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Generalized Anxiety Disorder

by John H. Greist, MD

Generalized anxiety disorder (GAD) is characterized by excessive anxiety and worry that is present more days than not for 6 mo about a number of activities or events. The cause is unknown, although it commonly coexists in people who have alcohol abuse, major depression, or panic disorder. Diagnosis is based on history and physical examination. Treatment is psychotherapy, drug therapy, or both.

GAD is common, affecting about 3% of the population within a 1-yr period. Women are twice as likely to be affected as men. The disorder often begins in childhood or adolescence but may begin at any age.

Symptoms and Signs

The focus of the worry is not restricted as it is in other psychiatric disorders (eg, to having a panic attack, being embarrassed in public, or being contaminated); the patient has multiple worries, which often shift over time. Common worries include work and family responsibilities, money, health, safety, car repairs, and chores.

The course is usually fluctuating and chronic, with worsening during stress. Most patients with GAD have one or more other comorbid psychiatric disorders, including major depression, specific phobia, social phobia, and panic disorder.

Diagnosis

  • Clinical criteria

Diagnosis is clinical based on criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Patients have excessive anxiety and worries about a number of activities or events. Patients have difficulty controlling the worries, which occur more days than not for ≥ 6 mo. The worries must also be associated with ≥ 3 of the following:

  • Restlessness or a keyed-up or on-edge feeling

  • Easily fatigability

  • Difficulty concentrating

  • Irritability

  • Muscle tension

  • Disturbed sleep

Also, the anxiety and worry cannot be accounted for by substance use or another medical disorder (eg, hyperthyroidism).

Treatment

  • Antidepressants and often benzodiazepines

Certain antidepressants, including SSRIs (eg, escitalopram, starting dose of 10 mg po once/day) and serotonin-norepinephrine reuptake inhibitors (eg, venlafaxine extended-release, starting dose 37.5 mg po once/day) are effective but typically only after being taken for at least a few weeks. Benzodiazepines (anxiolytics—see Table: Benzodiazepines) in small to moderate doses are also often and more rapidly effective, although sustained use may lead to physical dependence. One strategy involves starting with concomitant use of a benzodiazepine and an antidepressant. Once the antidepressant becomes effective, the benzodiazepine is tapered.

Buspirone is also effective; the starting dose is 5 mg po bid or tid. However, buspirone can take at least 2 wk before it begins to help.

Psychotherapy, usually cognitive-behavioral therapy, can be both supportive and problem-focused. Relaxation and biofeedback may be of some help, although few studies have documented their efficacy.

Benzodiazepines

Drug

Starting Oral Dose

Maintenance Oral Dose*

Onset/ Duration

Alprazolam

0.25 mg bid

Extended-release: 0.5 mg once/day

1 mg tid

Extended-release: 3 mg once/day

Intermediate/intermediate

Chlordiazepoxide

5 mg tid

25 mg tid

Intermediate/long

Clonazepam

0.25 mg once/day

1 mg tid

Intermediate/long

Clorazepate

7.5 mg bid

7.5 mg tid or 15 mg bid

Single-dose (sustained release): 22.5 mg once/day after stabilized on 7.5 mg tid

Rapid/long

Diazepam

2 mg tid

5 mg tid

Rapid/long

Lorazepam

0.5 mg tid

1 mg tid

Intermediate/short

Oxazepam

10 mg tid

15 mg qid

Slow/short

*Maintenance dose can vary and depends on individual response.

An oral disintegrating tablet or wafer is available. Onset does not differ from other formulations. Although these tablets disintegrate in the mouth, they are absorbed in the stomach and intestine, as are standard tablets.

Generally, these drugs are not recommended in the elderly because of a long half-life.

Resources In This Article

Drugs Mentioned In This Article

  • Drug Name
    Select Trade
  • LEVOPHED
  • XANAX
  • No US brand name
  • LEXAPRO
  • EFFEXOR XR
  • LIBRIUM
  • KLONOPIN
  • VALIUM
  • TRANXENE
  • ATIVAN

* This is a professional Version *