GAD - Treating generalised anxiety disorder

Generalised anxiety disorder (GAD) is a long-term condition, but a number of different treatments can help.

Before you begin any form of treatment, your GP should discuss all your treatment options with you. They should outline the pros and cons of each and make sure you are aware of any possible risks or side effects.

With your GP, you can make a decision on the treatment most suited to you, taking into account your personal preferences and circumstances.

If you have other problems alongside GAD, such as depression and drug or alcohol misuse, these may need to be treated before having treatment specifically for GAD.

Initial treatment

At first, your GP may suggest trying an individual self-help course for a month or two to see if it can help you learn to cope with your anxiety.

This will usually involve working from a book or computer programme on your own (you will be given advice about how to use the book or programme before you start), with only occasional contact with your doctor.

Alternatively, you may prefer to go on a group course where you and a few other people with similar problems meet with a therapist every week to learn ways to tackle your anxiety.

See self-help tips for anxiety for more information about these treatments.

If these initial treatments do not help, you will usually be offered either a more intensive psychological treatment or medication. These are described below.

Psychological treatment

If you have been diagnosed with GAD, you will usually be advised to try psychological treatment before you are prescribed medication.

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) is one of the most effective treatments for GAD. Studies of different treatments for GAD have found that the benefits of CBT may last longer than those of medication, but no single treatment is best for everyone.

CBT helps you to understand how your problems, thoughts, feelings and behaviour affect each other. It can also help you to question your negative and anxious thoughts, and do things you would usually avoid because they make you anxious.

CBT will usually involve meeting with a specially trained and accredited therapist for a one-hour session every week for three to four months.

Your therapist should carry out CBT in a standardised way according to a treatment manual, and they should receive regular supervision to support them in providing the most effective treatments.

Applied relaxation

Applied relaxation is an alternative type of psychological treatment that can be as effective as CBT in treating GAD.

Applied relaxation focuses on relaxing your muscles in a particular way during situations that usually cause anxiety. The technique needs to be taught by a trained therapist, but generally involves:

learning how to relax your muscles
learning how to relax your muscles quickly and in response to a trigger, such as the word "relax"
practising relaxing your muscles in situations that make you anxious

As with CBT, applied relaxation therapy will usually mean meeting with a therapist for a one-hour session every week for three to four months.

Medication

If the psychological treatments above have not helped you or you would prefer not to try them, you will usually be offered medication.

Your GP can prescribe a variety of different types of medication to treat GAD. Some medication is designed to be taken on a short-term basis, while other medicines are prescribed for longer periods.

Depending on your symptoms, you may require medicine to treat your physical symptoms as well as your psychological ones.

If you are considering taking medication for GAD, your GP should discuss the different options with you in detail, including the different types of medication, length of treatment, side effects and possible interactions with other medicines, before you start a course of treatment.

You should also have regular appointments with your doctor to assess your progress when you are taking medication for GAD. These will usually take place every two to four weeks for the first three months, then every three months after that.

Tell your GP if you think you may be experiencing side effects from your medication. They may be able to adjust your dose or prescribe an alternative medication.

The main medications you may be offered to treat GAD are described below.

Selective serotonin reuptake inhibitors (SSRIs)

In most cases, the first medication you will be offered will be a type of antidepressant called a selective serotonin reuptake inhibitor (SSRI). This type of medication works by increasing the level of a chemical called serotonin in your brain.

Examples of SSRIs you may be prescribed include sertraline, escitalopram and paroxetine.

SSRIs can be taken on a long-term basis but, as with all antidepressants, they can take several weeks to start working. You will usually be started on a low dose, which will gradually be increased as your body adjusts to the medicine.

Common side effects of SSRIs include:

feeling sick
low sex drive
blurred vision
diarrhoea or constipation
dizziness
dry mouth
loss of appetite
sweating
feeling agitated
problems sleeping (insomnia)

Some of the side effects – such as feeling sick, an upset stomach, problems sleeping and feeling agitated or more anxious – are more common in the first one or two weeks of treatment, but these will usually settle as your body adjusts to the medication.

If you or your GP feels that your medication is not helping after about two months of treatment, or if it is causing unpleasant side effects, your GP may prescribe an alternative SSRI to see if that has any effect.

When you and your GP decide that it is appropriate for you to stop taking your medication, you will normally have your dose slowly reduced over the course of a few weeks to reduce the risk of withdrawal effects. Never stop taking your medication unless your GP specifically advises you to.

Serotonin and noradrenaline reuptake inhibitors (SNRIs)

If SSRIs do not help ease your anxiety, you may be prescribed a different type of antidepressant known as a serotonin and noradrenaline reuptake inhibitor (SNRI). This type of medicine increases the amount of the chemicals serotonin and noradrenaline in your brain.

Examples of SNRIs you may be prescribed include venlafaxine and duloxetine.

Common side effects of SNRIs include:

feeling sick
headaches
drowsiness
dizziness
dry mouth
constipation
insomnia
sweating

SNRIs can also increase your blood pressure, so your blood pressure will be monitored regularly during treatment.

As with SSRIs, some of the side effects – such as feeling sick, an upset stomach, problems sleeping and feeling agitated or more anxious – are more common in the first one or two weeks of treatment, but these will usually settle as your body adjusts to the medication.

Pregabalin

If SSRIs and SNRIs are not suitable for you, you may be offered pregabalin. This is a medication known as an anticonvulsant, which is used to treat conditions such as epilepsy (a condition that causes repeated seizures). However, it has also been found to be beneficial in treating anxiety.

Side effects of pregabalin can include:

drowsiness
dizziness
increased appetite and weight gain
blurred vision
headaches
dry mouth
vertigo (the sensation that you, or the environment around you, is moving or spinning)

Pregabalin is less likely to cause nausea or a low sex drive than SSRIs or SNRIs.

Benzodiazepines

Benzodiazepines are a type of sedative that may sometimes be used as a short-term treatment during a particularly severe period of anxiety because they help ease the symptoms within 30 to 90 minutes of taking the medication.

Examples of benzodiazepines you may be prescribed include chlordiazepoxide, diazepam and lorazepam.

Although benzodiazepines are very effective in treating the symptoms of anxiety, they cannot be used for long periods of time because they can become addictive if used for longer than four weeks. Benzodiazepines also start to lose their effectiveness after this time.

For these reasons, you will not usually be prescribed benzodiazepines for any longer than two to four weeks at a time.

Side effects of benzodiazepines can include:

drowsiness
difficulty concentrating
headaches
vertigo
tremor (an uncontrollable shake or tremble in part of the body)
low sex drive

As drowsiness is a particularly common side effect of benzodiazepines, your ability to drive or operate machinery may be affected by taking this medication. You should therefore avoid these activities during treatment.

Referral to a specialist

If you have tried the treatments mentioned above and have significant symptoms of GAD, you may want to discuss with your GP whether you should be referred to a mental health specialist.

A referral will work differently in different areas of the UK, but you will usually be referred to your community mental health team. These teams include a range of specialists, including psychiatrists, psychiatric nurses, clinical psychologists, occupational therapists and social workers.

An appropriate mental health specialist from your local team will carry out an overall reassessment of your condition. They will ask you about your previous treatment and how effective you found it.

They may also ask about things in your life that may be affecting your condition, or how much support you get from family and friends.

Your specialist will then be able to devise a treatment plan for you, which will aim to effectively treat your symptoms.

As part of this plan, you may be offered a treatment you have not tried before, which might be one of the psychological treatments or medications mentioned above.

Alternatively, you may be offered a combination of a psychological treatment with a medication, or a combination of two different medications.