Uogólnione zaburzenie lękowe
Rokowania, prognozy i postęp choroby
Rokowanie w zaburzeniach lękowych uogólnionych (GAD) jest zróżnicowane i zależy od nasilenia objawów oraz czynników współistniejących, takich jak depresja, niski status socjoekonomiczny czy ograniczone wsparcie społeczne. Badanie CALM wykazało, że obecność depresji i wyższe nasilenie lęku korelują z gorszą odpowiedzią na leczenie, a długotrwałość objawów wiąże się z mniejszą skutecznością terapii poznawczo-behawioralnej (CBT). Skala GAD-7, z wartością graniczną 7 punktów (czułość 78,4%, swoistość 80,8%), jest użytecznym narzędziem do oceny nasilenia lęku i prognozowania odpowiedzi na terapię. Intensywne interwencje terapeutyczne, łączące farmakoterapię i wspomaganą komputerowo CBT, wykazują wyższą skuteczność niż standardowa opieka, szczególnie u kobiet, pacjentów z nasilonymi objawami depresji oraz osób o niskim statusie socjoekonomicznym.
Generalised anxiety disorder (GAD) – rokowanie i predykcja wyników
Rokowanie w przypadku zaburzeń lękowych uogólnionych (GAD) może być zróżnicowane w zależności od nasilenia objawów oraz współistniejących czynników. W niektórych przypadkach GAD ma charakter przewlekły i trudny do leczenia, jednak u większości pacjentów obserwuje się poprawę objawów przy zastosowaniu farmakoterapii i/lub psychoterapii1. Większość pacjentów z zaburzeniami lękowymi otrzymuje leczenie w ramach podstawowej opieki zdrowotnej, dlatego istotne jest zidentyfikowanie czynników predykcyjnych wpływających na skuteczność terapii.
Czynniki prognostyczne w GAD
Na podstawie badań klinicznych, w tym badania CALM (Coordinated Anxiety Learning and Management), zidentyfikowano szereg czynników związanych z gorszymi wynikami leczenia zaburzeń lękowych, w tym GAD23:
- Współistniejąca depresja – obecność i nasilenie objawów depresyjnych są silnie związane z gorszymi wynikami leczenia zaburzeń lękowych
- Nasilenie objawów lękowych – ogólne nasilenie objawów lękowych negatywnie koreluje z prawdopodobieństwem remisji i odpowiedzi na leczenie
- Niski status socjoekonomiczny (zarówno postrzegany, jak i faktyczny) – silnie predykcyjny dla słabej odpowiedzi na leczenie i remisji
- Ograniczone wsparcie społeczne – związane z gorszymi wynikami terapeutycznymi
Warto zaznaczyć, że długotrwałe występowanie objawów GAD wiąże się z mniejszą redukcją lęku w terapii poznawczo-behawioralnej (CBT) i standardowym leczeniu w porównaniu do pacjentów z krótszym przebiegiem choroby6. Pacjenci z długotrwałymi objawami mogą odnieść większe korzyści z wielokrotnego praktykowania mniejszej liczby umiejętności niż uczenia się wielu technik terapeutycznych jednocześnie.
Grupy pacjentów odnoszące szczególne korzyści z interwencji terapeutycznych
Badania wskazują, że niektóre grupy pacjentów mogą odnieść szczególne korzyści z interwencji terapeutycznych w porównaniu do standardowej opieki. Do tych grup należą7:
- Kobiety – wykazujące lepszą odpowiedź na intensywne interwencje terapeutyczne
- Pacjenci z nasilonymi objawami depresji i GAD – paradoksalnie odnoszący większe korzyści z intensywnych programów terapeutycznych
- Osoby o niskim statusie socjoekonomicznym – pomimo ogólnie gorszych wyników leczenia, wykazują lepszą odpowiedź na intensywne programy interwencyjne niż na standardową opiekę
W kontekście współwystępowania depresji z GAD, istnieją dowody sugerujące, że terapia poznawczo-behawioralna (CBT) może być bardziej skuteczna niż trening relaksacyjny (AR) u pacjentów z towarzyszącą depresją9. Wyższy poziom depresji prognozuje lepszą odpowiedź na CBT niż na sam trening relaksacyjny, co sugeruje, że CBT jest pomocna dla osób ze współistniejącą depresją.
Narzędzia oceny prognostycznej w GAD
Skala Uogólnionego Zaburzenia Lękowego (GAD-7) jest efektywnym, łatwym w użyciu i ważnym narzędziem do pomiaru nasilenia lęku, które pomaga w późniejszej diagnozie klinicznej10. Badania wykazały, że GAD-7 charakteryzuje się wysoką spójnością wewnętrzną i dobrym dopasowaniem do struktury jednoczynnikowej. W kontekście rokowania, wyniki GAD-7 mogą być pomocne w identyfikacji grup prognostycznych z różnym prawdopodobieństwem odpowiedzi na leczenie.
Analiza krzywej ROC (Receiver Operating Characteristic) w badaniach nad GAD wykazała możliwość identyfikacji podgrup prognostycznych z dużymi różnicami w prawdopodobieństwie odpowiedzi na leczenie11. Wartość graniczna 7 punktów w skali GAD-7 dla wywiadu diagnostycznego CIDI (Composite International Diagnostic Interview) dała najwyższy indeks Youdena, z czułością i swoistością wynoszącą odpowiednio 78,4% i 80,8%12.
Skuteczność różnych modeli leczenia
Model interwencji terapeutycznych zastosowany w badaniu CALM, obejmujący farmakoterapię, wspomaganą komputerowo CBT lub obie metody jednocześnie, okazał się wysoce skuteczny w porównaniu do standardowej opieki13. Randomizacja do intensywnej interwencji terapeutycznej w porównaniu do standardowej opieki była często najsilniejszym predyktorem pozytywnego wyniku leczenia.
Dalsze badania powinny koncentrować się na skuteczności wdrażania interwencji terapeutycznych w społecznych ośrodkach leczenia, gdzie pacjenci zazwyczaj mają niski status socjoekonomiczny i mogą szczególnie skorzystać z intensywnych programów terapeutycznych14.
Prognoza długoterminowa
Długoterminowe rokowanie w GAD może być złożone. Badania wskazują, że współistniejące duże zaburzenie depresyjne prognozuje mniejsze prawdopodobieństwo naturalnej remisji GAD w ciągu ośmiu lat obserwacji15. Wskazuje to na znaczenie wczesnej i skutecznej interwencji u pacjentów z GAD i współistniejącą depresją.
Wyniki badań sugerują, że dla wielu pacjentów, szczególnie tych bez poważnych czynników obciążających, rokowanie w GAD może być dobre przy odpowiednim leczeniu. Jednakże dla pacjentów z współistniejącymi zaburzeniami, ciężkim przebiegiem choroby, niskim statusem socjoekonomicznym lub ograniczonym wsparciem społecznym, GAD może mieć charakter bardziej przewlekły i trudniejszy do leczenia1617.
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Materiały źródłowe
- #1 Generalized Anxiety Disorder (GAD): Symptoms & Treatmenthttps://my.clevelandclinic.org/health/diseases/23940-generalized-anxiety-disorder-gad
The prognosis (outlook) for generalized anxiety disorder can vary depending on how severe it is. In some cases, GAD is long-term (chronic) and difficult to treat. However, most people experience improvement in their symptoms with medicine and/or talk therapy.
- #2https://pmc.ncbi.nlm.nih.gov/articles/PMC4930076/
Most patients with anxiety disorders receive treatment in primary care settings. Limited moderator data is available to inform clinicians on likely prognostic outcomes for individual patients. We identify baseline characteristics associated with outcome in adults seeking treatment for anxiety disorders. […] Randomization to ITV over UC was often the strongest predictor of outcome. Several baseline patient characteristics were associated with poor treatment outcome including comorbid depression, increased severity of underlying anxiety disorder(s) (p.001), low socioeconomic status [perceived (p.001) and actual (p.05)] and limited social support (p.001). Patient characteristics associated with particular benefit from ITV were being female (p.05), increased depression(p.01)/GAD severity (p.05), and low socioeconomic status (p.05). ROC analysis demonstrated prognostic subgroups with large differences in response likelihood.
- #3https://pmc.ncbi.nlm.nih.gov/articles/PMC4930076/
This secondary analysis of the CALM trial demonstrated: (1) particular characteristics of patients with anxiety disorders associated with poor treatment outcome comorbid depression, increased severity of underlying anxiety disorder(s), low socioeconomic status (perceived and actual) and limited social support; (2) particular patient characteristics associated with particular benefit from the ITV intervention female, increased depression and GAD severity and low socioeconomic status; and (3) prognostic subgroup identifying likelihood of treatment response of individual patients with anxiety disorders.
- #4https://pmc.ncbi.nlm.nih.gov/articles/PMC4930076/
Further research should focus on the effectiveness of implementing the ITV intervention of CALM in community treatment centers where patients typically are of low socioeconomic status and may particularly benefit from ITV. […] Moderator analyses of the CALM trial yielded several types of patient characteristics strongly and consistently associated with treatment outcome. Presence and severity of comorbid depressive symptoms were strongly associated with poorer outcomes to the anxiety disorder treatment. Overall severity of anxiety disorder symptoms was negatively associated with likelihood of both remission and response. […] The ITV model in the CALM trial involving pharmacotherapy, computer-assisted CBT, or both was demonstrated to be highly effective compared to UC. […] Low socioeconomic status (perceived or actual) was highly predictive of poor treatment response and remission across the entire sample in both our logical regression and ROC analyses.
- #5https://pmc.ncbi.nlm.nih.gov/articles/PMC4930076/
This secondary analysis of the CALM trial demonstrated: (1) particular characteristics of patients with anxiety disorders associated with poor treatment outcome comorbid depression, increased severity of underlying anxiety disorder(s), low socioeconomic status (perceived and actual) and limited social support; (2) particular patient characteristics associated with particular benefit from the ITV intervention female, increased depression and GAD severity and low socioeconomic status; and (3) prognostic subgroup identifying likelihood of treatment response of individual patients with anxiety disorders.
- #6 Time-Varying Moderation of Treatment Outcomes by Illness Duration and Comorbid Depression in Generalized Anxiety Disorderhttps://pmc.ncbi.nlm.nih.gov/articles/PMC6632089/
Longer GAD duration predicted less anxiety reduction in CBT and ND relative to AR. […] Higher depression predicted better response to CBT than AR and ND. […] GAD clients with longstanding symptoms may benefit more from repeatedly practicing fewer skills than learning multiple skills. […] Clients with comorbid major depressive disorder predicted a lower probability of naturalistic remission from GAD over the course of eight years. […] Comorbid depressive symptoms predicted better or comparable outcomes from either individual or group CBT, suggesting that CBT is helpful for those with comorbid depression. […] There is a reason to believe, however, that CBT would be more effective than AR in GAD patients with comorbid depression. […] The present study aimed to extend the sparse literature on moderation of GAD treatment outcomes using a novel analytic approach that allows for testing time-varying moderation effects. […] The current findings provide at least preliminary implications for treatment selection between AR and CBT for GAD.
- #7https://pmc.ncbi.nlm.nih.gov/articles/PMC4930076/
This secondary analysis of the CALM trial demonstrated: (1) particular characteristics of patients with anxiety disorders associated with poor treatment outcome comorbid depression, increased severity of underlying anxiety disorder(s), low socioeconomic status (perceived and actual) and limited social support; (2) particular patient characteristics associated with particular benefit from the ITV intervention female, increased depression and GAD severity and low socioeconomic status; and (3) prognostic subgroup identifying likelihood of treatment response of individual patients with anxiety disorders.
- #8https://pmc.ncbi.nlm.nih.gov/articles/PMC4930076/
Most patients with anxiety disorders receive treatment in primary care settings. Limited moderator data is available to inform clinicians on likely prognostic outcomes for individual patients. We identify baseline characteristics associated with outcome in adults seeking treatment for anxiety disorders. […] Randomization to ITV over UC was often the strongest predictor of outcome. Several baseline patient characteristics were associated with poor treatment outcome including comorbid depression, increased severity of underlying anxiety disorder(s) (p.001), low socioeconomic status [perceived (p.001) and actual (p.05)] and limited social support (p.001). Patient characteristics associated with particular benefit from ITV were being female (p.05), increased depression(p.01)/GAD severity (p.05), and low socioeconomic status (p.05). ROC analysis demonstrated prognostic subgroups with large differences in response likelihood.
- #9 Time-Varying Moderation of Treatment Outcomes by Illness Duration and Comorbid Depression in Generalized Anxiety Disorderhttps://pmc.ncbi.nlm.nih.gov/articles/PMC6632089/
Longer GAD duration predicted less anxiety reduction in CBT and ND relative to AR. […] Higher depression predicted better response to CBT than AR and ND. […] GAD clients with longstanding symptoms may benefit more from repeatedly practicing fewer skills than learning multiple skills. […] Clients with comorbid major depressive disorder predicted a lower probability of naturalistic remission from GAD over the course of eight years. […] Comorbid depressive symptoms predicted better or comparable outcomes from either individual or group CBT, suggesting that CBT is helpful for those with comorbid depression. […] There is a reason to believe, however, that CBT would be more effective than AR in GAD patients with comorbid depression. […] The present study aimed to extend the sparse literature on moderation of GAD treatment outcomes using a novel analytic approach that allows for testing time-varying moderation effects. […] The current findings provide at least preliminary implications for treatment selection between AR and CBT for GAD.
- #10 Assessing anxiety among adolescents in Hong Kong: psychometric properties and validity of the Generalised Anxiety Disorder-7 (GAD-7) in an epidemiological community sample | BMC Psychiatry | Full Texthttps://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-022-04329-9
The GAD-7 showed high internal consistency and strong fit to the one-factor structure. […] A cut-off score of 7 should indicate a potential diagnosable condition in Asian adolescents, which requires our attention but should not be used as a formal diagnostic screening tool. […] The findings revealed the local dependence of the items of the GAD-7 and that the scale can separate respondents into at least two groups and items into numerous groups according to the separation index. […] The current study examined the validity of the Chinese version of the GAD-7 in detail using a representative epidemiological sample of adolescents aged 15 to 24 years in Hong Kong. The findings indicate that the GAD-7 is a valid and reliable tool for identifying youths with a probable GAD state in Hong Kong. […] A cut-off of 7 for the CIDI diagnostic interview yielded the highest Youden Index, with a sensitivity and specificity of 78.4% and 80.8%, respectively. […] The GAD-7 is an efficient, easy-to-use, and valid measure of anxiety severity that aids in subsequent clinical diagnosis.
- #11https://pmc.ncbi.nlm.nih.gov/articles/PMC4930076/
Most patients with anxiety disorders receive treatment in primary care settings. Limited moderator data is available to inform clinicians on likely prognostic outcomes for individual patients. We identify baseline characteristics associated with outcome in adults seeking treatment for anxiety disorders. […] Randomization to ITV over UC was often the strongest predictor of outcome. Several baseline patient characteristics were associated with poor treatment outcome including comorbid depression, increased severity of underlying anxiety disorder(s) (p.001), low socioeconomic status [perceived (p.001) and actual (p.05)] and limited social support (p.001). Patient characteristics associated with particular benefit from ITV were being female (p.05), increased depression(p.01)/GAD severity (p.05), and low socioeconomic status (p.05). ROC analysis demonstrated prognostic subgroups with large differences in response likelihood.
- #12 Assessing anxiety among adolescents in Hong Kong: psychometric properties and validity of the Generalised Anxiety Disorder-7 (GAD-7) in an epidemiological community sample | BMC Psychiatry | Full Texthttps://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-022-04329-9
The GAD-7 showed high internal consistency and strong fit to the one-factor structure. […] A cut-off score of 7 should indicate a potential diagnosable condition in Asian adolescents, which requires our attention but should not be used as a formal diagnostic screening tool. […] The findings revealed the local dependence of the items of the GAD-7 and that the scale can separate respondents into at least two groups and items into numerous groups according to the separation index. […] The current study examined the validity of the Chinese version of the GAD-7 in detail using a representative epidemiological sample of adolescents aged 15 to 24 years in Hong Kong. The findings indicate that the GAD-7 is a valid and reliable tool for identifying youths with a probable GAD state in Hong Kong. […] A cut-off of 7 for the CIDI diagnostic interview yielded the highest Youden Index, with a sensitivity and specificity of 78.4% and 80.8%, respectively. […] The GAD-7 is an efficient, easy-to-use, and valid measure of anxiety severity that aids in subsequent clinical diagnosis.
- #13https://pmc.ncbi.nlm.nih.gov/articles/PMC4930076/
Further research should focus on the effectiveness of implementing the ITV intervention of CALM in community treatment centers where patients typically are of low socioeconomic status and may particularly benefit from ITV. […] Moderator analyses of the CALM trial yielded several types of patient characteristics strongly and consistently associated with treatment outcome. Presence and severity of comorbid depressive symptoms were strongly associated with poorer outcomes to the anxiety disorder treatment. Overall severity of anxiety disorder symptoms was negatively associated with likelihood of both remission and response. […] The ITV model in the CALM trial involving pharmacotherapy, computer-assisted CBT, or both was demonstrated to be highly effective compared to UC. […] Low socioeconomic status (perceived or actual) was highly predictive of poor treatment response and remission across the entire sample in both our logical regression and ROC analyses.
- #14https://pmc.ncbi.nlm.nih.gov/articles/PMC4930076/
Further research should focus on the effectiveness of implementing the ITV intervention of CALM in community treatment centers where patients typically are of low socioeconomic status and may particularly benefit from ITV. […] Moderator analyses of the CALM trial yielded several types of patient characteristics strongly and consistently associated with treatment outcome. Presence and severity of comorbid depressive symptoms were strongly associated with poorer outcomes to the anxiety disorder treatment. Overall severity of anxiety disorder symptoms was negatively associated with likelihood of both remission and response. […] The ITV model in the CALM trial involving pharmacotherapy, computer-assisted CBT, or both was demonstrated to be highly effective compared to UC. […] Low socioeconomic status (perceived or actual) was highly predictive of poor treatment response and remission across the entire sample in both our logical regression and ROC analyses.
- #15 Time-Varying Moderation of Treatment Outcomes by Illness Duration and Comorbid Depression in Generalized Anxiety Disorderhttps://pmc.ncbi.nlm.nih.gov/articles/PMC6632089/
Longer GAD duration predicted less anxiety reduction in CBT and ND relative to AR. […] Higher depression predicted better response to CBT than AR and ND. […] GAD clients with longstanding symptoms may benefit more from repeatedly practicing fewer skills than learning multiple skills. […] Clients with comorbid major depressive disorder predicted a lower probability of naturalistic remission from GAD over the course of eight years. […] Comorbid depressive symptoms predicted better or comparable outcomes from either individual or group CBT, suggesting that CBT is helpful for those with comorbid depression. […] There is a reason to believe, however, that CBT would be more effective than AR in GAD patients with comorbid depression. […] The present study aimed to extend the sparse literature on moderation of GAD treatment outcomes using a novel analytic approach that allows for testing time-varying moderation effects. […] The current findings provide at least preliminary implications for treatment selection between AR and CBT for GAD.
- #16 Generalized Anxiety Disorder (GAD): Symptoms & Treatmenthttps://my.clevelandclinic.org/health/diseases/23940-generalized-anxiety-disorder-gad
The prognosis (outlook) for generalized anxiety disorder can vary depending on how severe it is. In some cases, GAD is long-term (chronic) and difficult to treat. However, most people experience improvement in their symptoms with medicine and/or talk therapy.
- #17https://pmc.ncbi.nlm.nih.gov/articles/PMC4930076/
This secondary analysis of the CALM trial demonstrated: (1) particular characteristics of patients with anxiety disorders associated with poor treatment outcome comorbid depression, increased severity of underlying anxiety disorder(s), low socioeconomic status (perceived and actual) and limited social support; (2) particular patient characteristics associated with particular benefit from the ITV intervention female, increased depression and GAD severity and low socioeconomic status; and (3) prognostic subgroup identifying likelihood of treatment response of individual patients with anxiety disorders.