Generalized anxiety disorder
Generalized anxiety disorder is excessive, hard-to-control worry about multiple life domains occurring more days than not for at least 6 months, with at least 3 of 6 associated physical symptoms and functional impairment. Screen with the GAD-7 after excluding hyperthyroidism and substance use, then treat first-line with cognitive behavioral therapy and/or an SSRI or SNRI such as escitalopram or venlafaxine extended-release, reserving benzodiazepines for short-term severe symptom control only.
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What this article covers
- Overview
A chronic, diffuse worry disorder: generalized anxiety disorder (GAD) is excessive anxiety and worry about multiple activities or events, such as work, school, health, or family, that a patient finds…
- Epidemiology
Common in the general population: lifetime prevalence is 5% to 10%.
- Risk factors
Female sex. A comorbid mood or other anxiety disorder: major depressive disorder, panic disorder, or social phobia predispose to a GAD diagnosis.
- Pathophysiology
A specific GAD neurobiology is not established: GAD is described clinically, so treatment targets map onto well-characterized neurotransmitter systems instead.
- Clinical features
Excessive, hard-to-control worry across multiple domains: the defining feature is excessive anxiety about several activities or events, such as work, school, family, or finances, occurring more days than not for at least 6 months.
- Differential diagnosis
Panic disorder: attacks peaking within 10 minutes with at least 4 of palpitations, dyspnea, chest pain, choking, dizziness, derealization, and fear of dying or losing control, plus at least 1 month…
- Diagnosis
The diagnosis is clinical: GAD is diagnosed when a patient has excessive, hard-to-control worry about multiple activities or events, occurring more days than not for at least 6 months, with at least…
- Management
First action is cognitive behavioral therapy (CBT) and/or a first-line selective serotonin reuptake inhibitor (SSRI), for example escitalopram 10 mg PO once daily: CBT and pharmacotherapy are equally…
- Complications
Sustained functional impairment: untreated or undertreated GAD causes ongoing distress and impairment in social, academic, or occupational functioning by definition.
- Prognosis
A chronic, fluctuating course: symptoms wax and wane rather than remitting spontaneously, and GAD tends to persist once established, unlike the self-limited 6-month course of adjustment disorder.
- Prevention
Screen with the GAD-7 or the 2-item GAD-2 in patients with significant anxiety or multiple unexplained physical symptoms, rather than waiting for the patient to volunteer that they feel anxious.
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Related articles
- Panic disorder
Panic disorder is an anxiety disorder defined by recurrent, unexpected panic attacks, discrete surges of fear that peak within 10 minutes with 4 or more characteristic symptoms, followed by at least 1 month of persistent worry about further attacks, worry about their consequences, or a maladaptive behavior change. Medical mimics such as acute coronary syndrome, pulmonary embolism, arrhythmia, hyperthyroidism, pheochromocytoma, and hypoglycemia must be excluded first. First-line treatment is a selective serotonin reuptake inhibitor such as sertraline, started low and titrated slowly, combined with cognitive behavioral therapy; benzodiazepines are reserved for short-term acute control.
- Social anxiety disorder
Social anxiety disorder is marked, persistent fear of scrutiny or embarrassment in social or performance situations lasting at least 6 months with significant functional impairment. Generalized social anxiety disorder is treated with cognitive behavioral therapy (CBT) plus an SSRI such as sertraline, while the performance-only subtype is treated with a PRN beta blocker such as propranolol taken before the anticipated situation.
- Obsessive-compulsive disorder
Obsessive-compulsive disorder (OCD) is defined by ego-dystonic obsessions and/or compulsions that are time-consuming or cause significant distress and functional impairment, distinguishing it from the ego-syntonic perfectionism of obsessive-compulsive personality disorder. Diagnosis is clinical. First-line treatment combines cognitive behavioral therapy using exposure and response prevention with a high-dose selective serotonin reuptake inhibitor, with clomipramine as an effective second-line tricyclic and an OCD trial that can take up to 10 weeks to judge full response.
- Post-traumatic stress disorder
Posttraumatic stress disorder follows exposure to actual or threatened death, serious injury, or sexual violence, producing intrusive re-experiencing, avoidance, negative alterations in cognition and mood, and hyperarousal that persist beyond 1 month with significant distress or impairment. First-line treatment is trauma-focused cognitive behavioral therapy combined with an SSRI or SNRI, with prazosin added for persistent nightmares.
- Specific phobias
Specific phobia is a marked, persistent fear or anxiety about a circumscribed object or situation, lasting 6 months or more, that is out of proportion to the actual danger, provokes immediate fear on exposure, and is actively avoided or endured with distress; the diagnosis is clinical. First-line treatment is graded exposure therapy (a form of cognitive behavioral therapy), with a short-acting benzodiazepine reserved for a single known, planned exposure.
- Hyperthyroidism
Hyperthyroidism is the clinical syndrome of thyroid hormone excess, produced by a range of causes from Graves disease and autonomously functioning nodules to destructive thyroiditis and exogenous hormone ingestion. Diagnosis begins with a suppressed thyroid-stimulating hormone and elevated free thyroxine, followed by radioactive iodine uptake testing or antibody measurement to identify the cause, and first-line treatment is a beta blocker for symptom control while the underlying cause directs thionamide, radioactive iodine ablation, or thyroidectomy therapy.
- Major depressive disorder
Major depressive disorder is a mood disorder defined by 5 or more of 9 major depressive episode symptoms, including depressed mood or anhedonia, present nearly every day for at least 2 weeks and causing significant functional impairment. Diagnosis is clinical, screened with the Patient Health Questionnaire. First-line treatment is cognitive behavioral therapy, a selective serotonin reuptake inhibitor (SSRI) such as sertraline, or both, escalating to augmentation, esketamine, or electroconvulsive therapy for refractory or acutely suicidal presentations.