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, although it commonly coexists in people who have alcohol use disorder, major depression, or panic disorder. Diagnosis is based on clinical criteria. Treatment includes behavioral interventions, psychotherapy, pharmacotherapy, or a combination.
(See also Overview of Anxiety Disorders.)
Generalized anxiety disorder (GAD) is common, affecting about 3% of the population within a 1-year period (1). Prevalence is twice as high in women as in men (2). 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, specific phobia, social anxiety disorder, or panic disorder.
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).
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).
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)
Psychotherapy
Selective serotonin reuptake inhibitors1). 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, 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 Benzodiazepines). Then, when the GAD symptoms have become manageable, the benzodiazepine can be tapered and continued at a lower dose, or discontinued.
2), 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). Relaxation techniques, hypnosis, exercise, improved sleep, and mindfulness-based stress reduction are also often helpful.
Benzodiazepines
Medication | Onset/Duration |
|---|---|
Intermediate/intermediate | |
Intermediate/long | |
Intermediate/long | |
Rapid/long | |
Rapid/long | |
Intermediate/short | |
Slow/short | |
Generally, these medications are not recommended for older patients because of a long half-life. | |
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
