Evaluation of Methods for Treating Generalised Anxiety Disorder

A Critical Evaluation of Three Different Methods for Treating Generalised Anxiety Disorder

Anxiety is a normal feeling associated with the body sending an alarm for potential danger (Burton, Western, & Kowalski, 2019). A person with an anxiety disorder is subject to frequent feelings of anxiety inhibiting their life (Burton et al., 2019). Bandelow, and Michaelis (2015, as cited in Burton et al., 2019) estimated that 33.7% of people will be subject to an anxiety disorder in their lifetime. Generalised Anxiety disorder (GAD) is shaped by constant anxiety with irrational concerns about general life situations (Stapinksi, Abbott, & Rapee, 2010, as cited in Burton et al., 2019). GAD can have consequential impairment such as Low occupational level (Massion, Warshaw, & Keller, 1993 as cited in Crits-Christoph et al., 2011), increased suicidal risk (Boden, Fergusson, & Horwood, 2007 as cited in Crits-Christoph et al., 2011) and low emotional health (Robins & Regier, 1991 as cited in Crits-Christoph et al., 2011). This essay will critical evaluate three different types of treatments for GAD, which are Cognitive Behavioural Therapy (CBT), Psychodynamic therapy, and herbal medicine (specifically the use of chamomile extract).  It will discuss the benefits and disadvantages of all three treatments, and that CBT is the preferred treatment over psychodynamic therapy, and chamomile extract.

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Herbal medication, such as chamomile extract, can be an effective alternative to conventional drugs in the treatment for GAD (Keefe, Mao, Soeller, Li, & Amsterdam, 2016). Studies on chamomile extract have shown positive results like producing anxiolytic activity, and a reduction in the severity, in GAD (Keefe et al., 2016). The production of anxiolytic activity, with chamomile, affects hormone and neurotransmitters, such as dopamine and y-aminobutyric acid (Keefe et al., 2016).  Keefe et al. (2016) conduct an open-label study on the short-term effects of chamomile therapy to treat GAD. Keefe et al. hypothesised that Chamomile extract would reduce adverse effects and the severity of GAD. The study consisted of 180 patients with 179 taking at least one dose, 500mg to 1500mg daily, of chamomile extract over the course of eight weeks (Keefe et al., 2016). Over half (58.1%) of the participants of the study experienced a meaningful response (Keefe et al., 2016). A small percentage of people (11.7%) experienced side-effects that were considered mild (Keefe et al., 2016). Drowsiness was the most commonly occurring side-effect (7.2%) and 3.9% experienced a lingering herbal taste (Keefe et al., 2016). These side effects are mild compared to Vilazodone, a conventional drug, where common side effects were nausea 27.6% and diarrhea 26.1% (Zareifopoulos & Dylia, 2017).

Chamomile extract has limitations, that should be considered before use in the treatment if GAD, including limited research and mild side effects (Keefe et al., 2016). It is difficult to confirm the benefits of chamomile extract, as there has been few human clinical trials (Keefe et al., 2016). Keefe et al. (2016) discuss the need for more research in Chamomile to treat GAD, including blind testing and longer studies, noting it is a limitation. Chamomile extract has yielded promising results, but further long-term studies are needed to confirm its benefits on GAD (Keefe et al., 2016). This herbal medication still needs to be considered for people as an alternative to traditional medication, only once it has been further tested for people suffering from GAD. As such it cannot be used in a safe and effective way to treat GAD until further studies are conducted.

Psychodynamic therapy focuses on the understanding of processing impeding emotions and difficult relationship patterns (Crits-Christoph, 2002; Blagys & Hilsenroth, 2000 as cited in Lilliengren, Johansson, Town, Kisely, and Abbass, 2017). Short-term psychodynamic psychotherapy (STPP) (Salzer, Winkelbach, Leweke, Leibing, & Leichsenring, 2011), and intensive short-term dynamic psychotherapy (ISTDP) are effective types of psychodynamic therapy (Lilliengren, Johansson, Town, Kisely, & Abbass, 2017). Lilliengren et al. (2017) conducted a study on ISTDP for GAD and hypothesised the benefits in psychiatric symptoms, interpersonal problems and a reduction in the cost of healthcare. ISTDP was delivered in two varying formats (Lilliengren et al., 2017). The first format was graded for patients with low anxiety tolerance and the second was a standard format for patients with emotional detachment (Lilliengren et al., 2017). A session typically lasted 50 minutes and patients received an average of 8.3 sessions (Lilliengren et al., 2017). Over half of the patients (60.9%) completed at least one self-assessment to report their results (Lilliengren et al., 2017). These sessions reduced psychiatric and interpersonal symptoms in patients (Lilliengren et al., 2017). Studies into STPP have had lasting positive effects after 12 months in the treatment of GAD (Salzer et al., 2011). In Salzer et al. (2011) study initially 28 people were treated with up to 30 sessions of STPP and 17 were used in a follow up of the results after 12 months (Salzer et al., 2011). The study showed positive results as GAD symptoms were significantly improved and maintained (Salzer et al., 2011).

STPP and ISDTP has limitations when compared to CBT, high drop-out rates, and limited research (Salzer et al., 2011; Lilliengren et al., 2017). Lilliengren et al. (2017) had one third of the patients stopped treatment after one session. With limited sessions the results need to be viewed with caution, as ISTDP may not be the reason for the patient’s improvement (Lilliengren et al., 2017). ISTDP produced positive outcomes, but the study is not adequate, due to high drop-out rates and the average amount of sessions required not used by patients. Salzer et al. (2011) compared STPP and CBT at 12 months after the initial treatment. Salzer et al. noted that both treatments had consistent significant improvement of symptoms after 12 months, but CBT showed superior results in trait anxiety and worry. This study’s sample size is too small to be able to determine the superior treatment of the two and further studies into long term success is needed (Salzer et al., 2011). Even though STPP and ISTDP have shown positive results (Lilliengren et al., 2017; Salzer et al., 2011), CBT has shown some better preliminary results (Salzer et al., 2011).

CBT uses various cognitive and behavioural techniques which focus on changing maladaptive behaviours on unwarranted anxiety in GAD (Hofmann, 2008; Smits, Julian, Rosenfield, & Powers, 2012, as cited in Carpenter et al., 2018). CBT is effective in treating GAD and had positive outcomes in several studies (Cuijpers et al., 2014; Carpenter et al., 2018; Salzer et al., 2011; Crits-Christoph et al., 2011). Salzer et al. (2011) study showed positive results for CBT, and in trait anxiety and worry, CBT demonstrated some better preliminary results to STPP. Cuijpers et al. (2014) compared 41 randomized trials on psychotherapy of which 35 included CBT as a therapy. Out of these 35 studies it was shown that CBT is an effective treatment against GAD (Cuijpers et al., 2014). The CBT in Crits-Christoph et al. (2011) study consisted of various techniques from the Borkovec and Costello (1993) and Borkovec, Newman, Pincus and Lytle (2002) studies (as cited in Crits-Christoph et al, 2011). CBT has shown some positive results and may have longer lasting results than other care (Cuijpers et al., 2014). Carpenter et al. (2018), compared 41 studies of CBT to a pill placebo for patients with anxiety related disorders in a meta-analysis. Two studies of the 41 were specifically related to GAD, with 57 patients, which showed that CBT is moderately effective for treatment of GAD compared to the placebo (Carpenter et al., 2018). 

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CBT has had similar results to medication trials (Crits-Christoph et al., 2011). and without the need for patient interaction, medication can be more successful. Crits-Christoph et al. (2011) research involved a study of CBT combined with medication. The CBT in Crits-Christoph et al. study consisted of various techniques from the Borkovec and Costello (1993) and Borkovec, Newman, Pincus and Lytle (2002) studies (as cited in Crits-Christoph et al, 2011). Twelve weeks of CBT was offered to patients, as all patients were initially offered a medication trial, the enthusiasm for CBT was low, and two-thirds declined the treatment offered (Crits-Christoph et al. 2011). These reasons may have affected the results as CBT and medication combined with CBT had the same results as medication alone (Crits-Christoph et al., 2011). CBT needs further follow-up studies for treatment in GAD but has shown positive results.

GAD is defined by excessive worry over normal life situations and can lead to disruption in a person’s normal daily activities. Chamomile is a herbal treatment that has shown some improvement for GAD sufferers. Chamomile has had little research and while side effects are low and mild, they still exist. Therefore, Chamomile cannot be used in a safe and effective way to treat GAD. STPP and ISDTP both have shown positive results and STPP research has had similar results to CBT. As ISDTP and SSTP have not had the same level of studies, and follow-up studies conducted, it cannot be determined to be as effective as CBT. CBT having the highest quantity of studies, most successful research, and without side-effects can be effective in treatment of GAD. All treatment for GAD is personal and as such CBT may not work for all people suffering, as it requires patient involvement. Therefore, for the most beneficial outcome, GAD should be treated with the patient’s personal opinion in mind, offering CBT as a first option.

References

• Burton, L., Westen, D., & Kowalski, R. (2019). Psychology: Fifth Australian and New Zealand (5^th ed.) Milton, Australia: Wiley
• Carpenter, J.K., Andrews, L.A., Witcraft, S.M., Powers, M.B., Smits, J.A.J., & Hofmann, S.G. (2018) Cognitive behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials. Depression and Anxiety, 35, 502–514. https://doi.org/10.1002/da.22728
• Crits-Christoph, P., Newman, M.G., Rickels, K., Gallop, R., Gibbons, M.B.C., Hamilton, J.L., Ring-Kurtz, S., & Pastva, A.M. (2011). Combined medication and cognitive therapy for generalized anxiety disorder. Journal of Anxiety Disorders, 25, 1087–1094. doi: 10.1016/j.janxdis.2011.07.007
• Cuijpers, P., Sijbrandij, M., Koole, S., Huibers, M., Berking, M., Andersson, G. (2014). Psychological treatment of generalized anxiety disorder: A meta-analysis. Clinical Psychology Review, 34, 130–140. http://dx.doi.org/10.1016/j.cpr.2014.01.002
• Keefe, J.R., Mao, J.J., Soeller, I., Li, Q.S., & Amsterdam, J.D. (2016). Short-term open-label chamomile (Matricaria chamomilla L.) therapy of moderate to severe generalized anxiety disorder. Phytomedicine, 23, 1699–1705. http://dx.doi.org/10.1016/j.phymed.2016.10.013
• Lilliengren, P., Johansson, R., Town, J.M., Kisely, S., & Abbass, A. (2017). Intensive Short‐Term Dynamic Psychotherapy for generalized anxiety disorder: A pilot effectiveness and process‐outcome study. Clinical Psychology & Psychotherapy, 24, 1313–1321. https://doi.org/10.1002/cpp.2101
• Salzer, S., Winkelbach, C., Leweke, F., Leibing, E., & Leichsenring, F. (2011). Long-Term effects of Short-Term Psychodynamic Psychotherapy and Cognitive-Behavioural Therapy in generalized anxiety disorder: 12-month follow-up. The Canadian Journal of Psychiatry, 56(8), 503–508. https://doi.org/10.1177/070674371105600809
• Zareifopoulos, N., & Dylja, I. (2017). Efficacy and tolerability of vilazodone for the acute treatment of generalized anxiety disorder: A meta-analysis. Asian Journal of Psychiatry, 26, 115–122. http://dx.doi.org/10.1016/j.ajp.2017.01.016