Generalised Anxiety Disorder
Benzodiazepines Treatment for Generalized Anxiety Disorder
The effectiveness of benzodiazepine in generalised anxiety has been well established.. This class of drugs represents the treatment of choice for limited generalised anxiety because of its rapid action and the effective reduction of insomnia and somatic/adrenergic symptoms. The BDZ treatment leads in 65% of the cases to a rapid response within one or two weeks. There is evidence that BDZs may be more effective on some specific symptoms, particularly the somatic symptoms of arousal existing of autonomic dysregulation. There should be somewhat less effect for the cluster of psychic symptoms, which includes apprehensive worry and irritability.
Several studies have shown that irritability may even worsen in conjunction with high-potency BDZs. It is also worth noting that subsyndromal depressive symptoms may predict a less favourable response to BDZs. Psychic symptoms may be more responsive to other drugs such as buspirone or imipramine.
Overall, BDZs remain a widely used option for GAD. There is little doubt that this situation is influenced by a wide acceptance of both patients and practitioners, an overall excellent tolerance, and a rapid onset of action. However, there is a relative lack of well-controlled data to support continued benefits of BDZs over the long term in GAD. It has been estimated that approximately 70% of patients with GAD will respond well to adequate BDZ treatment, but within one year 65% will suffer from recurrences of symptomatology.
Another complicating factor is the changing concept of GAD. Since its first delineation in the DSM-III, the multiple revisions of the diagnostic criteria show a continued tendency to emphasisethe so-called psychic component to the detriment of the autonomic/somatic symptoms. The growing trend is to consider that the core of GAD lies in its being a‘‘cognitive’’ condition, mainly characterised by pathological worry and ruminations. Now we have noted that BDZs are believed to be relatively less effective on that component of the disorder, compared with the autonomic dysregulation. It is therefore less clear how effective BDZs will appear when GAD is defined according the latest criteria.
The use of BDZs includes a serious risk for physical dependence and a withdrawal reaction.
Factors predicting major difficulties in withdrawal are the following
- High anxiety and depression levels before treatment
- High dosage of BDZs
- The use of BDZs with a short half-life
- Current tobacco dependence
- History of recreational drugs use
- The presence of an axis II pathology
- A history of panic attacks
Rapid rate of BDZ taper.
The risks for physical dependence and withdrawal problems at the end of the treatment have resulted in a relative limitation of BDZ use. There are pharmacological alternatives to BDZs even though the effectiveness, feasibility and long-term effects of these alternatives have been less documented. A treatment with buspirone or an antidepressant may be a good choice.