What is the diagnosis and treatment approach for a patient with suspected Generalized Anxiety Disorder (GAD)?

Diagnosis of Generalized Anxiety Disorder (GAD)

Core Diagnostic Criteria

GAD is diagnosed when a patient exhibits excessive, uncontrollable worry about multiple everyday situations or activities persisting for at least 6 months, causing clinically significant distress or functional impairment in social, occupational, academic, or other important life domains. 1

The diagnosis requires:

• Excessive worry that is difficult to control about multiple areas of life (not just a single concern or stressor), distinguishing it from normal everyday worries 1, 2
• Duration of at least 6 months with persistent symptoms 1, 3
• Significant functional impairment affecting home, relationship, work, or school performance 1
• Associated symptoms including restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance 3, 4

Screening and Assessment Algorithm

Initial Screening Tool

Use the GAD-7 (Generalized Anxiety Disorder-7 scale) as the primary screening instrument, which assesses seven key symptoms over the past 2 weeks 5, 6:

• Feeling nervous, anxious, or on edge
• Cannot stop or control worry
• Worrying too much about different things
• Trouble relaxing
• Being so restless it's hard to sit still
• Becoming easily annoyed or irritable
• Feeling afraid as if something awful might happen 5

Each item is scored 0-3 (0=not at all, 1=several days, 2=more than half the days, 3=nearly every day) 5

Score Interpretation and Treatment Pathways

GAD-7 scores guide treatment intensity 5, 6:

• 0-4 (none): No intervention needed; monitor 5
• 5-9 (mild): Low-intensity interventions (education, support services, self-help) 5
• 10-14 (moderate): Referral to psychology/psychiatry; consider high-intensity interventions 5, 2
• 15-21 (severe): Immediate referral to mental health specialist; high-intensity interventions required 5, 2

Immediate Safety Assessment

Before proceeding with any diagnostic workup, screen for imminent safety concerns 5, 2:

• Suicidal ideation or self-harm intent
• Intent to harm others
• Severe agitation, psychotic symptoms, or confusion/delirium

Any positive response requires immediate psychiatric referral or emergency evaluation with one-to-one observation and interventions to reduce harm risk 5, 2

Essential Diagnostic Considerations

Assess Risk Factors and History

Systematically evaluate the following risk factors 5, 6:

• Family history of anxiety disorders, particularly in first-degree relatives 6
• Personal psychiatric history including prior anxiety or mood disorders 5
• Comorbid psychiatric conditions, especially major depressive disorder (present in many GAD patients) 5, 6
• Substance use history including alcohol or drug use/abuse (current or past) 5, 2
• Chronic medical illnesses that increase vulnerability to anxiety 5, 6
• Major life stressors or transitions (retirement, divorce, family crisis) 6

Screen for Comorbid Depression

Administer the PHQ-9 or directly assess for depressive symptoms (depressed mood, anhedonia, sleep changes, appetite changes, guilt, concentration problems, psychomotor changes, suicidal thoughts) because GAD and major depressive disorder frequently co-occur 6, 2

Rule Out Medical Causes

Obtain TSH (thyroid-stimulating hormone) as routine screening since thyroid dysfunction commonly presents with anxiety symptoms and has significant comorbidity with anxiety disorders 6

Consider other medical conditions that mimic anxiety 4, 7:

• Endocrine disorders (hyperthyroidism, hypoglycemia, pheochromocytoma)
• Cardiovascular conditions (arrhythmias, angina)
• Respiratory disorders (asthma, COPD)
• Neurologic conditions
• Medication side effects or withdrawal phenomena 7

Assess Functional Impairment

Determine specific examples of how anxiety interferes with daily functioning 2:

• Missing work or reduced work performance
• Avoiding social situations or relationship difficulties
• Difficulty completing household tasks or self-care
• Academic impairment (if applicable)

The level of functional impairment guides treatment intensity, with moderate impairment suggesting moderate GAD and marked impairment indicating severe GAD 5, 2

Evaluate Coping and Support

Assess current coping strategies and access to social support to inform treatment planning 5, 2

Ask about prior treatment experiences with self-help techniques, relaxation methods, therapy, or medications 2

Differential Diagnosis

Distinguish GAD from Other Anxiety Disorders

GAD involves worry about multiple areas of life, whereas other anxiety disorders have more specific foci 2:

• Panic disorder: Episodic, abrupt panic attacks with at least 4 autonomic/cardiopulmonary symptoms, rather than chronic worry 7
• Social anxiety disorder: Fear limited to social situations 5
• Specific phobias: Fear of particular objects or situations 5
• PTSD: Anxiety related to specific traumatic event 5

Screen for these comorbid anxiety disorders as they frequently co-occur with GAD 5, 2

Distinguish from Adjustment Disorder

GAD can manifest without identifiable emotional stressors, whereas adjustment disorder requires a clear precipitating stressor 7

Both conditions can be comorbid with major depressive disorder, requiring assessment for depressive symptoms 2

Cultural Considerations

Recognize cultural variations in GAD presentation 2:

• Non-Western populations more commonly report somatic symptoms (fatigue, muscle tension, palpitations, dizziness, indigestion) rather than psychological symptoms 2
• Failure to recognize somatic presentations is a common diagnostic pitfall 2

Clinical Presentation Nuances

Patients with GAD may not present with overt "anxiety" 5:

• The pathognomonic symptom is multiple excessive worries that may be described as "concerns" or "fears" 5
• Worry may be disproportionate to actual risk (e.g., excessive fear of cancer recurrence, worry about multiple symptoms not associated with current condition) 5
• Somatic complaints (headache, noncardiac chest pain, fatigue, insomnia, abdominal discomfort) may dominate the presentation 7

Common Diagnostic Pitfalls to Avoid

• Missing comorbid depression: Always screen with PHQ-9 or direct questioning, as GAD and major depression frequently co-occur 2
• Overlooking substance use disorders: These require concurrent treatment and complicate anxiety management 2
• Failing to recognize somatic presentations, particularly in non-Western populations 2
• Not assessing functional impairment: This is essential for diagnosis and treatment planning 1, 2
• Attributing symptoms to medical conditions without proper evaluation: Always rule out thyroid dysfunction and other medical causes 6