Generalized Anxiety Disorder

What is generalized anxiety disorder?

In generalized anxiety disorder, a person has frequent or nearly constant nagging feelings of worry or anxiety. These feelings are either unusually intense or out of proportion to the real troubles and dangers of the person's everyday life.

The disorder is defined as persistent worry for more days than not, for at least several months. In some cases, a person with generalized anxiety disorder feels he or she has always been a worrier, even since childhood or adolescence. In other cases, the anxiety may be triggered by a crisis or a period of stress, such as a job loss, a family illness, or the death of a relative. The crisis or stress may have ended, but an unexplained feeling of anxiety may last months or years.

In addition to suffering from constant or nonstop worries and anxieties, people with generalized anxiety disorder may have low self-esteem or feel insecure. They may see people's intentions or events in negative terms, or they may experience them as intimidating or critical. Physical symptoms may lead them to seek treatment from a primary care doctor, cardiologist, pulmonary specialist, or gastroenterologist. Stress can intensify the anxiety.

Some people with this disorder have a genetic (inherited) tendency to develop it. The disorder probably stems from how a variety of brain structures communicate with each other as the individual tries to manage the fear response. Life experience, significant relationships, and environmental stresses also influence the development of this disorder.

About 3% to 5% of people in the United States have generalized anxiety disorder. Women are diagnosed with the condition much more often than men. The average adult patient first seeks professional help between the ages of 20 and 30. However, the illness can occur at any age.

Of all psychiatric illnesses, generalized anxiety disorder is the least likely to occur alone. Between 50% and 90% of people with the disorder also have at least one other problem, usually panic disorder, a phobia, depression, alcoholism, or some other form of substance abuse.

Symptoms of generalized anxiety disorder

Symptoms of generalized anxiety disorder include:

Persistent worry or anxiety that lasts for at least several months. (Although the American Psychiatric Association's diagnostic manual sets the minimum at six months, but you don't need to wait that long to seek help.)
Worry or anxiety is excessive, troubling, and hard to control. It often interferes with the ability to function at home, at work, or in social situations.
Feeling restless or keyed up.

Here are some of the other defining symptoms or behaviors common in the disorder:

having tense muscles
having difficulty concentrating or remembering (your mind goes blank)
having trouble falling asleep or staying asleep, or not feeling rested after sleep
avoiding activities that could turn out badly (avoiding even small risks)
spending excessive effort preparing for events that could have a negative outcome
procrastinating or having trouble making decisions
worrying that leads to repeatedly asking for reassurance.

People with generalized anxiety disorder also may have physical symptoms that feel like symptoms of heart disease, respiratory illness, digestive diseases, and other medical illnesses.

Diagnosing generalized anxiety disorder

You may consult a primary care doctor first if you suspect your physical symptoms are part of a medical illness. Your doctor may recommend tests to check for medical problems. If the results are normal, your doctor may ask about your family history, your history of any mental distress, current anxieties, recent stresses, and daily use of prescription and nonprescription drugs (because some drugs can cause anxiety symptoms). The doctor then may refer you to a mental health provider for care.

A mental health provider will diagnose generalized anxiety disorder based on a full psychological evaluation that includes:

asking you to describe your worries, anxieties, and anxiety-related symptoms
determining how long you have had these symptoms
assessing how worry and anxiety have affected your ability to function normally at home, at work, and socially
checking for symptoms of other forms of psychiatric illness that might be present at the same time as generalized anxiety disorder. Symptoms of depression are common in someone with this disorder.

Expected duration of generalized anxiety disorder

Although the diagnosis of generalized anxiety disorder may be made after several months of symptoms, the condition can last years, especially without treatment. Many people experience the symptoms as part of a lifelong pattern.

Preventing generalized anxiety disorder

There is usually no way to prevent generalized anxiety disorder in someone who is prone to developing it. However, once diagnosed, various treatments can effectively reduce symptoms.

Treating generalized anxiety disorder

If you have generalized anxiety disorder, the most effective treatments are psychotherapy, medications, or a combination of the two. Your doctor may also offer treatment for other conditions that may be making matters worse, such as a medical problem or depression.

You may need to try more than one approach before you find the right one. Many different kinds of medications can relieve anxiety. Here are the most common categories prescribed.

Antidepressants: Despite their name, many of these drugs are very effective for anxiety. They are used very commonly to treat generalized anxiety disorder.

The popular selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac), sertraline (Zoloft), and escitalopram (Lexapro), are often the first choice. Antidepressants that have a different mechanism of action may work as well. Examples are mirtazapine (Remeron), venlafaxine (Effexor), and duloxetine (Cymbalta). Older antidepressants such as tricyclic antidepressants (for example, nortriptyline or imipramine) are also effective, but can have more troublesome side effects.

Since antidepressants often take several weeks to work, your doctor may also prescribe a fast-acting benzodiazepine for relief.

Antiseizure drugs: Despite the name of this group, these medicines, including pregabalin (Lyrica) and gabapentin (Neurontin, others), can be effective for anxiety. They tend to be prescribed if antidepressant drugs are not effective.

Benzodiazepines: These drugs affect a chemical messenger that works in the brain's fear response system. Examples include clonazepam (Klonopin), lorazepam (Ativan), and diazepam (Valium). They may bring quick relief from symptoms of anxiety. These drugs are often prescribed only for a relatively short time because of the concern about dependency and loss of effect over time. In addition, benzodiazepines may worsen depression. For these reasons, they are often reserved for people who have had little or no benefit from other treatments.

Buspirone: Buspirone is an anti-anxiety drug that can be effective for generalized anxiety disorder. However, it is used much less frequently than the drugs listed above. Like antidepressants, it usually takes two to three weeks to begin working.

Psychotherapy

A number of psychotherapy techniques may be helpful. Here are some examples:

Cognitive behavioral therapy helps you recognize and change unreasonable patterns of thinking and behavior.
Psychodynamic or insight-oriented psychotherapy helps you understand the history behind your symptoms. For example, you may become more aware of how you have carried past fears into the present day. This insight may help you face challenges more confidently now.
Interpersonal psychotherapy can help you sort out anxiety-provoking conflicts in important relationships and resolve them more effectively.
Exposure and desensitization are behavioral techniques that provides support so you can confront a specific fear and overcome it. It is particularly helpful when anxiety is causing you to avoid important tasks or responsibilities.
Applied relaxation teaches people with generalized anxiety disorder to control their symptoms by using imagination and muscle control. Relaxation techniques, such as diaphragmatic breathing, meditation, and visualization, can relieve some of the more bothersome physical symptoms.

Your therapist may combine any of the above approaches, or may recommend others such as meditation, hypnosis, or exercise, you so that the approach fits your specific problems and needs.

When to call a professional

See your doctor if you are troubled by severe worry or anxiety, especially if:

your anxious feelings have lasted several months
you feel that you can no longer control your anxious feelings and this causes you to spend unreasonable amounts of time managing your symptoms
your constant anxiety is interfering with your personal relationships, or with your ability to function normally at home, at school, or at work
you are having difficulty concentrating or remembering
you are having trouble sleeping
you have unexplained physical symptoms that may be anxiety-related.

Prognosis

In general, the outlook is good. Studies suggest that with appropriate treatment, 70% or more of people with generalized anxiety disorder experience significant improvement.