Generalised Anxiety Disorder (GAD)

What is anxiety?

When you are anxious you feel fearful and tense. In addition you may also have one or more unpleasant physical symptoms. For example: a fast heart rate, palpitations, feeling sick, shaking (tremor), sweating, dry mouth, chest pain, headaches, a 'knot in the stomach', 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, or before an important race. The burst of adrenaline and nerve impulses which we have in response to stressful situations can help us to 'fight or flight'. Some people are more prone to 'normal' anxieties. For example, some people are more anxious before exams than others.

Anxiety is 'abnormal' if it:

• is out of proportion to the stressful situation, or
• persists when a stressful situation has gone, or 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). There are other leaflets for other types of anxiety disorders (such as panic disorder, phobias, acute reaction to stress, post traumatic stress disorder, etc.)

What is generalised anxiety disorder?

If you have generalised anxiety disorder (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 'goes blank' quite often.
• poor sleep (insomnia). Usually it is difficulty in getting off to sleep, or in staying asleep.

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 gets generalised anxiety disorder?

GAD develops in about 1 in 50 people at some stage in life. Slightly more women are affected than men. It usually first develops in your 20s.

What causes generalised anxiety disorder?

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. 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. 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 diagnosed?

If the typical symptoms develop and persist for at least six months, then a doctor can usually be confident that you have GAD. However, 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, SSRI antidepressants.
• An overactive thyroid gland.
• Taking some street drugs.
• Certain heart conditions which cause palpitations (uncommon).
• Low blood sugar level (rare).
• Tumours which make too much adrenaline and other similar hormones (very rare).

What is the outlook (prognosis)?

Without treatment, GAD tends to persist throughout life. It is relatively mild in some cases, but for some it can be very disabling.

The severity of symptoms tends to 'wax and wane' with some good spells, and some not so good spells. 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 wellbeing.

Treatment can help to ease symptoms, and can improve your quality of life. However, there is no 'quick fix' or complete cure.

What are the treatment options?

TALKING TREATMENTS AND OTHER NON-DRUG TREATMENTS

Cognitive therapy
This is probably the most effective treatment. Studies show that it works for over half of people with 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.

(Note: cognitive therapy is not a therapy that 'looks into the events of the past' but deals with your current thought processes.)

Counselling
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.

Self help
You can get leaflets, books, tapes, videos, etc, on relaxation and combating stress. They teach simple deep breathing techniques and other measures to relieve stress, help you to relax, and may ease anxiety symptoms. A longer leaflet in this series called 'Anxiety - a Self Help Guide' is a good start. There is also a leaflet called 'Stress - and Tips on How to Avoid it'.

MEDICATION

Buspirone
This medicine is commonly prescribed to treat GAD. It is an 'anti-anxiety' medicine, but different to the benzodiazepines (discussed below). 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 takes two weeks or more to begin to work. Therefore, if it is prescribed you need to give it time to work.
• Usually a low dose is started and gradually built up over 2-3 weeks.
• A common plan is to try an eight week trial. If it does not help, it should be stopped and a different treatment tried. If it helps, it can be continued. However, it is not clear how long it should be taken for. It is licensed for short-term use only. However, specialists sometimes advise for it to be taken for several months. It is not thought to be addictive.
• It is less likely to work if you have taken a benzodiazepine medicine such as diazepam within the previous 30 days.
• Some people get side-effects such as feeling sick, headaches and dizziness. These are less likely to occur if you build up the dose over 2-3 weeks. Read the leaflet that comes with the medication for a full list of possible side-effects.
  

Beta-blocker medicines such as propranolol
These are sometimes used. They tend to work better in acute (short lived) anxiety rather than in GAD. They may ease some of the physical symptoms such as trembling, but do not affect the 'mental' symptoms such as worry.

Antidepressant medicines
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 straight away. 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 (selective serotonin reuptake inhibitors) are the ones most commonly used for anxiety disorders.
• 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
These 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 2-3 weeks may be an option 'now and then' to help you over a particularly bad spell.

Hydroxyzine
This is a an antihistamine which is sometimes used to ease anxiety symptoms. A common side-effect though is drowsiness.

A combination of treatments
For example, cognitive therapy and buspirone may work better in some cases than either treatment alone.

Further help and advice

Ask your doctor or practice nurse for information about any local support groups for people with anxiety disorders. The following may also be of help.

National Phobics Society
Zion Community Resource Centre, 339 Stretford Road, Hulme, Manchester, M15 4ZY
Tel: 0870 122 2325    Web: www.phobics-society.org.uk
A leading UK charity for anxiety disorders.

NO PANIC (National Organisation For Phobias, Anxiety, Neuroses, Information & Care)
93 Brands Farm Way, Randlay, Telford, Shropshire TF3 2JQ
Helpline: 0808 808 0545    Web: http://nopanic.org.uk

Anxiety Care
Cardinal Heenan Centre, 326 High Road, Ilford, Essex, IG1 1QP
Tel: 020 8478 3400   Web: www.anxietycare.org.uk

First Steps to Freedom
1 Taylor Close, Kenilworth, Warwickshire, CV8 2LW
Helpline: 0845 120 2916    Web: www.first-steps.org
For people with general anxiety, phobias, obsessional compulsive disorder, panic attacks, etc.

© EMIS and PIP 2005   Updated: August 2005

The authors and editors of this article are employed to create accurate and up to date content reflecting reliable research evidence, guidance and best clinical practice. They are free from any commercial conflicts of interest.

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