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Generalized anxiety disorder
Last reviewed: 07.07.2025

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Generalized anxiety disorder is characterized by excessive, nearly daily worry and anxiety about multiple events or activities for 6 months or more. The cause is unknown, although generalized anxiety disorder often occurs in patients with alcohol dependence, major depression, or panic disorder. Diagnosis is based on history and physical examination. Treatment is psychotherapy, medication, or a combination of both.
Symptoms of Generalized Anxiety Disorder
The immediate trigger for anxiety is not as clearly defined as in other mental disorders (eg, expecting a panic attack, public anxiety, or fear of contamination); the patient worries about many things, and the anxiety fluctuates over time. Common concerns include work commitments, money, health, safety, car repairs, and daily responsibilities. To meet Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria, the patient must have 3 or more of the following symptoms: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbances. The course is usually fluctuating or chronic, with worsening during periods of stress. Most patients with GAD also have one or more comorbid mental disorders, including major depressive episode, specific phobia, social phobia, and panic disorder.
Clinical manifestations and diagnosis of generalized anxiety disorder
A. Excessive worry or anxiety (anxious anticipation) about a number of events or activities (such as work or school) and occurring most of the time for at least six months.
B. Anxiety is difficult to control voluntarily.
B. Anxiety and worry are accompanied by at least three of the following six symptoms (with at least some symptoms present most of the time for the past six months).
- Anxiety, feeling on edge, on the verge of a breakdown.
- Rapid fatigue.
- Impaired concentration.
- Irritability.
- Muscle tension.
- Sleep disorders (difficulty falling asleep and maintaining sleep, restless sleep, dissatisfaction with the quality of sleep).
Note: Children may only have one of the symptoms.
D. The focus of anxiety or worry is not limited to the motives characteristic of other disorders. For example, anxiety or worry is not associated only with the presence of panic attacks (as in panic disorder), the possibility of getting into an awkward situation in public (as in social phobia), the possibility of infection (as in obsessive-compulsive disorder), being away from home (as in separation anxiety disorder), weight gain (as in anorexia nervosa), the presence of numerous somatic complaints (as in somatization disorder), the possibility of developing a dangerous disease (as in hypochondria), the circumstances of a psycho-traumatic event (as in post-traumatic stress disorder).
D. Anxiety, restlessness, somatic symptoms cause clinically significant discomfort or disrupt the patient’s life in social, professional or other important areas.
E. The disturbances are not caused by the direct physiological action of exogenous substances (including addictive substances or drugs) or a general disease (for example, hypothyroidism), and are not observed only in the occurrence of affective disorders, psychotic disorder, and are not associated with a general developmental disorder.
Course of generalized anxiety disorder
Symptoms of generalized anxiety disorder are often observed in patients who seek medical attention from general practitioners. Typically, such patients present with vague somatic complaints: fatigue, muscle pain or tension, mild sleep disturbances. The lack of data from prospective epidemiological studies does not allow us to speak with certainty about the course of this condition. However, retrospective epidemiological studies indicate that generalized anxiety disorder is a chronic condition, since most patients had symptoms for many years before the diagnosis was made.
Differential diagnosis of generalized anxiety disorder
Like other anxiety disorders, generalized anxiety disorder should be differentiated from other mental, somatic, endocrinological, metabolic, neurological diseases. In addition, when establishing a diagnosis, one should keep in mind the possibility of a combination with other anxiety disorders: panic disorder, phobias, obsessive-compulsive and post-traumatic stress disorders. The diagnosis of generalized anxiety disorder is made when a full set of symptoms is detected in the absence of comorbid anxiety disorders. However, in order to diagnose generalized anxiety disorder in the presence of other anxiety conditions, it is necessary to establish that anxiety and worry are not limited to the range of circumstances and topics characteristic of other disorders. Thus, the correct diagnosis involves identifying the symptoms of generalized anxiety disorder with the exclusion or in the presence of other anxiety conditions. Since patients with generalized anxiety disorder often develop major depression, this condition also needs to be excluded and properly differentiated from generalized anxiety disorder. Unlike depression, in generalized anxiety disorder, anxiety and worry are not associated with affective disorders.
Pathogenesis. Of all the anxiety disorders, generalized anxiety disorder is the least studied. The lack of information is partly due to the rather dramatic changes in views on this condition over the past 15 years. During this time, the boundaries of generalized anxiety disorder have gradually narrowed, while the boundaries of panic disorder have expanded. The lack of pathophysiological data is also explained by the fact that patients are rarely referred to psychiatrists for the treatment of isolated generalized anxiety. Patients with generalized anxiety disorder usually have comorbid affective and anxiety disorders, and patients with isolated generalized anxiety disorder are rarely identified in epidemiological studies. Therefore, many pathophysiological studies are rather aimed at obtaining data that allow differentiating generalized anxiety disorder from comorbid affective and anxiety disorders, primarily panic disorder and major depression, which are characterized by particularly high comorbidity with generalized anxiety disorder.
Genealogical studies. A series of twin and genealogical studies have revealed differences between generalized anxiety disorder, panic disorder, and major depression. The findings suggest that panic disorder is transmitted in families differently than generalized anxiety disorder or depression, while the differences between the latter two conditions are less clear. Based on data from a study of adult female twins, the researchers suggested that generalized anxiety disorder and major depression have a common genetic basis that is expressed as one or the other disorder under the influence of environmental factors. The researchers also found a link between polymorphisms in the serotonin reuptake transporter and the level of neuroticism, which in turn is closely associated with symptoms of major depression and generalized anxiety disorder. The results of a long-term prospective study in children confirmed this point of view. It turns out that the links between generalized anxiety disorder in children and major depression in adults are no less close than between depression in children and generalized anxiety disorder in adults, as well as between generalized anxiety disorder in children and adults, and between major depression in children and adults.
Differences from panic disorder. A number of studies have compared neurobiological changes in panic and generalized anxiety disorders. Although a number of differences between these two conditions have been identified, both differ from the state of mentally healthy individuals in the same parameters. For example, a comparative study of the anxiogenic response to the introduction of lactate or inhalation of carbon dioxide showed that in generalized anxiety disorder this reaction is enhanced compared to healthy individuals, and panic disorder differs from generalized anxiety disorder only by more pronounced dyspnea. Thus, in patients with generalized anxiety disorder, the reaction was characterized by a high level of anxiety, accompanied by somatic complaints, but not associated with respiratory dysfunction. In addition, in patients with generalized anxiety disorder, a smoothing of the growth hormone secretion curve in response to clonidine was revealed - as in panic disorder or major depression, as well as a change in the variability of cardiac intervals and indicators of the activity of the serotonergic system.
Diagnostics
Generalized anxiety disorder is characterized by frequent or persistent fears and worries that arise about real events or circumstances that cause concern to the person, but are clearly excessive in relation to them. For example, students often fear exams, but a student who is constantly worried about the possibility of failure, despite good knowledge and consistently high grades, may have generalized anxiety disorder. Patients with generalized anxiety disorder may not realize that their fears are excessive, but severe anxiety causes them discomfort. In order to diagnose generalized anxiety disorder, the above symptoms must be observed frequently enough for at least six months, the anxiety must be uncontrollable, and at least three of the six somatic or cognitive symptoms must be detected. These symptoms include: a feeling of restlessness, rapid fatigue, muscle tension, insomnia. It should be noted that anxious fears are a common manifestation of many anxiety disorders. Thus, patients with panic disorder experience concerns about panic attacks, patients with social phobia - about possible social contacts, patients with obsessive-compulsive disorder - about obsessive ideas or sensations. Anxiety in generalized anxiety disorder is more global in nature than in other anxiety disorders. Generalized anxiety disorder is also observed in children. Diagnosis of this condition in children requires the presence of only one of the six somatic or cognitive symptoms specified in the diagnostic criteria.
Treatment of Generalized Anxiety Disorder
Antidepressants, including selective serotonin reuptake inhibitors (SSRIs) (eg, paroxetine, starting dose 20 mg once daily), serotonin-norepinephrine reuptake inhibitors (eg, venlafaxine extended-release, starting dose 37.5 mg once daily), and tricyclic antidepressants (eg, imipramine, starting dose 10 mg once daily) are effective but only after use for at least several weeks. Benzodiazepines in low to moderate doses are also often effective, although long-term use usually leads to physical dependence. One treatment strategy is to initially give a benzodiazepine and an antidepressant together. When the antidepressant's effect occurs, the benzodiazepine is gradually withdrawn.
Buspirone is also effective at an initial dose of 5 mg 2 or 3 times daily. However, buspirone must be taken for at least 2 weeks before it begins to have an effect.
Psychotherapy, often cognitive-behavioural, can be either supportive or problem-focused. Relaxation and biofeedback may be helpful to some extent, although research supporting their effectiveness is limited.