Telephone Assessment for New Patient with GAD-7 Score of 11

Immediate Safety Screening

• The American College of Oncology recommends that patients with a GAD-7 score of 11 should be immediately screened for safety concerns, including suicidal ideation, self-harm thoughts, or intent to harm others, with any positive response requiring immediate psychiatric referral or emergency evaluation 1, 2
• Patients should also be screened for severe agitation, psychotic symptoms, or confusion/delirium, as these warrant urgent specialist evaluation 1, 2

Assess Functional Impairment

• The assessment should determine how anxiety symptoms interfere with work, home responsibilities, and relationships, with moderate GAD typically causing mild to moderate functional impairment 1, 2
• The level of functional impairment should be assessed to guide treatment intensity, with symptoms interfering "moderately" versus "markedly" with daily functioning 1, 2
• Specific examples of functional impairment, such as missing work, avoiding social situations, or difficulty completing household tasks, should be asked about 2

Screen for Comorbidities and Risk Factors

• The American College of Oncology recommends systematically assessing for major depressive disorder using PHQ-9 or by asking about depressed mood, anhedonia, and other depressive symptoms, as depression commonly co-occurs with GAD 3
• Patients should be asked about alcohol or substance use/abuse, as this frequently complicates anxiety disorders and must be treated concurrently 1, 2
• Other chronic medical illnesses, family history of anxiety or mood disorders, and other anxiety disorders, such as panic attacks or social phobia, should be screened for 1, 2

Assess Coping and Support

• The patient's current coping strategies and access to social support should be assessed to determine the treatment approach 1, 2
• The patient's prior experiences with self-help, relaxation techniques, therapy, or medications should be determined 2

Treatment Decision Algorithm

• With a GAD-7 score of 10-14, the American College of Oncology recommends offering referral to psychology/psychiatry for diagnosis and formal treatment, as guidelines recommend specialist involvement at this severity level 1, 2
• If specialist access is limited or delayed, low-intensity interventions, such as education about GAD, guided self-help, and consideration of starting an SSRI or SNRI, should be initiated 2
• Active monitoring with follow-up in 2-4 weeks to reassess symptoms and functional impairment is recommended 2

Common Pitfalls to Avoid

• Comorbid depression should not be missed, and patients should be screened with PHQ-9 or direct questioning about depressive symptoms, as GAD and major depression frequently co-occur 3
• Substance use disorders should not be overlooked, as they require concurrent treatment and complicate anxiety management 1

Diagnostic and Treatment Considerations for Generalized Anxiety Disorder (GAD) and Adjustment Disorder

Diagnostic Criteria

• The American Psychiatric Association characterizes Generalized Anxiety Disorder (GAD) by persistent and excessive anxiety and worry about various domains that is difficult to control 4
• GAD involves worry about multiple areas beyond just a single concern or stressor 4
• Symptoms of GAD include restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance 4
• Patients with GAD typically present with excessive worry about multiple areas of life 4
• Worry in GAD is described as difficult to control or "uncontrollable" 5
• Cultural variations exist in GAD presentation, with non-Western populations more likely to report somatic symptoms 6, 7
• Common somatic symptoms in GAD include fatigue, muscle tension, sleep disturbance, palpitations, dizziness, and indigestion 5, 7

Treatment Approach

• First-line treatments for GAD include cognitive-behavioral therapy (CBT) and antidepressants (SSRIs, SNRIs) 4, 8
• For moderate to severe GAD symptoms, combined psychotherapy and pharmacotherapy is often recommended 8
• GAD must be distinguished from normal worries and fears that are common to everyday life 4
• Both GAD and adjustment disorder can be comorbid with major depressive disorder, requiring assessment for depressive symptoms 4
• Overlooking cultural variations in GAD presentation, particularly somatic symptoms that are common in non-Western populations, is a clinical pitfall to avoid 5, 6, 7

Diagnosis and Assessment of Generalized Anxiety Disorder

Screening and Assessment

• The American College of Physicians recommends using the GAD-7 (Generalized Anxiety Disorder-7 scale) as the primary screening instrument, which assesses seven key symptoms over the past 2 weeks, with scores guiding treatment intensity, ranging from no intervention for scores 0-4 to high-intensity interventions for scores 15-21 9, 10

• The GAD-7 scores are interpreted as follows:

  Score	Interpretation
  0-4	None, monitor
  5-9	Mild, low-intensity interventions
  10-14	Moderate, referral to psychology/psychiatry
  15-21	Severe, immediate referral to mental health specialist

  9

  Essential Diagnostic Considerations

• The American Psychiatric Association suggests systematically evaluating risk factors, including personal psychiatric history, comorbid psychiatric conditions, substance use history, chronic medical illnesses, and major life stressors, to inform treatment planning 9, 10
• The National Institute of Mental Health recommends assessing functional impairment, including specific examples of how anxiety interferes with daily functioning, to guide treatment intensity 9

Differential Diagnosis

• The Diagnostic and Statistical Manual of Mental Disorders (DSM) distinguishes GAD from other anxiety disorders, such as panic disorder, social anxiety disorder, specific phobias, and PTSD, which have more specific foci, and recommends screening for these comorbid anxiety disorders 9, 10
• The International Classification of Diseases (ICD) differentiates GAD from adjustment disorder, which requires a clear precipitating stressor, and recommends assessing for depressive symptoms, as both conditions can be comorbid with major depressive disorder 10

Diagnostic Criteria and Screening for Generalized Anxiety Disorder

Core Diagnostic Features

• The primary symptom of generalized anxiety disorder is excessive, uncontrollable worry that the patient describes as “uncontrollable” or difficult to control, persisting for at least six months across multiple life domains【11】.
• According to the American Psychiatric Association, a diagnosis requires ≥3 of the 6 associated symptoms; one of these is restlessness (feeling keyed up or on edge)【12】.

Functional Impairment

• GAD must produce clinically significant distress or impairment in social, occupational, or other important areas of functioning【11】.
• Moderate GAD typically leads to mild‑to‑moderate functional limitation, whereas severe GAD markedly interferes with daily activities【11】.

Screening Tools

• The American College of Physicians recommends the GAD‑7 as the primary screening instrument, evaluating seven core anxiety symptoms over the past two weeks【12】.

• GAD‑7 severity stratification:

  Score	Interpretation	Recommended action
  0‑4	Minimal/no anxiety	Monitor only
  5‑9	Mild anxiety	Low‑intensity interventions
  10‑14	Moderate anxiety	Referral to psychology/psychiatry
  15‑21	Severe anxiety	Immediate specialist referral

• The GAD‑7 items assess: feeling nervous/on edge, inability to stop/control worry, excessive worry about different things, trouble relaxing, restlessness, irritability, and fear of something awful happening【11】.
• GAD‑Q‑IV (9‑item self‑report) and the Penn State Worry Questionnaire (PSWQ) (16‑item scale) are validated alternatives for assessing DSM criteria and worry severity, respectively【12】.

Exclusion Criteria

• Before confirming GAD, clinicians must rule out medical conditions that can mimic anxiety, including hyperthyroidism, hyperparathyroidism, cardiac arrhythmias, and other chronic medical illnesses【12】【11】.
• Substance‑induced anxiety (e.g., alcohol, stimulants, caffeine) must be identified and treated concurrently【11】.
• Medication‑induced anxiety (e.g., interferon, corticosteroids) should be evaluated as a possible cause【12】.

Risk Factors and Comorbidities

• Prior anxiety disorder diagnoses increase the likelihood of current GAD【11】.
• Major depressive disorder co‑occurs in approximately 31 % of GAD cases; screening with the PHQ‑9 is advised【11】.
• Current or past alcohol/substance use or abuse are recognized risk factors【11】.
• The presence of other chronic medical illnesses also raises GAD risk【11】.

Diagnostic Criteria for Generalized Anxiety Disorder

Core Diagnostic Requirements

• A diagnosis of Generalized Anxiety Disorder requires the presence of excessive, uncontrollable worry about multiple topics that persists for at least six months in the individual. 13
• The worry must be clearly excessive and difficult for the patient to control. 13

Symptom Threshold

• In addition to the core worry, at least three of the following six associated symptoms must be present:

  Symptom	Citation
  Restlessness or feeling on edge	13
  Easy fatigue	13
  Difficulty concentrating or mind going blank	13
  Irritability	14
  Muscle tension	14
  Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)	14

Functional Impairment

• The anxiety and worry must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 13

Screening Versus Formal Diagnosis

• The GAD‑7 screening instrument comprises seven items; a total score of ≥8–9 is commonly used as a screening threshold, but this does not constitute a formal diagnosis. 15
• Formal DSM diagnostic criteria require only three of the six associated symptoms (as outlined above), regardless of the GAD‑7 score. 13
• Clinicians should avoid conflating screening cut‑offs with diagnostic criteria; a positive GAD‑7 prompts further evaluation, but a definitive diagnosis must still meet the symptom count and functional‑impairment requirements. 15