Generalized anxiety disorder

An anxiety disorder characterized by persistent, excessive worry about multiple everyday things (such as work, health, finances) on most days for ≥6 months, often accompanied by physical symptoms (e.g., restlessness, muscle tension, sleep disturbance).

• Very common (∼3% yearly prevalence, twice as common in women) and often underdiagnosed. Chronic excessive anxiety leads to distress, impaired daily functioning (poor concentration, fatigue, missed work), and high healthcare utilization due to frequent worry-driven visits. Early recognition and treatment can greatly improve quality of life and reduce the risk of depression or self-medication (e.g., alcohol use).

• Chronic "worrier" who anticipates the worst about many areas (health, family, finances, work) for months or years. They often report difficulty controlling the worry and feeling constantly on edge, with frequent irritability and fatigue.
• Physical symptoms are common: patients may have tension headaches, GI upset (e.g., irritable bowel symptoms), palpitations, or insomnia. They often make repeated medical visits for these somatic complaints, which are ultimately attributed to anxiety after tests come back normal.
• On mental status exam, the person appears restless or tense but without delusions or cognitive impairment. There are no discrete panic attacks or specific phobic triggers—rather the anxiety is "free-floating." GAD usually has a gradual onset in teens or early adulthood and tends to be long-term (fluctuating with stress).

1. Ensure DSM-5 criteria are met: anxiety/worry occurring most days ≥6 months, difficulty controlling the worry, ≥3 associated symptoms (restlessness, fatigue, poor concentration, irritability, muscle tension, sleep disturbance), causing significant distress or dysfunction and not due to substances or another illness.
2. Rule out medical causes of anxiety: perform a focused workup for conditions like hyperthyroidism (check TSH), cardiac arrhythmias (if palpitations), substance abuse (caffeine, stimulant use), etc. Also review medications that can cause anxiety (e.g., bronchodilators, steroids).
3. Use screening tools such as the GAD-7 questionnaire to assess severity of anxiety symptoms and monitor response to treatment over time.
4. Evaluate for comorbid conditions and stressors: GAD often coexists with major depression or other anxiety disorders, and patients may have life stressors that exacerbate worry. Addressing these (or referring for therapy) is part of management.

1. SSRIs or SNRIs (e.g., escitalopram, sertraline, venlafaxine) are first-line medications for GAD. They typically take 4–6 weeks to significantly reduce anxiety. Start low to minimize initial jitteriness; may need long-term use to prevent relapse.
2. Psychotherapy – particularly cognitive-behavioral therapy (CBT) – is equally first-line. CBT helps patients identify and challenge anxious thoughts and practice relaxation techniques. Combining medication + CBT often yields the best results.
3. Benzodiazepines (e.g., alprazolam, diazepam) can provide quick relief of anxiety symptoms but carry risks of sedation, cognitive impairment, and dependence. They are used for short-term or acute situations (or as a bridge) and should be tapered off as soon as possible.
4. Buspirone is a non-benzodiazepine anxiolytic that is effective for chronic GAD without causing sedation or dependency. It has a slow onset (takes a couple of weeks to work) but is a good option for long-term management, especially in patients at risk for substance abuse.

• Mnemonic: Worry WARTS – Wound-up (keyed up/on edge) & Worn-out (fatigued), Absent-minded (poor concentration), Restless, Touchy (irritable), Sleepless (insomnia). People with GAD are often called "worry warts."

• Suicidal ideation or hopelessness in an anxious patient – GAD can coexist with depression, so any thoughts of self-harm require urgent evaluation (don't assume it's "just anxiety").
• Late-onset or atypical anxiety symptoms (e.g., new severe anxiety at age 50+, or anxiety with prominent physical signs like sweating, tachycardia, weight loss) – consider an underlying medical condition (like hyperthyroidism or pheochromocytoma) rather than primary GAD.

1. Chronic anxiety symptoms present (excessive worry ≥6 months) → screen for GAD.
2. Confirm diagnosis: thorough history to ensure multiple worry topics and ≥3 anxiety symptoms; rule out other causes (labs for thyroid, review medications/substances, etc).
3. Start with psychoeducation and lifestyle changes (stress management, sleep hygiene, exercise). If mild, consider therapy first; if moderate-severe or patient prefers, initiate an SSRI/SNRI.
4. For severe anxiety or functional impairment, a short-term benzodiazepine may be added for immediate relief while waiting for the antidepressant to take effect (then taper it off).
5. Follow up in a few weeks to assess improvement. Adjust treatment if needed (switch SSRIs, add therapy, etc). Continue successful treatment for at least 12 months; then consider gradual taper while monitoring for relapse.

• A 30-year-old with an 8-month history of constant worry about "everything" (family, finances, job) and associated muscle tension, irritability, and insomnia, who has no discrete panic attacks → Generalized anxiety disorder.
• A patient with multiple unexplained complaints (headaches, fatigue, upset stomach) and repeated normal exams, who admits to chronic worry about many aspects of life for over a year → GAD manifesting as somatic concerns (after ruling out medical causes).