Generalized Anxiety Disorder (GAD)

Overview

It’s normal to feel anxious from time to time, especially if your life is stressful. However, excessive, ongoing anxiety and worry that are difficult to control and interfere with day-to-day activities may be a sign of generalized anxiety disorder.

It’s possible to develop a generalized anxiety disorder as a child or an adult. Generalized anxiety disorder has symptoms that are similar to panic disorder, obsessive-compulsive disorder, and other types of anxiety, but they’re all different conditions.

Living with generalized anxiety disorder can be a long-term challenge. In many cases, it occurs along with other anxiety or mood disorders. In most cases, generalized anxiety disorder improves with psychotherapy or medications. Making lifestyle changes, learning coping skills, and using relaxation techniques also can help.

What Is GAD?

Generalized Anxiety Disorder (GAD) is characterized by persistent and excessive worry about a number of different things. People with GAD may anticipate disaster and may be overly concerned about money, health, family, work, or other issues. Individuals with GAD find it difficult to control their worry. They may worry more than seems warranted about actual events or may expect the worst even when there is no apparent reason for concern.

Occasional anxiety is a normal part of life. You might worry about things like health, money, or family problems. But people with a generalized anxiety disorder (GAD) feel extremely worried or feel nervous about these and other things even when there is little or no reason to worry about them. People with GAD find it difficult to control their anxiety and stay focused on daily tasks.

Most people feel anxious and worried from time to time, especially when faced with stressful situations like taking an exam, speaking in public, playing competitive sport, or going for a job interview. This sort of anxiety can make you feel alert and focused, helping you get things done faster or perform at your best.

People with GAD, however, feel anxious and worried most of the time, not just in specific stressful situations, and these worries are intense, persistent, and interfere with their normal lives. Their worries relate to several aspects of everyday life, including work, health, family, and/or financial issues, rather than just one issue. Even minor things such as household chores or being late for an appointment can become the focus of anxiety, leading to uncontrollable worries and a feeling that something terrible will happen.

GAD is diagnosed when a person finds it difficult to control worry on more days than not for at least six months and has three or more symptoms. This differentiates GAD from worry that may be specific to a set stressor or for a more limited period of time.

GAD affects 6.8 million adults, or 3.1% of the U.S. population, in any given year. Women are twice as likely to be affected. The disorder comes on gradually and can begin across the life cycle, though the risk is highest between childhood and middle age. Although the exact cause of GAD is unknown, there is evidence that biological factors, family background, and life experiences, particularly stressful ones, play a role.

Sometimes just the thought of getting through the day produces anxiety. People with GAD don’t know how to stop the worry cycle and feel it is beyond their control, even though they usually realize that their anxiety is more intense than the situation warrants. All anxiety disorders may relate to a difficulty tolerating uncertainty and therefore many people with GAD try to plan or control situations. Many people believe worry prevents bad things from happening so they view it is risky to give up worry. At times, people can struggle with physical symptoms such as stomachaches and headaches.

When their anxiety level is mild to moderate or with treatment, people with GAD can function socially, have full and meaningful lives, and be gainfully employed. Many with GAD may avoid situations because they have the disorder or they may not take advantage of opportunities due to their worry (social situations, travel, promotions, etc). Some people can have difficulty carrying out the simplest daily activities when their anxiety is severe.

Symptoms of generalized anxiety disorder

GAD affects the way a person thinks, and it can lead to physical symptoms. Symptoms of GAD can include:

Symptoms of GAD include:

• difficulty concentrating
• difficulty sleeping
• irritability
• fatigue and exhaustion
• muscle tension
• repeated stomachaches or diarrhea
• sweaty palms
• shaking
• rapid heartbeat
• neurological symptoms, such as numbness or tingling in different parts of the body

Symptoms in children and teenagers

In children, excessive worrying centers on future events, past behaviors, social acceptance, family matters, personal abilities, and school performance. Unlike adults with GAD, children and teens often don’t realize that their anxiety is disproportionate to the situation, so adults need to recognize their symptoms. Along with many of the symptoms that appear in adults, some red flags for GAD in children are:

• What if fears about situations far in the future
• Feeling that they’re to blame for any disaster, and their worry will keep tragedy from occurring
• The conviction that misfortune is contagious and will happen to them
• Perfectionism, excessive self-criticism, and fear of making mistakes
• Need for frequent reassurance and approval

Children and teenagers may have similar worries to adults, but also may have excessive worries about:

• Performance at school or sporting events
• Family members’ safety
• Being on time (punctuality)
• Earthquakes, nuclear war or other catastrophic events

A child or teen with excessive worry may:

• Feel overly anxious to fit in
• Be a perfectionist
• Redo tasks because they aren’t perfect the first time
• Spend excessive time doing homework
• Lack of confidence
• Strive for approval
• Require a lot of reassurance about performance
• Have frequent stomachaches or other physical complaints
• Avoid going to school or avoid social situations

People with generalized anxiety disorder often also have other anxiety disorders such as panic disorder or phobias, obsessive-compulsive disorder, clinical depression, or problems with drug or alcohol misuse.

Diagnostic

How is generalized anxiety disorder diagnosed?

GAD is diagnosed with a mental health screening that your primary care provider can perform. They will ask you questions about your symptoms and how long you’ve had them. They can refer you to a mental health specialist, such as a psychologist or psychiatrist.

Your doctor may also do medical tests to determine whether there is an underlying illness or substance abuse problem causing your symptoms. 

If you have symptoms of GAD, your doctor will begin an evaluation by asking questions about your medical and psychiatric history. You may also get a physical exam. Lab tests don’t diagnose anxiety disorders, but some can help doctors check for any physical illness that might be causing the symptoms.

The doctor bases their diagnosis of GAD on reports of how intense and long-lasting the symptoms are, including any problems with daily life caused by the symptoms. The doctor then determines whether the person has a specific anxiety disorder or generalized anxiety disorder.

For someone to be diagnosed with GAD, symptoms must interfere with daily living and be present for more days than not for at least 6 months.

Anxiety has been linked to:

• gastroesophageal reflux disease (GERD)
• thyroid disorders
• heart disease
• menopause

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

Causes and Risk Factors:

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.

As with many mental health conditions, the cause of generalized anxiety disorder likely arises from a complex interaction of biological and environmental factors, which may include:

• Differences in brain chemistry and function
• Genetics
• Differences in the way threats are perceived
• Development and personality 

The exact cause of GAD is not fully understood, although it’s likely that a combination of several factors plays a role.

Research has suggested that these may include:

• overactivity in areas of the brain involved in emotions and behavior
• an imbalance of the brain chemicals serotonin and noradrenaline, which are involved in the control and regulation of mood
• the genes you inherit from your parents – you’re estimated to be 5 times more likely to develop GAD if you have a close relative with the condition
• having a history of stressful or traumatic experiences, such as domestic violence, child abuse or bullying
• having a painful long-term health condition, such as arthritis
• having a history of drug or alcohol misuse

It is important to rule out medical causes of anxiety, such as thyroid disorders, before a diagnosis is made.

Causes of and risk factors for GAD may include:

• a family history of anxiety
• recent or prolonged exposure to stressful situations, including personal or family illnesses
• excessive use of caffeine or tobacco, which can make existing anxiety worse
• childhood abuse

According to the Mayo Clinic, women are twice as likely as men to experience GAD.

Risk factors

Women are diagnosed with generalized anxiety disorder somewhat more often than men are. The following factors may increase the risk of developing generalized anxiety disorder:

• Personality. A person whose temperament is timid or negative or who avoids anything dangerous may be more prone to generalized anxiety disorder than others are.
• Genetics. A generalized anxiety disorder may run in families.
• Experiences. People with a generalized anxiety disorder may have a history of significant life changes, traumatic or negative experiences during childhood, or a recent traumatic or negative event. Chronic medical illnesses or other mental health disorders may increase risk.

Experts don’t know the exact causes of generalized anxiety disorder. Several things including genetics, brain chemistry, and environmental stresses appear to contribute to its development.

Genetics. Some research suggests that family history plays a part in making it more likely that a person will have GAD. This means that the tendency to develop GAD may be passed on in families. But no anxiety genes have been identified, and families may also pass down the tendency through lifestyle or environment.

Brain chemistry. This is complex. GAD has been linked to problems with certain nerve cell pathways that connect particular brain regions involved in thinking and emotion. These nerve cell connections depend on chemicals called neurotransmitters that send information from one nerve cell to the next. If the pathways that connect particular brain regions don’t work well, problems related to mood or anxiety may result. Medicines, psychotherapies, or other treatments that are thought to work on these neurotransmitters may improve the signaling between circuits and help to improve symptoms related to anxiety or depression.

Environmental factors. Trauma and stressful events such as abuse, the death of a loved one, divorce, and changing jobs or schools may contribute to GAD. The condition can also worsen when stress feels out of hand. The use of and withdrawal from addictive substances (including alcohol, caffeine, and nicotine) can also worsen anxiety.

Complications

Having a generalized anxiety disorder can be disabling. It can:

• Impair your ability to perform tasks quickly and efficiently because you have trouble concentrating
• Take your time and focus on other activities
• Sap your energy
• Increase your risk of depression

Generalized anxiety disorder can also lead to or worsen other physical health conditions, such as:

• Digestive or bowel problems, such as irritable bowel syndrome or ulcers
• Headaches and migraines
• Chronic pain and illness
• Sleep problems and insomnia
• Heart-health issues

Generalized anxiety disorder often occurs along with other mental health problems, which can make diagnosis and treatment more challenging. Some mental health disorders that commonly occur with a generalized anxiety disorder include:

• Phobias
• Panic disorder
• Post-traumatic stress disorder (PTSD)
• Obsessive-compulsive disorder (OCD)
• Depression
• Suicidal thoughts or suicide
• Substance abuse

Prevention

There’s no way to predict for certain what will cause someone to develop a generalized anxiety disorder, but you can take steps to reduce the impact of symptoms if you experience anxiety:

• Get help early. Anxiety, like many other mental health conditions, can be harder to treat if you wait.
• Keep a journal. Keeping track of your personal life can help you and your mental health professional identify what’s causing you stress and what seems to help you feel better.
• Prioritize issues in your life. You can reduce anxiety by carefully managing your time and energy.
• Avoid unhealthy substance use. Alcohol and drug use and even nicotine or caffeine use can cause or worsen anxiety. If you’re addicted to any of these substances, quitting can make you anxious. If you can’t quit on your own, see your doctor or find a treatment program or support group to help you.

Generalized Anxiety Disorder Prevention

Anxiety disorders like GAD can’t always be prevented. But there are some things that you can do to control or lessen symptoms, including:

• Seek counseling and support after a traumatic or disturbing experience, or if you’ve noticed that you’re feeling more anxious than usual. It’s better to address a problem, not avoid it.
• Lead a healthy, active lifestyle.
• Stay connected to others. Don’t get isolated.
• Take breaks when you start to worry. Try to let go of concerns about the past.
• If you have an anxiety treatment plan, stick with it.
• Ask your doctor or pharmacist before taking any over-the-counter drugs or herbal remedies. Many contain chemicals that can increase anxiety symptoms.
• Practice stress management techniques.
• Consider joining a support group for people dealing with anxiety.

Treatment

GAD is treatable and seeking professional support is the first step towards recovery. There are two main types of effective treatments for GAD; psychological treatments will generally be the first line of treatment. In some severe cases, medication can also be effective.

First, talk to your doctor about your symptoms. Your doctor should do an exam and ask you about your health history to make sure that an unrelated physical problem is not causing your symptoms. Your doctor may refer to you a mental health specialist, such as a psychiatrist or psychologist.

GAD is generally treated with psychotherapy, medication, or both. Talk with your doctor about the best treatment for you.

It’s possible to become dependent upon sedative-hypnotic medications (benzodiazepines) if those medications are used on an ongoing basis.

Side effects of antidepressants that treat GAD vary by specific drug and the person taking them. Common side effects can include sleepiness, weight gain, nausea, and sexual problems.

There are no negative side effects from therapy or healthy lifestyle measures. Whether those are enough to handle an anxiety disorder, or if medications are also needed, is a decision to make with your health care provider.

GAD is treatable and seeking professional support is the first step towards recovery. There are two main types of effective treatments for GAD; psychological treatments will generally be the first line of treatment. In some severe cases, medication can also be effective.

If you’ve given self-help a fair shot, but still can’t seem to shake your worries and fears, it may be time to see a mental health professional. But remember that professional treatment doesn’t replace self-help. In order to control your GAD symptoms, you’ll still want to make lifestyle changes and look at the ways you think about worrying

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

Cognitive-behavioral therapy (CBT) is one type of therapy that is particularly helpful in the treatment of GAD. CBT examines distortions in our ways of looking at the world and ourselves. Your therapist will help you identify automatic negative thoughts that contribute to your anxiety. For example, if you catastrophize always imagining the worst possible outcome in any given situation you might challenge this tendency through questions such as, “What is the likelihood that this worst-case scenario will actually come true?” and “What are some positive outcomes that are more likely to happen?”.

GAD can have a significant effect on your daily life, but several different treatments are available that can ease your symptoms.

These include:

• psychological therapies – you can get psychological therapies like cognitive behavioral therapy (CBT) on the NHS; you do not need a referral from a GP and you can refer yourself for psychological therapies service in your area
•  of medicine – such as a type of antidepressant called selective serotonin reuptake inhibitors (SSRIs)

With treatment, many people are able to control their anxiety levels. But some treatments may need to be continued for a long time and there may be periods when your symptoms worsen.

The five components of CBT for anxiety are:

Education. CBT involves learning about generalized anxiety disorder. It also teaches you how to distinguish between helpful and unhelpful worry. An increased understanding of your anxiety encourages a more accepting and proactive response to it.

Monitoring. You learn to monitor your anxiety, including what triggers it, the specific things you worry about, and the severity and length of a particular episode. This helps you get perspective, as well as track your progress.

Physical control strategies. CBT for GAD trains you in relaxation techniques to help decrease the physical over-arousal of the “fight or flight” response.

Cognitive control strategies teach you to realistically evaluate and alter the thinking patterns that contribute to generalized anxiety disorder. As you challenge these negative thoughts, your fears will begin to subside.

Behavioral strategies. Instead of avoiding situations, you fear, CBT teaches you to tackle them head-on. You may start by imagining the thing you’re most afraid of. By focusing on your fears without trying to avoid or escape them, you will feel more in control and less anxious.

Medications

If your doctor recommends drugs, they will most likely create a short-term medication plan and a long-term medication plan.

Short-term medications relax some of the physical symptoms of anxiety, such as muscle tension and stomach cramping. These are called anti-anxiety medications. Some common anti-anxiety medications are:

• alprazolam (Xanax)
• clonazepam (Klonopin)
• lorazepam (Ativan)

Anti-anxiety drugs aren’t meant to be taken for long periods of time, as they have a high risk of dependence and abuse.

Medications called antidepressants work well for long-term treatment. Some common antidepressants are:

• buspirone (Buspar)
• citalopram (Celexa)
• escitalopram (Lexapro)
• fluoxetine (Prozac, Prozac Weekly, Sarafem)
• fluvoxamine (Luvox, Luvox CR)
• paroxetine (Paxil, Paxil CR, Pexeva)
• sertraline (Zoloft)
• venlafaxine (Effexor XR)
• desvenlafaxine (Pristiq)
• duloxetine (Cymbalta)

These medications can take a few weeks to start working. They can also have side effects, such as dry mouth, nausea, and diarrhea. These symptoms bother some people so much that they stop taking these medications.

There is also a very low risk of increased suicidal thoughts in young adults at the beginning of treatment with antidepressants. Stay in close contact with your prescriber if you’re taking antidepressants. Make sure you report any mood or thought changes that worry you.

Your doctor may prescribe both an anti-anxiety medication and an antidepressant. If so, you’ll probably only take the anti-anxiety medication for a few weeks until your antidepressant starts working, or on an as-needed basis.

Medication for anxiety

Medication for GAD is generally recommended only as a temporary measure to relieve symptoms at the beginning of the treatment process, with therapy as the key to long-term success.

There are three types of medication prescribed for a generalized anxiety disorder:

Buspirone. This anti-anxiety drug, known by the brand name Buspar, is generally considered to be the safest drug for generalized anxiety disorder. Although buspirone will take the edge off, it will not entirely eliminate anxiety.

Benzodiazepines. These anti-anxiety drugs act very quickly (usually within 30 minutes to an hour), but physical and psychological dependence are common after more than a few weeks of use. They are generally recommended only for severe, paralyzing episodes of anxiety.

Antidepressants. The relief antidepressants provide for anxiety is not immediate, and the full effect isn’t felt for up to six weeks. Some antidepressants can also exacerbate sleep problems and cause nausea or other side effects.

Other Medications

Beta-blockers, such as propranolol, 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.

Alcohol and anxiety

Drinking alcohol can make you feel less anxious almost immediately. This is why many people who suffer from anxiety turn to drinking alcohol to feel better.

However, it’s important to remember that alcohol can have a negative effect on your mood. Within a few hours after drinking, or the day after, you may feel more irritability or depression. Alcohol can also interfere with the medications used to treat anxiety. Some medication and alcohol combinations can be fatal.

If you find that your drinking is interfering with your daily activities, talk to your primary care provider. You can also find free support to stop drinking through Alcoholics Anonymous (AA).

When to see a doctor

Some anxiety is normal, but see your doctor if:

• You feel like you’re worrying too much, and it’s interfering with your work, relationships, or other parts of your life
• You feel depressed or irritable, have trouble with drinking or drugs, or you have other mental health concerns along with anxiety
• You have suicidal thoughts or behaviors seek emergency treatment immediately

Your worries are unlikely to simply go away on their own, and they may actually get worse over time. Try to seek professional help before your anxiety becomes severe it may be easier to treat early on.

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