Clinical Care Guideline: Generalized Anxiety Disorder (GAD)

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. 

DSM-5-TR Diagnostic Criteria for Generalized Anxiety Disorder in Adults

A) Excessive anxiety and worry, occurring more days than not for at least six months, about a number of events or activities. *Note: Some research suggests using a one-month symptom duration because the six-month requirement may unnecessarily exclude from treatment those patients whose symptoms are early in onset or may fluctuate.

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:

  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 

D) The focus of the anxiety and worry is not confined to features of an Axis I disorder (e.g., social phobia, obsessive-compulsive disorder, separation anxiety disorder, somatization disorder, etc.).

E) The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

F) The disturbance is not due to the direct physiologic effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism).

noun-lightbulb-1262995.png 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


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 


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. 

noun-lightbulb-1262995.png 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. 

noun-lightbulb-1262995.png 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

There is considerable cultural variation in the expression of generalized anxiety disorder. For example, in some cultural contexts, somatic symptoms predominate in the expression of the disorder, whereas in other cultural contexts, cognitive symptoms tend to predominate. It is important to consider the social and cultural context when evaluating whether worries about certain situations are excessive. In the United States, higher prevalence is associated with exposure to racism and ethnic discrimination. (DSM-5-TR)

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:


  1. 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
  2. American Academy of Family Physicians. 
  3. Journal of Clinical Psychiatry. 
  4. World Health Organization.
  5. American Academy of Family Physicians.

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