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Generalized Anxiety Disorder (GAD)

Diagnostic Criteria

  1. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
  2. The person finds it difficult to control the worry.
  3. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months).
    Note: Only one item is required in children.
    1. restlessness or feeling keyed up or on edge
    2. being easily fatigued
    3. difficulty concentrating or mind going blank
    4. irritability
    5. muscle tension
    6. sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
  4. The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not about having a Panic Attack (as in Panic Disorder), being embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive-Compulsive Disorder), being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder), or having a serious illness (as in Hypochondriasis), and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder.
  5. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  6. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder.

Treatment Options

  1. Therapy
    • Psychotherapy: Most patients with mild symptoms can be treated with supportive counseling and education without need for medication.
    • Other therapies: Relaxation training and cognitive therapy.
  2. General measures: Regular exercise and avoidance of caffeine and alcohol.
  3. Medications:
    • Tricyclic Antidepressants (TCAs). Imipramine 25 to 150 mg/day. Does not become effective for 2 to 3 weeks. Most beneficial in patients with comorbid depression or sleep disturbance.
    • Antihistamines. Hydroxyzine (Atarax, Vistaril) 50 to 100 mg QID may be used PRN, as an adjunct to other medications, or as an alternative therapy for patients with addiction potential.
    • Benzodiazepines. Usually of short-term use with no long-term efficacy proved. Use lowest dose that alleviates anxiety. Longer half-life drugs may be easier to taper. May cause rebound anxiety with taper or withdrawal. Examples: Alprazolam (Xanax) 0.25 to 0.5 mg PO TID initial dose; rarely need to exceed 4 mg/day. Diazepam (Valium) 2 to 10 mg PO BID to QID. Lorazepam (Ativan) 1 mg PO BID or TID initially; rarely need to exceed 10 mg/day. Use lower doses than above in the elderly.
    • Buspirone. May be less effective than other agents. Start 5 mg PO TID and increase to typical dose of 20 to 30 mg/day. Takes 2 weeks to be effective. Nonsedating. Little abuse potential.
    • Selective Serotonin Reuptake Inhibitors (SSRIs). Clinically appear helpful but not well studied yet. Use in doses similar to those for Panic Disorder. In select patients may add a benzodiazepine for first several weeks of treatment, since it has a quicker onset of action and avoids potential initial side effect of increased anxiety with SSRIs (Prozac, Paxil, Luvox, Zoloft).
    • Beta-blockers. Propranolol (Inderal) may help physical symptoms (not FDA approved) but has no effect on psychic component of anxiety.

Associated Feature

  • Depressed Mood
  • Somatic or Sexual Dysfunction
  • Anxious or Fearful or Dependent Personality

Differential Diagnosis

Some disorders have similar or even the same symptoms. The clinician, therefore, in his diagnostic attempt has to differentiate against the following disorders which he needs to rule out to establish a precise diagnosis.

  • Anxiety Disorder Due to a General Medical Condition;
  • Substance-Induced Anxiety Disorder;
  • Panic Disorder;
  • Social Phobia;
  • Obsessive-Compulsive Disorder;
  • Anorexia Nervosa;
  • Hypochondriasis;
  • Somatization Disorder;
  • Separation Anxiety Disorder;
  • Obsessional thoughts;
  • Posttraumatic Stress Disorder;
  • Adjustment Disorder;
  • Mood Disorders;
  • Psychotic Disorders;
  • Nonpathological anxiety