The Natural History of Generalized Anxiety Disorder: A Review

Catherine L. Woodman, MD


Medscape Psychiatry & Mental Health eJournal. 1997;2(3) 

In This Article

Diagnostic Criteria

A major change in the nosology of anxiety disorders occurred in 1980, when changes in classification adopted by the American Psychiatric Association (APA) separated anxiety neurosis (DSM-II) into (1) panic disorder, characterized by spontaneous episodes of intense anxiety, and (2) GAD, a residual category for patients who have chronic, sustained anxiety without panic attacks (DSM-III).[2] The distinction between these 2 disorders was defended at the time by the observation of a differential response to medication. Klein[3] noted that panic disorder responded to imipramine while GAD responded best to benzodiazepines (although it has been demonstrated more recently that patients with GAD also respond to imipramine as well as or better than to benzodiazepines if taken for a sufficient length of time[4]). In DSM-III, hierarchical rules prohibited the diagnosis of GAD if another psychiatric disorder was comorbid with the chronic anxiety symptoms.

In DSM-III-R, GAD was given independent status, with clearly defined symptom criteria.[5] The trait of excessive worry was identified as the core symptom of GAD. With the revised classification, most hierarchical rules were eliminated, making it possible for patients to meet criteria for GAD and other anxiety or depressive disorders simultaneously. Current diagnostic criteria from DSM-IV are listed in Table I.[6] In contrast to DSM-III-R, DSM-IV eliminated from the criteria the autonomic symptoms of anxiety: Although these symptoms are common in GAD, they had led to diagnostic confusion with panic attacks. The 6 remaining symptoms are characteristic of prolonged, excessive arousal.

The changes in diagnostic criteria from DSM-III to DSM-IV are summarized in Table II. Over time, the criteria for GAD have been more systematically studied; in DSM-IV, the symptom checklist has been consolidated to reflect symptoms that best discriminate between normal and pathologic anxiety.


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