Table of Contents

Generalized Anxiety Disorder (GAD)

Primer

Generalized Anxiety Disorder (GAD) is mental disorder characterized by excessive anxiety and worry about multiple events or activities (e.g. - school or work difficulties, relationships, finances) on a majority of days over at least half a year. There are also associated symptoms, such as restlessness, muscle tension, fatigue, poor concentration, irritability, and sleep changes.

Epidemiology
Prognosis
Comorbidity
Risk Factors
Cultural

DSM-5 Diagnostic Criteria

Criterion A

Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

Criterion B

The individual finds it difficult to control the worry.

Criterion C

The anxiety and worry are associated with at least 3 of the 6 symptoms (with at least some symptoms present for more days than not for the past 6 months);

Only 1 item is required in children
  1. Blanking out or difficulty concentrating
  2. Easily fatigued
  3. Sleep changes (difficulty falling or staying asleep, or restless, unsatisfying sleep)
  4. Keyed up, on edge, or restless
  5. Irritability
  6. Muscle tension

Mnemonic

The mnemonic BESKIM can be used to remember the criteria for generalized anxiety disorder.
  • B - Blank mind
  • E - Easily fatigued
  • S - Sleep disturbance
  • K - Keyed Up/Restless/On-edge
  • I - Irritability
  • M - Muscle tension
Criterion D

The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Criterion E

The disturbance is not attributable to the physiological effects of a substance (e.g. - a drug of abuse, a medication) or another medical condition (e.g. - hyperthyroidism).

Criterion F

The disturbance is not better explained by another mental disorder:

Specifiers

Panic Attack Specifier

Specify if:

  • Recurrent unexpected panic attacks. An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time at least 4 of the following symptoms occur (Note: The abrupt surge can occur from a calm state or an anxious state):
  1. Sweating
  2. Trembling or shaking
  3. Unsteady, dizziness, light-headed, or faint
  4. Derealization (feelings of unreality) or depersonalization (being detached from one self)
  5. Excessive/accelerated heart rate, palpitations, or pounding heart
  6. Nausea or abdominal distress
  7. Tingling, numbness, parathesesias
  8. Shortness of breath
  9. Fear of losing control or “going crazy”
  10. Fear of dying
  11. Choking feelings
  12. Chest pain or discomfort
  13. Chills or heat sensations
Note: The symptoms presented in this specifier are for the purpose of identifying a panic attack. However, panic attacks are not a mental disorder. Panic attacks can occur in the context of any anxiety disorder as well as other mental disorders (e.g. - depressive disorders, posttraumatic stress disorder, substance use disorders) and some medical conditions (e.g. - cardiac, respiratory, vestibular, gastrointestinal). When the presence of a panic attack is identified, it should be noted as a specifier (e.g. - “social anxiety disorder with panic attacks”). For panic disorder, the presence of panic attack is contained within the criteria for the disorder and panic attack is not used as a specifier.
Note: Culture-specific symptoms (e.g. - tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.

Signs and Symptoms

Screening and Rating Scales

Generalized Anxiety Scales

Name Rater Description Download
Generalized Anxiety Disorder 7 (GAD-7) Patient The GAD-7 is a 7-item self-reported questionnaire for screening and a severity measure of generalized anxiety disorder Download
Beck Anxiety Inventory (BAI) Patient The BAI is a 21-question self-report inventory for screening and a severity measure of generalized anxiety disorder Download

Pathophysiology

Differential Diagnosis

Anxiety is a Broad Term!

Anxiety is also such a broad term that you must explore it in more detail to determine the correct diagnosis when someone says they are “anxious.” If the anxiety is about:

Don't Forget About Medical Etiologies

Certain medical conditions can be misdiagnosed as generalized anxiety disorder, or vice versa. Refer to these two papers for an overview to avoid misdiagnosis!
  • Anxiety disorder due to another medical condition
    • The diagnosis of anxiety disorder associated with another medical condition should be assigned if the individual's anxiety and worry are judged, based on history, laboratory findings, or physical examination, to be a physiological effect of another specific medical condition (e.g. - pheochromocytoma, hyperthyroidism). A thorough work up should be considered if there are associated physical exam findings, or ongoing acute symptoms without improvement after treatment.
    • A substance/medication-induced anxiety disorder is different GAD by the fact that a substance or medication (e.g. - a drug of abuse, exposure to a toxin) is temporally and etiologically related to the anxiety. For example, severe anxiety that occurs only in the context of heavy coffee use would be diagnosed as caffeine-induced anxiety disorder, rather than GAD.
    • Individuals with social anxiety disorder often have anticipatory anxiety about upcoming social situations where they must perform or be evaluated by other. Contrast this with GAD, where individuals worry persistently (whether or not they are being evaluated).
    • Several features distinguish the excessive worry of GAD from the obsessional thoughts in OCD. In GAD, the focus of the worry is about upcoming problems. In OCD, the obsessions are intrusive and unwanted thoughts, urges, or images.
    • Anxiety is naturally present in posttraumatic stress disorder. Thus, GAD is not diagnosed if the anxiety and worry are better explained by a diagnosis of PTSD. Anxiety may also be present in adjustment disorder, but this residual category should be used only when the criteria are not met for any other disorder (including generalized anxiety disorder). Also note that in adjustment disorders, the anxiety occurs in response to an identifiable stressor within 3 months of the onset of the stressor and does not persist for more than 6 months after the termination of the stressor.
    • Generalized anxiety/worry is a common associated feature of major depressive disorder, bipolar disorder, and psychotic disorders. Thus, GAD should not be diagnosed if the excessive worry is occurring in the context of these other disorders.
  • Other disorders of childhood
    • According to DSM-5, generalized anxiety disorder may be overdiagnosed in children, and other mental disorders such as separation disorder, social anxiety disorder, and OCD should be explored first.[9]

Investigations

Treatment

Psychotherapy

  • Cognitive behavioural therapy (CBT) is an effective first-line option for the treatment of GAD and is as effective as pharmacotherapy. Internet-based and computer-based CBT have also demonstrated efficacy.
  • The evidence does not support the routine combination of CBT and pharmacotherapy, but when patients do not benefit from CBT, a trial of pharmacotherapy is advisable, and vice versa.
Recommended Reading

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Pharmacotherapy

Pharmacotherapy for generalized anxiety disorder

Katzman, M. A. et al. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.
1st line Monotherapy: agomelatine, duloxetine, escitalopram, paroxetine, paroxetine CR, pregabalin, sertraline, venlafaxine XR
2nd line Monotherapy: alprazolam*, bromazepam*, bupropion XL*, buspirone, diazepam*, hydroxyzine, imipramine, lorazepam*, quetiapine XR*, vortioxetine
3rd line Monotherapy: citalopram, divalproex chrono, fluoxetine, mirtazapine, trazodone
Adjunctive therapy Second-line: pregabalin
Third-line: aripiprazole, olanzapine, quetiapine, quetiapine XR, risperidone
Not recommended: ziprasidone
Not recommended Beta blockers (propranolol), pexacerfont, tiagabine

Child and Adolescent Considerations

Guidelines

Generalized Anxiety Disorder Guidelines

Guideline Location Year PDF Website
Canadian Clinical Practice Guidelines for the Management of Anxiety, Posttraumatic Stress and Obsessive-Compulsive Disorders Canada 2014 - Link
Canadian Network for Mood and Anxiety Treatments (CANMAT) Canada 2012 - Link
National Institute for Health and Care Excellence (NICE) UK 2011, 2019 - Link
Royal Australian and New Zealand
College of Psychiatrists (RANZCP)
AUS, NZ 2018 - Link

Resources

1) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
6) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
7) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
8) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
9) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.