Cognitive-Behavioral Therapy vs. Medication for GAD

Introduction

Ever since Mick Jagger wrote about "mother's little helpers," much of the population has viewed medications as the instant cure for such modern-day maladies as Generalized Anxiety Disorder (GAD). It is undeniable that the prevalence of GAD is expanding as the world becomes more complex, global, and difficult to comprehend — and, one might argue, more mechanistic and less humanistic. Recent studies have shown that, despite the current overwhelming allegiance to medication, cognitive-behavioral interventions are more effective for GAD. Several major investigations and a recent small empirical study confirm that cognitive-behavioral counseling works better and more rapidly than medication intervention provided without attendant therapy.

The National Institutes of Mental Health (NIMH) shows that anxiety disorders are the most common mental illnesses in the United States, with more than 23 million people affected each year (Public Health Reports, 2005). Within this population, several varieties of anxiety disorder appear, including panic disorder, obsessive-compulsive disorder, phobias, post-traumatic stress disorder, and generalized anxiety disorder (GAD). NIMH defines GAD as "chronic or exaggerated worry and tension; almost always anticipating disaster even though nothing seems to provoke it. Worrying is often accompanied by physical symptoms, like trembling, muscle tension, headache, and nausea" (Public Health Reports, 2005). This is an adequate working definition for the current study.

NIMH also notes that there are several forms of effective treatment for anxiety disorder, among them medication, specific forms of psychotherapy known as behavioral therapy and cognitive-behavioral therapy, or a combination of medication and non-medication therapies. Medication, for the purposes of this study, will be taken to mean any psychotropic drug used to treat anxiety, or any drug developed for other purposes that has been found useful in treating some psychiatric conditions — such as antihistamines, which have been found useful for some generalized anxiety disorder patients.

Procedure and Method

Hypothesis: In Maverick County, generalized anxiety disorder patients function better without medication than with it, if medication is the only or primary aspect of treatment. In order to examine this assertion, two groups were studied. One group was provided with appropriate medication and minimal therapy; the second group received no medication but participated in a well-tested cognitive-behavioral regimen based on the Rational-Emotive Therapy of Dr. Albert Ellis, as described in his book A Guide to Rational Living, which participants were asked to read.

To ascertain the relative value of medication combined with traditional group therapy versus cognitive therapies alone in treating generalized anxiety disorder, two groups of young to middle-aged participants were formed. Each group began with four members drawn from clients of an Employee Assistance Program. All participants had developed generalized anxiety disorder after being transferred or otherwise placed under the supervision of ineffective, antisocial, overbearing, or micromanaging supervisors. All were seeking other employment but had to cope with their current situations in the meantime. Given a soft job market, none expected to wait it out without help; many had also expressed a need to overcome their anxiety in order to make the job search itself possible.

Group A was the group that agreed to medication. Medications were prescribed according to each patient's individual needs; no single medication was used by all. Among those prescribed were:

Antihistamines such as Vistaril™ and Atarax™, especially for those who hyperventilated (Schmetzer, 2003). Hydroxyzine was used for those whose primary expression of anxiety was insomnia (Schmetzer, 2003). Inderal™ was used for those with anticipatory anxiety — for instance, those who experienced symptoms prior to planned encounters with a problematic supervisor (Schmetzer, 2003).

Group A met once a week for one hour. Each session began with generalized statements from members about their experience of anxiety during the previous week and whether it had increased or decreased. The counselor identified the most common response among group members and commented on an appropriate emotional reaction to the issue raised. Group members then shared their own experiences — what their response had been and what it might be in the future. At the end of each session, the counselor did not assign any tasks for the following week. However, each group member maintained two journals: one concerning the specifics of their job search, and the other recording the specifics of their mental, emotional, and physical reactions to their situation.

Results

Group B took no medication and met for two hours each week. This group was approached through a variety of cognitive methods, with Rational-Emotive Therapy (RET) serving as the primary therapeutic framework. At the first session, each member was taught the "dispute" method of handling anxieties developed by Dr. Albert Ellis. Each was asked to set two goals before the following session: the first concerned concrete steps for their job search, and the second was a benchmark for anxiety reduction — for example, reducing hyperventilation in situations where an unpleasant encounter with a supervisor was anticipated.

By week six, Group A was reporting diminished physical symptoms of generalized anxiety; however, emotional responses to the anxiety triggers were not significantly reduced, according to both observation and participant self-reports. None had found a new job, and only one had begun sending out résumés.

Group B had experienced significant success in coping with their triggers. Members particularly responded to the reframing technique — a paraphrase of a Dr. Ellis approach they had been taught: "Although it is nice for everyone to like me and treat me well, I won't die if they don't." The physical symptoms had virtually disappeared for this group. One member had been so successful at "disputing" irrational beliefs that she reached an accommodation with her supervisor through a frank conversation and was planning to remain in her position, which she otherwise valued. The other members had all begun a job search; two had secured interviews. All had come to grips with their immediate situation well enough to attend work each day and return home each evening to prepare résumés and pursue other job-hunting tasks. Self-reports also indicated that those with families were functioning more easily at home, as were their family members. One member of Group B had even taught her equally stressed husband several of the techniques she had learned.