MSD Manual

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Generalized Anxiety Disorder

By

John W. Barnhill

, MD, Weill Cornell Medical College and New York Presbyterian Hospital

Last full review/revision Apr 2020| Content last modified Apr 2020
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Topic Resources

Generalized anxiety disorder is characterized by excessive anxiety and worry about a number of activities or events that is present more days than not for 6 months. The cause is unknown, although it commonly coexists in people who have alcohol use disorder, major depression, or panic disorder. Diagnosis is based on history and physical examination. Treatment is psychotherapy, drug therapy, or both.

Generalized anxiety disorder is common, affecting about 3% of the population within a 1-year period. Women are twice as likely to be affected as men. The disorder often begins in childhood or adolescence but may begin at any age.

Symptoms and Signs

The focus of the worry is not restricted as it is in other psychiatric disorders (eg, to having a panic attack, being embarrassed in public, or being contaminated); the patient has multiple worries, which often shift over time. Common worries include work and family responsibilities, money, health, safety, car repairs, and chores.

The course is usually fluctuating and chronic, with worsening during stress. Most patients with generalized anxiety disorder have one or more other comorbid psychiatric disorders, including major depression, specific phobia, social phobia, and panic disorder.

Diagnosis

  • Clinical criteria

Diagnosis is clinical based on criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

Patients have

  • Excessive anxiety and worries about a number of activities or events

Patients have difficulty controlling the worries, which occur more days than not for ≥ 6 months. The worries must also be associated with ≥ 3 of the following:

  • Restlessness or a keyed-up or on-edge feeling

  • Easily fatigability

  • Difficulty concentrating

  • Irritability

  • Muscle tension

  • Disturbed sleep

Also, the anxiety and worry cannot be accounted for by substance use or another medical disorder (eg, hyperthyroidism).

Treatment

  • Antidepressants and often benzodiazepines

Certain antidepressants, including selective serotonin reuptake inhibitors (SSRIs; eg, escitalopram, starting dose of 10 mg orally once a day) and serotonin- norepinephrine reuptake inhibitors serotonin-norepinephrine reuptake inhibitor (SNRIs; eg, venlafaxine extended-release, starting dose 37.5 mg orally once a day) are effective but typically only after being taken for at least a few weeks. Benzodiazepines (anxiolytics) in small to moderate doses may also be effective, although sustained use may lead to physical dependence. One strategy involves starting with concomitant use of a benzodiazepine and an antidepressant. Once the antidepressant becomes effective, the benzodiazepine is tapered.

Buspirone is also effective; the starting dose is 5 mg orally two or three times a day. However, buspirone may require moderately high doses (ie, > 30 mg/day) and at least 2 weeks before it begins to help.

Psychotherapy, usually cognitive-behavioral therapy, can be both supportive and problem-focused. Relaxation and biofeedback may be of some help, although few studies have documented their efficacy.

Table
icon

Benzodiazepines

Drug

Starting Oral Dose

Maintenance Oral Dose*

Onset/ Duration

Alprazolam

0.25 mg twice a day

Extended-release: 0.5 mg once a day

1 mg three times a day

Extended-release: 3 mg once a day

Intermediate/intermediate

Chlordiazepoxide

5 mg three times a day

25 mg three times a day

Intermediate/long

Clonazepam

0.25 mg once a day

1 mg three times a day

Intermediate/long

Clorazepate

7.5 mg twice a day

7.5 mg three times a day or 15 mg twice a day

Single-dose (sustained release): 22.5 mg once a day after stabilized on 7.5 mg three times a day

Rapid/long

Diazepam

2 mg three times a day

5 mg three times a day

Rapid/long

Lorazepam

0.5 mg three times a day

1 mg three times a day

Intermediate/short

Oxazepam

10 mg three times a day

15 mg four times a day

Slow/short

* Maintenance dose can vary and depends on individual response.

† An oral disintegrating tablet or wafer is available. Onset does not differ from that of other formulations. Although these tablets disintegrate in the mouth, they are absorbed in the stomach and intestine, as are standard tablets.

‡ Generally, these drugs are not recommended for older patients because of a long half-life.

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