CHAPTER 25

Generalized Anxiety Disorder

Arezou Mortazavi, Soo Jeong Youn, Michelle G. Newman,
and Louis G. Castonguay

CLINICAL PROBLEM

Generalized Anxiety Disorder (GAD) is defined in the DSM-5 as persistent and

excessive anxiety and worry about a number of domains in the person’s life,
present for at least 6 months. The worry and anxiety are difficult to control and
cause significant distress and/or impairment in the individual’s functioning.
In addition, in order to meet DSM-5 criteria, at least three of the following
symptoms must also be present for at least 6 months: restlessness, being easily
fatigued, difficulty concentrating, irritability, muscle tension, and disturbed sleep.
The symptoms cannot be better explained by another mental disorder, medical
disorder, and/or substance abuse/dependence. The course of this disorder is
chronic and often debilitating, and is associated with reduced quality of life.
Diagnosis in children follows similar criteria with the exception of one associated
symptom being present rather than the three required for adults. This disorder is
commonly seen in primary care settings as compared with other anxiety disorders
and results in higher utilization and cost of health care resources.
Comorbidity with Major Depressive Disorder (MDD) and other anxiety and
psychiatric disorders may be as high as 90%. There has already been some
investigation done on different conceptualizations of GAD, such as viewing GAD
and MDD as a unified disorder or classifying GAD as a mood disorder. The basis of
these arguments stems from the high overlap in symptoms between these conditions
and their high comorbidity. However, exploration in this area has yielded mixed
theories. Angst, Gamma, Ajdacic, Rossler, and Regier suggest that GAD and Bipolar
Disorder may share more similarities than GAD and MDD. Further, a review by
Hettema found no basis for unifying MDD and GAD. He argues that although
the two share characteristics, these are diagnostically unspecific. Kessler at al.
found that while GAD and MDD may have a possibly identical genetic basis, they
greatly differ in their environmental determinants. GAD has also been shown to be
frequently comorbid with substance abuse. It may be aggravated by poor family
environment, comorbidity with Cluster C personality disorders, and comorbid Axis
I disorders.
GAD is one of the least reliably diagnosed anxiety disorders, perhaps owing to
cultural and developmental factors. Evidence suggests that the use of structured
assessment measures complements clinical judgment and assists in differential
diagnosis. GAD is also unique from other anxiety disorders in that the worry is
future-focused rather than related to past events and these individuals view

183
184  II. ADULTS

worry as having positive utility for their coping. Assessment may be improved by
determining the focus of the worry for the individual as well as inquiry regarding
current and lifetime symptoms of depression.

PREVALENCE

GAD has been found to have an incidence of 5% in the general population. It has
a lifetime prevalence of 5% to 6.1%, 12-month prevalence of 3.1%, and a current
prevalence of about 2% to 3%. Projected lifetime prevalence at age 75 is 8.3%.
Current comorbidity for GAD has been reported to range from 8% to 22% for
dysthymia, 8.6% to 46% for major depression, 10.7% to 27% for social phobia,
and 11% to 36% for panic disorder—the four most common comorbid Axis I
diagnoses. Women are affected more than men with a ratio of 1:1.9 for lifetime
and 1:2.2 for 12-month prevalence; however, men show higher comorbidity with
substance abuse.

CULTURAL DIVERSITY ISSUES

Individuals with GAD may present different symptoms or manifestations of the

disorder across cultures, with variation observed in rates, clinical presentation,
and interpretation of symptoms. GAD also presents differently among gender,
ethnic, and social groups. For example, individuals from Asian cultures and
women tend to present with more somatic symptoms, whereas Americans and
men tend to present with more psychological symptoms. Some of the proposed
explanations for the cultural differences may be due to the variance in assessment
and diagnostic criteria validity, and perception and experience of the disorder.

EVIDENCE BASED TREATMENTS

A recent review conducted by Turk and Mennin indicates that GAD is the least
researched of the anxiety disorders. GAD has also been found to be the most
resistant to treatment among the anxiety disorders, with remission rates of 0.38
at 5 years post treatment. Acute treatment of GAD targets reduction of symptoms
while long-term care focuses on full remission.
Cognitive behavior therapy (CBT) has been extensively researched for treatment
of GAD and found to be more effective compared to waitlist, pill placebo, placebo
treatment, and analytic psychotherapy. However, the success of this treatment
remains at 50% symptom reductions with high rates of relapse. CBT for GAD
is currently informed by four different conceptual models of GAD: Cognitive
Avoidance Theory, Metacognitive Model, Intolerance of Uncertainty Model, and
Emotional Dysregulation Model. These models overlap in that they view worry as
a persevering type of thought that occurs following a triggering thought, feeling, or
event. Furthermore, all of these models conceptualize worry as a means for coping
with future negative events that may arise.
The investigation of the impact of comorbidity on GAD treatment outcome has
yielded inconclusive results. A study conducted by Newman, Przeworski, Fisher,
and Borkovec has shown that comorbidity is associated with greater severity of
symptomatology at treatment entry. However, these comorbid clients show greater
change and thus, the efficacy of CBT for these individuals is not reduced. However,
 25.  Generalized Anxiety Disorder 185

another study conducted by Provencher, Ladouceur, and Dugas found that CBT is
less effective for patients with a diagnosis of GAD and other comorbid diagnoses,
including panic disorder, at 6 months follow-up. 
Medications for treatment of GAD may be used either alone or in adjunction with
psychotherapy. The use of antidepressants such as selective serotonin reuptake
inhibitors (SSRIs, such as sertraline, paroxetine, escitalopram) or serotonin–
norepinephrine reuptake inhibitors (SNRIs, such as venlafaxine or duloxetine) is
considered to be the first line of treatment. These have been shown to have limited
efficacy, with less than 40% remission rates, with a high risk of relapse and adverse
effects. Current research is exploring the effects of atypical antipsychotics, either as
monotherapy or as augmentation in the treatment of GAD.
Other empirically supported treatments include mindfulness, relaxation tech-
niques through the use of meditation, yoga, biofeedback, and exercise.

FUTURE RESEARCH

Future research should address the changing theoretical conceptualizations of

GAD. For example, a new model has been proposed by Newman and Llera that
depicts GAD as an attempt by the individual to use chronic worry as a means
for avoiding an emotional contrast from a positive state to a negative state.
Another area for further exploration should focus on the development of more
effective treatment options for GAD, such as mindfulness-based CBT, focus
on interpersonal styles within GAD treatment, Cognitive Bias Modification
interventions, and Acceptance-Based Behavioral Therapy. Research should also
focus on the identification and application of the effective components of CBT.
Integration of interpersonal and emotional processing has been investigated
through client recognition of interpersonal needs and behavior patterns,
development of more effective processing skills and exposure to avoided
emotional content. This area holds particular promise given that individuals with
GAD report difficulty experiencing uncomfortable emotions as well as difficulty
in interpersonal relationships. However, investigation thus far of the effects of
adding these components to treatment for GAD has provided mixed results. A
recent study by Newman et al. found effect sizes for integrative therapy that
were higher than average results for CBT alone, while another study found no
significant differences when interpersonal and emotional processing techniques
were added to standard CBT.

KEY REFERENCES

Borkovec, T. D., & Ruscio, A. M. (2001). Psychotherapy for generalized anxiety disorder. Journal of Clinical
Psychiatry, 62(Suppl. 11), 37–45.
Katzman, M. A. (2009). Current considerations in the treatment of generalized anxiety disorder. CNS Drugs,
23, 103–120.
Newman, M. G., & Llera, S. J. (2011). A novel theory of experiential avoidance in generalized anxiety disorder:
A review and synthesis of research supporting a contrast avoidance model of worry. Clinical Psychology
Review, 31(3), 371–382. doi: 10.1016/j.cpr.2011.01.008