Generalized anxiety disorder (GAD) is one of the most common mental health conditions, affecting more than 6.8 million U.S. adults.(1) Characterized by excessive anxiety and worry about a variety of events or activities, people with generalized anxiety disorder find it difficult to control their worry, which often leads to impairment in social, occupational, or other areas of functioning.
This care guideline offers a brief summary of the evidence-based, best practices for the effective treatment of generalized anxiety disorder in adults.
Diagnostic Considerations for GAD in Adults
Over the past 6 months (or longer), has your client been experiencing:
- Excessive anxiety and worry about a number of different things?
- Is it difficult for the client to control the worry?
- As a result of the anxiety and worry, does the client experience symptoms such as:
- Feeling restless or often “on edge”
- Irritability
- Muscle tension
- Sleep difficulties
- Trouble concentrating
- Easily fatigued
- Have the anxiety, worry, and/or physical symptoms negatively impacted the client’s ability to function in important areas of life, such as relationships, work, and school, or complete activities of daily living (such as hygiene, keeping up with responsibilities, etc.)?
It’s important to note that the above symptoms and experiences may also be attributable to an alternative disorder (such as obsessive-compulsive disorder or somatization disorder), a neurological cause, or the direct physiologic effects of a substance. As a result, a clinical best practice is to engage in a differential diagnostic assessment prior to determining if GAD is the clinically indicated diagnosis.
For complete diagnostic criteria, consult the Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). American Psychiatric Association. (2022). https://doi.org/10.1176/appi.books.9780890425787
| When documenting care, be sure to include the specific symptoms of GAD experienced by the client. This ensures your note reflects alignment with the diagnosis and demonstrates medical necessity for the service. |
Symptom Screening and Monitoring
The GAD-7 (Generalized Anxiety Disorder - 7 item) is a brief validated, client self-report screening tool used to assess the frequency and severity of anxiety symptoms. Routine use of this measure is foundational to providing effective care for individuals who experience anxiety, as it supports accurate diagnoses, identification of treatment plan goals based on symptom severity, and can guide effective clinical interventions. You can learn more about the GAD-7 and strategies for incorporating Measurement Informed Care (MIC) into your practice here.
Evidence-Based Approaches to Treatment
Research demonstrates that adults with GAD can be effectively treated through psychotherapy, medication management, or a combination of the two. In fact, evidence suggests that utilizing medication as a complementary approach alongside therapy is likely to be more effective than either treatment alone (AAFP).(2)
Psychotherapy
Cognitive behavior therapy (CBT) is the most well-studied, and effective, form of psychotherapy to treat GAD.1 Common evidence-based CBT interventions include:(3)
- Psychoeducation
- Thought Monitoring
- Cognitive Restructuring
- Relaxation, Mindfulness, and Grounding
- Exposure
- Behavior modification
Medication
Selective serotonin reuptake inhibitors (SSRIs) are generally considered “first-line medications” for the effective treatment of GAD and are approved by the U.S. Food and Drug Administration (FDA) for this indication.(2) Examples include but are not limited to:
- paroxetine (Paxil)
- escitalopram (Lexapro)
- duloxetine (Cymbalta)
- venlafaxine (Effexor)
Benzodiazepines (such as diazepam and clonazepam) are generally not recommended for the treatment of anxiety due to their high potential for dependence as well as their limited long-term effectiveness.
When should I refer my client for psychiatric medication management?
Clients with moderate to severe anxiety may benefit from discussing the use of medication (in conjunction with continued therapy) with a Psych NP or Psychiatrist to maximize treatment response and symptom reduction. This step by step guide walks you through how to easily refer your client for a psychiatric medication management evaluation at Rula.
| As a reminder, it is beyond the scope of a psychotherapist to suggest specific medications, groups of medications, specific supplements, or advise on the frequency of taking or stopping medications. These discussions must only be carried out by a medical provider. |
Assessing Risk and Higher Level of Care Needs
According to the World Health Organization,(4) anxiety disorders increase the risk for depression, substance use disorders, and risk of suicidal thoughts and behaviors. Particularly for clients who present with a GAD-7 score of 15 or higher (indicating severe anxiety symptoms). It is important for therapists to engage in (and document) regular assessment of risk, completion of a safety plan, and referral for additional services (such as IOP, PHP, Group therapy, etc) if clinically indicated.
| Rula’s team of care coordinators is available to support your client in accessing these additional clinical services outside of Rula. Click here to learn more about how to easily refer your client for a Higher Level of Care (HLOC). |
Cultural Considerations
The expression of anxiety symptoms is often influenced by cultural contexts, including perceptions of illness and symptoms (including their causes), ideas related to shame and what is shaming, gender and racial identification, what life experiences are considered typical in a particular cultural environment as well as whether a person's response to those stimuli are considered “unreasonable” or “excessive”.(7) As a result, it is important to always consider the social and cultural contexts of a client's treatment needs as part of the diagnostic process.
“When a mental health professional understands the role that culture plays in the diagnosis of a condition and incorporates cultural needs and differences into a person’s care, it significantly improves outcomes.”(8)
Disclaimer: GAD in Children and Adolescents
This care guide focuses on best practice guidelines for treating Adults with GAD, however, anxiety disorders are the most common psychiatric conditions in children and adolescents, affecting nearly 1 in 12 children and 1 in 4 adolescents.(5) For information on providing effective care for children and adolescents with GAD, check out the below resources:
- Clinical Practice Guideline for the Assessment and Treatment of Children and Adolescents With Anxiety Disorders (American Academy of Child and Adolescent Psychiatry)
- Generalized Anxiety Disorder in Kids (Child Mind Institute)
- The Management of Anxiety and Depression in Pediatrics (NIH)
Downloadable Digital Guide
Click HERE for a downloadable digital copy of this guide.
References
- National Institute of Health. Mishra AK, Varma AR. A Comprehensive Review of the Generalized Anxiety Disorder. Cureus. 2023 Sep 28;15(9):e46115. doi: 10.7759/cureus.46115. PMID: 37900518; PMCID: PMC10612137
- American Academy of Family Physicians. https://www.aafp.org/pubs/afp/issues/2022/0800/generalized-anxiety-disorder-panic-disorder.html#afp20220800p157-b53
- Journal of Clinical Psychiatry. https://www.psychiatrist.com/wp-content/uploads/2021/02/18304_treating-generalized-anxiety-disorder-cognitive-behavioral.pdf
- World Health Organization. https://www.who.int/news-room/fact-sheets/detail/anxiety-disorders
- American Academy of Family Physicians. https://www.aafp.org/pubs/afp/issues/2022/1200/anxiety-disorders-children-adolescents.html
- American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
- National Institute of Health. Hofmann SG, Anu Asnaani MA, Hinton DE. Cultural aspects in social anxiety and social anxiety disorder. Depress Anxiety. 2010 Dec;27(12):1117-27. https://doi.org/10.1002/da.20759
- National Alliance on Mental Illness (NAMI). (n.d.). Identity and Cultural Dimensions. https://www.nami.org/your-journey/identity-and-cultural-dimensions/