Diagnostic Criteria of Generalized Anxiety Disorder (GAD)

DSM-5 Diagnostic Criteria for Generalized Anxiety Disorder

Criterion A: Excessive Anxiety and Worry

Excessive anxiety and worry (apprehensive expectation) about a number of events or activities (such as work or school performance), occurring more days than not for at least 6 months

Breaking Down This Complex Criterion:

“Excessive Anxiety and Worry”

Anxiety:

• Physiological arousal and tension
• Nervous system activation (sympathetic arousal)
• Physical manifestations of nervous tension
• Feeling keyed up, tense, on edge

Worry:

• Repetitive thoughts about potential future problems or threats
• “What if” thinking
• Mental process of anticipating negative outcomes
• Cognitive activity focused on potential dangers
• Chain of thoughts about uncertain, potentially negative events

“Apprehensive Expectation”:

• Anticipating that something bad will happen
• Expecting negative outcomes
• Dread about future events
• Bracing for difficulties or problems
• Sense of impending threat or doom

“Excessive”:

• More intense than situation warrants
• Greater frequency than reasonable
• Longer duration than necessary
• Disproportionate to actual likelihood or severity of feared outcome
• More than most people would experience in same situation
• Worry that continues even when problem unlikely or unimportant

How GAD Worry Differs from Normal Worry:

”About a Number of Events or Activities”

“Number of” (Multiple Domains):

• NOT limited to one concern or theme
• Worry about various different areas of life
• At least 2 different domains typically
• Shifts from topic to topic
• “Free-floating anxiety” - not tied to one specific thing

Common Worry Topics in GAD:

Work/School/Performance:

• Job performance and competence
• Making mistakes at work
• Being fired or failing
• Meeting deadlines
• School grades and academic success
• Exams and assignments
• Teacher/boss evaluations

Health:

• Own health (worry about illness, symptoms, disease)
• Health of family members, especially children and parents
• Dying or loved ones dying
• Medical appointments and test results
• Physical symptoms (constantly monitoring body)

Finances:

• Having enough money
• Ability to pay bills
• Job security and income
• Retirement savings
• Financial future
• Economic conditions
• Unexpected expenses

Family:

• Safety and well-being of children, spouse, parents
• Children’s development, health, success
• Relationship problems
• Family members’ problems
• Aging parents’ care

Safety:

• Personal safety and safety of loved ones
• Accidents (car accidents, home accidents)
• Crime and victimization
• Natural disasters
• World events, wars, terrorism

Social/Interpersonal:

• Relationships (being liked, fitting in)
• Social interactions and performance
• What others think of them
• Maintaining friendships
• Disappointing others

Responsibilities and Competence:

• Meeting obligations
• Being responsible parent, employee, friend
• Managing all duties and tasks
• Competence and adequacy
• Not letting people down

Minor Matters:

• Being on time (punctuality)
• Household chores and tasks
• Weather affecting plans
• Traffic and delays
• Minor decisions
• Things beyond their control

“Such as Work or School Performance”:

• DSM-5 gives examples but not limited to these
• The parenthetical note is illustrative, not exhaustive

Characteristic Pattern:

• Worry about one thing resolves, immediately replaced by worry about something else
• “Worry shifts” - moves between concerns
• Always something to worry about
• Can have difficulty identifying specific worry (just general sense of anxiety)

“More Days Than Not”

Frequency Requirement:

• Worry occurs on majority of days
• More than 50% of days
• At least 4 days per week typically
• Can occur every day

Chronic Nature:

• Nearly constant
• Persistent baseline of worry
• Part of daily experience
• May vary in intensity but consistently present

Throughout Day:

• Not just brief moments of worry
• Worry is present for significant portions of day
• May be relatively continuous
• Person finds it difficult to have worry-free time

”For at Least 6 Months”

Duration Requirement:

• Must be persistent for minimum of 6 months
• Most have had symptoms much longer (often years)
• 6 months distinguishes from transient anxiety

Why 6 Months?:

• Distinguishes GAD from normal reactions to stressful life events
• Temporary increases in worry are normal during stressful periods (job loss, illness, divorce)
• GAD is chronic condition, not temporary reaction
• 6 months indicates persistent pattern

Long-Term Pattern:

• Many people with GAD have had symptoms for years before diagnosis
• Some report “always having been a worrier”
• Chronic, long-standing condition
• Often begins in childhood or adolescence, continues into adulthood

Waxing and Waning:

• Symptom intensity may fluctuate
• Periods of worse symptoms (often during stress)
• Periods of somewhat better symptoms
• But excessive worry persists throughout

Criterion B: Difficulty Controlling Worry

The individual finds it difficult to control the worry

“Difficult to Control”:

• Can’t simply “stop worrying” or “let it go”
• Thoughts keep returning despite efforts to dismiss them
• Feels involuntary or automatic
• Persistent despite knowing worry is excessive
• Can’t redirect thoughts to other topics for long

Manifestations:

Can’t Stop Worrying:

• Once worry starts, difficult to stop
• Thoughts keep cycling back
• Even when try to think about something else, worry intrudes
• “Stuck” on worries

Can’t Prevent Worry:

• Worry starts automatically
• Triggers seem to be everywhere
• Can’t keep self from starting to worry
• Anticipatory worry begins as soon as think about future event

Worry Interferes:

• Interferes with concentration on tasks
• Intrudes during other activities
• Difficult to focus on conversations, work, leisure
• Mind repeatedly pulled back to worries

Attempts to Control:

• Person tries various strategies to stop or reduce worry:
  • Distraction (doesn’t work for long)
  • Reassurance-seeking (temporarily helps, then worry returns)
  • Avoidance (avoiding triggers, but triggers are everywhere)
  • Trying to “solve” all problems (impossible)
  • Trying to think positively (worry breaks through)
• These attempts fail or provide only brief relief
• Failure to control adds to distress

Subjective Experience:

• Feel taken over by worry
• Worry feels uncontrollable
• Helpless to stop it
• Frustrated by inability to control
• “My mind won’t shut off”
• “I can’t stop these thoughts”

Why Control Attempts Fail:

• Worry has become habitual, automatic
• Multiple triggers in environment
• Perceived as necessary or helpful (believe worrying prevents bad outcomes)
• Negative beliefs about not worrying (“If I don’t worry, something bad will happen”)
• Intolerance of uncertainty fuels worry

Differentiates GAD from Normal Worry:

• Normal worry: Can set aside when needed, redirect attention
• GAD worry: Feels uncontrollable, persistent, intrusive

Criterion C: Associated Symptoms

The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months):

Note: Only one symptom is required in children

The Six Symptoms:

1. Restlessness or Feeling Keyed Up or On Edge

Restlessness:

• Can’t relax or settle
• Feeling need to move or do something
• Fidgeting, pacing
• Difficulty sitting still
• Inner sense of agitation
• Physically restless

Feeling Keyed Up:

• Revved up, wound up
• Like a motor running
• Primed for action
• High alert
• Ready to react

On Edge:

• Tense, wired
• Jumpy, easily startled
• Nerves frayed
• Like waiting for bad news
• Braced for something bad
• Can’t let guard down

Experience:

• Sense of inner tension
• Can’t fully relax even when trying
• Always somewhat tense
• Even during leisure, can’t completely unwind

2. Being Easily Fatigued

Mental Fatigue:

• Mind feels tired, worn out
• Mental exhaustion
• Difficulty with sustained mental effort
• Brain fog
• Concentration takes extra effort

Physical Fatigue:

• Body feels heavy, weary
• Low energy
• Feel tired much of the time
• Not refreshed by rest
• Tasks take more effort

Chronic Fatigue:

• Present day after day
• Not relieved by sleep or rest
• Wakes up tired
• Exhaustion accumulates

Why Fatigue Occurs in GAD:

• Chronic tension and arousal is exhausting
• Worry is mentally draining
• Sleep often disrupted
• Difficulty relaxing prevents recovery
• Constant vigilance depletes energy

Impact:

• Difficulty completing tasks
• Reduced productivity
• Everything feels effortful
• Need more rest but rest doesn’t help

3. Difficulty Concentrating or Mind Going Blank

Difficulty Concentrating:

• Can’t focus on task at hand
• Mind wanders
• Easily distracted (especially by worries)
• Have to re-read material multiple times
• Difficulty following conversations or lectures
• Lose track of what doing

Attention Hijacked by Worry:

• Worries intrude into awareness
• Can’t keep mind on current activity
• Worry pulls attention away
• Constantly returning attention to task

Mind Going Blank:

• Sudden inability to think or remember
• Especially during stress (tests, conversations, performance situations)
• Temporary mental paralysis
• Information seems to disappear from mind
• “Drawing a blank”

Impact on Functioning:

• Academic: Difficulty studying, taking tests, following lectures
• Occupational: Errors, reduced productivity, difficulty with complex tasks
• Social: Difficulty following conversations, appearing distracted
• Daily life: Forgetting tasks, difficulty making decisions

Mechanism:

• Working memory capacity consumed by worry
• Less cognitive resources available for other tasks
• Chronic arousal impairs executive function
• Sleep deprivation (from GAD) impairs cognition

4. Irritability

Definition: Easily annoyed, angered, or frustrated; low tolerance for stress or frustration

Manifestations:

• Short temper
• Snapping at others
• Getting upset over minor things
• Impatient
• Easily frustrated
• Overreacting to small annoyances
• Feeling touchy or grumpy
• Hostile reactions

Triggers:

• Interruptions
• Delays or waiting
• Others not meeting expectations
• Minor inconveniences
• Noise or disruptions
• Children’s behavior
• Partner or family members

Not Typical for Person:

• More irritable than usual
• Out of character
• Others notice increased irritability
• Person may feel guilty about irritability

Why Irritability Occurs:

• Chronic tension and stress
• Depleted coping resources
• Fatigue
• Feeling overwhelmed
• Lack of control over worry
• Everything feels like “one more thing”

Impact:

• Relationships: Strains relationships with family, friends, coworkers
• Parenting: Impatience with children; guilt afterward
• Work: Conflicts with coworkers; difficulty working in teams
• Self-image: Feeling bad about being irritable

5. Muscle Tension

Definition: Tightness, stiffness, or soreness in muscles

Common Locations:

• Neck and shoulders: Most common (tight, knotted muscles)
• Back: Upper and lower back tension and pain
• Jaw: Clenching, TMJ problems, teeth grinding (especially at night)
• Forehead: Furrowed brow, tension headaches
• Chest: Tight chest, difficulty breathing deeply
• Stomach: Tense abdomen, contributes to GI problems

Characteristics:

• Chronic: Present most of the time
• Sometimes unaware: May be so constant person doesn’t realize extent of tension
• Worsens with stress: Increases during high worry periods
• Doesn’t fully relax: Even during rest periods, some tension remains

Associated Problems:

• Headaches: Tension headaches very common
• Pain: Chronic muscle pain, myofascial pain
• Fatigue: Chronic muscle tension is tiring
• Poor posture: Shoulders hunched, body braced
• Difficulty relaxing: Physically can’t let go of tension

Impact:

• Discomfort: Chronic pain or achiness
• Sleep: Tension interferes with falling asleep and sleep quality
• Function: Pain interferes with activities
• Medical visits: May seek medical care for pain (often no clear physical cause found)

Why Muscle Tension Occurs:

• Chronic autonomic arousal: Sympathetic nervous system activation keeps muscles tense
• Bracing for threat: Body in constant state of readiness
• Stress response: Part of fight-or-flight (muscles tense for action)
• Doesn’t discharge: Unlike acute stress (where tension releases after threat passes), chronic anxiety maintains tension

6. Sleep Disturbance

Types of Sleep Problems:

Difficulty Falling Asleep (Onset Insomnia):

• Lying awake for long time before falling asleep
• Mind racing with worries
• Can’t “turn off brain”
• Reviewing day’s events, planning tomorrow, worrying about problems
• Body tense, difficult to relax enough to sleep

Difficulty Staying Asleep (Maintenance Insomnia):

• Frequent awakenings during night
• Waking up and immediately starting to worry
• Difficulty falling back asleep after waking
• Multiple awakenings each night

Early Morning Awakening:

• Waking up hours before need to (e.g., 3 or 4 AM)
• Unable to return to sleep
• Mind immediately goes to worries
• Lying awake worrying for hours

Restless, Unsatisfying Sleep:

• Tossing and turning
• Light sleep, easily awakened
• Not feeling rested or refreshed in morning
• Feels like didn’t really sleep even if actually slept
• Unrefreshing sleep

Nightmares or Disturbing Dreams:

• Dreams about worries or fears
• Anxiety-themed dreams
• Waking from disturbing dreams

Sleep Anxiety:

• Worrying about not being able to sleep
• Anxiety about consequences of not sleeping
• Performance anxiety about sleep
• This worry makes sleep harder (vicious cycle)

Daytime Impact:

• Fatigue and exhaustion
• Impaired concentration and memory
• Irritability
• Reduced functioning
• Worsens all other GAD symptoms

Vicious Cycle:

• Worry causes poor sleep
• Poor sleep worsens anxiety and worry
• Increased worry causes worse sleep
• Cycle perpetuates

Criterion D: Not Limited to Features of Another Disorder

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

Clinically Significant: Meaningful impact on life; not just minor discomfort

Types of Impairment:

Distress:

• Significant subjective distress from worry and anxiety
• Life feel overwhelmed, burdened
• Quality of life diminished
• Constant state of tension and concern

Social Impairment:

• Worry interferes with enjoying social activities
• Difficulty being present in relationships (preoccupied with worry)
• Irritability strains relationships
• May avoid social situations if worried about things
• Others frustrated by person’s constant worry
• Family dynamics affected

Occupational/Academic Impairment:

• Concentration difficulties reduce productivity
• Indecisiveness (worry about making wrong decision)
• Procrastination (worry about doing task perfectly)
• Absenteeism (fatigue, medical appointments)
• Reduced performance
• Difficulty handling work stress
• May change jobs or reduce responsibilities due to anxiety

Physical Health:

• Chronic tension causes pain
• Sleep deprivation affects health
• May develop stress-related health problems
• Frequent medical visits for physical symptoms
• Weakened immune system

Daily Functioning:

• Difficulty completing household tasks
• Indecisiveness about routine matters
• Procrastination
• Avoidance of potentially anxiety-provoking situations
• Exhaustion limits activities

Enjoyment and Quality of Life:

• Can’t fully enjoy positive experiences (worrying about future or what could go wrong)
• Limited leisure activities
• Constant state of distress
• Feel life is consumed by worry

Criterion E: Not Attributable to Substance or Medical Condition

The disturbance is not attributable to the physiological effects of a substance (e.g., drug of abuse, medication) or another medical condition (e.g., hyperthyroidism)

Substances That Can Cause Anxiety:

Stimulants:

• Caffeine: Excessive consumption can cause anxiety symptoms
• Amphetamines, cocaine: Stimulant drugs cause arousal and anxiety
• Some over-the-counter cold medications: Containing pseudoephedrine
• Energy drinks: High caffeine content

Withdrawal:

• Alcohol withdrawal: Causes severe anxiety
• Benzodiazepine withdrawal: Rebound anxiety
• Other substance withdrawal: Many substances produce anxiety during withdrawal

Medications:

• Corticosteroids: Can cause anxiety, restlessness
• Thyroid medications: If dose too high
• Some asthma medications: Bronchodilators
• Some antidepressants: Initially, before therapeutic effect

Medical Conditions That Can Cause Anxiety-Like Symptoms:

Endocrine/Hormonal:

• Hyperthyroidism: Overactive thyroid causes anxiety, restlessness, palpitations, tremor
• Hypoglycemia: Low blood sugar causes anxiety, trembling, sweating
• Pheochromocytoma: Rare tumor causes anxiety, palpitations, sweating
• Cushing’s syndrome: Excess cortisol

Cardiovascular:

• Arrhythmias: Irregular heartbeat can cause anxiety
• Angina/heart disease: Chest pain and fear
• Mitral valve prolapse: May be associated with anxiety symptoms

Respiratory:

• Asthma: Breathlessness can cause anxiety
• COPD: Chronic breathing difficulties
• Pulmonary embolism: Life-threatening, causes severe anxiety

Neurological:

• Seizure disorders: Some seizures manifest as anxiety
• Vestibular disorders: Dizziness and balance problems can cause anxiety
• Multiple sclerosis: Can have anxiety symptoms
• Brain tumors: Rarely, can cause anxiety

Key Point: Must rule out that symptoms are not caused by substance or medical condition

If Due to Medical Condition or Substance: Diagnose “Anxiety Disorder Due to Another Medical Condition” or “Substance/Medication-Induced Anxiety Disorder” instead

Can Coexist: Person can have GAD and medical condition (separate disorders)

Criterion F: Not Better Explained by Another Mental Disorder

The anxiety and worry are not better explained by another mental disorder

Must distinguish GAD from worry that is:

Panic Disorder:

• If worry is specifically about having panic attacks

Social Anxiety Disorder:

• If worry is specifically about social situations and negative evaluation

Separation Anxiety:

• If worry is specifically about separation from attachment figures

Anorexia Nervosa:

• If worry is specifically about weight gain

Illness Anxiety Disorder (Hypochondriasis):

• If worry is specifically about having serious illness

OCD:

• If worry is response to obsessive thoughts
• OCD: Intrusive, unwanted thoughts (ego-dystonic); GAD: Excessive worry about real-life concerns (ego-syntonic)

PTSD:

• If anxiety is related to trauma and trauma reminders

Body Dysmorphic Disorder:

• If anxiety is about perceived appearance flaws

Somatic Symptom Disorder:

• If preoccupation is with physical symptoms

Hoarding Disorder:

• If worry is about discarding possessions

Key Distinction:

• GAD: Worry about multiple, various aspects of life (not limited to one theme)
• Other disorders: Worry focused on specific content related to that disorder

However: Can diagnose GAD along with other anxiety or mental disorders if criteria for both are met and worries extend beyond the focus of the other disorder

Example:

• Person has social anxiety disorder (worries about social situations) AND GAD (also worries excessively about finances, health, family, work performance, minor matters)
• Can diagnose both

Additional Diagnostic Considerations

Generalized Anxiety Disorder in Children

Criteria Differences:

• Only need ONE associated symptom from Criterion C (instead of three)
• Children may not recognize worry as excessive
• May express anxiety through somatic complaints

Common Presentations:

• Worry about competence, performance (grades, sports)
• Worry about family (parents’ well-being, family finances)
• Worry about safety (own safety, family safety)
• Worry about disasters (fires, earthquakes, war)
• Worry about future events
• Excessive concern about punctuality, perfectionism
• Need for reassurance

Expression:

• Somatic complaints (stomachaches, headaches)
• School refusal
• Difficulty separating from parents
• Perfectionism
• Need for approval
• Redoing work repeatedly

Age of Onset and Course

Age of Onset:

• Can begin at any age
• Often begins in childhood or adolescence
• May begin in adulthood
• Many adults report having been “worriers” their whole lives

Course:

• Chronic and fluctuating
• Symptoms wax and wane
• May be exacerbated by stress
• Rarely remits spontaneously
• Often lifelong without treatment
• Treatment can be very effective

Gender Differences

Prevalence:

• Twice as common in females than males (2:1 ratio)
• Reasons unclear

Presentation May Differ:

• Females: May worry more about relationships, health
• Males: May worry more about work, competence

Prevalence

Lifetime Prevalence: 3-5% of population

12-Month Prevalence: 2-3%

Higher in:

• Females
• Middle-aged adults
• Individuals with low socioeconomic status
• Those separated, divorced, or widowed

Common: One of the more common anxiety disorders

Cultural Considerations

Worry Content Varies by Culture:

• Different cultures have different typical worry themes
• Some cultures emphasize social harmony (more interpersonal worry)
• Economic concerns vary by context
• Religious or spiritual concerns in some cultures

Somatic vs. Psychological Expression:

• Some cultures express emotional distress through physical symptoms more than psychological
• Important to assess both

Comorbidity

Very High Comorbidity:

Other Anxiety Disorders (50-60%):

• Social anxiety disorder
• Specific phobia
• Panic disorder

Mood Disorders (40-60%):

• Major depressive disorder (most common comorbidity)
• Dysthymia

Substance Use Disorders (20-30%):

• Often self-medication (especially alcohol)

Other:

• Somatic symptom disorders
• Irritable bowel syndrome
• Other medical conditions (headaches, chronic pain)

Impact of Comorbidity:

• More severe symptoms
• Greater impairment
• Worse prognosis
• More difficult to treat

Suicide Risk

• Increased risk compared to general population
• Especially if comorbid depression
• Chronic distress and hopelessness increase risk
• Important to assess

Key Points for Exams

Six Criteria (A-F):

1. Criterion A: Excessive anxiety and worry about multiple events/activities, more days than not, for 6+ months
2. Criterion B: Difficult to control the worry
3. Criterion C: At least 3 of 6 associated symptoms (only 1 in children):
   • Restlessness or feeling keyed up or on edge
   • Being easily fatigued
   • Difficulty concentrating or mind going blank
   • Irritability
   • Muscle tension
   • Sleep disturbance
4. Criterion D: Clinically significant distress or impairment
5. Criterion E: Not attributable to substance or medical condition
6. Criterion F: Not better explained by another mental disorder

Key Features:

• Multiple worry topics (not limited to one theme)
• Chronic and persistent (6+ months minimum)
• Difficult to control
• More days than not
• “Free-floating anxiety” - shifts between concerns
• Physical symptoms of tension (fatigue, muscle tension, sleep problems)

Epidemiology:

• 3-5% lifetime prevalence
• 2:1 female to male ratio
• Can begin any age; often childhood/adolescence
• Chronic course without treatment

Comorbidity:

• Very high with other anxiety disorders and depression
• Often comorbid with multiple disorders

Differential Diagnosis:

• Must distinguish from worry specific to other disorders
• GAD involves worry about multiple different life concerns