Generalized Anxiety Disorder (GAD)

Key takeaways

• Generalized anxiety disorder is a condition in which people experience disproportionate anxiety or worry about different aspects of their lives

• Generalized anxiety disorder is the result of interactions between biological, genetic, social, and psychological factors

• The most common treatments for generalized anxiety disorder are psychotherapy and medication. Combining these treatments can lead to better results

Overview of generalized anxiety disorder

Generalized anxiety disorder is a long-term mental condition in which people experience excessive worry about multiple areas of their lives, including work, relationships, health, and money. These worries can range from whether they might lose a loved one in an accident to whether someone they passed in the street thought they appeared rude.

Generalized anxiety disorder often co-occurs with other mental disorders. Importantly, generalized anxiety disorder and major depressive disorder (MDD) occur more commonly together than either disorder does alone.^[2]

Symptoms

Someone with generalized anxiety disorder will often think of themselves as a generally anxious person. They are likely to worry about lots of different issues and feel as though they can’t control their thoughts or worries.

Other symptoms of generalized anxiety disorder include^[3]

• Feeling restless or on edge

• Becoming fatigued easily

• Struggling to concentrate or feeling as though their mind has gone blank

• Muscle tension

• Problems with sleep

• Being easily irritated or annoyed

• Low mood or depression

• Racing heart or irregular heartbeat (palpitations)

• Feeling lightheaded or dizzy

Some people with generalized anxiety disorder may also experience panic attacks.

Symptoms in children and adolescents

Children and adolescents face different worries than adults, and they may have fewer resources to cope with those.

Common worries experienced by children with GAD include

• Worries about the future, especially serious but unlikely or distant events such as the death of a parent

• Social position, especially around whether others are honest in their liking of the child

• Safety and security of their home life, for example, the risk of divorce

• Whether they are good enough. This can include all kinds of areas, including sports, school, and social skills

In addition to the symptoms experienced by adults, children and adolescents with GAD may experience the following symptoms.

• Perfectionism

• Requiring excessive reassurance

• Muscle aches

• Nausea or an upset stomach

• Headaches

Children may show fewer generalized anxiety disorder symptoms than adults.

Causes of generalized anxiety disorder

As with most mental disorders, there is no simple cause for generalized anxiety disorder. It most likely occurs through a combination of genetic predisposition and biological, social, and psychological factors.

There is a genetic aspect to whether someone is predisposed to develop generalized anxiety disorder. Current estimates suggest that heritability is between 30 and 50%.^[4]

Between 1 in 3 and half of people with generalized anxiety disorder who receive SSRI antidepressants see an improvement in their symptoms.^[3]This suggests that there may be an underlying neurotransmitter imbalance, but the serotonin system does not appear to be directly involved.^[5]

Researchers have also put forward several cognitive models of generalized anxiety disorder, demonstrating how certain patterns of thinking may lead to symptoms of GAD. For example, the Avoidance Model of Worry claims that believing that worrying about something improves problem solving makes someone more likely to develop generalized anxiety disorder. Alternatively, the Metacognitive Model predicts that people with generalized anxiety disorder primarily worry about their worrying.^[6]These models suggest that worrying can be a maladaptive coping strategy that leads to generalized anxiety disorder.

Risk factors

Some people are more at risk of generalized anxiety disorder than others. Having a close family member with the disorder makes it more likely that someone will develop it.^[7]Other risk factors include being female, unmarried, in poor health, with low education, and experiencing stressful situations.^[3]Childhood trauma can be especially damaging, leaving people vulnerable to many mood and anxiety disorders.

GAD and the brain

Researchers still don’t fully understand how generalized anxiety disorder affects the brain, but they have discovered some patterns of activation that appear to relate to GAD symptoms.

Two areas of the brain closely associated with anxiety are the amygdala and the prefrontal cortex (PFC). Activity in the amygdala is associated with emotions, especially fear, while the PFC is associated with more rational thought. Activity in the PFC usually decreases activity in the amygdala, allowing us to recover from fear as we begin to respond more thoughtfully to our situation.^[8]

People with generalized anxiety disorder typically show decreased connectivity between the amygdala and the PFC, meaning that the amygdala remains highly activated for longer.^[9]Activity in the ventrolateral PFC, which is most closely associated with negative emotions, increases following either CBT or medication treatment for generalized anxiety disorder, possibly explaining the effectiveness of these treatments.^[10]

How generalized anxiety disorder can affect daily life

Generalized anxiety disorder can be highly disruptive to someone’s daily life. People with this condition may find that they spend much of their time consumed by worry. They may struggle to make decisions because they are concerned about making a wrong choice and have trouble relaxing or switching off.^[11]

GAD affects sleep, concentration, and physical health. Many people with the disorder are tired, easily distracted, and experience headaches or other forms of pain.^[12]

Prevention of generalized anxiety disorder

There is currently no evidence that generalized anxiety disorder can be prevented, but prompt treatment can help patients recover faster and minimize the negative effects the condition has on their lives. This is especially important for children and adolescents, who can benefit from learning new skills to manage their condition.

Diagnosis of generalized anxiety disorder

A doctor, healthcare provider, or mental health professional can diagnose someone with generalized anxiety disorder. They will usually do this through the use of a clinical interview, in which they will talk to you and ask about your symptoms. They may also use a screening test, such as GAD-7, which is designed to quickly discover important symptoms.

For a diagnosis of GAD, you must have experienced excessive worry for at least 6 months and felt unable to control that worry.^[13]During that time, you must also have experienced at least three of

• Restlessness, feeling keyed up, or on edge

• Being easily fatigued

• Difficulty in concentrating or mind going blank, irritability

• Muscle tension

• Sleep disturbance

• Irritability

For children, only one of these symptoms is required.^[14]

Your clinician will ask how this has been affecting your everyday life and look for any evidence that there might be a different explanation for your symptoms, such as another medical condition. This may include tests, such as

• Thyroid tests

• Blood glucose tests

• Echocardiograms

Treatment for generalized anxiety disorder

Only about 1 in 3 people with generalized anxiety disorder seek treatment, and most of those who do wait for at least 10 years before asking for help.^[15][16]Treatment is available, but it is not always easy to access. In one study, only 25% of people were helped by the first person they saw about their disorder, but 70% did find the help they eventually received to be effective.^[15]

Psychotherapy

The most common psychological therapy offered to people with generalized anxiety disorder is cognitive behavioral therapy (CBT). This therapy works to address inaccurate thoughts and beliefs you might have, which are fueling your worry, for example, the belief that worrying helps to improve problem-solving.^[17]By encouraging patients to challenge and test these beliefs, CBT can reduce levels of rumination and worry.

Some people with generalized anxiety disorder may prefer other forms of psychotherapy. Those with a history of trauma, especially serious childhood trauma, may do better with psychodynamic or insight-focused therapies. These therapies focus on helping patients understand how their past experiences led to their current situation.^[18]

Interpersonal therapy (IPT) is another type of therapy offered to people with generalized anxiety disorder. This therapy aims to develop supportive relationships and resolve relationship conflicts the patient is currently experiencing, enabling them to build a strong, supportive social network.^[19]

Medication

Medication can be an effective treatment that helps many patients with generalized anxiety disorder. The first medications offered are usually selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). These are antidepressants, but they also help to reduce anxiety symptoms. Between 30-50% of patients respond to the first of these medications they are offered.^[3]

Antidepressant medications typically take several weeks to take effect. Patients with severe GAD may be offered benzodiazepines to help control their symptoms while waiting for the antidepressants to take effect. These are highly effective at controlling anxiety symptoms, but they can be highly addictive and are usually only offered for a short period.^[20]

Alternative

Physical activity and yoga can increase brain-derived neurotrophic factor (BDNF), which may help patients learn new associations to replace fear and anxiety. Exercise typically improves anxiety symptoms about 30 minutes after finishing the activity. Yoga can also regulate the hypothalamic-pituitary-adrenal (HPA) axis, which reduces stress.^[21]

Virtual reality (VR) headsets offer some benefits to people with severe generalized anxiety disorder symptoms, whose symptoms make traditional psychotherapy difficult. Further research is necessary to see how effective this is and whether any improvements last.^[22]

Repetitive TMS (rTMS) also seems to benefit some patients, though group sizes have been small so far, and there is uncertainty about how long the effects last.^[23]

Herbal treatments, including Kava Kava, lavender, and valerian, require better quality evidence before they can be recommended.^[24]

Barriers to treatment

The majority of people with generalized anxiety disorder never seek treatment.^[15]Common barriers that prevent them from seeking treatment include^[25]

• Wanting to manage their condition alone

• Feelings of shame and stigma

• Financial concerns

• Believing that treatment is unlikely to be effective

• Finding few local treatment options

• Not knowing where to seek help

Some patients will also have disclosed their symptoms in the past and not had them taken seriously. This is a particular problem for older patients, which can make it harder to seek treatment now.

Final thoughts

Generalized anxiety disorder is a common mental health condition that, if left untreated, can lead to a poor quality of life. Seeking treatment and surrounding yourself with supportive people who understand your condition can help, especially because relapse is common.^[3]Having a support system, including friends and medical professionals, can help reduce the impact GAD has on your life.