Generalized anxiety disorder [GAD]

Generalized anxiety disorder (GAD) is a chronic state of intense worry and tension, often without a trigger. People with this disorder regularly anticipate disaster and often worry excessively about health, money, family, or work. Just getting through the day leads to a state of anxiety.

People with generalized anxiety disorder are unable to shake their worries, although they usually realize that much of their anxiety is unwarranted. People with this disorder may not be able to relax and often have difficulty falling or staying asleep. Their worries are accompanied by physical symptoms such as trembling, twitching, muscle tension, headaches, irritability, sweating, flushing, and feeling lightheaded or short of breath.

Many people with this disorder are easily frightened. They tend to feel tired, have trouble concentrating, and may suffer from depression. Generalized anxiety disorder may cause nausea, frequent trips to the bathroom, or a lump in the throat.

When their anxiety is mild, people with this disorder may have normal social and work behaviors, but when their anxiety is severe, they may have difficulty performing the simplest daily activities.

This disorder affects more than one million adult Italians; women are twice as likely to be affected as men. The disorder can begin at any time in life, but usually develops between childhood and middle age. The prevalence of the diagnosis peaks in middle age and declines in the later years of life.

The disorder is often accompanied by other disorders related to anxiety, depression, or substance abuse. Generalized anxiety disorder is often treated with medication or cognitive-behavioral therapy, but co-occurring disorders must also be treated with appropriate therapies.

Characteristics of generalized anxiety disorder

Generalized anxiety disorder is a syndrome characterized by persistent fears and worries about many events or thoughts that the patient generally perceives as excessive and inappropriate. Most people with generalized anxiety disorder also have other mood and anxiety disorders.

Anxiety symptoms tend to be present throughout the day, all day long, and the worries relate to issues in the patient’s daily life, such as family, finances, work, and personal health (Roemer et al., 1997). People with generalized anxiety disorder also report a state of constant worry about the future, along with a generalized state of tension and restlessness that they are unable to control.

What are the symptoms of anxiety disorder?

Generalized anxiety disorder is defined by the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) as a disorder that is chronic for six months or more, characterized by exaggerated worry and tension that is unwarranted or much more severe than the normal anxiety experienced by most people.

Agitation and restlessness

  • palpitations or rapid heartbeat;
  • sweating;
  • trembling or shaking;
  • dry mouth (not due to medication or dehydration).

Chest and abdomen symptoms

  • difficulty breathing;
  • feeling of suffocation;
  • chest pain or discomfort;
  • nausea or abdominal pain (such as stomach upset).

Symptoms that affect mental status

  • feeling of dizziness;
  • unsteadiness;
  • fainting or lightheadedness;
  • feeling out of control, “going crazy,” or passing out;
  • fear of dying.

General symptoms

  • hot flushes or chills;
  • numbness or tingling sensations;
  • muscle tension or aches;
  • restlessness or inability to relax;
  • feeling tense, nervous, or mentally preoccupied;
  • feeling of a lump in the throat or difficulty swallowing.

Other nonspecific symptoms

  • exaggerated reaction to small surprises or being surprised;
  • difficulty concentrating or “empty feeling” due to worry or anxiety;
  • persistent irritability;
  • difficulty falling asleep due to worry.

In children and adolescents with generalized anxiety disorder, anxiety and worry are often associated with school performance or sporting events. Worries may also include punctuality, conformity, and perfectionism.

Generalized Anxiety Disorder and the DSM-5

The DSM-5, compiled by the American Psychiatric Association and published in 2013, places Generalized Anxiety Disorder in the chapter on anxiety disorders. According to the DSM-5, GAD is characterized as a state of excessive anxiety that interferes with various areas and events of daily life (such as school or work) and is difficult for the individual to manage.

In addition, at least three of the following symptoms are present

  • feeling restless, agitated, or on edge
  • feeling tired easily
  • difficulty concentrating or memory lapses
  • irritability
  • muscle tension
  • sleep problems (difficulty falling asleep or staying asleep, or disturbed sleep)

Generalized anxiety disorder is usually found in comorbidity with other psychiatric disorders. In fact, it is common to find a correlation between GAD and depression, or between GAD and panic disorder or other anxiety or mood disorders.

Differential diagnosis

A diagnosis of generalized anxiety disorder may be made if the patient does not meet the diagnostic criteria for any of the following disorders: panic disorder, specific phobia, obsessive-compulsive disorder, or illness anxiety disorder. If the symptoms are due to a physical, neurological, or substance-related disorder, generalized anxiety disorder is excluded.

Causes of generalized anxiety disorder

Anxiety disorders are complex and result from a combination of genetic, behavioral, and developmental factors. Risk factors for generalized anxiety disorder include a family history of anxiety and recent or prolonged periods of stress.

Like many mental disorders, GAD is considered a multifactorial disorder. This means that psychological, biological, and environmental variables may interact to cause the disorder.

From a psychological point of view, explanations of generalized anxiety disorder vary according to different theoretical reference approaches.

The brain circuitry involved in fear and anxiety is known to contribute to the experience of the disorder, although the mechanism by which this disorder is activated is unknown. Twin and family studies suggest that genes play a role in the development of anxiety disorders. Childhood adversity and parental overprotectiveness have both been associated with later development of generalized anxiety disorder. It is important to rule out medical causes of anxiety, such as thyroid disorders, before making a diagnosis.

Risk factors

Possible causes and risk factors for generalized anxiety disorder include

  • Negative or traumatic experiences (recent or past)
  • Prolonged exposure to stressors
  • Chronic and disabling illnesses
  • Avoidant, introverted, and pessimistic personalities.

In addition, twin studies have shown that the familial rate of generalized anxiety disorder is about 20%. Thus, there is an important genetic component that increases the risk of developing the disorder.

Treatment for generalized anxiety disorder


Both cognitive psychotherapy and anxiety management therapy have been shown to be effective in treating generalized anxiety disorder. Anxiety management therapy is a structured therapy that includes psychoeducation, relaxation training, and exposure, but does not include cognitive restructuring; cognitive behavioral therapy adds this extra element instead.


Relaxation involves the practice of techniques that lead to muscle or body relaxation, of which Jacobson’s progressive muscle relaxation and autogenic training are the most well-known.

Exposure, on the other hand, involves gradual and repeated confrontation (first through simple imagery, then through actual exposure) with anxiety-provoking stimuli.

Cognitive restructuring

Finally, cognitive restructuring is a cognitive-behavioral technique that challenges dysfunctional automatic thought processes (e.g., “I am worthless”) by helping the patient change them.

Numerous studies have shown that cognitive-behavioral psychotherapy results in significantly greater improvements in anxiety and depression in 4-12 weeks compared with untreated groups, anxiety management alone, relaxation alone, or non-directive psychotherapy (Westen D, Morrison K, 2001).

Recent third-generation cognitive-behavioral psychotherapies have also been shown to be effective in treating generalized anxiety disorder.

Pharmacological therapy

Psychopharmacological therapy is usually prescribed by a psychiatrist and involves the use of various types of medications. Among the most commonly used medications for the treatment of generalized anxiety disorder are antidepressants.

Several categories of antidepressants, in fact, in addition to acting on mood, also act on anxiety by reducing its symptoms.

Antidepressants known as SSRIs (selective serotonin reuptake inhibitors) act on a chemical messenger in the brain called serotonin and are often prescribed for this disorder. Venlafaxine and duloxetine, an SNRI (serotonin-norepinephrine reuptake inhibitor), are also prescribed in these cases.

An older class of antidepressants, tricyclics, is also useful in treating the disorder, but many doctors and patients prefer the newer drugs because tricyclics can cause dizziness, drowsiness, dry mouth, and weight gain.


Other medications used to pharmacologically treat anxiety are benzodiazepines. Benzodiazepines have shown good efficacy in treating anxiety symptoms in the short term, although they are addictive and tolerable in the long term.

Thus, they are effective drugs for episodic use, less suitable for long-term use, and should be tapered, especially after long-term use, as indicated by the physician.

Benzodiazepines are among the most widely used (and abused) psychotropic drugs and can cause true benzodiazepine dependence.

For these reasons, drug therapy must be constantly monitored by a physician, who calibrates doses and determines dosages. In fact, do-it-yourself management may worsen the patient’s symptom picture in the long run.

High-potency benzodiazepines relieve symptoms quickly and have few side effects, although drowsiness can be a problem. Because people can develop a tolerance to them and would need to keep increasing the dose to get the same effect, benzodiazepines are usually prescribed for short periods of time. People who have had problems with drug or alcohol use are usually not optimal candidates for these drugs because they can become dependent on them.

Some people experience withdrawal symptoms if they stop taking benzodiazepines abruptly rather than gradually reducing their intake, and anxiety may return when the medication is stopped. Potential problems with benzodiazepines have led some doctors not to use them in treatment or to use them in inappropriate doses, even when they are of potential benefit to the patient.

The phenomenon of worry

Worry plays an important role in generalized anxiety disorder. Worry is the cognitive activity represented by a negative view of future events. We all worry from time to time: worry becomes pathological when it is perceived as excessive and uncontrollable. The worries of generalized anxiety disorder have the following characteristics

  • they are numerous; it can feel as if one is afraid of everything (panophobia)
  • They follow one another: one is immediately or almost immediately followed by another.
  • are accompanied by feelings of alarm, anxiety, and fear
  • Often involve highly unlikely future catastrophic events
  • reduce the ability to think clearly
  • are difficult to control.

People with GAD may spend more than half of their waking hours worrying about events that will not happen. Only when the feared event does not occur do most realize that the worry was excessive and inappropriate.

People with this disorder often worry about having worries, i.e., they have “second-level worries,” which can lead to a vicious cycle that further exacerbates symptoms and difficulties in social, personal, and occupational functioning.

Beliefs that worry can be helpful, such as “If I worry, I will be better prepared to deal with the bad things that are coming,” also exacerbate the disorder.

Protective behaviors

Protective behaviors are behaviors that are used to reduce anxiety, but over time lead to a consolidation of symptoms. These include

  • Seeking reassurance from others: the relief from reassurance is usually short-lived; after a while, the anxiety returns and more reassurance is needed;
  • Being a perfectionist;
  • Avoidance of situations or events believed to be anxiety-provoking: avoidance does not allow you to de-escalate the danger;
  • Procrastination: for example, not starting a task because of fear of an unsatisfactory outcome. In most cases, the consequences feared by the procrastinator are exaggerated and unrealistic;
  • Actively trying to suppress the worry: Worries can get worse when an attempt is made to suppress them, precisely because the person focuses his or her attention on them.


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