Generalized anxiety disorder

Generalized Anxiety Disorder (GAD) is a chronic anxiety disorder characterized by excessive, persistent, and difficult-to-control worry about multiple everyday life events or activities occurring more days than not for an extended period.

The anxiety is disproportionate to actual circumstances and is commonly associated with psychological distress and physical symptoms such as muscle tension and sleep disturbance. GAD significantly affects social, occupational, and functional performance and frequently coexists with depression and substance use disorders.

Risk Factors

• Family history of anxiety disorders

• Female gender

• Chronic stress exposure

• Childhood adversity or trauma

• Personality traits such as neuroticism

• Chronic medical illness

• Substance or alcohol misuse

• Socioeconomic stressors

• Previous anxiety or depressive disorders

Signs and Symptoms

Psychological Symptoms

• Persistent and excessive worry

• Feeling constantly tense or “on edge”

• Irritability

• Difficulty controlling worry

• Fear of negative outcomes

Cognitive Symptoms

• Poor concentration

• Memory difficulties

• Indecisiveness

• Mental fatigue

Physical (Somatic) Symptoms

• Sleep disturbances

• Muscle tension

• Tremors

• Headache

• Restlessness

• Sweating

• Palpitations

• Gastrointestinal discomfort

Diagnostic Criteria

Diagnosis is clinical and includes:

• Persistent worry occurring most days for ≥6 months

• Anxiety difficult to control

• Presence of symptoms such as:

  • Persistent worry

  • Sleep disturbance

  • Poor concentration

  • Mood disturbance

  • Muscle tension

  • Tremors

• Significant distress or impairment in functioning

• Symptoms not explained by substance use, medical illness, or another psychiatric disorder

Investigations

Investigations aim to exclude medical causes mimicking anxiety.

Clinical Assessment

• Comprehensive psychiatric evaluation

• Mental status examination

• Suicide risk assessment

• Functional impairment evaluation

Laboratory Tests

• Thyroid function tests

• Blood glucose level

• Full blood count

• Electrolytes

Additional Evaluation

• Substance use screening

• Cardiovascular assessment when indicated

Management

Treatment goals:

• Reduce excessive anxiety

• Improve daily functioning

• Prevent chronic disability

• Manage comorbid conditions

Most patients can be effectively treated on an outpatient basis.

Non-Pharmacological Management

Psychotherapy (First-Line Treatment)

• Cognitive Behavioural Therapy (CBT)

• Supportive psychotherapy

• Stress management therapy

• Relaxation techniques

• Mindfulness-based therapy

• Problem-solving therapy

Psychological therapy provides sustained long-term benefit and reduces relapse.

Pharmacological Management

Medication is indicated when anxiety significantly interferes with normal daily functioning or when psychotherapy alone is insufficient.

Acute Management

For acute episodes or intense prolonged anxiety:

• Diazepam 2–5 mg orally as a single dose

• May repeat up to 12-hourly if required

• Maximum duration: up to 2 weeks

• Gradual taper recommended within 6 weeks

Avoid prolonged benzodiazepine use due to tolerance, dependence, and withdrawal risk.

Maintenance Therapy

Selective Serotonin Reuptake Inhibitors (First-Line)

Fluoxetine

• 10–40 mg orally daily

OR

Citalopram

• 10–40 mg orally daily

Tricyclic Antidepressant

Amitriptyline

• 25–75 mg orally at night

Treatment Principles

• Initiate at low dose

• Gradually titrate according to tolerability

• Therapeutic response may take 4–8 weeks

• Treatment duration is variable due to chronic course

• Extended treatment should be monitored by a specialist

• Avoid combining multiple benzodiazepines

Complications

• Major depressive disorder

• Substance dependence

• Chronic insomnia

• Occupational impairment

• Reduced quality of life

• Increased suicide risk

Prevention

• Early recognition of anxiety symptoms

• Stress reduction and coping strategies

• Lifestyle modification

• Limiting caffeine and stimulant use

• Regular physical activity

• Continued psychological support

• Long-term follow-up care

Prognosis

GAD typically follows a chronic fluctuating course. Early combined psychological and pharmacological treatment improves long-term outcomes and functional recovery.

Patient Education

• Anxiety disorder is a treatable medical condition

• Symptoms are not due to personal weakness

• Medication effects may take several weeks

• Avoid abrupt discontinuation of medication

• Regular follow-up improves recovery outcomes