Treatment options for generalized anxiety disorder

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, breathing exercises or yoga. There is a lack of research on how well these approaches work when people with anxiety disorders use them on their own. Relaxation techniques are often used in psychological treatments, but it's not known how effective they are when used without the support of others.

Some people try herbal sedatives like valerian, lavender, chamomile or passion flower. There's a lack of good-quality research in this area, too. Many people assume that herbal remedies are better tolerated and safer than conventional medications. But they can also have side effects and may influence the effects of other medication you're taking.

Also, if you try to manage your anxiety on your own, it might take a long time before you seek professional help. Only then can you start having treatments that have been proven to work, such as psychological treatment and certain medications.

There are various psychological treatments for generalized anxiety disorder. Cognitive behavioral therapy (CBT) is the best studied and most effective.

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, there's a lack of good research on the side effects of psychological treatments.

In Germany, CBT is offered by behavioral therapists and covered by statutory health insurers. It typically involves weekly sessions over several weeks or months. Depending on the circumstances and the technological set-up, these kinds of sessions can also be held virtually, for example as a video call.

Cognitive behavioral therapy has two 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 then challenge them,
• assess the actual likelihood and consequences of the things that trigger the anxiety, and
• cope with uncertainty.

One example of thought patterns that can make you feel anxious is “catastrophizing”: immediately jumping to extreme and exaggerated conclusions about the extent of an apparent 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 times she calls. To make it easier to change your behavior, the therapy also involves learning techniques to keep calm – like breathing exercises or relaxation techniques. You can also write down your feelings in a digital diary, for instance on a computer, tablet or cellphone. There are also virtual guides to relaxation exercises that you can use at home, at a time that best fits your daily routine.

Other types of psychological treatment focus more on trying to find the possible causes of the anxiety, such as traumatic childhood events. There's a lack of 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.

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 are antidepressants. They can relieve anxiety symptoms and help to 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 the symptoms improve when you take SSRIs, doctors recommend that you keep on taking them. If you stop too early or reduce the dose without talking to your doctor first, the anxiety symptoms could come back and you may also experience side effects. To prevent that from happening, doctors recommend taking the medicine for 6 to 12 months and then gradually reducing the dose. In some situations, it may make sense to take the medication for longer than that. It is 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 problems. 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 usually occur only during the first few weeks of use, so it may be worth waiting rather than stopping the treatment as soon as you notice side effects.

A number of other medications 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 certain reasons.

• Serotonin-norepinephrine reuptake inhibitors (SNRIs): This group of drugs includes duloxetine and venlafaxine. They have a similar effect to SSRIs.
• Pregabalin is mainly used to treat nerve-related pain, but it has also been approved for the treatment of generalized anxiety disorder. Several studies have shown that this medication is effective. It often causes dizziness and tiredness, though.
• Opipramol: There is a lack of good-quality research on the effectiveness of this antidepressant. For this reason, it is only very rarely used.
• Buspirone can relieve anxiety, but there has been less research on it than on other medications. So it's usually only used if, for example, SSRIs aren't effective or aren't well tolerated. Possible side effects include listlessness, nausea and sleep problems.
• Hydroxyzine: This antihistamine can also probably reduce the symptoms of generalized anxiety disorder. There is less good research on it than on other drugs, though, so it's hardly ever used.
• Benzodiazepines are sedatives that also help to relieve anxiety. They start working quickly, but there's 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.

Research has shown that certain medications, including some that are used to treat depression, are effective in the treatment of generalized anxiety disorder. But they haven't been approved for this purpose. 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 medications with each other. There is no evidence that any of the medications has clear advantages over the others. But because the various drugs can have different effects in different people, it may be worth trying out different medications.

There are a number of internet-based offers, such as apps, that are designed to help people who have an anxiety disorder. Some are free, and others can be downloaded for a fee. They may, for instance, provide written information and videos that you can use to practice a technique on your own. The content of these programs is often based on cognitive behavioral therapy (CBT).

There is a lack of good research into whether these online programs help and, if so, how much. CBT-based apps appear to help in adults who have generalized anxiety disorder – at least in the short term: For example, in studies that lasted 2 to 3 months, the apps were found to relieve psychological and physical symptoms, as well as improve quality of life. But a lot of questions remain unanswered: How long do these effects last? Do the apps help in teenagers, too? How effective are they compared to psychological treatment or medication? And can they have unpleasant side effects? According to specialists, it's best not to use these apps as your only treatment. Instead, they can be used alongside talking therapy or medication – or while waiting to start therapy.

Certain apps can be prescribed by a doctor or psychotherapist. In Germany, these certified digital health applications are known as "digitale Gesundheitsanwendungen (DiGAs)." Statutory health insurers cover the costs of DiGA apps that have been prescribed for you. DiGAs are assessed by the authorities to make sure they meet certain requirements regarding things like data protection and content quality.

There is a list of all the DiGAs for generalized anxiety disorder on the website of the German Federal Institute for Drugs and Medical Devices (BfArM). The website also provides information about what these apps include and how to use them.

When deciding whether to have psychological treatment, use medication or combine the two, 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 your individual situation and the severity of the disorder, it might be a good idea to start taking medication first. Sometimes it's not really possible to begin psychological treatment until medication has at least partially relieved the symptoms.

Some people don't want to start taking antidepressants because they're afraid they might end up becoming dependent on them. But – unlike with certain painkillers, sedatives and sleeping pills – you can't become dependent on antidepressants. Others see taking tablets to cope with their problems as a sign of weakness. There's no reason to feel ashamed of taking medication to treat a mental health problem, though. Medicine can be helpful, and in some cases even necessary, when trying to overcome deep-seated anxiety.

Regardless of what you decide to do, there are medications and psychological treatments that can help you cope with generalized anxiety disorder and start living a normal life again.