What is Generalized Anxiety Disorder (GAD)?

Generalized Anxiety Disorder (GAD)

Generalized Anxiety Disorder (GAD) is characterized by excessive, uncontrollable worries regarding numerous everyday situations or activities, persisting for at least 6 months, and causing significant distress or impairment in functioning. 1, 2

Definition and Diagnostic Criteria

• GAD is defined in the DSM-5 as persistent and excessive anxiety and worry about various domains that the person finds difficult to control 1
• The anxiety and worry must be associated with at least three of the following symptoms: restlessness/feeling keyed up, being easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance 2
• Symptoms must persist for at least 6 months and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning 2, 3
• GAD must be distinguished from normal worries and fears that are common to everyday life experiences 1

Clinical Presentation

• Patients typically present with excessive worry about multiple areas beyond just health concerns 1
• Physical symptoms often include fatigue, sleep disturbances, muscle tension, and concentration difficulties 1, 3
• Autonomic hyperactivity may manifest as sweating, heart pounding, cold hands, dry mouth, dizziness, and gastrointestinal discomfort 3
• Vigilance and scanning behaviors include hyperattentiveness resulting in distractibility, difficulty concentrating, insomnia, feeling "on edge," irritability, and impatience 4
• The severity of symptoms ranges from mild to severe, with corresponding levels of functional impairment 1

Epidemiology and Burden

• GAD is the most frequent anxiety disorder in primary care, present in approximately 22% of primary care patients who complain of anxiety problems 5
• Higher prevalence rates are seen in primary care (8%) compared to the general population (12-month prevalence 1.9-5.1%) 5
• GAD affects women more frequently than men, with higher prevalence in midlife (10% in females over age 35) and older adults 5
• The natural course of GAD is typically chronic with few complete remissions and a waxing and waning pattern of symptoms 5
• GAD causes significant impairment and disability comparable to major depression, even when not complicated by comorbid conditions 5

Assessment Tools

• The 7-item Generalized Anxiety Disorder scale (GAD-7) is a validated diagnostic tool designed for primary care settings 1
• GAD-7 scores help stratify severity: 0-4 (minimal), 5-9 (mild), 10-14 (moderate), and 15-21 (severe) 1
• The ultra-brief GAD-2 (first two questions of GAD-7) can be used as an initial screening tool with a cutoff score of ≥3 indicating the need for further assessment 1
• Other validated measures include the Penn State Worry Questionnaire (PSWQ) and Generalized Anxiety Disorder Questionnaire-IV (GAD-Q-IV) 1

Differential Diagnosis and Comorbidities

• GAD must be distinguished from other anxiety disorders such as panic disorder, social anxiety disorder, and specific phobias 1
• Medical or substance-induced causes of anxiety symptoms should be ruled out 1
• Major depressive disorder commonly co-occurs with GAD, requiring assessment for depressive symptoms 6
• Substance use disorders may complicate the clinical picture and treatment approach 1

Treatment Approaches

Psychological Interventions

• Cognitive Behavioral Therapy (CBT) is the most strongly supported psychological treatment for GAD 6, 7
• Other effective approaches include behavioral activation techniques, relaxation training, and acceptance and commitment therapy 6, 8
• Psychological treatments have shown long-term benefits for GAD and may be useful alone or as adjuncts to pharmacotherapy 7

Pharmacological Treatment

• First-line pharmacological options include:
  • Selective Serotonin Reuptake Inhibitors (SSRIs) such as escitalopram 2, 9
  • Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) such as venlafaxine and duloxetine 9, 7
  • These medications address both anxiety symptoms and comorbid depression 8
• Other medication options include:
  • Buspirone for the management of anxiety disorder or short-term relief of anxiety symptoms 4
  • Benzodiazepines (e.g., alprazolam) for short-term treatment, though limited by side effects and dependency concerns 3, 8
  • Pregabalin and quetiapine have also shown efficacy in GAD 9

Treatment Based on Severity

• For mild GAD symptoms (GAD-7 score 5-9): Education, active monitoring, guided self-help based on CBT principles, and group psychosocial interventions 1
• For moderate to severe GAD symptoms (GAD-7 score ≥10): Referral to psychology and/or psychiatry for diagnosis and treatment, with consideration of combined CBT and pharmacotherapy 6
• For treatment-resistant GAD: Consider possible comorbid anxiety diagnoses and intensify psychological interventions with structured therapy 6, 10

Special Considerations

• Cultural factors may influence the presentation and assessment of GAD symptoms, requiring culturally sensitive approaches 1
• Long-term medication management is often necessary given the chronic nature of GAD 10
• Regular reassessment of treatment effectiveness is important, especially for medications used beyond 3-4 weeks 4
• The combination of psychological and pharmacological treatments may offer the best approach for achieving long-term benefits 7