Aetiology/risk factors for GAD

1. Genetics: GAD may run in families
2. Personality: individual with timid or negative temperament may have increased risk of GAD
3. Environmental factors such as negative or traumatic life events, separation during childhood, role inversion during childhood, lack of social interaction, poor life satisfaction, modelling of a relative having an anxiety disorder
4. Chronic medical illnesses may increase the risk of GAD

Symptoms/presentations

The symptoms of GAD may vary, but they generally include emotional symptoms like persistent worry, anxiety, fear, and perceiving every situation as threatening; cognitive symptoms such as overthinking, fear of making wrong decisions, difficulty concentrating, and indecisiveness; and physical symptoms including trouble sleeping, restlessness, fatigue, muscle aches,  diarrhea, and irritability. In many cases, somatic complaints such as headaches, body pains, and gastrointestinal disturbances are often common and may overshadow the emotional and cognitive symptoms.

Clinical Findings

Expected findings for Generalized anxiety disorder can be discovered through: 

• Psychiatric Examination: Patients may experience trouble relaxing, excessive worry over trivial matters, feeling nervous or on edge, heightened state of alertness, and irritability.
• Physical Examination: Signs of muscle tension, trembling, restlessness, sweating, and fatigue might be observed 

Diagnosis

•  Excessive worry and anxiety occurring more days than not for atleast 6 months

• The individual finds it difficult to control the worry

• The worry and anxiety are associated with 3 or more symptoms from the followings; restlessness or feeling keyed up or an edge, difficulty concentrating or mind going blank,  easy fatigability, irritability, muscle tension, and sleep disturbances.

Differential Diagnosis 

Key conditions to rule out include:

Other Anxiety and Mood Disorders, such as panic disorder, anorexia nervosa, post-traumatic stress disorder, obsessive-compulsive disorder, and depression.  Several medical conditions, like hyperthyroidism, schizophrenia, and substance-induced anxiety, including drug abuse and drug withdrawal, can also coexist with GAD. 

Investigations

There are no specific laboratory or imaging tests for GAD. However, tests for thyroid function, blood, or urine may be carried out in cases of suspected medical conditions that could cause symptoms similar to anxiety. Urine Drug Toxicology Screening may be useful to rule out substance induced anxiety. Psychological screening tools such as the Generalized Anxiety Disorder-7 (GAD-7) scale, Hamilton Anxiety Scale (HAM-A) etc can also aid in diagnosis, assess severity and clinical improvement monitoring. 

Treatment

The management involves psychotherapeutic, pharmacotherapeutic and supportive approaches; and the effective treatment is the one that combined the 3 approaches. 

Psychotherapeutic: This includes Cognitive behavioral therapy, Supportive therapy, Insight- Oriented therapy, relaxation therapy, mindfulness therapies etc. 

Pharmacotherapy:  This involves the use of Selective serotonin reuptake inhibitors (such as sertraline and escitalopram), Benzodiazepines (usually used for a limited time due to risk of dependence), Buspirone, Venlafaxine. 

Other drugs that may be useful includes TCAs (like imipramine), B-Adrenergic blockers to manage the somatic symptoms (Propanolol)  The treatment of GAD may takes a duration of 6 months to 1 year or more.

Follow-Up

Consistent follow-up is important to mitigate symptom severity, enhance general functioning, and attain remission. The initial follow-up appointment should take place within 2-4 weeks of starting treatment, with subsequent visits at least every three months to track the course of the disorder. About 25% of patients relapse within 1 month of stopping the treatment while 60-80% relapse over the course of the next year.

Prevention and Control

GAD can be prevented and managed by; enlightening patients and the general public about anxiety disorders, particularly reassuring them that they are common and treatable; advising people to include self-directed activities and lifestyle modifications, such as journaling, yoga, mindfulness, meditation, good sleeping habits and other relaxation practices in their everyday life. o Routine  screening for GAD and prompt treatment in primary care settings and the incorporation of mental health services into general healthcare can also serve as effective ways of mitigating the disorders.

Conclusion

Generalized anxiety disorder is a common mental health condition that causes constant worry in individuals and makes achieving daily goals overwhelming. Though the condition can be hard to manage if neglected over time or if a self-management approach is employed, with early diagnosis, proper coping mechanisms, therapy, and medications, the burden of the disorder can be reduced and significant improvement in quality in quality of life of affected persons