Generalized Anxiety Disorder

What Is It?

In generalized anxiety disorder, a person has frequent or nearly constant, nagging feelings of worry or anxiety. These feelings are either unusually intense or out of proportion to the real troubles and dangers of the person's everyday life.

The disorder is defined as persistent worry for more days than not, for at least several months. In some cases, a person with generalized anxiety disorder feels he or she has always been a worrier, even since childhood or adolescence. In other cases, the anxiety may be triggered by a crisis or a period of stress, such as a job loss, a family illness or the death of a relative. The crisis or stress may have ended, but an unexplained feeling of anxiety may last months or years.

In addition to suffering from constant (or non-stop) worries and anxieties, people with generalized anxiety disorder may have low self-esteem or feel insecure. They may see people's intentions or events in negative terms, or they experience them as intimidating or critical. Physical symptoms may lead them to seek treatment from a primary care doctor, cardiologist, pulmonary specialist or gastroenterologist. Stress can intensify the anxiety.

Some people with this disorder have a genetic (inherited) tendency to develop it. The disorder probably stems from how a variety of brain structures communicate with each other as the individual tries to manage the fear response. Life experience, significant relationships and environmental stresses also influence the development of this disorder.

About 3% to 8% of people in the United States have generalized anxiety disorder. Women have the problem twice as often as men. The average adult patient first seeks professional help between the ages of 20 and 30. However, the illness can occur at any age. Generalized anxiety disorder also has been diagnosed in young children, teenagers and elderly people. The illness is the most common anxiety disorder affecting people age 65 and older.

Of all psychiatric illnesses, generalized anxiety disorder is the least likely to occur alone. Between 50% and 90% of people with the disorder also have at least one other problem, usually panic disorder, a phobia, depression, alcoholism or some other form of substance abuse.

Symptoms

In generalized anxiety disorder, the person has persistent worry or anxiety that lasts for at least several months. (The diagnostic manual in psychiatry sets the minimum to 6 months, but you don't need to use a precise timer to seek help.)

Worry or anxiety is excessive, troubling and hard to control. It often interferes with the ability to function at home, at work or in social situations.

Here are some of the other defining symptoms or behaviors common in the disorder:

• Feeling restless or keyed up

• Having tense muscles

• Having difficulty concentrating or remembering (your mind goes blank)

• Having trouble falling asleep or staying asleep, or not feeling rested after sleep

• Avoiding activities that could turn out badly (avoiding even small risks)

• Spending excessive effort preparing for events that could have a negative outcome

• Procrastinating or having trouble making decisions

• Worrying that leads to repeatedly asking for reassurance

People with generalized anxiety disorder also may have physical symptoms that feel like symptoms of heart disease, respiratory illness, digestive diseases and other medical illnesses.

Diagnosis

You may consult a primary care doctor first if you suspect your physical symptoms are part of a medical illness. Your doctor may do tests to check for medical problems. If the results are normal, your doctor may ask about your family history, your history of any mental distress, current anxieties, recent stresses, and daily use of prescription and nonprescription drugs. Some drugs can cause anxiety symptoms. The doctor then may refer you to a psychiatrist for care.

A psychiatrist will diagnose generalized anxiety disorder based on a full psychiatric evaluation that includes:

• Asking you to describe your worries, anxieties and anxiety-related symptoms.

• Determining how long you have had these symptoms.

• Assessing how worry and anxiety have affected your ability to function normally at home, at work and socially.

• Checking for symptoms of other forms of psychiatric illness that might be present at the same time as generalized anxiety disorder. Symptoms of depression are very common in someone with this disorder.

Expected Duration

Although the diagnosis of generalized anxiety disorder may be made after several months of symptoms, the condition can last years, especially without treatment. Many people experience the symptoms as part of a lifelong pattern.

Prevention

Since stress is a normal part of life, there is usually no way to prevent generalized anxiety disorder in someone who is vulnerable. However, once diagnosed, various treatments can effectively reduce symptoms.

Treatment

If you have generalized anxiety disorder, the most effective treatment is usually a combination of medications and psychotherapy. Research shows that using both has a more lasting positive effect than either one alone. Your doctor may also offer treatment for other conditions that may be making matters worse, such as a medical problem or depression.

You may need to try more than one approach before you find the right one. Many different kinds of medications can relieve anxiety. Here are the most common categories prescribed:

Antidepressants — Despite their name, many of these drugs are very effective for anxiety. They are used very commonly to treat generalized anxiety disorder. The popular selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac), sertraline (Zoloft) and escitalopram (Lexapro) are often the first choice. Antidepressants that have a different mechanism of action work too. Examples are mirtazapine (Remeron), venlafaxine (Effexor) and duloxetine (Cymbalta). Older antidepressants are also effective. They include tricyclic antidepressants (for example, nortriptyline, imipramine) and monoamine oxidase inhibitors (MAOIs, for example, phenelzine). Since antidepressants often take several weeks to work, your doctor may also prescribe a fast-acting benzodiazepine for relief.

Benzodiazepines — These drugs affect a chemical messenger that works in the brain's fear response system. Examples of benzodiazepines are clonazepam (Klonopin), lorazepam (Ativan), diazepam (Valium) and alprazolam (Xanax). They are reasonably safe and often bring quick relief from symptoms of anxiety. Since they act immediately, they may be prescribed during the first weeks of treatment while waiting for an antidepressant medication to take hold. Another reason these drugs are prescribed for a relatively short time is that the body sometimes becomes accustomed to the effect. That is, benzodiazepines may provide less relief as time goes on. If you need to stop taking these drugs, do so gradually under a doctor's direction, because withdrawal reactions can occur.

Buspirone (BuSpar) — Buspirone is an antianxiety drug that can be effective for generalized anxiety disorder. However, it is used much less frequently than the drugs listed above. Like antidepressants, it usually takes two to three weeks to begin working.

Psychotherapy

A number of psychotherapy techniques may be helpful. Here are some examples:

• Cognitive behavioral therapy helps you recognize and change unreasonable patterns of thinking and behavior.

• Psychodynamic or insight-oriented psychotherapy helps you understand the history behind your symptoms. For example, you may become more aware of how you have carried past fears into the present day. This insight may help you face challenges more confidently now.

• Interpersonal psychotherapy can help you sort out anxiety-provoking conflicts in important relationships and resolve them more effectively.

• Exposure and desensitization is a behavioral technique that provides support so you can confront a specific fear and overcome it. It is particularly helpful when anxiety is causing you to avoid important tasks or responsibilities.

• Applied relaxation teaches people with generalized anxiety disorder to control their symptoms by using imagination and muscle control. Relaxation techniques, such as diaphragmatic breathing, meditation and visualization, can relieve some of the more bothersome physical symptoms.

• Biofeedback uses special sensors attached to the skin to teach people with generalized anxiety disorder to recognize anxiety-related changes in their physiological functions, for example, pulse, skin temperature and muscle tone. With time and practice, patients learn to modify these anxiety-related changes and to control the effect of anxiety on the entire body.

Your therapist may combine any of the above approaches or may discuss others — for example, meditation, hypnosis or exercise — with you so that the approach fits your specific problems and needs.

When To Call a Professional

See your doctor if you are troubled by severe worry or anxiety, especially if:

• Your anxious feelings have lasted for several months.

• You feel that you can no longer control your anxious feelings, and this causes you to spend unreasonable amounts of time managing your symptoms.

• Your constant anxiety is interfering with your personal relationships or with your ability to function normally at home, at school or at work.

• You are having difficulty concentrating or remembering.

• You are having trouble sleeping.

• You have unexplained physical symptoms that may be anxiety-related.

Prognosis

In general, the outlook is good. With appropriate treatment, about 50% of patients improve within 3 weeks of starting treatment, and 77% improve within 9 months.

External resources

American Psychiatric Association
1000 Wilson Blvd.
Suite 1825
Arlington, VA 22209-3901
Phone: 703-907-7300
Toll-Free: 1-888-357-7924 (1-888-35-PSYCH)
http://www.psychiatry.org/

National Institute of Mental Health
Science Writing, Press, and Dissemination Branch
6001 Executive Boulevard, Room 6200, MSC 9663
Bethesda, MD 20892-9663
1-866-615-6464 (toll-free)
1-301-443-8431 (TTY)
1-866-415-8051 (TTY toll-free)
Available in English and Spanish
Monday through Friday
8:30 a.m. to 5:00 p.m. ET
http://www.nimh.nih.gov/

Anxiety and Depression Association of America
8701 Georgia Ave., Suite 412
Silver Spring, MD 20910
Phone: 240-485-1001
http://www.adaa.org/

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