A person whose temperament is timid or negative or who avoids anything dangerous may be more prone to generalized anxiety disorder than others are.
• Genetics. Generalized anxiety disorder may run in families.
• Experiences. People with generalized anxiety disorder may have a history of significant life changes, traumatic or negative experiences during childhood, or a recent traumatic or negative event. Chronic medical illnesses or other mental health disorders may increase risk.

Complications

Having generalized anxiety disorder can be disabling. It can:

• Impair your ability to perform tasks quickly and efficiently because you have trouble concentrating
• Take your time and focus from other activities
• Sap your energy
• Increase your risk of depression

Generalized anxiety disorder can also lead to or worsen other physical health conditions, such as:

• Digestive or bowel problems, such as irritable bowel syndrome or ulcers
• Headaches and migraines
• Chronic pain and illness
• Sleep problems and insomnia
• Heart-health issues

Generalized anxiety disorder often occurs along with other mental health problems, which can make diagnosis and treatment more challenging. Some mental health disorders that commonly occur with generalized anxiety disorder include:

• Panic disorder
• Post-traumatic stress disorder (PTSD)
• Obsessive-compulsive disorder (OCD)
• Suicidal thoughts or suicide
• Substance abuse

There's no way to predict for certain what will cause someone to develop generalized anxiety disorder, but you can take steps to reduce the impact of symptoms if you experience anxiety:

• Get help early. Anxiety, like many other mental health conditions, can be harder to treat if you wait.
• Keep a journal. Keeping track of your personal life can help you and your mental health professional identify what's causing you stress and what seems to help you feel better.
• Prioritize issues in your life. You can reduce anxiety by carefully managing your time and energy.
• Avoid unhealthy substance use. Alcohol and drug use and even nicotine or caffeine use can cause or worsen anxiety. If you're addicted to any of these substances, quitting can make you anxious. If you can't quit on your own, see your doctor or find a treatment program or support group to help you.
• Generalized anxiety disorder. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. Arlington, Va.: American Psychiatric Association; 2013. http://dsm.psychiatryonline.org. Accessed June 26, 2017.
• Gabbard GO, ed. Generalized anxiety disorder. In: Gabbard's Treatments of Psychiatric Disorders. 5th ed. Arlington, Va.: American Psychiatric Association; 2014. http://psychiatryonline.org/doi/book/10.1176/appi.books.9781585625048. Accessed June 26, 2017.
• Baldwin D. Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis. https//:www.uptodate.com/contents/search. Accessed June 26, 2017.
• Craske M, et al. Approach to treating generalized anxiety disorder in adults. https//:www.uptodate.com/contents/search. Accessed June 26, 2017.
• Craske M. Psychotherapy for generalized anxiety disorder in adults. https//:www.uptodate.com/contents/search. Accessed June 26, 2017.
• Bystritsky A. Pharmacotherapy for generalized anxiety disorder in adults. https//:www.uptodate.com/contents/search. Accessed June 26, 2017.
• Bystritsky A. Complementary and alternative treatments for anxiety symptoms and disorders: Herbs and medications. https//:www.uptodate.com/contents/search. Accessed June 20, 2017.
• Bystritsky A. Complementary and alternative treatments for anxiety symptoms and disorders: Physical, cognitive, and spiritual interventions. https//:www.uptodate.com/contents/search. Accessed June 20, 2017.
• Generalized anxiety disorder: When worry gets out of control. National Institute of Mental Health. https://www.nimh.nih.gov/health/publications/generalized-anxiety-disorder-gad/index.shtml. Accessed June 26, 2017.
• Natural medicines in the clinical management of anxiety. Natural Medicines. https://naturalmedicines.therapeuticresearch.com. Accessed June 20, 2017.
• Anxiety disorders. Natural Medicines. https://naturalmedicines.therapeuticresearch.com. Accessed June 20, 2017.
• AskMayoExpert. Anxiety disorders. Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2017. Accessed June 20, 2017.
• Valerian. Natural Medicines. https://naturalmedicines.therapeuticresearch.com. Accessed June 26, 2017.
• Facts for families: The anxious child. American Academy of Child and Adolescent Psychiatry. http://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/Facts_for_Families_Pages/The_Anxious_Child_47.aspx. Accessed June 26, 2017.
• Brown A. Allscripts EPSi. Mayo Clinic, Rochester, Minn. April 21, 2017.
• Kava. National Center for Complementary and Integrative Health. https://nccih.nih.gov/health/kava. Accessed July 21, 2017.
• Valerian. National Center for Complementary and Integrative Health. https://nccih.nih.gov/health/valerian. Accessed July 21, 2017.
• Passion flower. National Center for Complementary and Integrative Health. https://nccih.nih.gov/health/passionflower. Accessed July 21, 2017.
• Stein MB, et al. Treating anxiety in 2017: Optimizing care to improve outcomes. JAMA. 2017;318:236.
• Sawchuk CN (expert opinion). Mayo Clinic, Rochester, Minn. July 25, 2017.
• Anxiety and diet
• Herbal treatment for anxiety: Is it effective?
• Test anxiety: Can it be treated?

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Module 4: Anxiety Disorders

Case studies: examining anxiety, learning objectives.

• Identify anxiety disorders in case studies

Case Study: Jameela

Jameela was a successful lawyer in her 40s who visited a psychiatrist, explaining that for almost a year she had been feeling anxious. She specifically mentioned having a hard time sleeping and concentrating and increased feelings of irritability, fatigue, and even physical symptoms like nausea and diarrhea. She was always worried about forgetting about one of her clients or getting diagnosed with cancer, and in recent months, her anxiety forced her to cut back hours at work. She has no other remarkable medical history or trauma.

For a patient like Jameela, a combination of CBT and medications is often suggested. At first, Jameela was prescribed the benzodiazepine diazepam, but she did not like the side effect of feeling dull. Next, she was prescribed the serotonin-norepinephrine reuptake inhibitor venlafaxine, but first in mild dosages as to monitor side effects. After two weeks, dosages increased from 75 mg/day to 225 mg/day for six months. Jameela’s symptoms resolved after three months, but she continued to take medication for three more months, then slowly reduced the medication amount. She showed no significant anxiety symptoms after one year. [1]

Case Study: Jane

Jane was a three-year-old girl, the youngest of three children of married parents. When Jane was born, she had a congenital heart defect that required multiple surgeries, and she continues to undergo regular follow-up procedures and tests. During her early life, Jane’s parents, especially her mother, was very worried that she would die and spent every minute with Jane. Jane’s mother was her primary caregiver as her father worked full time to support the family and the family needed flexibility to address medical issues for Jane. Jane survived the surgeries and lived a functional life where she was delayed, but met all her motor, communication, and cognitive developmental milestones.

Jane was very attached to her mother. Jane was able to attend daycare and sports classes, like gymnastics without her mother present, but Jane showed great distress if apart from her mother at home. If her mother left her sight (e.g., to use the bathroom), Jane would sob, cry, and try desperately to open the door. If her mother went out and left her with a family member, Jane would fuss, cry, and try to come along, and would continually ask to video-call her, so her mother would have to cut her outings short. Jane also was afraid of doctors’ visits, riding in the car seat, and of walking independently up and down a staircase at home. She would approach new children only with assistance from her mother, and she was too afraid to take part in her gymnastics performances.

Jane also had some mood symptoms possibly related to her medical issues. She would intermittently have days when she was much more clingy, had uncharacteristically low energy, would want to be held, and would say “ow, ow” if put down to stand. She also had difficulty staying asleep and would periodically wake up with respiratory difficulties. [2]

• Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 93–107. ↵
• Hirshfeld-Becker DR, Henin A, Rapoport SJ, et alVery early family-based intervention for anxiety: two case studies with toddlersGeneral Psychiatry 2019;32:e100156. doi: 10.1136/gpsych-2019-100156 ↵
• Modification, adaptation, and original content. Authored by : Margaret Krone for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• Treatment of anxiety disorders. Authored by : Borwin Bandelow, Sophie Michaelis, Dirk Wedekind. Provided by : Dialogues in Clinical Neuroscience. Located at : http://Treatment%20of%20anxiety%20disorders . License : CC BY: Attribution

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Treatment of anxiety disorders in clinical practice: a critical overview of recent systematic evidence

Vitor iglesias mangolini.

I Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR

II Departamento de Psiquiatria, Instituto de Psiquiatria, LIM-23, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR

Laura Helena Andrade

Francisco lotufo-neto, yuan-pang wang.

The aim of this study was to review emerging evidence of novel treatments for anxiety disorders. We searched PubMed and EMBASE for evidence-based therapeutic alternatives for anxiety disorders in adults, covering the past five years. Eligible articles were systematic reviews (with or without meta-analysis), which evaluated treatment effectiveness of either nonbiological or biological interventions for anxiety disorders. Retrieved articles were summarized as an overview. We assessed methods, quality of evidence, and risk of bias of the articles. Nineteen systematic reviews provided information on almost 88 thousand participants, distributed across 811 clinical trials. Regarding the interventions, 11 reviews investigated psychological or nonbiological treatments; 5, pharmacological or biological; and 3, more than one type of active intervention. Computer-delivered psychological interventions were helpful for treating anxiety of low-to-moderate intensity, but the therapist-oriented approaches had greater results. Recommendations for regular exercise, mindfulness, yoga, and safety behaviors were applicable to anxiety. Transcranial magnetic stimulation, medication augmentation, and new pharmacological agents (vortioxetine) presented inconclusive benefits in patients with anxiety disorders who presented partial responses or refractoriness to standard treatment. New treatment options for anxiety disorders should only be provided to the community after a thorough examination of their efficacy.

INTRODUCTION

According to the World Health Organization ( 1 ), anxiety disorders are burdensome “common mental disorders” to communities. These prevalent disorders are not communicable and affect approximately one in every five individuals of the world population ( 2 - 4 ). This figure represents the largest share of the prevalence of all mental disorders, whereas severe psychotic and bipolar disorders affect only between 1% and 2% of the population. In an upper-middle income country such as Brazil, the 12-month prevalence of anxiety disorders has been estimated as 19.9% among the dwellers of a large metropolitan area ( 5 ).

The cost of anxiety disorders to the working world is remarkable, corresponding to a total loss of 74.4 billion Euros in 2010 ( 3 ). The global burden of anxiety disorders represents 10.4% of years lived with adjusted disability (DALY) of mental disorders, reaching 26,800,000 DALYs ( 2 ). Despite the societal burden of this morbidity, only approximately one in five patients diagnosed with anxiety disorder obtain access to treatment ( 6 , 7 ).

Anxiety disorders present an early onset, even during childhood. Their enduring waxing and waning course deeply affects patients’ functionality and interpersonal relationships throughout the lifespan ( 8 ). Most pathological anxiety (specific phobias, social anxiety, generalized anxiety, separation anxiety, obsessive-compulsive, and panic disorder) is underrecognized, and patients seek treatment in outpatient settings, either in medical or specialized mental health-care contexts ( 7 ). However, anxiety disorders receive less attention from clinicians when compared with major mental disorders, such as psychotic conditions and substance use disorders that require hospitalization. Moreover, anxiety is less reported in the media than depression and suicide attempts, which reduces the help-seeking behaviors of patients suffering from anxiety. Figure 1 summarizes key uncontroversial characteristics and clinical practices regarding the treatment of anxiety disorders ( 9 - 11 ). Most experts advocate either psychotherapy and/or pharmacotherapy for alleviating or controlling symptoms of anxiety. The combination of psychological treatment with psychotropic drugs is recommended for patients with severe cases of disabling anxiety.

Traditionally, several talk therapies are subsumed as techniques of psychological treatment and have been recommended to handle different degrees of anxiety ( 11 ). Well-accepted but not always efficacious modalities of psychotherapy vary from psychoanalytic, cognitive-behavioral, interpersonal, supportive, and group therapy to brief therapy. The literature on cognitive-behavioral therapy (CBT) has established a foundation of effectiveness evidence for different anxiety disorders ( 9 , 11 ), but new therapeutic modalities should have their benefit assessed. In addition, the existing number of mental health professionals is insufficient for the number of patients who need treatment ( 6 ). Thus, a more accessible and cost-effective modality of psychotherapeutic treatment for anxiety should be offered to the community.

More than six decades ago, since the synthesis of chlordiazepoxide in 1957 ( 12 ), benzodiazepine medications have become the main class of pharmacological agents for the treatment of anxiety disorders. The introduction of these anxiolytic medicines received an immediate welcome from medical professionals and anxiety-laden patients. Nonetheless, the risk of side effects, a withdrawal syndrome and dependence on benzodiazepines have led patients in need of treatment to seek less harmful therapeutic substitutes, which do not always have proven efficacy. Accepted psychopharmacological medicines include antidepressants, buspirone, beta-blockers, and antipsychotics. Their efficacy has been demonstrated in well-designed clinical trials and abridged in comprehensive reviews ( 10 ). The combined use of psychological treatment with psychotropic drugs is more commonly recommended for cases of anxiety of greater severity and disability ( 11 ).

Many complementary and alternative treatments of mild forms of anxiety have gained popularity because of their alleged harmlessness. Examples of complementary treatment include aromatherapy, acupuncture, herbal medicine, homeopathy, massage therapy, yoga, mindfulness, exercise practice, relaxation, etc. ( 6 , 7 ). The diversity of modalities that a patient is exposed to varies in accordance with the guidance of the therapist, use of an active substance, and body manipulation. Exhaustive classification is difficult. While mental health professionals support the adjunctive addition of these modalities, for anxiety disorders in particular, the exclusive use of alternative therapies as a surrogate to well-established forms of treatment should be avoided ( 11 ). Most complementary and alternative treatments lack evidence of effectiveness. It is possible that a placebo effect and a good therapeutic relationship between the practitioner and patients underlie their positive outcomes.

There are a wealth of treatments devoted to controlling the symptoms of anxiety, but nonconventional and newer psychotherapeutic treatments and pharmacological agents are propagated without an acceptable confirmation of benefit. In the present review, we searched for recent evidence of nonbiological (psychological) and biological (pharmacological) modalities for treating anxiety disorders. The comprehensive summary of treatment advances is organized for a professional who is in training or is not a specialist in mental health to supplement existing modalities. Complementary and alternative treatments with evidence of effectiveness are explored herein under the group of nonbiological therapies. Additionally, high-quality systematic reviews (SRs) were chosen over sparse clinical trials in need of additional replication. The usefulness and public health importance of the treatment of anxiety are subsequently discussed.

Our research question was to update the evidence on recent interventions for the broad category of anxiety disorders. In the present study, the PICO components included adult Patients with a clinical diagnosis of “anxiety disorder”, who were subjected to one or more Interventions (either biological or nonbiological). The intervention must be Compared with a placebo or standard therapeutics for assessing the treatment Outcomes.

We searched for articles in the PubMed and EMBASE databases on the treatment of anxiety disorders. The key Medical Subject Heading (MeSH) terms were “anxiety disorders” AND “treatment”. The retrieved articles were displayed in the Mendeley platform and filtered in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines ( 13 ). The arguments of the search strategy can be found in Supplementary Table 1 .

Footnotes : CCDANCTR : The Cochrane Depression, Anxiety and Neurosis Review Group’s Specialized Register; CDSR : Cochrane Database of Systematic Reviews; CENTRAL : The Cochrane Central Register of Controlled Trials; CINAHL : Cumulative Index to Nursing and Allied Health Literature; Cochrane : Cochrane’s Collaboration Tool to Assess Risk of Bias; CRD : Centre for Reviews and Dissemination; DAI : Dissertation Abstracts International; ICTRP : World Health Organization’s trials portal; PBSC : Psychology and Behavioral Sciences Collection; SIGN : Scottish Intercollegiate Guidelines Network.

For inclusion, the article type must be an SR, with or without meta-analysis, of clinical trials involving adult patients diagnosed with an anxiety disorder. Rigorous randomized clinical trials (RCTs) compared with placebo or active interventions were considered the highest evidence of effectiveness. Those articles wherein participants encompassed a mixed sample of adults and children were not eligible unless separate data were comprehensively presented. Only articles published in the last 5 years, from January 2013 through September 31, 2018, were considered appropriate. There was no language restriction regarding published articles.

After hand searching, by reading the reference list of retained articles and chapters, and contact with potential authors, we identified two additional articles ( 14 , 15 ).

Regarding exclusion criteria, articles containing primary data, duplicate SR or animal models of anxiety were not eligible. Posttraumatic stress disorder was not considered in the present overview because this disorder is not covered under the MeSH term “anxiety disorders” and is no longer listed in the DSM-5 chapter of anxiety disorders ( 16 ). In contrast, while the DSM-5 describes obsessive-compulsive disorders in a separate chapter, this group of disorders is still listed under the MeSH entry of anxiety disorders. Furthermore, treatments on the cooccurrence of anxiety disorders in a specialized medical context (e.g., heart disease, endocrinological, neurological conditions, pain clinics, etc.) were eliminated. Observational studies, case reports, comments, practice guidelines and editorials on therapeutic modalities were also excluded from this overview. Two authors (V.I.M. and Y.P.W.) decided the final list of selected articles.

Study method

Often, an individual SR cannot address all proposed interventions for the same problem. Recent advances in the treatment of anxiety disorders are updated in the current study with the methodological framework of a systematic overview ( 17 ). Accordingly, this type of meta-review is a relatively new method to achieve a high level of evidence, wherein systematic evidence gathered from more than one SR or meta-analysis is examined in a single accessible work, also known as a “systematic review of systematic reviews” ( 17 ). The compilation of evidence synthesizes different interventions for the same problem or condition on different outcomes for different conditions, problems or populations. The ultimate result provides a global summary of the available evidence rather than providing data synthesis ( 17 , 18 ). Thus, an overview aims to examine the highest level of evidence and provide a global account of findings ( 19 ). This type of review has the advantage of rapidly combining relevant data to make evidence-based clinical decisions. Stakeholders, managers and health professionals can appraise multiple high-quality studies in a single general summary of a particular question.

The quality of the retained review articles was assessed in accordance with “A MeaSurement Tool to Assess systematic Reviews” (AMSTAR version 2) ( 20 ). The 16-item AMSTAR checklist ( https://amstar.ca ) represents a critical appraisal of the quality of SRs, covering different aspects related to study planning and conduct, such as the research question, review protocol, selection of study design, search strategy, explicit inclusion and exclusion criteria, risk assessment of bias, and publication bias. For the interpretation of detected weaknesses in critical and noncritical items, the AMSTAR recommends a categorization of the overall confidence in the results of the SR as follows: high, moderate, low, and critically low. The assessment of the risk of bias of an SR was supplemented with the Risk Of Bias In Systematic review (ROBIS) guidelines ( 21 ), which allows classification of the existence of bias as low, high or unclear. All rating disagreements were reconciled during discussion meetings.

Figure 2 shows the PRISMA flow diagram of the retrieved articles in this overview. From the initial 96 review articles published between 2013 and 2018, 92 nonduplicated articles were screened for title and abstract. Most studies ( k =66) were removed because the participants presented anxiety symptoms in the context of medical diseases or were nonadults. After eliminating ineligible articles that fell outside the topic of overview, 26 articles were retained for full-text reading. An additional 7 articles were excluded because 6 did not present an SR and 1 did not contain recent data. The reasons for article exclusion can be found in Supplementary Table 2 . Accordingly, 19 recent SRs were included in the final list for the qualitative synthesis. Of these studies, 3 did not estimate the pooled effect size of the outcomes through a meta-analytical quantitative synthesis ( 22 - 24 ).

NA: not applicable - no meta-analysis.

RCT/NRCT : randomized controlled trials/nonrandomized controlled trials.

Table 1 summarizes the main characteristics and methods of the 19 retained studies. From these articles, 11 referred to nonbiological treatments for anxiety (media- or internet-assisted CBT therapy, brief psychodynamic therapy, Morita therapy, effects of safety behavior, practices of exercise, mindfulness, and yoga, etc.), 5 referred to biological treatments for anxiety (repetitive transcranial magnetic stimulation and pharmacotherapy), and 3 referred to multimodal combined treatment comparisons (stepped care vs . care-as-usual and comparison of multiple treatments). All articles were published in English, and the investigators had searched for relevant articles in at least two databases. Although our search was restricted between 2013 and 2018, the majority of retained SRs covered the previous period, from the database inception date up to 2017.

Across the SRs, there were a total of 811 RCTs (range: 2–234 RCTs), with an included total of 87,773 adult participants (range: 40-37,333 patients). Three SRs ( 15 , 35 , 36 ) included over 10,000 participants, 6 SRs ( 25 - 29 , 37 ) between 9,999 and 1,000 participants, 8 SRs less than 1,000 participants ( 22 , 23 , 30 - 34 , 38 ), and 2 SRs did not report the exact number due to the mixture of adult and underage participants ( 14 , 24 ). Most SRs ( k =14) did not report or summarize the percentage of female participants. The other 5 SRs ( 25 , 28 , 30 , 33 , 38 ) indicated the proportion of women (range: 55.5%-67.7%).

Regarding the diagnosis of the participants, the majority of studies investigated the disorder either under a generic diagnostic label of anxiety disorders or common mental disorders. SRs evaluated the effects of specific interventions in social anxiety ( 14 , 15 , 23 , 24 , 35 ), panic ( 14 , 15 , 33 ), generalized anxiety ( 14 , 15 ), and obsessive-compulsive disorder ( 36 ). All articles described the exclusion of ineligible participants (e.g., posttraumatic stress or acute stress disorders, depressive disorders, comorbid physical illnesses, psychotic disorders, nonappropriate psychiatric diagnoses, underage participants, etc.) and inappropriate studies (e.g., small sample size or case studies, sampling or statistical issues, unsuitable interventions, etc.).

The Cochrane’s Collaboration Tool to Assess Risk of Bias was the most commonly used instrument ( k =14) to evaluate the risk of bias in each individual SR. Two SRs ( 14 , 15 ) used the Scottish Intercollegiate Guidelines Network (SIGN) checklist, and an additional 3 SRs ( 24 , 36 , 37 ) did not assess the risk of bias.

Evidence of treatment efficacy

Regarding the results of nonbiological or psychological treatments, 5 SRs evaluated computer-delivered psychological therapy ( 14 , 15 , 25 , 26 , 28 ). The evidence suggested that the online therapeutic approach is a feasible and beneficial treatment option. However, face-to-face therapist-guided therapy seemed to be clinically superior when compared with the computer-guided approach. Additionally, the benefit widely varied in accordance with the type and characteristics of anxiety disorder.

A meta-analysis ( 27 ) reported that short-term psychodynamic psychotherapies appear to show a reduction in anxiety symptoms in the short and medium term. The SR of Morita therapy-a specific type of self-acceptance method-showed data of limited applicability because all eligible studies were conducted in China, restricting the utility of conclusions in Western countries ( 30 ).

Three SRs ( 23 , 24 , 35 ) had specifically included patients with social anxiety. Mindfulness and acceptance-based treatment ( 23 ) was a viable option, but the level of evidence was limited due to the risk of bias. For social anxiety, limited evidence suggested that reductions in the use of safety behaviors or avoidance were related to a better CBT outcome ( 24 ). In addition, symptomatic decreases in social anxiety predicted reduced safety-behavior use over the course of treatment.

Two SRs ( 22 , 31 ) evaluated the benefit of exercise in reducing anxiety symptoms. Both studies indicated that the exercise practice was effective, regardless of the type and intensity of physical activity. However, exercise alone was less effective than standard antidepressant treatment ( 15 ). Although the effect of yoga on anxiety disorder was considered a safe intervention, the gathered evidence for its effects was inconclusive ( 32 ). Main critiques referred to the variety of diagnoses, heterogeneity of interventions, potential bias of low-quality studies, and lack of comparison to other treatments.

Regarding biological or pharmacological treatments, one meta-analysis ( 33 ) assessed transcranial magnetic stimulation in 40 participants with panic disorder. However, there was insufficient evidence to draw any solid conclusion about its efficacy because of the small sample size and significant methodological flaws. In addition to sampling issues (randomization and allocation concealment), the evidence in the 2 RCTs reviewed was of very low quality.

For pharmacological treatments, there was evidence of low-to-moderate quality for the use of selective serotonin reuptake inhibitors (SSRIs) for social anxiety ( 35 ). However, their tolerability seemed to be lower than placebo. The augmentation strategy did not appear to be beneficial in patients with treatment-resistant anxiety disorders, e.g., generalized anxiety, social anxiety, and panic disorder ( 34 ). In a comparison of the effects of second-generation antidepressants for obsessive-compulsive vs . generalized anxiety disorder, panic disorder, posttraumatic stress disorder, and social anxiety disorder (in over 15,000 participants), an SR ( 36 ) found that pharmacotherapy presented a smaller overall change score than placebo for those five categories of anxiety disorders. Finally, an SR of incipient trials of vortioxetine supported its use for anxiety ( 37 ), but more long-term placebo-controlled trials are warranted.

The SR on multimodal combined treatments reviewed 10 RCTs and compared the package of stepped care versus care-as-usual ( 38 ). The authors concluded that the stepped-care model of treatment of anxiety disorders appeared to be superior than care-as-usual in terms of efficacy and cost-effectiveness. As a consequence, stepped care can reduce the burden on service providers and increase availability. In a comprehensive SR on multiple treatment modalities with over 37 thousand participants ( 15 ), the average pre-post effect sizes of medications were more effective than psychotherapies. In general, the effects of psychotherapies did not differ from placebo pills. Surprisingly, not only psychotherapy but also medications and, to a lesser extent, placebo conditions have shown similar enduring effects in the improvement of anxiety disorders ( 14 ). Nevertheless, long-lasting treatment effects observed in the follow-up period were superimposed in patients receiving different therapeutics at the same time.

Quality of evidence

Using the AMSTAR guideline, Table 2 presents the assessment of the quality of each individual SR. The overall confidence of each study was rated after evaluating critical and noncritical items of the AMSTAR. Several SRs ( k =6) were rated as high quality ( 25 , 27 , 28 , 30 , 33 , 35 ); 3, as moderate ( 23 , 26 , 31 ); 7, as low ( 14 , 15 , 22 , 29 , 31 , 34 , 38 ); and 3, as critically low ( 24 , 36 , 37 ). All six reliable articles (AMSTAR high quality and ROBIS low risk of bias) were published in the Cochrane Database of Systematic Reviews and rigorously adhered to the guidelines of the Cochrane’s Collaboration Tool to Assess Risk of Bias.

Most of the studies clearly described the planning phase of the SR, which included explicit research questions, selection criteria, data extraction and assessment of the risk of bias. Not all studies previously registered a protocol before performing the SR. Only 3 studies reported the source of funding of the included studies ( 25 , 30 , 35 ). During the data interpretation, the most frequent problems were no clear discussion of the individual bias of selected studies ( k =9) and did not account for publication bias ( k =5). Notably, the 3 SRs that did not subject the RCTs to a meta-analytical synthesis also presented several shortcomings that critically affected the quality of the articles (e.g., omission of excluded studies, nonevidence-based discussion of results, and no prior protocol registration).

The risk of bias was rated with the aid of ROBIS ( Table 2 ), with 8 SRs having low risk ( 25 - 28 , 30 , 31 , 33 , 35 ); 8, uncertain risk ( 14 , 15 , 22 , 23 , 29 , 31 , 34 , 38 ); and 3, high risk ( 24 , 36 , 37 ). There was a rough agreement between the quality of an SR (AMSTAR) and the risk of bias (ROBIS). Unsurprisingly, while most high-to-moderate quality studies presented a low risk of bias, all three studies of critically low quality also presented a high risk of bias ( 24 , 36 , 37 ). In Supplementary Table 3 , detailed ROBIS ratings for each retained study are shown.

Supplementary Table 2

1. Alladin A. The wounded self: new approach to understanding and treating anxiety disorders. Am J Clin Hypn. 2014;56(4):368-88.

2. Bluett EJ, Homan KJ, Morrison KL, Levin ME, Twohig MP. Acceptance and commitment therapy for anxiety and OCD spectrum disorders: an empirical review. J Anxiety Disord. 2014;28(6):612-24.

3. Palm U, Leitner B, Kirsch B, Behler N, Kumpf U, Wulf L, et al. Prefrontal tDCS and sertraline in obsessive compulsive disorder: a case report and review of the literature. Neurocase. 2017;23(2):173-7.

4. Spiegel SB. Current issues in the treatment of specific phobia: recommendations for innovative applications of hypnosis. Am J Clin Hypn. 2014;56(4):389-404.

5. Reinhold JA, Rickels K. Pharmacological treatment for generalized anxiety disorder in adults: an update. Expert Opin Pharmacother. 2015;16(11):1669-81.

6. Shahar B. Emotion-focused therapy for the treatment of social anxiety: an overview of the model and a case description. Clin Psychol Psychother. 2014;21(6):536-47.

7. Gotink RA, Chu P, Busschbach JJ, Benson H, Fricchione GL, Hunink MG. Standardised mindfulness-based interventions in healthcare: an overview of systematic reviews and meta-analyses of RCTs. PLoS One. 2015;10(4):e0124344.

The current overview summarized the evidence of the efficacy of emerging treatment options in the last 5 years for adult patients with an anxiety disorder. The conclusions of 19 relevant SRs were synthesized and combined, for a total of 87,773 participants distributed in 811 RCTs. There was great cross-study heterogeneity in terms of the research question, target disorder, type of intervention, methodology, number of included RCTs, sample size of participants, and measured outcomes. Most studies investigated the benefit of different forms of psychotherapy and physical activity. In terms of biological treatments, no great evidence of effectiveness was found for transcranial magnetic stimulation and pharmacological strategies (drug augmentation or novel agents).

Newer treatments for anxiety disorders are highly relevant because the majority of cases are underdetected and undertreated within health-care systems, even in economically developed countries ( 14 ). Most anxious patients worldwide do not receive standard treatment with combined psychotherapy and pharmacological agents in terms of adherence, frequency, and adequacy ( 6 , 9 , 11 ). Consequently, untreated patients with these disorders chronically endure these symptoms, which are associated with severe impairments and restrictions in role functioning and disabilities ( 6 ). The present overview of SRs presented a resynthesis of existing data to allow better choices among emerging interventions for anxiety disorders. This rapid review of high-quality evidence can be of great clinical utility for decision-makers and public health administrators. Until more robust evidence is published, the initial enthusiasm for many proposed anti-anxiety alternatives has shrunk. Meanwhile, the evidence of many therapeutic alternatives should be watchfully disseminated to the community.

Interpretation and implications

From the present overview, there is convincing evidence that computer-delivered psychological treatment is helpful for the treatment of distressing anxiety of different intensities ( 25 ). However, the therapist-oriented CBT approach has yielded better results ( 25 , 28 ). Along similar lines, short-term psychodynamic psychotherapies have shown consistent gains, but larger studies with specific anxiety disorders are warranted ( 27 ). From a public health standpoint, computer-assisted treatment is not readily accessible in several nondeveloped countries, but this strategy can benefit those patients living in distant places or unwilling to start formal psychotherapy. Furthermore, sharing a single computer device and delivering brief psychotherapy are cost-effective for a community ( 40 ).

There is evidence of moderate-to-high quality suggesting that the online approach may be favorable and more efficacious than a wait list, informational pamphlets, or online discussion groups ( 25 ). Therefore, the self-help approach can be recommended as the first step in the treatment of mild anxiety disorders, but the short- and long-term effects of computer-delivered interventions and brief psychotherapies need to be fully established.

Although the SR of Morita therapy was of high quality and free of the risk of bias, its applicability is limited ( 30 ). All 7 RCTs of Morita therapy were conducted in Eastern countries, curbing its generalizability to Western populations ( 41 ).

Two promising high-quality SRs still required additional evidence of effectiveness with additional RCTs; pioneering transcranial magnetic stimulation ( 33 ) and the use of SSRIs in social anxiety ( 35 ) have shown insufficient evidence of efficacy. The SR of transcranial stimulation studies was conducted on 2 RCTs with 40 patients with panic disorder. Therefore, further trials with a larger sample are needed. The use of SSRIs in social anxiety has shown low-to-moderate evidence of efficacy and was less tolerable than placebo ( 35 ). These two strategies can be advised for specific anxiety disorders and those patients who presented partial response or refractoriness to standard treatment ( 35 , 42 - 45 ). In a further meta-analysis based on weekly outcome data ( 46 ), the treatment benefits of SSRIs and serotonin norepinephrine reuptake inhibitors (SNRIs) were shown for social anxiety. Higher doses of SSRIs, but not SNRIs, were associated with symptomatic improvement and treatment response. However, the potential risk of intolerance may surpass the benefit to the patients ( 46 ).

With an ever-growing list of psychotropic compounds showing apparent anxiolytic properties, current pharmacological options for treating clinical anxiety are broad and vast. Existing SRs ( 14 , 15 ) demonstrate that the magnitude of efficacy for most anxiolytic agents compared with placebo was superior. However, the likelihood of symptomatic remission after a pharmacological trial remains largely unknown. Progress in neuroscience and neurophysiology may unravel the pathways of therapeutic responsiveness.

Thus, the generalizability of emerging treatments, e.g., transcranial stimulation and newer pharmacological strategies, is limited due to sampling issues, methodological flaws, and applicability in specific anxiety disorders. These potential interventions might not be available to all consumers, and therefore, larger and more pragmatic RCTs are needed to evaluate and maximize the benefits of available interventions ( 42 - 45 ).

Behavioral recommendations of regular exercise ( 22 , 31 ), mindfulness practice ( 23 ), and yoga ( 32 ) have also been shown to be beneficial for improving anxiety symptoms. However, these SRs were of low-to-moderate quality and vulnerable to the risk of bias. The universal campaign of healthy activities might be recommended as an adjunctive treatment to standard treatment and a cost-effective strategy in regions where there is a shortage of qualified therapists. Nonetheless, these practices were less effective when compared with antidepressant pharmacotherapy ( 15 ). Even without sufficient evidence of effectiveness, these nonstandard treatments seem to be safe, inexpensive and can be easily implemented with preventive purposes to community dwellers ( 47 ).

Although methodological questions remain before its broad implementation can be supported, the personalized therapist-guided CBT approach is the most recommended nonpharmacological treatment for anxiety ( 48 ). Similarly, while the practice of physical activities is safe and helpful, traditional antidepressant treatment presents better results ( 9 , 14 ). One unanswered question refers to the potential adverse effects of the nonsupervised use of computer-assisted therapies and exercise practice. These concerns need to be refined in future RCTs.

Among those patients receiving long-term treatments with partial response or refractoriness, it is possible that novel strategies can enhance and sustain the improvements in anxiety. Hence, there is a large amount of room for amendments to treatment plans ( 34 - 38 ), at least for specific and severe anxiety disorders. Future studies should include stratification of anxiety by severity status and persistence to characterize the dose-response relationship of interventions and the combined efficacy of psychotherapy and pharmacotherapy in treating anxiety disorders, in addition to rule out potential confounding factors that affect treatment effectiveness ( 49 , 50 ).

Some SRs were untrustworthy due to their low quality and serious biases. For example, the impact of safety behaviors in social anxiety remains unknown ( 24 ), as well as the reduced response to placebo and antidepressants in obsessive-compulsive disorders ( 36 ) and the benefit of vortioxetine for the treatment of anxiety disorders ( 37 ). In general, the most common shortcomings were the lack of a published protocol, unclear study selection, inadequate search strategy, lack of explicit inclusion and exclusion criteria, nonexhaustive assessment of bias, invalid interpretation, and no report of publication bias. Consequently, these topics require urgent clarification, using a more stringent methodology and longer follow-up to answer the proposed research question.

Limitations

The heterogeneous interventions reported in these SRs with diverse outcomes preclude conducting a quantitative meta-analytical synthesis as an umbrella review ( 17 - 19 , 39 ). However, the present systematic overview has assessed the risk of bias of each individual SR, and it is secure to claim that most of the evidence reported herein was trustworthy.

The search for recent SRs on the treatment of anxiety disorders has identified main review articles, but some gray literature might have been missed. Although the studies in the Cochrane library were covered in PubMed and EMBASE, ongoing SRs must be finalized to draw solid conclusions. Along these lines, the Cochrane register and PROSPERO data were not scanned to detect other SRs. However, preliminary findings or unpublished SRs should not be integrated into the present overview. It is possibly that a selection bias of new treatment alternatives for specific anxiety disorders occurred at the time of the search. The potential omission of ongoing RCTs cannot be ruled out, but untrustworthy or partial evidence should not be taken as high-quality information.

A potential bias of overview studies is overlap in the retrieved articles or the use of the same primary study in multiple included SRs ( 51 , 52 ). In the present review, most of the treatment modalities were addressed by only one included SR, which probably reduced the probability of overlap across those studies. However, there were two interventions that were addressed by multiple studies: media-delivered psychotherapy and physical exercises. Five SRs examined media-delivered psychotherapy, with a total of 463 RCTs included in the reviews. It is possible that overlap occurred across these SRs, and subtle differences exist regarding the sample, scientific question, comparator, and inclusion of therapist. Therefore, we cannot rule out the possibility of overlapping articles, and the strength of the conclusion about media-delivered psychotherapy should be softened. In contrast, in the two existing SRs on physical exercises, we found 16.7% overlap across the included RCTs. In addition, the overall quality of the articles on physical exercise was low-to-moderate according to the AMSTAR analysis. This fact likely endorses the lower efficacy of physical exercises than standard care.

The covered period of five years may have not included all published studies before 2013. Nevertheless, these recent articles have offered updated coverage of previous studies conducted more than five years ago. Because our primary goal was to condense recent advances on the evidence-based therapeutics for anxiety, well-known modalities were outside the scope of the present review. Notwithstanding, two comprehensive meta-analyses conducted by Bandelow’s group ( 14 , 15 ) provided a broad summary of existing evidence on treatments for anxiety disorders, as well as the comparative enduring effect of psychological treatments and efficacy of treatments.

Trials with negative results might remain unpublished, and practitioners continue advising off-label use without any evidence of effectiveness or benefit. This publication bias of the file drawer effect cannot be ruled out. Small study bias and excluded participants may have affected the scientific soundness of the conclusions. For example, repetitive transcranial stimulation still requires a larger sample ( 42 - 45 ), and Morita therapy should be investigated in Western countries and regions in different stages of development ( 41 ).

CONCLUSIONS

The present overview of recent treatment trends for anxiety disorders provides an account of the evolving directions to pursue, in terms of state-of-art scientific development. Effective and older treatments should be enhanced with technological innovations such as computer-based CBT and supplemented by adjunctive physical activities. New biological or pharmacological treatment modalities for anxiety disorders still need further evidence of usefulness. Thus, all treatments for anxiety disorders with proven effectiveness should be continuously investigated to make them available to the community.

The worldwide burden of anxiety disorders is high. Therefore, obtaining access to reliable health-care services is a bonafide and essential need in a globalized world. However, direct-to-consumer universal access to emerging treatments for anxiety should be recommended only after demonstration of robust evidence of efficacy.

Supplementary Table 1 - Search Strategies

DATABASE #1

• Article types: Review
• Time period covered: Last 5 years
• Language: English, Portuguese and Spanish
• Age: Adults 19+
• Species: Humans

Search strategy:

anxiety disorders[Title/Abstract] AND treatment[Title/Abstract] AND (Review[ptyp] AND “2013/01/01”[PDAT] : “2018/12/31”[PDAT] AND “humans”[MeSH Terms] AND (English[lang] OR Portuguese[lang] OR Spanish[lang]) AND “adult”[MeSH Terms])

# of articles retrieved: 72

DATABASE #2

• Time period covered: 2013-2018
• Age: Adults

‘anxiety disorder’:ab,ti AND ‘treatment’:ab,ti AND [review]/lim AND ([english]/lim OR [portuguese]/lim OR [spanish]/lim) AND [adult]/lim AND [humans]/lim AND [2013-2018]/py

# of articles retrieved: 22

AUTHOR CONTRIBUTIONS

Mangolini VI and Wang YP contributed equally to the manuscript and were responsible for the study conception, data acquisition and extraction, and manuscript drafting. Andrade LH and Lotufo-Neto F have critically reviewed the discussion and conclusion. All of the authors approved the final version of the submitted manuscript.

Supplementary Table 3

Acknowledgments.

V.I.M. has been awarded a scholarship for graduate students from the São Paulo Research Foundation (FAPESP #2017/15060-0). The National Council for Scientific and Technological Development (CNPq) supports L.H.A.

No potential conflict of interest was reported.

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Post-Traumatic Stress Disorder (PTSD)

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About 3.5% of American adults develop post-traumatic stress disorder (PTSD) each year. PTSD is a mental health condition that triggers your body’s “fight or flight” stress response after experiencing a traumatic or distressing event. Some examples of events that may cause PTSD include gun violence, military combat, or intimate partner abuse.

Experiencing this condition can be challenging for your mind and body, causing symptoms like rapid heart rate, anxiety, and trouble sleeping. Fortunately, several treatment options can help manage symptoms, offer support, and improve your quality of life. Your exact treatment plan will depend on the severity of your symptoms, but healthcare providers often recommend psychotherapy, medications, and support groups.

PTSD Symptoms in Adults

Post-traumatic stress disorder can cause a variety of emotional, physical, and behavioral symptoms that affect your daily functioning. While everyone experiences some stress from time to time, symptoms of stress usually go away. However, PTSD symptoms persist even when you're no longer in imminent danger or experiencing something stressful

Generally, you can expect PTSD symptoms to develop within three months of a traumatic event.

There are four categories of PTSD symptoms: re-experiencing, avoidance, arousal or reactivity, and cognition and mood.

Re-Experiencing

With PTSD, you may re-experience the trauma, which may cause symptoms such as:

• Flashbacks to the traumatic event
• Racing heart rate

PTSD can often cause you to avoid certain situations out of fear of re-experiencing a similar traumatic event. As such, you may experience symptoms like:

• Avoiding the location of the traumatic event
• Withdrawal from people involved in the event 
• Refusal to acknowledge feelings or memories from the event

Arousal and Reactivity

Several behavioral changes can occur as a result of PTSD. These symptoms are known as arousal or reactivity, which may manifest as:

• Being easily started
• Feeling on edge or hypervigilant 
• Trouble concentrating 
• Difficulty falling or staying asleep
• Anxiety or irritability
• Angry outbursts
• Risky behavior 

Cognitive and Mood Changes

Living with PTSD not only interferes with your daily activities and behaviors but can also affect you emotionally. You may experience the following changes to your cognition (thinking) and mood:

• Trouble remembering details of the traumatic event
• Exaggerated feelings of blame or shame
• Negative self-image
• Loss of interest in favorite activities 
• Social withdrawal 
• Inability to feel positive emotions 

PTSD Symptoms in Children

Symptoms in young people tend to look different. If your child or teenager experiences something traumatic and develops PTSD, it's a good idea to keep an eye out for changes in their behavior and mood.

In children younger than six years old, symptoms of PTSD may include:

• Frequent bedwetting
• Forgetting how to talk 
• Anxiously clinging to parents or caregivers
• Replaying the traumatic event over and over

In older children and adolescents, symptoms can look similar to the signs of PTSD in adults. They may also exhibit the following behaviors:

• Acting out in school
• Being disruptive or disrespectful
• Engaging in destructive or risky behaviors

Post-traumatic stress disorder can sometimes develop if you experience or witness an extremely distressing or traumatic event. It can also be caused by learning that it happened to someone you care about (e.g., racial trauma) or being exposed to details of an extremely distressful event (e.g., a therapist hearing about a traumatic event from a client).

It's normal to feel fear during and after trauma. The fight-or-flight response is protective and helps you avoid danger when possible. However, being in a state of fear and distress long after the event may be a sign of PTSD.

Risk Factors

Researchers aren’t certain why some people develop PTSD after trauma while others do not. However, some factors may raise your risk of experiencing the condition. Possible risk factors for PTSD include:

• Having a history of abuse , violence, war, natural disaster, or military combat
• Experiencing a physical injury or seeing other people get hurt
• Feeling horror or helplessness
• Lacking social support

Additionally, Black, Indigenous, and other people of color (BIPOC), people assigned female at birth, and those with a family history of mental health conditions also have a higher risk of developing PTSD.

If you or a loved one are experiencing symptoms of post-traumatic stress disorder, seeing a healthcare provider can help you get a proper diagnosis and the support you need to feel better.

Unlike physical health conditions that can be diagnosed with a blood or imaging test, there's no one-size-fits-all test for PTSD. That said, your primary care provider will likely refer you to a psychiatrist or psychologist with experience in diagnosing and treating PTSD to test you for the condition.

You can expect your mental healthcare provider to conduct a thorough psychiatric evaluation, ask you about your symptoms, and sometimes request insight from your loved ones about your behaviors and moods. A PTSD diagnosis requires experiencing symptoms for at least one month and meeting the following criteria:

• One re-experiencing symptom
• One avoidance symptom
• Two arousal and reactivity symptoms
• Two cognition and mood symptoms

PTSD Treatment

Receiving a diagnosis of post-traumatic stress disorder can feel overwhelming. The good news is that having a diagnosis can help you get the treatment you need to reduce your symptoms and improve your quality of life. In fact, several treatment options can help you live well with your condition.

Before treatment begins, your healthcare provider will ask questions to determine if you are currently in an unsafe situation that contributes to your symptoms. The first goal of treatment is to address any ongoing trauma and ensure your safety. The next goals of treatment will be to help you reduce symptoms, manage ongoing stress, and develop resilience.  

Who Can Help?

Your healthcare team will likely consist of your primary care provider, a psychiatrist (a doctor who can treat mental health conditions with medications), and a psychologist (a licensed therapist who can offer holistic treatment options that support your emotional well-being).

Psychotherapy

Psychotherapy or talk therapy is the main treatment for post-traumatic stress disorder. This involves meeting with a psychologist or therapist regularly to process your feelings around the traumatic event and learn coping skills. 

The types of trauma therapy that can help treat PTSD include:

• Cognitive behavioral therapy (CBT): Identifies and changes troubling thoughts, emotions, and behaviors 
• Trauma-focused cognitive behavioral therapy (TF-CBT): A family-focused therapy approach for children and their caregivers that includes trauma-sensitive interventions
• Exposure therapy: Gradually exposes you to a traumatic event's memories in a safe way 
• Cognitive restructuring: Helps you make sense of a traumatic event by addressing guilt and shame
• Eye movement desensitization and reprocessing (EMDR) therapy : Encourages you to process memories from trauma by focusing on a sound or motion
• Group therapy: Connects you with survivors of similar traumatic events for social support

Most people with PTSD receive therapy anywhere from 6-16 weeks. Your exact treatment plan will depend on the severity of your symptoms. It's worth noting that you shouldn't feel shame or guilt in asking for mental health help. The more support you have early on, the better your long-term health outcomes.  

Medications

In addition to psychotherapy, your healthcare team may also recommend medications to address PTSD symptoms such as anxiety or depression . Research says that taking medications alongside therapy can be even more effective than taking either treatment option alone.

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are antidepressant medications—both of which can help reduce PTSD symptoms. Antidepressant medications approved to treat PTSD include:

• Zoloft (sertraline)
• Paxil (paroxetine)
• Effexor (venlafaxine)

It may not always be possible to prevent PTSD. The condition develops after you experience a traumatic or extremely distressing event—oftentimes which you may have no control over. However, resilience and mental toughness can often help you lower your risk of developing PTSD and experience fewer symptoms after a stressful event.

Common factors of resilience include:

• Having a robust support system
• Developing healthy stress management techniques
• Feeling self-confidence and self-efficacy in the ability to overcome challenges

That said, if you experience a triggering or traumatic event, seeking early support from your loved ones, a support group, and your healthcare team can also help keep symptoms at bay and give you the support you need to process the trauma with care.  

PTSD is not the only mental health condition that can develop after a traumatic or stressful event. Conditions related to trauma and PTSD may include:

• Generalized anxiety disorder (GAD): A mental health condition that causes feelings of intense worry and stress
• Depression: A chronic mental health condition that causes persistent feelings of sadness
• Substance use disorder (SUD): A mental health disorder that occurs when a person becomes dependent on a substance such as alcohol or drugs
• Acute stress disorder (ASD): A short-term mental health condition that occurs three days to one month after a traumatic event
• Adjustment disorder (AD): A temporary condition that happens in response to a life change or stressful event
• Disinhibited social engagement disorder (DSED): A serious mental health condition that develops in children who have experienced neglect or abuse before age 2
• Reactive attachment disorder (RAD): A mental health condition that occurs in children who have experienced abuse or neglect and are unable to form close bonds with others

Living With PTSD

PTSD may affect every area of your life and learning how to live with PTSD can be challenging. There is hope, however, and it's possible to live well after experiencing trauma.

Seeking treatment from a mental health provider as soon as you develop symptoms of PTSD or experience a traumatic event can be one of the most beneficial ways to keep PTSD symptoms at bay. Once you connect with a mental health provider, they can support you in processing your trauma.

Making necessary lifestyle changes to improve your overall well-being is just as important. This may include making time for family and friends, engaging in gentle daily movement, cooking meals, or setting up a relaxing evening routine. Soothing and relaxing activities can bolster your mental health and ensure your safety.

Symptoms of PTSD don't disappear overnight. Your symptoms will improve gradually, and it's best to be patient during your treatment journey. That said, aside from your healthcare team and loved ones, there are other sources you can use as support:

• PTSD brochure from the National Institute of Mental Health
• National Center for PTSD from the U.S. Department of Veterans Affairs
• Substance Abuse and Mental Health Services Administration  
• Suicide & Crisis Lifeline available via text at 988 or chat at 988lifeline.org  

Frequently Asked Questions

CPSTD refers to complex post-traumatic stress disorder. These two conditions share many of the same symptoms, but people with CPTSD may also experience long-term difficulties with emotional regulation and anger management.  

There is no cure for PTSD, but it is possible to recover and manage your symptoms. Many people feel like they have recovered within 6-12 months of treatment.  

PTSD triggers the body’s stress response. This may cause a racing heart, high blood pressure, muscle tension, headaches, and body aches. You may also experience nausea and fatigue.

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