Treatment options for generalized anxiety disorder
Generalized anxiety disorder can dominate your life, and often lasts a long time. But there are a number of different treatment approaches that can help you learn to better manage your anxiety and lead a normal life again. Some medications are also effective.
People who have generalized anxiety disorder (GAD) aren't afraid of specific things or situations, but of a wide range of things, which is why it is referred to as “generalized” anxiety. This can take a great emotional toll and also cause a number of physical symptoms such as drowsiness, muscle tension and a racing heartbeat. Being in a state of constant worry is exhausting, but there are different treatments that can help reduce the anxiety down to a tolerable level.
Unlike other kinds of anxiety disorders, generalized anxiety disorder often first develops in middle-aged people. But anxiety disorders can affect people of all ages.
What can you do yourself?
Many people with generalized anxiety disorder don't even think of going to see a doctor. They try to manage their fears on their own, for example using books or information from the internet. Some learn relaxation techniques, such as progressive muscle relaxation, autogenic training or yoga. The effectiveness of these kinds of strategies for managing anxiety disorders on your own is not well studied in scientific studies. Relaxation techniques are often used in psychological treatments, but it isn't known how effective they are when used alone.
Some people try herbal sedatives like valerian, lavender or passion flower. There hasn't been much research on these products either. Many people assume that herbal remedies are better tolerated and safer than other kinds of medicine. But they can also have side effects and may influence the effects of other medication.
People who treat an anxiety disorder on their own may only seek professional help after a very long time. If an anxiety disorder is really affecting your everyday life, certain kinds of psychological treatment and medication can help.
What happens in psychological treatments?
There are various psychological treatments for generalized anxiety disorder. Cognitive behavioral therapy (CBT) is the best studied and most effective.
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.
What kinds of drug treatments are available?
There are a number of different medications for the treatment of generalized anxiety disorder. Selective serotonin re-uptake inhibitors (SSRIs) are one commonly used treatment.
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.
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.
Which treatment is most suitable?
When deciding whether to have psychological treatment or use medication, your personal preference and individual needs will play a big role. The right kind of psychological treatment can be very effective and help you to overcome your anxiety. But it takes a lot of motivation and determination, and you often have to wait a long time to get an appointment. Depending on a person’s individual situation and the severity of their disorder, it might therefore be a good idea to start taking medication first. Sometimes it isn't really possible to begin psychological therapy until medication has been used to at least partially relieve the symptoms.
Some people don't want to start taking antidepressants because they are afraid they might end up becoming dependent on them. But – unlike some painkillers, sedatives and sleeping pills – antidepressants do not lead to dependency. Others see taking tablets to cope with their problems as a sign of weakness. But there's no reason to feel ashamed of taking medication to treat a mental illness. Medicine can be helpful, and in some cases even necessary, when trying to overcome anxiety.
Regardless of what decision you make, there are medications and psychological treatments that can help you cope with generalized anxiety disorder and start living a normal life again.
Bandelow B, Boerner RJ, Kasper S, Linden M, Wittchen HU, Möller HJ. Generalisierte Angststörung: Diagnostik und Therapie. Dtsch Arztebl Int 2013; 110(17): 300-310.
Deutsche Gesellschaft für Psychosomatische Medizin und Ärztliche Psychotherapie (DGPM). S3-Leitlinie: Behandlung von Angststörungen. AWMF-Registernr.: 051-028. April 15, 2014.
Gale CK, Millichamp J. Generalised anxiety disorder. BMJ Clin Evid 2011: pii: 1002.
IQWiG health information is written with the aim of helping
people understand the advantages and disadvantages of the main treatment options and health
Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The suitability of any of the described options in an individual case can be determined by talking to a doctor. informedhealth.org can provide support for talks with doctors and other medical professionals, but cannot replace them. We do not offer individual consultations.
Our information is based on the results of good-quality studies. It is written by a team of health care professionals, scientists and editors, and reviewed by external experts. You can find a detailed description of how our health information is produced and updated in our methods.