Continuing Education Activity
Generalized anxiety disorder is a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed. It is characterized by excessive, persistent, and unrealistic worry about everyday things. This activity illustrates the evaluation and management of generalized anxiety disorder and explains the interprofessional team's role in managing patients with this condition.
Summarize the etiology of generalized anxiety disorder.
Describe the use of the Generalized Anxiety Disorder 7-Item Questionnaire in the evaluation of generalized anxiety disorder.
Identify the use of cognitive-behavioral therapy in the management of patients with a generalized anxiety disorder.
Outline the importance of collaboration and communication among the interprofessional team to enhance care delivery for patients affected by a generalized anxiety disorder.
Generalized anxiety disorder is one of the most common mental disorders. Up to 20% of adults are affected by anxiety disorders each year. Generalized anxiety disorderproduces fear, worry, and a constant feeling of being overwhelmed. Generalized anxiety disorder is characterized by persistent, excessive, and unrealistic worry about everyday things. This worry could be multifocal such as finance, family, health, and the future. It is excessive, difficult to control, and is often accompanied by many non-specific psychological and physical symptoms. Excessive worry is the central feature of generalized anxiety disorder.
Diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) includethe following:
Excessive anxiety and worry for at least six months
Difficulty controlling the worrying.
The anxiety is associated with three or more of the below symptoms for at least 6 months:
Restlessness, feeling keyed up or on edge
Being easily fatigued
Difficulty in concentrating or mind going blank, irritability
The anxiety results in significant distress or impairment in social and occupational areas
The anxiety is not attributable to any physical cause
The etiology may include:
A physical condition such as diabetes or other comorbidities such as depression
Genetic, first-degree relatives withgeneralized anxiety disorder(25%)
Environmental factors, such as child abuse
Substance use disorder
Childhood anxiety occurs in about 1 in 4children at some timebetween the ages of 13 and 18 years. The median age at onset is 11 years. However, the lifetime prevalence of a severe anxiety disorder in children ages 13 to 18is approximately 6%. General prevalence in children younger than 18 years is between 5.7% and 12.8%. The prevalence is approximately twice as high among women as among men.
The American Psychiatric Association first introduced the diagnosis of generalized anxiety disorder two decades ago in the DSM-III. Before that time,generalized anxiety disorderwas conceptualized as one of the two core components of anxiety neurosis, the other being panic. A recognition thatgeneralized anxiety disorderand panic, although often occurring together, are sufficiently distinct to be considered independent disorders led to their separation in the DSM-III.
The DSM-III definition ofgeneralized anxiety disorderrequired uncontrollable and diffuse (i.e., not focused on a single major life problem) anxiety or worry that is excessive or unrealistic relative to objective life circumstances and persists for one month or longer. Several related psychophysiological symptoms were alsorequired for a diagnosis ofgeneralized anxiety disorder. Early clinical studies evaluating DSM-III, according to this definition, found that the disorder seldom occurred in the absence of another comorbid anxiety or mood disorder. Comorbidity ofgeneralized anxiety disorderand major depression was especially strong and led somecommentators to suggest thatgeneralized anxiety disordermight better be conceptualized as a prodrome, residual, or severity marker than as an independent disorder. The rate of comorbidity ofgeneralized anxiety disorderwith other disorders decreases as the duration ofgeneralized anxiety disorderincreases. Based on this finding, the DSM-III-R committee ongeneralized anxiety disorderrecommended that the duration required for the disorder be increased to six months. This change was implemented in the final version of the DSM-III-R. Additional changes in the definition of excessive worry and the required number of associated psychophysiological symptoms were made in the DSM-IV.
These changes in diagnostic criteria led to delays in cumulating data on the epidemiology ofgeneralized anxiety disorder. Nonetheless, such data became available over the past decade. As described in more detail later, this new data challenged the view thatgeneralized anxiety disordershould be conceptualized as a prodrome, residual, or severity marker of other disorders. Instead, itsuggests thatgeneralized anxiety disorderis a common disorder that, although often comorbid with other mental disorders, does not have a higher comorbidity rate than those found in most other anxiety or mood disorders. The new data also challenged the validity of the threshold decisions embodied in the DSM-5.
The exact mechanism is notentirely known. Anxiety can be a normal phenomenon in children. Stranger anxiety begins at seven to nine months of life. Noradrenergic, serotonergic, and other neurotransmitter systems appear to play a role in the body's response to stress. The serotonin system and the noradrenergic systems are common pathways involved in anxiety. Many believe thatlow serotonin system activity and elevated noradrenergic system activity are responsible for its development. Therefore, it is selective serotonin reuptake inhibitors (SSRI) and serotonin-norepinephrine reuptake inhibitors (SNRI) that are the first-line agent for its treatment.
History and Physical
Patients with anxiety can pose a diagnostic challenge, as somatic symptoms are more common than psychological symptoms. Most patients present with vague or nonspecific somatic complaints, including, but not limited to,shortness of breath, palpitations, fatigability, headache, dizziness, and restlessness. Patients may also describe psychologic symptoms such as excessive, nonspecific anxiety and worry, emotional lability,difficulty concentrating, and insomnia.
Factors commonly associated with generalized anxiety include:
Presence of stressors
The median age of presentation is 30 years.
Many scales have been developed to assess the severity and diagnosis. The GAD-7 has been validated as a diagnostic tool and severity assessment scale.
Initial assessment begins by addressing behavioral or somatic symptoms. Evaluate for psychosocial stress, psychosocial difficulties, and developmental issues. Review past medical history,includingtrauma, psychiatric conditions, and substance abuse.
The following evaluation may be obtained to exclude organic causes:
Thyroid function tests
Blood glucose level
The Generalized Anxiety Disorder 7-Item (GAD-7) Questionnaire is a screening tool that can also be used to monitor patients withgeneralized anxiety disorder.
Treatment / Management
The two main treatments for generalized anxiety disorder are cognitive behavioral therapy and medications. Patients may benefit most from a combination of the two. It may take sometrial and error to discover which treatments work best.
Cognitive Behavioral Therapy
This includes psychoeducation, changing maladaptive thought patterns, and gradual exposure to anxiety-provoking situations.
Patients who do not respond to cognitive behavioral therapy may be treated with medications. Some patients with severe symptoms are treated with both initially. Several types of medications are used to treat generalized anxiety disorder.
Selective serotonin reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI) classes are the first-line agents with a response rate of 30% to 50%. This class of drugs includes escitalopram (Lexapro), duloxetine (Cymbalta), venlafaxine (Effexor XR), and paroxetine (Paxil, Pexeva). In a study, 81% of children with anxiety disorders who received combined sertraline hydrochloride and CBT responded to the treatment.
Antipsychotics may also help some patients, especially those with associated behavior problems.
Examples are diazepam and clonazepam, which are long-acting agents. These agents are used when an immediate reduction of symptoms is desired, or a short-term treatment is needed. Generally, cooperative and compliant patients who are aware that their symptoms have a psychological basis are more likely to respond to benzodiazepines. Since there is a concern for misuse and dependence, patients with a history of alcoholism or drug abuse are not appropriate candidates for this treatment.
Buspirone is a non-benzodiazepine that does not cause dependency. It is also less sedating than benzodiazepines, and tolerance does not occur at therapeutic doses. This agent has a therapeutic lag in the efficacy of two to threeweeks, limiting its use.
All medications should be titrated slowly and continued for at least 4 weeks to determine if they work. Once symptoms are under control, the medications need to be used for at least 12 months before gradually tapering them. Every medication has adverse effects like weight gain, hyperlipidemia, and diabetes; thus, the patients need to be monitored.
Psychotherapy is used in addition to medications; this combination has proven to be effective.
The education of the patient is vital as it can help ease anxiety. The triggers for anxiety should be managed by avoiding caffeine, alcohol, nicotine, and stress) and improving sleep.
Many complementary and alternative remedies are available, but the evidence to support their efficacy is lacking. Further, some agents like Kava may injure the liver. Others, like St John's wort and hydroxytryptophan, may interact with SSRIs and induce serotonin syndrome.
Chronic obstructive pulmonary disease
Transient ischemic attack
Use of caffeine, decongestants, and albuterol
The prognosis for patients with generalized anxiety disorder is guarded. Many patients are not compliant with medications because of cost and adverse effects. Relapses are common, and patients often search for physicians who comply with their needs. Because of the lack of conventional medicine to cure the disorder, many opt for alternative therapies without much success. Overall, the quality of life of these patients is poor.
Complications of generalizedanxiety disorder can also lead to, or worsen, other mental and physical conditions:
Depression (often presents concomitantly with an anxiety disorder)
Drug or alcohol use disorder
Issues functioning at work/school
Impaired quality of life
Deterrence and Patient Education
Patients with anxiety disorders need to understand the importance of medication compliance (anxiolytics, antidepressants, sleepinducers), working with any cognitive therapy prescribed, and thebenefit of stopping the use of caffeine or other stimulants.
Pearls and Other Issues
Consider further evaluation for anxiety disorder if an adult is excessively anxious or an infant or child is excessively clingy and difficult to console during the pediatric visit. Many medical conditions may mimic anxiety disorders. One should distinguish between anxiety and illness and should evaluate for organic diseases before making this diagnosis.
Enhancing Healthcare Team Outcomes
Anxiety disorders are verycommon and can have a diverse presentation of signs and symptoms. The condition has very high morbidity and mortality and is best managed by an interprofessional team that includes a mental health nurse, pharmacist, psychologist, psychiatrist, and primary care provider. Many patients have moderate to severe symptoms, which lead to poor quality of life. Most have no idea that the condition can be treated. Thus, the key to improving outcomes is patient education. The nurse practitioner, pharmacist, and primary care provider should urge the patient to stop tobacco, alcohol, and caffeinated beverages. Also, relief of stress is vital, and thus a referral for cognitive behavior therapy may help.
Many drugs can be used to treat anxiety, but they all have side effects, which is a common reason for non-compliance. The pharmacist should emphasize the benefits of these medications and urge compliance to improve the symptoms. At the same time, the primary care provider should monitor for hyperlipidemia, diabetes, and weight gain due to the medications.
Overall, anxiety disorders are underdiagnosed and undertreated. When left untreated, anxiety disorders often lead to severe depression and abuse of drugs and alcohol. Additionally, there is a high rate of suicide among these patients. Many patients with chronic anxiety have a poor quality of life. The education of both the patient and family by the pharmacist, nurse, and provider as a team is important to reduce the high morbidity and addiction problems with treatment medications. Family members should help ensure medication compliance and provide a supportive environment. Unfortunately, despite optimal treatment, relapse rates are high.[Level5]
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Disclosure: Sadaf Munir declares no relevant financial relationships with ineligible companies.
Disclosure: Veronica Takov declares no relevant financial relationships with ineligible companies.
Generalized anxiety disorder is a condition of excessive worry about everyday issues and situations. It lasts longer than 6 months. In addition to feeling worried you may also feel restlessness, fatigue, trouble concentrating, irritability, increased muscle tension, and trouble sleeping.What are the 5 symptoms of generalized anxiety disorder? ›
- Restlessness or feeling keyed up or on edge.
- Being easily fatigued.
- Difficulty concentrating or mind going blank.
- Muscle tension.
- Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
This extreme anxiety can be debilitating, but it is also treatable. It is possible to live well with GAD if a person gets professional treatment, practices relaxation strategies, actively works toward changing negative thoughts, and engages in healthy lifestyle habits that minimize stress.What triggers generalized anxiety disorder? ›
People with generalized anxiety disorder may have a history of significant life changes, traumatic or negative experiences during childhood, or a recent traumatic or negative event. Chronic medical illnesses or other mental health disorders may increase risk.Is GAD considered a mental illness? ›
Generalized anxiety disorder is a mental health disorder that produces fear, worry, and a constant feeling of being overwhelmed. It is characterized by excessive, persistent, and unrealistic worry about everyday things.What is the 3 3 3 rule for anxiety? ›
Look around you and name three things you see. Then, name three sounds you hear. Finally, move three parts of your body — your ankle, fingers, or arm. Whenever you feel your brain going 100 miles per hour, this mental trick can help center your mind, bringing you back to the present moment, Chansky says.Do I have GAD or just anxiety? ›
When people experience normal anxiety, they tend to worry about things related to the anxiety-provoking situation or several other things that make them fearful. People with GAD tend to be described as "worrying about everything all the time.” If that describes you, it may be more than normal anxiety.What is the best medication for generalized anxiety disorder? ›
Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are first-choice options for treating generalized anxiety disorder (GAD). If an SSRI or SNRI doesn't work, there are other options. These include buspirone and hydroxyzine.What is high functioning anxiety? ›
Instead, high-functioning anxiety typically refers to someone who experiences anxiety while still managing daily life quite well. Generally, a person with high-functioning anxiety may appear put together and well- accomplished on the outside, yet experience worry, stress or have obsessive thoughts on the inside.What happens to the brain with GAD? ›
The participants with GAD also exhibited lower neural activity in the ventromedial prefrontal cortex. This area of the brain is responsible for regulating the autonomic nervous system and generates feelings of fear or safety.
- Keep physically active. ...
- Avoid alcohol and recreational drugs. ...
- Quit smoking, and cut back or quit drinking caffeinated beverages. ...
- Use stress management and relaxation techniques. ...
- Make sleep a priority. ...
- Eat healthy foods. ...
- Learn about your disorder.
Limit alcohol, caffeine, and sugar consumption. Take time out for yourself every day. Even 20 minutes of relaxation or doing something pleasurable for yourself can be restorative and decrease your overall anxiety level.Who is most likely to have generalized anxiety disorder? ›
Females are believed to be twice as likely as males to experience generalized anxiety disorder. GAD begins gradually, often in childhood or adolescence, with symptoms that may worsen during times of stress. The age of onset varies but occurs more often in adolescents and older children than in younger children.Is GAD on the autism spectrum? ›
Anxiety is not considered a core feature of autism spectrum disorder (ASD) in adults, but generalized anxiety disorder is autism's most common comorbid condition.What is the hardest mental illness to live with? ›
Borderline personality disorder is one of the most painful mental illnesses since individuals struggling with this disorder are constantly trying to cope with volatile and overwhelming emotions.Is GAD a form of PTSD? ›
Again, you may recognize some symptoms of GAD in the diagnostic criteria for PTSD. However, GAD doesn't include dissociative symptoms, which individuals who have PTSD often experience. While fear or worry is common in PTSD and GAD, people with GAD experience persistent or excessive worry.What is the 5 5 5 anxiety rule? ›
First, you may want to start with a simple deep breathing exercise called the 5-5-5 method. To do this, you breathe in for 5 seconds, hold your breath for 5 seconds, and then breathe out for 5 seconds. You can continue this process until your thoughts slow down or you notice some relief.What are the three A's of anxiety? ›
“It is more than okay to not feel 100% all the time or to experience unexplained anxiousness. Take a moment to see it, absorb it, identify it. Accept it,” she added as she talked about the '3-3-3 rule' that “grounds us to the present moment creating mindfulness that helps us depart from unhealthy emotions”.What does GAD look like in a person? ›
Generalized anxiety disorder is a condition of excessive worry about everyday issues and situations. It lasts longer than 6 months. In addition to feeling worried you may also feel restlessness, fatigue, trouble concentrating, irritability, increased muscle tension, and trouble sleeping.Is having anxiety a disability? ›
Anxiety disorders like OCD, panic disorders, phobias, or PTSD are considered a disability. Therefore, they can qualify for Social Security disability benefits. Individuals must prove that it is so debilitating that it prevents them from working.
GAD can make daily life feel like a constant state of worry, fear, and dread. The good news is GAD is treatable.What works like Xanax but not addictive? ›
- Fluoxetine (Prozac®)
- Escitalopram (Lexapro®)
- Citalopram (Celexa®)
- Paroxetine (Paxil®)
- Sertraline (Zoloft®)
To diagnose an anxiety disorder, a doctor performs a physical exam, asks about your symptoms, and recommends a blood test, which helps the doctor determine if another condition, such as hypothyroidism, may be causing your symptoms. The doctor may also ask about any medications you are taking.What is the first drug of choice for anxiety? ›
Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) SSRIs and SNRIs are often the first-line treatment for anxiety. Common SSRI brands are Celexa, Lexapro, Luvox, Paxil, and Zoloft.What is the sneaky red flag of high-functioning anxiety? ›
Some of the sneaky signs of high-functioning anxiety include: Being a “people pleaser,” never wanting to let others down, even at your own expense. Overthinking everything. Procrastination followed by periods of “crunch-time” work.What is considered extreme anxiety? ›
your worrying is uncontrollable and causes distress. your worrying affects your daily life, including school, your job and your social life. you cannot let go of your worries. you worry about all sorts of things, such as your job or health, and minor concerns, such as household chores.What are 3 signs of high-functioning anxiety? ›
- Constantly overthinking and overanalyzing.
- Fear of failure and striving for perfection.
- Insomnia and fatigue.
- The need to please others and difficulty saying no.
- Tendency to dwell on past mistakes.
- Nervous habits such as nail-biting, hair twirling, or leg shaking.
Brain imaging can reveal unsuspected causes of your anxiety. Anxiety can be caused by many things, such as neurohormonal imbalances, post-traumatic stress syndrome, or head injuries. Brain scans can offer clues to potential root causes of your anxiety, which can help find the most effective treatment plan.When should you be hospitalized for anxiety? ›
You can be hospitalized for severe anxiety if your symptoms have become so intense that you are unable to function at work, in school, or in another important area of your life.What is an example of a generalized anxiety disorder? ›
The worry in GAD often interferes with a person's day-to-day life, or is bothersome. For example, people with GAD may find themselves having difficulty working, sleeping, socializing, or enjoying themselves as a result of their worries.
- Listen. Listening may seem obvious but can be challenging. ...
- Educate Yourself. ...
- Seek Help. ...
- Don't Minimize Their Struggles. ...
- Offer to Be an Accountability Partner. ...
- Encourage Self-Care. ...
- Watch for Potential Co-occurring Disorders.
The best stress-relieving drinks include ginger, chamomile tea, valerian, black tea, coconut water, milk, green tea, coffee, lemon balm tea, water, and vegetable and fruit juice. Aromatherapy is another self-soothing practice shown to have benefits for mental health.What foods calm anxiety? ›
Foods naturally rich in magnesium may, therefore, help a person to feel calmer. Examples include leafy greens, such as spinach and Swiss chard. Other sources include legumes, nuts, seeds, and whole grains. Foods rich in zinc such as oysters, cashews, liver, beef, and egg yolks have been linked to lowered anxiety.What foods make anxiety better? ›
- Fatty fish. Fatty fish, such as salmon, mackerel, sardines, trout, and herring, are high in omega-3s. ...
- Eggs. Egg yolks , especially from pasture-raised hens, are another good source of vitamin D. ...
- Pumpkin seeds. ...
- Dark chocolate. ...
- Turmeric. ...
- Chamomile. ...
- Yogurt. ...
- Green tea.
Untreated anxiety can result in changes to the prefrontal cortex and hippocampus. This impaired functioning may increase the risk of developing neuropsychiatric disorders such as depression and dementia.Does anxiety get worse with age? ›
Anxiety disorders don't necessarily get worse with age. But the number of people dealing with them may change across the lifespan.What does a person with generalized anxiety disorder worry about? ›
Generalized anxiety disorder (GAD) is a mental health condition that causes fear, worry and a constant feeling of being overwhelmed. It's characterized by excessive, frequent and unrealistic worry about everyday things, such as job responsibilities, health or chores. It can affect children and adults.What is the most noticeable symptom of generalized anxiety disorder? ›
Generalized anxiety disorder is a condition of excessive worry about everyday issues and situations. It lasts longer than 6 months. In addition to feeling worried you may also feel restlessness, fatigue, trouble concentrating, irritability, increased muscle tension, and trouble sleeping.What are three characteristics of a person with a general anxiety disorders? ›
- Feeling restless, wound-up, or on-edge.
- Being easily fatigued.
- Having difficulty concentrating.
- Being irritable.
- Having headaches, muscle aches, stomachaches, or unexplained pains.
- Difficulty controlling feelings of worry.
- Having sleep problems, such as difficulty falling or staying asleep.
- a churning feeling in your stomach.
- feeling light-headed or dizzy.
- pins and needles.
- feeling restless or unable to sit still.
- headaches, backache or other aches and pains.
- faster breathing.
- a fast, thumping or irregular heartbeat.
- sweating or hot flushes.
The main symptom is a constant and exaggerated sense of tension and anxiety. You may not be able to pinpoint a reason why you feel tense. Or you may worry too much about ordinary things, such as bills, relationships, or your health. It can upset your sleep and cloud your thinking.What type of people are prone to generalized anxiety disorder? ›
Research has indicated that individuals with high emotional reactivity (high neuroticism) and introverted tendencies (low extroversion) are more likely to experience anxiety than other personality types .Who suffers the most from generalized anxiety disorder? ›
Generalized anxiety disorder (GAD) is the most common anxiety disorder among older adults, though anxiety disorders in this population are frequently associated with traumatic events such as a fall or acute illness. Read the best way to treat anxiety disorders in older adults.How do you fix generalized anxiety? ›
- Psychotherapy. Cognitive behavioral therapy (CBT), a research-supported type of psychotherapy, is commonly used to treat GAD. ...
- Medication. ...
- Support Groups. ...
- Healthy Habits. ...
- Educate Yourself. ...
- Communicate. ...
- Know When to Seek Help. ...
- Behavioral Health Treatment Services Locator.
A little anxiety is fine, but long-term anxiety may cause more serious health problems, such as high blood pressure (hypertension). You may also be more likely to develop infections. If you're feeling anxious all the time, or it's affecting your day-to-day life, you may have an anxiety disorder or a panic disorder.What are the signs of anxiety in a woman? ›
- Excessive fear or worry.
- Changes in behavior, such as avoiding things that cause anxiety.
- Difficulty focusing or making decisions.
- Feeling restless or on edge.
- Muscle tension.
- Shortness of breath.
- Increased heart rate.
Everyone gets anxious sometimes, but if your worries and fears are so constant that they interfere with your ability to function and relax, you may have generalized anxiety disorder (GAD). GAD is a common anxiety disorder that involves constant and chronic worrying, nervousness, and tension.Which drug is most rapidly effective for generalized anxiety? ›
Benzodiazepines have a high effective rate for GAD compared to other medication options. 16 They're also fast-acting, providing more immediate anxiety relief. Medications in this class include Klonopin (clonazepam), Ativan (lorazepam), and Xanax (alprazolam).