Snapshot A 40-year-old man seeks help at an urgent care for palpitations. He is otherwise healthy. After an electrocardiogram rules out any cardiac issues, the physician performs a thorough history and exam, noting that he has restlessness. He reports these feelings come and go, and he has felt this way for the past 3 years. He has anxiety surrounding multiple different unrelated aspects of his life including his health, his performance at work, his marriage, his parenting, and his financial stability among many other things that he finds troublesome. Introduction Overview generalized anxiety disorder (GAD) is a type of anxiety disorder, which also includes panic disorder, phobia disorders, and obsessive-compulsive disorder GAD is characterized by anxiety lasting > 6 months unrelated to any specific triggers or if identifiable stressor has ended Epidemiology Incidence very common Risk factors genetic susceptibility environmental instability ETIOLOGY Pathogenesis mechanism unclear but mediators of anxiety in the brain appear to be norepinephrine, serotonin, dopamine, and GABA some patients may also have genetic predisposition to anxiety Associated conditions other mood disorders major depressive disorder substance misuse disorders Presentation Symptoms excessive anxiety and persistent worrying at least 3 of the following restlessness fatigue difficulty concentrating irritability muscle tension sleep disturbance Physical exam excitation/hyperactivity tremors rapid heartbeat sweating restlessness dry mouth globus sensation cold and clammy hands shaking Differential Social anxiety disorder Physiological distress, avoidance behaviors, fear of embarrassment, humiliation, and rejection in social situations Distinguish from generalized anxiety disorder, as it only occurs in the setting of social situations Adjustment disorder key distinguishing factors anxiety or other mood changes with onset within 3 months of an identifiable stressor or trigger, lasting < 6 months once that stressor has ended treatment also consists of cognitive behavioral therapy and selective serotonin reuptake inhibitors Treatment Lifestyle cognitive behavioral therapy indications all patients may often need pharmacotherapy as well Medical selective serotonin reuptake inhibitors (SSRIs) indications first-line drugs fluoxetine paroxetine sertraline escitalopram serotonin-norepinephrine reuptake inhibitors (SNRIs) indications first-line drugs venlafaxine duloxetine tricyclic antidepressants (TCA) indications second-line due to worse side effect profile buspirone indication adjunct to SSRIs benzodiazepines indications second-line due to potential for addiction and short-lived effects herbal indication patients wary of medications modalities kava plant has been shown in verified studies to have a mild beneficial effect for patients with generalized anxiety disorder kava toxicity manifests as liver failure, hepatitis, or cirrhosis Complications Complications decreased quality of life substance abuse