Generalized Anxiety Disorder (GAD)

What GAD feels like

Everyone worries. In GAD, worry is out of proportion, hard to control and jumps from one topic to the next: a partner being late becomes a car crash, a minor symptom becomes a serious illness, a work email becomes losing your job. People often know their worry is excessive but cannot stop it.

Psychological symptoms

• persistent worrying or anxiety about many areas of life
• overthinking plans and solutions to all possible worst outcomes
• seeing situations and events as threatening even when they are not
• difficulty handling uncertainty
• indecisiveness and fear of making the wrong decision
• inability to let go of a worry
• feeling on edge or unable to relax

Physical symptoms

• muscle tension, aches and jaw clenching
• restlessness and feeling keyed up
• fatigue
• trouble falling or staying asleep
• headaches
• nausea, diarrhea or irritable bowel symptoms
• sweating, trembling, a racing heart
• being easily startled

Many people with GAD first see a doctor for physical symptoms such as headaches, stomach problems or poor sleep, without recognizing anxiety as the cause.

Diagnostic criteria

The DSM-5-TR requires:

1. excessive anxiety and worry about several events or activities, on more days than not, for at least 6 months
2. difficulty controlling the worry
3. at least 3 of 6 symptoms in adults (1 in children): restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance
4. significant distress or impairment
5. not due to a substance, medicine or medical condition, and not better explained by another mental disorder

GAD vs other anxiety conditions

GAD commonly occurs with depression, other anxiety disorders and substance use.

Causes and risk factors

• genetics: anxiety disorders run in families
• brain function: overactivity in fear circuits and differences in neurotransmitters such as serotonin and GABA
• temperament: a tendency toward shyness, negative emotions or avoiding harm from childhood
• life experiences: childhood adversity, trauma, chronic stress, major life changes
• health problems: chronic illness and pain
• substances: caffeine, alcohol withdrawal, stimulants and some medicines

Diagnosis

A primary care clinician or mental health professional will ask about worry, physical symptoms, sleep, mood, substance use and how symptoms affect daily life. Screening tools include the GAD-7, a 7-question questionnaire scored from 0 to 21, with scores of 10 or more suggesting moderate anxiety. The US Preventive Services Task Force recommends anxiety screening for adults under 65.

Doctors will consider medical causes that can mimic anxiety:

• overactive thyroid
• heart rhythm problems
• low blood sugar
• asthma and COPD medicines, steroids and decongestants
• caffeine and stimulant use, and alcohol or sedative withdrawal

Treatment

Psychotherapy

Cognitive behavioral therapy (CBT) is the best-studied therapy for GAD. It teaches you to:

• notice and question catastrophic or unhelpful thoughts
• tolerate uncertainty
• reduce reassurance-seeking, avoidance and over-planning
• use relaxation and problem-solving skills
• schedule "worry time" to contain worry

It usually involves 12 to 20 sessions. Guided self-help and internet-based CBT also work for many people. Acceptance and commitment therapy (ACT) and applied relaxation are other options.

Medicines

• SSRIs (escitalopram, sertraline, paroxetine) and SNRIs (venlafaxine, duloxetine) are first-line. They take 2 to 6 weeks to start working and are usually continued for at least 6 to 12 months after improvement.
• Buspirone is another option.
• Pregabalin is used in some countries.
• Hydroxyzine can be used short term.
• Benzodiazepines (such as lorazepam or alprazolam) relieve anxiety quickly but carry risks of dependence, withdrawal, falls and memory problems, and are dangerous with alcohol or opioids. Guidelines advise avoiding them or using them only briefly.

Therapy and medicine combined can help those with more severe symptoms.

Self-help that makes a difference

• regular exercise: aerobic activity reduces anxiety
• cut back on caffeine and alcohol
• keep a regular sleep routine
• practice relaxation: slow breathing, progressive muscle relaxation, mindfulness or yoga
• limit news and social media if they feed worry
• stay connected with people you trust

Outlook

GAD is often long-lasting and can wax and wane with stress, but treatment works for most people. Many achieve significant relief, and some become symptom-free. Learning CBT skills reduces the chance of relapse.

Frequently asked questions

What are the symptoms of generalized anxiety disorder?

GAD causes persistent, excessive worry about many everyday things that is hard to control, along with physical symptoms such as restlessness, fatigue, poor concentration, irritability, muscle tension and trouble sleeping. Headaches, stomach upset and a racing heart are also common.

What is the difference between anxiety and GAD?

Anxiety is a normal emotion in response to stress. GAD is a condition in which worry is excessive, hard to control, spreads across many areas of life, and lasts at least 6 months, causing distress or problems with daily functioning.

What is the best treatment for generalized anxiety disorder?

Cognitive behavioral therapy and SSRI or SNRI antidepressants are the most effective treatments, used alone or together. Exercise, good sleep habits, limiting caffeine and alcohol, and relaxation techniques add to their benefits.

Can generalized anxiety disorder be cured?

GAD can be treated very effectively, and many people become symptom-free or nearly so. Because it can return during stressful periods, ongoing use of CBT skills, and sometimes longer-term medicine, helps keep it under control.

Can anxiety cause physical symptoms?

Yes. Anxiety activates the body's stress response, causing muscle tension, headaches, fatigue, stomach problems, a racing heart, sweating, trembling and poor sleep. New chest pain, breathlessness or fainting should still be checked by a doctor before being attributed to anxiety.