Risa B.

Weisberg

Overview of Generalized Anxiety Disorder:

Epidemiology, Presentation, and Course
Risa B. Weisberg, PhD

Generalized anxiety disorder (GAD) was defined relatively recently, and the diagnostic criteria are
still being refined. The essential feature of the disorder has changed from persistent anxiety to exces-
sive worry, and the required symptom duration has changed from 1 month to 6 months. Additionally,
exclusion criteria involving permissibility of the diagnosis in children and wording regarding the rela-
tionship of GAD with mood disorders have changed. Nosologic controversies still surround the crite-
ria for excessive worry, symptom duration, the relationship between GAD and major depressive disor-
der, and the required number of associated symptoms. Alterations in the criteria have been suggested,
but more research is needed on the validity of these proposed changes. Generalized anxiety disorder
appears to be highly prevalent. In the United States, the lifetime prevalence of DSM-IV GAD is esti-
mated to be about 5% and the current prevalence to be about 2% to 3%. The disorder is differentially
prevalent across gender and ethnic and social groups. The course of GAD is chronic and can be exac-
erbated by poor family relationships, comorbid cluster C personality disorders, and comorbid Axis I
disorders. Impairment and suicidal ideation are associated with GAD.
(J Clin Psychiatry 2009;70[suppl 2]:4–9)

G eneralized anxiety disorder (GAD) was defined rel-

atively recently, in 1980. The Diagnostic and Statis-
tical Manual of Mental Disorders (DSM) definition of the
cording to the National Comorbidity Survey Replication
(NCS-R),5 GAD was found to have a 5.7% lifetime preva-
lence,6 and the 12-month prevalence rate was reported to
disorder underwent modification from DSM-III to DSM- be 3.1%.5 Other US epidemiologic studies have supported
III-R and to DSM-IV and DSM-IV-TR (Table 1).1–4 The these data and reported only slightly varying rates.7 Over-
validity of the definition of GAD is still questioned, and all, the lifetime rate of GAD in American adults is thought
several changes to the criteria for the disorder have been to be about 5%, and current prevalence rates are thought to
suggested. Although diagnostic criteria have varied among range from about 2% to 3%.8
studies, available research has suggested that GAD is In Europe, epidemiologic studies have reported more
highly prevalent, with a chronic course, significant impair- variable rates of DSM-IV GAD, with lifetime prevalence
ment, and risk of suicidality. rates ranging from 0.1% to 6.9%, according to a meta-
analysis9 of studies that used DSM-IV criteria in 6 Eu-
EPIDEMIOLOGY OF GAD ropean countries. The largest of these studies, an epi-
demiologic sample of over 21,000 adults in Western
Prevalence of DSM-IV GAD in the General Population Europe, reported a lifetime prevalence of DSM-IV GAD
Recent prevalence studies have used DSM-IV criteria of 2.8%.10
to measure the rates of GAD. In the United States, ac-
Prevalence Across Lifespan and Social Groups
The median age at onset of GAD in the US population
is estimated to be 31 years. Approximately 25% of cases
From the Department of Psychiatry and Human Behavior and of GAD have an age at onset of 20 years and an additional
the Department of Family Medicine, Brown University, Providence,
Rhode Island. 50% have an age at onset between 20 and 47 years.6 Simi-
This article is derived from the planning teleconference series larly, European studies have found that GAD prevalence
“Insights Into Generalized Anxiety Disorder,” which was held
June–August 2008, and supported by an educational grant from
increases from young adulthood through the mid-50s, a
AstraZeneca Pharmaceuticals LP. pattern unlike that of other anxiety disorders.9 Therefore,
Dr Weisberg has received grant/research support from Pfizer GAD is typically a disorder of adult onset. In fact, GAD
and from a Mentored Patient-Oriented Research Career Development
Award from the National Institute of Mental Health, K23 MH069595. has the oldest median age at onset of any of the anxiety
Corresponding author and reprints: Risa B. Weisberg, PhD, disorders and has a pattern of age at onset that is more
Brown University, Box G-BH, Duncan Building, Providence, RI
02912 (e-mail: [email protected]). similar to that of major depressive disorder (MDD) than it
© Copyright 2009 Physicians Postgraduate Press, Inc. is to the other anxiety disorders.6 In older adults (65 years

4 PSYCHIATRIST.COM J Clin Psychiatry 2009;70 (suppl 2)

 GAD: Epidemiology, Presentation, and Course

FOR CLINICAL USE

◆ The prevalence of GAD appears to be higher among women; adults; whites; people with a
low income; and those who are widowed, separated, or divorced.
◆ Reduced likelihood of recovery and remission is associated with poor family relationships,
comorbid cluster C personality disorders, comorbid Axis I disorders, and female sex.
◆ Diagnostic criteria for GAD have been controversial since their introduction in 1980 and
still cause confusion and debate.

and older), the prevalence of anxiety disorders except Probability of Recovery and Recurrence
GAD appears to decrease compared with younger ages, The Epidemiologic Catchment Area (ECA) study,18
but the rate of GAD may actually grow; the current prev- which used DSM-III criteria, reported that GAD persisted
alence of GAD in older adults has been estimated to be for longer than 5 years in 40% of individuals who were
4%.11 However, a study12 of DSM-IV disorders in older diagnosed with the disorder. Most of the available data on
African-American adults (55 years and older) reported the the longitudinal course of GAD come from the Harvard-
lifetime prevalence of GAD to be 3.09%, somewhat lower Brown Anxiety Research Project (HARP) study,19 which
than in the general population. In this sample,12 GAD was used DSM-III-R criteria. The HARP data support the
found to be less prevalent than social phobia and posttrau- chronic nature of GAD, as reported in the ECA study,18
matic stress disorder (PTSD) and also less prevalent than even though the GAD criteria changed considerably from
MDD and alcohol abuse. DSM-III to DSM-III-R (see Table 1). In HARP,19 over
Scant data are available for the prevalence of DSM-IV 12 years, DSM-III-R GAD was found to have a probabil-
GAD in children and adolescents, in part due to changes ity of recovery of 0.58, and the probability of recurrence in
in nomenclature. Prior to DSM-III-R, the diagnosis of patients who recovered was 0.45. During the 12 years of
GAD did not apply to children and adolescents. Even with the study, the average amount of time that patients with
the DSM-III-R criteria allowing the GAD diagnosis in GAD spent ill was 74%.
younger patients, the symptoms of GAD in children over- Utilizing data from the Primary Care Anxiety Project,
lapped with those of overanxious disorder. However, Rodriguez and colleagues20 examined the probability of
available research suggests that strictly defined DSM-IV recovery in primary care patients with DSM-IV GAD. In
GAD is uncommon in children and adolescents. Low life- this sample, the probability of recovery was 0.39 over 2
time rates of DSM-IV GAD in children were found in Eu- years, which is somewhat higher than that at 2 years in the
ropean studies (0.4 to 2.7%).9 Further, the 1-year prev- HARP study.19 The difference in probability rates between
alence of DSM-IV GAD was 0.5% in children and the 2 studies may relate to different population samples or
adolescents in a US primary care site; this prevalence rate to differences between DSM-IV and DSM-III-R criteria,
was the lowest of any of the psychiatric disorders mea- but most of the methodology for these studies was very
sured in the sample.13 similar. Rodriguez and colleagues20 found that older age at
Generalized anxiety disorder appears to be differen- onset and less severe psychosocial impairment were asso-
tially prevalent across genders and cultural groups. The ciated with an increased likelihood of recovery.
disorder occurs approximately twice as often in women
as it does in men.4,14 Studies15,16 in the United States have Predictors of the Course of GAD
found that, besides female gender and older age, risk fac- Predictors of the course of GAD include the status
tors for GAD include having a low income and being wid- of family relationships, the presence of comorbidity, and
owed, separated, or divorced; groups that have a lower gender. Poor relationships with a spouse or relatives and
risk for GAD are Asian, Latino, and black adults. A greater the presence of comorbid cluster C personality disorders
12-month prevalence of GAD has been reported in lesbian have been associated with a reduced likelihood of GAD
and bisexual women compared with heterosexual women remission.21 Comorbid Axis I disorders have also been
(14.7% vs 3.8%), but no difference has been found be- found to affect the course of GAD; patients with GAD
tween gay men and heterosexual men.17 who had comorbid MDD, panic disorder with agorapho-
bia, or substance use disorders were found to be less likely
COURSE OF GAD to recover from GAD than those without these comorbid
disorders.19 Gender also seemed to affect the course of
Generalized anxiety disorder is a long-term illness with GAD; women were found to be less likely to remit than
a high likelihood of recurrence. The course of GAD can be men, but they also appeared to be less likely to relapse
predicted or exacerbated by several factors. once they had remitted.22

J Clin Psychiatry 2009;70 (suppl 2) PSYCHIATRIST.COM 5

Risa B. Weisberg

Table 1. Evolution of Key Criteria for Generalized Anxiety Disorder in the Diagnostic and Statistical Manual of Mental Disorders
DSM-IV, 1994,c and
DSM-III, 1980a DSM-III-R, 1987b DSM-IV-TR, 2000d
Generalized, persistent anxiety of at least 1 month’s Unrealistic or excessive worry Anxiety and worry that:
duration, without symptoms of phobias, panic, or about 2 or more circumstances, Are excessive and difficult to control, occur more
obsessive compulsive disorder; or symptoms due more days than not, for 6 days than not for at least 6 months, and are about
to another mental disorder, such as depressive months’ duration a number of events or activities
disorder or schizophrenia
Symptoms from 3 of the following At least 6 symptoms from the Are associated with 3 or more of the
4 categories: following 3 categories: following 6 symptoms:
• Motor tension • Motor tension • Restlessness or feeling keyed up or on edge
• Autonomic hyperactivity • Autonomic hyperactivity • Being easily fatigued
• Apprehensive expectation (including anxiety, • Vigilance/scanning • Difficulty concentrating or mind going blank
worry, fear) and vigilance • Irritability
• Must be at least 18 years old (manifested as • Muscle tension
“overanxious disorder” in children) • Sleep disturbance
Symptoms must not occur Cause significant distress or impairment
exclusively during the Do not occur exclusively during a mood
course of a mood disorder disorder, psychotic disorder, pervasive
Diagnosis permissible and developmental disorder, or posttraumatic
identical in children. However, stress disorder
diagnosis of overanxious May occur in children
disorder continued to exist
with great overlap in criteria
for children
a
Based on American Psychiatric Association.1
b
Based on American Psychiatric Association.2
c
Based on American Psychiatric Association.3
d
Based on American Psychiatric Association.4

Impairment and Severity based survey28 of adults in the Netherlands, DSM-III-R

Impairment and severity of GAD have been examined GAD was found to be an independent risk factor for
in several studies. In the NCS-R,5 77% of GAD cases suicidal ideation, but not suicide attempts, after adjusting
were classified as being of moderate or serious severity, for demographic factors and comorbid Axis I disorders.
which included having impairment in occupational or role In a large longitudinal study of young adults (16 to 25
function. Similarly, in an Australian survey23 of current years) in the United States,29 GAD was associated with a
DSM-IV disorders in the general population, 72% of re- 6-fold increased likelihood of suicidal ideation and a more
spondents with GAD had moderate or severe disability ac- than 2-fold greater likelihood of attempted suicide, after
cording to the Medical Outcomes Study 12-Item Short controlling for other Axis I disorders and stressful life
Form; no other anxiety disorder had a rate of moderate or events.
severe disability as high as that of GAD.
Significant impairment in life satisfaction and well- NOSOLOGY
being is also associated with GAD. In a Canadian commu-
nity sample,24 after controlling for the effects of MDD, Nosologic issues and controversies have existed since
lifetime and current DSM-III-R GAD were both associ- GAD first appeared in the nomenclature in DSM-III. The
ated with decreased perceived overall well-being. Life- diagnostic criteria have been adjusted over time and con-
time GAD was also associated with dissatisfaction with tinue to be debated.
the individual’s main activity in life and with family rela-
tionships. However, GAD was not independently associ- Past Definitions of GAD
ated with dissatisfaction with friendships, leisure activi- When GAD first appeared in DSM-III, the essential
ties, or income. In other large community surveys (using features were generalized persistent anxiety that lasted
both DSM-III-R and DSM-IV criteria),25–27 GAD was as- 1 month or longer and did not contain symptoms of
sociated with impairment that was not only independent of phobia, panic, or obsessive compulsive disorder (see
the effects of MDD but also equivalent in magnitude to the Table 1). These features were substantially changed in the
impairment caused by MDD. DSM-III-R to worry that was unrealistic or excessive, that
An association with suicide, in any disorder, is one of was present for more days than not for at least 6 months,
the measures of impairment that has the greatest impact, and that was about 2 or more circumstances.
and epidemiologic data show that GAD may be uniquely The original diagnosis of GAD required symptoms
associated with suicidality. In a prospective population- from 3 of 4 categories. Diagnosis in the DSM-III-R

6 PSYCHIATRIST.COM J Clin Psychiatry 2009;70 (suppl 2)

 GAD: Epidemiology, Presentation, and Course

revision, however, required 6 symptoms from 3 catego- similar between GAD defined by a 6-month minimum
ries. Additionally, GAD could not occur exclusively dur- duration and GAD defined by a 1-month minimum dura-
ing the course of a mood disorder. tion; among the 16 comorbid disorders measured, only
In DSM-III criteria, the individual had to be at least 18 PTSD, panic disorder, major depression, and bipolar I dis-
years of age to have GAD. If the individual had similar order were significantly (P < .05) more common after
symptoms and was a child or adolescent, the syndrome 6 months. The odds of having comorbid dysthymia in-
was diagnosed as overanxious disorder. In DSM-III-R, a creased after 12 months. Episode duration appeared to in-
diagnosis of GAD became permissible in children, but the crease social impairment but was unrelated to family or
diagnosis of overanxious disorder still existed, leading to parental history of GAD, age at onset, work impairment,
a great deal of overlap in the criteria for children. and persistence.33,34
Poor interrater diagnostic reliability was found for Excessive worry. The DSM-IV criterion that states that
both DSM-III and DSM-III-R.30–32 High rates of comor- anxiety and worry must be excessive is controversial. One
bidity associated with GAD caused difficulty with diag- of the changes in the criteria from DSM-III-R to DSM-IV
nosis and in part sparked the change in the duration crite- was that the worry no longer needed to be “unrealistic,”
rion from 1 month to 6 months in DSM-III-R; because of but the requirement that worry was “excessive” was main-
the comorbidity, debate surrounded whether GAD was tained (see Table 1). Excessive worry is not required by
a residual category or a prodrome of other anxiety disor- the International Statistical Classification of Diseases,
ders or MDD.31,32 Additionally, the 1-month duration had 10th Revision,35 for a diagnosis of GAD.
caused challenges in distinguishing GAD from adjust- Ruscio and colleagues36 argued that the excessive
ment disorders or situational stress reactions.32 worry criterion poses diagnostic problems because of con-
fusion over operationally defining the term, which leads
Remaining Nosologic Controversies to inconsistency. The excessive worry criterion was asso-
Controversies still surround the DSM-IV GAD criteria ciated with the lowest interrater agreement among GAD
(Table 1). Current debate relates to the duration and ex- diagnoses, and eliminating this criterion was associated
cessive worry criteria, the number of associated symp- with a large increase in interrater reliability.37 An ex-
toms that should exist in order for GAD to be diagnosed, amination36 of NCS-R data compared participants who
and the relationship between GAD and MDD. met the full DSM-IV criteria for GAD with those who
Duration. Changing the duration criterion would met the criteria except for excessive worry; this study
affect estimates of the prevalence of GAD, but other showed that, when the excessive worry criterion was
findings about GAD, such as family history and level of dropped, the lifetime prevalence of the disorder increased
work impairment, may not change. As might be expected, by about 40%.
the prevalence of GAD increases as the duration require- Differences were found in the presentation of GAD
ment decreases. An analysis33 of data from the NCS-R with and without excessive worry.36 Generalized anxiety
found that if the DSM-IV minimum duration criterion was disorder with excessive worry was associated with an ear-
changed from 6 months to between 1 and 12 months, the lier age at onset, a more persistent course, greater odds
lifetime prevalence of GAD changed from 6.1% to be- of having comorbid Axis I disorders, and greater symptom
tween 4.2% (12-month minimum duration requirement) severity. However, no differences were found in parental
and 12.7% (1-month minimum duration requirement). history of GAD, functional impairment, and treatment
The 1-year prevalence changed from 2.9% to between seeking among individuals with or without the excessive
2.2% and 5.5% (12-month and 1-month minimum dura- worry criterion. Ruscio and colleagues36 argued that the
tion requirements, respectively). Angst and colleagues34 excessiveness criterion may leave out many individuals
found that nearly half of the patients in a large Swiss pro- who are impaired by subthreshold GAD.
spective study who were treated for generalized anxiety Number of associated symptoms. In the DSM-IV, cri-
would not have met the 6-month duration requirement in teria for a GAD diagnosis require that 3 of 6 associated
DSM-IV, and so they argued that this duration require- symptoms be present (Table 1); however, whether or not
ment may exclude some individuals who are significantly 3 symptoms is the optimal threshold is unclear. Little
impaired and seek treatment. research has examined this issue, but Brown and col-
A duration requirement less than 6 months is generally leagues38 reported that 4 rather than 3 symptoms appear to
not associated with less comorbidity than the 6-month be optimal with regard to sensitivity and specificity.
criterion. The Swiss prospective study34 found that GAD Ruscio and colleagues39 suggested relaxing the crite-
with a duration criterion of less than 6 months was associ- rion for associated symptoms from 3 to 2. Requiring only
ated with similar comorbidity of major depressive epi- 2 of the 3 associated symptoms had little effect on GAD
sodes, bipolar disorder, and suicide attempts compared prevalence in NCS-R data because fewer than 8% of
with GAD of 6 months’ duration. An examination33 of participants who endorsed any of the symptoms endorsed
NCS-R data also found that comorbidity rates were only 2 of them. In fact, Breslau and Davis40 reported that

J Clin Psychiatry 2009;70 (suppl 2) PSYCHIATRIST.COM 7

Risa B. Weisberg

74% of patients with a 1-month or longer duration of GAD about pharmaceutical agents that is outside US Food and Drug
Administration–approved labeling has been presented in this article.
reported 6 symptoms.
Independence from mood disorders. Current DSM-IV
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