Cognitive behavioral therapy

Cognitive behavioral therapy has benefits that go beyond just helping to reduce anxiety. It can also help with the symptoms of depression, for example, which may accompany generalized anxiety disorder. Because CBT involves directly confronting your fears, the therapy itself can sometimes be quite distressing. Generally speaking, the side effects of psychological treatments haven't been well studied.

In Germany, CBT is offered by behavioral therapists and covered by statutory health insurers. It typically involves weekly sessions over several weeks or months, and has two main parts: a “cognitive” part that deals with thoughts and feelings, and one that deals with behavior.

The goal of the cognitive approach is to change thought patterns that trigger anxiety by learning to

• identify unrealistic anxieties and fears and challenge them,
• assess the actual likelihood and consequences of the things that trigger the anxiety, and
• cope with insecurities.

One example of thought patterns that contribute to feelings of anxiety is “catastrophizing” – immediately jumping to extreme and exaggerated conclusions about the extent of a possible threat as soon as anything unsettling happens. By detecting these kinds of thoughts with the help of a therapist, you can try to get rid of them or find a way to better cope with them. Overall, cognitive behavioral therapy helps you to be more aware of your thoughts and control them better.

The second part of the therapy involves slowly lowering your level of anxiety in certain situations and changing your behavior. The fear is confronted in order to gradually overcome it. For example, a working mother who constantly calls the kindergarten in order to check up on her child may try to gradually reduce the number of calls she places. To make it easier to change your behavior, the therapy also involves learning techniques to keep calm – like breathing exercises or relaxation techniques.

Other psychological treatment approaches

Other types of psychological treatment focus more on trying to find the possible causes of the anxiety, such as traumatic childhood events. There hasn't been much good research on the effectiveness of these approaches in people with generalized anxiety disorder. The few studies that have compared them with cognitive behavioral therapy suggest that these “psychodynamic” therapies aren't as helpful as cognitive behavioral therapy.

Selective serotonin re-uptake inhibitors (SSRIs):

Selective serotonin re-uptake inhibitors are antidepressants. They can relieve anxiety symptoms and help reduce the symptoms of depression that often accompany anxiety disorders.

It usually takes 2 to 6 weeks for SSRIs to start reducing the anxiety. They are only effective in some people, though, so it may be necessary to try various medications. Escitalopram and paroxetine are two SSRIs for people with generalized anxiety disorder that are well studied and have been approved in Germany.

If an SSRI is effective, it is recommended to take the medication for another 6 to 12 months, and then gradually reduce the dose. Research suggests that this lowers the risk of anxiety returning. It's sometimes difficult to keep taking the medication regularly. One reason might be the side effects, but people also tend to stop taking the medication when they start feeling better.

Possible side effects of SSRIs include nausea, insomnia and sexual dysfunction. Some people have less interest in sex or can't have an orgasm. Men may only ejaculate small amounts of semen, or not ejaculate at all. But most people don't have any side effects.

It can be hard to tell whether insomnia or nausea are actually caused by the medication because these problems are quite common in general. The body often "gets used to" the medication. Side effects often occur only during the first few weeks of use, so it may be worth it to wait rather than stopping the treatment as soon as you notice side effects.

Other medications

There are a number of other medications that can be used to treat generalized anxiety disorder. But many of them are generally only considered if treatment with SSRIs doesn't work or isn't possible for particular reasons.

• Selective norepinephrine re-uptake inhibitors (SNRIs): This group of drugs includes duloxetine and venlafaxine. They have a similar effect to SSRIs.
• Pregabalin: This drug is mainly used to treat nerve-related pain, but it is also approved for the treatment of generalized anxiety disorder. Several studies have shown that this medication is effective, but it often causes dizziness and tiredness.
• Opipramol: Opipramol is an antidepressant whose effectiveness has only been very poorly studied. For this reason, it is only very rarely used.
• Buspirone: This drug can relieve anxiety, but it hasn't been as well studied as the other medications. So it is usually only used if, for example, SSRIs aren't effective or aren't well tolerated. The possible side effects of buspirone include drowsiness, nausea and sleep problems.
• Hydroxyzine: This antihistamine can also probably reduce the symptoms of generalized anxiety disorder. There has been less research on it than on other drugs, though, so it's hardly ever used.
• Benzodiazepines: Benzodiazepines are sedatives that also help to relieve anxiety. They have a fast effect, but there is a risk of becoming dependent on them after just a few weeks of use. For this reason, benzodiazepines aren't recommended for the treatment of generalized anxiety disorder.

Medications such as imipramine (a tricyclic antidepressant) or quetiapine (a neuroleptic) were found to be effective in studies. But because SSRIs are effective and better tolerated, these medications aren't approved for the treatment of generalized anxiety disorder. Doctors only prescribe them if all of the other treatments haven't helped (off-label use).

Only relatively few studies in this area have directly compared drugs with each other. There is no evidence that any of the drugs has significant advantages over the others. But because the various drugs have different effect in different people, it may be worth trying out different medications.