Generalized anxiety disorder (GAD) is the most common mental disorders. The hallmark of GAD is excessive, out-of-control worry. This condition can negatively impact a patient's quality of life and disrupt important activities of daily living. Women are twice as likely as men to have the disorder. It often begins in childhood or adolescence but may start at any age.

Typical Presentation and Diagnostic Criteria

Patients with GAD typically present with excessive anxiety about ordinary, day-today situations. The anxiety is intrusive, causes distress or functional impairment, and often encompasses multiple domains (e.g., finances, work, health).

The anxiety is often associated with physical symptoms, such as sleep disturbance, restlessness, muscle tension, gastrointestinal symptoms, and chronic headaches.

Diagnostic and Statistical Manual of Mental Disorders, 5th ed, (DSM-5) diagnostic criteria for GAD are listed below:

Treatment of Generalized Anxiety Disorder

Lifestyle Modifications

Common lifestyle recommendations that may reduce anxiety-related symptoms include identifying and removing possible triggers (e.g., caffeine, stimulants, nicotine, dietary triggers, stress), and improving sleep quality/quantity and physical activity.

Physical activity is associated with improved physical health, life satisfaction, cognitive functioning, and psychological well-being. Physical activity is a cost-effective approach in the treatment of GAD. Exercising at 60% to 90% of maximal heart rate for 20 minutes three times weekly has been shown to decrease anxiety; yoga is also effective.

Psychotherapy

Cognitive behavioral therapy, psychodynamic therapies (which address underlying conflicts that are thought to be the source of anxiety), mindfulness-based therapies (including acceptance and commitment therapy, which encourages a focus on the present and on core values that transcend symptoms and illness), and applied relaxation therapy (which teaches approaches to inducing a relaxed state).

Among these forms of therapy, the evidence is strongest for the use of cognitive behavioral therapy in the treatment of generalized anxiety disorder, for which it can be considered a first-line treatment.

MEDICATION

Antidepressants: Selective serotonin-reuptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs) are generally considered to be first-line pharmacotherapies for generalized anxiety disorder

Examples of antidepressants used to treat generalized anxiety disorder include escitalopram, duloxetine, venlafaxine and paroxetine.

Tricyclic antidepressants (TCAs) are thought to be effective for GAD.

Benzodiazepines such as diazepam and clonazepam (both of which are long-acting agents) are also efficacious in the treatment of generalized anxiety disorder. Benzodiazepines relieve anxiety quickly, typically almost immediately.

However, because of concerns about misuse and dependence, most prescribing guidelines suggest that benzodiazepines should be used only on a short-term basis (3 to 6 months). They can be reasonably used as an initial adjunct while SSRIs are titrated to an effective dose, and they can then be tapered while the SSRI is continued.

NICE guidelines recommend only short-term use during crises. Benzodiazepines with an intermediate to long onset of action such as clonazepam may have less potential for abuse and less risk of rebound.

However, many specialists believe that, with close monitoring, benzodiazepines are a reasonable option in selected patients (i.e., those without current or past alcohol-use or other substance-use problems) for who preferred agents are ineffective or associated with a poor side-effect profile.

Azapirones, such as buspirone, are better than placebo for GAD.

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