What is generalized anxiety disorder (GAD)?

Introduction

Generalized anxiety disorder (GAD) is characterized by excessive worry about a variety of topics. This anxiety occurs every day, over a period of at least six months. The worries tend to be difficult to control and to diminish the person’s quality of life. Signs and symptoms of GAD include restlessness, difficulty concentrating, fatigue, irritability, impatience, being easily distracted, muscle tension, trouble falling asleep or staying asleep, excessive sweating or hot flashes, shortness of breath, diarrhea, headache, stomachache, having trouble swallowing, feeling light-headed, and having to go to the bathroom frequently.

Possible Causes

The cause of generalized anxiety disorder is not known, although there are a number of theories as to its cause. There may be a hereditary tendency to develop GAD. Some of the causative theories are based on experiences in the person’s life, such as traumatic events occurring in childhood, serious illness, and stressful life experiences. Anxiety may be an inherent part of the person’s personality. Some medications and medical conditions can cause GAD. It is also theorized that persons with GAD may produce low levels of brain chemicals such as serotonin, gamma-aminobutyric acid (GABA), norepinephrine, and dopamine, which are thought to improve mood. It is thought that the amygdala, a small structure within the brain, is a depository for memories of frightening and other highly emotional events. Persons with GAD may have an overly sensitive amygdala that tends to react to situations that are not actually threatening. Questions remain as to whether physical changes in the brain lead to anxiety or whether stressful situations and the resulting anxiety lead to changes in the brain.

Diagnosis

In 2013, the American Psychiatric Association published its most recent edition of the DSM (Diagnostic and Statistical Manual of Mental Disorders). The DSM-5 describes all currently identified mental health problems that may receive a formal medical diagnosis in the United States. In this edition, the section on anxiety disorders is split into twelve individual sub-disorders: separation anxiety disorder, selective mutism, specific phobia, social anxiety disorder, panic disorder, panic attack, agoraphobia, generalized anxiety disorder, substance/medication-induced anxiety disorder, anxiety disorder due to another medical condition, other specified anxiety disorder, and unspecified anxiety disorder.

The diagnosis of GAD is a subjective one and is based on the patient’s reporting of excessive worrying about a variety of topics that has lasted at least six continuous months. GAD can develop in people of all ages, including children. However, all anxiety disorders, including GAD, are more common in women and in older persons.

Treatment Options

The treatment for GAD is antianxiety medications, cognitive behavior therapy(CBT), or both. Antianxiety medications used to treat GAD include benzodiazepines, selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants, and an azpirone derivative.

Benzodiazepines are the first medications prescribed for GAD. They cause mental and physical relaxation by increasing levels of GABA in the brain. They include alprazolam (Xanax), lorazepam (Ativan), clonazepam (Klonopin), and diazepam (Valium). Benzodiazepines are highly addictive and their use should be monitored.

SSRIs (selective serotonin reuptake inhibitors) are drugs, developed in the 1990s, that interfere with the reabsorption (reuptake) of serotonin in the brain, leading to higher levels of serotonin in the body. These medications are less habit-forming than the benzodiazepines and have fewer side effects than older antidepressant medications. SSRIs include fluoxetine (Prozac), paroxetine(Paxil), citalopram (Celexa), sertraline (Zoloft), and escitalopram (Lexapro).

Serotonin-norepinephrine reuptake inhibitors (SNRIs) interfere with the reabsorption of both serotonin and norepinephrine in the brain. There are two drugs in this group: venlafaxine (Effexor) and duloxetine (Cymbalta).

Tricyclic antidepressants (TCAs), which were developed in the 1970s, interfere with the reabsorption of serotonin and norepinephrine in the brain, and they increase the sensitivity of the serotonin and norepinephrine receptors. TCAs have more side effects and more serious side effects than SSRIs, including altering the rhythm of the heart. TCAs include amitriptyline (Elavil), clomipramine (Anafranil), and imipramine (Tofranil).

There is only one azapirone derivative, buspirone (BuSpar). Buspirone increases the activity of serotonin and decreases the activity of dopamine. It accomplishes this by binding to the serotonin and dopamine receptors in the brain. Buspirone has few side effects compared with other drugs used to treat GAD.

Cognitive behavior therapy increases the levels of serotonin and norepinephrine in the body by changing the negative thought patterns of the patient. Persons with anxiety disorders, including GAD, tend to get caught up in their excessive reactions to stressful situations. Cognitive behavior therapy teaches them to stop these negative thoughts and to evaluate the validity of their fears.

Bibliography

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