Anxiety Disorders ____________________________________________________________________________
10,000. Fluoxetine, sertraline, paroxetine, and escitalopram had the lowest overdose lethality rates at 0.79–1.34 per 10,000 ingestions [252]. Substance Use Disorder Anxious patients often use alcohol or anxiolytics to regulate general anxiety, distressing panic symptoms, or social anxiety and social skills deficits. Substance use disorder is highly prevalent in patients with anxiety disorders and interferes with treatment response and leads to poor outcomes [28]. More than 33% of patients with GAD have an alcohol use disorder, and patients with SAD have a lifetime substance use disorder prevalence of roughly 40%. Nicotine dependence is also disproportionately high among patients with panic disorder [253; 254; 255]. Self-medication of anxiety disorder symptoms has been con- clusively identified as a significant predictor for later develop- ment of alcohol or drug dependence. This is consistent with the self-medication hypothesis, which posits that the specific substance used for anxiety relief/control tends to be the sub- stance to which the person develops a substance use disorder [256]. Ongoing substance use problems are abundantly linked to worse outcomes in comorbid anxiety disorders. Long-term effects of substance use negatively interact with anxiety symp- toms, and quitting substances may improve anxiety in some patients. A trial of abstinence will usually answer this ques- tion. The duration must be several months to evaluate the link between anxiety and substance use, and there should be ongoing treatment, preferably in a 12-step program. Twelve- step programs have been shown to have anxiolytic effects themselves due to the support and empowerment they offer. Residual anxiety then should be treated with either medica- tion or CBT [28]. If substance use is suspected, patients should be screened during diagnosis. A motivational interviewing approach is recommended to frame the rationale for substance abuse in a non-judgmental manner and explore patient desire and readiness for change. For patients initiating efforts to decrease substance use, concurrent treatment with an SSRI or venla- faxine is reasonable; benzodiazepines should be avoided due to the abuse liability [257]. Detoxification from alcohol or benzodiazepines is indicated if signs of substance withdrawal appear, and referral to a formal substance abuse treatment is recommended. Recognition and treatment of underlying substance abuse is an essential component in the overall treat- ment plan [13; 28]. Anxiety Disorder Treatment Effect Sizes A 2015 meta-analysis of panic disorder, GAD, and SAD assessed treatment efficacy [224]. Studies published through 2012 were used to calculate medication, psychologic, or combination treatment efficacy. Effect sizes were calculated from pre- versus post-treatment and treatment versus control comparisons ( Table 3 ) [224]. A significantly higher average pre-post effect size was found for medication outcomes than
psychotherapy outcomes. Side effects, contraindications, drug interactions, and efficacy should all guide drug selection. Benzodiazepine abuse, dependence, and withdrawal potential; TCA side effects; and quetiapine metabolic risks make these agents second- to fourth-line options and not first-line options, as suggested by effect sizes alone [224]. TREATMENT OF GENERALIZED ANXIETY DISORDER The goals of GAD treatment are reduction in severity of ambi- ent symptoms followed by prevention of symptoms and relief of disability. Pharmacotherapy (SSRIs and SNRIs) is considered the mainstay of therapy; psychotherapy (CBT or cognitive therapy) is also highly effective and may be preferred during pregnancy and by patients who cannot tolerate or wish to avoid medication [54; 258]. GAD is associated with specific biases for mood-congruent information. Patients with GAD are vigilant for threatening stimuli and tend to misinterpret ambiguous information as threat. These cognitive biases diminish with successful psychologic or drug treatment [243].
PSYCHOTHERAPY First-Line Options CBT
CBT for GAD uses some combination of psychoeducation (understanding safety behaviors), worry exposure, applied relax- ation, and re-structuring common automatic thoughts (e.g., catastrophizing). Meta-analyses clearly demonstrate that CBT significantly reduces GAD symptoms and is markedly more effective than placebo or wait-list control conditions [120]. Sessions should occur at least weekly over 6 to 12 weeks and involve 12 to 20 sessions. While fewer than eight sessions is as effective as eight or more sessions for anxiety symptoms, more intense regimens are more effective in improving worry and depression symptoms [258; 259; 260]. Individual and group CBT seem equally effective in anxiety symptom reduction, but individual therapy may lead to earlier improvement in worry and depression symptoms [120].
According to the National Collaborating Centre for Mental Health, the
recommended high-intensity psychological intervention for persons with generalized anxiety disorder is cognitive-behavioral therapy (CBT) or applied relaxation. (https://www.nice.org.uk/guidance/cg113. Last accessed April 27, 2025.) Level of Evidence : Expert Opinion/Consensus Statement
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