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 person 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 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
5. muscle tension
6. sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
D. The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not about having a Panic Attack (as in Panic Disorder), being embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive-Compulsive Disorder), being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder), or having a serious illness (as in Hypochondriasis), and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder.
E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
F. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder.
The essential feature of Generalized Anxiety Disorder is excessive anxiety and worry (apprehensive expectation), occurring more days than not for a period of at least 6 months, about a number of events or activities (Criterion A). The individual finds it difficult to control the worry (Criterion B). The anxiety and worry are accompanied by at least three additional symptoms from a list that includes restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, and disturbed sleep (only one additional symptom is required in children) (Criterion C). The focus of the anxiety and worry is not confined to features of another Axis I disorder such as having a Panic Attack (as in Panic Disorder), being embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive-Compulsive Disorder), being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder), or having a serious illness (as in Hypochondriasis), and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder (Criterion D). Although individuals with Generalized Anxiety Disorder may not always identify the worries as “excessive,” they report subjective distress due to constant worry, have difficulty controlling the worry, or experience related impairment in social, occupational, or other important areas of functioning (Criterion E). The disturbance is not due to the direct physiological effects of a substance (i.e., a drug of abuse, a medication, or toxin exposure) or a general medical condition and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder (Criterion F).
The intensity, duration, or frequency of the anxiety and worry is far out of proportion to the actual likelihood or impact of the feared event. The person finds it difficult to keep worrisome thoughts from interfering with attention to tasks at hand and has difficulty stopping the worry. Adults with Generalized Anxiety Disorder often worry about everyday, routine life circumstances such as possible job responsibilities, finances, the health of family members, misfortune to their children, or minor matters (such as household chores, car repairs, 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.
Associated Features and Disorders
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, or 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 and Posttraumatic Stress Disorder. Depressive symptoms are also common.
Generalized Anxiety Disorder very frequently co-occurs with Mood Disorders (e.g., Major Depressive Disorder or Dysthymic Disorder), with other Anxiety Disorders (e.g., Panic Disorder, Social Phobia, Specific Phobia), and with Substance-Related Disorders (e.g., Alcohol or Sedative, Hypnotic, or Anxiolytic Dependence or Abuse). Other conditions that may be associated with stress (e.g., irritable bowel syndrome, headaches) frequently accompany Generalized Anxiety Disorder.
Specific Culture, Age, and Gender Features
There is considerable cultural variation in the expression of anxiety (e.g., in some cultures, anxiety is expressed predominantly through somatic symptoms, in others through cognitive symptoms). It is important to consider the cultural context when evaluating whether worries about certain situations are excessive.
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 approval and require excessive reassurance about their performance and their other worries.
Generalized Anxiety Disorder may be overdiagnosed in children. In considering this diagnosis in children, a thorough evaluation for the presence of other childhood Anxiety Disorders should be done to determine whether the worries may be better explained by one of these disorders. Separation 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 Phobia 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.
In clinical settings, the disorder is diagnosed somewhat more frequently in women than in men (about 55%–60% of those presenting with the disorder are female). In epidemiological studies, the sex ratio is approximately two-thirds female.
In a community sample, the 1-year prevalence rate for Generalized Anxiety Disorder was approximately 3%, and the lifetime prevalence rate was 5%. In anxiety disorder clinics, up to a quarter of the individuals have Generalized Anxiety Disorder as a presenting or comorbid diagnosis.
Many individuals with Generalized Anxiety Disorder report that they have felt anxious and nervous all their lives. Although over half of those presenting for treatment report onset in childhood or adolescence, onset occurring after age 20 years is not uncommon. The course is chronic but fluctuating and often worsens during times of stress.
Anxiety as a trait has a familial association. Although early studies produced inconsistent findings regarding familial patterns for Generalized Anxiety Disorder, more recent twin studies suggest a genetic contribution to the development of this disorder. Furthermore, genetic factors influencing risk of Generalized Anxiety Disorder may be closely related to those for Major Depressive Disorder.