Generalized anxiety disorder (GAD) is an anxiety disorder characterized by excessive, uncontrollable and often irrational worry, that is, apprehensive expectation about events or activities. This excessive worry often interferes with daily functioning, as individuals with GAD typically anticipate disaster, and are overly concerned about everyday matters such as health issues, money, death, family problems, friendship problems, interpersonal relationship problems, or work difficulties. Individuals may exhibit a variety of physical symptoms, including feeling tired, fidgeting, headaches, numbness in hands and feet, muscle tension, difficulty swallowing, upset stomach, vomiting, diarrhea, breathing difficulty, difficulty concentrating, trembling, irritability, sweating, restlessness, sleeping difficulties, hot flashes, rashes, and inability to fully control the anxiety. These symptoms must be consistent and ongoing, persisting at least six months, for a formal diagnosis of GAD.
Causes of Generalized Anxiety Disorder
GAD affects the way a person thinks, but the anxiety can lead to physical symptoms, as well. Symptoms of GAD can include:
- Excessive, ongoing worry and tension
- An unrealistic view of problems
- Restlessness or a feeling of being “edgy”
- Muscle tension
- difficulty concentrating
- difficulty sleeping
- fatigue and exhaustion
- muscle tension
- repeated stomachaches or diarrhea
- sweaty palms
- rapid heartbeat
- neurological symptoms, such as numbness or tingling in different parts of the body
- Difficulty concentrating
- The need to go to the bathroom frequently
- Trouble falling or staying asleep
- Being easily startled
Symptoms of Generalized Anxiety Disorder
Generalized anxiety disorder (GAD) is characterized by 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:
- Can’t control their excessive worrying
- Have difficulty falling or staying asleep
- Experience muscle tension
- Expect the worst
- Worry excessively about money, health, family or work, even when there are no signs of trouble
- Are unable to relax
- Are irritable
- Are easily startled
- Are easily fatigued
- Have difficulty concentrating or the mind goes blank
Common body symptoms are
Diagnosis of Generalized Anxiety Disorder
The diagnostic criteria for GAD as defined by the Diagnostic and Statistical Manual of Mental Disorders DSM-5 (2013),published by the American Psychiatric Association, are paraphrased as follows
- Too much anxiety or worry over more than six months. This is present most of the time in regards to many activities.
- Inability to manage these symptoms
At least three of the following occur:
Note: Only one item is required in children.
- Tires easily
- Problems concentrating
- Muscle tension.
- Problems with sleep
- Symptoms result in problems with functioning.
- Symptoms are not due to medications, drugs, other physical health problems
- Symptoms do not fit better with another psychiatric problem such as panic disorder
No major changes to GAD have occurred since publication of the Diagnostic and Statistical Manual of Mental Disorders (2004); minor changes include the wording of diagnostic criteria.
ICD-10 Generalized anxiety disorder “F41.1” Note: For children different criteria may be applied
- A period of at least six months with prominent tension, worry, and feelings of apprehension, about everyday events and problems.
- At least four symptoms out of the following list of items must be present, of which at least one from items (1) to (4).
- Autonomic arousal symptoms
- (1) Palpitations or pounding heart, or accelerated heart rate.
- (2) Sweating.
- (3) Trembling or shaking.
- (4) Dry mouth (not due to medication or dehydration).
- Symptoms concerning chest and abdomen
- (5) Difficulty breathing.
- (6) Feeling of choking.
- (7) Chest pain or discomfort.
- (8) Nausea or abdominal distress (e.g. churning in the stomach).
- Symptoms concerning brain and mind
- (9) Feeling dizzy, unsteady, faint or light-headed.
- (10) Feelings that objects are unreal (derealization), or that one’s self is distant or “not really here” (depersonalization).
- (11) Fear of losing control, going crazy, or passing out.
- (12) Fear of dying.
- General symptoms
- (13) Hot flashes or cold chills.
- (14) Numbness or tingling sensations.
- Symptoms of tension
- (15) Muscle tension or aches and pains.
- (16) Restlessness and inability to relax.
- (17) Feeling keyed up, or on edge, or of mental tension.
- (18) A sensation of a lump in the throat or difficulty with swallowing.
- Other non-specific symptoms
- (19) Exaggerated response to minor surprises or being startled.
- (20) Difficulty in concentrating or mind going blank, because of worrying or anxiety.
- (21) Persistent irritability.
- (22) Difficulty getting to sleep because of worrying.
- The disorder does not meet the criteria for panic disorder (F41.0), phobic anxiety disorders (F40.-), obsessive-compulsive disorder (F42.-) or hypochondriacal disorder (F45.2).
- Most commonly used exclusion criteria: not sustained by a physical disorder, such as hyperthyroidism, an organic mental disorder (F0) or psychoactive substance-related disorder (F1), such as excess consumption of amphetamine-like substances, or withdrawal from benzodiazepines
If your primary care provider suspects that a medical condition or substance abuse problem is causing anxiety, they may perform more tests. These may include:
- blood tests, to check hormone levels that may indicate a thyroid disorder
- urine tests, to check for substance abuse
- gastric reflux tests, such as an X-ray of your digestive system or an endoscopy procedure to look at your esophagus, to check for GERD
- X-rays and stress tests, to check for heart conditions
Treatment of Generalized Anxiety Disorder
Antidepressants including medications in the selective serotonin reuptake inhibitor (SSRI) and serotonin and norepinephrine reuptake inhibitor (SNRI) classes are the first line medication treatments. Examples of antidepressants used to treat generalized anxiety disorder include escitalopram , duloxetine, venlafaxine and paroxetine . Your doctor also may recommend other antidepressants.
An anti-anxiety medication called buspirone may be used on an ongoing basis. As with most antidepressants, it typically takes up to several weeks to become fully effective.
Selective serotonin reuptake inhibitors
Pharmaceutical treatments for GAD include selective serotonin reuptake inhibitors (SSRIs). These are the preferred first line of treatment. SSRIs used for this purpose include escitalopram and paroxetine
Benzodiazepines are most often prescribed to people with generalized anxiety disorder. Research suggests that these medications give some relief, at least in the short term. However, they carry some risks, mainly impairment of both cognitive and motor functioning, and psychological and physical dependence that makes it difficult for patients to stop taking them. It has been noted that people taking benzodiazepines are not as alert on their job or at school. Additionally, these medications may impair driving and they are often associated with falls in the elderly, resulting in hip fractures. These shortcomings make the use of benzodiazepines optimal only for short-term relief of anxiety. CBT and medication are of comparable efficacy in the short-term but CBT has advantages over medication in the longer term.
Pregabalin and gabapentin
Pregabalin (Lyrica) acts on the voltage-dependent calcium channel to decrease the release of neurotransmitters such as glutamate, norepinephrine and substance P. Its therapeutic effect appears after 1 week of use and is similar in effectiveness to lorazepam, alprazolam and venlafaxine but pregabalin has demonstrated superiority by producing more consistent therapeutic effects for psychic and somatic anxiety symptoms. Long-term trials have shown continued effectiveness without the development of tolerance and additionally, unlike benzodiazepines, it does not disrupt sleep architecture and produces less severe cognitive and psychomotor impairment.
Other psychiatric medications
- 5-HT1A receptor partial agonists, such as buspirone and tandospirone.
- Serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine and duloxetine.
- Newer, atypical serotonergic antidepressants, such as vilazodone and agomelatine.
- Tricyclic antidepressants (TCAs), such as imipramine and clomipramine.
- Certain monoamine oxidase inhibitors (MAOIs), such as moclobemide and phenelzine.
- Propranolol – Sympatholytic, beta blocker.
- Clonidine – Sympatholytic, α2-adrenergic receptor agonist.
- Guanfacine – Sympatholytic, α2-adrenergic receptor agonist.
- Prazosin – Sympatholytic, alpha blocker.