Mayo Clinic information https://www.mayoclinic.org/diseases-conditions/generalized-anxiety-disorder/symptoms-causes/syc-20360803 AND https://www.mayoclinic.org/diseases-conditions/post-traumatic-stress-disorder/symptoms-causes/syc-20355967
THE DESCRIPTIONS HERE ARE TAKEN FROM THE DSM-V STATISTICAL MANUEL OF MENTAL DISORDERS
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
performance).
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
sleep).
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.
Prevalence
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,
hyperthyroidism).
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
conditions.
Comorbidity
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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