Dr Robert London

Use Two-Pronged Approach to Treat GAD

Clinical Psychiatry News - Volume 35, Issue 4, Page 16 (April 2007)

The Diagnostic and Statistical Manual's definition of anxiety has been anything but static. Fortunately, however, each version of the DSM has characterized anxiety disorders in a way that gets those of us who see patients every day closer to effective treatments.

Within the DSM-II, the category that best encompassed generalized anxiety disorder (GAD) was the neurosis category—more specifically “anxiety neurosis”—as opposed to the 11 other neuroses listed in that manual. The DSM-II, however, failed to do justice to defining excessive anxiety and excessive worry in certain people. Nor did it recognize impaired concentration, extreme restlessness, and excessive muscle tension and sleep disturbances, to name a few symptoms that accompany these anxiety conditions.

In other words, many patients who would be diagnosed with GAD today might have been missed by those who were depending on the DSM-II.

The DSM-III was better. It acknowledged that GAD involved excessive motor tension, increased symptoms of anxiety and apprehension, and, of course, concurrent sleep problems. However, with the development of subsequent DSMs, we have come to view excessive anxiety and excessive worry, over a period of time, as the dominant symptoms leading to a GAD diagnosis.

Although the DSM-IV's definition of GAD can be seen as too narrowly focused, its clarity offers more guidance both in terms of identifying symptomatology and diagnosis. As a clinician, I get value out of the latter approach.

Definitions of psychiatric disorders may continue to change, particularly as we get more reliable biologic markers, but in the meantime we can continue to develop treatment strategies that will help patients overcome their specific problems and lead more productive lives.

The strategies I developed for one patient illustrate this point well.

The patient, a 31-year-old accountant, experienced severe worry and anxiety over one issue after another related to his career.

Would he make a mistake on a tax form? Would he be party to a crime if information given to him proved false? Would his boss find out how much he worried? Would he ever have an accounting practice of his own? The list went on and on.

The patient also had personal issues that worried him and led to great anxiety. An upcoming flu season could lead him into severe worry and anxiety, but it took second place to his professional worries and anxieties. It was in his work that he measured success, and this appeared to define his identity.

His primary care physician had been able to help him overcome some worry and anxiety by prescribing benzodiazepines. However, as good as these medications are for severe anxiety and worry, they also became a great source of worry and subsequent anxiety. The patient began to worry about becoming a “benzo addict.” His fear and anxiety about this possibility became overwhelming.

His primary care physician had begun receiving several telephone calls a week about this potential benzodiazepine problem. He offered numerous assurances to the patient: The doses were well in the normal range, there was no abuse, and he—the primary care physician—was the only provider of these medications.

Eventually, the primary care physician began to worry himself that he might be missing something—psychologically—in this patient. That's when he made the referral to me.

This patient's problem clearly fit a DSM- IV diagnosis of GAD. In 1950, 1960, or 1970 he might have been diagnosed with an anxiety neurosis. And yep, you guessed it, such a diagnosis might have led to psychoanalytic therapy five times a week for years. More about that later.

After talking with him, I learned that career success was a major part of the “indoctrination” of his upbringing, as he described it. The patient was interested in controlling the problem and achieving a higher level of functioning—meaning less worry and anxiety.

I decided on a two-pronged treatment approach. First, I would teach a relaxation exercise to help control anxiety. Second, I would challenge his worrisome negative and often inaccurate thoughts by getting him to reframe the issues.

In other words, I like to keep it simple and circumscribed as we address the specific anxiety and worry problem. In my experience, this type of two-pronged, simple technique gives the necessary focus leading to problem resolution.

For the relaxation part of the therapy, I used a straightforward eye roll, deep breathing-type exercise, which the patient can learn in 30–40 minutes. The instructions that go along with this type of relaxation exercise are for the patient—in his own time—to practice 10 times a day for a minute or two, going into a comfortable, relaxed state in which he then allows himself to float more and more into this ongoing relaxed state. Much of the tension and anxiety generated by excessive worry simply begin to disappear as the patient masters this technique.

For the second leg of my approach—dealing with worry—again, I like to keep it simple. The accountant had the focus and discipline to develop thoughtful challenges to the inaccuracy and negativity that led to the ongoing excessive worry, which, of course, led to the needless anxiety.

I posed a straightforward question: Those worry problems centered on real possibilities, but were they probable? I like to use the concept of possibilities vs. probabilities. I teach patients, over several visits, cognitive styles of thinking to challenge overwhelming, inaccurate, and negative concepts with possibilities and probabilities.

For example, the patient would obsess about getting inaccurate information from a client that he would subsequently process and sign off on, which would then get the client into some sort of tax difficulty for which he would be responsible. The worry for this man would become so much a part of his hippocampal/limbic/prefrontal circuitry that he would be tyrannized by it.

Following a cognitive therapeutic model, I began to explain to the patient the possibilities vs. probabilities framework for thinking about these problems. Since the explanation alone had no effect in this case, we established a set of challenges with a clear analysis of possibilities and probabilities for the patient over a 12-week period. This approach successfully helped the patient establish new parameters around his worries.

A new logic was introduced into the patient's daily fears and worries. In essence, we worked on a hierarchy of a half-dozen specific worries, going from least to worst—keeping it simple using the possibilities vs. probabilities approach.

From time to time, we took a break and practiced relaxation exercises. The results were rewarding: The patient's thought processes did change and he could, with a new vocabulary, reprocess the everyday data tied to his work life with substantially less anxiety and worry.

Now you might ask: What about the faulty learning and the insight this patient could have received from a better understanding of what he described as the “indoctrination” of his upbringing—where career took precedence over so much else? Indeed, in some part of our 12 visits, we did take a time shuttle back to this indoctrination.

Examining these concepts did give perspective to some of the genesis of the problem (disorder), but the connections, when made, became rapidly therapeutic.

Endless time spent on insight is no longer the holy grail of talk psychotherapy. The patient population wants relief from the problem, and it appears there is more than one way to get there.

Much to my surprise, a new trend seems to be emerging: Many traditional psychoanalysts are now resolving problems inside of a year, seeing patients once a week or less and using the challenging of thoughts as the treatment mode. They may even call this insight-oriented psychoanalytic therapy. But I believe that cognitive-behavioral therapy has influenced them, perhaps unwittingly, and that they are using their own modification of behavioral techniques to resolve patients' problems. And that's okay too.

Let me know your thoughts on using relaxation techniques and reprocessing thoughts to help treat patients with GAD, and I'll try to pass them along to my readers.

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