What GAD is

Generalized anxiety disorder is persistent, hard-to-control worry about many parts of life, such as work, health, money, family, or being late, on most days for at least six months. The worry is out of proportion to the actual risk, and it comes with physical symptoms: restlessness, muscle tension, fatigue, trouble concentrating, irritability, and poor sleep. About 6 in 100 US adults will have GAD at some point (Kessler et al., 2005).

What it looks like in practice

GAD is easy to miss in people who function well, because worry can pass for conscientiousness. You over-prepare. You reread every email before sending. You cannot delegate because nobody else will do it right. You rehearse conversations that have not happened and plan for disasters that probably will not. Everyone around you sees someone reliable, while you feel worn out.

The body is part of it too: tension headaches, jaw clenching, stomach trouble, a tight chest, and lying awake while the to-do list starts running at 2 a.m.

Sorting out what drives the anxiety

Anxiety is a symptom before it is a diagnosis. Before settling on GAD, I rule in or out panic disorder, social anxiety, OCD, PTSD, depression (which often arrives with anxiety), bipolar disorder, and ADHD, since living with unmanaged ADHD is itself anxiety-provoking. I also look for medical and substance contributors: thyroid disease, anemia, perimenopause, sleep apnea, heavy caffeine use, alcohol and the rebound anxiety that follows it, stimulants, and some cold and asthma medications. The treatments differ, so the label matters.

I start with a detailed history and the GAD-7, a seven-question scale widely used to flag and track anxiety severity (Spitzer et al., 2006). A score of 10 or higher usually means a closer look is warranted. It is a starting point, not a diagnosis.

Treatment

Therapy and medication both work, and both are first-line. A large meta-analysis of anxiety disorder treatments found meaningful improvement with cognitive behavioral therapy and with SSRI and SNRI medications (Bandelow et al., 2015). A JAMA review of anxiety treatment reaches a similar conclusion (Stein & Craske, 2017).

Medication. SSRIs and SNRIs, such as fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), venlafaxine (Effexor), and duloxetine (Cymbalta), are the usual starting point. I start low, because early side effects like jitteriness and nausea can be harder on anxious people. Benefit builds over about four to six weeks. Once you feel well, most people stay on the medication for a while before we discuss a taper. Buspirone (Buspar), hydroxyzine, and propranolol are useful for specific situations.

Benzodiazepines. Drugs like alprazolam (Xanax) and lorazepam (ativan) work fast and feel good, and that is the problem. They are not first-line for GAD because of tolerance, physical dependence, and effects on memory and coordination. In 2020 the FDA strengthened its boxed warning to cover abuse, misuse, addiction, physical dependence, and withdrawal. Short-term use with a clear plan can make sense in some cases, but most of the time we try to avoid using benzodiazepines. If you are already on one and want to come off it safely, see my page on addiction and de-prescribing.

Therapy. CBT for GAD teaches you to change your relationship with worry: tolerating uncertainty, dropping safety behaviors like constant reassurance-seeking and over-checking, and testing the predictions your mind makes. It works best with a therapist trained in it like myself. In my practice, I offer both therapy and medication management in one convenient visit. If we are not a good fit for therapy then no problem, I can help you find one while helping you maintain your medication.

Holistic lifestyle interventions. Sleep, caffeine, alcohol, and exercise matter more than people want them to. Alcohol in particular can feel calming and then worsen anxiety the next day. In my practice, we will do a thorough evaluation that includes holistic and lifestyle factors that may affect anxiety.