258 CHAPTER 7
the amygdala that underlie learning to fear objects or situations (Huang & Kandel,
2007); thus, reducing serotonin may make learning to fear or worry about specifi c
objects or situations more diffi cult. Moreover, other studies have shown that de-
creasing serotonin levels reduces the responsiveness of key parts of the amygdala,
which dampens the expression of learned fear (Macedo et al., 2007). Buspirone
must be taken daily, and it may take 2 weeks or more for symptoms of GAD to di-
minish and 6 weeks for the medication to attain its maximal effects.
Most people with GAD are also depressed, and buspirone only helps anxiety
symptoms (Davidson, 2001). In contrast, the serotonin/norepinephrine reuptake
inhibitor (SNRI) venlafaxine (Effexor) and certain selective serotonin reuptake in-
hibitors (SSRIs), such as paroxetine (Paxil) and escitalopram (Lexapro), appear
to relieve both anxiety and depressive symptoms (Baldwin & Polkinghorn, 2005;
Davidson et al., 1999). This is why an SNRI is considered the fi rst-line medication
for people with both GAD and depression, meaning that it is the medication that
clinicians try fi rst with these patients (unless there is a reason not to use it). How-
ever, when medication is the sole treatment and patients stop taking it, symptoms
are likely to return. For this reason, medication may be used in conjunction with
behavioral and cognitive methods.Targeting Psychological Factors
Psychological treatments for GAD generally have several aims:- to increase the person’s sense of control over thoughts and worries,
- to allow the person to assess more accurately how likely and dangerous perceived
threats actually are, and - to decrease muscle tension.
Psychotherapy for GAD generally consists of behavioral and cognitive methods,
which can successfully decrease symptoms (Borkovec & Ruscio, 2001; Cottraux,
2004; Durham et al., 2003).
Behavioral Methods
Behavioral methods to treat GAD focus on three main areas (Barlow, 2002a):- awareness and control of breathing,
- awareness and control of muscle tension and relaxation, and
- elimination, reduction, or prevention of behaviors associated with worry.
Breathing retraining requires patients to become aware of their breathing and to try
to control it by taking deep, relaxing breaths. Such breathing can help induce relaxation
and provide a sense of coping (of doing something positive in response to worry).
Similarly, muscle relaxation training requires patients to become aware of early
signs of muscle tension, a symptom of GAD, and then to relax those muscles. (How-
ever, it is important to note that not all people with GAD exhibit muscle tension;
Conrad, Isaac, & Roth, 2008.) Patients can learn how to identify tense muscles and
then relax them through standard relaxation techniques or biofeedback (see Chap-
ter 4). When electrodes are attached to a targeted muscle or group of muscles, the
patient can see on a monitor or hear from a speaker signals that indicate whether
the monitored muscles are tense or relaxed. This feedback helps the patient learn
how to detect and reduce the tension, eventually without relying on the feedback.
People with GAD often develop behaviors that are associated with their worries.
For instance, a patient who worries that “something bad” may happen to her family
may call home several times each day. By calling home and fi nding out that everyone is
fi ne, she temporarily lessens her anxiety, thus (negatively) reinforcing the calling behav-
ior. People with GAD do not naturally habituate to such anxiety; as they worry about
one set of concerns, they get increasingly anxious until they shift the focus of their worry
to another set of concerns, never becoming habituated to any specifi c set of concerns.
Exposure is one method used to eliminate or reduce symptoms associated with
GAD. Exposure relies on the principle of habituation (see Chapter 4) and when
used to treat GAD, patients undergo prolonged exposure to their worries. They are
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