- Last edited on April 30, 2020
Generalized Anxiety Disorder (GAD)
Primer
Generalized Anxiety Disorder (GAD) is mental disorder characterized by excessive anxiety and worry about multiple events or activities (e.g. - school or work difficulties, relationships, finances) on a majority of days over at least half a year. There are also associated symptoms, such as restlessness, muscle tension, fatigue, poor concentration, irritability, and sleep changes.
Epidemiology
The 12-month prevalence is up to 5%, and the lifetime prevalence is 6%. For youth (age 13-18), it is 3%. GAD is more frequent in Caucasians compared to other groups. It affects 2 females for every 1 male. The usual age of onset varies and may be bimodal with the median age of onset being approximately 31 years. GAD is associated with high rates of comorbid psychiatric conditions including other anxiety disorders and depression.
Diagnostic Criteria
Criterion A
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).
Criterion B
The individual finds it difficult to control the worry.
Criterion C
The anxiety and worry are associated with at least 3
of the 6 symptoms (with at least some symptoms present for more days than not for the past 6
months);
1
item is required in children- Blanking out or difficulty concentrating
- Easily fatigued
- Sleep changes (difficulty falling or staying asleep, or restless, unsatisfying sleep)
- Keyed up, on edge, or restless
- Irritability
- Muscle tension
Criterion D
The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Criterion E
The disturbance is not attributable to the physiological effects of a substance (e.g. - a drug of abuse, a medication) or another medical condition (e.g. - hyperthyroidism).
Criterion F
The disturbance is not better explained by another mental disorder:
- Anxiety or worry about having panic attacks (panic disorder)
- Negative evaluation (social anxiety disorder)
- Contamination or other obsessions (obsessive-compulsive disorder)
- Separation from attachment figures (separation anxiety disorder)
- Reminders of traumatic events (post-traumatic stress disorder)
- Gaining weight (anorexia nervosa)
- Physical complaints (somatic symptom disorder)
- Perceived appearance flaws (body dysmorphic disorder)
- Having a serious illness (illness anxiety disorder)
- The content of delusional beliefs (schizophrenia or delusional disorder)
Mnemonic
The mnemonicBESKIM
can be used to remember the criteria for generalized anxiety disorder.[1]
B
- Blank mindE
- Easily fatigued
S
- Sleep disturbanceK
- Keyed Up/Restless/On-edgeI
- IrritabilityM
- Muscle tension
Scales
Generalized Anxiety Scales
Name | Rater | Description | Download |
---|---|---|---|
Generalized Anxiety Disorder 7 (GAD-7) | Patient | The GAD-7 is a 7-item self-reported questionnaire for screening and a severity measure of generalized anxiety disorder | Download |
Beck Anxiety Inventory (BAI) | Patient | The BAI is a 21-question self-report inventory for screening and a severity measure of generalized anxiety disorder | Download |
Pathophysiology
Differential Diagnosis
Anxiety is a broad term!
Anxiety is also such a broad term that you must explore it in more detail to determine the correct diagnosis when someone says they are “anxious.”If the anxiety is about:
- A fear of panicking, dying, or losing control, think panic disorder
- Being trapped or being unable to escape, think agoraphobia
- Being embarrassed in front of, or judgment by others, think social anxiety
- Constant, pervasive worries, and they can't stop worrying, think generalized anxiety disorder
- Thinking that something terrible will happen if certain rituals/complusions aren't performed, or they will never feel “right,” think obsessive-compulsive disorder
Don't Forget About Medical Etiologies
Certain medical conditions can be misdiagnosed as generalized anxiety disorder, or vice versa. Refer to these two papers for an overview to avoid misdiagnosis!Investigations
Baseline investigations include: CBC, fasting glucose, fasting lipid profiles, electrolytes, liver enzymes, serum bilirubin, serum creatinine, urinalysis, urine toxicology for substance use, TSH. An ECG should be performed for age > 40 years of age, beta-HCG (if relevant), and prolactin levels.[2]
Treatment
The following treatment recommendations are based on the 2014 Canadian Clinical Practice Guidelines for anxiety, posttraumatic stress and obsessive-compulsive disorders:[3]
Psychotherapy
Cognitive Behavioural Therapy (CBT) is an effective first-line option for the treatment of GAD and is as effective as pharmacotherapy. Internet-based and computer-based CBT have also demonstrated efficacy. The evidence does not support the routine combination of CBT and pharmacotherapy, but when patients do not benefit from CBT, a trial of pharmacotherapy is advisable, and vice versa.
Medications
Pharmacotherapy for generalized anxiety disorder
1st line | Agomelatine, duloxetine, escitalopram, paroxetine, paroxetine CR, pregabalin, sertraline, venlafaxine XR |
---|---|
2nd line | Alprazolam*, bromazepam*, bupropion XL*, buspirone, diazepam*, hydroxyzine, imipramine, lorazepam*, quetiapine XR*, vortioxetine |
3rd line | Citalopram, divalproex chrono, fluoxetine, mirtazapine, trazodone |
Adjunctive therapy | Second-line: pregabalin Third-line: aripiprazole, olanzapine, quetiapine, quetiapine XR, risperidone Not recommended: ziprasidone |
Not recommended | Beta blockers (propranolol), pexacerfont, tiagabine |
Combination Therapy
There is no current evidence to support the routine combination of CBT and pharmacotherapy. However, as in other anxiety and related disorders, when patients do not benefit from CBT or have a limited response, a trial of pharmacotherapy is advisable.
Pediatric Considerations
Psychological therapies for children often need to be adapted to suit the chronological and developmental ages of young patients and to include parental involvement. Meta-analyses support the efficacy of CBT for the treatment of anxiety and related disorders in children and adolescents.[4] When pharmacotherapy is warranted, SSRIs are generally preferred, but all antidepressants should be used with caution in pediatric patients.
For children and adolescents, psychological treatments are generally preferred over pharmacotherapy, or if warranted combination therapy may be an option. RCTs comparing combined pharmacological and psychological treatments in younger patients with anxiety have demonstrated efficacy equal or superior to either treatment alone.[5]
Pharmacotherapy for generalized anxiety disorder in pediatric populations
Antidepressants | Fluoxetine, fluvoxamine, sertraline |
---|---|
Benzodiazepines | Alprazolam |