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Depression: Major Depression & Unipolar Varieties
Obsessive-Compulsive Spectrum Disorders
Post-Traumatic Stress Disorder

Treatment of Generalized Anxiety Disorder and Trauma

Mark Dombeck, Ph.D.

Most anxiety disorders are readily treatable with a combination of psychotherapy and medication. Learn the details of these treatments and other treatment options for generalized anxiety disorder, panic disorder, agoraphobia, social phobia, specific phobia, and post-traumatic stress disorder/acute stress disorder. Treatments for anxiety depend upon the specific disorder diagnosed by a trained mental health professional. Below you will find some general treatment guidelines for different Anxiety Disorders.

This document deals with the treatment of Generalized Anxiety and Trauma. Other available documents deal with the treatment of Panic-Related Anxiety (including Agoraphobia), and Phobias (fears).

Generalized Anxiety Disorder

Introduction

Since anxiety disorders can sometimes have a medical cause or component, it is important for individuals to have a thorough medical exam before immediately assuming that their anxiety symptoms are due to psychological causes. For instance, individuals who drink a lot of caffeine can present with many similar symptoms of anxiety, and even have panic attacks from caffeine intoxication. The following are all medical syndromes that can cause significant anxiety and physiological arousal: hypoglycemia, lack of sleep, allergies, mitral valve prolapse, hyperthyroidism, and premenstrual syndrome. A good medical examination is important to rule out the possibility that anxiety symptoms are being caused by biological or environmental problems.

Anxiety is often a component found within many other mental disorders as well. The most common mental disorder that presents with anxiety is depression. Clinicians generally regard such anxiety as a good sign, because it means that the individual hasn't simply accepted their depressed mood as they would a free meal; they are anxious because they are aware that being depressed does not fit with the image that person has of himself/herself. A thorough initial evaluation is rudimentary to ruling out other possible and more appropriate diagnoses.

Treatment for generalized anxiety disorder (also known as GAD) is varied and a number of approaches work equally well. Several of the approaches for GAD work well in reducing the underlying cognitive and physiological symptoms associated with the other anxiety disorders as well. Typically the most effective treatment to reduce anxiety will be an approach that incorporates cognitive-behavioral interventions.
Depending upon the severity of the anxiety, both psychological and psychopharmacologic approaches may be needed. Medications, while usually helpful in treating the bodily symptoms of acute anxiety (e.g., panic attacks), are best used for this disorder as a short-term treatment only (a few months). Clinicians should be especially watchful of the individual becoming psychologically or physiologically addicted to certain anti-anxiety medications, such as the benzodiazepine, Xanax.

It is very important to note that medications should never be used solely to treat anxiety disorders because that will just act as a band-aid covering up the symptoms. Pure medical treatment of anxiety will likely guarantee a return of the symptoms once medication is stopped. Effective psychotherapeutic treatment interventions are designed to treat the underlying dynamics of the symptoms, which leads to long-term symptom reduction. Medication are most useful when anxiety is moderate to severe, and causing great discomfort or impairment to the client who needs relief immediately.

Psychotherapy

Psychotherapy for GAD should be oriented towards combating the individual's low-level, ever-present anxiety as well as helping the patient to develop healthier thinking patterns that will help combat the patient's tendency to worry excessively, thereby reducing anxiety. Because poor planning skills, high stress levels, and difficulty in relaxing often accompany this anxiety, the therapist can play an especially effective teaching role.

Relaxation skills can be taught either alone or with the use of biofeedback. Education about relaxation and simple relaxation exercises, such as deep breathing, are excellent places to begin therapy. Progressive muscle relaxation and more general imagery techniques can be used as therapy progresses. Teaching an individual how to relax, and the ability to do it in any place or situation is vital to reducing the low-level anxiety levels. Individuals who learn these skills, which can be taught in a brief-therapy framework, go on to lead productive, generally anxiety-free lives once therapy is complete. A common reason for failure to make any gains with relaxation skills is simply because the client does not practice them outside of the therapy session. From the onset of therapy, the individual who suffers from GAD should be encouraged to set a regular schedule in which to practice relaxation skills learned in session, at least twice a day for a minimum of 20 minutes (although more often and for longer periods of time is better). Lack of treatment progress can often be traced to a failure to follow through with homework assignments of practicing relaxation.

Reducing stress and increasing overall coping skills may also be beneficial in helping the client. Many people who have GAD also lead very active (some would say, "hectic") lives. Helping the individual find a better balance in their lives between self-enrichment, family, significant other, and work may be important. People who have GAD have lived with their anxiety for such a long time they may not recognize a life without constant worrying and activity. Helping the individual realize that life doesn't have to be boring just because one isn't always worrying or doing things may also help.

Individual therapy is usually the recommended treatment modality. It is very beneficial for the therapist to take a cognitive approach to treatment. A cognitive therapeutic approach will help the person learn to identify unrealistic beliefs that cause them anxiety and then challenge the validity of their beliefs. As the therapy progresses, the patient is taught how to replace the old anxiety producing beliefs with more realistic or adaptive ways of thinking so that his/her anxiety and worrying are reduced. The therapeutic environment should also be a supportive and accepting one so that the patient feels safe to explore his/her unrealistic belief systems. In addition, examining stressors in the client's life and helping the individual find better ways of handling these stressors is likely to be beneficial. Modeling techniques of appropriate social behaviors within the therapy session may help as well.

Hypnotherapy is also an appropriate treatment modality for those individuals who are highly suggestible. Hypnotherapy can be used as an effective relaxation technique to battle anxiety.

Medications

Medication should be prescribed if the anxiety symptoms are serious and interfering with normal daily functioning. Psychotherapy and relaxation techniques can't be worked on effectively if the individual is overwhelmed by anxiety or cannot concentrate.

The most commonly prescribed anti-anxiety agent for this disorder has historically been benzodiazepines. Some of the most commonly prescribed benzodiazepines are Alprazolam (Xanax), Lorazepam (Ativan), and Clonazepam (Klonopin). Individuals on these medications should always be advised about the medications' side effects, especially their sedative properties and impairment on performance throughout the day. These medications can also be quite addictive or habit-forming so it is important that someone who is taking these be closely monitored by a psychiatrist. These medications should not be prescribed to someone who has a substance abuse problem or addictive tendencies.

Another effective anti-anxiety medication called Buspar (Buspirone) has been found to alleviate anxiety symptoms with very few side effects. Another added benefit of Buspar is that it is not addictive or habit-forming like the benzodiazepines, which makes it a highly appropriate drug of choice for GAD. In addition, some antidepressant medications can also be helpful in relieving symptoms of anxiety.

Self-Help

The medical profession often overlooks self-help methods for the treatment of this disorder because very few professionals are involved in them. Many support groups exist within communities throughout the world, which are devoted to helping individuals with this disorder share their common experiences and feelings of anxiety. Individuals should first be able to tolerate and effectively handle a social group interaction. Pushing an individual into a group setting, whether it is self-help or a regular group therapy experience, is counterproductive and may lead to a worsening of symptoms.

The mind/body integrative approach called Mindfulness may be very helpful for those suffering from GAD and is a self help intervention that can be sought out on one's own. Mindfulness combines stress management skills with Eastern Practices, such as meditation and yoga. Mindfulness is usually taught by an instructor during a 6-8 week course. The underlying principle of Mindfulness emphasizes keeping one's mind focused on the present and approaching stress in a way that allows for better coping abilities. Because of its emphasis on staying focused on the here-and-now it may be highly effective for those suffering from GAD who are always worrying about possible future stressors.

Obsessive-Compulsive Disorder

Please view the treatment section of our Obsessive-Compulsive Disorder Center

Post-Traumatic Stress Disorder/Acute Stress Disorder

Introduction

Post-traumatic stress disorder (PTSD) occurs after a person has experienced a terrifying event in which he/she perceives that their life or the physical integrity of themselves or others is in danger and their response to that event involves a significant degree of horror, fear, and/or helplessness. Most often, PTSD is associated with the psychological effects of military combat, especially veterans of the Vietnam and Gulf Wars. Today, we know that other victims of traumatic events experience PTSD, including those exposed to earthquakes and other natural disasters, rapes, muggings, car accidents, and poorly performed invasive medical procedures. The greatest numbers of victims struggling with PTSD today are women and men who been raped. Due to the high number of female rape victims in the United States, women experience PTSD twice as often as men do.

It is estimated that around 7.8 percent of people in the United States will experience PTSD at some point throughout their lives. Because of the psychological and physiological symptoms characterized by PTSD including nightmares, recurrent images of the traumatic experience, physiological reactivity, sleep disturbances, difficulty concentrating, increased irritability, hypervigilance, and exaggerated startle response, it negatively impacts those suffering from PTSD on a daily basis. These symptoms begin to impair an individual's ability to perform effectively at work or in relationships. In an effort to try and cope with their symptoms, those suffering from PTSD can often turn to substance abuse, gambling, or develop an eating disorder in an attempt to numb themselves from their emotional pain.

Fortunately, researchers have developed effective treatments and therapies for those suffering from PTSD. Similar treatment interventions are utilized for both PTSD and Acute Stress Disorder in which the symptoms from a trauma last only between 2 days to 4 weeks. The treatment interventions for both stress disorders focus on the over-riding symptoms of re-experiencing the event through nightmares and/or flashbacks, avoidance of anything that reminds the person of the traumatic event, emotional numbing, increased physiological arousal, and hypervigilance of their environment in an effort to protect themselves from any threatening future incidents.

Psychotherapy

There are three main psychotherapy treatments at present that have proven to be most effective in treating post-traumatic stress disorder and acute stress disorder. These include stress inoculation training (SIT), prolonged exposure (PE), and cognitive processing therapy (CPT). A first step within the initial sessions, though, no matter which treatment intervention is utilized, is to create a safe, nurturing, and supportive environment for the patient in which there are no implications that the patient is to blame for the event (s) that took place.

Stress inoculation training teaches the victim a variety of coping skills in order to achieve mastery over his/her fears. The average length of therapy is twelve sessions and it combines techniques that focus on the three main areas of functioning affected by PTSD including behavioral, cognitive, and physical abilities. To help the patient learn how to cope better behaviorally, covert modeling and role-playing techniques are taught. Covert modeling consists of imagining facing a feared situation and then imagining successfully handling the situation so that it does not seem so scary or leave a person feeling victimized. By imagining these scenarios, it prepares a person for how to successfully handle similar scenarios that evoke fear or anxiety in real life. The second behavioral technique of role-playing involves the therapist and client acting out successful ways of coping in anxiety-producing scenes that the client is confronted with throughout his/her day that are associated with the traumatic event. Role-playing can also be done in a group therapy setting as well.

The client's cognitive beliefs that are negatively affected by a traumatic event are also addressed through the techniques of thought stopping and guided self-dialogue. Thought stopping helps teach the client how to stop the ruminative thoughts he/she has about the traumatic event. During a session, the patient is asked to talk about the ruminative thoughts in which the therapist shouts, "STOP" and breaks the patient's cognitive ruminating. The client is then taught to say, "Stop", or whatever cue is preferred, to himself/herself and ultimately the client says it covertly rather than out loud. Guided dialogue is when a patient is asked to talk about the traumatic event and the therapist points out cognitive distortions along the way. The therapist then helps the client replace the distorted cognition with a more realistic cognitive belief. For example, the patient might say, "I guess I am to blame for being raped because I did not scream or fight back." The therapist would help the patient in the moment develop a realistic belief to replace the old belief such as, "I am not to blame for being raped because I did everything I could to try and keep myself safe during an act of violence done to me against my will."

To help the client gain mastery over his/her increased physiological arousal and anxiety, the client is taught muscle relaxation and deep breathing exercises. Clients are taught to employ these relaxation techniques when they are role-playing or imagining anxiety-producing scenes so that if the scenario is feeling too intense they can handle it. Also, they can utilize relaxation techniques when confronted with anxiety producing incidents in real life to help them gain mastery over the incident and be able to handle it successfully.

The second treatment intervention that has been found to be effective with PTSD is called prolonged exposure. This technique involves having the patient imagine the traumatic event while describing it aloud to the therapist. As sessions progress, the patient provides greater and greater amounts of detail as compared to earlier sessions. Before each session is over, the therapist helps reduce the patient's anxiety levels so that the patient does not leave the session feeling emotionally vulnerable. Because the patient is exposed to the event by talking about it repeatedly, this helps the patient learn to process the memory in a different way so that it no longer seems as emotionally painful.

The third technique called cognitive processing therapy combines exposure with cognitive re-structuring. It is a twelve session structured approach that challenges the cognitions the patient has that were disrupted due to the trauma. Memories of the event are elicited by having the patient write about the traumatic event in detail including thoughts, feelings and sensory stimuli they may have experienced. The patient is instructed to read the accounts that they wrote several times to themselves and then to read them aloud to the therapist during the first few sessions. As the client reads his/her account of the event, the therapist helps the client with several therapeutic processes. First, the therapist helps the client label his/her feelings. Second, the therapist points out to the client places where he/she got "stuck", meaning where a conflict occurred for the patient between prior cognitive beliefs and new information from the traumatic event. The themes of these client conflicts usually involve beliefs about themselves and the world, such as safety, intimacy, competence, and self-esteem. And lastly, the therapist helps the client modify his/her cognitions around these stuck points.

While these three interventions are generally the treatments of choice for PTSD, there is another technique called Eye Movement Desensitization and Reprocessing (EMDR) that has also been used with some success in treating PTSD patients.

EMDR is a supplemental technique to be used within a comprehensive treatment plan; it is not in itself a panacea. The technique focuses on helping the patient to more readily access painful memories around incidents that were traumatic or threatening to one's self-esteem. According to the founder of this technique, Francine Shapiro, Ph.D., memories and their emotional and sensory associations seemed to be more easily accessible when a person's eyes moved back and forth while following the motion of another person's finger. Dr. Shapiro found that when the patient would talk about the memory with their eyes moving back and forth, that Dr. Shapiro could suggest to the patient alternative successful ways to handle the traumatic event, which then became incorporated into the patient's memory processing system. Thus, by replacing the patient's negative associations to the event with associations that do not feel so emotionally upsetting and painful, the traumatic event did not hold the same emotional power it once did. EMDR has been studied primarily with Vietnam Veterans, and while not conclusive, the research has shown this to be an effective technique for some people struggling with PTSD.

Medications

There are no medications to treat the entire syndrome of PTSD. Instead, when specific symptoms or associated disorders, such as anxiety and/or depression, become significant enough to warrant medication, then specific medications are prescribed. Anxiety symptoms, such as insomnia, difficulty concentrating, nervousness, and panic attacks tend to be the ones most commonly experienced by those with PTSD. The SSRI antidepressant medications, such as Paxil and Zoloft are commonly prescribed for anxiety. The anti-anxiety medication, Buspar, can be quite helpful to those suffering from anxiety symptoms and has very few serious side effects. The benzodiazepines, such as Klonopin and Xanax, are used cautiously for PTSD, because of their highly addictive nature.

For associated depression, the SSRI antidepressant medications, again, are the treatment of choice. For those who do not have a positive response to these medications, there are the MAOI (monoamine oxidase inhibitor) antidepressant medications, which require maintaining a strict diet of foods that do not include the pressor amine, Tyramine, such as cheese, alcohol, or yeast products. If these foods are eaten while a person is taking an MAOI they run the risk of having a hypertensive crisis, which can lead to a stroke or heart attack. Because of the dietary restrictions with MAOIs, they are not commonly prescribed.

Self-Help

For those suffering from PTSD, there are several self-help activities to help get through painful times. Incorporating stress management techniques such as daily exercise, eating right, and getting adequate rest is a good place to start to take care of oneself. These types of lifestyle practices help a person have the energy to deal with the extra demands of PTSD symptoms or at least to reduce some of the anxiety symptoms.

Another powerful self-help technique that is important for a PTSD sufferer is to empower oneself. There are many ways to feel empowered. Self-empowerment activities might include joining a support group; re-claiming a sense of self in the world through involvement with nature, whether it be hiking, sitting by a serene body of water, or working with animals; taking a self-defense class; reading books; learning assertiveness skills, keeping a diary; or joining a house of worship.

A very important aspect of self-help for those with PTSD is to reach out to others and develop a strong social support network if one is not already in place. Having a support network helps to combat the alienation from others that often accompanies PTSD. Many withdraw from other people as part of the avoidance and emotional numbing that can occur with PTSD. Also, since PTSD can be very draining on a person's energy levels, it can be quite helpful to have a support system in which a person can reach out and ask others for help in order to relieve some of the stresses of daily life. By asking others for help, it allows the PTSD sufferer to be able to put more energy into his/her emotional healing process.

Reference:
Summarized from "Post-Traumatic Stress Disorder", by Calhoun, Karen and Resick,Patricia. In Clinical Handbook of Psychological Disorders. Barlow, David. The Guilford Press, 1993.