What are the DSM‑5 criteria for Generalized Anxiety Disorder (GAD)?

DSM-5 Criteria for Generalized Anxiety Disorder (GAD)

Generalized Anxiety Disorder is characterized by excessive, uncontrollable worries regarding numerous everyday situations or activities, with the ICD-10 code F41.1. 1

Core Diagnostic Criteria

The DSM-5 requires the following elements to diagnose GAD:

A. Excessive Anxiety and Worry

• Must involve multiple everyday situations or activities
• The worry is excessive and difficult to control
• Occurs more days than not for at least 6 months 1

Important caveat: The "excessiveness" criterion has been challenged in recent research, as removing it would identify clinically significant cases who worry appropriately given difficult life circumstances but still meet all other criteria and show comparable impairment 2. However, DSM-5 retains this requirement.

B. Associated Symptoms

The anxiety and worry must be accompanied by at least three of the following six symptoms (only one required in children):

1. Restlessness or feeling keyed up or on edge
2. Being easily fatigued
3. Difficulty concentrating or mind going blank
4. Irritability
5. Muscle tension
6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)

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Critical note: Research in youth populations suggests that irritability is most strongly associated with GAD diagnosis, while restlessness is least associated 4. The proposed DSM-5 changes to reduce these symptoms to only restlessness or muscle tension were not adopted, which is important as 10.9% of children with GAD would have been excluded under that narrower criterion 4.

C. Clinical Significance

• The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning 1

D. Exclusion Criteria

• Not attributable to physiological effects of a substance (medication, drug of abuse) or another medical condition
• Not better explained by another mental disorder (e.g., worry about panic attacks in panic disorder, negative evaluation in social anxiety disorder, contamination in OCD, separation from attachment figures in separation anxiety disorder, etc.) 1

Duration Requirement

The 6-month duration is mandatory for adults. In children under 18 years, the duration must also be at least 6 months 1.

Research has shown that shortening this to 3 months (as was proposed for DSM-5) would increase prevalence by approximately 9% while maintaining similar severity levels 5. However, the 6-month criterion was retained in the final DSM-5.

Key Distinguishing Features

GAD must be differentiated from normal developmental worries:

• Infants: Being startled, stranger anxiety
• Toddlers: Separation from caregivers
• Preschoolers: Supernatural creatures
• School-aged children: Physical well-being, natural disasters
• Adolescents: Social and existential concerns

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Assessment Tools

The GAD-7 is a validated 7-item self-report scale specifically assessing GAD symptomatology, with scores ≥5,10, and 15 indicating mild, moderate, and severe anxiety respectively 3. The GAD-Q-IV is a 9-item scale assessing DSM-IV criteria including uncontrollable worry, functional impairment, physical symptoms, and subjective distress 3.

Common Diagnostic Pitfalls

• Medical masqueraders must be ruled out: hyperthyroidism, caffeinism, hypoglycemia, pheochromocytoma, CNS disorders 1
• Substance-induced anxiety from medications or drugs must be excluded
• The worry content varies across cultures (e.g., Cambodian refugees may worry about spiritual status of deceased relatives), but the core features of excessive, uncontrollable worry remain consistent 6
• In elderly patients, fears may be under-diagnosed due to over-attribution to age-related constraints 7