Generalised anxiety disorder

It is an anxiety disorder in which worry becomes excessive, hard to control and spreads across several topics, such as health, work, family or money. For the diagnosis, worry is present on most days for at least six months, comes with physical and psychological symptoms, and causes distress or limits daily life.²

The worry is often diffuse and does not depend on a recent event, although certain situations make it worse.³ It is a common disorder: in the United States, about 6% of people are estimated to have it at some point in their lives, and it is about twice as common in women.^3,5 Even so, it remains under-diagnosed and under-treated.⁴

Other forms of anxiety, such as panic attacks and social anxiety, are summarised on the Anxiety page.

Besides worry, DSM-5-TR requires, in adults, at least three of six symptoms, present on most days:²

• restlessness or feeling “keyed up” or on edge;
• being easily tired;
• difficulty concentrating or the mind going blank;
• irritability;
• muscle tension;
• sleep disturbance, such as difficulty falling asleep or restless, unrefreshing sleep.

Palpitations, a dry mouth and sweating are also common; these symptoms are part of the anxiety picture rather than separate complaints.³ Many people first see their GP about physical complaints, a chronic illness or the need for reassurance about their health, and generalised anxiety disorder can go unnoticed.¹

Worry is a normal part of life and can help solve problems. In generalised anxiety disorder, it changes in four ways:²

• Proportion: it is excessive relative to the real likelihood or impact of what is feared.
• Control: it is hard to stop, even when the person recognises it is out of proportion.
• Range and duration: it moves from one topic to another and persists on most days for months.
• Impact: it comes with physical symptoms and interferes with work, relationships or rest.

Intense worry limited to a specific, recent problem, which eases when the problem is resolved, does not usually amount to this disorder.

There is no single cause. Generalised anxiety disorder is more common in relatives of people who have it, and twin studies attribute about a third of the vulnerability to genetic factors; the rest depends mainly on individual experiences and the environment.⁶

It often occurs alongside other conditions: depression, other anxiety disorders and substance use.^1,7 Anxiety disorders tend to follow a chronic course, but they become less common with age.⁷ Generalised anxiety disorder is also associated with a higher risk of suicide and of cardiovascular disease, which makes recognising and treating it all the more important.⁴ The links between mental health and the heart are described in Mental health, cardiovascular disease and dementia.

The assessment characterises the worry, physical symptoms, duration and impact, and looks for:^1,2

• associated depression or other anxiety disorders;
• use of alcohol, other substances or medicines that may cause or worsen anxiety;
• medical conditions that explain the symptoms, such as hyperthyroidism, or that coexist with the anxiety;
• previous treatments and how well they worked.

When depression or another anxiety disorder is present, the more severe condition is treated first, and harmful substance use takes priority, because treating it may in itself improve the anxiety.¹ When physical symptoms predominate, working with the GP or other specialties can help. Psychiatric consultations can take place in person in Lisbon or as an online consultation, in Portuguese, English or Spanish.

UK guidelines organise treatment in steps, starting with the least intrusive effective intervention:¹

• Step 1: recognition and assessment, information about the disorder and treatment options, and regular monitoring of symptoms.
• Step 2: if there is no improvement, low-intensity psychological interventions, such as guided self-help or psychoeducational groups.
• Step 3: if the response is inadequate or there is marked impairment, a high-intensity psychological intervention or medication, chosen according to the person’s preference, because there is no evidence that one is better than the other.
• Step 4: in complex, treatment-refractory situations, with very marked impairment or a risk of self-harm, specialist care.

Psychotherapy. The two recommended high-intensity interventions are cognitive behavioural therapy (CBT) and applied relaxation, in weekly sessions over a few months.¹ In meta-analyses, psychotherapy had medium to large effects, and there are indications that the benefit of CBT is maintained at follow-up.^8,9

Medication. The first option is an antidepressant from the selective serotonin reuptake inhibitor (SSRI) class. If it is not effective, a different SSRI or a serotonin–noradrenaline reuptake inhibitor (SNRI) can be used; if none of these is tolerated, a gabapentinoid may be considered, with attention to the risk of misuse and dependence.^1,5 Several classes of medicine have proven efficacy, and a lack of response to the first one does not mean medication cannot help.¹⁰ At the start there may be a temporary increase in anxiety, agitation or sleep problems, and people under 30 are monitored more closely in the first weeks.¹

Benzodiazepines are not recommended for treating generalised anxiety disorder, except briefly during a crisis, and antipsychotics are not recommended in primary care.¹ When the response is partial, psychotherapy can be added to medication.¹ Research on psychedelics in anxiety is described in Psychedelics for anxiety.

Generalised anxiety disorder tends to be persistent, with better and worse periods and relapses, and even with treatment some symptoms often remain.³ Evidence-based treatments reduce worry and physical symptoms in the short and medium term, and also improve associated depressive symptoms.^3,8,9

A realistic goal is to reduce the intensity and frequency of worry, recover sleep and concentration, and return to the activities that anxiety had been limiting. When medication is effective, guidelines advise continuing it for at least a year, because the risk of relapse is high; recognising early signs of relapse is also part of the plan.¹ Regular sleep, physical activity and less caffeine and alcohol help day to day and complement treatment, as described on the Anxiety page; when insomnia becomes a problem in its own right, see Insomnia.

It is worth seeking an assessment when:

• worry takes up much of the day and has been hard to stop for weeks or months;
• sleep, concentration or performance at work are being affected;
• there are repeated visits to the doctor or the emergency department for physical symptoms with no cause found;
• you rely on alcohol or sedatives to control anxiety;
• persistent sadness, hopelessness or loss of interest appear, which may indicate depression.

There is no need to wait until worry becomes severe: an earlier assessment makes it possible to start with the least intrusive effective intervention and to follow progress over time.¹