What are the symptoms of generalized anxiety disorder (GAD)?

Symptoms of Generalized Anxiety Disorder

Generalized anxiety disorder is characterized by excessive, uncontrollable worry about multiple life domains persisting for at least 6 months, accompanied by at least three of six core physical and cognitive symptoms: restlessness, easy fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance. 1

Core Symptom: Excessive Worry

• The hallmark feature is excessive anxiety and worry (apprehensive expectation) about numerous events or activities such as work, school performance, health, family, and finances that the person finds difficult to control. 1
• The worry must occur more often than not for at least 6 months and be clearly excessive relative to the actual likelihood or impact of feared events. 1
• Patients typically worry about multiple areas of life simultaneously, not just a single concern or stressor, which distinguishes GAD from adjustment disorders. 1, 2

Six Associated Physical and Cognitive Symptoms

At least three of the following six symptoms must be present (only one symptom required in children): 1

• Restlessness or feeling keyed up or on edge – patients describe feeling tense, unable to relax, or "wound up." 1
• Being easily fatigued – persistent tiredness despite adequate rest, often worsening throughout the day. 1
• Difficulty concentrating or mind going blank – impaired focus, forgetfulness, or inability to complete tasks requiring sustained attention. 1
• Irritability – increased frustration, impatience, or anger that is out of proportion to circumstances. 1
• Muscle tension – persistent tightness in neck, shoulders, back, or jaw; may present as tension headaches. 1
• Sleep disturbance – difficulty falling asleep, staying asleep, or experiencing restless, unsatisfying sleep. 1

Additional Common Presentations

• Somatic complaints are frequent, particularly in non-Western populations, including palpitations, dizziness, sweating, trembling, indigestion, and nonspecific abdominal discomfort. 3, 4
• Patients often present to primary care with medically unexplained symptoms such as headache, noncardiac chest pain, or chronic fatigue rather than reporting anxiety directly. 5
• Hypervigilance and scanning behaviors—constantly monitoring the environment for threats or checking for signs of feared outcomes. 6

Functional Impairment Requirement

• The anxiety, worry, and associated symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 1, 3
• Moderate GAD typically produces mild-to-moderate functional limitation (e.g., difficulty completing work tasks, avoiding social situations), while severe GAD markedly interferes with daily activities (e.g., missing work, inability to maintain relationships). 3

Screening and Assessment

• The GAD-7 scale is the validated primary care screening tool, assessing the seven core symptoms over the past 2 weeks with scores interpreted as: 0-4 (minimal), 5-9 (mild), 10-14 (moderate), 15-21 (severe). 1, 2
• The GAD-2 (first two questions of GAD-7) serves as an ultra-brief screen, with a score ≥3 warranting full GAD-7 assessment. 1
• A positive screening score does not constitute a formal diagnosis—DSM criteria require only three of six associated symptoms plus the core worry feature, regardless of GAD-7 score. 3

Common Pitfalls to Avoid

• Do not miss comorbid major depression, which co-occurs in approximately 31% of GAD cases; always screen with PHQ-9 or direct questioning about depressed mood and anhedonia. 3, 2
• Rule out medical mimics before confirming GAD, including hyperthyroidism, hyperparathyroidism, cardiac arrhythmias, and medication effects (e.g., corticosteroids, stimulants, caffeine). 3
• Screen for substance use disorders, particularly alcohol abuse, which frequently complicates anxiety and requires concurrent treatment. 3
• Cultural variations exist—non-Western patients more commonly report somatic symptoms (fatigue, muscle tension, dizziness) rather than psychological worry, which can lead to missed diagnoses if clinicians focus only on cognitive symptoms. 3
• Distinguish GAD from adjustment disorder: GAD can occur without identifiable stressors and persists ≥6 months, whereas adjustment disorder requires a clear precipitating stressor and symptoms develop within 3 months of that stressor. 1, 5