Will drugs ever completely replace psychotherapy?

Treatment options for generalized anxiety disorder

People with generalized anxiety disorder (GAS) are not afraid of specific things or situations, but rather fear everything possible. Therefore one speaks of "generalized" fear. It is psychologically very stressful and also causes various physical symptoms such as drowsiness, muscle tension or a racing heart. Being afraid all the time is very exhausting. However, there are various treatments that can be used to reduce anxiety to a manageable level.

In contrast to other anxiety disorders, generalized anxiety disorder often does not appear until middle adulthood. Basically, you can get an anxiety disorder at any age.

What can i do on my own?

Many people with generalized anxiety disorder don't think about seeing a doctor at first. They first try to get their fears under control themselves, for example with the help of books and information on the Internet. Some learn relaxation techniques such as progressive muscle relaxation, autogenic training or yoga. The effectiveness of such self-management strategies for anxiety disorders has not been well studied in studies. Relaxation techniques are often used as part of psychotherapy. How useful they are when they are used without any other aids is not yet known.

Some people resort to herbal tranquilizers such as valerian, lavender, or passion flower petals. These agents, too, have so far hardly been researched in studies. Many people assume that herbal medicines are better tolerated and safer than other medicines. However, they can certainly have side effects and in some cases influence the effectiveness of other drugs.

Self-treatment can mean that it takes a long time to seek professional help. When an anxiety disorder severely restricts everyday life, certain psychotherapies and medications can help.

What happens during psychotherapy?

There are several psychotherapeutic approaches to treating generalized anxiety disorder. The best studied and most effective is cognitive behavioral therapy (CBT).

Cognitive behavioral therapy

CBT is not only beneficial for anxiety. It can also relieve other conditions, such as depression, that can be associated with an anxiety disorder. Since the therapy requires a direct confrontation with one's own fears, the treatment itself can sometimes be stressful. In general, adverse effects of psychotherapy have not yet been well investigated in studies.

In Germany, behavioral therapists offer cognitive behavioral therapy and are covered by statutory health insurances. It usually consists of weekly sessions over several weeks or months. Cognitive behavioral therapy has two parts: a "cognitive" part, which deals with thoughts and feelings, and one that deals with behavior.

The aim of the cognitive approach is to change fear-inducing thought patterns by learning

  • to recognize and question unrealistic fears and worries,
  • assess the actual probabilities and consequences of fear triggers and
  • deal with uncertainty.

An example of frightening thought patterns are "catastrophic" thoughts, such as immediately drawing extreme, exaggerated conclusions about the extent of the supposedly impending disaster as soon as something disturbing happens. If such thoughts are recognized with the help of the therapist, one works to reduce them or to deal with them better. In this way, CBT ultimately helps you think more clearly and better control your own thoughts.

The second part of the therapy is about gradually reducing anxiety in certain situations and changing behavior. In doing so, you face fear in order to gradually overcome it. For example, a working mother who keeps calling kindergarten to make sure her child is safe could gradually reduce the number of calls she made. In order to facilitate such behavioral changes, the therapy also teaches what can help to keep calm - for example breathing exercises or relaxation techniques.

Other psychotherapeutic approaches

The effectiveness of psychotherapies that deal more with the possible causes of anxiety, such as childhood traumatic events, has not been well researched in people with generalized anxiety disorder. The few studies comparing it with cognitive behavioral therapy indicate that these "psychodynamic" therapies are less helpful than CBT.

What drug treatments are there?

There are several medications that can be used to treat generalized anxiety disorder. Selective serotonin reuptake inhibitors (SSRIs) are often used.

Selective Serotonin Reuptake Inhibitors (SSRIs)

These drugs belong to the group of antidepressants. They can alleviate symptoms of anxiety and help against depressive symptoms, which many sufferers also have to deal with.

It usually takes 2 to 6 weeks for SSRIs to have anti-anxiety effects. However, they only help a fraction of the people who take them. It may therefore be necessary to try several active ingredients. From the SSRI group, escitalopram and paroxetine have been well studied for people with generalized anxiety disorder and are approved in Germany.

If treatment with SSRIs improves, it is recommended that the medication be continued for another 6 to 12 months and then slowly reduced. Studies suggest that the risk of relapse is lower then. However, some people find it difficult to take the medication permanently. One reason can be side effects, another: when you feel better, you tend to quickly stop taking it.

Possible side effects of SSRIs include nausea, insomnia, and sexual problems. For example, some people feel less inclined to have sex or do not have an orgasm. In men, ejaculation may be weaker or absent. Most people have no side effects.

In the case of insomnia or nausea, it can be difficult to tell whether the medication is actually the cause. Because these complaints are generally quite common. The body often gets used to the active ingredients. Usually side effects only occur in the first few weeks of use. It can therefore be worthwhile to wait and not to stop the treatment immediately if a side effect becomes noticeable.

More medication

There are a number of other drugs that can be used for generalized anxiety disorder. However, many are usually only considered if treatment with SSRIs has not been successful or is not possible for certain reasons:

  • selective norepinephrine reuptake inhibitors (SNRI): These include the active ingredients duloxetine and venlafaxine. They work in a similar way to SSRIs.
  • Pregabalin: This remedy is primarily used for nerve-related pain. However, it is also approved for the treatment of generalized anxiety disorder. The effectiveness of the drug has been proven in several studies. However, it often causes dizziness and fatigue.
  • Opipramol: Opipramol is an antidepressant whose effectiveness has only been poorly studied and is therefore only an option in exceptional cases.
  • Buspirone: This drug can reduce anxiety symptoms, but it has not been as well researched as other drugs. It is therefore usually only used if, for example, SSRIs are not working or are not tolerated. Possible side effects of buspirone include drowsiness, nausea, and insomnia.
  • Hydroxyzine: This antihistamine drug is also likely to relieve symptoms of generalized anxiety disorder. However, it is also less well researched than other remedies and is therefore rarely used.
  • Benzodiazepines: Benzodiazepines are sleeping pills and sedatives that also help relieve anxiety. They work quickly, but they can become addicting after just a few weeks. Therefore, these agents are not recommended for treating generalized anxiety disorder.

Active substances such as imipramine from the group of tricyclic antidepressants or the neuroleptic quetiapine have shown an effect on generalized anxiety disorder in studies. However, since there are drugs that are effective and better tolerated with the SSRI, these drugs are not approved for the treatment of the disorder. Doctors only prescribe these drugs if all other treatments have not helped (so-called off-label use).

There are relatively few studies that have compared drugs directly with one another. The studies available do not reveal any clear advantages for a specific active ingredient. However, since not every drug has the same effect on everyone, it can make sense to try different drugs.

Which treatment is suitable?

Whether you opt for psychotherapy or drug treatment has a lot to do with personal attitudes and needs. Appropriate psychotherapy can be very effective and help overcome anxiety. However, it requires a lot of initiative and strength, and you often have to wait longer for a therapy place. Depending on the personal situation and the severity of the disease, it can therefore be useful to take medication first. Sometimes it is only possible to begin psychotherapy when the symptoms have been alleviated somewhat by medication.

Some people don't want to take antidepressants because they fear becoming addicted. In contrast to certain painkillers, sleeping pills and tranquilizers, antidepressants are not addictive. Others find it a sign of weakness to take pills to help them manage their problems. But there is no reason to be ashamed of taking medication for mental illness. In order to overcome deep fears, medication can be helpful, and sometimes even necessary.

Whatever you decide, there are both medication and psychotherapy that can help you cope with generalized anxiety disorder and get back to normal everyday life.