Evidence-based assessment/Generalized anxiety disorder (assessment portfolio)/extended version

What is a "portfolio"?

 * For background information on what assessment portfolios are, click the link in the heading above.

Does this page feel like too much information? Click here for the condensed version.

Diagnostic criteria for generalized anxiety disorder
ICD-11 Diagnostic Criteria 
 * Generalised anxiety disorder is characterized by marked symptoms of anxiety that persist for at least several months, for more days than not, manifested by either general apprehension (i.e. ‘free-floating anxiety’) or excessive worry focused on multiple everyday events, most often concerning family, health, finances, and school or work, together with additional symptoms such as muscular tension or motor restlessness, sympathetic autonomic over-activity, subjective experience of nervousness, difficulty maintaining concentration, irritability, or sleep disturbance. The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. The symptoms are not a manifestation of another health condition and are not due to the effects of a substance or medication on the central nervous system.

Changes in DSM-5


 * The diagnostic criteria for generalized anxiety disorder changed slightly from DSM-IV-TR to DSM-5. Summaries are available here.

Base rates of GAD in different clinical settings
This section describes the demographic setting of the population(s) sampled, base rates of diagnosis, country/region sampled and the diagnostic method that was used. Using this information, clinicians will be able to anchor the rate of GAD that they are likely to see in their clinical practice.


 * To see prevalence rates across multiple disorders, click here.

Search terms: [General Anxiety Disorder] AND [youth OR adolescents OR pediatric] AND [prevalence OR incidence] in GoogleScholar and PsycINFO

Psychometric properties of screening instruments for GAD
The following section contains a list of screening and diagnostic instruments for generalized anxiety disorder. The section includes administration information, psychometric data, and PDFs or links to the screenings.
 * Screenings are used as part of the prediction phase of assessment; for more information on interpretation of this data, or how screenings fit in to the assessment process, click here.
 * For a list of more broadly reaching screening instruments, click here.

Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

Likelihood ratios and AUCs of screening instruments for GAD

 * For a list of the likelihood ratios for more broadly reaching screening instruments, click here.

Note: “LR+” refers to the change in likelihood ratio associated with a positive test score, and “LR-” is the likelihood ratio for a low score. Likelihood ratios of 1 indicate that the test result did not change impressions at all. LRs larger than 10 or smaller than .10 are frequently clinically decisive; 5 or .20 are helpful, and between 2.0 and .5 are small enough that they rarely result in clinically meaningful changes of formulation.

Search terms: [General Anxiety Disorder] AND [children OR adolescents OR pediatric] AND [sensitivity OR specificity] in GoogleScholar and PsycINFO

Interpreting GAD screening measure scores

 * For information on interpreting screening measure scores, click here.

Gold standard diagnostic interviews

 * For a list of broad reaching diagnostic interviews sortable by disorder with PDFs (if applicable), click here.

Recommended diagnostic instruments for GAD
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

Severity interviews for GAD
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

Process phase
The following section contains a list of process and outcome measures for generalized anxiety disorder. The section includes benchmarks based on published norms for several outcome and severity measures, as well as information about commonly used process measures. Process and outcome measures are used as part of the process phase of assessment. For more information of differences between process and outcome measures, see the page on the process phase of assessment.

Outcome and severity measures

 * This table includes clinically significant benchmarks for generalized anxiety disorder specific outcome measures
 * Information on how to interpret this table can be found here.
 * Additionally, these vignettes might be helpful resources for understanding appropriate adaptation of outcome measures in practice.
 *  For clinically significant change benchmarks for the CBCL, YSR, and TRF total, externalizing, internalizing, and attention benchmarks,  see here.

Note: “A” = Away from the clinical range, “B” = Back into the nonclinical range, “C” = Closer to the nonclinical than clinical mean.

Search terms: [General Anxiety Disorder] AND [children OR adolescents OR pediatric] AND [clinical significance OR outcomes] in GoogleScholar and PsycINFO

Treatment
Individuals suffering from GAD tend to be high users of outpatient medical care. When treating GAD, physicians should first determine whether pharmacotherapy, psychotherapy, or a combination of the two treatments would be most beneficial to the patient. Literature suggests that treatment of GAD frequently consists of a combination of psychotherapy and pharmacotherapy. Although these therapies have the potential to be effective individually, previous work demonstrates that when combined the degree of clinically significant change increases significantly. Recent studies (e.g., Gorman, 2003 ; Walkup et al., 2008 ) have provided evidence to support this claim with the most efficacious medication and behavioral interventions listed below.


 * 1) Medication Interventions
 * 2) Sertraline (Zoloft) has been shown to reduce experiences and effects of GAD above and beyond that of placebo conditions.
 * 3) Pregabalin. The mean baseline-to-endpoint decreases in total Hamilton anxiety scale score in the patients given 150 mg/day of pregabalin (–9.2) was significantly greater than the decrease in those given placebo (–6.8).
 * 4) Paroxetine. Remission was achieved by 30% of patients in the 20-mg paroxetine groups compared with 20% given placebo. For all three domains of the Sheehan Disability Scale, significantly greater improvement was seen with paroxetine than placebo.
 * 5) Behavioral interventions
 * 6) Cognitive behavioral therapy. Fourteen 60-minute sessions, which include CBT in anxiety-management skills, followed by behavioral exposure to anxiety-provoking situations have been shown to be effective in treating GAD. A review of studies by Fisher and Durham (1999) revealed significant recovery rates at a 6 month follow up after CBT.
 * 7) Exposure therapy and modeling therapy. One meta-analysis found that virtual reality exposure therapy for anxiety disorders had a large effect size (Cohen's d=1.11) compared to controls.
 * 8) Mindfulness meditation. New treatment options such as mindfulness meditation-based stress reduction interventions have also shown to reduce symptoms over the long-term.
 * 9) Combination treatment
 * 10) Previous research suggests that combination therapy that includes components of psychotherapy and pharmacotherapy are the most efficacious in treating GAD. In a study comparing the efficacies GAD treatments, Walkup and colleagues demonstrated a 21-25% improvement of combination therapy over cognitive behavioral therapy or sertraline alone during short-term treatment. These findings suggest that among effective treatments, combination therapy has the potential to provide the best chance for a positive outcome. See Gorman, 2003 ; Walkup et al., 2008.


 * Please refer to the page on generalized anxiety disorder for more information on available treatment or go to Effective Child Therapy for a curated resource on effective treatments for GAD.
 * For information on conducting Exposure Therapy for anxiety disordered youth, see www.BravePracticeForKids.com

External Resources

 * 1) ICD-10 diagnostic criteria
 * 2) Find-a-Therapist
 * 3) *This is a curated list of find-a-therapist websites where you can find a provider
 * 4) NIMH entry about anxiety disorders
 * 5) OMIM (Online Mendelian Inheritance in Man)
 * 6) *607834
 * 7) eMedicine entry about anxiety disorders
 * 8) Society of Clinical Child and Adolescent Psychology
 * 9) Effective Child Therapy information on Fear, Worry, & Anxiety
 * 10) *Effective Child Therapy is website sponsored by Division 53 of the American Psychological Association (APA), or The Society of Clinical Child and Adolescent Psychology (SCCAP), in collaboration with the Association for Behavioral and Cognitive Therapies (ABCT). Use for information on symptoms and available treatments.
 * 11) Links to SCARED Child, Parent, and Adult + Translations