Approach
Be alert to the potential diagnosis of GAD, given that anxiety disorders are frequently underdiagnosed and undertreated.[46][47] Patients with anxiety disorders present most commonly to primary care. Determining the specific subtype of anxiety disorder is important for selecting the most appropriate evidence-based treatment.[48][49][50]
The common clinical feature in all patients with GAD is a history of chronic, excessive anxiety and worry about a number of events or activities for at least 6 months, which causes distress and impairment. In adults, at least three key symptoms out of a possible six are required to make a diagnosis (only one is required in children). Fatigue is a common complaint.[1] The natural history of untreated GAD is of a chronic condition with exacerbations and remissions across the lifespan.[51]
GAD is in part a diagnosis of exclusion. Physical health conditions, other mental health disorders, medication adverse effects, and substance misuse should all be considered in the differential diagnosis. GAD is frequently comorbid with these types of conditions and their presence complicates diagnosis and treatment.[1] In practice, there is often a need to assign multiple diagnoses, and to use this to prioritize management.[21] Comorbidity with depression is particularly common, and is associated with greater illness severity.
Physical examination and laboratory studies are generally normal if no co-existing physical health problems or substance misuse issues exist. Patients may use healthcare resources excessively to find physical causes for their worry and associated symptoms.
History
The physician should ask about:
Any family history of anxiety disorders, depression, or other mental health conditions
History of physical or emotional trauma, depression or anxiety disorders, or substance misuse or dependence issues, including in pregnancy or the postpartum period
Response to any previous treatment for anxiety or other mental health conditions
Current stress levels
Any history of physical health problems
Effect of anxiety symptoms on occupational and social function.
A thorough list of prescribed and over-the-counter medications and herbal medicines should be obtained to determine if any medications the patient is taking cause anxiety as an adverse effect. Common examples include asthma medications (e.g., albuterol, theophylline), herbal medicines (e.g., ma huang, St. John's wort, ginseng, guarana, belladonna), corticosteroids, and some antidepressants.[52] Additionally, a history of any alcohol or illicit drug use should be obtained, as these substances can cause anxiety symptoms acutely and in withdrawal.
In adults, at least three of the following key symptoms are required to make a diagnosis in addition to a predominant picture of chronic, excessive worry for 6 months that causes distress or impairment (only one item is required in children):[1]
Muscle tension
Sleep disturbance
Fatigue
Restlessness or sense of feeling "on edge"
Irritability
Poor concentration.
Other symptoms may include muscle aches, sweating, dizziness, shortness of breath, chest pain, nausea, diarrhea, or other gastrointestinal complaints.
If assessing a child, the clinician should interview the child and his or her parents or caregivers.
When assessing pregnant and postpartum women, the clinician should also assess:[53][54]
Physical wellbeing (including weight, smoking, nutrition and activity level)
Any physical problems experienced by the mother (e.g., anemia or thyroid disease), the fetus, or the baby
The woman's attitude towards and experience of pregnancy or the mother-baby relationship
Caring responsibilities for other children, young people, or adults
Domestic violence and abuse, sexual abuse, trauma, or childhood maltreatment
Social factors including: social isolation, quality of interpersonal relationships, living conditions, housing, employment, economic status, and immigration status.
Consider whether the method of assessment needs to be modified according to the needs of the patient: for example, by providing independent translators or bilingual therapists, or using communications aids such as the distress thermometer in patients with sensory impairment or a learning disability.[55]
Physical examination
This is generally normal if no co-existing physical health conditions or substance misuse issues exist. Trembling, shakiness, an exaggerated startle response, or increased heart rate not confined to a discrete episode (i.e., a panic or anxiety attack) may be seen on exam.
Mental health examination
The possible etiology of the anxiety should be determined through a thorough psychiatric history and mental status examination.
Other mental health disorders are suggested if the anxiety is confined to the following circumstances:
A panic attack (panic disorder)
Embarrassment in public (social phobia)
Fear of contamination (obsessive-compulsive disorder)
Fear of gaining weight (anorexia nervosa)
Fear of being away from home (separation anxiety disorder or agoraphobia)
Exposure to reminders of past trauma (PTSD)
Having multiple physical complaints (somatization disorder).
Comorbid mental health disorders are common, such as mood disorders, other anxiety disorders, and substance misuse disorders.[1][56] Finding evidence of a comorbid mental health disorder does not exclude GAD if the anxiety and excessive worry is not confined to a specific circumstance.
Assessment in children
A developmentally appropriate approach is needed to assess children and young teenagers. Specific recommendations for this assessment taken from clinical practice guidelines (US and Canadian) include:[57][58]
Speak to both the parent/guardian and child, either separately or together or both, as developmentally and clinically indicated.
For adolescents, conduct a one-on-one, confidential, and nonjudgmental interview, and consider utilizing a history-taking tool (e.g., Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Suicide/Mental Health, Safety or HEEADSSS).
Consider the use of an anxiety questionnaire (e.g., SCARED) to screen for severity of symptoms before exploring further with additional questioning; standardized symptom rating scales are also useful as a baseline for tracking treatment response over time.
Consider the child's level of functioning across a range of developmental domains (e.g., cognitive, language, social, and motor) as part of the assessment, and note that cognitive and language levels may preclude the ability to disclose symptoms of anxiety, necessitating additional collateral information, for example from parents.
In older children and adolescents, ask about substances that can cause anxiety, including marijuana, cocaine, anabolic steroids, and hallucinogens, as well as withdrawal from nicotine, alcohol, and caffeine.
Create a safe space for parents to disclose their own history of anxiety or mental health problems that may be affecting relational responses and coping strategies.
Explore safety risks including suicidal thoughts and behaviors, self-harm, risk-taking behaviors, and impulsivity, as well as the possibility of abuse and neglect, both initially and during treatment. The American Academy of Child and Adolescent Psychiatry recommends that a safety assessment should culminate in two basic questions: "Is the patient at current risk? Are the patient and family able to adhere to recommendations regarding supervision, safeguarding, and follow-up care?" The answers can lead to the appropriate level and intensity of care.[58]
Note that the diagnostic evaluation may involve more than one session, especially where this includes multiple sources of information (collateral history).
Investigations
There are no investigations that confirm a diagnosis of GAD, and results are generally normal if no co-existing physical health problems or substance misuse issues exist.
Specific laboratory tests are indicated only if there are persistent signs, symptoms, or a medical history suggestive of a physical health condition that is strongly associated with anxiety, such as thyroid disease, pulmonary disease, or cardiovascular conditions (e.g., presence of arrhythmias; episodic hypertension and tachycardia in cases of pheochromocytoma). In particular, there is high comorbidity between thyroid dysfunction and anxiety disorders, and testing for thyroid disorders should be considered.[59]
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