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Dr. Jordan Bawks: [00:00:10] Welcome to Psyched, the Educational Psychiatry Podcast by Medical Learners for Medical Learners. Thanks for joining us as we continue our series on core topics in psychiatry. This is the second episode in our series on Generalised Anxiety Disorder or as we will commonly refer to it, GAD. Within psychiatry, we use biological, psychological and social model of understanding the illness experience. And today we'll be focusing on a variety of treatment options that help people who are suffering from symptoms of GAD. If you haven't already, I'd recommend you check out part one where we talked about diagnosis, but it's your life and we're happy to have you here. Either way. Your Psyched hosts today are Dr. Jordan Bawks, a second year resident. That's me and Dr. Bruce Fage, fourth year psychiatry resident at the University of Toronto. We are joined by Dr. Jared Peck. Again, last episode we teased you, saying that Jared had done an earlier episode with us, but I'm here to correct that today. This is actually the second episode with Dr. Peck. We're very happy to have him back once again. He is still the head of ambulatory psychiatry at the Mount Sinai Hospital, still an assistant professor at the University of Toronto and still a bike safety enthusiast, especially as the weather warms up here in Toronto. In addition, Dr. Peck is a certified CBT therapist with the Academy of Cognitive Therapy and trained at the Beck Institute for Cognitive Behavioural Therapy. And that's one of the reasons we're so happy to have him here to talk about CBT and anxiety. Thanks for bringing your expertise and clinical experience to talk about GAD with us again. Dr. Peck.
Dr. Jared Peck: [00:01:47] My pleasure. Thanks for having me back.
Dr. Bruce Fage: [00:01:50] So in terms of the objectives for this episode, we're going to be focusing on treatment and we're going to focus on things like lifestyle modifications, psychopharmacology, including first line treatments with some second and third line options. After that, we're going to talk about psychotherapy, some different options, though, focusing on cognitive behavioural therapy, and then we'll wrap up, provide you a summary and some additional reading.
Dr. Jordan Bawks: [00:02:15] So, Dr. Peck, can you walk us through the general approach to treating GAD? For example, if you are working to support a person with GAD, what would you say about the treatment options and process?
Dr. Jared Peck: [00:02:29] Sure. Well, first and foremost, the foundation of all treatment starts with providing people with just education about their illness. So if we rewind to our last session, those questions and the things we talked about in terms of pathological versus non pathological anxiety, kind of explaining what really the disorder is, is the starting place so people can understand that it's about their worry creeping up when there's less of a need for worry or misinterpreting situations as more dangerous and then experiencing those physical symptoms. So that's the first piece. And then, you know, we'd want to look at lifestyle and from the biopsychosocial perspective, we can look at kind of social or lifestyle things as well as biological and then psychological treatments.
Dr. Jordan Bawks: [00:03:22] And when you talk to patients about sort of like lifestyle changes and generalised anxiety disorder that have evidence or kind of just make good clinical sense, what are the typical big things that you highlight?
Dr. Jared Peck: [00:03:34] Well, you know, increasingly we live in a society where everyone's turned on with their phones and always checking them. And I think, you know, there's always this sort of drive that we have and kind of we need to check things, we need to check. So I think turning off a little bit is an important piece, and that can include exercise, yoga, things like that. And there's some evidence for those things as well as it just kind of being, quote, common sense. But lots of things become common sense when you when you after the fact. In addition to that, we want to look at substance use. People are often drinking coffee. Not everyone with anxiety is or with generalised anxiety disorder is super sensitive to the effects of caffeine, but many people are, so the coffee will make them physically feel a bit keyed up or revved up. It's difficult because sometimes people compensate with having coffee because as part of their anxiety they have a hard time sleeping. Which leads us into talking about sleep hygiene. And I don't know if you guys are doing a podcast on sleep hygiene, but you know, the basics of it are making sure you really have this winding down period and keeping the bed for for sleeping. Not a lot of screen time before, not exercise just before bed, you know, not eating too late, not smoking too late, getting out of bed if you're really thinking about something. So there's a bunch of principles there.
Dr. Jordan Bawks: [00:05:02] So it's sort of like reducing stimulants when possible, like caffeine increasing, kind of like non-electronic, like relaxing, focussed kind of exercises, like exercising or yoga or meditation and also like protecting sleep through sleep hygiene.
Dr. Jared Peck: [00:05:21] Yeah. And then also people sometimes have a drink of alcohol to wind down and drinking is okay. But again, people with anxiety disorders, one drink might kind of cut the edge off things. But when people drink and then alcohol is getting out of the system, you can have rebound anxiety. And so we really want to educate people around the impact of alcohol on their anxiety.
Dr. Bruce Fage: [00:05:47] So it sounds like even before we get to medical treatment, there are lots of options for patients to consider in managing their own anxiety and symptoms of generalised anxiety disorder. In terms of medications and psychotherapy, do you have a sense of which one is superior?
Dr. Jared Peck: [00:06:06] Um, well, there's not clear evidence that one is superior over the other. There's some signal towards psychotherapy being more long lasting, meaning that once you're not engaged in the act of psychotherapy, you continue to have gains. Whereas if you're on medications and you're no longer taking the medications, you don't have gains. So there's a signal that there's more sustained gains. But really the evidence is that both can be helpful. And there's questions around whether a combination can be more helpful or less helpful, paradoxically. But that's the jury's still out on that.
Dr. Bruce Fage: [00:06:48] Thanks for explaining that. I guess I'm wondering if you can tell us a little bit about some of the medications that you use for treating generalised anxiety disorder.
Dr. Jared Peck: [00:06:56] Sure. You know, there's there's generally two classes that have the most evidence or technically three classes in terms of response with all medications. We want to look at the individual, we want to look at what potential comorbid conditions they have, if they've had treatment in the past, how they've tolerated that. Look at the potential side effects. And as always, as a reminder, we want to have full informed consent around the risks, benefits, common and very serious side effects. So if we look at probably the most commonly used medications or the ones with the the most commonly used first line medications, those would be the selective serotonin reuptake inhibitors and the serotonin norepinephrine reuptake inhibitors, what we refer to as the SSRIs and SNRIS. These drugs don't work immediately. We start at a lower dose and then try to fairly rapidly, but not too quickly increase them until we hit the therapeutic window and then leave them there for a few weeks and then increase more over time. They can take. People can get early benefits. So in the first 2 to 3 weeks, but often it's 4 to 6 weeks and sometimes with anxiety can be a bit longer, getting closer to eight weeks, which can sometimes be a little bit longer than in treatment of depression, but not always. They're generally well tolerated. The early side effects and the ones that are most common are a lot of gastrointestinal side effects. So like feeling a bit bloated, your bowels, movements changing one direction or the other, or a bit of nausea, that usually settles.
Dr. Jared Peck: [00:08:56] And that's why we ease people in. People can get a bit of a headache and tremor sometimes, sometimes not. With all of them, but sometimes initially there can be a little bit of a spike in the anxiety. Or it can be what we often refer to as, quote, activating, which is, you know, a bit energising but can sometimes be experienced as some physical anxiety. We tell everyone that you can, with all the SSRI and SNRIs, have changes in your sexual functioning. So it can be anything upon anything along the sexual response curve. So it could be decreased interest kind of taking longer for someone to become physically aroused right through to delays or inability for people to orgasm. It doesn't happen in everyone. It's usually somewhat dose dependent. If it happens with one medication, it's not necessarily going to happen with another one, but that's an important one. With SNRIs, particularly as we increase the dose, they can affect people's blood pressure. So we want to watch that as well. So those are the SSRI and SNRIs. Then there's another class of medications, Alpha two, Delta drug, and that's a medication called Pregabalin. Now, Pregabalin is also first line evidence for GAD. I believe it's used more in Europe than in North America, but I'm not sure what what has led to that prescribing practice. But I think it's increasingly being used here.
Dr. Jared Peck: [00:10:38] It's clear from studies and from treatment guidelines that it's an effective medication. There's some advantages and disadvantages when we compare Pregabalin to SSRIs. The advantage would be it doesn't have the sexual side effects up front. And probably although SSRIs and SNRIs are well tolerated overall, it's probably a bit better tolerated in terms of having less of those GI symptoms up front, although people can get a bit of that. And one of the disadvantages is that as we talked about previously, a lot of people have comorbid depression or other anxiety disorders, and SSRIs and SNRIs in general are indicated for most anxiety disorders. Pregabalin is not indicated for all anxiety disorders, and in addition, Pregabalin is not an antidepressant. So you lose that that sort of dual treatment. I have found, though, in some people it can be tremendously helpful. There is some evidence for treatment in alcohol use disorders, which is positive. As we know, alcohol use disorders can be comorbid with anxiety and generally there are there are few interactions with Pregabalin. I've kind of gone all over the place with the pros and cons, but another con would be it's more expensive. So, you know, hopefully people have drug coverage. If they don't, then it's going to be quite expensive. And, you know, one of the SSRIs would be where you start. Also, in general, in medicine, we prefer things that are dosed once a day and Pregabalin is b.i.d. Dosing.
Dr. Bruce Fage: [00:12:40] And just to for our listeners, bid means twice a day.
Dr. Jared Peck: [00:12:43] Yes.
Dr. Bruce Fage: [00:12:44] Yeah.
Dr. Jordan Bawks: [00:12:44] And yeah, it's interesting because it's like it seems like there's a lot of excitement about Pregabalin in the current kind of clinical environment because it's a new kind of class of agent, right? It's, you know, sometimes when you rotate people between SSRIs and SNRIs, you do get a response, right? Like some people will respond to Sertraline when they don't respond to Escitalopram. But I think it's, you know, it's nice to have a totally different class of drug. And the other thing, too, is there seems to be some signal in the literature that people respond to Pregabalin a little bit earlier, like whereas SSRI takes, you know, 4 to 6 weeks or maybe more and anxiety disorders. I think the literature kind of supports that. In Pregabalin, you can see it within like 1 to 2 weeks if you're doing a rapid titration.
Dr. Jared Peck: [00:13:27] Anecdotally, I would say that in my experience I've prescribed more SSRI or SNRIs over time for anxiety than Pregabalin. But when I've had people improve, the improvement has been earlier. So I would agree with that.
Dr. Jordan Bawks: [00:13:49] And I think too, because people generally get less exposure to Pregabalin, they may be less comfortable with dosing. And it's worth noting that there's for people who are interested in the evidence that supports Pregabalin, there's a great systematic review and meta analysis by Generoso. We'll put that in our show notes. It was done in 2017 and I was looking at the dosage ranges and it's anything from like 150 to 600. And they also look at the tolerability, the compared to Benzodiazepines. So again, you're looking in that 150 to 600 kind of dosage range, which you'll find in most sort of clinical practice recommendations. And but usually when you get above like 150, you need to do bid and it's a short acting drug. So especially you need to do it twice a day because it doesn't last in your system long enough. Another thing that I'm almost like reticent to mention on a podcast that goes out to the broader public, but I think it's worth knowing for prescribers that there does seem to be some case reports of people abusing Pregabalin as well, like it's a sedative medication that acts fast. And so when you're prescribing it, you should watch for kind of like signals of misuse, people running out early or asking for dosage ranges that aren't clinically indicated. So something for prescribers to be aware of.
Dr. Jared Peck: [00:15:11] Yeah. And and a lot with respect to the sedative aspect, particularly as you increase the dose with the bid dosing, sometimes that can get get in the way a little bit. If someone's up to, you know, 200, 300 or even. Yeah, yeah. Around that much in the morning can can be a bit sedating but not in everyone.
Dr. Jordan Bawks: [00:15:33] And also something that we don't often think about with the SSRIs is kidney function. So if you have a patient who has like medical comorbidities, it's important to check their creatinine clearance because that's how Pregabalin gets out of the system. So you could you might need to adjust dosing based on that.
Dr. Jared Peck: [00:15:48] Yes. Now, there's a couple other drugs that we see used. Quetiapine seems to be the pandiagnostic drug or in regular terms the drug that's used for everything. And there it doesn't have first line evidence as being a drug to use for generalised anxiety disorder. But there are some studies that show some evidence looking at the literature and in my experience I tend to use smaller doses of it. The sedating piece we're talking about with Pregabalin is nothing compared to the sedation people can have with Quetiapine. And you know, looking at the literature, it seems to be more at lower doses. So 150 mg going up to 300 does not necessarily improve things and sometimes makes it worse and less tolerable because people feel quite groggy and less sharp. A pro to it is that when people take it, they can get that anti-anxiety effect pretty early and it's used for other disorders. It has clear evidence in bipolar depression, in psychotic illness and in unipolar depression or major depressive disorder. So Quetiapine is something that's there. It's always important to remember when we're using Quetiapine regardless of the dose. We want to do all of our metabolic monitoring. So looking at people's sugars, their weight and their cholesterol and that's a key with it because we don't know what dose that starts at. But in theory people can have those side effects at any dose.
Dr. Jordan Bawks: [00:17:39] And so, yeah, and because of those, because of those metabolic side effects and the tolerability issues, they are listed as a second line agent in many of the clinical practice guidelines, including the one that we often use here in Toronto, the Katzman Canadian clinical guidelines.
Dr. Jared Peck: [00:17:57] Yeah. And I guess finally, possibly, you know, we said up front the most commonly used being the SSRIs and SNRIs, but other commonly used class of drugs is the benzodiazepines. People will sometimes end up on these when they're first seeing their doctor in the context of having a real spike of their anxiety and benzodiazepines do have evidence for treatment of generalised anxiety disorder, but they can be quite tricky. They're not more efficacious or better than the other classes in the long term. And in fact you can run in some into some problems with them long term. There's short acting, benzodiazepines and long-acting benzodiazepines. The short-acting ones have a greater potential for people to misuse them because they kind of really switch on quickly and calm people down. But then they switch off and you can get a little bit of increase in your anxiety, similar to what I was talking about earlier with alcohol. And the long acting ones can do that as well. The challenge with benzodiazepines is that over time people's bodies get used to them and they need higher doses. And then they're having, as I said, somewhat of that what we call withdrawal or rebound anxiety. So we want to be careful. Often we use them when we're first starting on SSRI or SNRI to combat that potential activation or to help people get some benefit while we're waiting for the other medication to kick in. But we want to really watch how long we're keeping people on them. We also know about the comorbid substance use, and if people have a history of alcohol use disorder or other substance use disorder, we want to be really, really careful around prescribing benzodiazepines. And we want to know, obviously, what people's liver functions like, particularly as people are getting older, even though they. Their liver livers still functioning. You know, things change and the body composition changes. And we really want to avoid benzodiazepines. In the older population, people are at higher risk of falls and it can be quite dangerous.
Dr. Jordan Bawks: [00:20:18] So when do you see yourself using benzodiazepines in when you're treating patients with generalised anxiety disorder?
Dr. Jared Peck: [00:20:26] So as I mentioned, there's the situation when you're starting an SSRI or an SNRI and you're they're getting either some activation or increase in anxiety temporarily, then you might use that. Or even if they're not getting that to help tone things down. And that would be like.
Dr. Jordan Bawks: [00:20:42] For weeks, like a month.
Dr. Jared Peck: [00:20:45] I would say. So somewhere in the range of so weeks over those first four weeks or so. The other case would be the individual who I've really tried everything else and doesn't have a substance use disorder. And the benzodiazepine has helped. Right. So maybe a longer-acting one that they're taking once or twice a day. You know, they they do have a time and a place. You just want to be careful about how you're prescribing them. So in that individual, I can think of multiple people I've treated over time where we've tried everything and they're even either haven't tolerated it or they haven't gotten the benefit. So I think those would be the two cases up front. And then there's obviously cases where people have comorbid illnesses or things that are more severe and and you're using some of it as well.
Dr. Bruce Fage: [00:21:41] So it sounds like benzodiazepines can be used with great caution for short periods of time with careful management. Dr. Peck, when you're starting somebody on a medication, what kind of things do you tell them about how likely it is to work or how likely they are to to experience a reduction in their symptoms?
Dr. Jared Peck: [00:22:02] So, you know, the majority of people get benefit. I think it's about two thirds of people that will have benefits from a first try and then drops to around 40% for, you know, moving to a second drug. So I tell them that, you know, we're we're not going to make everything go away, but there's a good chance here. I also talk with them about anxiety in general. I think a really important key is that as part of prescribing medications and as health care professionals, it's not just seeing someone for, you know, five minutes and giving them a prescription. It's important that you look at those lifestyle modifications and talk about that stuff with them. And we're going to talk about CBT in a few minutes, but use some of those principles of CBT embedded in while you're on medication as well. So I usually talk about those things with people. The other challenge, obviously you tell people about side effects and we have to do, you know, provide informed consent. But people with generalised anxiety disorders worry a lot and they scan their environment looking for signs of danger. And you know, the environment that they're always in literally is their body. And so when people with generalised anxiety disorder are prescribed a medication, not all, but many people tend to scan their body. And, you know, if any of us scans our body, whether we're taking medication or not, we're going to notice things. And so people with generalised anxiety disorder are often somewhat more I don't know if the word sensitive or if there's just greater awareness of potential side effects or attribute physical sensations to the medication they're on. So sometimes it can be a challenge around starting a medication with with, you know, people with GAD. I think you can work through that by going with low doses, but still making sure that you're increasing them over time and sometimes meeting a little bit more often to provide the reassurance around it.
Dr. Jordan Bawks: [00:24:13] Yeah, and that's a common thing that I emphasise when I'm starting medications in people who have anxiety and they have a history of saying like, Oh, you know, I have a lot of side effects to this or that medication and it's spending the time to go through the side effects and say like, you know, this is what you can expect. And so like this is if this is how you're feeling like that, that's okay. And like, we're going to work through this together, we're going to go slow and it's going to get better. And that, I think, is like something I really try and emphasise is that like often with SSRIs, I tell them just so they have that expectation that it might get worse before it gets better, you know, because I worry that someone's on a medication for four days. And you know what? This isn't working. It's actually making me worse. This medication doesn't work for me, but we know that they need to be on the medication for 4 to 6 weeks. So it's important to set that expectation kind of ahead of time that this is sort of what it's going to be like. Dr. Peck, let's not forget about tricyclic antidepressants. They're in a lot of the guidelines in the Katzman 2014 guidelines, Imipramine, second line. I know we don't get a lot of exposure to prescribing them in our current kind of like residency environment. What role do you see TCAS playing in in management of GAD?
Dr. Jared Peck: [00:25:27] So that's a good question. I think for medical students, they should know what TCAS are. They're not going to be the first drug you use. People probably most commonly see them used at lower doses for pain or for sleep. Sometimes I think that they are underused in treatment of depression and in treatment of anxiety. They've been around for a long time. We have to be careful watching when people are at risk of overdose or if people have cardiac conditions, but that particularly Desipramine and Nortriptyline, which are better tolerated. I've used them in people and I think once you've gone through the first line treatments, if they haven't been effective, you definitely want to try those. There's the tolerability issue, but you can work around that. So I think we don't want to forget about them. They're one of the tools we have. It's not going to be the first tool that you use, but definitely something to remember about and consider.
Dr. Jordan Bawks: [00:26:33] Okay, great. So before we move on to talk about the psychotherapies, let's just do a quick recap of what we covered in psychopharmacology for the management of Generalised Anxiety Disorder. SSRIs and SNRIs are the standard first-line therapy. They work fairly well, they're fairly well tolerated. It's a medication that you hear us talk about lots on the show over time. We've talked about Pregabalin, which is an emerging treatment for generalised. An anxiety disorder that has a different mechanism of action may work a bit quicker, but doesn't have the same evidence for depression if that comorbidity exists and also is a little bit more expensive. We talked about Qeutiapine, which is also a very commonly used agent sort of across the board for different disorders. That versatility is a strength, but it comes with metabolic side effects and also sedation. And that's why it remains sort of second line. We talked about the role of Benzodiazepines, a somewhat controversial medication that's used very commonly and sort of, you know, to be used cautiously. But they do have a place in the management of generalised anxiety disorder in terms of bringing people onto another first line therapy or in helping to manage people who have very sort of severe disorder, who haven't had a good response to other things. And of course TCAs, which people should still know about and should be used when other options have been tried. Moving on to psychotherapies, Dr. Peck, can you outline some of the psychotherapy options that have evidence in the treatment of generalised anxiety disorder?
Dr. Jared Peck: [00:28:13] So the psychotherapy with the most evidence is cognitive behavioural therapy or CBT. There's different protocols or different forms of CBT and there's things that fall under the umbrella of CBT, but that's where there's the greatest evidence for treatment of generalised anxiety disorder. Now, CBT or cognitive behavioural therapy is based on the cognitive model, which is just a way for us to look at the world so we can break down any situation into a few different elements, what the person is experiencing with respect to their mood state or their emotional feelings, what they're physically feeling in any situation, the thoughts or cognitions going through their mind and their behavioural response. When we're looking at all emotional disorders, it's hard for us to just change the mood, right? If we could do that, then that would be great. And I think our medication somewhat target that. And so in cognitive therapy, we or cognitive behavioural therapy, we recognise that those four different elements all interact with each other. So the way you're feeling emotionally impacts the thoughts that you have, the thoughts that you have, impact what you're feeling emotionally, both your emotions and your thoughts impact what you experience physically and what you experience physically feeds back and also impacts those two and the way you behaviourally respond. So the things you do can trigger emotional states or thoughts and also in either directions. And the thoughts can or the emotional state or physical sensation can trigger your behaviours. So there's these sort of bidirectional arrows between those four areas. And so since we can't directly target.
Dr. Jared Peck: [00:30:14] People's moods or emotional state in cognitive behavioural therapy. What we can do is first get people to be aware of what they're feeling physically, what emotional state they're in, what thoughts they're having linked to that, and what their response is in terms of their actions. And in generalised anxiety disorder, we see some common thinking patterns in situations. People are often what we call catastrophizing. So sort of jumping ahead to some negative conclusions. And in general, people with GAD tend to overestimate the likelihood of there being a bad event or a bad outcome and underestimate their ability to cope. So if you take that belief about the world and there's sort of that filter over the way that you look at things, you can imagine that you start to see danger in places and you think you're not going to be able to handle that which leads into changes in your behaviour. So in CBT we try to get people to recognise these thoughts and then evaluate them. We don't try to convince people of anything but get them to to look from a sort of neutral perspective, look at the evidence around what they're predicting will happen or what they're thinking and see if we can, you know, remove some of that filter and gain some cognitive or thinking skills. But a really other important, important piece is then the be part of cognitive behavioural therapy, which is when we get people to try out little experiments of behaving in different ways and seeing if what they predict or they think will happen actually happens.
Dr. Jared Peck: [00:32:09] And we know that, you know, basic learning theory teaches us about how people learn and that's through experiences and testing out your thoughts. So CBT can be help very helpful in that way. Specifically, when we look at the idea of behaviours people often have in anxiety disorders, what we would call avoidance behaviours, right? They often will stay away from doing things or sometimes it's an avoidance behaviour will be a mental avoidance. So not think about something or overthink about something, but they're often avoidance behaviours and some of their behaviours are also what we refer to as safety behaviours. So a safety behaviour would be a behaviour that makes you feel more calm and then you attribute success in a situation and success is often, you know, completing something or not feeling as anxious. You will then attribute it to that safety behaviour as opposed to yourself and it'll reinforce for the person that they have to do that safety behaviour. So that safety behaviour could be having a drink before they go to a certain place, or it could be double checking something multiple times, it could be having a person attend something with them. It could be, you know, taking one of those benzodiazepines that we talked about earlier before doing something. And so in cognitive behavioural therapy, we try to look at what the safety behaviours are and then test out acting in ways where we're slowly removing some of those safety behaviours so that people can learn that they do have the ability to cope with these situations.
Speaker4: [00:34:00] Thanks, Dr. Peck, for that.
Dr. Jordan Bawks: [00:34:03] Comprehensive introduction to the theory and sort of realities of cognitive behavioural therapy. It sounds to me like the main thrust of the CBT approach to GAD is to help anxious people re-evaluate the probability that a feared outcome will take place and also re-evaluate, like the consequences should it occur. So like helping them see that they can cope if the bad thing that they're worried about does in fact happen.
Dr. Jared Peck: [00:34:35] Yeah. Yeah, that's that's at the core of it.
Dr. Jordan Bawks: [00:34:39] All right. Easy peasy. So now everyone who's listening can go conduct CBT. So now I know that in the Katzman 2014 article, there are some other therapies that are mentioned as emerging kind of therapies for the treatment of generalised anxiety disorder. Can you just say a couple of words about those other therapies where they're at and kind of the evidence chain?
Speaker5: [00:35:06] And so yeah, so there's, there's evidence for mindfulness based interventions.
Dr. Jared Peck: [00:35:12] I view mindfulness as what would be called the third wave of CBT. So it takes CBT principles and is under the umbrella of cognitive behavioural therapy and a specific type but incorporates meditation acceptance Commitment Therapy Act is also sort of under that third-wave umbrella. And so those are a couple of the, the treatments that. That are more more advanced. And then there's specific protocols for GAD, something called the Laval model that comes out of Quebec. And in the UK, Anthony Wells has developed something called metacognitive therapy, which are forms of CBT.
Dr. Jordan Bawks: [00:35:59] Is it Anthony Wells or Adrian Wells?
Dr. Bruce Fage: [00:36:05] Adrian, if you're listening, we're sorry.
Dr. Jordan Bawks: [00:36:07] Come help us on the podcast.
Dr. Bruce Fage: [00:36:09] Come explain your model. You'd be happy to have you.
Dr. Jordan Bawks: [00:36:13] So there's these third wave, So there's like MBCT. So Mindfulness based cognitive therapy, acceptance and commitment therapy, and then some of the kind of like second generation, we're talking about third wave, second generation, very technical, but basically like just like progressions of CBT applied to generalised anxiety, which is sort of looking at the Metacognitive theory of worry and the Laval model. Is that correct? Okay. So I have from working with Dr. Peck, who is my CBT supervisor. I know that he knows a lot more about CBT for generalised anxiety disorder, but I think it's probably this is a good place to sort of cap the episode off for our basic medical audience and maybe we'll be able to bring Dr. Peck back and we can talk more about sort of advanced CBT techniques which will be targeted at residents and practitioners of CBT in a later episode. Bruce, why don't you give us a summary of everything we talked about today?
Dr. Bruce Fage: [00:37:20] Sure. So I think it was really great to have you, Dr. Peck, and outlining a number of different treatments for generalised anxiety disorder. And I think we highlighted that there's more than simply medication that can be used to help people who are suffering from these these symptoms in particular. There's lots of different lifestyle modifications that people can try, such as exercise, reducing your caffeine intake as well as different psychotherapeutic techniques like CBT and some of the newer models that are that are emerging for the treatment of GAD.
Dr. Jared Peck: [00:37:51] The one thing I'd add actually is that CBT everywhere can be hard for people to access, and not everyone needs to have CBT in individually or in a group. There's several really good books out there and if someone's motivated, they can learn a lot of these skills and the workbooks go through modules that are on a weekly basis and incorporate a lot of the tools. And so and people can get just as much benefit from that as they would from an individual course of therapy, because it's really about learning new ways to look at situations and to test out acting differently.
Dr. Bruce Fage: [00:38:36] And I think that's an excellent point, particularly when we when we know that sometimes it can be really challenging to access mental health treatment.
Dr. Jordan Bawks: [00:38:43] And I think from the Katzman article, they actually showed some evidence that Internet based CBT was non-inferior to in-person CBT. So I think that's an early field of research, but also another way potentially to increase access. Thanks everybody for tuning in to our episode. As always, we encourage, request, beg for your feedback. We are actively trying to make this the best possible educational experience for our listeners, so let us know what you like, what you don't like, episode length type of guests type of material covered. If you want Jordan to stop hosting the episodes, please let us know. We'll kick him off the team. And yeah, you can find us at our website psyched podcast.org or on Facebook. If you type in psyched podcast, we have our own page now. I think we're also on Twitter and you can find out how to reach us there.
Dr. Jordan Bawks: [00:39:50] So thank you to the University of Toronto Psychiatry Department for providing funding that makes this show possible. A big thank you as well to all of the background staff at the PsychEd podcast, including all our residents and medical students and staff supervisors who make the show possible.
Dr. Bruce Fage: [00:40:11] And special thanks to the Canadian Psychiatric Association, who is working to help us spread our message and increase the availability of free, open access, medical education.
Dr. Jordan Bawks: [00:40:21] Thanks again. See you guys next time.