Generalized anxiety disorder

GAD appears regularly in NCMHCE cases, and the exam tests whether the worry is pervasive and chronic rather than tied to one stressor, one fear or a medical cause.

Criteria at exam depth. Excessive anxiety and worry about a number of events or activities (work, health, finances, family, everyday matters), occurring more days than not for at least six months. The client finds the worry difficult to control. The worry is associated with three or more of six symptoms in adults (only one required in children): restlessness or feeling keyed up or on edge, being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, and sleep disturbance. Symptoms cause clinically significant distress or impairment, are not due to a substance or medical condition, and are not better explained by another mental disorder (for example, worry only about panic attacks, social evaluation, contamination, separation, weight or health).

Hinge differentials.

• Adjustment disorder with anxiety: linked to an identifiable stressor, begins within three months of it, and does not meet GAD's six-month, multi-domain pattern.
• Major depressive disorder: worry that occurs only during depressive episodes is generally treated as part of the depression; check for anhedonia and depressed mood.
• Illness anxiety disorder: worry focused on having a serious illness, not spread across many areas.
• Panic disorder: fear centered on unexpected attacks and their consequences.
• OCD: intrusive, ego-dystonic obsessions often paired with compulsions, versus everyday future-oriented worry.
• Hyperthyroidism, caffeine and stimulants: physical causes of restlessness, tremor, insomnia and anxiety; withdrawal from alcohol or sedatives can mimic GAD too.

On the NCMHCE. The counselor should ask about caffeine, stimulants, alcohol and sedative use and recommend a medical evaluation (thyroid, cardiac, medication review) before concluding GAD. Use a standardized measure such as the GAD-7 or BAI for baseline and progress. Screen for co-occurring depression and substance use and assess suicide risk when depression is present. First-line counseling is CBT (cognitive restructuring, worry exposure, problem solving, tolerance of uncertainty) along with relaxation training and mindfulness-based approaches. Refer for medication evaluation when impairment is significant; SSRIs and SNRIs are commonly prescribed classes, and benzodiazepines carry dependence concerns, especially with substance use history. Culture shapes how anxiety is expressed; some clients present mainly with somatic complaints.

Clinical Pearl: Six months, many topics, hard to control, three of six symptoms (one in children). Before diagnosing, rule out caffeine, stimulants, withdrawal and thyroid disease, and confirm the worry is not about a single focus that defines another disorder.