Generalized Anxiety Disorder

Introduction & Epidemiology - Worry Whirlwind Basics

• Core: Excessive, uncontrollable anxiety and worry concerning multiple everyday events or activities (e.g., work, health).
• Duration: Occurs more days than not for at least 6 months (DSM-5 criteria).
• Symptoms (≥3 required):
  • Restlessness/on edge.
  • Easy fatigue.
  • ↓Concentration.
  • Irritability.
  • Muscle tension.
  • Sleep disturbance.
• Epidemiology:
  • Prevalence: Lifetime 5-9%; 12-month 3%. Notably common.
  • Gender: Females > Males (≈ 2:1).
  • Onset: Median age of onset ~30 years; typically chronic, fluctuating course.
  • Comorbidity: High with depression & other anxiety disorders.

⭐ Hallmark: Chronic, pervasive worry, difficult to control, often shifting between multiple everyday concerns, causing significant distress.

Clinical Features & Diagnosis - Spotting the Stress Storm

• Core Feature: Persistent, excessive, uncontrollable anxiety/worry (multiple domains).
• Duration: ≥ 6 months (more days than not).
• Associated Symptoms (≥ 3 required; ≥ 1 in children):
  • Restlessness, feeling "keyed up"/"on edge".
  • Easy fatigability.
  • Difficulty concentrating, mind going blank.
  • Irritability.
  • Muscle tension.
  • Sleep disturbance (e.g., insomnia, unsatisfying sleep).
• Impact: Clinically significant distress or functional impairment.
• Exclusion: Not due to substance, medical condition, or other mental disorder.

Diagnosis:

• Clinical diagnosis based on DSM-5 criteria.
• Key step: Rule out other causes:
  • Other anxiety/mood disorders (e.g., Panic Disorder, MDD).
  • Medical conditions (e.g., hyperthyroidism, cardiac issues).
  • Substance use/withdrawal.
• Screening Tool: GAD-7 (Generalized Anxiety Disorder 7-item scale).
  • Score ≥ 5: Mild.
  • Score ≥ 10: Moderate (clinically significant).
  • Score ≥ 15: Severe.

⭐ > GAD often co-occurs with Major Depressive Disorder (MDD) and other anxiety disorders.

Etiology & Comorbidities - Roots & Risky Relatives

• Genetic Factors:

  • Heritability ~30%.
  • Complex polygenic inheritance.

• Neurobiological Factors:

  • Neurotransmitters: Imbalances: ↓ GABA, ↓ Serotonin (5-HT), ↑ Norepinephrine. Corticotropin-releasing hormone (CRH) dysregulation implicated.
  • Brain Regions: Amygdala hyperactivity (fear). Altered prefrontal cortex (PFC) & anterior cingulate cortex (ACC) activity (worry circuits).
  • 📌 Mnemonic: "Anxious GADgets have Sad Nerves & Grumble" (Serotonin↓, Norepinephrine↑, GABA↓).

• Psychological Factors:

  • Cognitive Biases: Intolerance of uncertainty, negative problem orientation, catastrophizing.
  • Personality Traits: High neuroticism, harm avoidance.

• Environmental Factors:

  • Chronic life stressors, childhood adversity, trauma.

• Comorbidities:

  • High: 50-90% lifetime comorbidity with other psychiatric disorders.
  • Most Frequent: Major Depressive Disorder (MDD).
  • Other Common: Other anxiety disorders (panic disorder, social anxiety disorder), substance use disorders. ⭐ > GAD frequently precedes Major Depressive Disorder onset, a significant risk factor.

Management - Taming the Tension

• Goal: Symptom reduction, functional improvement.
• Core: Psychotherapy (CBT) + Pharmacotherapy (SSRIs/SNRIs).

• Pharmacotherapy:
  • SSRIs (First-line): Escitalopram (10-20 mg/day), Sertraline (50-200 mg/day), Paroxetine.
    • Start low, titrate. Effect in 4-6 wks.
  • SNRIs (First-line): Venlafaxine XR (75-225 mg/day), Duloxetine (60-120 mg/day).
  • Buspirone: Non-sedating. Onset 2-4 wks. Augmentation.
  • Pregabalin: Anxiolytic, for somatic symptoms.
  • BZDs: (Clonazepam, Lorazepam)
    • Short-term (<2-4 wks) for acute distress. ⚠️ Dependence risk.
  • Others: Hydroxyzine, TCAs (Imipramine - less preferred).
• Psychotherapy:
  • CBT: Gold standard. Psychoeducation, relaxation, cognitive restructuring, exposure.
  • Mindfulness-based therapies.

⭐ SSRIs (e.g., Escitalopram, Sertraline) are the first-line pharmacological agents for Generalized Anxiety Disorder, typically continued for 6-12 months after remission.

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High‑Yield Points - ⚡ Biggest Takeaways

• GAD: Chronic, excessive worry (≥6 months) about multiple domains.
• Requires ≥3 somatic symptoms (e.g., restlessness, fatigue, muscle tension, sleep issues, poor concentration).
• First-line: SSRIs/SNRIs and Cognitive Behavioral Therapy (CBT).
• Benzodiazepines: For short-term relief only; risk of dependence.
• Buspirone: Non-sedating, delayed onset (2-4 weeks), good for long-term.
• Differentiate from panic disorder (sudden attacks) & social anxiety (social phobia).
• High comorbidity with depression and other anxiety disorders.