390 TREATMENT OF SPECIFIC ANXIETY DISORDERS
Clinician Guideline 10.1
Generalized anxiety disorder (GAD) is a persistent state of generalized anxiety involving
chronic, excessive, and pervasive worry that is accompanied by physical or mental symptoms
of anxiety that cause significant distress or impairment in daily functioning. The worry and
anxiety must involve multiple life events or activities and they can not be limited to concerns
that are characteristic of another Axis I disorder.GAD: A Diagnostic Enigma?
The origins of GAD can be traced back to the concept of anxiety neurosis, character-
ized as excessive anxiety over prolonged periods without marked avoidance (Roemer,
Orsillo, & Barlow, 2002). DSM-II (APA, 1968) retained the term “anxiety neurosis”
but the diagnosis failed to distinguish between chronic, generalized anxiety and acute
panic attacks (Mennin et al., 2004). DSM-III (APA, 1980) partially rectified this prob-
lem by providing specific diagnostic criteria for GAD but the imposition of hierarchical
exclusionary criteria meant that DSM-III GAD was largely a residual category with
poor diagnostic reliability that was excluded if the patient met criteria for another anxi-
ety disorder. As a result practitioners were left bewildered over whether individuals
met criteria for GAD (Mennin et al., 2004; Roemer et al., 2002). However DSM-III-R
(APA, 1987) offered a substantial revision to GAD with most of the hierarchical exclu-
sionary rules lifted, the duration criterion was extended to 6 months, and a more central
role was assigned to worry. Now GAD could be diagnosed in the presence of another
anxiety disorder as long as the anxiety and worry focused on additional concerns not
table 10.1. Dsm-iv-tr Diagnostic Criteria for generalized anxiety Disorder
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 of the symptoms present for more days than not for the past 6 months).
(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 focus of the anxiety and worry is not confined to features of an Axis I disorder e.g., the
anxiety or worry about having a Panic Attack (as in Panic Disorder), being embarrassed in
public (as in Social Phobia), being contaminated (as in Obsessive Compulsive Disorder), etc., 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 impairments 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., drug of
abuse, medication) or to a general medical condition (e.g., hyperthyroidism), and does not
occur exclusively during a Mood Disorder, a Psychotic Disorder or a Pervasive Developmental
Disorder.
Note. From American Psychiatric Association (2000). Copyright 2000 by the American Psychiatric Association.
Reprinted by permission.