Generalized anxiety disorder (GAD) is a common condition defined as chronic, excessive worry for at least 6 months that causes distress or impairment.
At least three key symptoms out of a possible six are required to make a diagnosis of GAD in adults according to the Diagnostic and statistical manual of mental disorders, fifth edition, (DSM-5) criteria. These include restlessness or nervousness, being easily fatigued, poor concentration, irritability, muscle tension, and/or sleep disturbance. One key symptom is required to make the diagnosis in children.
It is in part a diagnosis of exclusion: physical health conditions, other mental health disorders, and medications or other substances should be ruled out as a primary cause.
Physical examination and laboratory studies are generally normal if no co-existing physical or mental health conditions or substance misuse issues exist.
Treatment is primarily with psychotherapy (cognitive behavioral therapy or cognitive therapy), serotonergic antidepressants, or a combination of these approaches.
Generalized anxiety disorder (GAD) is defined as at least 6 months of excessive worry about everyday issues that is disproportionate to any inherent risk, causing distress or impairment. The worry is not confined to features of another mental health disorder, a result of substance misuse, or relating only to a physical health condition.
At least three of the following symptoms are present most of the time: restlessness or nervousness, being easily fatigued, poor concentration, irritability, muscle tension, or sleep disturbance. In children, at least one key symptom should be present most of the time.
Other common complaints are autonomic in nature, such as sweating, lightheadedness, palpitations, dizziness, and epigastric discomfort. Anxiety may be "free-floating" (i.e., not restricted to, or even strongly predominating in, any particular environmental circumstances). Examples of worries include fears that the patient or a relative will shortly become ill or have an accident.
History and exam
Key diagnostic factors
- excessive worry for at least 6 months
- anxiety not confined to another mental health disorder
- anxiety not due to medication or substance
- muscle tension
- sleep disturbance
- poor concentration
Other diagnostic factors
- gastrointestinal symptoms
- muscle aches
- increased heart rate
- shortness of breath
- exaggerated startle response
- chest pain
- family history of anxiety
- physical or emotional stress
- history of physical, sexual, or emotional trauma
- other anxiety disorder
- chronic physical health condition
- female sex
1st investigations to order
- clinical diagnosis
Investigations to consider
- thyroid function tests
- urine drug screen
- 24-hour urine for vanillylmandelic and metanephrines
- pulmonary function tests
anxiety symptoms meeting DSM-5 criteria
anxiety symptoms not meeting Diagnostic and statistical manual of mental disorders, 5th edition criteria
Christopher Gale, BHB, MPH, MBChB, FRANZCP
Southern District Health Board
Department of Psychological Medicine
Dunedin School of Medicine
CG is an author of the Royal Australian and New Zealand College of Psychiatrists clinical practice guideline on social phobia, panic disorder, and generalized anxiety disorder. Otago University has commercial and research relationships with multiple pharmaceutical companies. He is an author of a number of references cited in this topic.
Dr Christopher Gale would like to gratefully acknowledge Dr Richard P. Swinson, Dr Elizabeth Hoge, and Dr Phebe Tucker, previous contributors to this topic.
RPS has personally received royalties for articles published in UpToDate (Wolters Kluwer) and the Compendium of Therapeutic Choices, 2nd edition (Canadian Pharmacists Association). EH is an author of a number of references cited in this topic. PT has done research for GlaxoSmithKline, Bristol-Myers Squibb, Wyeth Pharmaceuticals, Astra-Zeneca, Cephalon, Inc., and Ortho-McNeil. She has also consulted for Forest Pharmaceuticals and received honoraria from Pfizer, Inc. and Forest Pharmaceuticals.
Lori Davis, MD
University of Alabama
School of Medicine Tuscaloosa Campus
College of Community Health Sciences
LD declares that she has no competing interests.
Arianna Di Florio, MD, PhD
Senior Clinical Lecturer
Division of Psychological Medicine and Clinical Neurosciences
ADF declares that she has no competing interests.
Elaine Lockhart, MB, BCH, BAO
Consultant in Paediatric Liaison Psychiatry
Royal Hospital for Children
EL declares that she has no competing interests.
- Panic disorder
- Social phobia
- Obsessive-compulsive disorder
- Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of panic disorder, social anxiety disorder and generalised anxiety disorder
- Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines from the British Association for Psychopharmacology
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