Internet Mental Health
 
GENERALIZED ANXIETY DISORDER
 


Prediction: Chronic

      Occupational-Economic:
  • Occupational impairment (due to constant worrying, physical complaints)
      Social:
  • Negative emotion (generalized "free-floating" anxiety, depressed mood, irritability, restlessness)
  • Cognitive impairment (poor concentration)
      Medical:
  • Stress related disorders (e.g., irritable bowel syndrome, headaches, muscle tension, insomnia, fatigue)


SYNOPSIS

Generalized Anxiety Disorder F41.1 - ICD10 Description, World Health Organization

Anxiety that is generalized and persistent but not restricted to, or even strongly predominating in, any particular environmental circumstances (i.e. it is "free-floating"). The dominant symptoms are variable but include complaints of persistent nervousness, trembling, muscular tensions, sweating, lightheadedness, palpitations, dizziness, and epigastric discomfort. Fears that the patient or a relative will shortly become ill or have an accident are often expressed.
Generalized Anxiety Disorder - Diagnostic Criteria, American Psychiatric Association

An individual diagnosed with generalized anxiety disorder needs to meet all of the following criteria:

  • Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

  • The individual finds it difficult to control the worry.

  • The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one item is required in children.

    • Restlessness or feeling keyed up or on edge.

    • Being easily fatigued.

    • Difficulty concentrating or mind going blank.

    • Irritability.

    • Muscle tension.

    • Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep).

  • The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  • The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

  • The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).

This disorder is a very common condition in which people suffer from excessive worry or anxiety about everyday events and problems. This excessive worry or anxiety is chronic (at least 6 months), over-reactive (out of proportion to any inherent risk), and causes distress and impairment. The individual must have at least 3 of the following symptoms: restlessness or nervousness, easy fatigability, poor concentration, irritability, muscle tension, or sleep disturbance. This disorder must not be due to a drug, medication, general medical condition, or other mental disorder.

Effective Therapies

80% of individuals with this disorder respond to treatment with at least a 50% reduction in symptoms; unfortunately, only 40% have a full symptomatic remission. Cognitive behavioral therapy (CBT) and supportive therapy have been found to be equally effective, and both are first-line therapies. Antidepressants (imipramine, venlafaxine and paroxetine) are first-line treatments for this disorder (with a NNT= 5.1). Second-line treatments for this disorder are: hydroxyzine (an anti-histamine medication), benzodiazepines (antianxiety drugs), pregabalin (an anticonvulsant), hydroxyzine (an antihistamine), and quetiapine (a second-generation antipsychotic).

Ineffective Therapies

Vitamins and dietary supplements are ineffective for this disorder.

Complications

Individuals with this disorder have more pain and physical illness and decreased physical, social, and role functioning. Symptoms of autonomic hyperarousal (e.g., accelerated heart rate, shortness of breath, dizziness) are less prominent in this disorder than in other anxiety disorders, such as panic disorder and post-traumatic stress disorder. Depressive symptoms are also common.

Comorbidity

This disorder often co-occurs with mood disorders (e.g., major depressive disorder or persistent depressive disorder), with other anxiety disorders (e.g., panic disorder, social anxiety disorder, specific phobia), and with substance use disorders (e.g., alcoholism or drug dependence). Other stress related disorders (e.g., irritable bowel syndrome, headaches) frequently accompany this disorder.

Associated Laboratory Findings

No laboratory test has been found to be diagnostic of this disorder.

Prevalence

In a community sample, the 1-year prevalence rate for this disorder is 3%, and the lifetime prevalence rate is 5%. The sex ratio is approximately two-thirds female.

Course

Over half of those presenting for treatment report onset in childhood or adolescence, however onset occurring after age 20 is not uncommon. The course is chronic but fluctuating and often worsens during times of stress. During the course of the disorder, the focus of worry may shift from one concern to another.

Familial Pattern

Anxiety as a trait has a familial association. Twin studies suggest a genetic contribution to the development of this disorder. The genetic factors influencing risk of generalized anxiety disorder may be closely related to those for major depressive disorder.

Description




Stories

Free Diagnosis Of This Disorder

Rating Scales

Treatment

  • Generalized Anxiety Disorder Treatment Guidelines
  • Self-Help Strategies for Generalized Anxiety Disorder - AnxietyBC.com
  • Cognitive Behavioral Treatment of Anxiety Disorders - AnxietyBC.com
  • Pregabalin for the treatment of generalized anxiety disorder. (2012) Pregabalin is effective and well tolerated in the treatment of GAD. As somnolence and dizziness are common adverse effects, caution should be used in elderly patients. Pregabalin rapidly relieves anxiety.
  • Second-generation antipsychotic drugs for anxiety disorders. (2011) Participants with generalised anxiety disorder responded significantly better to quetiapine than to placebo, measured as a reduction in the Hamilton Anxiety Scale (HAM-A). Participants treated with quetiapine were more likely to drop out due to adverse events, to gain weight, to suffer from sedation or to suffer from extrapyramidal side effects. The evidence on the other second-generation antipsychotics is currently too limited to draw any conclusions.
  • Pharmacological treatment of generalized anxiety disorder. (2010) Recent evidence-based guidelines for the pharmacological management of patients with GAD have recommended initial treatment with either a selective serotonin reuptake inhibitor (SSRI) or a serotonin-norepinephrine reuptake inhibitor (SNRI), on the basis of their proven efficacy and reasonable tolerability in randomized placebo-controlled trials. Response rates to first-line treatment can be disappointing and it is hard to predict reliably which patients will respond well and which will have only a limited treatment response. The relative lack of longitudinal studies of clinical outcomes in GAD, and the small number of placebo-controlled relapse prevention studies lead to uncertainty about the optimal duration of treatment after a satisfactory initial response.
  • Psychological therapies for people with generalised anxiety disorder. (2010) People attending for psychological therapy based on a CBT approach were more likely to have reduced anxiety at the end of treatment than people who received treatment as usual or were on a waiting list for therapy. CBT was also very effective in reducing secondary symptoms of worry and depression. People who attended for group CBT and older people were more likely to drop out of therapy. None of the studies comparing CBT with treatment as usual or waiting list looked at the long-term effectiveness of CBT. It is not clear whether people attending for CBT sessions were more likely to have reduced anxiety than people attending for psychodynamic therapy or supportive therapy.
  • Antidepressants for generalized anxiety disorder. (2009) Our review showed that antidepressants were better than placebo (dummy treament) for treating GAD and were well tolerated. We did not find evidence to conclude whether some types of antidepressant are better than others. Overall, about 5 people need to be treated in order for one person with GAD to benefit.
  • Pregabalin: its efficacy, safety and tolerability profile in generalized anxiety. (2007) Pregabalin's anxiolytic activity in generalized anxiety disorder has been demonstrated in seven acute randomized, double-blind, placebo-controlled trials of four to eight weeks duration, and in one six-month relapse-prevention study at doses of 150-600 mg/day using twice-daily or three-times-daily regimes. The magnitude of pregabalin's anxiolytic effects was similar to that of alprazolam, lorazepam or venlafaxine. Pregabalin showed less cognitive and psychomotor impairment than alprazolam. The most frequently reported adverse events were dizziness and somnolence, although tolerance to these developed within a few weeks. Withdrawal symptoms during a one-week taper phase were mild.

Research

Other Web Pages

Internet Mental Health 1995-2011 Phillip W. Long, M.D.