Defining and Treating Generalized Anxiety Disorder (GAD)
What is GAD?
Much like depression, we are all susceptible to bouts of anxiety from time to time. And, like depression, the difference comes down to frequency, severity, and chronicity. How often do you experience anxiety? How intense is it? Does it interfere with your daily life? And how long-lasting have the symptoms been? An anxiety disorder, or any mental disorder, is serious partly because it involves a serious impediment to the activities of daily life. People with mental illness are not somehow “damaged” or less-than anyone else. In recent years we’ve seen the wide adoption of the terms “neurotypical” and “neuroatypical,” with the latter describing people, such as those with an anxiety disorder or other mental illnesses, who do not fit neatly into society’s view of “normal” behavior. It’s important to remember that, even in the throes of an anxiety attack, intense emotions like uncontrolled anxiety will always be but one portion of the endless combination of personality traits that make a human being. There are several subtypes of anxiety disorders ranging from social phobias to debilitating and terrifying panic disorder. Their treatment is never simple, and often requires a significant investment of time and effort on the part of both patient and clinician to begin to understand and ameliorate the destructive foundation of the disorder.
Benzodiazepines
Alprazolam (Xanax) is probably as culturally salient as fluoxetine. In fact, most patients who do need benzodiazepines do not take alprazolam because of its extremely high potential for abuse. When you are in the throes of an anxiety attack, the desire for a pill that melts aways the misery is understandably very urgent. But while these medicines have their place in treating certain patients, they must be used with extreme caution. Unlike drugs like escitalopram, any benzodiazepine will cause feelings of calmness and even euphoria no matter what, if any, psychiatric condition the user is suffering from. These medicines also can cause severe physical withdrawal if taken for a sustained period of time. More concerning still, is that it appears that long term use of benzodiazepines can cause brain damage, further making the case for extremely judicious prescribing. I mention benzodiazepines first on this page because of the broad cultural awareness they enjoy, but there are other effective pharmaceutical (and non-pharmaceutical) tools to combat anxiety that would usually be my first choice of treatment.
Escitalopram
You can learn more about escitalopram for depression here. It’s evident to anyone who’s ever suffered from these disorders that severe anxiety and clinical depression frequently go together. Anxiety and depression both can have heterogeneous presentations, that is, they can wreak the same havoc on different people while looking very different. This is why it’s essential that the patient form a therapeutic alliance with their provider to carefully examine symptoms that have been troubling the patient, and try to determine a way forward together. What’s more, while I use the DSM-5 for diagnostic and insurance reimbursement purposes, the specific diagnoses as found within that venerable—and flawed—tome are only of limited use in actually helping people. Escitalopram is so widely used because it can help treat the symptoms of multiple psychiatric conditions while being relatively safe and well tolerated. It has been established that escitalopram is an effective treatment for anxiety disorders in many people without the potentially severe downsides of the benzodiazepines.
There exist several alternatives to escitalopram or benzodiazepines. Many of these medications were mediocre in their original purpose, but have demonstrated real efficacy for other uses. Buspirone, for example, has been shown in several studies to be as effective as benzodiazepines. Anxiety can be like someone pounding on the door to your house twenty-four hours a day, demanding your attention and threatening your life if you don’t give in, so it’s understandable to feel like a powerful sedative and plenty of it is called for. But the goal of psychiatric treatment must be long-term stability and remission, and drugs with a better safety profile that aren’t taken to treat an acute anxiety attack are frequently the best way toward this goal. At my practice, I see the whole patient, and I hope to see that patient thrive without necessarily becoming dependent on substances that carry a high risk of addiction.
Other medicines