Generalized Anxiety

Symptoms for GAD can vary in intensity, and the anxiety level changes depending on the situation.

Occasionally, people with GAD may find that their symptoms suddenly increase in severity, preventing normal functioning.

GAD differs from other conditions with similar symptoms. Social anxiety disorder, for instance, brings intense anxiety only in social situations, with fear of negative judgment from other people. People with depression may occasionally feel anxious. But not as often as those with GAD.

Likewise, those with simple/ specific phobia also have intense worries but usually about one particular thing. In contrast, those with GAD worry about a number of different topics but are not usually as intense as a phobia.

Psychological

• Persistent worrying or anxiety about a number of areas.

• The persistent worries or anxieties are out of proportion to the impact of the events.

• Overthinking plans and solutions to all possible worst-case outcomes.

• The inability to control constant worries.

• Perceiving/ misreading a lot of situations or events as threatening.

• Difficulty dealing with uncertainty.

• Feeling unable to set aside or let go of worries.

• Fear of making the wrong decision.

• Feeling unable to relax and being irritable.

• Feeling as if the mind goes blank.

• General feeling of being on edge.

• Having difficulties concentrating.

Physical

• Sweating

• Fatigue

• Trouble sleeping

• Nausea

• Stomach aches

• Headaches

• Trembling or feeling twitchy

• Muscle tension

• Light-headedness

• Frequent need to urinate

DSM-5 and ICD-11 Diagnostic Criteria

Clinicians diagnose GAD using the DSM-5 (American Psychiatric Association, 2013) or the World Health Organization’s ICD-11. The DSM-5 requires:

• Excessive worry: anxiety and worry about a number of events or activities, more days than not, for at least six months.
• Difficulty controlling it: the person finds the worry hard to control.
• Physical and mental symptoms: three or more of six (only one in children): feeling on edge, tiring easily, poor concentration, irritability, muscle tension, and disrupted sleep.
• Impairment: significant distress or impairment that a substance, medical condition, or other mental disorder does not explain.

The six-month rule separates GAD from the ordinary worry everyone feels. GAD is not worry alone. It is worry joined to a tense, over-aroused body.

The ICD-11 reaches the same territory by a different route. It describes either general apprehension (“free-floating anxiety”) or excessive worry about several everyday events, lasting several months, with symptoms such as muscle tension and irritability.

The ICD-11 also no longer bars a GAD diagnosis when a depressive episode is present. That reflects how often anxiety and depression co-occur.

GAD is hard to pin down. An early structured-interview study found lower agreement between clinicians for GAD than for disorders such as simple phobia or OCD (Di Nardo et al., 1993).

Worry is universal. So the line between clinical and ordinary worry is a matter of degree, and critics argue the thresholds are somewhat arbitrary.

GAD lacks the dramatic panic attacks of panic disorder or the visible avoidance of a phobia. As a result, it is often missed in primary care, where people tend to report physical complaints first.

Cognitive Distortions in GAD

Some key features of GAD maintain and perpetuate anxiety. These include cognitive distortions: negative automatic thoughts and maladaptive assumptions.

Negative automatic thoughts keep anxiety going. Examples include catastrophizing (e.g., believing that something terrible is going to happen) and labeling (e.g., labeling themselves as a bad person). 

Maladaptive assumptions are unrealistic thoughts and attitudes (e.g., ‘all anxiety is bad,’ ‘I must get rid of all of my anxiety’). When people cannot meet these unrealistic rules, excessive worry and anxiety can follow. 

What Keeps GAD and Worry Going?

At the core of anxiety is worrying about potential threats. Anxiety is an attempt to cope with a future event that is believed to be negative and threatening.

However, anxiety can keep people stuck in an endless loop of more anxiety, and thus it becomes a vicious cycle.

Cognitive Models of Worry

Three cognitive models explain why worry becomes excessive and why it persists. Reviewers conclude that they overlap and are best read as complementary lenses on one disorder, not rivals (Behar et al., 2009).

• Intolerance of uncertainty: worry is a failed attempt to eliminate uncertainty.
• Metacognitive beliefs: worrying about worry turns ordinary worry into a disorder.
• Avoidance: worry dampens fear briefly but stops it from fading.

Intolerance of Uncertainty

Dugas and colleagues trace excessive worry to intolerance of uncertainty (IU): an inability to bear the possibility, however small, that something bad might happen (Dugas et al., 1998). People high in IU find ambiguity stressful in itself, whatever the real odds.

To feel prepared, they mentally rehearse every possible outcome. That rehearsal is worry. Because the future can never be fully certain, the worry never resolves.

The model adds three maintaining factors:

• Positive beliefs about worry: for example, “it helps me cope.”
• Negative problem orientation: low confidence in solving problems.
• Cognitive avoidance: using verbal worry to avoid more distressing mental imagery.

Experiments show the link is causal. Participants whose intolerance of uncertainty was raised during a gambling task later worried more than those whose intolerance was lowered (Ladouceur, Gosselin, & Dugas, 2000).

A 2026 meta-analysis of 115 studies found IU was linked to anxiety most strongly in GAD (r = .54). Worry carried more of that link in GAD than in any other disorder studied (Akbari et al., 2026).

Metacognitive Beliefs

Adrian Wells, Professor of Clinical and Experimental Psychopathology at the University of Manchester, locates the problem in beliefs about worrying itself (Wells, 1995).

Ordinary “Type 1” worry concerns real problems. It becomes pathological when people start worrying about their worry, judging it uncontrollable and dangerous.

People with GAD often hold two clashing beliefs:

• Positive belief: worrying keeps me safe and prepared.
• Negative belief: worrying is uncontrollable and harming me.

In a community survey, some people said worry “keeps me prepared for what could possibly happen.” Others described having “no control” over it (Joubert et al., 2022).

The clash fuels meta-worry. Failed attempts at thought control then make intrusive thoughts more frequent.

As Wells explains, anxiety is driven by these beliefs, not by the intrusive thoughts themselves. Therapy should therefore change a person’s relationship to worrying rather than dispute the content of each worry.

Worry as Avoidance

Thomas Borkovec’s avoidance theory notes that worry is mostly verbal, a stream of “what if” sentences. This verbal quality suppresses the vivid imagery and bodily arousal that a feared scenario would otherwise trigger (Borkovec, Alcaine, & Behar, 2004).

Worry therefore feels as if it works. The cost is that the fear is never fully processed.

In a classic experiment, speech-anxious people pictured a feared scene after worrying, thinking neutral thoughts, or relaxing. The worriers showed the least heart-rate reactivity, yet reported the most fear (Borkovec & Hu, 1990).

This is why CBT includes worry exposure: confronting feared images directly lets the fear fade.

Early Experiences

Why do some people develop high IU? One answer is early maladaptive schemas. These rigid patterns of thought and emotion form when a caregiver fails to meet a child’s core needs. Adverse childhood experiences are thought to create them.

A 2026 study compared 38 adults with GAD and 148 low-anxiety students. Once IU and schemas were counted, adverse childhood experiences no longer predicted GAD.

IU and the schema of vulnerability to harm still did (Riley et al., 2026). Early adversity may therefore act through IU.

Avoidance and safety behaviors

People with anxiety often cope through avoidance. This is where they try to avoid feared situations as much as possible to reduce their anxiety. Avoidance can cause a quick decrease in anxiety, but it can worsen anxiety in the long run.

Safety behaviors are another way to cope. They include relying on anxiety-reducing medication, having an exit plan, or using a phone excessively to distract oneself. See also safety behaviors in anxiety.

These behaviors can ease anxiety in the moment. But people can become dependent on them. They never get to learn that the perceived threat is not that threatening.

Also, safety behaviors may not be available in every anxiety-provoking situation, so when not available, more feelings of anxiety may be produced.

The cycle of anxiety

If someone has anxiety, they are more likely to be scanning their environment for potential threats, paying them more attention. This causes physical symptoms of anxiety to intensify.

To cope with the anxiety, individuals may choose to either avoid or escape the situation which brings them short-term and usually instant relief.

Although this relief can make someone with anxiety, feel better short term, in the long term this can be detrimental.

Long-term effects of avoidance and escape can result in an increase in physical symptoms, a loss of confidence about coping, and increased use of safety behaviors.

This keeps the anxiety going and repeats the cycle. The anxiety may even increase or generalize to other situations.

Reversing the cycle

To break the vicious cycle of anxiety, gradually confront feared situations while dropping safety behaviors.

At first, this can increase anxiety. After a while, the physical symptoms and the scanning for potential threats should decrease.

The use of healthy coping skills can help reduce anxiety to a manageable level. This can build confidence slowly in order to get used to these situations and control responses.

By challenging themselves in structured and repeated ways, there should be a better chance of reducing anxiety overall.

Causes and Risk Factors

As with most mental health conditions, there is not thought to be one direct cause of the development of GAD. GAD is likely to develop from a complex interaction between the biological, psychological and social factors of the individual, including:

• Brain biology: differences in brain structure, function, and chemistry.

• Genetics: people with immediate family members who have an anxiety disorder or other mental health condition may be more likely to develop GAD.

• Threat perception: differences in the way threats are perceived.

• Personality: a timid temperament, a pessimistic outlook, or a tendency to avoid anything dangerous may increase vulnerability.

• Experiences: people with GAD may have a history of significant life change, trauma, or negative experiences, including a difficult childhood or a recent traumatic event.

• Other conditions: a chronic medical illness or another mental health disorder may increase the risk of developing GAD.

Genetics and Temperament

GAD runs in families. A meta-analysis of the genetic epidemiology of anxiety disorders estimated its heritability at about 0.32 (Hettema, Neale, & Kendler, 2001). In other words, genes account for roughly a third of the differences in risk.

That is a modest share. The rest comes largely from individual experiences that family members do not share.

What seems to be inherited is not GAD itself but a broad temperamental vulnerability: high trait anxiety, behavioral inhibition, and a tendency to feel negative emotion. It is shared with major depression, which helps explain why the two conditions so often co-occur.

Experience then shapes how that vulnerability plays out. Childhood adversity, trauma, chronic illness, and accumulating life stress can all turn inherited sensitivity into GAD.

Brain Chemistry: GABA and Serotonin

Two neurotransmitter systems feature most in biological accounts of GAD. GABA (gamma-aminobutyric acid) is the brain’s main inhibitory neurotransmitter, a natural brake on arousal and anxiety. Low GABA activity may leave threat circuits under-regulated and easily excited. Together, these effects bias the whole system toward anxiety.

This idea comes partly from drug effects. Benzodiazepines reduce acute anxiety by boosting GABA’s action at the GABA-A receptor. Their calming effect implies that GABA is a key part of anxiety regulation.

Serotonin and noradrenaline also tune mood, threat sensitivity, and arousal.

That is the rationale for treating GAD with antidepressants that act on these systems. Because they take weeks to work, they seem to produce gradual neuroadaptive change in the brain rather than simple symptomatic sedation.

Brain Circuitry: Amygdala and Prefrontal Cortex

The amygdala is a key brain area in GAD. Part of the limbic system, it helps process and regulate emotions, including fear.

Monk et al. (2008) used fMRI to scan young people with and without GAD. They viewed masked angry faces, shown too briefly to be consciously seen. Those with GAD had a hyperactive amygdala.

The right ventrolateral prefrontal cortex, an area involved in critical thinking and reasoning, shows threat-related negative connectivity with the amygdala. This suggests it dampens the amygdala’s response to threat.

The amygdala supports vigilance through immediate threat processing, whereas the ventrolateral prefrontal cortex supports later emotion regulation.

If these interactions are disturbed, the amygdala may override the part of the brain that provides logical reasoning about perceived threats. This is thought to fuel anxiety.

The presence of other mental health disorders could also contribute as a risk factor for developing GAD. 

As previously mentioned, sometimes GAD can develop from environmental experiences that are either stressful or traumatic.

The outbreak of COVID-19, which many consider a stressful or traumatic event, has been investigated for its impact on mental health. It was found in a 2021 study that reported psychological distress regarding COVID-19 was positively correlated to depressive symptoms as well as to GAD (Nikčević et al., 2021).

This makes sense. During the pandemic, many people developed more extreme worries about their health, others’ health, work, and finances. These are the major worries that people with GAD tend to have.

GAD in Children and Adolescents

GAD is also common in children and adolescents, who may experience some of the same symptoms but may have different worries.

They may worry about their performance at school or family members’ (e.g., parents’) safety. Children and adolescents with GAD may:

• Feel overly anxious to fit in with their peers

• Lack confidence

• Strive for approval

• Redo tasks until they are perfected

• Spend an excessive amount of time on their homework

• Need lots of reassurance about their performance

• Experience stomach aches or other physical complaints

• Avoid school or social situations

When to Seek Help

It is usually recommended to see a doctor when the individual:

• Feels as if the worry is excessive and interferes with work, relationships, and other aspects of functioning.

• Feels depressed or irritable due to anxiety, has issues with substance abuse, or has another mental health condition.

• Is experiencing suicidal thoughts or behaviors.

• Feels as if the anxiety is getting worse and is persistent. It is important to seek help before the anxiety becomes extreme.

• Finds themselves constantly seeking help and reassurance from others.

• Repeatedly tries different methods of anxiety management to no avail.

GAD is twice as likely in women. Because of this, some women’s health professionals recommend that girls and women over 13 be screened for anxiety (Gregory et al., 2020).

Many people do not seek help for GAD because they lack the extreme physical symptoms of panic attacks. But panic is not always present in GAD. It is still worth seeking help for physical anxiety symptoms.

It may also be helpful to note the physical symptoms that are being experienced before attending an appointment with a professional.

Anxiety features in many mental health conditions, including obsessive-compulsive disorder (OCD), social anxiety disorder, and post-traumatic stress disorder (PTSD).

Finding a professional who knows the specific criteria for each helps ensure an accurate diagnosis and the right treatment.

Treatment for GAD: Medication, Therapy, and Lifestyle

Medication

For treating GAD, some short-term medications can be taken to relax some of the physical symptoms of anxiety, such as muscle tension and stomach cramping.

Benzodiazepines are the main class of medications giving short term relief for anxiety. Some examples of benzodiazepines are:

• Alprazolam (Xanax)

• Clonazepam (Klonopin)

• Lorazepam (Ativan)

They work quickly by boosting the calming effect of GABA, the brain’s main inhibitory neurotransmitter. But tolerance, dependence, withdrawal, and sedation limit them to short-term use. They can also be abused.

Other medications, such as antidepressants, are medications that reduce psychological symptoms such as depression and anxiety, and are safe to be taken long-term.

Selective serotonin reuptake inhibitors (SSRIs), which affect serotonin levels in the brain, are a frequent choice for many. Some SSRIs that can be prescribed include:

• Citalopram (Celexa)

• Fluoxetine (Prozac)

• Sertraline (Zoloft)

SSRIs and SNRIs are the first-line medications for GAD, effective for acute symptoms and for preventing relapse (Baldwin, Waldman, & Allgulander, 2011).

SSRIs take at least a few weeks to begin working. They can also cause side effects, such as nausea, dry mouth, and weight gain, particularly at the start of treatment.

Some medications may also increase suicidal thoughts, so regular monitoring by a professional is important.

Other medications are also used for GAD:

• SNRIs: serotonin-noradrenaline reuptake inhibitors, such as venlafaxine and duloxetine, also have specific evidence for preventing relapse.

• Pregabalin: an anticonvulsant with a different mechanism from antidepressants. It is an effective, generally well-tolerated option for acute and maintenance treatment (Generoso et al., 2017).

Medication is usually reserved for more severe cases, patient preference, or where therapy is unavailable. 

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is a common therapy for anxiety. It is the first-line psychological treatment for GAD. Its benefits also tend to outlast medication once treatment stops (Cuijpers et al., 2014).

In CBT, people meet regularly with a therapist to replace negative or maladaptive thinking patterns and behaviors with more balanced, realistic, and helpful ones.

Sessions teach specific skills. These help people recognize and control anxious thoughts and manage worry directly.

The cognitive distortions associated with GAD are features that can be targeted in CBT sessions.

CBT for GAD typically combines several components:

• Cognitive restructuring: challenging catastrophic “what if?” thinking and the beliefs that sustain worry.

• Worry exposure: deliberately confronting feared images and testing predictions through behavioral experiments.

• Uncertainty work: learning to approach uncertainty rather than try to eliminate it.

• Fewer safety behaviors: dropping reassurance-seeking and other habits that stop feared outcomes from being disproved.

• Applied relaxation: progressive muscle relaxation used at the first signs of tension, which targets the chronic muscle tension of GAD.

Therapists also help people break the vicious cycle. They identify and gradually drop safety behaviors, and challenge negative thoughts.

Symptoms improve as people build on their success. CBT is typically delivered over 8 to 15 sessions, depending on the individual. It is often prescribed alongside medication.

Mindfulness-based cognitive therapy

Mindfulness-Based Cognitive Therapy (MBCT), a branch of CBT, teaches non-judgmental awareness of thoughts, feelings, and bodily sensations. It also builds mindfulness techniques for relaxation, self-compassion, and present-moment focus.

A randomized trial compared a mindfulness-based intervention, the antidepressant fluoxetine, and an active comparison condition. Attention skills did not explain improvement in anxiety. Self-compassion and non-judgment of one’s own inner experience did, whichever treatment people received (Costa et al., 2023).

Acceptance and commitment therapy

Acceptance and Commitment Therapy (ACT) helps individuals with generalized anxiety by teaching them to accept difficult thoughts and feelings rather than struggling against them.

ACT uses mindfulness techniques to observe anxiety from a distance, clarify personal values, and take meaningful action towards goals. This increases psychological flexibility, reduces the impact of anxiety, and allows individuals to pursue a fulfilling life despite anxiety.

Emotion-focused therapy

Emotion-Focused Therapy (EFT) helps individuals with generalized anxiety disorder (GAD) by increasing awareness and acceptance of underlying emotions driving anxiety.

Through empathic attunement and experiential techniques like chairwork, EFT helps clients identify, process, and transform core painful feelings fueling worry. This improves emotional regulation, reduces avoidance, and cultivates self-compassion, leading to lasting symptom reduction and improved well-being.

How Effective Is Treatment?

Comparing Psychotherapies

A meta-analysis of randomized trials found moderate-to-large effects of psychological treatment on GAD symptoms compared with control conditions. The gains were well maintained at follow-up (Cuijpers et al., 2014).

Therapy and medication gave broadly comparable results at first. The gains from therapy tended to last longer once treatment ended.

A 2024 network meta-analysis is the strongest evidence to date. It pooled 65 randomized trials with 5,048 adults and compared eight psychotherapies with one another and with treatment as usual (Papola et al., 2024).

Against treatment as usual, three approaches reduced symptoms in the short term:

• Third-wave CBTs: newer therapies built on acceptance and mindfulness (standardized mean difference about −0.76).
• CBT: the standard cognitive behavioral approach (about −0.74).
• Relaxation therapy: training in relaxing the body (about −0.59).

At 3 to 12 months, only CBT remained significantly better than treatment as usual. CBT is therefore the first-line psychotherapy.

Online and Brief CBT

Cost, distance, and time keep many people from therapy. Online delivery is one answer.

In a randomized trial of 78 adults with GAD, ten sessions of videoconference CBT gave a large advantage over a waitlist (d = 0.80). Afterward, 64% of the treatment group no longer met criteria for GAD (Trenoska Basile et al., 2024).

A five-session version also worked. In an open trial it produced similarly large improvements, and 92% of participants were satisfied with treatment (Trenoska Basile et al., 2025). Remote and brief CBT may therefore extend care to people who face barriers to in-person therapy.

Lifestyle

Aside from prescribed medications and therapy, some lifestyle changes and self-help methods could help someone who is struggling with GAD:

• Maintaining a healthy diet and taking up regular exercise

• Having enough sleep

• Taking up yoga, meditation, or other relaxing activities

• Avoiding stimulants such as coffee

• Avoiding alcohol: it eases anxiety briefly but can leave people more irritable or depressed, and it can interfere with some medications.

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