General Anxiety Disorder

If you've ever been in a car accident, especially one you may have caused, you know first-hand that it can be an extremely stressful situation. It is not uncommon to feel anxious about dealing with your insurance company or not having a car. However, people with generalized anxiety disorder may experience anxiety in this situation much higher than average, or, they may experience this level of anxiety during normal daily activities and events. Generalized anxiety disorder affects approximately 5% of children and adolescents and between 3–6% of adults (Strawn et al., 2018).¹

• What is generalized anxiety disorder?
• What are symptoms of generalized anxiety disorder?
• What are possible causes of generalized anxiety disorder?
• What are treatments for generalized anxiety disorder?

Definition of Generalized Anxiety Disorder

Everyone experiences anxiety from time to time. It’s not uncommon for occasional worries about health or money to arise for many people. However, people who have been diagnosed with generalized anxiety disorder (GAD) experience anxiety consistently and for a longer period of time. This begins to interfere with the person’s daily tasks and quality of life.

For people with generalized anxiety disorder, they may feel more extreme worry about health or money than would be expected. Or, sometimes there is no clear reason at all for their anxiety.

Symptoms of Generalized Anxiety Disorder

While the median age of onset for generalized anxiety disorder is 30 years, it can vary greatly. Many people may begin developing symptoms as early as childhood and adolescence while others may not begin to develop symptoms until older adulthood (Wittchen et al., 1994).² The onset of GAD is usually gradual and can have a variety of symptoms. In addition to constant worrying, people with a generalized anxiety disorder may experience other cognitive symptoms including:

• Constant overthinking of plans and solutions

• Difficulty making decisions or fear of making the wrong decision

• Fixation on potential threats

• Difficulty concentrating

• Irritability

• Feelings of helplessness

Constantly feeling stressed or worried can also cause physical symptoms as well. These may include:

• Chest pain

• Heart palpitations

• Fatigue

• Muscle aches

• Trouble sleeping

• Restlessness

• Dizziness

• Gastrointestinal problems

He may be experiencing insomnia due to anxiety. Freepik.com

These symptoms can present differently for everyone, especially children and adolescents. For example, symptoms of generalized anxiety disorder for a teenager may look like this:

Potential Causes of Generalized Anxiety Disorder

Generalized anxiety disorder can have many causes. For one, GAD can run in the family, suggesting there may be some genetic factors involved. Several twin studies have found strong evidence that there is a genetic component and that GAD has a heritability of about 30% (Gale & Browne, 2003).³

Brain chemistry and function can also play a role in GAD. For example, Hölzel et al. (2013)⁴ found that patients with a generalized anxiety disorder had a higher amygdala activation to facial expressions than healthy patients. This aligns with other studies that found that individuals with GAD have a more difficult time with emotional regulation as well as understanding their own emotions. (Marganska et al., 2013).⁵ Patients may also have an imbalance of brain chemicals such as norepinephrine and serotonin.

Finally, environmental risk factors can also increase a person's likelihood of developing generalized anxiety disorder such as constant exposure to stressful situations. For example, studies have found that childhood trauma and low socioeconomic status may also increase one's risk of GAD (Stein & Sareen, 2015).⁶ Additionally, constant caffeine or tobacco use, as well as other drug or alcohol misuse, may also trigger its onset.

Smoking can be a risk factor for developing a generalized anxiety disorder. Pikwizard.com

Diagnosis of Generalized Anxiety Disorder

To make a generalized anxiety disorder diagnosis, the patient must meet certain criteria. As aforementioned, experiencing anxiety occasionally is normal for everyone, however, GAD can be disabling and constantly interfere with daily functioning. For someone to be diagnosed with GAD, they must experience all of the following, as outlined in the DSM-V:

1. Excessive worry and anxiety about several activities, topics, or events. This worry is constant and occurs nearly every day for at least 6 months.

2. Worry is difficult or impossible to control and can shift from one topic to another.

3. At least three of the following symptoms are present alongside the anxiety and worry (for children, only one of the symptoms is required):

   • Fatigue

   • Difficulty concentration/impaired cognition

   • Irritability

   • Muscle aches or soreness

   • Insomnia

   • Edginess or restlessness

There are several assessment scales available that can be used to diagnose GAD. The GAD-7, for example, is one method of diagnosing generalized anxiety disorder. It is a self-assessment consisting of 7 questions. Scores range from 0 to 21 and a score of 10 or more suggests good diagnostic sensitivity. Other assessments include the Structured Clinical Interview for DSM Disorders (SCID) and the Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5).

One of the most important steps in diagnosing generalized anxiety disorder is to rule out other possible medical or mental health conditions. For example, it is easy to confuse GAD for major depressive disorder (MDD) because many of the symptoms are the same (i.e. fatigue and irritability) and they are often comorbid. However, the major difference between the two diagnoses is the presence of anhedonia.

Other medical and mental health conditions must be ruled out as well such as epilepsy, heart disease, bipolar disorder, and thyroid disorder, all of which my cause high levels of anxiety. Additionally, drug and alcohol use, though a possible risk factor, must also be ruled out as a primary cause of any presenting symptoms.

Treatment for Generalized Anxiety Disorder

Several generalized anxiety disorder treatments have proven successful including lifestyle modifications, psychotherapy, and medication. Additionally, patients must be routinely screened for depression and suicidality due to the comorbidity of these disorders. Simple lifestyle modifications can be effective in reducing some GAD symptoms. For example, patients may adjust their routine to practice good sleep behaviors such as creating a sleep schedule, avoiding smoking at night, and turning off all screens before bed. Other practices such as breathwork can help decrease anxiety and shallow breathing that often accompanies anxiety.

Cognitive Behavior Therapy (CBT)

Several forms of psychotherapy can be used to treat GAD. For example, cognitive behavior therapy (CBT) is effective in addressing a patient's tendency to overestimate the level of danger in their environment and underestimate their ability to cope (Stein & Sereen, 2015).⁶ In CBT, the goal is to help the patient restructure their thinking to understand that their worry is counterproductive. This may involve methods such as exposure therapy and relaxation training. CBT can be in the form of weekly individual sessions, group-based sessions, or phone sessions depending on the patient's accessibility.

Mindfulness-based Therapies

Another effective psychotherapy used to treat generalized anxiety disorder are mindfulness-based therapy. To address the lack of emotional regulation and awareness often present for individuals with GAD, mindfulness-based interventions focus on helping the patient be more aware of the present moment with an open and non-judgemental attitude (Hölzel et al., 2016).⁴ For example, acceptance and commitment therapy helps patients focus on their present, core values that should overshadow their symptoms.

Psychodynamic Therapy

Finally, psychodynamic therapy is effective in addressing underlying conflicts that are potential sources of the anxiety and worry a patient is experiencing. A psychoanalyst may explore past childhood traumas and life stressors that may be causing the GAD symptoms.

Medication for Generalized Anxiety Disorder

While psychotherapy treatments are efficacious in fostering better emotional regulation and helping clients become more comfortable with emotional experiences (Mennin et al., 2002),⁷ additional support from medication may be required for some individuals with generalized anxiety disorder. Some causes of GAD may be related to brain chemistry, specifically in the regulation of serotonin. Therefore, antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are often used to treat GAD. SSRI medications include:

• Fluoxetine (Prozac)

• Sertraline (Zoloft)

• Paroxetine (Paxil)

• Citalopram (Celexa)

Medications can be very helpful in reducing generalized anxiety disorder symptoms. Freepik.com

SNRI medications include:

• Venlafaxine (Effexor)

• Duloxetine (Cymbalta)

Benzodiazepines, on the other hand, balance brain chemistry by binding to the GABA receptor. These medications often offer immediate relief and may include:

• Diazepam (Valium)

• Alprazolam (Xanax)

• Clonazepam (Klonopin)

• Chlordiazepoxide (Librium)

While effective, benzodiazepines can be habit-forming and may lead to misuse. They are also not good for people who are predisposed to substance-use disorders. Another generalized anxiety disorder medication that can be effective in treating more mild cases is antihistamines (i.e. hydroxyzine) and beta-blockers (i.e. propranolol). Neither of these medications is habit-forming and, unlike antidepressants, they can be taken only when needed rather than every day.

While both psychotherapy and pharmacotherapy (medications) have proven efficacious in reducing GAD symptoms on their own, many experts suggest that psychotherapy can be used to enhance the response of medications (Strawn et al., 2018)¹. Stein and Sareen (2015)⁶ suggest that psychotherapy such as CBT should be the first step and pharmacotherapy should be added only if needed.