What are the diagnostic criteria and treatment options for Generalized Anxiety Disorder (GAD)?

Diagnostic Criteria and Treatment Options for Generalized Anxiety Disorder (GAD)

The diagnosis of Generalized Anxiety Disorder requires excessive, uncontrollable worry about multiple topics lasting at least 6 months, with significant functional impairment, and treatment should begin with either an SSRI/SNRI combined with cognitive behavioral therapy as first-line approach. 1

Diagnostic Criteria for GAD

Core Symptoms

• Excessive anxiety and worry about multiple events/activities occurring more days than not for ≥6 months
• Difficulty controlling the worry
• Associated with ≥3 of the following symptoms:
  • Restlessness or feeling keyed up/on edge
  • Being easily fatigued
  • Difficulty concentrating/"mind going blank"
  • Irritability
  • Muscle tension
  • Sleep disturbance (difficulty falling/staying asleep, restless sleep)
• Symptoms cause clinically significant distress or impairment in functioning
• Not attributable to substance use, medical condition, or better explained by another mental disorder

Assessment Tools

• GAD-7 scale is the recommended screening tool 2, 1
  • Scores 0-4: None/mild symptoms
  • Scores 5-9: Mild symptoms
  • Scores 10-14: Moderate symptoms
  • Scores 15-21: Moderate to severe/severe symptoms

Differential Diagnosis

• Rule out medical causes of anxiety (thyroid disorders, cardiac conditions)
• Rule out substance-induced anxiety (caffeine, medications, withdrawal)
• Distinguish from other anxiety disorders (panic disorder, social anxiety)
• Evaluate for comorbid conditions (depression, substance use disorders) 2

Treatment Algorithm for GAD

Step 1: Initial Assessment and Severity Determination

• Use GAD-7 to determine severity
• Evaluate for risk of self-harm or harm to others (requires immediate intervention)
• Assess for comorbid conditions, substance use, and medical causes

Step 2: First-Line Treatment Based on Severity

For Mild Symptoms (GAD-7 score 0-9):

• Education about anxiety and self-help strategies
• Low-intensity psychological interventions:
  • Self-help resources based on CBT principles
  • Group psychosocial interventions
  • Relaxation techniques
  • Physical activity/exercise

For Moderate to Severe Symptoms (GAD-7 score 10-21):

• Pharmacotherapy + Psychological Intervention 1
  • First-line medications:
    • SSRIs: Escitalopram (10-20 mg/day), Sertraline (50-200 mg/day), Paroxetine
    • SNRIs: Venlafaxine, Duloxetine
  • High-intensity psychological interventions:
    • Cognitive Behavioral Therapy (CBT) - 14 sessions over 4 months
    • Structured treatment including cognitive restructuring, behavioral activation, relaxation strategies
    • Delivered by licensed mental health professionals

Step 3: Monitoring and Follow-up

• Monthly assessment until symptoms subside
• Evaluate medication adherence and side effects
• Assess symptom reduction using GAD-7
• After 8 weeks, if poor response despite good adherence:
  • For those on medication only: Add psychological intervention
  • For those on psychological intervention only: Consider adding medication
  • For those on both: Consider changing medication

Step 4: Maintenance and Relapse Prevention

• Continue effective treatment for 12-24 months after achieving remission
• Consider tapering medication if symptoms well-controlled and environmental stressors resolved
• Provide relapse prevention strategies

Special Considerations

Benzodiazepines

• Not recommended for long-term management due to:
  • Risk of dependence and withdrawal
  • Cognitive impairment
  • Interaction with CNS depressants
• May be used short-term (2-4 weeks) with caution for acute severe anxiety while initiating other treatments 1, 3

Treatment-Resistant GAD

• Ensure adequate dose and duration of first-line treatments
• Consider switching to alternative SSRI/SNRI
• Consider augmentation strategies (pregabalin, quetiapine) 4
• Re-evaluate diagnosis and assess for undetected comorbidities

Common Pitfalls to Avoid

• Overlooking medical causes of anxiety symptoms
• Inadequate treatment duration - full response may take 8-12 weeks
• Focusing solely on medication without psychological intervention
• Prolonged benzodiazepine use leading to dependence
• Poor follow-through - implement proactive follow-up system 1
• Failure to address comorbidities that may contribute to treatment resistance

By following this structured approach to diagnosis and treatment, clinicians can effectively manage patients with GAD and improve their quality of life, reducing morbidity associated with chronic anxiety.