How many symptoms must be present to diagnose Generalized Anxiety Disorder?

Diagnostic Criteria for Generalized Anxiety Disorder

To diagnose Generalized Anxiety Disorder (GAD), a patient must have at least 3 of the 6 associated physical or cognitive symptoms, in addition to the core feature of excessive, uncontrollable worry lasting at least 6 months. 1

Core Diagnostic Requirements

The diagnosis of GAD requires two essential components that must both be present:

1. Primary Symptom (Required)

• Excessive anxiety and worry about multiple topics, events, or activities that occurs more days than not for at least 6 months 1
• The worry must be clearly excessive and very challenging to control 1
• The patient typically describes the worry as "uncontrollable" or difficult to stop 2

2. Associated Symptoms (≥3 Required)

At least 3 of the following 6 symptoms must be present: 1

• Restlessness or feeling keyed up or on edge
• Being easily fatigued
• Difficulty concentrating or mind going blank
• Irritability
• Muscle tension
• Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

Additional Diagnostic Requirements

Beyond the symptom count, the following criteria must also be met:

• The anxiety and worry must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning 1, 3
• The disturbance cannot be attributable to physiological effects of a substance or another medical condition 4
• The disturbance is not better explained by another mental disorder 5

Clinical Context and Screening

While the GAD-7 screening tool uses 7 items and various cutoff scores (≥8-9 for screening purposes), the formal DSM diagnostic criteria require only 3 of 6 associated symptoms for diagnosis 1. The GAD-7 is a screening instrument, not the diagnostic standard itself 1, 4.

Important Clinical Pitfalls

• Do not confuse screening thresholds with diagnostic criteria: A GAD-7 score helps identify patients who need further evaluation, but the formal diagnosis still requires meeting the DSM criteria of ≥3 associated symptoms 1
• Irritability is the most strongly associated symptom with GAD diagnosis in youth populations, while restlessness (despite being retained in proposed DSM-5 revisions) was actually the least associated 6
• Rule out medical mimics before confirming GAD, including hyperthyroidism, hyperparathyroidism, cardiac arrhythmias, and substance-induced anxiety 2, 4
• Screen for comorbid major depressive disorder, which co-occurs in approximately 31% of GAD cases 2