Generalized Anxiety Disorder (GAD)

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Generalized Anxiety Disorder

Overview

The lifetime prevalence of generalized anxiety disorder is 6%, it is more frequent in women than in men, with the age of onset reflecting a bimodal distribution (onset in late teens to early twenties, and again in the 30s and 40s). generalized anxiety disorder is associated with substantial functional impairment and a high prevalence of comorbid psychiatric and medical disorders. According to DSM-5 criteria, generalized anxiety disorder is characterized by excessive anxiety and worry about multiple situations and is associated with restlessness, muscle tension, and behavioral changes.

Cognitive behavior therapy is an effective first-line option to treat generalized anxiety disorder and is as effective as pharmacotherapy. Internet-based and computer-based cognitive behavior therapy has also shown efficacy. Evidence does not support the routine combination of cognitive behavior therapy and pharmacotherapy, but when patients do not benefit from cognitive behavior therapy, a trial of pharmacotherapy is advisable, and vice versa.

Pharmacotherapeutic approaches should begin with one of the first-line options including an SSRI such as escitalopram, paroxetine, or sertraline, an SNRI such as duloxetine or venlafaxine XR, or another antidepressant such as agomelatine. The anticonvulsant pregabalin is also a recommended first-line therapy.

If the response to optimal doses is inadequate or they do not tolerate the agent, we should switch therapy to another first-line agent before considering second-line medications. 

Second-line choices include bupropion XL, buspirone, hydroxyzine, imipramine, quetiapine XR, vortioxetine, and benzodiazepines, alprazolam, bromazepam, diazepam, and lorazepam.

We consider patients who do not respond to multiple courses of therapy to have a treatment-refractory illness. In such patients, it is important to reassess the diagnosis and consider comorbid medical and psychiatric conditions that may affect response to therapy. 

Third-line agents, adjunctive therapies, and biological and alternative therapies may be useful when patients cannot respond to an optimal treatment trial of first- and second-line therapies used alone and in combination.

Source: Canadian mood and anxiety network. 

Signs and Symptoms of Generalized Anxiety Disorder

Generalized anxiety disorder is characterized by excessive, uncontrollable, and often irrational worry about events or activities. Worry often interferes with daily functioning, and sufferers are overly concerned about everyday matters such as health, finances, death, family, relationship concerns, or work difficulties. Other symptoms may include restlessness, trouble sleeping, exhaustion, irritability, sweating, and trembling.

Symptoms must persist at least six months, for a formal diagnosis of generalized anxiety disorder. 

Individuals with a generalized anxiety disorder often suffer from other disorders including other psychiatric disorders (e.g., major depressive disorder), substance use disorder (especially alcohol use), obesity, and may have a history of trauma or family with a generalized anxiety disorder. 

Clinicians use screening tools such as the GAD-7 and GAD-2 questionnaires to determine if individuals may have a generalized anxiety disorder and warrant formal evaluation for the disorder. Other scales help clinicians to evaluate the severity of generalized anxiety disorder symptoms.

Diagnostic and Statistical Manual-5 Criteria

  1. Excessive anxiety or worry experienced most days over at least six months and involves several concerns.
  2. Inability to manage worry.
  3. At least three of the following occur:
    1. Restlessness
    2. Fatigability
    3. Problems concentrating
    4. Irritability
    5. Muscle tension
    6. Difficulty with sleep

In children, only one of the above items is required.

  1. One experiences significant distress in functioning (e.g., work, school, social life).
  2. Symptoms are not because of drug abuse, prescription medication, or other medical condition(s).
  3. Symptoms do not fit better with another psychiatric condition, such as panic disorder.

APA eliminated the requisite that the disorder does NOT occur entirely during a mood, psychotic, or pervasive developmental disorder eliminated. 

International Classification of Diseases-11 Criteria

Generalized anxiety disorder is characterized by marked symptoms of anxiety that persist for at least several months, for more days than not manifested by either general apprehension (i.e. ‘free-floating anxiety’) OR excessive worry focused on multiple everyday events, most often concerning family, health, finances, and school or work, together with additional symptoms such as 

  • muscle tension or restlessness, 
  • Autonomic overactivity, 
  • the subjective sense of nervousness, 
  • difficulty with concentration, 
  • irritability, or 
  • sleep disturbance. 

The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational, or other key areas of functioning. The symptoms are not a manifestation of another health condition and are not because of a substance or medication on the central nervous system.

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