In generalized anxiety disorder, a person has frequent or nearly constant, nagging feelings of worry or anxiety. These feelings are either unusually intense or out of proportion to the real troubles and dangers of the person's everyday life.

The disorder is defined as persistent worry every day or almost every day for six months or more. In some cases, a person with generalized anxiety disorder feels he or she has always been a worrier, even since childhood or adolescence. In other cases, the anxiety may be triggered by a crisis or a period of stress, such as a job loss, a family illness or the death of a relative. Although the crisis eventually goes away and the stress passes, an unexplained feeling of anxiety may last months or years.

In addition to suffering from constant (or non-stop) worries and anxieties, people with generalized anxiety disorder may have low self-esteem or feel insecure because they see people's intentions or events in negative terms, or they experience them as intimidating or critical. Physical symptoms may lead them to seek treatment from a primary care doctor, cardiologist, pulmonary specialist or gastroenterologist. Stress can intensify the anxiety.

Experts believe that some people with this disorder have a genetic (inherited) tendency to develop it. The disorder probably stems from how a variety of brain structures communicate with each other as they manage the fear response. Chemical messengers, gamma aminobutyric acid (GABA) and serotonin, transmit signals along the circuits connecting brain regions. The medications used to treat anxiety affect these chemicals.

About 3% to 8% of people in the United States have generalized anxiety disorder. Women have the problem twice as often as men. The average adult patient first seeks medical attention between the ages of 20 and 30. However, the illness can occur at any age. Generalized anxiety disorder also has been diagnosed in young children, teenagers and elderly people. The illness is the most common anxiety disorder affecting people age 65 and older.

Of all psychiatric illnesses, generalized anxiety disorder is the least likely to occur alone. Between 50% and 90% of people with the disorder also have at least one other problem, usually panic disorder, a phobia, depression, dysthymia (a less severe form of depression), alcoholism or some other form of substance abuse.

By definition, in generalized anxiety disorder, the person has persistent worry or anxiety that lasts for at least six months. This worry or anxiety is excessive, troubling and hard to control, and it often interferes with a person's ability to function at home, at work or in social situations.

To be diagnosed with generalized anxiety disorder, a person has to have at least three of the following symptoms:

• Feeling restless or keyed up
• Becoming tired very easily
• Having difficulty concentrating or remembering (your mind goes blank)
• Feeling irritable, crabby or grouchy
• Having tense muscles
• Having trouble falling asleep or staying asleep, or not feeling rested after sleep

People with generalized anxiety disorder also may have a wide range of anxiety-related physical symptoms that may seem like symptoms of heart disease, respiratory illness, digestive diseases and other medical illnesses.

You may consult a primary care doctor first if you suspect your physical symptoms are part of a medical illness. Your doctor may do tests to check for medical problems. If the results are normal, your doctor may ask about your family history, your history of any mental distress, current anxieties, recent stresses, and daily use of prescription and nonprescription drugs. Some drugs can cause anxiety symptoms. The doctor then may refer you to a psychiatrist for care.

Your psychiatrist will diagnose generalized anxiety disorder based on a full psychiatric evaluation that includes:

• Asking you to describe your worries, anxieties and anxiety-related symptoms
• Determining how long you have had these symptoms
• Assessing how worry and anxiety have affected your ability to function normally at home, at work and socially
• Checking for symptoms of other forms of psychiatric illness that might be present at the same time as generalized anxiety disorder. Symptoms of depression are very common in someone with this disorder.

The psychiatrist also may order diagnostic tests, if necessary, to check for a medical illness. These won't be needed if they already have been done by the doctor who referred you to the psychiatrist.

Symptoms of generalized anxiety disorder can last for many months, but the condition can last longer (many years) especially without treatment, with symptoms occurring over many years.

Since stress is a normal part of life, there is usually no way to prevent generalized anxiety disorder in someone who is vulnerable. However, once diagnosed, various treatments can effectively reduce symptoms.

If you have generalized anxiety disorder, the most effective treatment is usually a combination of medications and psychotherapy. Research shows that using both has a more lasting positive effect than either one alone. Your doctor may also offer treatment for other conditions that may be making matters worse, such as a medical problem or depression.

You may need to try more than one approach before you find the right one. Many different kinds of medications can relieve anxiety. Here are the most common categories prescribed:

• Antidepressants. Despite their name, many of these drugs are very effective for anxiety. They are a first-line treatment for an anxiety disorder, especially when it is long-lasting or when the person is also depressed. They may work because they affect the activity of serotonin, one of the chemical messengers involved in the brain's anxiety response. The popular selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac), sertraline (Zoloft) and paroxetine (Paxil) are commonly used. Also, the older tricyclic antidepressants, such as nortriptyline (Aventyl, Pamelor) and imipramine (Tofranil), are effective, as are newer medications venlafaxine (Effexor) and duloxetine (Cymbalta). Since antidepressants often take several weeks to work, your doctor may also prescribe a fast-acting benzodiazepine for relief.



• Benzodiazepines. This group of drugs affect another chemical messenger at work in the brain's fear response system -- gamma aminobutyric acid (GABA). Examples of benzodiazepines are clonazepam (Klonopin), lorazepam (Ativan), diazepam (Valium) and alprazolam (Xanax). They are very safe and often bring quick relief from symptoms of anxiety. Since they act immediately, they may be prescribed during the first weeks of treatment while waiting for an antidepressant medication to take hold. Another reason these drugs are prescribed for a relatively short time is that the body sometimes becomes accustomed to the effect. That is, benzodiazepines may provide less relief as time goes on. If you need to stop taking these drugs, do so gradually under a doctor's direction, because withdrawal reactions can occur.



• Buspirone (BuSpar). Buspirone is an antianxiety drug that can be effective for generalized anxiety disorder. However, it is used much less frequently than the drugs listed above. Like antidepressants, it usually takes two to three weeks to begin working.

Psychotherapy

A number of psychotherapy techniques may be helpful. Here are some examples:

• Cognitive behavioral therapy helps you recognize and change unreasonable patterns of thinking and behavior.



• Psychodynamic or insight-oriented psychotherapy helps you understand the history behind your symptoms. For example, you may become more aware of how you have carried past fears into the present day. This insight may help you face challenges more confidently now.



• Interpersonal psychotherapy can help you sort out anxiety-provoking conflicts in important relationships and resolve them more effectively.



• Exposure and desensitization is a behavioral technique that provides support so you can confront a specific fear and overcome it. It is particularly helpful when anxiety is causing you to avoid important tasks or responsibilities.



• Applied relaxation teaches people with generalized anxiety disorder to control their symptoms by using imagination and muscle control. Relaxation techniques, such as diaphragmatic breathing, meditation and visualization, can relieve some of the more bothersome physical symptoms.



• Biofeedback uses special sensors attached to the skin to teach people with generalized anxiety disorder to recognize anxiety-related changes in their physiological functions, for example, pulse, skin temperature and muscle tone. With time and practice, patients learn to modify these anxiety-related changes and to control the effect of anxiety on the entire body.

Your therapist may combine any of the above approaches or may discuss others -- for example, meditation, hypnosis or exercise -- with you so that the approach fits your specific problems and needs.

See your doctor if you are troubled by severe worry or anxiety, especially if:

• Your anxious feelings have lasted for several months.
• You feel that you can no longer control your anxious feelings, and this makes you feel helpless or frightened.
• Your constant anxiety is interfering with your personal relationships or with your ability to function normally at home, at school or at work.
• You are having difficulty concentrating or remembering.
• You are having trouble sleeping.
• You have unexplained physical symptoms that may be anxiety-related.

In general, the outlook is good. With appropriate treatment, about 50% of patients improve within 3 weeks of starting treatment, and 77% improve within 9 months.

American Psychiatric Association
1000 Wilson Blvd.
Suite 1825
Arlington, VA 22209-3901
Phone: 703-907-7300
Toll-Free: 1-888-357-7924
http://www.psych.org/

National Institute of Mental Health
Science Writing, Press, and Dissemination Branch
6001 Executive Blvd.
Room 8184, MSC 9663
Bethesda, MD 20892-9663
Toll-Free: 1-866-615-6464
TTY: 1-866-415-8051
Fax: 301-443-4279
http://www.nimh.nih.gov/

Anxiety Disorders Association of America
8730 Georgia Ave.
Silver Spring, MD 20910
Phone: 240-485-1001
Fax: 240-485-1035
http://www.adaa.org/