(See also Overview of Anxiety Disorders Overview of Anxiety Disorders Anxiety disorders are characterized by persistent and excessive fear and anxiety and the dysfunctional behavioral changes a patient may use to mitigate these feelings. Anxiety disorders are... read more .)
Generalized anxiety disorder (GAD) is common, affecting about 3% of the population within a 1-year period (1 General references Generalized anxiety disorder is characterized by excessive anxiety and worry about a number of activities or events that are present more days than not for ≥ 6 months. The cause is unknown,... read more ). Prevalence is twice as high in women as in men (2 General references Generalized anxiety disorder is characterized by excessive anxiety and worry about a number of activities or events that are present more days than not for ≥ 6 months. The cause is unknown,... read more ). The disorder more commonly begins in adulthood but may begin at any age. GAD typically has a chronic course and is often associated with significant functional disability and a diminished quality of life.
General references
1. Kessler RC, Chiu WT, Demler O, et al: Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62(6):617-627, 2005. doi: 10.1001/archpsyc.62.6.617
2. Wittchen HU, Zhao S, Kessler RC, et al: DSM-III-R generalized anxiety disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1994 May;51(5):355-64. doi: 10.1001/archpsyc.1994.03950050015002
Symptoms and Signs of Generalized Anxiety Disorder
People with GAD have multiple worries, which often shift over time. Common worries include work and family responsibilities, money, health, safety, car repairs, and chores. In GAD, the focus is not a single worry (eg, being embarrassed in public or becoming contaminated).
The course is usually fluctuating and chronic. Most patients with GAD have one or more comorbid psychiatric disorders, including major depression Major depressive disorder (unipolar depressive disorder) Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more , specific phobia Specific Phobias Specific phobias consist of persistent, unreasonable, intense fears (phobias) of specific situations, circumstances, or objects. The fears provoke anxiety and avoidance. The causes of phobias... read more , social anxiety disorder Social Anxiety Disorder Social anxiety disorder is characterized by fear of and anxiety about being exposed to certain social or performance situations. These situations are avoided or endured with substantial anxiety... read more , or panic disorder Panic Attacks and Panic Disorder A panic attack is the sudden onset of a discrete, brief period of intense discomfort, anxiety, or fear accompanied by somatic and/or cognitive symptoms. Panic disorder is the occurrence of repeated... read more .
Diagnosis of Generalized Anxiety Disorder
Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR) criteria
To meet DSM-5-TR criteria for GAD, patients must have excessive anxiety and worry about a number of activities or events (eg, work and school performance), occurring more days than not for ≥ 6 months (1 Diagnosis reference Generalized anxiety disorder is characterized by excessive anxiety and worry about a number of activities or events that are present more days than not for ≥ 6 months. The cause is unknown,... read more ).
The worries are difficult to control and must be associated with ≥ 3 of the following:
Restlessness or a keyed-up or on-edge feeling
Easy fatigability
Difficulty concentrating
Irritability
Muscle tension
Disturbed sleep
The psychiatric symptoms must cause significant distress or significantly impair social or occupational functioning. Also, the anxiety and worry cannot be accounted for by substance use or a general medical disorder (eg, hyperthyroidism Hyperthyroidism Hyperthyroidism is characterized by hypermetabolism and elevated serum levels of free thyroid hormones. Symptoms include palpitations, fatigue, weight loss, heat intolerance, anxiety, and tremor... read more ).
Diagnosis reference
1. Diagnostic and Statistical Manual of Mental Disorders, 5th edition,Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC, pp 250-254.
Treatment of Generalized Anxiety Disorder
Antidepressant medications (eg, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors)
Anxiolytic medications (eg, benzodiazepines, buspirone)
Psychotherapy
Selective serotonin reuptake inhibitors Selective Serotonin Reuptake Inhibitors (SSRIs) Several drug classes and drugs can be used to treat depression: Selective serotonin reuptake inhibitors (SSRIs) Serotonin modulators (5-HT2 blockers) Serotonin-norepinephrine reuptake inhibitors... read more (eg, escitalopram) and serotonin-norepinephrine reuptake inhibitors Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) Several drug classes and drugs can be used to treat depression: Selective serotonin reuptake inhibitors (SSRIs) Serotonin modulators (5-HT2 blockers) Serotonin-norepinephrine reuptake inhibitors... read more (eg, venlafaxine) are the preferred medications for the treatment of GAD; their use typically results in symptom improvement after 3 to 6 weeks (1 Treatment references Generalized anxiety disorder is characterized by excessive anxiety and worry about a number of activities or events that are present more days than not for ≥ 6 months. The cause is unknown,... read more ). Small to moderate doses of benzodiazepines may immediately reduce anxiety, although sustained use may lead to physical dependence as well as a variety of adverse effects Chronic effects Sedatives include benzodiazepines, barbiturates, and related drugs. High doses can cause decreased level of consciousness and respiratory depression, which may require intubation and mechanical... read more , including sedation, forgetfulness, and clumsiness. One strategy for treating GAD involves starting with both a benzodiazepine and an antidepressant medication, as well as an anxiety-focused psychotherapy (see table ). Then, when the GAD symptoms have become manageable, the benzodiazepine can be tapered and continued at a lower dose, or discontinued.
Buspirone may also be effective (2 Treatment references Generalized anxiety disorder is characterized by excessive anxiety and worry about a number of activities or events that are present more days than not for ≥ 6 months. The cause is unknown,... read more ), though typically symptoms do not diminish until the dose is gradually increased to the upper recommended range.
Psychotherapy, usually cognitive-behavioral therapy, can be both supportive and problem-focused (3 Treatment references Generalized anxiety disorder is characterized by excessive anxiety and worry about a number of activities or events that are present more days than not for ≥ 6 months. The cause is unknown,... read more ). Relaxation techniques, hypnosis, exercise, improved sleep, and mindfulness-based stress reduction are also often helpful.
Treatment references
1. Kapczinski F, Lima MS, Souza JS, et al: Antidepressants for generalized anxiety disorder. Cochrane Database Syst Rev (2):CD003592, 2003. doi: 10.1002/14651858.CD003592
2. Chessick CA, Allen MH, Thase M, et al: Azapirones for generalized anxiety disorder. Cochrane Database Syst Rev 2006(3):CD006115, 2006. doi: 10.1002/14651858.CD006115
3. DeMartini J, Patel G, Fancher TL: Generalized anxiety disorder. Ann Intern Med 170(7):ITC49-ITC64, 2019. doi: 10.7326/AITC201904020