Effective Treatment for Generalized Anxiety Disorder

Effective Treatment for commandized foreboding discommodeIntroductionIn autochthonic c be, as in different field of medical practice, it is essential that doctors atomic deem 18 able to apply the findings of scientific question to the circumstances of individual uncomplainings as part of their clinical decision-making process. This is known as evidence based medicine. In this review I meet interpreted an illness which often presents in primary charge, viz. Generalized Anxiety unhealthiness ( prodding), and by re fronting possible pr for each oneings pay developed the skills necessary to search various databases for applicable articles and the ability to assess the validity of the evidence found. In this review I focus specific in ally on Cognitive-Behavioural Therapy (CBT) as a potence discourse for spur.Generalized trouble deflect is characterized by chronic, uncontrollable worry associated with a wide regorge of physical symptoms including fatigue, headaches, muscle aches, ambitiousy swallowing, trembling, twitching, sweating, nausea and shortness of breath. A diagnosis of GAD is made when a person worries excessively ab protrude a variety of every day problems for at least 6 months. The disorder is common in by and byward animation, with a prevalence of 11.2% in primary awe where one fourth dimension(a) adults closely often seek treatment and everyplaceall is more prevalent than all severe cognitive impairment or depression in the over 65s. Despite this, misgiving disorders in the aging population have acquire relatively little research attention. Anxiety in later life has been linked to increased risk of physical disability, memory difficulties, decreased select of life and inappropriate use of medical services .There are on-goingly several treatment options available for GAD including drugs such(prenominal) as Benzodiazepines, Selective Serotonin Re-uptake Inhibitors (SSRIs), Azapir superstars, Barbituates and Prega blins. There are in whatever case utility(a) treatment options such as herbal remedies and psych separatewiseapy such as Cognitive-Behavioural Therapy and Psychodynamic Psychotherapy. Cognitive-behavioral therapy is a human body of psychotherapy which targets problematic emotions and behaviours via a range of approaches and displace be utilize a hugeside medication or as an alternative to it. When used to treat anxiety disorders the principle methods let in education and awareness, motivational interviewing, relaxation training, cognitive restructuring, exposure, problem-solving skills training and behavioural sleep management. Unlike anxiolytics, CBT has no known side effects or risk of physical dependence. Anxiolytics are currently the just approximately common treatment for late-life anxiety and surveys suggest that up to 20% of non-institutionalized antique persons may be using benzodiazepines. However, the use of these medications as a long term treatment for anxiety disorders is associated with potential risks for elderly patients such as cognitive impairment, falls and hip fractures, drug interactions and toxicity. as well as an over-reliance on medication may neglect potentially distinguished psychosociable factors such as social support, coping skills and interpersonal relationships. In light of this it is important that the durability of CBT is assessed as it could prove a utile alternative to long term medication particularly in the ageing population.MethodI conducted initial research using textbooks and the internet and then used different databases to search for relevant papers and articles. Searches were earlier conducted using MedLine (Medical Literature synopsis and Retrieval System) as it contains information from a wide range of palm including Medicine, Nursing, Pharmacy, Biology and Biochemistry and contains over 18 million records from approximately 5,000 publications. Web of experience was also used as it encompasses non except MedLine entirely also other databases such as the Social Sciences Citation Index. I also conducted searches using Scopus and the Cochrane Library but often found that the Cochrane Library yielded fewer or no results so these searches have been omitted. By beginning with gigantic search terms it was possible to refine these to yield fewer, more relevant results.An initial search of the terms cognitive-behavioral therapy and generalized anxiety disorder yielded the sideline results. The search was also demarcationed to include articles which had both these terms in the title and in the abstract.Various spellings and abbreviations such as CBT and GAD were used when searching for cognitive-behavioural therapy and generalized anxiety disorder in order to deliver the goods a high number of results and to ensure articles werent overlooked. After searching through the results, reading abstracts and dismissing articles which werent relevant to this topic or freely availab le, 4 articles were chosen to be include in this review. I chose to specifically focus on RCTs as this is the strongest take up design for testing cause and effect relationships. When critically appraising the papers include in this review, a series of questions primarily derived from the CASP (Critical Appraisal Skills Programme), but also incorporating other sources, were used and articles were judged on how more than information they provide and the quality of the evidence. Examples of these questions are as follows.Did the campaign have a clear objective?Is an RCT an appropriate study design to perform this question?How were the participants randomised?What was the average age of the participants?What were the exclusion criteria for participants?Were the subjects in from each one of the assemblys quasi(prenominal) on demographic and baseline clinical variants?How did the examination arrange for attrition?When/how often was data collected from participants during follo w up?How were outcomes mensural?Were expand of effect sizes and statistical significance given?Did the study have enough participants?Does the paper present a clear result?Results passwordThe initiatory study looked at was an RCT promulgated in 1996 entitled Treatments of Generalized Anxiety in of age(p) Adults A Preliminary Comparison of Cognitive-Behavioural and verificatory Approaches. This trial compared CBT with non directive Supportive Psychotherapy (SP), a form of therapy which rents education, guidance, listen to the patient and encouraging expression of emotions. Results showed substantial improvement in all measured outcomes for both interventions and generally large effect sizes. However, no noteworthy differences were found between the the devil hosts. The authors gave an extensive list of exclusion criteria, including current involvement in psychotherapy and low MMSE scores, which limits confounding factors and therefore the likeliness of type 1 errors. A ma jor limitation of this study withal is the high level of attrition. This study design could possibly be modify if it were to include another control sort out, which receives no treatment, with which to compare the twain interventions with. In this respect the more recent trial Treatment of generalized anxiety disorder in older adults, which is discussed later, improves on this trial and has a solidly raze attrition rate. However, the authors of this trial argue that by failing to include a waiting-list control group they alleviated the need to withhold treatment from any patients, which could be deemed ethically questionable. This trial had a follow-up sound judgment point of 6 months which is relatively short compared to the other studies in this review, one of which has a follow-up period of 15 months. It is arguable that this will limit conclusions made in this study regarding the long-term durability of treatment. Unlike other studies this study did not measure the eff ect of either intervention on the participants quality of life which is an important factor to consider as GAD has such a profound effect on the sufferers quality of life.An RCT published February 2003 entitled Treatment of generalized anxiety disorder in older adults, compared CBT with a discussion group (DG) and patients receiving no treatment on a waiting list period (WL). The discussion group was organized somewhat worry provoking topics and was designed to be structurally corresponding to CBT. DG consisted of a series of 12 discussions focused on topics known to be worry-provoking for older adults, including memory problems, health concerns, loss of independence and death of friends and family. both(prenominal) the CBT and DG groups consisted of 4-6 participants and a group leader, one of four advanced doctorial students in clinical psychology. These leaders were spread across the two interventions and each leader chaired at least one CBT group and one DG in order to avoid c onfounding the effectiveness of the therapist with the effectiveness of the therapeutic model. Participants in both CBT and DG were asked to spend approximately 30 minutes a day on homework exercises. The study gave unspoiled details of exclusion criteria including commencement of psychotropic medication within the departed 2 months. Patients who had started medication more than 2 months ago were included but were asked not to change their dose or type of medication for the duration of the trial. However, in light of this it is possible to argue that including participants on any form of anxiolytic medication restricts conclusions about the impact of CBT without concomitant pharmacological treatment. The authors included a table detailing demographic information about their study sample in order to support the generalisability of their findings. The table showed that participants came from a range of races, had differing marital and work statuses and suffered from a range of diff erent medical conditions, the just about common being osteoarthritis (36%) and hypertension (32%). Compared to the first study, participants not all scored themselves but were also assessed by trained research assistants who were unaware of which group the patient had been assigned to. This adds an element of blinding which is not present in the first study. This was the only study in which patients rated their impression of the treatment after the first session. The participants rated the credibility of the intervention, their enjoyment, perceived effectiveness, likelihood of recommending the intervention to a friend, likelihood of participating again in the future and perceived improvement. This is a useful addition to the trial as a patients satisfaction with a treatment method has a big impact on adherence and possibly symptom improvement. The results showed that participants in both CBT and DG improved compared to the waiting period but there was no significant difference be tween the two interventions. However, when effect sizes were calculated showed large effects whereas DG showed medium surface effects. Essentially this study shows that CBT is better than no treatment but gives no significant evidence to suggest that it is better than other forms of intervention such as group discussion. This is an interesting point which mirrors the findings of the first trial which compared CBT to SP.An RCT published in April 2003 entitled Cognitive- Behavioral Treatment of late-life generalized anxiety disorder (M A Stanley et al. 2002) evaluated the efficacy of CBT compared to minimal contact control (MCC). The results showed a significant improvement in worry, anxiety, depression and quality of life following CBT compared to MCC. 45% of patients were classed as responding to treatment compared with 8% who received MCC. Importantly these gains were maintained or enhanced over a 1 year follow-up. However, as in the other RCTs in this review, patients did not rep ort a complete counter to normal functioning or a complete removal of symptoms. When recruiting participants for this trial the Anxiety Disorders Interview Schedule-IV was used as a diagnostic tool. Patients underwent two separate diagnostic interviews conducted by two different evaluators over a period of at least two weeks. These evaluators were unaware of any introductory diagnoses made. This shows that all participants in the study had symptoms which were consistent and were not prone to alter over time, which means that any change during follow up perspicacity was more likely to be due to the intervention than to fluctuations in the roughness of their GAD. The study commented on potential variance in results due to sex activity and explained how they had adjusted for this. Similarly to the last study, this study used not only self-reported scores but also independent clinician rated scores. Unlike previous studies this trial did not include any participants currently rece iving medication for their GAD or associated symptoms in order to assess the effectiveness of CBT alone and not in conjunction with medication.A Randomised Control Trial, conducted by M A Stanley et al. entitled Cognitive Behaviour Therapy for Generalized Anxiety Disorder Among Older Adults in Primary Care (2009) compared group CBT conducted in primary care clinics over 3 months with a control of enhanced usual care (EUC). The authors chose to use group CBT rather than individual, one-on-one CBT as they believed that the loss of social support often experienced as a consequence of ageing indicated the potential benefits of group treatment. The results of this trial showed that CBT significantly improved worry severity, depressive symptoms and general mental health but there was no difference in GAD severity between the two groups. The authors clearly set out their objective and gave detailed information on where the study was set, where participants were chosen from, details of the intervention and main outcome measures at the start of the paper. The fact that the patients were recruited simply from a primary care setting and that the intervention was delivered in primary care makes this evidence particularly useful for this review. During recruitment all potential participants were screened using two questions from the Primary Care Evaluation of Mental Disorders, as well as undergoing the Mini-Mental State Examination and a Structured symptomatic Interview, in order to ensure that all had the same diagnosis and similar GAD severity. Race and ethnicity of participants were identified and the data used to facilitate conclusions about the generalizability of the data. The authors commented on effect sizes and stated that the effect sizes for symptom improvement were comparable to or greater than those in recent primary care studies of jr. adults with GAD and older adults with depression. The authors also commented that participants in this trial scored slightly lower mean change in worry severity over time scores in comparison with Treatment for Generalized Anxiety Disorder in older adults that was conducted several years earlier. One possible limitation of both this study and the previous study is that patients in the control group received minimal contact with health professionals compared to the intervention group. This may break patients go throughing neglected and as they are aware that theyre not receiving any form of treatment, they may not expect to get better and later score themselves lower on assessment than otherwise. In this respect the first two studies are somewhat better designed, as they compare CBT to interventions which involve a similar contact. The second study in particular deals with this egress well by comparing CBT with a discussion group, which requires the patient to be involved with the intervention, and a waiting list period in which the patient is very much aware that they are receiving no treatment.Sever al studies of anxiety in older adults have been conducted using community or cured centre volunteers with self-diagnosed, subjective anxiety symptoms and therefore the findings from these studies may not be applicable to a clinical population. In contrast the four RCTs included in this review were all conducted on patients with diagnosed GAD and CBT and was delivered in a primary care setting. All the studies gave detailed information on how the participants were randomized and how drop-outs were dealt with and had a follow-up period of at least 6 months. final stageIn conclusion, all four studies showed that CBT improves levels of anxiety, as well as other associated symptoms of GAD, when compared to both baseline measures and no treatment. However these studies also showed that when CBT is compared to other forms of therapy, namely Supportive Psychotherapy and discussion groups, there are no significant differences between the two interventions. Although CBT does lead to signific ant alleviation of symptoms, this evidence does not indicate that CBT is a long lasting cure for GAD and it does not prove CBT to be a better treatment option than other forms of psychotherapy. Therefore it is important to question whether or not the benefits felt by participants receiving CBT, SP or DG are due to a placebo effect compared to participants who are left on a waiting list who may feel they are being neglected and do not expect any improvement in symptoms. This raises the issue of blinding which is a limitation of most conceivable trials including CBT as it is not possible to make the participant unaware of what intervention they are receiving when when they have to actively participate in treatment.The shortfall of clinical trials, particularly RCT trials, investigating CBT as a treatment for GAD needs to be addressed if an acceptable amount of evidence in favour of CBT is to be established. Suggestions for future trials include RCTs comparing the effectiveness of grou p CBT compared with individual CBT for older adults and trials comparing CBT with anxiolytic medications such as benzodiazepines. This is a particularly pertinent issue considering the side effects associated with anxiolytics and old age, as previously mentioned. Future trials should aim to recruit a larger number of participants than seen in most of the studies discussed. In theory this should not be difficult if the prevalence of GAD in the elderly population is as alarmingly high as some statistics indicate.