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Generalized Anxiety Disorder

Sadaf Munir; Veronica Takov.

Author Information and Affiliations

Last Update: October 17, 2022.

Continuing Education Activity

Generalized anxiety disorder is a mental health disorder that produces fear, worry, and a constant
feeling of being overwhelmed. It is characterized by excessive, persistent, and unrealistic worry
about everyday things. This activity illustrates the evaluation and management of generalized
anxiety disorder and explains the interprofessional team's role in managing patients with this
condition.

Objectives:

Summarize the etiology of generalized anxiety disorder.

Describe the use of the Generalized Anxiety Disorder 7-Item Questionnaire in the
evaluation of generalized anxiety disorder.

Identify the use of cognitive-behavioral therapy in the management of patients with a

generalized anxiety disorder.

Outline the importance of collaboration and communication among the interprofessional

team to enhance care delivery for patients affected by a generalized anxiety disorder.

Access free multiple choice questions on this topic.

Introduction
Generalized anxiety disorder is one of the most common mental disorders. Up to 20% of adults
are affected by anxiety disorders each year. Generalized anxiety disorder produces fear, worry,
and a constant feeling of being overwhelmed. Generalized anxiety disorder is characterized by
persistent, excessive, and unrealistic worry about everyday things. This worry could be
multifocal such as finance, family, health, and the future. It is excessive, difficult to control, and
is often accompanied by many non-specific psychological and physical symptoms. Excessive
worry is the central feature of generalized anxiety disorder.[1][2][3]

Diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition
(DSM-5) include the following:

Excessive anxiety and worry for at least six months

Difficulty controlling the worrying.

The anxiety is associated with three or more of the below symptoms for at least 6 months:

1. Restlessness, feeling keyed up or on edge

2. Being easily fatigued

 3. Difficulty in concentrating or mind going blank, irritability

4. Muscle tension

5. Sleep disturbance

6. Irritability

The anxiety results in significant distress or impairment in social and occupational areas

The anxiety is not attributable to any physical cause

Etiology
The etiology may include:

Stress

A physical condition such as diabetes or other comorbidities such as depression

Genetic, first-degree relatives with generalized anxiety disorder (25%)

Environmental factors, such as child abuse

Substance use disorder

Epidemiology
Childhood anxiety occurs in about 1 in 4 children at some time between the ages of 13 and 18
years. The median age at onset is 11 years. However, the lifetime prevalence of a severe anxiety
disorder in children ages 13 to 18 is approximately 6%. General prevalence in children younger
than 18 years is between 5.7% and 12.8%. The prevalence is approximately twice as high among
women as among men.[4][5][6]

The American Psychiatric Association first introduced the diagnosis of generalized anxiety
disorder two decades ago in the DSM-III. Before that time, generalized anxiety disorder was
conceptualized as one of the two core components of anxiety neurosis, the other being panic. A
recognition that generalized anxiety disorder and panic, although often occurring together, are
sufficiently distinct to be considered independent disorders led to their separation in the DSM-III.

The DSM-III definition of generalized anxiety disorder required uncontrollable and diffuse (i.e.,
not focused on a single major life problem) anxiety or worry that is excessive or unrealistic
relative to objective life circumstances and persists for one month or longer. Several related
psychophysiological symptoms were also required for a diagnosis of generalized anxiety
disorder. Early clinical studies evaluating DSM-III, according to this definition, found that the
disorder seldom occurred in the absence of another comorbid anxiety or mood disorder.
Comorbidity of generalized anxiety disorder and major depression was especially strong and led
some commentators to suggest that generalized anxiety disorder might better be conceptualized
as a prodrome, residual, or severity marker than as an independent disorder. The rate of
comorbidity of generalized anxiety disorder with other disorders decreases as the duration
of generalized anxiety disorder increases. Based on this finding, the DSM-III-R committee
on generalized anxiety disorder recommended that the duration required for the disorder be
increased to six months. This change was implemented in the final version of the DSM-III-R.
Additional changes in the definition of excessive worry and the required number of associated
psychophysiological symptoms were made in the DSM-IV.

These changes in diagnostic criteria led to delays in cumulating data on the epidemiology
of generalized anxiety disorder. Nonetheless, such data became available over the past decade.
As described in more detail later, this new data challenged the view that generalized anxiety
disorder should be conceptualized as a prodrome, residual, or severity marker of other disorders.
Instead, it suggests that generalized anxiety disorder is a common disorder that, although often
comorbid with other mental disorders, does not have a higher comorbidity rate than those found
in most other anxiety or mood disorders. The new data also challenged the validity of the
threshold decisions embodied in the DSM-5.

Pathophysiology
The exact mechanism is not entirely known. Anxiety can be a normal phenomenon in children.
Stranger anxiety begins at seven to nine months of life. Noradrenergic, serotonergic, and other
neurotransmitter systems appear to play a role in the body's response to stress. The serotonin
system and the noradrenergic systems are common pathways involved in anxiety. Many believe
that low serotonin system activity and elevated noradrenergic system activity are responsible for
its development. Therefore, it is selective serotonin reuptake inhibitors (SSRI) and serotonin-
norepinephrine reuptake inhibitors (SNRI) that are the first-line agent for its treatment.

History and Physical

Patients with anxiety can pose a diagnostic challenge, as somatic symptoms are more common
than psychological symptoms. Most patients present with vague or nonspecific somatic
complaints, including, but not limited to, shortness of breath, palpitations, fatigability, headache,
dizziness, and restlessness. Patients may also describe psychologic symptoms such as excessive,
nonspecific anxiety and worry, emotional lability, difficulty concentrating, and insomnia.

Factors commonly associated with generalized anxiety include:

Female gender

Unmarried

Poor health

Low education

Presence of stressors

The median age of presentation is 30 years.

Many scales have been developed to assess the severity and diagnosis. The GAD-7 has been
validated as a diagnostic tool and severity assessment scale.

Evaluation
Initial assessment begins by addressing behavioral or somatic symptoms. Evaluate for
psychosocial stress, psychosocial difficulties, and developmental issues. Review past medical
history, including trauma, psychiatric conditions, and substance abuse.[7]

The following evaluation may be obtained to exclude organic causes:

 Thyroid function tests

Blood glucose level

Echocardiography

Toxicology screen

The Generalized Anxiety Disorder 7-Item (GAD-7) Questionnaire is a screening tool that can
also be used to monitor patients with generalized anxiety disorder.

Treatment / Management
The two main treatments for generalized anxiety disorder are cognitive behavioral therapy and
medications. Patients may benefit most from a combination of the two. It may take some trial
and error to discover which treatments work best.[8][9][10]

Cognitive Behavioral Therapy

This includes psychoeducation, changing maladaptive thought patterns, and gradual exposure to
anxiety-provoking situations.

Pharmacotherapy

Patients who do not respond to cognitive behavioral therapy may be treated with medications.
Some patients with severe symptoms are treated with both initially. Several types of medications
are used to treat generalized anxiety disorder.

Antidepressants

Selective serotonin reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor

(SNRI) classes are the first-line agents with a response rate of 30% to 50%. This class of drugs
includes escitalopram (Lexapro), duloxetine (Cymbalta), venlafaxine (Effexor XR), and
paroxetine (Paxil, Pexeva). In a study, 81% of children with anxiety disorders who received
combined sertraline hydrochloride and CBT responded to the treatment.

Antipsychotics may also help some patients, especially those with associated behavior problems.

Benzodiazepines

Examples are diazepam and clonazepam, which are long-acting agents. These agents are used
when an immediate reduction of symptoms is desired, or a short-term treatment is needed.
Generally, cooperative and compliant patients who are aware that their symptoms have a
psychological basis are more likely to respond to benzodiazepines. Since there is a concern for
misuse and dependence, patients with a history of alcoholism or drug abuse are not appropriate
candidates for this treatment.

Buspirone

Buspirone is a non-benzodiazepine that does not cause dependency. It is also less sedating than
benzodiazepines, and tolerance does not occur at therapeutic doses. This agent has a therapeutic
lag in the efficacy of two to three weeks, limiting its use.

All medications should be titrated slowly and continued for at least 4 weeks to determine if they
work. Once symptoms are under control, the medications need to be used for at least 12 months
before gradually tapering them. Every medication has adverse effects like weight gain,
hyperlipidemia, and diabetes; thus, the patients need to be monitored.

Psychotherapy is used in addition to medications; this combination has proven to be effective.

The education of the patient is vital as it can help ease anxiety. The triggers for anxiety should be
managed by avoiding caffeine, alcohol, nicotine, and stress) and improving sleep.

Many complementary and alternative remedies are available, but the evidence to support their
efficacy is lacking. Further, some agents like Kava may injure the liver. Others, like St John's
wort and hydroxytryptophan, may interact with SSRIs and induce serotonin syndrome.

Differential Diagnosis

Hyperthyroidism

Pheochromocytoma

Chronic obstructive pulmonary disease

Transient ischemic attack

Epilepsy

Bipolar disorder

Use of caffeine, decongestants, and albuterol

Prognosis
The prognosis for patients with generalized anxiety disorder is guarded. Many patients are not
compliant with medications because of cost and adverse effects. Relapses are common, and
patients often search for physicians who comply with their needs. Because of the lack of
conventional medicine to cure the disorder, many opt for alternative therapies without much
success. Overall, the quality of life of these patients is poor.

Complications
Complications of generalized anxiety disorder can also lead to, or worsen, other mental and
physical conditions[11]:

Depression (often presents concomitantly with an anxiety disorder)

Insomnia

Drug or alcohol use disorder

Gastrointestinal problems

Social isolation

Issues functioning at work/school

Impaired quality of life

Suicide potential

Deterrence and Patient Education

Patients with anxiety disorders need to understand the importance of medication compliance
(anxiolytics, antidepressants, sleep inducers), working with any cognitive therapy prescribed, and
the benefit of stopping the use of caffeine or other stimulants.

Pearls and Other Issues

Consider further evaluation for anxiety disorder if an adult is excessively anxious or an infant or
child is excessively clingy and difficult to console during the pediatric visit. Many medical
conditions may mimic anxiety disorders. One should distinguish between anxiety and illness and
should evaluate for organic diseases before making this diagnosis.

Enhancing Healthcare Team Outcomes

Anxiety disorders are very common and can have a diverse presentation of signs and symptoms.
The condition has very high morbidity and mortality and is best managed by an interprofessional
team that includes a mental health nurse, pharmacist, psychologist, psychiatrist, and primary care
provider. Many patients have moderate to severe symptoms, which lead to poor quality of life.
Most have no idea that the condition can be treated. Thus, the key to improving outcomes is
patient education. The nurse practitioner, pharmacist, and primary care provider should urge the
patient to stop tobacco, alcohol, and caffeinated beverages. Also, relief of stress is vital, and thus
a referral for cognitive behavior therapy may help.

Many drugs can be used to treat anxiety, but they all have side effects, which is a common reason
for non-compliance. The pharmacist should emphasize the benefits of these medications and urge
compliance to improve the symptoms. At the same time, the primary care provider should
monitor for hyperlipidemia, diabetes, and weight gain due to the medications.

Overall, anxiety disorders are underdiagnosed and undertreated. When left untreated, anxiety
disorders often lead to severe depression and abuse of drugs and alcohol. Additionally, there is a
high rate of suicide among these patients. Many patients with chronic anxiety have a poor quality
of life. The education of both the patient and family by the pharmacist, nurse, and provider as a
team is important to reduce the high morbidity and addiction problems with treatment
medications. Family members should help ensure medication compliance and provide a
supportive environment. Unfortunately, despite optimal treatment, relapse rates are high.[12][13]
[14] [Level 5]

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Disclosure: Sadaf Munir declares no relevant financial relationships with ineligible companies.

Disclosure: Veronica Takov declares no relevant financial relationships with ineligible companies.

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