THE ABC OF HEALTH – Anxiety treatments


Generalised anxiety disorder in adults – Treatment

Generalised anxiety disorder (GAD) is a long-term condition, but a number of different treatments can help.
Before you begin any form of treatment, your doctor should discuss all your treatment options with you. He/she should outline the pros and cons of each and make sure you’re aware of any possible risks or side effects.
With your doctor, you can make a decision on the most suitable treatment, taking into account your personal preferences and circumstances.
If you have other problems alongside GAD, such as depression and drug or alcohol misuse, these may need to be treated before having treatment specifically for GAD.

Initial treatment
At first, your doctor may suggest trying an individual self-help course for a month or two, to see if it can help you learn to cope with your anxiety.
This usually involves working from a book or computer program on your own (you’ll be given advice before you start), with only occasional contact with your doctor.
Alternatively, you may prefer to go on a group course where you and a few other people with similar problems meet with a therapist every week to learn ways to tackle your anxiety.

If these initial treatments don’t help, you’ll usually be offered either a more intensive psychological treatment or medication. These are described below.
Psychological treatment
If you’ve been diagnosed with GAD, you’ll usually be advised to try psychological treatment before you’re prescribed medication.

Cognitive behavioural therapy (CBT) is one of the most effective treatments for GAD. Studies of different treatments for GAD have found that the benefits of CBT may last longer than those of medication, but no single treatment is best for everyone.
CBT helps you to understand how your problems, thoughts, feelings and behaviour affect each other. It can also help you to question your negative and anxious thoughts, and do things you would usually avoid because they make you anxious.
CBT usually involves meeting with a specially trained and accredited therapist for a one-hour session every week for three to four months.
Your therapist should carry out CBT in a standardised way according to a treatment manual, and they should receive regular supervision to support them in providing the most effective treatments.

Mindfulness and applied relaxation
Mindfulness and applied relaxation are alternative types of psychological treatment that can be as effective as CBT in treating GAD.
Mindfulness works by focusing your awareness on the present moment and by acknowledging and accepting certain feelings. Being mindful can reduce anxiety caused by the fear of actual situations or sensations, or anticipated ones. It helps to counter the sense of “tunnel vision” that may develop during anxiety. Although mindfulness originates from Buddhism, it doesn’t require you to change or take on any religious beliefs.

Applied relaxation focuses on relaxing your muscles in a particular way during situations that usually cause anxiety. The technique needs to be taught by a trained therapist, but generally involves:
learning how to relax your muscles
learning how to relax your muscles quickly and in response to a trigger, such as the word “relax”
practising relaxing your muscles in situations that make you anxious
As with CBT, applied relaxation therapy will usually mean meeting with a therapist for a one-hour session every week for three to four months.

If the psychological treatments above haven’t helped or you would prefer not to try them, you’ll usually be offered medication.
Your doctor can prescribe a variety of different types of medication to treat GAD. Some medication is designed to be taken on a short-term basis, while other medicines are prescribed for longer periods.
Depending on your symptoms, you may need medicine to treat your physical symptoms, as well as your psychological ones.
If you’re considering taking medication for GAD, your GP should discuss the different options with you in detail before you start a course of treatment, including:
* the different types of medication
* length of treatment
* side effects and possible interactions with other medicines
You should also have regular appointments with your doctor to assess your progress when you’re taking medication for GAD. These will usually take place every two to four weeks for the first three months, then every three months after that.
Tell your doctor if you think you may be experiencing side effects from your medication. They may be able to adjust your dose or prescribe an alternative medication.
The main medications you may be offered to treat GAD are described below.
Selective serotonin reuptake inhibitors (SSRIs)
In most cases, the first medication you’ll be offered will be a type of antidepressant called a selective serotonin reuptake inhibitor (SSRI). This type of medication works by increasing the level of a chemical called serotonin in your brain.
Examples of SSRIs you may be prescribed include:
SSRIs can be taken on a long-term basis but, as with all antidepressants, they can take several weeks to start working. You’ll usually be started on a low dose, which is gradually increased as your body adjusts to the medicine.
Common side effects of SSRIs include:
feeling agitated
feeling or being sick
diarrhoea or constipation
loss of appetite and weight loss
blurred vision
dry mouth
excessive sweating
problems sleeping (insomnia) or drowsiness
low sex drive
difficulty achieving orgasm during sex or masturbation
in men, difficulty obtaining or maintaining an erection (erectile dysfunction)
These side effects should improve over time, although some – such as sexual problems – can persist.
If your medication isn’t helping after about two months of treatment, or if it’s causing unpleasant side effects, your GP may prescribe an alternative SSRI.
When you and your GP decide it’s appropriate for you to stop taking your medication, you’ll normally have your dose slowly reduced over the course of a few weeks to reduce the risk of withdrawal effects. Never stop taking your medication unless your GP specifically advises you to.
Serotonin and noradrenaline reuptake inhibitors (SNRIs)
If SSRIs don’t help ease your anxiety, you may be prescribed a different type of antidepressant known as a serotonin and noradrenaline reuptake inhibitor (SNRI). This type of medicine increases the amount of serotonin and noradrenaline in your brain.
Examples of SNRIs you may be prescribed include:
Common side effects of SNRIs include:
feeling sick
dry mouth
SNRIs can also increase your blood pressure, so your blood pressure will be monitored regularly during treatment.
As with SSRIs, some of the side effects – such as feeling sick, an upset stomach, problems sleeping and feeling agitated or more anxious – are more common in the first one or two weeks of treatment, but these usually settle as your body adjusts to the medication.
If SSRIs and SNRIs aren’t suitable for you, you may be offered pregabalin. This is a medication known as an anticonvulsant, which is used to treat conditions such as epilepsy. However, it’s also been found to be beneficial in treating anxiety.
Side effects of pregabalin can include:
increased appetite and weight gain
blurred vision
dry mouth
Pregabalin is less likely to cause nausea or a low sex drive than SSRIs or SNRIs.
Benzodiazepines are a type of sedative that may sometimes be used as a short-term treatment during a particularly severe period of anxiety, because they help ease the symptoms within 30 to 90 minutes of taking the medication.
If you’re prescribed a benzodiazepine, it will usually be diazepam.
Although benzodiazepines are very effective in treating the symptoms of anxiety, they can’t be used for long periods of time because they can become addictive if used for longer than four weeks. Benzodiazepines also start to lose their effectiveness after this time.
For these reasons, you won’t usually be prescribed benzodiazepines for any longer than two to four weeks at a time.
Side effects of benzodiazepines can include:
difficulty concentrating
tremor (an uncontrollable shake or tremble in part of the body)
low sex drive
As drowsiness is a particularly common side effect of benzodiazepines, your ability to drive or operate machinery may be affected by taking this medication. You should avoid these activities during treatment.
Referral to a specialist
If you’ve tried the treatments mentioned above and have significant symptoms of GAD, you may want to discuss with your doctor whether you should be referred to a mental health specialist.

An appropriate mental health specialist from your local team will carry out an overall reassessment of your condition. They’ll ask you about your previous treatment and how effective you found it.
They may also ask about things in your life that may be affecting your condition, or how much support you get from family and friends.
Your specialist will then be able to devise a treatment plan for you, which will aim to treat your symptoms.
As part of this plan, you may be offered a treatment you haven’t tried before, which might be one of the psychological treatments or medications mentioned above.
Alternatively, you may be offered a combination of a psychological treatment with a medication, or a combination of two different medications.

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