Generalized Anxiety disorder is a condition that is characteristic of chronic and persistent worry which is multifocal. The disease is associated with concerns on the internal and external events which are accompanied by different semantic and psychological complaints including restlessness, autonomic arousal fatigue, concentration problems, sleep problem, and irritability. The condition is considered a chronic disorder as most patients are usually still affected after 6-12 years. According to Cuijpers et al., (2014), the twelve months prevalence rates for the condition is approximately 1.2% and 1.9% while the lifetime prevalence is 4.3% and 5.9%. Randomized trials and meta-analysis have indicated that pharmacotherapy can be used to treat the condition. Such tests were conducted following the introduction of the disease to DSM in 1980. Clinicians and patients usually consider psychological treatment as opposed to drugs treatment for the condition. Different types of psychosocial procedures have been developed to help patients overcome the state. Majority of these constitute cognitive behavioral therapies that include one or more techniques, for instance, cognitive restructuring exposure, applied relaxation, problem-solving and biofeedback. Acceptance-based behavior therapy and meta-cognitive therapy are some of the contemporary CBT treatment for generalized anxiety disorder. Other forms of treatment for GAD include psychodynamic therapies, non-directive supportive therapy, and spiritual therapy. All medicines are delivered to the individual in the form of face to face. There are also possibilities of providing the treatment using group setting and guided self-therapy. Recently, internet-based remedies for GAD have been developed (Cuijpers et al., 2014; Stein & Sareen, 2015; Nagata, Suzuki & Teo, 2015).
According to a survey conducted in the US, the estimated prevalence of GAD in the entire population of the country is 3.1% in the past years and 5.7% in a patient's lifetime. The condition is more prevalent in women than men. The onset of GAD varies with some reported case occurring in childhood while majority begin at early adulthood usually in the form of a chronic physical health condition. It is needed that six months of anxiety must be observed for diagnosis to commence. The situation is prevalent in primary care environments in which case it occurs in 7-8% of the patients. In primary care, the predominant symptoms include a headache and gastrointestinal distress. In children, the condition can be identified as recurrent abdominal pain including other somatic symptoms that are likely to force the kids to stay away from the school. Other symptoms include major depression which is difficult to distinguish from the condition (Stein & Sareen, 2015). According to Kellett et al., (2016), previous reviews of the effect of CBT on GAD in older adults have led to inconsistent results. Studies have also indicated that CBT is less useful for older adults compared to the younger generations. The difference is as a result of cognitive decline due to age as well as psychiatric comorbidity. The authors recognize that there are weaknesses of the evidence base for talking treatment especially for the aging adults with GAD. Accordingly, the present reviews have tried to cover a wide range of issues on psychotherapeutic treatment alternatives or late-life anxiety disorders and therefore have masked the possible differences in specific psychotherapies. Other studies have measured the effect size using a pooled composite which has obscured the diagnosis effects concerning observable features of GAD. Researchers have been encouraged to employ the Penn State Worry Questionnaire in older adults (Nagata, Suzuki & Teo, 2015).
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Cognitive behavioral therapy is a class of interventions that assume that mental disorders, as well as psychological distress, are as a result of cognitive factors. The treatment approach was pioneered by Beck (1970) and Ellis (1962) and assumes that maladaptive cognitions lead to emotional distress and behavioral problems. In Beck's model, the cognitions incorporate general beliefs about the world the individual and the future, therefore, giving way to specific and automatic thoughts in different situations. The model holds that therapeutic approaches that alter the maladaptive lead to changes in emotional distress and other problematic behaviors. From its early formulation, different disorder-specific CBT protocols have been developed that address unique cognitive and behavioral maintenance of the disorders. The disorder-specific treatments have considerable differences in the various treatment techniques. However, all share a similar model and approach to treatment. The goal of therapy is symptoms reduction, remission of the disorder and improvement in functioning. The best results are achieved when the patient becomes an active participant in the problem-solving process. They test and challenge the validity of maladaptive cognition and in some instances; they modify any maladaptive behavior patterns. Contemporary CBT is a family of interventions that employ different cognitive, emotional and behavioral focused techniques. Despite their focus on cognitive factors, the strategies also include physiological, psychological and behavioral components for their role in the maintenance of the disorder.
Mindful based interventions are ancient meditative techniques. It involves seeing or especially observing something. It consists of being conscious, alert, aware and attention giving. It is a state in which an individual is required to be psychologically present and not to react to the happenings around them. The practice of meditation allows an individual to respond consciously and reflectively rather than responding to external or internal events. Mindfulness-Based stress reduction program was developed by Kabat Zinn in 1982 and facilitates adaption of medical illnesses. It involves an eight to ten weekly session that follows a skilled based educational format. Research shows that individuals who have been through the program show a significant reduction in psychological and physical symptoms. The program has been reported to be useful in stress-related medical conditions with emotional disorders. In India for example, there is evidence for mindfulness-based interventions in clinical and nonclinical settings for problems related to a headache, depression, obsessive-compulsive disorder, occupational stress and coronary heart diseases. In other quarters mindfulness has been used against anxiety and depression. Its use in combating anxiety disorders was first reported by Kabat- Zinn (Sharma et al., 2012).
According to Wong (2016), limited studies have been conducted to determine the efficacy of MBCT in patients with anxiety problems. Most of the studies have concentrated their effort on depression. Accordingly, limited studies have been carried out to determine its effectiveness on worry and anxiety associated with generalized anxiety disorder. According to the writer, such studies have been constrained by their study design for instance lack of control group comparison, randomization and having a small sample size. According to the author, mindfulness-based stress reduction with an active control has shown positive results on the reduction of anxiety symptoms in patients with GAD. Their study incorporated an active comparison group to help in evaluating the effectiveness of MBCT in anxiety and symptoms associated with worrying. The authors hypothesized that subjects in the MBCT group are better than psychoeducation control groups in CBT principles as well as the control care in reducing anxiety symptoms in affected individuals (Kimmel et al., 2015).
This study has been informed by the need to identify the relevant and pertinent evidence-based practice of the methodological application of CBT to GAD. The paper is intended to help in the integrative understanding of the theory and application of cognitive behavior and mindfulness-based cognitive-based therapies. The study will review eight current research articles on GAD from scholarly journals. This study will select two evidence-based practices of cognitive behavior-based treatments and two evidence-based practices of MiCBT based therapies
Methods
In conducting this research, past articles on generalized anxiety disorder were reviewed. The study involved a thorough search of different library databases and the internet for reliable journal articles for use in the analysis. The selected items were not more than five years and compared different previous studies on the matter. Therefore articles from academic journals that were published from 2012 to date were selected. The literature reviews and the arguments in each study were considered especially in areas that deal with the subject. Search titles included generalized anxiety disorder or cognitive behavioral therapy or behavior based therapies and practices of MiCBT based therapies. Reference list of retrieved articles and previous studies on treatment of GAD published in the last five years were also searched manually for online sources to identify potentially eligible studies. Eligibility criteria required that the article must be scholarly and published in an academic journal. Similarly, it must have a co-principle of GAD disorder. Preference was given to randomized controlled trials. Additionally, the studies needed to include treatment of the condition. Data extraction involved comparing the articles and capturing relevant information for the research. It also required the determination of the reference list in each report to determine the extent to which the study incorporated subsequent studies (Kellett et al., 2016).
Results
The systematic search yielded twenty-seven articles thirty-six abstracts which were reduced to eleven after duplicates were removed. From the materials, seventeen were eliminated because they did not meet the inclusion criteria. Eight articles that met the inclusion criteria were used for the analysis. In the included items five used material review and conducted a meta-analysis in with two using participants in psychotherapy condition. The articles recruited patients from clinical samples in addition to community referrals. In the eight included items, five dealt with general anxiety disorder while one dealt with cognitive behavior therapy and one dealt with mindfulness-based cognitive behavior. One article compared MBCT against group psycho-education for individuals with GAD (Cuijpers et al., 2014).
The quality of the different studies varies with five reporting adequate sequence while three were slightly different. The majority used blinding outcome assessors with one using self-reported outcome. The quality of the intervention also differed. In the majority of the articles, the writers were interested in finding the qualifications of the therapists who performed the studies and found out that majority were trained, therapist. Seven items met the integrity criteria (Cuijpers et al., 2014). From six articles, cognitive behavioral therapy was a standard delivery method with the duration ranging from six to eight weeks. It was typically delivered face to face, and according to one article, it can be provided over the phone. There was limited data on post-treatment follow up with three studies reporting a six month follow up of the patient after CBT. From the different articles, there was inconsistency in the definition of treatment response (Kellett et al., 2016).
Evidence-based GAD treatment
According to Allgulander (2015), the first line of treating GAD was serotine and noradrenaline reuptake inhibitors. The cost of treatment varies between countries. The European Commission approved the following medications based on a series of phase three studies escitalopram, venlafaxine, duloxetine, paroxetine, and pregabalin . Different countries have issued guidelines on the treatment of the condition. The Swedish board, for example, added benzodiazepines to the above list in its directive. The writer recognizes that cognitive behavioral therapy is a treatment for GAD, but there are limited studies on its use. He further notes that fifty percent of patients who completed the treatment and forty percent who enrolled in the controlled studies indicated improved functioning (Kimmel et al., 2015).
Cognitive behavior therapy techniques involve acceptance, psychoeducation, time to control and to master worry, and advice on possible ways of avoiding relapse. A combination CBT and pharmacotherapy showed no added benefit (Allgulander, 2015). CBT is a reliable first-line treatment for patients with GAD with support for a positive effect on secondary symptoms like anxiety sensitivity and sleep disorder. Internet-delivered therapy showed positive feedback for relieving immediate symptoms. The long-term effects of CBT are still unknown (Hofmann et al., 2012). CBT has also been found to be useful in other disorders like addiction and substance abuse, schizophrenia, and psychotic disorders, depression, and dysthymia. Other conditions include bipolar disorder, eating disorder, insomnia, personality disorder, anger and depression, criminal behaviors, general stress, chronic pain and fatigue, pregnancy complications and female hormonal conditions and somatoform disorders (Allgulander, 2015).
Patients who completed mindfulness-based cognitive therapy showed improved signs of anxiety. According to Sharma et al., 2012, MBCBT was effective in significantly reducing anxiety upon completion of the program. The post-therapy assessment indicated that cognitive semantic symptoms of anxiety as measured in CSAQ declined for participants who engaged in the entire agenda. The pre and post assessment appeared to be clinically significant. Their findings indicated that MBCT was effective in reducing physical or somatic symptoms and cognitive anxiety symptoms in patients with anxiety disorder. Their results were similar to previous studies that showed that mindfulness-based cognitive therapy led to clinically as well as statistically significant improvements of participants engaged in the program. Despite the fact that relaxation is not the aim of mindfulness meditation, there are definite benefits of recreation as a participant focus on breathing. Such findings are also supported by other studies that have shown the effectiveness of MBCT on symptoms of anxiety. From the survey, it was established that MBCT leads to a reduction in worry and dysfunctional cognition as the participant progresses with the therapy. Their finding, however, did not meet the criteria for clinical improvements. The study found out that there was a decline in worry, and dysfunctional cognition that was clinically significant. Mindfulness has been identified as having the potential to develop awareness of alternative alternatives by detaching an individual from their habitual way of responding. It focuses on the present moment and offers an alternative response that facilitates adaptive response.
The modification of individual dysfunctional beliefs requires time, and changes happen gradually. The components of cognitive programs result in significant changes in dysfunctional cognition. Such changes are not statistically significant. Alternative techniques for coping with anxiety rather than reducing the non-adaptive coping strategies are likely to be effective in bringing change. Mindfulness programs have also been incorporated in different cognitive-behavioral treatment for depression and substance abuse and as a comprehensive treatment for borderline personality disorder (Nagata, Suzuki & Teo, 2015).
CBT is a widely studied psychotherapy with different applications as identified in the discussion. It is applicable for patients of various ages ranging from children to adults. The study on CBT was one of the most comprehensive as well as a contemporary review of meta-analytic studies. Its ability to treat anxiety disorder was found to be robust even though there were challenges to the specific anxiety condition. CBT has been used for a variety of conditions, and its evidence base is solid especially for anxiety disorder. There is need to conduct high-quality studies on the efficacy of CBT further and for areas where weaknesses have been identified (Hofmann et al., 2012). MBCT has been found to be useful in the treatment of anxiety disorder. The study can be applied to the management of anxiety in the broader population and other countries. The applicability of MBCT can be practical as training of mindfulness meditation is cost effective and can be applied to a wide range of patients. The significant decline in anxiety for the participants indicates that MCBCT is a useful technique for managing patients with anxiety disorders. The study was however limited by the small sample size which can make it challenging to apply the findings to the entire population. Similarly, the absence of follow up is another limiting factor as it is difficult to ascertain the long-term result of such engagements. Wong, (2016) identified five limitations in the study which included participants in the MBCT having lower adherence than the one they randomized in the PEG group. The outcome of their research was based on a self-reported questionnaire which was collected at similar points of time. The researcher was only able to compare PEG and MBCT due to ethical issues. The participants in the study included individuals with moderate levels of anxiety symptoms. It was difficult to determine whether the reported differences between PEG, MBCT, and UC after five months were mere as a result of the differences in attention and time each participant received rather than the content. Lastly, the research had two primary outcome measures as well as comparisons in the study
References
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Cuijpers, P., Sijbrandij, M., Koole, S., Huibers, M., Berking, M., & Andersson, G. (2014). Psychological treatment of generalized anxiety disorder: A meta-analysis. Clinical Psychology Review, 34 (2), 130-140. doi:10.1016/j.cpr.2014.01.002
Hall, J., Kellett, S., Berrios, R., Bains, M. K., & Scott, S. (2016). Efficacy of Cognitive Behavioral Therapy for Generalized Anxiety Disorder in Older Adults: Systematic Review, Meta-Analysis, and Meta-Regression. The American Journal of Geriatric Psychiatry, 24 (11), 1063-1073. doi:10.1016/j.jagp.2016.06.006
Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognitive Therapy and Research, 36 (5), 427-440. doi:10.1007/s10608-012-9476-1
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Wong, S. Y., Yip, B. H., Mak, W. W., Mercer, S., Cheung, E. Y., Ling, C. Y., . . . Ma, H. S. (2016). Mindfulness-based cognitive therapy v. group psychoeducation for people with generalised anxiety disorder: randomised controlled trial. The British Journal of Psychiatry, 209 (1), 68-75. doi:10.1192/bjp.bp.115.166124
