Generalized anxiety disorder is chronic, pervasive worry plus physical symptoms over at least 6 months. The worry is excessive, difficult to control, spans multiple topics (work, family, health, finances), and is accompanied by at least three of: restlessness, easy fatigability, difficulty concentrating, irritability, muscle tension, sleep disturbance.
The neurobiological picture, by now familiar: hyperactive salience network flagging many stimuli as threats; sustained amygdala reactivity; reduced top-down PFC regulation of worry generation. The background tone of the entire system is shifted upward. Cortisol patterns often flattened. Sleep architecture often disrupted with reduced slow-wave sleep.
Prevalence is high — roughly 2-6% of adults annually meet criteria. Female predominance roughly 2:1. Often begins in late adolescence or early adulthood and runs chronically. Substantial functional impact: cardiovascular reactivity, gastrointestinal symptoms, headaches, sleep disruption, professional and relational consequences.
First-line pharmacology: SSRIs (escitalopram, sertraline, paroxetine) and SNRIs (duloxetine, venlafaxine) both have strong evidence. Effect emerges over 4-8 weeks. Some patients respond to one class but not the other. Buspirone is a partial 5-HT1A agonist with anxiolytic effect without dependence — slower onset, often used as adjunct or in patients avoiding antidepressants. Hydroxyzine, an H1 antihistamine, is effective acutely without controlled-substance concerns.
Benzodiazepines are effective acutely but carry dependence, cognitive, and fall risks with chronic use. Reasonable for short-term symptom relief during SSRI titration; problematic as primary chronic management. The Beers Criteria flag chronic benzodiazepine use in older adults specifically.
Psychotherapy: CBT for GAD has strong evidence — addresses both cognitive (worry challenging, cognitive restructuring) and behavioral (relaxation training, behavioral experiments) components. Acceptance and Commitment Therapy (ACT) and Mindfulness-Based Stress Reduction also evidence-based. Combined pharmacotherapy plus psychotherapy outperforms either alone for moderate-severe cases.
Clinical considerations: screen for comorbid mood disorders (50%+ of GAD patients have lifetime major depression), substance use (often self-medication with alcohol or cannabis), thyroid disease, cardiovascular conditions, sleep apnea. Treat comorbid conditions in parallel. The patient with GAD plus untreated sleep apnea cannot fully respond to anxiolytic treatment alone. When you encounter chronic pervasive worry, the treatment toolkit is broad and effective. Most patients improve substantially with appropriate care.