Generalized Anxiety Disorder - GAD

With generalized anxiety disorder, you feel anxious about many things most of the time. Generalized anxiety disorder affects up to 6 percent of adults at some point in their life.[1][ If you have generalized anxiety disorder, you feel on edge, restless, irritable, exhausted, have trouble sleeping and concentrating.

The good news is that Generalized Anxiety Disorder (GAD) is treatable. A good place to begin is with an overview of anxiety including the symptoms, causes, and treatment.

Seven Symptoms of GAD

• Worry about many things most of the time
• Anxious most of the time, but don’t know why
• Worry that something bad is going to happen
• Restless, tremble, trouble relaxing
• Trouble concentrating
• Headaches, muscle aches, stomach aches, unexplained pains
• Trouble falling asleep, staying asleep, easily tired

Definition of Generalized Anxiety Disorder

Generalized Anxiety Disorder criteria based on the DSM-5 [2]

• Do you often worry about a number of everyday things to a degree that is out of proportion to the actual risk?
• Do you find it difficult to control your worry?
• Have you been worrying much of the time for at least 6 months?
• Has your worry contributed to at least three of the following symptoms?
• Restless, feeling on edge
• Tire easily
• Difficulty concentrating, or your mind going blank
• Irritable
• Muscle tension, teeth clenching
• Disturbed sleep (difficulty falling or staying asleep, or restless, unsatisfying sleep).
• Has your worry had a significant negative impact on your life (relationships, work, social, or emotional life).
• Your symptoms are not due to medication, substance abuse, or any other medical condition (e.g., hyperthyroidism).
• Your symptoms are not due to another mental health condition such as panic disorder, social anxiety disorder, obsessive-compulsive disorder, or post-traumatic stress disorder.

If you answered yes to all of the above criteria, you may meet the DSM definition of generalized anxiety disorder.

Tests

Medical Tests

Your health care provider can determine if your generalized anxiety disorder is caused by an underlying medical condition, such as heart disease or thyroid problems. This may require blood tests and an electrocardiogram (ECG). A complete assessment should also include questions about your caffeine and alcohol consumption, and any substance use, which can contribute to an anxiety disorder.

Standardized Screening Test for Generalized Anxiety Disorder

The Generalized Anxiety Disorder (GAD-7) screening test has been proven effective for the diagnosis of GAD.[3] There are also a number of screening tests for anxiety in general.[4]

Here is an online version of the Generalized Anxiety Disorder GAD-7 test (pdf).

Causes of Generalized Anxiety Disorder

Before looking at the treatment of generalized anxiety disorder, understanding the causes can help guide you to the appropriate treatment.

Negative Thinking

How you think about yourself and the world has a major impact on your mood and happiness. These are the common types of negative thinking that can lead to generalized anxiety disorder:

• All-or-Nothing Thinking: “I have to do things perfectly, and anything less is a failure.”
• Negative Self-Labeling and Low Self-Esteem: “I’m a failure. If people knew the real me, they wouldn’t like me. I am flawed.”
• Catastrophizing: “If something is going to happen, it’ll probably be the worst-case scenario. I don’t get a break.”

Suppose you make a mistake at work. Your level of anxiety depends on how you interpret that mistake. If you think that you have to be perfect, you will interpret that mistake as a major failure (all-or-nothing thinking). You may even take your mistake as proof that you are a failure (negative self-labelling). You may think that you’re doomed and you can never do well (catastrophizing).

If you apply these types of negative thinking to other areas of your life, you will become anxious about almost everything. You will be worried and fearful with little relief.

Maybe you apply negative thinking to your friendships: “They don’t really like me. They’re just pretending to be nice. My life’s a mess, and they’re probably tired of hearing about my problems.”

Maybe you apply negative thinking to your relationship: “I don’t know what they see in me. I wouldn’t blame them if they said they had enough.”

Substance Use

Smoking tobacco increases anxiety and the risk of developing an anxiety disorder.[5] Even moderate amounts of caffeine can increase adrenaline and cortisol levels and increase the risk of anxiety.[6] If you suffer from an anxiety disorder, the quickest thing you can do to reduce your anxiety is quit smoking tobacco and reduce your caffeine use.

Long-term substance abuse of drugs or alcohol leads to increased anxiety.[7,8,9] Even drugs that are initially calming, such as tranquilizers, alcohol, and marijuana will eventually cause increased anxiety.

Medical Causes

A number of medical conditions can cause anxiety symptoms. These include an overactive thyroid, hypoglycemia, mitral valve prolapse, anemia, asthma, COPD, inflammatory bowel disease, Parkinson's disease, and dementia among others. Your physician may perform certain tests to rule out these conditions. But it is important to remember that anxiety is more often due to poor coping skills or substance abuse than any medical condition.

Treatment of GAD

The main treatments for generalized anxiety disorder are cognitive behavioral therapy (CBT), mindfulness-meditation, and anti-anxiety medications.

Five Things You Can Do About Your Generalized Anxiety Disorder

• Quit smoking, reduce your alcohol and caffeine use. These can all cause or worsen anxiety symptoms.
• Review your over-the-counter medications such as diet pills and cold medications that can contain stimulants, which may trigger anxiety.
• Learn relaxation and stress-management techniques and make them part of your life. Develop healthy coping skills.
• Rule out any medical causes for your symptoms.
• Ask for help. Talk with a health professional about your anxiety. Review your thought patterns, and identify any negative thinking that can contribute to your anxiety.

Cognitive Therapy

If you don’t change the underlying negative thinking that causes your anxiety, then any other treatment will probably have only temporary benefits.

Cognitive behavioral therapy (CBT) changes your inner dialogue. It is a step-by-step method for identifying the negative thinking that contributes to your generalized anxiety disorder and replacing it with healthier ways of thinking. Numerous studies have shown that cognitive behavioral therapy is effective for treating all forms of anxiety.[10]

MRI studies have shown that the benefits of cognitive behavioral therapy are not just temporary. It has lasting benefits, because you change your own brain pathways through CBT, and they begin to reflect your new way of thinking.[11, 12]

Besides changing your thinking, cognitive behavioral therapy also has a behavioral component. The idea is to take small steps into your anxiety-provoking situations as you develop healthier thinking patterns. In this way you get to exercise your new coping skills and see that you can effectively deal with life without anxiety. (Learn more about cognitive behavioral therapy)

Stress Management, Meditation and Mindfulness for Anxiety

Stress management techniques such as meditation and mindfulness have been proven effective in treating anxiety disorders and are being incorporated into standard medical treatment.[13, 14] There are a number of stress management techniques to choose from. All are effective, and which one works for you is largely a matter of personal choice. Start slowly with ten minutes a day, and see how you will reduce your anxiety and change your life. (Learn more about stress management and mindfulness)

Anti-Anxiety Medication

Your doctor may prescribe medication to help treat your GAD. Research has shown that individuals treated with a combination of psychotherapy and medication have better outcomes than those treated with only one or the other. The two most common classes of medications used are antidepressants and benzodiazepines/ tranquilizers.

Benzodiazepines, also known as sedatives or tranquilizers, are sometimes prescribed for short-term management of severe anxiety. These medications are effective in rapidly decreasing anxiety, but they can cause dependence and addiction. If you take any benzodiazepine for longer than 3–4 weeks, you are likely to suffer withdrawal symptoms if you stop suddenly. Research suggests that to reduce the risk of dependence, you should only be prescribed a one- to two-week supply of benzodiazepines.[15,16]

Generalized anxiety disorder is treatable. The most important step you can take is reaching out and asking for help. You can change your life.

References

1. National Comorbidity Survey, Lifetime Prevalence of DSM-IV Disorders.  https://www.hcp.med.harvard.edu/ncs/ftpdir/NCS-R_Lifetime_Prevalence_Estimates.pdf.
2. American Psychiatric Association, DSM-5 The Diagnostic and Statistical Manual of Mental Disorders. 5 ed, ed. D. Kupfer: American Psychiatric Association.
3. Spitzer, R. L., Kroenke, K., Williams, J. B., & Lowe, B., A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med, 2006. 166(10): p. 1092-7.
4. Beidas, R. S., Stewart, R. E., Walsh, L., Lucas, S., et al., Free, brief, and validated: Standardized instruments for low-resource mental health settings. Cogn Behav Pract, 2015. 22(1): p. 5-19. PMC4310476.
5. Moylan, S., Jacka, F. N., Pasco, J. A., & Berk, M., Cigarette smoking, nicotine dependence and anxiety disorders: a systematic review of population-based, epidemiological studies. BMC Med, 2012. 10: p. 123. PMC3523047.
6. Lane, J. D., Adcock, R. A., Williams, R. B., & Kuhn, C. M., Caffeine effects on cardiovascular and neuroendocrine responses to acute psychosocial stress and their relationship to level of habitual caffeine consumption. Psychosom Med, 1990. 52(3): p. 320-36.
7. Kushner, M. G., Sher, K. J., & Beitman, B. D., The relation between alcohol problems and the anxiety disorders. Am J Psychiatry, 1990. 147(6): p. 685-95.
8. Poyares, D., Guilleminault, C., Ohayon, M. M., & Tufik, S., Chronic benzodiazepine usage and withdrawal in insomnia patients. J Psychiatr Res, 2004. 38(3): p. 327-34.
9. Substance Abuse Treatment for Persons With Co-Occurring Disorders No 42: Substance Abuse and Mental Health Services Administration (SAMHSA US), 2005.
10. Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T., The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clin Psychol Rev, 2006. 26(1): p. 17-31.
11. Beutel, M. E., Stark, R., Pan, H., Silbersweig, D., et al., Changes of brain activation pre- post short-term psychodynamic inpatient psychotherapy: an fMRI study of panic disorder patients. Psychiatry Res, 2010. 184(2): p. 96-104.
12. Linden, D. E., How psychotherapy changes the brain--the contribution of functional neuroimaging. Mol Psychiatry, 2006. 11(6): p. 528-38.
13. Manzoni, G. M., Pagnini, F., Castelnuovo, G., & Molinari, E., Relaxation training for anxiety: a ten-years systematic review with meta-analysis. BMC Psychiatry, 2008. 8: p. 41. PMC2427027.
14. Vollestad, J., Nielsen, M. B., & Nielsen, G. H., Mindfulness- and acceptance-based interventions for anxiety disorders: a systematic review and meta-analysis. Br J Clin Psychol, 2012. 51(3): p. 239-60.
15. Ashton, H., The diagnosis and management of benzodiazepine dependence. Curr Opin Psychiatry, 2005. 18(3): p. 249-55.
16. Brett, J., & Murnion, B., Management of benzodiazepine misuse and dependence. Aust Prescr, 2015. 38(5): p. 152-5. PMC4657308.