Generalized anxiety disorder (GAD): diagnosis and current treatments

Generalized Anxiety Disorder (GAD) is a mental disorder that manifests itself as excessive anxiety in daily life and affects many areas: relationships, family, finances, work, school, health, political and world affairs.

People with GAD tend to feel like they have no control over the situation, that something must go wrong and could even end in disaster. They avoid events that could have negative consequences and spend significant time preparing for difficult events.

According to the biopsychosocial model, the disease develops when three factors combine :

  1. Biological predisposition – genetic, biochemical or anatomical features of the nervous system;
  2. Psychological characteristics – the number and intensity of stressful experiences, character traits, coping strategies, emotional sphere and thinking;
  3. Social situation – cultural and political environment, economic situation, family, friends, professional environment.

For instance:

genetic predisposition (one of the relatives with a diagnosis of GAD) + ruminative thinking and increased emotional sensitivity + financial instability = very high likelihood of developing GAD

Generalized Anxiety Disorder Symptoms

GAD is characterized by severe anxiety that lasts for several days over several months. Anxiety manifests itself in a feeling of general constant apprehension, in excessive anxiety, focused on multiple everyday events. Most often, these concerns are related to family, health, finances, school or work.

Additional symptoms are present:

  • muscle tension
  • motor restlessness, excessive activity,
  • subjective experience of nervousness,
  • difficulty concentrating
  • irritability,
  • sleep disturbance.

When diagnosing GAD, it is important to take into account its high comorbidity with other anxiety disorders and depression. The presence of a comorbidity increases the severity of the disorder and requires longer treatment.

When diagnosing GAD, it is important to take into account its high comorbidity with other anxiety disorders and depression.

Only a psychiatrist or psychotherapist can diagnose GAD. If a person turned to a psychotherapist with a psychological education, then a specialist should refer him to a doctor for examination and possible prescription of pharmacological treatment. Diagnosis may require more than one appointment, especially when GAD is comorbid with other mental disorders.

In the future, the client meets the therapist once or twice a week, and a psychiatrist – every few weeks to monitor drug therapy and symptoms of the disorder.

How An Anxiety Disorder Is Different From Normal Anxiety

Anxiety in generalized anxiety disorder differs from ordinary anxiety in the following ways:

The intensity of anxiety in GAD is not consistent with the adverse event. Anxiety in GAD is higher than that congruent with the strength of the stimulus – an adverse event or anticipation of an adverse event. People with GAD spend much more time per day worrying and worrying about something than non-clinical populations (Andrews et al., 2016).

People with GAD worry about the future even when things are going well. For example, they are worried about being fired, even if they have good reviews from their superiors.

Worry is difficult to control, obsessive and interferes with concentration. Feels unable to end or reduce anxiety.

The history of worry is long – months and years, not hours or days.

Symptoms result in significant distress or significant disruption in personal, family, social, academic, professional, or other important areas of functioning.

Treatment of GAD should be comprehensive – psychotherapy and drug treatment.

GAD treatment


The recommended psychotherapy for generalized anxiety disorder is cognitive behavioral therapy (CBT) . The guidelines refer to meta-analyzes of various studies on the effectiveness of cognitive behavioral therapy: CBT significantly reduces symptoms of GAD and is significantly more effective than placebo. The effectiveness of CBT for GAD is comparable to that of drug therapy.

Individual, group and digital forms of therapy (online consultation) are all equally effective in reducing symptoms, but individual therapy can lead to earlier reduction in symptoms of anxiety and depression.

Cognitive behavioral therapy for GAD is significantly more effective than placebo.

There is insufficient research on the effectiveness of other psychotherapeutic methods for GAD to recommend them .

The duration of CBT for GAD varies and depends on the severity of the disorder, comorbidity with other diseases, the experience of the therapist, and the client’s characteristics. The psychotherapist evaluates all factors and informs the client about the estimated duration of therapy.

Psychotherapy focuses on physical, cognitive and behavioral symptoms and relapse management. Typical CBT programs for GAD include three stages and many components. I can not fully describe the protocol here , since a specialist always adapts it for a specific client.

The first stage is diagnosis and case formulation; providing an overview of generalized anxiety disorder with a rationale for treatment; identification of factors that promote or interfere with therapy; teaching the client to notice their usual anxiety.

The second step in treating generalized anxiety disorder is to reduce the severity of GAD symptoms.

For physical symptoms , these are muscle relaxation, breathing exercise, and cardio exercise.

For cognitive symptoms , this is identifying and working with cognitive distortions, underestimating the ability to cope with problems, intolerance to uncertainty, beliefs about the benefits of worry. By cognitive distortions include, for example, disasterization – reassessment of the probability that something bad will happen. Structured problem solving techniques are used to convert concerns into an action plan when needed.

By cognitive distortions include, for example, disasterization – reassessment of the probability that something bad will happen.

Working with behavior – is encouraging patients to the formation of inescapable behavior, the use of a graded exposure and behavioral experiments to obtain a new life experience.

The third and final stage is relapse management. Completing a course of pharmacological and psychotherapy does not guarantee the absence of relapses. Therefore, the goal of GAD psychotherapy is also to teach relapse prevention and self-help. This stage includes identifying strategies for maintaining health, detecting early signs of relapse and drawing up a plan of action when such signs appear.

On the whole process of psychotherapy conducted periodically monitoring symptoms.

How is generalized anxiety disorder treated?

Drug therapy

Only a doctor can prescribe or change the pharmacotherapy regimen.

Treatment should be preceded by training the patient (psychoeducation) to recognize anxiety and symptoms of generalized anxiety disorder, and advice on lifestyle factors that may support the manifestation of the disease. The doctor and patient should discuss treatment options, the approximate rate of onset, and possible side effects.

Pharmacotherapy can vary depending on the response (or lack thereof) of the body to the drugs. In general terms, several guidelines from different countries agree on recommendations for first and second line pharmacotherapy.

The first line is a drug from the group of selective serotonin reuptake inhibitors (SSRIs).

The second line is another SSRI or SSRI (selective serotonin and norepinephrine reuptake inhibitor ).

Opinions differ with regard to other drugs. For example, barbiturates, previously widely used for anxiety disorders, are currently not recommended by some guidelines due to the high risk of addiction. In addition, the use of these drugs makes psychotherapeutic work with GAD almost impossible .

The pharmacotherapy regimen may vary depending on the response to it. It is important to remember that changing or canceling a drug on your own can have unpleasant or dangerous consequences. If there are doubts about pharmacotherapy, side effects or thoughts like “there are no more symptoms, you can stop drinking the pills ” , it is better to go to the doctor. The psychiatrist will assess the condition of the body and make the best health decision on the pharmacotherapy regimen.

In the recommendations for the treatment of GAD, exactly this order of choice of treatment is indicated: first, psychotherapy, and then, in the absence of positive dynamics, pharmacotherapy is added. This is due to the fact that CBT has good performance indicators for GAD – it can level symptoms, reduce the frequency and intensity of relapses. At the same time, it is often pharmacotherapy that creates the necessary physiological resource for psychotherapeutic work.

In the recommendations for the treatment of GAD, exactly this order of choice of treatment is indicated: first, psychotherapy, and then, in the absence of positive dynamics, pharmacotherapy is added.

With good treatment and adherence to preventive measures, GAD will not have a significant impact on a person’s life.


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