Diagnostic Criteria for Generalized Anxiety Disorder
For a formal diagnosis of GAD, symptoms must persist for at least 6 months, though treatment can begin earlier when clinically indicated. 1, 2, 3
Core Diagnostic Features
GAD is defined by persistent and excessive anxiety and worry about multiple life domains that the person finds difficult to control. 4 The disorder must be distinguished from normal everyday worries and fears. 4
The diagnosis requires the presence of at least 6 of the following 18 symptoms across three categories: 2
Motor Tension
- Trembling, twitching, or feeling shaky
- Muscle tension, aches, or soreness
- Restlessness
- Easy fatigability 2
Autonomic Hyperactivity
- Shortness of breath or smothering sensations
- Palpitations or accelerated heart rate
- Sweating or cold clammy hands
- Dry mouth
- Dizziness or light-headedness
- Nausea, diarrhea, or other abdominal distress
- Flushes or chills
- Frequent urination
- Trouble swallowing or 'lump in throat' 2
Vigilance and Scanning
- Feeling keyed up or on edge
- Exaggerated startle response
- Difficulty concentrating or 'mind going blank' because of anxiety
- Trouble falling or staying asleep
- Irritability 2
Screening and Assessment Tools
Use the GAD-7 scale as the primary screening tool, with scores stratified as follows: 5, 4
- 0-4: Minimal anxiety
- 5-9: Mild anxiety
- 10-14: Moderate anxiety
- 15-21: Severe anxiety
The GAD-7 assesses seven items over the past two weeks, rated as 0 (not at all), 1 (several days), 2 (more than half the days), or 3 (nearly every day): feeling nervous/anxious/on edge, cannot stop or control worrying, worrying too much about different things, trouble relaxing, being so restless it's hard to sit still, becoming easily annoyed or irritable, and feeling afraid as if something awful might happen. 5
For ultra-brief screening, the GAD-2 (first two items of GAD-7) can be used, with a cutoff score of ≥3 indicating need for further assessment. 4
Critical Differential Diagnosis
These symptoms must not be secondary to another psychiatric disorder or caused by an organic factor. 2 Specifically assess for:
- Medical or substance-induced causes of anxiety (e.g., interferon administration, thyroid disorders, stimulant use) 5
- Major depressive disorder (commonly co-occurs with GAD) 5, 4
- Other anxiety disorders: panic disorder, social anxiety disorder, specific phobias 4
- Delirium or psychosis 5
Patients with GAD typically have worries about multiple areas beyond just one concern (e.g., not just health-related). 5, 4
Functional Impairment Assessment
Anxiety, concern, or physical symptoms must significantly impair social, academic, or occupational functioning to qualify for diagnosis. 3 Assess:
- Home and relationship functioning
- Social functioning
- Occupational performance
- Duration and severity of impairments 5
Risk Assessment
Immediate referral to psychiatry is required for: 5
- Risk of harm to self or others
- Severe anxiety or agitation
- Presence of psychosis
- Confusion or delirium
Treatment Algorithm Based on Severity
Mild Symptoms (GAD-7 Score 5-9)
Offer low-intensity interventions: 5
- Education and active monitoring
- Guided self-help based on cognitive behavioral therapy (CBT) principles
- Group psychosocial interventions
- Structured physical activity/exercise programs
Moderate Symptoms (GAD-7 Score 10-14)
Offer referral to supportive care services and high-intensity interventions: 5
- Individual psychological therapy delivered by licensed mental health professionals using CBT, behavioral activation, or acceptance and commitment therapy 5
- Consider pharmacotherapy with SSRIs or SNRIs (venlafaxine, escitalopram, duloxetine) 6, 7
- Structured group therapy led by licensed professionals 5
Severe Symptoms (GAD-7 Score 15-21)
Immediate referral to psychology and/or psychiatry for diagnosis and treatment. 1 Implement:
- High-intensity psychological interventions (individual CBT) 5
- Pharmacotherapy: SSRIs (escitalopram, paroxetine) or SNRIs (venlafaxine, duloxetine) as first-line agents 6, 7
- Combined CBT and pharmacotherapy may offer additional benefits 8
- Benzodiazepines (alprazolam, lorazepam) or buspirone for short-term use only, with caution regarding dependence 2, 6
Pharmacological Treatment Specifics
For antidepressant therapy (first-line): 6, 7
- Venlafaxine: Effective anxiolytic with sustained long-term benefit and antidepressant efficacy for comorbid depression 6
- Escitalopram, duloxetine, paroxetine: Effective for GAD with good tolerability 7
For benzodiazepines (short-term use only): 2
- Alprazolam: Start 0.25-0.5 mg three times daily, may increase at 3-4 day intervals to maximum 4 mg/day in divided doses 2
- Monitor for dependence risk, which increases with dose and duration 2
- Taper gradually when discontinuing (decrease by no more than 0.5 mg every 3 days) 2
Special Populations
Elderly patients: 9
- Antidepressants (citalopram, venlafaxine, escitalopram) are the pharmacological treatment of choice
- If benzodiazepines are necessary, use lorazepam or oxazepam due to favorable pharmacokinetics
- CBT appears less efficacious in older adults than younger adults
Pediatric patients (ages 6-17): 10
- Monitor weight and height during treatment with venlafaxine
- Use culturally sensitive assessments 5, 1
Follow-Up and Monitoring
Reassess monthly or until symptoms subside: 5
- Assess compliance with psychological/psychosocial referrals and satisfaction with services
- Monitor pharmacologic treatment adherence, side effects, and symptom relief
- Consider tapering antidepressants if anxiety symptoms are controlled and environmental stressors have resolved
- After 8 weeks of treatment, if symptom reduction is poor despite good compliance, alter the treatment course (add or switch interventions) 5
Common pitfall: Patients with GAD often avoid following through on referrals due to anxiety about threatening stimuli—proactively address barriers to compliance. 5