NEW PSYCHOTHERAPY APPROACH IN GENERALIZED ANXIETY DISORDERS

INTRODUCTION
Generalized Anxiety Disorder (GAD) is described in the DSM-5 through excessive anxiety and anticipated anxiety, and it is difficult for the patient to control these feelings so that for the diagnosis, these symptoms should be present for a longer period than six months, and the social, professional, and family roles of the patient be affected by these symptoms. More precisely, GAD is associated with three or more of the following six symptoms: (1) patients are feeling restless or feeling keyed up or on edge; (2) He/she becomes easily fatigued, with difficulty concentrating; (3) Irritability characterizes mood mood; (4) muscle tension; (5) sleep disorder (difficulty falling or staying asleep, or restlessness, unsatisfactory sleep) (1). Mental health surveys data indicate that anxiety disorders affect up to 33.7% of population during their lifetime. The lifetime prevalence of GAD varies between 2.8 % and 6.2 %, and the presence of GAD for a 12-month period is 2.8% and 2.9 % (2).
GAD occurs mainly in young adults and the average age at onset is 31 years (3). However, approximately 25% of GAD cases debut around the age of
20 years, and 50% of onsets occur between 20 and 47 years (4). Also, there is a high likelihood of chronic anxiety to associate over time with an organic comorbidity. In the case of GAD, over time, there is an increase of comorbidity between Irritable Bowel Syndrome (IBS) and chronic pain. For this reason, it is recommended that these patients undergo periodic medical investigation in order to prevent medical complications (5).
From an economic point of view, a French study revealed that the costs of psychiatric treatment for GAD (with no comorbidity) and additional medical consultations (internal medicine, radiology, etc.) carried out in order to exclude organic pathologies could reach $733/month. Additionally, in the case of co-occurrence of GAD with another physical disease, the cost could reach $1,208/month for a single patient. The study also showed that the adjacent costs, resulting from inability to work, was $233/month in GAD patients with no comorbidities, and $416/month in comorbidity with another psychiatric diagnosis (6). Thus, it is important to identify causes, determinants, or new treatment methods designed to decrease treatment costs and discomfort, and to increase quality of life for these patients. Even though the GAD diagnosis has been widely disputed over time, the unanimously accepted conclusion is that this disorder becomes chronic in some patients over time which directly influences the quality of patients’ lives (7).
PERSONALITY DIMENSION AND GAD
At the same time, there is a combination of TAG with personality dimensions, following The Big Five (FFM). These five big factors are biologically determined, being at the same time inborn and genetically transmissible features (8). Additionally, behavioral models of shyness or shame can be explained by a factorial combination of low Emotional Stability and low Extraversion (9). From a genetic point of view, certain risk factors also exist in association with various psychiatric conditions. A genome-wide single- nucleotidepolymorphism (SNP) assessment shows 6% to 12% of phenotypical variation in the case of low Extraversion and Emotional Stability. These results are identical with the estimations in the Cloninger temperament scale (10) (11), as well as the Risk Avoidance and Novelty Seeking scales (12). We note that T A G e t i o p a t h o g e n e s i s ( a s m a n y o t h e r psychopathological spectra) has a bio-psycho-social determinant.
MALADAPTIVE/DYSFUNCTIONAL COGNITIVE SCHEMAS (MCS)
From a psychological point of view, for optimal development children have certain basic needs that must be satisfied. First and foremost, children have the need for safety, stability, and acceptance, with attachment figures responding to these needs by building close relationships with the children. At the same time, in order to experience healthy development, children have the need for autonomy to acquire skills and discover their own identities. Thus, children’s freedom to express feelings and emotions, to engage in spontaneity and playful activities while also having appropriate limits and self-control, contribute to their emotional and mental health in adulthood (13) (14) (15). Furthermore, there is an association between early parental styles (e.g., rigid parenting) and developing Maladaptive / Dysfunctional Cognitive Schemes (MCS), which could determine the onset of certain symptoms particular to personality disorders, or chronic anxiety and / or depressive disorders (16). Once the Maladaptive / Dysfunctional Cognitive Schemes (MCS) are triggered by a negative life event, this process will be accompanied by intense negative emotions that generate major discomfort in patients. These MCS are considered to be absolute truths even though individuals are not consciously aware of the great impact they have on their perception of life’s events. Despite causing distress, these schemata are considered to be “correct” by the individuals (17) (18).
Therefore, from the point of view of developmental psychology, GAD could be explained by using an interpersonal perspective whereas if early childhood needs (e.g., need for safety, trust, or affection) are not met this could facilitate the onset of feelings of fear and worry. Consequently, these dysfunctional schemas are developed over time and effect the individual’s thought processes during future interpersonal relationships. With regard to the relationship between MCS and GAD, for instance in the case of patients with psychoactive substance addictions, there is an association between the symptoms of generalized anxiety and the autonomy and performance fields specific to MCS (19). Additionally, referring to anxiety disorders, common schemas exist which occur in social phobia and social anxiety, but which are different from the specific EMS occurring in panic attacks (20).
“THE THIRD WAVE” APPROACH IN GAD
By determining these specific patterns with the profile of this disorder, practitioners from the mental health system could improve psychological treatments for GAD. Treatment consists of anti-depressant and anxiolytic medication and/or Cognitive Behavior Therapy (CBT). It is known that therapy consisting of the combination of CBT and antidepressant medication is not superior to monotherapy (21). However, regarding anxiety disorders (e.g., GAD), CBT is considered a viable and efficient therapeutic choice, whether or not associated with medication (22).
Furthermore, the Metacognitive Model (MCM) shows that two types of worries occur in association within GAD. Type I worries are responsible for the distorted informational processing that cause the anxiety. Type II worries refer to ‘worrying about worrying’ and they are responsible for the occurrence of inefficient avoidance strategies, thought suppression, or focusing on emotion in situations which patients regard as dangerous (23) (24) (25) (26) (27). Approaching GAD through Metacognitive Therapy (MCT), with a particular focus on Type II worries (3-12 sessions), resulted in a significant reduction of worry-related symptomatology as well as an enduring effect seen in follow-up sessions demonstrating the efficiency of MCT in treating this disorder (28) (29).
By applying TCC specific techniques, maladaptive cognitive schemes are modified in particular by assimilation by the patient of new information through cognitive restructuring. The induction of positive emotions in the psychotherapeutic process contributes to the processing of information as a whole, the easier accumulation of new information and the development of a type of thinking characterized by flexibility by the patient with TAG. Thus, the induction of positive emotions in TAG psychotherapy can prevent restoration of anxiety after the completion of behavioral exposure techniques (30).
Acceptance and commitment therapy (ACT) it is another CBT orientation specific of “the Third Wave”. ACT is a therapy characterized as belonging to the post- Skinnerian behavioral orientation, and is based on the relational framework theory, represented by the relational context frame (RTF) and functional context (FC): (1) From the RTF perspective psychopathology occurs because the patient makes the confusion between the content of thought and the product of thought. (2) Functional context, is a derived branch of pragmatic psychology and radical behaviorism. As such, in relation with this approach past experiences are responsible for our present behavior. (31) (32) (33). In summary, from the perspective of ACT, for patients with GAD the map becomes the same as the territory. Thoughts are linked / generate specific emotions, manifest behaviors, respectively, correlated with the first situation in which they occurred (33) (34). ACT is a therapy in which patients are not taught to fight with their thoughts and discomfort, but paradoxically, they are encouraged to accept their anxiety and states, the focus being on the behavioral changes of the patient. Progress in therapy is achieved when the patient has no more existential avoidance, acts responsibly and in relation to his or her life values and acquires new adaptive behaviors by which he/ she manages to cope with anxiety (35). ACT is a new approach that attempts to alter maladaptive behaviors in anxiety by reference to values, present and action. This does not mean that ACT excludes CBT or that the two are not complementary. CBT tries instead to modify the patient’s negative thoughts, dysfunctional cognitive schemes, targeting the emotional discomfort caused by anxiety. The two approaches seem different, giving them a common denominator: the behavioral techniques that are used successfully in both interventions (36). Also, a recent study investigated the effectiveness of Metacognitive Therapy (MCT) versus Cognitive-Behavioral Therapy in Treatment-Anxiety Disorders. The results indicated that MCT had a faster effect on anxiety symptom reduction, but after completion of treatment, the clinical effect was similar, with no major difference in clinical efficacy in treating anxiety between the two psychotherapeutic approaches (37).
CBT APPROACHES FOR GAD
According to Beck’s cognitive model on anxiety and depression, there are three levels of information processing. The first, which is the most profound, corresponds to the disadaptive cognitive care schemes embodying central beliefs such as “I’m unlovable; I have no value; I am unnecessary”. The peculiarities of these systems consist of their absolute rigidity and their absolute and definite character being related to the experience of life once you activate, distort the information and produce, through the mechanism of inference, negative thoughts that make anxiety contribute to selective processing related to danger and helplessness (38). GAD treatment through CBT requires a multimodal and integrative perspective. Combining CBT with progressive relaxation techniques and desensitization leads to a significant improvement in the symptoms of anxiety and depression in TAG. It is supposed that adding an interpersonal component to CBT psychotherapeutic treatment would increase therapeutic effectiveness and reduce the post- therapy recovery rate and increase the quality of life for these patients (39).
From the neurophysiological point of view, there is pre-treatment CBT of sub-activation of the anterior cingulate and the island. After the treatment, there is a greater connection in the amygdalo-insular area, and a sub-activation of amygdalar and subgenual anterior cingulate in patients with GAD. The intervention of CBT is associated inclusive with a change in cingulo- amygdalar reactivity (40).
CONCLUSIONS
However, the comparison of CBT standard with “third wave” therapy approaches, shows that there are no significant differences between the two types of guidelines for effective anxiety treatment. Nevertheless, in terms of efficacy proven over time, CBT standard remains the “gold standard” in psychotherapeutic interventions in GAD.

ABBREVIATIONS:
ACT = Acceptance and Commitment Therapy
FFM = The Big Five
MCS = Cognitive Maladaptive Schemes
MCT = Metacognitive Therapy
GAD = Generalized Anxiety Disorder
CBT = Cognitive-Behavioral Therapy

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