Generalised anxiety disorder is a condition where you have excessive anxiety on most days. You are most likely to be offered ideas about how to help yourself (self-help) and/or psychological treatment in the first instance. Other treatment options include antidepressant medicines and sometimes other types of medicines.
What is anxiety?
When you are anxious you feel fearful and tense. In addition you may also have one or more unpleasant physical symptoms. These may be:
- A fast heart rate.
- The sensation of having a 'thumping heart' (palpitations).
- Feeling sick (nausea).
- Shaking (tremor).
- Dry mouth.
- Chest pain.
- Fast breathing.
The physical symptoms are partly caused by the brain which sends lots of messages down nerves to various parts of the body when we are anxious. The nerve messages tend to make the heart, lungs and other parts of the body work faster. In addition, you release stress hormones (such as adrenaline) into the bloodstream when you are anxious. These can also act on the heart, muscles and other parts of the body to cause symptoms.
Anxiety is normal in stressful situations and can even be helpful. For example, most people will be anxious when threatened by an aggressive person. The burst of adrenaline and nerve impulses which we have in response to stressful situations can encourage a 'fight or flight' response. Some people are more prone to normal anxieties. For example, some people are more anxious than others before examinations. Anxiety is abnormal if it:
- Is out of proportion to the stressful situation; or
- Persists when a stressful situation has gone, or if the stress is minor; or
- Appears for no apparent reason when there is no stressful situation.
What are anxiety disorders?
There are various conditions (disorders) where anxiety is a main symptom. This leaflet is about generalised anxiety disorder (GAD). See separate leaflets for other types of anxiety disorders (eg, social anxiety disorder, panic attack and panic disorder, phobias, acute stress reaction, post-traumatic stress disorder, etc).
What is generalised anxiety disorder (GAD)?
If you have GAD you have a lot of anxiety (feeling fearful, worried and tense) on most days. The condition persists long-term. Some of the physical symptoms of anxiety (detailed above) may come and go. Your anxiety tends to be about various stresses at home or work, often about quite minor things. Sometimes you do not know why you are anxious.
It can be difficult to tell the difference between normal mild anxiety in someone with an anxious personality and someone with GAD. As a rule, symptoms of GAD cause you distress and affect your day-to-day activities. In addition, you will usually have some of the following symptoms:
- Feeling restless, on edge, irritable, muscle tension, or keyed up a lot of the time.
- Tiring easily.
- Difficulty concentrating and your mind going blank quite often.
- Poor sleep (insomnia). Usually it is difficulty in getting off to sleep.
You do not have GAD if your anxiety is about one specific thing. For example, if your anxiety is usually caused by fear of one thing then you are more likely to have a phobia.
Who develops generalised anxiety disorder (GAD)?
GAD develops in about 1 in 50 people at some stage in life. Twice as many women as men are affected. It usually first develops in your 20s but is frequently being recognised in older people.
What causes generalised anxiety disorder (GAD)?
The cause is not clear. The condition often develops for no apparent reason. Various factors may play a part. For example:
- Your genetic 'makeup' may be important (the material inherited from your parents which controls various aspects of your body). Some people have a tendency to have an anxious personality, which can run in families.
- Childhood traumas such as abuse or death of a parent, may make you more prone to anxiety when you become older.
- A major stress in life may trigger the condition. For example, a family crisis or a major civilian trauma such as a toxic chemical spill. But the symptoms then persist when any trigger has gone. Common minor stresses in life, which you may otherwise have easily coped with, may then keep the symptoms going once the condition has been triggered.
Some people who have other mental health problems such as depression or schizophrenia may also develop GAD.
How is generalised anxiety disorder (GAD) diagnosed?
If the typical symptoms develop and persist then a doctor can usually be confident that you have GAD. Current guidelines (ICD-10) suggest the diagnosis should be made if you have had your symptoms for six months but it is sometimes difficult to tell if you have GAD, panic disorder, depression, or a mixture of these conditions.
Some of the physical symptoms of anxiety can be caused by physical problems which can be confused with anxiety. So, sometimes other conditions may need to be ruled out. For example:
- Drinking a lot of caffeine (in tea, coffee and cola).
- The side-effect of some prescribed medicines. For example, selective serotonin reuptake inhibitor (SSRI) antidepressants.
- An overactive thyroid gland.
- Taking some street drugs.
- Certain heart conditions which cause the sensation of having a 'thumping heart' (palpitations) - uncommon.
- Low blood sugar level (rare).
- Tumours which make too much adrenaline and other similar hormones (very rare).
What are the treatment options?
TALKING TREATMENTS AND OTHER TREATMENTS NOT USING MEDICATION
Cognitive behavioural therapy (CBT)
Cognitive Behavioural Therapy (CBT) is probably the most effective treatment. It probably works for over half of people with generalised anxiety disorder (GAD) to reduce symptoms and improve quality of life.
- Cognitive therapy is based on the idea that certain ways of thinking can trigger or fuel certain mental health problems such as anxiety. The therapist helps you to understand your current thought patterns - in particular, to identify any harmful, unhelpful and false ideas or thoughts which you have that can make you anxious. The aim is then to change your ways of thinking to avoid these ideas. Also, to help your thought patterns to be more realistic and helpful. Therapy is usually done in weekly sessions of about 50 minutes each, for several weeks. You have to take an active part and are given homework between sessions. For example, you may be asked to keep a diary of your thoughts which occur when you become anxious or develop physical symptoms of anxiety.
- Behavioural therapy aims to change any behaviours which are harmful or not helpful. For example, with phobias your behaviour or response to the feared object is harmful and the therapist aims to help you to change this. Various techniques are used, depending on the condition and circumstances. As with cognitive therapy, several sessions are needed for a course of therapy.
- CBT is a mixture of the two where you may benefit from changing both thoughts and behaviours. (Note: cognitive and behavioural therapies do not look into the events of the past. They deal with and aim to change, your current thought processes and/or behaviours.)
In particular, counselling that focuses on problem-solving skills may help some people.
Anxiety management courses
These may be an option if they are available in your area. Some people prefer to be in a group course rather than have individual therapy or counselling. The courses may include learning how to relax, problem-solving skills, coping strategies and group support.
You can get leaflets, books, CDs, DVDs and downloads on relaxation and combating stress. They teach simple deep-breathing techniques and other measures to relieve stress and help you to relax. They may ease anxiety symptoms. There are also websites offering online self-help advice, treatment and support on the internet. - eg Fearfighter© (see below). See separate leaflet called Stress and Tips on How to Avoid It.
These are commonly used to treat depression but also help reduce the symptoms of anxiety even if you are not depressed. Research trials suggest that antidepressants can ease symptoms in over half of people with GAD. They work by interfering with brain chemicals (neurotransmitters) such as serotonin which may be involved in causing anxiety symptoms.
- Antidepressants do not work straightaway. It takes 2-4 weeks before their effect builds up. A common problem is that some people stop the medicine after a week or so, as they feel that it is doing no good. You need to give them time to work.
- Antidepressants are not tranquillisers and are not usually addictive. There are several types of antidepressants, each with various pros and cons. For example, they differ in their possible side-effects. However, SSRI antidepressants are the ones most commonly used for anxiety disorders. The two SSRIs licensed to treat GAD are escitalopram and paroxetine. Other antidepressants that have been found to help include venlafaxine and duloxetine.
- Note: after first starting an antidepressant, in some people the anxiety symptoms become worse for a few days before they start to improve.
Benzodiazepines, such as diazepam, used to be the most commonly prescribed medicines for anxiety. They usually work well to ease symptoms. The problem is, they are addictive and can lose their effect if you take them for more than a few weeks. They may also make you drowsy. Therefore, they are not used much now for persistent anxiety conditions such as GAD. A short course of up to 2-4 weeks may be an option now and then to help you over a particularly bad spell.
Buspirone is another option to treat GAD. It is an anti-anxiety medicine but different to the benzodiazepines. It is not clear how it works but it is known to affect serotonin, a brain chemical which may be involved in causing anxiety symptoms. It causes less drowsiness than benzodiazepines but is also addictive and it should only be used for a short time.
Pregabalin is a medicine used for several conditions (principally epilepsy). It has been found useful in GAD. It tends to be considered for GAD if the other treatments mentioned above have been unhelpful.
Beta-blockers, such as propranolol, tend to work better in acute (short-lived) anxiety rather than in GAD and so are not usually considered appropriate treatment here.
A combination of treatments
CBT plus an antidepressant medicine may work better in some cases than either treatment alone.
What is the outlook (prognosis)?
Although generalised anxiety disorder (GAD) gets better in some people, in others it tends to come and go. Some people need to take medicines for a long time but are otherwise able to lead perfectly normal lives.
Symptoms may flare up and become worse for a while during periods of major life stresses. For example, if you lose your job or split up with your partner.
People with GAD are more likely than average to smoke heavily, drink too much alcohol and take street drugs. Each of these things may ease anxiety symptoms in the short term. However, addiction to nicotine, alcohol or drugs makes things worse in the long term and can greatly affect your general health and well-being.
Further help & information
Dr Tim Kenny
Dr Roger Henderson
Dr Laurence Knott