Generalized Anxiety Disorder

Generalized Anxiety Disorder (GAD) is a chronic state of severe worry and tension, often without provocation. Those with GAD regularly anticipate disaster, often worrying excessively about health, money, family, or work. Merely getting through the day brings on anxiety.

People with GAD can't shake their concerns, even though they usually realize that much of their anxiety is unwarranted. People with GAD may be unable to relax and often have trouble falling or staying asleep. Their worries are accompanied by physical symptoms such as trembling, twitching, muscle tension, headaches, irritability, sweating, hot flashes, and feeling lightheaded or out of breath.

Many individuals with GAD startle easily. They tend to feel tired, have trouble concentrating, and may suffer from depression. GAD may involve nausea, frequent trips to the bathroom, or feeling like there is a lump in the throat.

When their anxiety level is mild, people with GAD can function socially and hold down a job, but may have difficulty carrying out the simplest of daily activities if their anxiety is severe.

GAD affects about 6.8 million American adults; women are twice as likely as men to be afflicted. The disorder can begin at any point in the life cycle but usually develops between childhood and middle age. The prevalence of the diagnosis peaks in middle age and decreases across the later years of life. 

Other anxiety disorders, depression, or substance use disorder often accompany GAD. GAD is commonly treated with medication or cognitive-behavioral therapy, but co-occurring conditions must also be treated using the appropriate therapies.

Symptoms

GAD is characterized by the DSM-5 as six months or more of chronic, exaggerated worry and tension that is unfounded or much more severe than the normal anxiety most people experience. People with this disorder usually experience symptoms including:

  • Inability to control excessive worrying
  • Difficulty falling or staying asleep
  • Irritability
  • Easily startled or scared
  • Difficulty concentrating or the mind goes blank

Common physical symptoms include:

  • Headaches and fatigue
  • Muscle tension and aches
  • Having a hard time swallowing
  • Trembling or twitching
  • Sweating 
  • Shaking
  • Rapid Heartbeat
  • Nausea
  • Light-headedness and tingling in the extremities.
  • Feeling out of breath
  • Having to go to the bathroom frequently
  • Hot flashes

In children and adolescents with generalized anxiety disorder, anxieties and worries are often associated with performance or competence at school or in sporting events. Additionally, worries may include punctuality, conformity, and perfectionism.

Causes

Anxiety disorders are complex and result from a combination of genetic, behavioral, developmental, and other factors. Risk factors for GAD include a family history of anxiety and recent or extended periods of stress

The brain circuitry involved in fear and anxiety is known to contribute to the experience of GAD, though the mechanism by which GAD is activated is unknown. Studies of twins and families suggest that genes play a role in the origin of anxiety disorders. Childhood adversity and parental overprotection have both been associated with the later development of GAD. It is important to rule out medical causes of anxiety, such as thyroid disorders, before a diagnosis is made.  

Treatment

Medication and Cognitive Behavioral Therapy (CBT) are the most commonly recommended treatments for this disorder.

Antidepressants

A number of medications that were originally approved for treating depression are effective for anxiety disorders. These must be taken for several weeks before symptoms start to fade, so it is important not to get discouraged and stop taking these medications. They need a chance to work.

Antidepressants known as SSRIs (selective serotonin reuptake inhibitors) act on a chemical messenger in the brain called serotonin and are often prescribed for GAD. Venlafaxine, an SNRI (serotonin norepinephrine reuptake inhibitor), is also prescribed as a first drug of choice.

An older class of antidepressants called tricyclics are also useful in treating the disorder, but many physicians and patients prefer the newer drugs because tricyclics may cause dizziness, drowsiness, dry mouth, and weight gain. Imipramine, prescribed for panic disorder and GAD, is one such medication. 

Anti-Anxiety Medications

High-potency benzodiazepines relieve symptoms quickly and have few side effects, although drowsiness can be a problem. Because people can develop a tolerance to them—and would have to continue increasing the dosage to get the same effect—benzodiazepines are generally prescribed for short periods of time. People who have had problems with drug or alcohol use are not usually good candidates for these medications because they may become dependent.

Some people experience withdrawal symptoms when they stop taking benzodiazepines abruptly instead of tapering off, and anxiety can return once the medication is stopped. Potential problems with benzodiazepines have led some physicians to shy away from using them, or to use them in inadequate doses, even when they are of potential benefit to the patient. Alprazolam is a benzodiazepine that is helpful for panic disorder and GAD. Clonazepam (Klonopin) is used for social phobia and GAD.

Buspirone, a member of a class of drugs called azipirones, is an anti-anxiety medication used to treat GAD. Possible side effects include dizziness, headaches, and nausea. Unlike the benzodiazepines, buspirone must be taken consistently for at least two weeks to achieve an anti-anxiety effect.

Other Medications

Beta-blockers, such as propanolol, are often used to treat heart conditions but are also helpful in certain anxiety disorders, particularly social phobia. When a feared situation can be predicted in advance, such as giving a scheduled oral presentation, your doctor may prescribe a beta-blocker to stop your heart from pounding, your hands from shaking, and to keep other physical symptoms under control.

Psychotherapy

Psychotherapy involves talking with a trained mental health professional, such as a psychiatrist, psychologist, social worker, or counselor to learn how to deal with problems like anxiety disorders.

Cognitive-Behavioral Therapy

CBT is very useful in treating anxiety disorders. The cognitive dimension helps people change the thinking patterns that support their fears, and the behavioral dimension helps people change the way they react to anxiety-provoking situations.

CBT may be conducted in a group, provided the people in the group have sufficiently similar problems. Group therapy is particularly effective for people with social phobia. Often "homework" is assigned for participants to complete between sessions. 

For many people, the best approach to treatment is medication combined with therapy.  

References

  • Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
  • National Institute of Mental Health    
  • National Institute of Mental Health (Genetics Workgroup) - Genetics and Mental Disorders 

Last reviewed 02/14/2019