Practice Briefs

Generalized Anxiety Disorder

Introduction

Generalized anxiety disorder (GAD) is a condition marked by excessive anxiety and worry that occurs more days than not for at least six months; this worry concerns various events or activities (American Psychological Association [APA], 2022). GAD is one of the most commonly diagnosed anxiety disorders listed in the Diagnostic and Statistical Manual of Mental disorders (5th ed., text rev.; DSM-5-TR; APA, 2022). As stated in the DSM-5-TR, “the essential feature of generalized anxiety disorder is excessive anxiety and worry (apprehensive expectation) about several events or activities. The intensity, duration, or frequency of the anxiety and worry is out of proportion to the actual likelihood or impact of the anticipated event” (p. 251).

In 2019, about 6% of adults in the US experienced severe or moderate symptoms of anxiety (Terlizzi & Zablotsky, 2024). Anxiety prevalence rates have remained high even after the COVID-19 pandemic, which caused a steep rise in anxiety symptoms (Arnett & Mitra, 2025). The pandemic spiked prevalence from 31.4% in August 2020 to 36.9% in December 2020 (Vahratian et al., 2021). However, prevalence estimates vary, with a 2023 survey reporting that up to 44% of the adult population in the United States experiences symptoms of anxiety (Kavelaars et al., 2023).

In the U. S., the lifetime prevalence of GAD is approximately 6.2% and the combined prevalence of anxiety disorders is 34% (Szuhany & Simon, 2022). Females exhibit a higher prevalence of GAD (21.4%) compared to males (14.8%) (Terlizzi & Zablotsky, 2024). Also, prevalence was disproportionately found among respondents with lower education levels, household incomes, and employment status (Ruscio et al., 2017).

Anxiety disorders are the most common form of pediatric mental disorder, with prevalence figures reaching 20% among children and adolescents (Rapee et al., 2023). Children with GAD typically present with concerns regarding their competence at school, perfectionism tendencies, and an overzealous quest for reassurance and validation (APA, 2022).

GAD is also the most common anxiety disorder among older individuals (ADAA, n.d.). While the prevalence of other anxiety disorders tends to decrease in later life, 24.6% report the onset of the disorder after 50 (Zhang et al., 2015). Prevalence rates of GAD among individuals above 60 years remains high, with studies linking it to significant distress, cognitive decline, and cardiovascular disease (Andreescu & Lee, 2020). Up to 44.3% of persons with disabilities reported experiencing frequent anxiety symptoms (Sarmiento et al., 2025).

Description of Generalized Anxiety Disorder

The DSM-5-TR provides six diagnostic features of GAD. These include at least six months of excessive worry and anxiety, which the individual finds difficult to control. This is accompanied by physical symptoms including restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance. For children, only one symptom is required to qualify for a GAD diagnosis. These symptoms cause significant impairment in the important areas of functioning and are not attributable to the physiological effects of a substance or better explained by another condition (APA, 2022).

Excessive worrying affects the individual’s physical, social, emotional, and cognitive functioning. The age of onset, however, varies broadly with symptoms waning and waxing across the lifespan, with the primary variation across age groups being the content of the person’s worry (APA, 2022). The DSM-5-TR provides nine categories for assigning a differential diagnosis.

Assessment Strategies

Assessment strategies should evaluate emotional, behavioral, and physiological self-regulation while also considering factors such as medical history, family dynamics, developmental milestones, trauma, lifestyle, and neurological risks to collaboratively develop an effective treatment plan (Field et al., 2024). A multicultural assessment framework recognizes how cultural norms, power dynamics, and systemic inequities influence chronic worry, somatic symptoms, and emotional expression (Sheperis et al., 2020). Multiple assessment methods, including culturally tailored interviews, self-report questionnaires, and information from family or community members, are recommended to cross-check data and ensure an ethically responsible and culturally sensitive diagnosis (Sheperis et al., 2020).

Assessment involves collaborative engagement, appropriate use of standardized tools, and cultural responsiveness throughout the diagnostic process (ACA, 2014). Common screening instruments include:

• Beck Anxiety Inventory: Assesses the severity of anxiety symptoms (Sheperis et al., 2020; Hays, 2024).
• State-Trait Anxiety Inventory: Evaluates both state (temporary) and trait (long-term) anxiety characteristics (Sheperis et al., 2020; Hays, 2024).
• Multidimensional Anxiety Questionnaire: Measures various dimensions of anxiety (Sheperis et al., 2020; Hays, 2024).
• Posttraumatic Stress Disorder Symptom Scale: Assesses anxiety symptoms related to trauma (Sheperis et al., 2020; Hays, 2024).
• Fear Questionnaire: Evaluates specific fears and phobias, which may overlap with anxiety disorders (Hays, 2024).

Counselors should confirm an instrument aligns with DSM-5-TR standards (Sheperis et al., 2020).

The DSM-5-TR indicates a heightened risk of suicidal thoughts and actions among individuals with GAD, even when no other comorbidities or major stressors are present (APA, 2022). Therefore, safety risk assessment and monitoring are recommended. The Level 1 and Level 2 Cross-Cutting Symptom Measures are designed to assess symptoms across different diagnostic categories, such as anxiety, mood, and sleep issues for adults and children/adolescents (APA, 2022). The WHODAS 2.0 supports assessment by measuring how conditions like GAD impair daily functioning across multiple life domains, even though it does not directly assess anxiety symptoms (APA, 2022).

Counselors assessing GAD should remain attentive to standard rule-outs, which include considering substances and underlying medical conditions that can present with anxiety-like symptoms (First, 2024). Anxiety is a commonly associated with a wide range of medical disorders, including endocrine imbalances (e.g., hyperthyroidism), cardiopulmonary conditions (e.g., congestive heart failure, sleep apnea), neurological concerns (e.g., stroke, Parkinson’s disease), autoimmune disorders or systemic infections (e.g., lupus, systemic infection), and nutritional or metabolic deficits (e.g., thiamine or niacin deficiency). Anxiety may also stem from drug withdrawal, hormone shifts (e.g., menopause, premenstrual syndrome), or rare tumors like pheochromocytoma (Morrison, 2015). In each case, symptoms may mimic or co-occur with mood and anxiety disorders, complicating diagnostic clarity.

Certain over-the-counter substances can exacerbate GAD. Caffeine, while potentially reducing anxiety at moderate doses, has been shown to increase anxiety severity, trigger restlessness, and interfere with sleep when consumed in excessive amounts, particularly exceeding 300–400 mg per day (Shi et al., 2025; Hoppe et al., 2025).Counselors should help clients to work with medical professionals when symptoms appear unusual, have a sudden onset, or do not respond to psychotherapeutic treatment (Morrison, 2015). Scope of Practice

Licensed professional counselors are trained and licensed to assess, diagnose, and treat mental health conditions. Their diagnostic scope is legally defined and varies among U.S. jurisdictions (National Conference of State Legislatures, 2025). Most states allow counselors to diagnose mental health conditions. Under the Counseling Compact, eligible counselors may apply for a privilege to practice in member states. While their license is issued in their home state, they must adhere to the scope of practice, laws, and regulations of each remote state where they practice under the Compact. Counselors are expected to exercise prudence, maintain competence, and collaborate with other qualified professionals when making differential diagnoses, especially in cases involving overlapping physical symptoms (Counseling Compact, 2022).

Counselors have an ethical duty to work collaboratively with clients during assessment and diagnosis, ensuring that clinical choices match the linguistic, developmental, cultural, and contextual needs (ACA, 2014). When diagnosis is unnecessary or potentially harmful, counselors may ethically choose not to diagnose if their interventions are based on professional responsibilities like fidelity, client welfare, accurate assessment, licensure regulations, and informed decision-making (ACA, 2014). This process maintains the counselor’s primary responsibility to promote client well-being and to use assessment methods that align with professional competence, ethical standards, and client preferences (ACA, 2014).

Treatment Approaches

Cognitive and behavioral approaches, especially cognitive behavior therapy (CBT), are still the most widely supported treatments for GAD (Kress et al., 2020). Assessment often includes standardized measures, structured interviews, and collaborative case formulation.

CBT focuses on identifying and changing maladaptive thought patterns and avoidance behaviors that sustain anxiety (Kress et al., 2020). The Dysfunctional Thought Record worksheet, for example, helps clients disrupt worry loops and build more adaptive beliefs, while third-wave behavioral therapies infuse mindfulness and acceptance strategies (Kress et al., 2020). Acceptance and commitment therapy (ACT) emphasizes values-driven behavior and cognitive diffusion, and mindfulness-based cognitive therapy (MBCT) fosters nonjudgmental awareness and a decentered stance toward anxious thinking (Kress et al., 2020).

A pluralistic framework builds on these models by emphasizing therapist-client collaboration and flexibility (Kupfer et al., 2023; Cooper & Dryden, 2016). Cooper (2023) deepens an integrative perspective by encouraging counselors to recognize how anxiety may stem from structural stressors (e.g., economic instability, marginalization, chronic uncertainty) and help the client engage in an emancipatory process. In this context, counseling addresses symptom management while restoring agency and honoring dignity. Pluralistic approaches call for “caring humanism,” which resists procedural rigidity and prioritizes authenticity, warmth, and mutual respect (Ratts et al., 2016). Research continues to affirm that the therapeutic relationship—particularly the alliance, empathy, and attunement to client preferences—has a greater impact on outcomes than technique alone (Parrow, 2024; Norcross, 2010).

Clients with GAD may be supported by a combination of counseling and pharmacologic support, and counselors should understand how medications can reduce anxiety symptoms, how side effects may interfere with therapeutic gains, and how to collaborate with prescribers (Stahl, 2021; Preston et al., 2021). Common prescriptions for GAD include:

• Selective Serotonin Reuptake Inhibitors and Serotonin-Norepinephrine Reuptake Inhibitors (SSRIs and SNRIs): First-line medications like escitalopram (Lexapro), paroxetine (Paxil) and venlafaxine extended-release (Effexor XR) enhance serotonin and/or norepinephrine transmission. They typically reduce excessive worry, somatic tension, and irritability but require 2–4 weeks to achieve their full effect. Side effects may include gastrointestinal upset, sexual dysfunction, and activation (e.g., restlessness). Youth may exhibit irritability or increased suicidal ideation; individuals 60 and older are at risk for low sodium and falls (Stahl, 2021; Preston et al., 2021).
• Buspirone and Hydroxyzine: Buspirone (BuSpar), a serotonin 1A partial agonist, is non-sedating and non-addictive but has a delayed onset. Hydroxyzine (Vistaril), an antihistamine, is often employed for short-term somatic anxiety but may cause sedation. In individuals aged 60 and older, the anticholinergic burden of hydroxyzine can lead to confusion or urinary retention; in children, drowsiness may affect functioning (Preston et al., 2021).
• Mirtazapine, Pregabalin, and Quetiapine Extended-Release: These off-label options may be used when first-line agents are ineffective. Mirtazapine (Remeron) can enhance sleep and appetite, but it often leads to weight gain, especially concerning clients with Type 2 diabetes. Pregabalin (Lyrica) may offer quick relief from physical symptoms, but it can result in sedation or misuse. Quetiapine XR (Seroquel XR) is sometimes utilized in treatment-resistant cases, but it requires metabolic monitoring due to risks such as weight gain and insulin resistance, particularly in older adults and among individuals experiencing food insecurity (Stahl, 2021; American Diabetes Association Professional Practice Committee, 2024).
• Benzodiazepines: Alprazolam (Xanax) and lorazepam (Ativan) may provide rapid symptom relief but carry significant risks of tolerance, dependence, and cognitive slowing. They are not recommended for long-term use and pose particular risks for older adults (e.g., fall risk, delirium) and youth (e.g., developmental impact; Preston et al., 2021).

Cultural and Ethical Considerations

Culturally competent assessment interviews should consider factors like acculturation, language proficiency, and historical mistrust when interpreting responses and scores (Sheperis et al., 2020). The cultural formulation interview (CFI) provides a structured framework for understanding an individual's cultural perspective on their clinical problems, including anxiety (Lewis-Fernández et al., 2016; APA, 2022). The CFI offers tools to explore how individuals define, perceive, and cope with their problems and their beliefs about causes, stressors, supports, and barriers to care. The interview emphasizes the importance of understanding cultural identity and its impact on the individual's condition, which can be particularly relevant for navigating anxiety in diverse populations (APA, 2022).

For some clients, spiritual and religious practices can serve as meaningful coping strategies that help regulate anxiety. Counselors should practice cultural humility when exploring how spirituality can act as both a protective factor and a potential barrier while respecting their beliefs and promoting emotional understanding (Parrow, 2024; Cashwell & Young, 2020).

Advocacy

Cultural stigma, social determinants of health, and systemic inequities significantly impact the presentation and management of GAD among diverse populations; this was particularly evident during the COVID pandemic (Ma et al., 2025). Advocacy-informed approaches are recommended when working with minority populations. Clients benefit most from treatments attuned to their language, worldviews, and values (Huey et al., 2023). Sustainable cultural competence is not a fixed endpoint but a continuous endeavor that requires ongoing advocacy for funding, policy reform, and training initiatives to expand access to culturally responsive interventions.

Systemic inequalities and limited access to health care may increase the likelihood and severity of GAD among minority communities (Ma et al., 2025). Professional counselors have an ethical obligation to advocate for policy reforms that address these disparities, particularly when public health systems inadequately serve clients facing barriers such as language access, citizenship status, or economic precarity. Advocacy in this context includes dismantling structural racism and institutional neglect (McAuliffe & Associates, 2020).

Gender, ethnicity, and socioeconomic status are strongly correlated with elevated rates of GAD among adolescents, especially during times of acute sociopolitical stress, such as the COVID-19 pandemic and immigration policy (Kumra & Patange, 2025; Fortuna et. al., 2025)). Counselors embedded in K-12 settings should seek specialized training and supervision to support youth- and school-based systemic action.

Culturally alert school-based interventions must recognize the intersectionality of students' diverse identities and how systemic oppression contributes to anxiety in educational environments (McAuliffe & Associates, 2020). These efforts to consider cultural reflect a counselor’s dual role as both a clinical professional and a systems-change advocate by adopting a stance of “critical consciousness” that interrogates the broader ecological understanding of the client’s experience of generalized anxiety, distress, and treatment.

Conclusion

Generalized anxiety disorder remains one of the most common and debilitating mental health conditions across all life stages, influenced by biological, psychological, cultural, and systemic factors. Accurate diagnosis relies on understanding DSM-5-TR criteria, assessment strategies, and rule-outs, using ICD-10-CM code F41.1 for clinical documentation in the U.S., and evaluating differential diagnoses through interdisciplinary consultation and collaboration (APA, 2022; Centers for Medicare & Medicaid Services & National Center for Health Statistics, 2023). Effective assessment and treatment require culturally responsive care that considers structural barriers, lived experience, and the client’s sociocultural context. Supporting clients with GAD involves more than symptom management; it includes helping clients regain a sense of control, fostering relational safety, and supporting wellness within the realities of complex and often inequitable ecological systems.

Resources

• DSM-5 Handbook on the Cultural Formulation Interview by R. Lewis-Fernández, N. K. Aggarwal, L. Hinton, D. E. Hinton, & L. J. Kirmayer
• Cross-cutting measures:
  • DSM-5-TR Online Assessment Measures (APA)
  • Level 1 Cross-Cutting Symptom Measure — Adult
  • Level 1 Cross-Cutting Symptom Measure — Child 11–17 (Self-Rated)
  • Level 1 Cross-Cutting Symptom Measure — Parent/Guardian of Child Age 6–17
• Anxiety and Depression Association of American (ADAA): Offers webinars with CE/CME credit, clinical tools, and free client resources.
• The National Institute of Mental Health (NIMH): Provides evidence-based information on GAD.
• National Alliance on Mental Health (NAMI): Provides resources on GAD including symptom and treatment guides.

To Cite This Practice Brief:

Duggan, J., & Isiko, J. (2026, March) Generalized anxiety disorder [Practice Brief]. Counseling Nexus. https://doi.org/10.63134/JVNU5767

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