History and exam

Key diagnostic factors

common

excessive worry for at least 6 months

The presence of chronic excessive anxiety and worry occurring more days than not for at least 6 months (about a number of issues), which leads to distress or impairment, is the core symptom of GAD. This is required in order to make the diagnosis according to the Diagnostic and Statistical Manual of mental disorders, fifth edition, text revision (DSM-5-TR) criteria.[1]

anxiety not confined to another mental health disorder

Determine if anxiety is not confined to another Axis I mental disorder (e.g., panic disorder, social phobia, PTSD, or a somatoform disorder such as somatization disorder or hypochondriasis).

This feature is required for diagnosis according to the DSM-5-TR criteria.

anxiety not due to medication or substance

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 antidepressants.

Additionally, a history of any alcohol or illicit drug use should be obtained, as these substances can cause anxiety symptoms acutely and in withdrawal.

muscle tension

One of six core symptoms in the predominant picture of chronic excessive worry, of which at least three are required to make a diagnosis in adults (only one symptom is required in children).[1]

May lead patients to seek medical care.

sleep disturbance

One of six core symptoms in a picture of chronic excessive worry, of which at least three are required to make a diagnosis in adults (only one symptom is required in children).[1]

Includes difficulty falling or staying asleep, or restless sleep.

fatigue

A common complaint, and one of six core symptoms in a picture of chronic excessive worry, of which at least three are required to make a diagnosis in adults (only one symptom is required in children).[1]

Patients are easily fatigued.

restlessness

One of six core symptoms in a picture of chronic excessive worry, of which at least three are required to make a diagnosis in adults (only one symptom is required in children).[1]

Also described as feeling "on edge."

irritability

One of six core symptoms in a picture of chronic excessive worry, of which at least three are required to make a diagnosis in adults (only one symptom is required in children).[1]

poor concentration

One of six core symptoms in a picture of chronic excessive worry, of which at least three are required to make a diagnosis in adults (only one symptom is required in children).[1]

Other diagnostic factors

common

headache

Patients may present with headache.

sweating

Patients may present with excess sweating.

dizziness

Symptom of hyperarousal.

gastrointestinal symptoms

Patients may have gastrointestinal complaints such as nausea and diarrhea, or irritable bowel syndrome.

muscle aches

Patients may have muscle aches due to muscle tension.

increased heart rate

Sign of hyperarousal.

Not confined to a discrete episode (i.e., a panic or anxiety attack).

shortness of breath

Sign of hyperarousal.

trembling

Patients may have trembling or shakiness on examination.

exaggerated startle response

May be seen on examination.

uncommon

chest pain

The presence of anxiety does not exclude cardiac pathology.

Appropriate workup should be done for suspected organic etiology; for example, in people with exertional symptoms or cardiac risk factors.

Risk factors

strong

family history of anxiety

GAD shows a significant familial aggregation. There is also a family link for comorbidity with other anxiety disorders and with depression.[26][27][38]

physical or emotional stress

Experiencing life stressors, such as bullying or peer victimization, is linked with an increased incidence. Work and domestic difficulties may also be relevant.[18][25]

history of physical, sexual, or emotional trauma

Exposure to trauma, such as being a victim of physical or sexual assault or abuse, involvement in a motor vehicle accident, or the sudden, unexpected loss of a loved one, increases the rate.[10][20][39]​ In these cases, GAD is often comorbid with PTSD. Childhood risk factors that predispose to later GAD include maltreatment, parental mental health problems or substance use, family disruption (e.g., divorce), and exposure to an overly harsh or overprotective parenting style.[21]​[22]​[23]​

other anxiety disorder

Other anxiety disorders such as panic disorder, social phobia, or specific phobias may co-occur.

Panic disorder occurs in 25% of patients with GAD.[40]​​

chronic physical health condition

Increased incidence of GAD is associated with a number of chronic physical health conditions, including cardiovascular disease, cancer, respiratory diseases, polycystic ovary syndrome, and diabetes.[10][41][42]

female sex

The female-to-male ratio is approximately 2:1.[1][7][11]

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