Mayo Clinic information AND


Generalized Anxiety Disorder

Diagnostic Criteria 300.02 (F41.1)

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than

not for at least 6 months, about a number of events or activities (such as work or school


B. The individual finds it difficult to control the worry.

C. 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 item is 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


D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment

in social, occupational, or other important areas of functioning.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a

drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

F. The disturbance is not better explained by another mental disorder (e.g., anxiety or

worry about having panic attacks in panic disorder, negative evaluation in social anxiety

disorder [social phobia], contamination or other obsessions in obsessive-compulsive

disorder, separation from attachment figures in separation anxiety disorder,

reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia

nervosa, physical complaints in somatic symptom disorder, perceived appearance

flaws in body dysmorphic disorder, having a serious illness in illness anxiety

disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).

Diagnostic Features

The essential feature of generalized anxiety disorder is excessive anxiety and worry (apprehensive

expectation) about a number of events or activities. The intensity, duration, or

frequency of the anxiety and worry is out of proportion to the actual likelihood or impact

of the anticipated event. The individual finds it difficult to control the worry and to keep

worrisome thoughts from interfering with attention to tasks at hand. Adults with generalized

anxiety disorder often worry about everyday, routine life circumstances, such as

possible job responsibilities, health and finances, the health of family members, misfortune

to their children, or minor matters (e.g., doing household chores or being late for appointments).

Children with generalized anxiety disorder tend to worry excessively about

their competence or the quality of their performance. During the course of the disorder,

the focus of worry may shift from one concern to another.

Several features distinguish generalized anxiety disorder from nonpathological anxiety.

First, the worries associated with generalized anxiety disorder are excessive and typically interfere

significantly with psychosocial functioning, whereas the worries of everyday life

are not excessive and are perceived as more manageable and may be put off when more

pressing matters arise. Second, the worries associated with generalized anxiety disorder are

Generalized Anxiety Disorder 223

more pervasive, pronounced, and distressing; have longer duration; and frequently occur

without precipitants. The greater the range of life circumstances about which a person

worries (e.g., finances, children’s safety, job performance), the more likely his or her symptoms

are to meet criteria for generalized anxiety disorder. Third, everyday worries are much

less likely to be accompanied by physical symptoms (e.g., restlessness or feeling keyed up

or on edge). Individuals with generalized anxiety disorder report subjective distress due

to constant worry and related impairment in social, occupational, or other important areas

of functioning.

The anxiety and worry are accompanied by at least three of the following additional

symptoms: restlessness or feeling keyed up or on edge, being easily fatigued, difficulty

concentrating or mind going blank, irritability, muscle tension, and disturbed sleep, although

only one additional symptom is required in children.

Associated Features Supporting Diagnosis

Associated with muscle tension, there may be trembling, twitching, feeling shaky, and

muscle aches or soreness. Many individuals with generalized anxiety disorder also experience

somatic symptoms (e.g., sweating, nausea, diarrhea) and an exaggerated startle response.

Symptoms of autonomic hyperarousal (e.g., accelerated heart rate, shortness of

breath, dizziness) are less prominent in generalized anxiety disorder than in other anxiety

disorders, such as panic disorder. Other conditions that may be associated with stress (e.g.,

irritable bowel syndrome, headaches) frequently accompany generalized anxiety disorder.


The 12-month prevalence of generalized anxiety disorder is 0.9% among adolescents and

2.9% among adults in the general community of the United States. The 12-month prevalence

for the disorder in other countries ranges from 0.4% to 3.6%. The lifetime morbid risk

is 9.0%. Females are twice as likely as males to experience generalized anxiety disorder. The

prevalence of the diagnosis peaks in middle age and declines across the later years of life.

Individuals of European descent tend to experience generalized anxiety disorder more

frequently than do individuals of non-European descent (i.e., Asian, African, Native

American and Pacific Islander). Furthermore, individuals from developed countries are

more likely than individuals from nondeveloped countries to report that they have experienced

symptoms that meet criteria for generalized anxiety disorder in their lifetime.

Development and Course

Many individuals with generalized anxiety disorder report that they have felt anxious and

nervous all of their lives. The median age at onset for generalized anxiety disorder is 30

years; however, age at onset is spread over a very broad range. The median age at onset is

later than that for the other anxiety disorders. The symptoms of excessive worry and anxiety

may occur early in life but are then manifested as an anxious temperament. Onset of

the disorder rarely occurs prior to adolescence. The symptoms of generalized anxiety disorder

tend to be chronic and wax and wane across the lifespan, fluctuating between syndromal

and subsyndromal forms of the disorder. Rates of full remission are very low.

The clinical expression of generalized anxiety disorder is relatively consistent across

the lifespan. The primary difference across age groups is in the content of the individual’s

worry. Children and adolescents tend to worry more about school and sporting performance,

whereas older adults report greater concern about the well-being of family or their

own physical heath. Thus, the content of an individual’s worry tends to be age appropriate.

Younger adults experience greater severity of symptoms than do older adults.

The earlier in life individuals have symptoms that meet criteria for generalized anxiety

disorder, the more comorbidity they tend to have and the more impaired they are likely to

224 Anxiety Disorders

be. The advent of chronic physical disease can be a potent issue for excessive worry in the

elderly. In the frail elderly, worries about safety—and especially about falling—may limit

activities. In those with early cognitive impairment, what appears to be excessive worry

about, for example, the whereabouts of things is probably better regarded as realistic

given the cognitive impairment.

In children and adolescents with generalized anxiety disorder, the anxieties and worries

often concern the quality of their performance or competence at school or in sporting

events, even when their performance is not being evaluated by others. There may be excessive

concerns about punctuality. They may also worry about catastrophic events, such

as earthquakes or nuclear war. Children with the disorder may be overly conforming, perfectionist,

and unsure of themselves and tend to redo tasks because of excessive dissatisfaction

with less-than-perfect performance. They are typically overzealous in seeking

reassurance and approval and require excessive reassurance about their performance and

other things they are worried about.

Generalized anxiety disorder may be overdiagnosed in children. When this diagnosis

is being considered in children, a thorough evaluation for the presence of other childhood

anxiety disorders and other mental disorders should be done to determine whether the

worries may be better explained by one of these disorders. Separation anxiety disorder, social

anxiety disorder (social phobia), and obsessive-compulsive disorder are often accompanied

by worries that may mimic those described in generalized anxiety disorder. For

example, a child with social anxiety disorder may be concerned about school performance

because of fear of humiliation. Worries about illness may also be better explained by separation

anxiety disorder or obsessive-compulsive disorder.

Risk and Prognostic Factors

Temperamental. Behavioral inhibition, negative affectivity (neuroticism), and harm

avoidance have been associated with generalized anxiety disorder.

Environmental. Although childhood adversities and parental overprotection have been

associated with generalized anxiety disorder, no environmental factors have been identified

as specific to generalized anxiety disorder or necessary or sufficient for making the diagnosis.

Genetic and physiological. One-third of the risk of experiencing generalized anxiety

disorder is genetic, and these genetic factors overlap with the risk of neuroticism and are

shared with other anxiety and mood disorders, particularly major depressive disorder.

Culture-Related Diagnostic Issues

There is considerable cultural variation in the expression of generalized anxiety disorder.

For example, in some cultures, somatic symptoms predominate in the expression of the

disorder, whereas in other cultures cognitive symptoms tend to predominate. This difference

may be more evident on initial presentation than subsequently, as more symptoms

are reported over time. There is no information as to whether the propensity for excessive

worrying is related to culture, although the topic being worried about can be culture specific.

It is important to consider the social and cultural context when evaluating whether

worries about certain situations are excessive.

Gender-Related Diagnostic Issues

In clinical settings, generalized anxiety disorder is diagnosed somewhat more frequently

in females than in males (about 55%–60% of those presenting with the disorder are

female). In epidemiological studies, approximately two-thirds are female. Females and

males who experience generalized anxiety disorder appear to have similar symptoms but

Generalized Anxiety Disorder 225

demonstrate different patterns of comorbidity consistent with gender differences in the

prevalence of disorders. In females, comorbidity is largely confined to the anxiety disorders

and unipolar depression, whereas in males, comorbidity is more likely to extend to

the substance use disorders as well.

Functional Consequences of

Generalized Anxiety Disorder

Excessive worrying impairs the individual’s capacity to do things quickly and efficiently,

whether at home or at work. The worrying takes time and energy; the associated symptoms

of muscle tension and feeling keyed up or on edge, tiredness, difficulty concentrating,

and disturbed sleep contribute to the impairment. Importantly the excessive worrying

may impair the ability of individuals with generalized anxiety disorder to encourage confidence

in their children.

Generalized anxiety disorder is associated with significant disability and distress that is

independent of comorbid disorders, and most non-institutionalized adults with the disorder

are moderately to seriously disabled. Generalized anxiety disorder accounts for 110 million

disability days per annum in the U.S. population.

Differential Diagnosis

Anxiety disorder due to another medical condition. The diagnosis of anxiety disorder

associated with another medical condition should be assigned if the individual’s anxiety

and worry are judged, based on history, laboratory findings, or physical examination, to

be a physiological effect of another specific medical condition (e.g., pheochromocytoma,


Substance/medication-induced anxiety disorder. A substance/medication-induced

anxiety disorder is distinguished from generalized anxiety disorder by the fact that a substance

or medication (e.g., a drug of abuse, exposure to a toxin) is judged to be etiologically

related to the anxiety. For example, severe anxiety that occurs only in the context of heavy

coffee consumption would be diagnosed as caffeine-induced anxiety disorder.

Social anxiety disorder. Individuals with social anxiety disorder often have anticipatory

anxiety that is focused on upcoming social situations in which they must perform or

be evaluated by others, whereas individuals with generalized anxiety disorder worry,

whether or not they are being evaluated.

Obsessive-compulsive disorder. Several features distinguish the excessive worry of

generalized anxiety disorder from the obsessional thoughts of obsessive-compulsive disorder.

In generalized anxiety disorder the focus of the worry is about forthcoming problems,

and it is the excessiveness of the worry about future events that is abnormal. In

obsessive-compulsive disorder, the obsessions are inappropriate ideas that take the form of

intrusive and unwanted thoughts, urges, or images.

Posttraumatic stress disorder and adjustment disorders. Anxiety is invariably present

in posttraumatic stress disorder. Generalized anxiety disorder is not diagnosed if the

anxiety and worry are better explained by symptoms of posttraumatic stress disorder.

Anxiety may also be present in adjustment disorder, but this residual category should be

used only when the criteria are not met for any other disorder (including generalized anxiety

disorder). Moreover, in adjustment disorders, the anxiety occurs in response to an

identifiable stressor within 3 months of the onset of the stressor and does not persist for

more than 6 months after the termination of the stressor or its consequences.

Depressive, bipolar, and psychotic disorders. Generalized anxiety/worry is a common

associated feature of depressive, bipolar, and psychotic disorders and should not be di226

Anxiety Disorders

agnosed separately if the excessive worry has occurred only during the course of these



Individuals whose presentation meets criteria for generalized anxiety disorder are likely

to have met, or currently meet, criteria for other anxiety and unipolar depressive disorders.

The neuroticism or emotional liability that underpins this pattern of comorbidity is

associated with temperamental antecedents and genetic and environmental risk factors

shared between these disorders, although independent pathways are also possible. Comorbidity

with substance use, conduct, psychotic, neurodevelopmental, and neurocognitive

disorders is less common.

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