Generalised Anxiety Disorder (GAD) is a common mental health condition characterised by excessive and uncontrollable worries.
Fear is a natural human experience, warning and protecting individuals from threats. However, when anxieties become uncontrollable, they take on a life of their own. Those affected by generalised anxiety find themselves constantly consumed by irrational worries without any particular triggers.
CHMC, our German Clinic for Psychiatry and Psychology, offers diagnosis and treatment for generalised anxiety disorder in Dubai. To book an appointment, contact:
Symptoms of Generalized Anxiety Disorder
Individuals with generalised anxiety disorder experience a continuous stream of unrealistic and exaggerated fears not tied to any immediate danger. As a result, people with GAD live in a constant state of apprehension, fearing everything from unfounded worries about their health and their loved ones’ safety to trivial matters like losing keys. They might also worry about the anxiety itself. The individuals with generalised anxiety live in a constant state of emergency, which impacts their social and professional performance, limiting significantly their life quality.
Generalised anxiety is frequently associated with depression, adding additional burden on the sufferers.
Physical Symptoms Associated with General Anxiety
In response to anxiety, the body’s release of adrenaline, the “fight and flight” hormone, prepares the individual to master an imaginative danger. People with generalised anxiety develop physical responses typical for the fight-and-flight reaction, such as heart racing, palpitations, sweating, and muscle tension. Additional physical symptoms include dizziness, shortness of breath, and gastrointestinal distress. Constant fears cause also sleeplessness, fatigue, and decreased concentration.
It’s crucial to distinguish generalised anxiety from panic attacks. While in generalised anxiety the individual is consistently present, panic attacks occur suddenly, “out of the blue,” with symptom-free intervals between the attacks.
Causes of Generalized Anxiety Disorder
The causes of generalised anxiety are only partially understood. They likely involve genetic, psychological, and environmental factors. Evidence also suggests a genetic predisposition, with some families having a higher incidence of anxiety disorders. Some individuals may have experienced traumatic events in childhood or later in life. Such traumas can be caused by losses of significant others or prolonged periods of extreme stress related to social or occupational pressure. Life crises can trigger fears that might evolve into a full-blown generalised anxiety. Additionally, generalised anxiety can be comorbid with other conditions like depression, panic disorder, phobias, or substance abuse.
Prevalence of GAD
Generalised anxiety disorder is a common condition, affecting an estimated 5% of the population at some point in their lives. Women are twice as likely to be affected as men. While the onset typically occurs in mid-adulthood, it can also manifest in childhood or in older age.
Diagnosing Generalized Anxiety Disorder
Diagnosing generalised anxiety disorder can be challenging. Its symptoms may overlap with those of other mental health conditions like phobias, panic disorder, or obsessive-compulsive disorder. Additionally, many affected individuals may experience symptoms more aligned with depression.
The physical symptoms associated with generalised anxiety, such as fears, rapid heart rate, sweating, and muscle tension, can also occur in conditions like hyperthyroidism or be triggered by stimulating drugs, for example amphetamine.
As a result, reaching a diagnosis of generalised anxiety disorder can be time-consuming, especially if individuals initially seek help due to physical symptoms, perhaps even in an emergency room setting. However, through initial conversations and the necessary diagnostics, professionals can ultimately arrive at the correct diagnosis.
Diagnostic Mesures for General Anxiety Disorder
The process of diagnosing an anxiety disorder begins with a thorough evaluation of the patient’s medical history, known as an anamnesis. The anamnesis gathers crucial information about the onset, nature, and severity of the anxiety symptoms. However, before a definitive diagnosis of an anxiety disorder can be made, the psychiatrist must rule out any underlying physical causes. These could include conditions affecting the lungs, cardiovascular system, or central nervous system. Additionally, the presence of other concurrent mental health problems must be assessed.
A comprehensive diagnostic approach involves a physical examination, laboratory tests, and an electrocardiogram (ECG) to detect physical illnesses. Depending on the patient’s medical history, specific symptoms, or preexisting conditions, further investigative tests such as lung function tests, electroencephalograms (EEG), or Magnetic Resonance Imaging (MRI) may be recommended.
A diagnosis of “generalised anxiety disorder” is established when anxiety:
- Persists for at least six months, occurring on most days within that period
- Becomes uncontrollable
- Significantly impairs daily functioning
- Is accompanied by at least three physical symptoms, such as a rapid pulse, trembling, muscle tension, or gastrointestinal problems
Treatment of Generalized Anxiety Disorder with Medication
When anxiety is severe or extremely severe, it is important to seek the services of a psychiatrist to establish a diagnosis and consider pharmacotherapy (using medication in addition to counselling).
The fastest treatment for generalised anxiety is the use of medication. The first line of treatment is the use of antidepressants. However, the antidepressants need a few weeks to unfold their efficacy. Therefore, the initial use of an anti-anxiety medication with an immediate fear-reducing effect, called benzodiazepines, might be indicated. In severe cases of anxiety, the common pharmacotherapy requires the combination of antidepressants with benzodiazepines. The latter get obsolete after the effect of antidepressants takes over.
There are many controlled studies on the use of medications for GAD, showing response rates between 44% and 81%. Medication dosages are detailed in Box 4, and the pros, cons, and side effects of different drug classes are summarized in Table 1. It is always recommended to combine medication with psychotherapy for optimal results.
General Considerations
All medication-based treatments require careful medical supervision and empathetic guidance from the prescribing doctor. Side effects, particularly at the start of treatment, may be challenging, especially as therapeutic benefits are not immediate. Educating patients about common side effects—such as initial restlessness when starting Selective Serotonin Reuptake Inhibitors (SSRIs)—can improve adherence. Explaining the delayed onset of antidepressant effects (2–6 weeks) can also help avoid unnecessary use of benzodiazepines for immediate relief.
Overview of Medication Options
Selective Serotonin Reuptake Inhibitors (SSRIs)
Medications like Escitalopram, Paroxetine, and Sertraline have been shown to be effective in controlled studies.
- Common Side Effects: Initial restlessness, nervousness, or increased anxiety; long-term use may lead to sexual dysfunction or discontinuation symptoms (though less severe than benzodiazepine withdrawal).
- Administration: Best taken in the morning to reduce sleep disturbances.
- Onset of Effect: 2–6 weeks.
Selective Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Medications like Venlafaxine (typically in extended-release form) and Duloxetine are effective for GAD.
- Common Side Effects: Nausea, restlessness, or sleep problems during the initial phase.
- Onset of Effect: 2–6 weeks, sometimes longer.
Tricyclic Antidepressants (TCAs)
Imipramine is an option for GAD but generally less preferred due to higher rates of side effects compared to SSRIs and SNRIs.
- Common Side Effects: Increased anxiety at the start, sedation, weight gain, and anticholinergic effects.
- Onset of Effect: 2–6 weeks or longer.
- When Used: Typically considered only when other standard medications fail or are not tolerated.
Benzodiazepines
Examples include Alprazolam, Diazepam, and Lorazepam.
- Benefits: Rapid relief of anxiety symptoms, making them suitable for acute phases.
- Risks: Sedation, dizziness, impaired reaction time, and potential dependence after prolonged use (4–8 months).
- Use: Short-term (4–8 weeks) to manage acute symptoms, often alongside antidepressants to bridge their delayed onset. Not suitable for patients with a history of substance abuse.
- Limitation: Minimal impact on coexisting depressive symptoms.
Other Medications
- Buspirone: Some studies show effectiveness, but it is less effective than SNRIs and comparable to placebo in certain cases.
- Hydroxyzine: Effective in short-term studies but lacks evidence for long-term relapse prevention.
- Opipramol: An anxiolytic similar to TCAs, found to be more effective than placebo and comparable to Alprazolam in one study. Long-term data are lacking.
- Quetiapine: An atypical antipsychotic effective at low doses for GAD, though not officially approved for this use. Reserved for cases where standard treatments fail.
- Agomelatin: A newer antidepressant with some efficacy in GAD, not yet approved for this condition. Requires liver function monitoring due to potential liver toxicity.
Psychotherapy in Treatment for Generalized Anxiety
Typically, in the case of mild or moderate anxiety, working with a qualified counsellor, psychologist, or psychotherapist is sufficient. The most researched, evidence-based treatment approach for generalised anxiety is cognitive behavioural therapy (CBT). Other psychotherapy methods effective in treatment of GAD are exposure response prevention (ERP), systematic approximations, and psychodynamic psychotherapy.
Cognitive Behavioural Therapy (CBT):
CBT is based on the idea that anxiety disorders, like other mental health conditions, are partly caused by distorted, illogical, or unrealistic thoughts. The goal of CBT is to help individuals develop skills to independently identify, interrupt, and correct these dysfunctional beliefs and thoughts, enabling them to respond more appropriately to different situations.
Key elements of CBT for GAD include:
- Psychoeducation: Teaching patients about the nature of anxiety and its mechanisms.
- Exposure Techniques: For instance, imagining feared scenarios (in-sensu exposure) to confront and process worries, such as anticipated catastrophes.
- Problem-Solving Strategies: Helping patients tackle specific challenges in a constructive way.
- Therapeutic Relationship: Building a strong, supportive relationship between the therapist and the patient is an essential foundation of therapy.
Numerous randomized clinical trials have shown the effectiveness of CBT for GAD. It has been proven superior to waitlist conditions and has specific therapeutic components beyond general placebo effects. Response rates for CBT in studies range between 47–75%, though the exact definition of “response” varies between studies.
Internet-Based CBT (iCBT):
In recent years, studies have explored internet-based CBT. These treatments involve either self-guided therapy through various media or therapy supported by brief therapist contact via email or phone. Results show significant improvements compared to waitlist controls, except in one study where iCBT and internet-based psychodynamic therapy did not differ from waitlist outcomes. However, due to the lack of direct comparisons with traditional in-person CBT, internet therapy cannot currently be recommended. Practical and ethical concerns (e.g., managing suicidal patients) also limit its applicability.
Psychodynamic (Psychoanalytic) Therapy:
Psychodynamic approaches to GAD focus on underlying emotional conflicts, particularly those rooted in insecure attachment and central relationship conflicts. A specialized psychoanalytic focal therapy for GAD has been developed based on supportive-expressive psychotherapy. This method emphasizes the therapeutic relationship and is often conducted as a short-term therapy with a more active therapeutic stance.
Research on psychodynamic therapy for GAD is limited. Studies suggested comparable effects between CBT and psychodynamic therapy, though numerical results favoured CBT.
Other Psychodynamic Approaches:
There is no substantial evidence available for other psychodynamic methods, such as long-term analytic psychotherapy or depth-oriented therapy, due to insufficient data.
Complementary Treatment for GAD
Relaxation techniques, including autogenic training, progressive muscle relaxation, and breathing exercises, can be used for treatment of GAD not alone but in combination with psychotherapy and/or medication.
Course of Generalized Anxiety
The course of generalised anxiety disorder typically unfolds gradually, with fears and physical symptoms like heart racing and palpitation initially going unnoticed. It’s only over time that these symptoms increasingly encroach upon one’s daily life and well-being.
GAD can be remarkably persistent, often taking years to overcome. During this journey, individuals may experience phases of reduced anxiety. The studies show that approximately one in four individuals had recovered from generalised anxiety spontaneously within 2 years. In the long term, many people do manage their anxieties, and as individuals age, GAD often diminishes naturally.
Living with Generalized Anxiety Disorder
Living with generalised anxiety impacts both professional and personal life. Anxiety impacts the work performance and the social life of the affected individuals. They tend to withdraw socially, retreating to the safety of their homes, avoiding situations that might exacerbate their anxiety or trigger physical symptoms. In extreme cases, generalised anxiety leads to full invalidism.
Opening up about an anxiety disorder is challenging and often limited to the closest circle of family and friends. With therapeutic support, however, it’s possible to share one’s struggles with family members, educating them about the condition and involving them in the treatment.
Seeking professional assistance and support are crucial steps in managing anxiety. It should be stressed out that generalised anxiety is a well-treatable disorder that can be fully curbed under the condition of proper management.
Treatment for Generalised Anxiety Disorder in Dubai. Summary
Generalised Anxiety Disorder (GAD) is a common and serious condition. It is characterised by excessive worry about real dangers, where the likelihood of these dangers occurring is greatly overestimated and the potential negative consequences are imagined as catastrophic. These worries can quickly spread to various aspects of life, such as health, relationships, work, or finances, affecting both the person and their loved ones.
People with GAD often show patterns of avoidance and safety-seeking behaviour. For example, they might postpone or avoid activities they consider risky, such as travelling. These fears often manifest physically, leading to symptoms like restlessness, muscle tension, or difficulty sleeping, which may prompt extensive medical evaluations to rule out physical causes.
Medication for GAD treatment:
- SSRIs and SNRIs are first-line treatments for GAD, with evidence of efficacy and generally manageable side effects.
- Benzodiazepines are useful for short-term relief but carry a risk of dependence and limited use in depression.
- Alternative medications like Pregabalin and TCAs are options for specific cases, while others like Quetiapine or Agomelatin are reserved for resistant cases or experimental use.
- Medication should always be paired with psychotherapy for the best outcomes.
Psychotherapy for GAD Treatment
The most researched, evidence-based treatment approach for generalised anxiety is cognitive behavioural therapy (CBT). Recent studies also proved the effectiveness of psychodynamic psychotherapy with even fewer relapses compared with CBT.