Excessive, hard-to-control worry about multiple domains >=6 months with physical and cognitive symptoms.
Also known as: GAD, generalized anxiety, chronic anxiety
Overview
Persistent and excessive anxiety and worry about multiple events or activities, occurring more days than not for >=6 months, accompanied by physical and cognitive symptoms and causing significant distress or functional impairment.
Epidemiology
Lifetime prevalence ~5-9%; 12-month prevalence ~3%. Female-to-male ratio ~2:1. Median onset age 30, though prodromal anxiety often present from childhood. Frequently comorbid with MDD, other anxiety disorders, and substance use.
Try two board-style Generalized Anxiety Disorder questions
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Question 1PsychiatryEasy
A 35-year-old man reports 7 months of excessive, hard-to-control worry about work, health, and finances, accompanied by muscle tension, restlessness, difficulty concentrating, and poor sleep. He has no medical illness, substance use, or other psychiatric diagnosis to account for the symptoms. Which of the following is the most appropriate first-line pharmacotherapy?
ABuspirone
BClonazepam
CSertraline
DPropranolol
Reveal answer & full explanation
Correct answer: C — Sertraline
ABuspirone
BClonazepam
CSertraline✓
DPropranolol
Why Sertraline is correct
Excessive, difficult-to-control worry across multiple domains for more than 6 months with muscle tension, restlessness, concentration difficulty, and sleep disturbance meets DSM-5 criteria for generalized anxiety disorder (GAD)
SSRIs such as sertraline or escitalopram (or an SNRI) are first-line pharmacotherapy for GAD per current guidance, with durable benefit against the core cognitive worry
Combining medication with cognitive behavioral therapy (CBT) is more effective than either modality alone
Why the others are wrong
Buspirone — a reasonable adjunct or alternative for GAD but less effective than SSRIs and not first-line; it tempts learners who buzzword-match 'anxiolytic' to any anxiety disorder
Clonazepam — benzodiazepines give rapid relief but cause tolerance, dependence, and cognitive impairment and are avoided as maintenance therapy for chronic GAD (right-symptom-wrong-strategy trap)
Propranolol — blunts peripheral autonomic symptoms in performance or situational anxiety but does not treat the pervasive worry that defines GAD; it catches learners who confuse GAD with performance anxiety
Question 2PsychiatryMedium
A 34-year-old woman reports 8 months of excessive worry about her job, finances, and her children's health that she finds difficult to control. She also notes restlessness, poor concentration, irritability, and trouble sleeping, and recently has felt warmer than usual and lost 4 kg without dieting. On exam her heart rate is 104/min, she has a fine resting tremor, and her skin is warm and slightly moist. Her GAD-7 score is 14. Which of the following is the most appropriate next diagnostic test?
ASerum thyrotropin assay
BDexamethasone suppression
CFasting plasma glucose level
DPlasma free metanephrines
Reveal answer & full explanation
Correct answer: A — Serum thyrotropin assay
ASerum thyrotropin assay✓
BDexamethasone suppression
CFasting plasma glucose level
DPlasma free metanephrines
Why Serum thyrotropin assay is correct
Before diagnosing generalized anxiety disorder, an organic medical mimic must be excluded, and hyperthyroidism is the classic one.
This patient's heat intolerance, unintentional weight loss, resting tremor, tachycardia, and warm moist skin are red flags that her anxiety symptoms could be thyrotoxic in origin.
TSH (thyrotropin) is the most sensitive initial screen for thyroid dysfunction; a suppressed value would redirect the workup away from a primary anxiety disorder. Standard initial GAD labs are TSH, CBC, and BMP.
Why the others are wrong
Plasma free metanephrines — screen for pheochromocytoma, which causes paroxysmal headache, palpitations, and diaphoresis with spells of hypertension; her sustained, gradual symptoms with weight loss and heat intolerance point to thyroid disease first.
Fasting plasma glucose level — new-onset diabetes can produce unintentional weight loss and recurrent hypoglycemia can mimic adrenergic anxiety, but neither accounts for heat intolerance with a fine resting tremor, tachycardia, and warm moist skin, so glucose testing does not outrank thyroid screening here.
Dexamethasone suppression — evaluates for hypercortisolism, which typically presents with central weight gain, striae, and hypertension rather than weight loss and tremor, so it is not the appropriate first study.
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Female sex, family history of anxiety or mood disorders
Behavioral inhibition in childhood
Adverse childhood experiences
Chronic medical illness, chronic pain
Caffeine, stimulants, withdrawal states
Pathophysiology
Hyperactivity of amygdala-driven fear circuits with reduced prefrontal cortical regulation. Imbalance among GABAergic inhibition and glutamatergic, serotonergic, and noradrenergic transmission. Heritability ~30%.
Clinical presentation
Symptoms
Excessive worry across multiple domains (work, finances, family, health) most days for >=6 months
Pheochromocytoma — Episodic headache, palpitations, diaphoresis with paroxysmal hypertension
Caffeine/stimulant use or substance withdrawal — Temporal relationship; resolves with abstinence
Adjustment disorder with anxiety — Identifiable stressor; subthreshold duration/severity
Diagnostic workup
Diagnostic criteria
DSM-5-TR: Excessive anxiety and worry occurring more days than not for >=6 months about multiple events/activities; difficulty controlling worry; >=3 of 6 associated symptoms (restlessness, fatigue, poor concentration, irritability, muscle tension, sleep disturbance); causes significant distress/impairment; not attributable to substance or medical condition; not better explained by another mental disorder. GAD-7 screening: 5 mild, 10 moderate, 15 severe.
Labs
TSH, CBC, BMP
Consider urine drug screen, urine metanephrines if paroxysmal symptoms
Imaging
Not routinely indicated
Diagnostic algorithm
GAD-7 score
Severity
Suggested action
0-4
Minimal
Education, reassessment
5-9
Mild
Watchful waiting, lifestyle, CBT
10-14
Moderate
CBT and/or SSRI/SNRI
15-21
Severe
CBT + medication; consider specialty referral
GAD-7 severity bands and treatment intensity.
Treatment
First-line
Cognitive behavioral therapy (CBT) — first-line; comparable to medication and durable benefits
Buspirone — non-sedating 5-HT1A partial agonist; takes 2-4 weeks for effect; avoid combining with MAOIs
Hydroxyzine — sedating antihistamine; useful PRN, no dependence
Pregabalin or gabapentin — particularly with comorbid pain
Benzodiazepines (lorazepam, clonazepam, diazepam) — short-term bridge only due to dependence, falls in elderly, and cognitive effects; avoid as monotherapy and in patients with SUD
Complications
Comorbid depression, panic disorder, substance use disorders
Functional and occupational impairment
Increased medical utilization and somatic preoccupation
Cardiovascular morbidity through chronic sympathetic activation
PANCE pearls
Start SSRIs at low dose (e.g., sertraline 25 mg) — anxious patients are sensitive to initial activation and may stop prematurely.
Benzodiazepine prescribing for chronic anxiety has fallen out of favor — use only as a short bridge while SSRI takes effect, and avoid in older adults and patients with SUD.
Always check TSH and consider caffeine intake before initiating chronic anxiolytics.
USPSTF (2023) recommends screening adults <65 for anxiety; insufficient evidence for >=65 screening.
References
USPSTF 2023 — Screening for Anxiety Disorders in Adults: USPSTF Recommendation Statement. JAMA 2023
APA / NICE — NICE Clinical Guideline 113: Generalised anxiety disorder and panic disorder in adults
DSM-5-TR — American Psychiatric Association. DSM-5-TR (2022)
GAD-7 — Spitzer RL et al. A brief measure for assessing generalized anxiety disorder. Arch Intern Med 2006
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