Fact sheet: Generalized anxiety disorder

Everybody sometimes feels anxious, experiences real fear or is scared. In situations where we are actually in danger, fear is a healthy way of protecting ourselves. It alarms us to a threat and makes sure that we can react quickly. When we are anxious we worry about things in the future or things that might not even happen at all. Being fearful can also protect us: for example, from getting into a critical or dangerous situation in the first place. But being overly worried or frightened can also become a burden.

When we are anxious, the hormone adrenaline is released. It speeds up the body’s functions so that we are vigilant and ready to react. The heart beats faster, and breathing can become more shallow and rapid. If this state of alarm lasts too long, we can feel lightheaded, nervous and easily agitated. This makes being worried all the time exhausting.

Most people know whether they tend to be anxious or not. But no more than 1 out of 20 people reaches a point sometime during their life where their worries and fears become unbearable and chronic. These people have developed a disorder called “generalized anxiety disorder” (GAD). If you do have GAD, you are in a state of fear most of the time, and this lasts for a period of more than 6 months. You are for the most part aware that your fears are disproportionate, and that you cannot control them – which in itself might be causing you to worry even more.

But there are many things that can be done to help. It is important that you try to get a handle on your fear in order to avoid other problems. If you worry too much, you could develop depression or other anxiety disorders such as panic attacks. Constant tension can also cause or worsen symptoms like back pain or stomach aches. It is difficult for people who live in a state of deep fear to get out of it – but it can be done.

What is GAD and how do I tell if I have it?

There are different kinds of anxiety disorders with different symptoms. These include phobias, panic disorders and obsessive-compulsive disorders. People who have GAD can develop other anxiety disorders if their condition does not improve. Fear can also be a sign of depression, however. That is why it is important to find out what the problem is. If you want to work on your problems independently, for example by reading books or using the internet, you must find out in advance which type of fear you have and whether you really have a disorder.

You may have developed GAD if you constantly harbor unrealistic and exaggerated fears that affect many different parts of your life. Doctors and psychologists call this “generalized” or “free-floating” fear, because in this case fear is not a reaction to any threat and it is not limited to certain things or situations. The fears can be related to practically anything.

It might be the case, for instance, that in one moment you are worrying that your partner has an accident on the way to work. In the next moment you fear that your child will be run over on the way to school; and then that you have lost your keys, that you could lose your job and finally, that you could have a heart attack tomorrow. You worry about practically everything, large and small events, and even completely unimportant things as well.

Of course, some fears are also justified. Most mothers would worry if their child did not return from school on time. But if you have generalized anxiety disorder, you probably know that your worries are no longer normal. The amount of fear or how long it lasts are no longer in proportion to the probability that the feared event actually could happen – or to the consequences that could result from it occurring.

If your ability to lead a normal life is severely restricted by constant worrying and it becomes impossible to relax, you could have GAD. If you can no longer concentrate on the tasks at hand because you are repeatedly distracted by your worries, you are likely to have a real problem with your anxiety.

How is GAD diagnosed?

Diagnosis of a generalized anxiety disorder is based on two steps: asking questions that could suggest the existence of GAD, and ruling out other disorders or problems. The medical diagnosis of GAD is made if the exaggerated fears

• have persisted on most days for at least six months,
• have become uncontrollable,
• are so burdensome that they interfere with daily activities, AND
• there are at least three physical symptoms of constant fear.

If the following physical symptoms occur for a longer time, they could be signs of GAD: faster pulse, an irregular heartbeat, trembling, restlessness, muscle tension, sweating, dry mouth, stomach complaints, numbness, difficulty concentrating, dizziness, and tension headaches. Sleep disorders and the inability to relax (constantly feeling “wound up”) are also possible symptoms of GAD. These symptoms could also be caused by certain physical disorders, such as hyperthyroidism. Some medications and drugs like amphetamines (“speed”) can also trigger these symptoms. Your doctor will question you thoroughly before diagnosing GAD.

If your fears only occur in certain situations or when you are in a particular emotional state, you most likely do not have GAD. Suddenly occurring fears or panic attacks are not characteristic of the disorder, either. Yet there are some people who have both GAD and panic disorder at the same time. Obsessive-compulsive disorders are also different from GAD.

What are the causes of GAD and can it get worse?

Like other kinds of anxiety, generalized anxiety is not a disease, but a disorder. It is not caused by physical problems or agents of disease, but by mental or emotional factors. It is not known exactly why some people develop GAD and others do not. Although the tendency to have fears and worries as well as to develop GAD can run in the family, it is not the cause of GAD. It is most likely caused by a combination of things.

Some people who have GAD were severely traumatized during their childhood, especially by being abused. Others experienced severe trauma later on in life or had a lot of distressing experiences, for instance an extreme workload or other types of stress at the workplace. Sometimes an extremely distressing life crisis can trigger fears that later develop into GAD – even if the crisis was successfully managed. Daily problems and demands that used to be easily mastered suddenly are enough to trap individuals in a virtually inescapable cycle of anxiety.

Usually GAD develops slowly, so that it often remains undetected for a long time. Sometimes only a part of the disorder is recognized and treated, for example poor sleep. GAD typically begins in people aged 30 to 35, but it can also develop earlier or later. Children may also have GAD. In general, it occurs less in older people and hardly ever in people over the age of 65 years. Women develop GAD more often than men.

GAD is usually quite persistent. If you have developed GAD, you are likely to need support and you will have to be active to overcome it. GAD can also be less-developed, so that some people simply try to cope with their fears or to get used to being rather unhappy. Here there is a danger of the disorder getting worse, or of developing other anxiety disorders or depression. Learning how to better deal with anxiety not only improves your life situation now, but can prevent greater problems as well.

Of those who do not seek treatment, only 1 out of 4 people who have GAD do better after 4 years. After five years, 4 out of 10 people could still have problems. Some people will possibly never be free of GAD without help. Others experience cycles of phases that are better and ones that are worse. A lot of stress may also cause symptoms to flare up again.

What treatment options are there?

There is no quick or easy “cure” for people who have GAD. But there are some things that can help to reduce the problems and to learn how to better deal with stress and anxiety. There are three basic groups of treatment methods, whereby not every one of them can actually help:

• Psychological techniques for learning how to direct your thoughts and fears, and how to relax and deal with stress, including psychotherapy and traditional strategies like yoga,
• Medication, including complementary drugs like valerian, and
• Self-help interventions like books and websites that use psychological techniques, as well as self-help groups.

Learning to deal with GAD and trying to settle into a less anxiety-ridden life can take months. But it is possible to achieve noticeable improvement after just a few weeks. Getting over the disorder, though, needs time and persistence, just as it probably took quite some time for the fear to become so strong that it was not possible to cope with it. You can try different treatment options individually, or combine them.

Which treatments have been proven to help?

The most effective method of treatment that has the fewest adverse effects is probably a psychotherapeutic method called “cognitive behavioral therapy” (CBT). This method requires working together with a therapist who has been trained in the method and has experience helping people with GAD. CBT also requires weekly sessions for several months and lots of participation and commitment – but in return it could help you to deal with your fears in the long term.

Cognitive behavioral therapy combines two approaches: The goal of the “cognitive” approach is to change patterns of thought that trigger fear. In doing so your therapist helps you to recognize thoughts that are not helpful, and on the contrary cause anxiety and are “catastrophizing”. This means that when something unsettling happens, you jump to extreme and exaggerated conclusions about the extent of the supposed looming disaster. CBT helps you to think more clearly and to better control your thoughts.

The “behavioral” part of CBT aims to change the way you react to situations that cause anxiety. Standing on the edge of a cliff is in itself not necessarily dangerous or unnerving. Yet if you picture yourself falling down the cliff the situation can become very scary. If you do have a problem with anxiety, you will have difficulties in shutting down your fear even in situations that are far less dangerous. But you can learn to better evaluate the fear and its cause. In CBT you learn ways of behavior that can help you to calm down instead of being caught up in the fear. For example, you could learn to stop your anxiety by consciously taking in deep breaths so that your body and your breathing return to a state of rest. You concentrate on your breathing instead of what is causing your fear. There are many of these types of techniques that are relatively easy to learn.

CBT does not examine a person’s early childhood or possible traumas. It does not analyze why something causes fear, but explains how thoughts, feelings and behavior influence one another in an anxiety disorder. It allows strategies to be developed to reduce symptoms and lower the degree of fear.

The other treatment method that has been tested in trials and proven to help at least some people who have generalized anxiety disorder is medication therapy. If the medication works, improvement can be felt within a few days or weeks. Yet even the most effective medications help only part of the people who take them. There is no drug that is able to help the majority of people who have GAD. In addition they are not suitable for regular use over a longer period of time, which may be necessary in the treatment of GAD.

The medications most commonly used for treating severe GAD are benzodiazepine and antidepressants. These are not used in combination. Both can help to lessen symptoms, but are associated with a relatively high risk of adverse effects. Benzodiazepines are sedatives that can be addictive. If an addiction has developed, withdrawal symptoms will occur when use of the medication is stopped. In the future we will include more information about these therapy options on our website.

The third medication used to treat anxiety disorders is the anti-anxiety drug buspirone. It seems to be less effective than the others, but it probably has fewer adverse effects. You can read more about research on buspirone here.

Can GAD recur?

People who have already had episodes of GAD can also experience more phases later on. Yet most are spared. If you have learned to better manage anxiety and stress, they will most likely not get out of control again. Also, the probability of a new occurrence lessens with age, because older people are more experienced in dealing with stress and fear. They often have a more sober view of things, too.

It is difficult to cope with extreme fear, but it can be learned. There are helpful therapists who listen closely to you and recognize the basic patterns of your anxieties and worries. They can work together with you so that you can change the way you think and feel. Fear does not have to rule your life forever.

© IQWiG (Institute for Quality and Efficiency in Health Care)