Generalized Anxiety Disorder

Definition

Generalized Anxiety Disorder is a condition in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) category of Anxiety Disorders.

Generalized Anxiety Disorder is characterized by persistent and excessive anxiety and worry which is far out of proportion to the actual likelihood or impact of the anticipated event(s). The worry is often about everyday circumstances (e.g., the health of family members, being late for appointments, finances). The focus of concern may shift from one concern to another.

Criteria Set for Generalized Anxiety Disorder

The Generalized Anxiety Disorder criteria set is derived from the DSM-5.

Generalized Anxiety Disorder:

Criterion A

Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

Criterion B

The individual finds it difficult to control the worry.

Criterion C

The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months).

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 (difficulty falling or staying asleep, or restless, unsatisfying sleep).

Criterion D

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

Criterion E

The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., Hyperthyroidism).

Criterion F

The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in Panic Disorder, negative evaluation in Social Anxiety Disorder [Social Phobia], contamination or other obsessions in Obsessive-Compulsive Disorder, separation from attachment figures in Separation Anxiety Disorder, reminders of traumatic events in Posttraumatic Stress Disorder, gaining weight in Anorexia Nervosa, physical complaints in Somatic Symptom Disorder, perceived appearance flaws in Body Dysmorphic Disorder, having a serious illness in Illness Anxiety Disorder, or the content of delusional beliefs in Schizophrenia or Delusional Disorder).

Diagnostic Standard

A diagnosis from a qualified medical practitioner (family physician or psychiatrist) or a registered/licensed psychologist is required.

The diagnosis is made clinically. Supporting documentation should be as comprehensive as possible.

NOTE: Entitlement should be granted for a chronic condition only. For VAC purposes, "chronic" means the signs and symptoms of the condition have existed for at least six months. Signs and symptoms are generally expected to persist despite medical attention, although they may wax and wane over the six month period and thereafter.

Entitlement Considerations

A. Causes And / Or Aggravation

Causal or Aggravating Factors versus Predisposing Factors

Causal or aggravating factors directly result in the onset or aggravation of the claimed psychiatric condition.

Predisposing factors do not cause a claimed condition. Predisposing factors are experiences or exposures which affect the individual's ability to cope with stress. Predisposing factors makes an individual more susceptible to developing the claimed condition. For example, the presence of a remote history of severe childhood abuse may be a predisposing factor in the onset of a significant psychiatric condition later in life.

Partial entitlement should only be considered for non-service related causal or aggravating factors.

Partial entitlement should not be considered for predisposing factors.

If it is unclear if a factor is a causal or aggravating factor versus a predisposing factor consultation with Medical Advisory is strongly recommended.

NOTE: The factors listed in Section A of the Entitlement Considerations include specific timelines for the clinical onset or aggravation of Generalized Anxiety Disorder. The timelines are not binding. Each case should be adjudicated on the evidence provided and its own merits. If the medical evidence indicates an alternate timeline, consultation with Medical Advisory is strongly recommended.

NOTE: The following list of factors is not all inclusive. Factors, other than those listed in Section A, may be claimed to cause or aggravate Generalized Anxiety Disorder. Other factors may be considered based on the individual merits and medical evidence provided for each case. Consultation with Medical Advisory is strongly recommended.

1. Being a prisoner of war before the clinical onset or aggravation of Generalized Anxiety Disorder
2. Directly experiencing a traumatic event(s) within the five years before the clinical onset or aggravation of Generalized Anxiety Disorder
   
   Traumatic events include, but are not limited to:
   1. exposure to military combat
   2. threatened physical assault or being physically assaulted
   3. threatened sexual assault or being sexually assaulted
   4. being kidnapped
   5. being taken hostage
   6. being in a terrorist attack
   7. being tortured
   8. being in a natural or human-made disaster
   9. killing or injuring a person in a non-criminal act
   10. experiencing a sudden, catastrophic medical incident
3. Witnessing, in person, a traumatic event(s) as it occurred to another person(s) within the five years before the clinical onset or aggravation of Generalized Anxiety Disorder
   
   Witnessed traumatic events include, but are not limited to:
   1. threatened or serious injury to another person
   2. an unnatural death
   3. physical or sexual abuse of another person
   4. a medical catastrophe in a close family member or close friend
4. Learning a close family member or close friend experienced a violent or accidental traumatic event(s) within the two years before the clinical onset or aggravation of Generalized Anxiety Disorder
   
   Traumatic events include, but are not limited to:
   1. physical assault
   2. sexual assault
   3. serious accident
   4. serious injury
5. Experiencing repeated or extreme exposure to aversive details of a traumatic event(s) within the five years before the clinical onset or aggravation of Generalized Anxiety Disorder
   
   Exposures include, but are not limited to:
   1. viewing and/or collecting human remains
   2. viewing and/or participating in the clearance of critically injured casualties
   3. repeated exposure to the details of abuse and/or atrocities inflicted on another person(s)
   4. dispatch operators exposed to violent or accidental traumatic event(s)
   Note: Factor 5 applies to exposure through electronic media, television, movies and pictures only if the exposure is work related.
6. Living or working in a hostile or life-threatening environment for a period of at least four weeks before the clinical onset or aggravation of Generalized Anxiety Disorder

   Situations or settings which have a pervasive threat to life or bodily integrity including but not limited to:

   1. being under threat of artillery, missile, rocket, mine or bomb attack
   2. being under threat of nuclear, biologic or chemical agent attack
   3. being involved in combat or going on combat patrols
7. Experiencing the death of a close family member or close friend within the two years before the clinical onset or aggravation of Generalized Anxiety Disorder
8. Experiencing a stressful life event within one year before the clinical onset or aggravation of Generalized Anxiety Disorder

   Events which qualify as stressful life events include, but are not limited to:

   1. being socially isolated and unable to maintain friendships or family relationships, due to physical location, language barriers, disability, or medical or psychiatric illness
   2. experiencing a problem with a long-term relationship including: the break-up of a close personal relationship, the need for marital or relationship counselling, marital separation, or divorce
   3. having concerns in the work or school environment including: on-going disharmony with fellow work or school colleagues, perceived lack of social support within the work or school environment, perceived lack of control over tasks performed and stressful workloads, or experiencing bullying in the workplace or school environment
   4. experiencing serious legal issues including: being detained or held in custody, on-going involvement with law enforcement concerning violations of the law, or court appearances associated with personal legal problems
   5. having severe financial hardship including, but not limited to: loss of employment, long periods of unemployment, foreclosure on a property, or bankruptcy
   6. having a close family member or close friend experience a major deterioration in their health
   7. being a full-time caregiver to a family member or close friend with a severe physical, mental or developmental disability
9. Having a clinically significant psychiatric condition within the ten years before the clinical onset or aggravation of Generalized Anxiety Disorder
   
   A clinically significant psychiatric condition is a mental disorder as defined in the DSM-5.
10. Having a medical illness or injury which is life-threatening or which results in serious physical or cognitive disability within the five years before the clinical onset or aggravation of Generalized Anxiety Disorder
11. Having chronic pain of at least three months duration at the time of the clinical onset or aggravation of Generalized Anxiety Disorder
12. Having epilepsy at the time of the clinical onset or aggravation of Generalized Anxiety Disorder
13. Having experienced severe childhood abuse before the clinical onset of Generalized Anxiety Disorder
    
    Severe childhood abuse is:
    1. serious physical, emotional, psychological or sexual harm to a child under the age of 16 years; or
    2. neglect involving a serious failure to provide the necessities for health, physical and emotional development, or wellbeing of a child under the age of 16 years;

    where such serious harm or neglect has been perpetrated by a parent, a care provider, an adult who works with or around the child, or any other adult in contact with the child.

14. Inability to obtain appropriate clinical management of Generalized Anxiety Disorder

B. Medical Conditions Which Are To Be Included In Entitlement / Assessment

NOTE: If specific conditions are listed for a category, only these conditions are included in the entitlement and assessment of Generalized Anxiety Disorder.

If no conditions are listed for a category, all conditions within the category are included in the entitlement and assessment of Generalized Anxiety Disorder.

• Other Anxiety Disorders
• Trauma- and Stressor-Related Disorders
• Obsessive-Compulsive and Related Disorders
• Depressive Disorders
• Bipolar and Related Disorders
• Schizophrenia Spectrum and other Psychotic Disorders
• Personality Disorders
• Feeding and Eating Disorders
• Substance-Related and Addictive Disorders
• Dissociative Disorders
• Somatic Symptom and Related Disorders
  • Somatic Symptom Disorder
  • Illness Anxiety Disorder
  • Conversion Disorder
• Pain Disorders/Chronic Pain Syndrome (DSM-IV-TR Axis I Diagnosis)
• Sleep-Wake Disorders
  • Insomnia Disorder
  • Hypersomnolence Disorder
• Neurodevelopmental Disorders
  • Attention-Deficit/Hyperactivity Disorder
• Decreased Libido - if the medical information indicates decreased libido is a symptom of a psychiatric condition.

Separate entitlement is required for a DSM-5 condition not included in Section B of the Generalized Anxiety Disorder Entitlement Eligibility Guideline.

C. Common Medical Conditions Which May Result In Whole Or In Part From Generalized Anxiety Disorder And / Or Its Treatment

Section C medical conditions may result in whole or in part as a direct result of Generalized Anxiety Disorder, from the treatment of Generalized Anxiety Disorder or the combined effects of Generalized Anxiety Disorder and its treatment.

Conditions listed in Section C of the Entitlement Considerations are only granted entitlement if the individual merits and medical evidence of the case determines a consequential relationship exists. Consultation with Medical Advisory is strongly recommended.

If it is claimed a medication required to treat Generalized Anxiety Disorder resulted in whole, or in part, in the clinical onset or aggravation of a medical condition the following must be established:

1. The individual was receiving the medication at the time of the clinical onset or aggravation of the medical condition.
2. The medication was used for the treatment of the Generalized Anxiety Disorder.
3. The medication is unlikely to be discontinued or the medication is known to have enduring effects after discontinuation.
4. The individual's medical information and the current medical literature support the medication can result in the clinical onset or aggravation of the medical condition.
5. Note: Individual medications may belong to a class, or grouping, of medications. The effects of a specific medication may vary from the grouping. The effects of the specific medication should be considered and not the effects of the group.

The list of Section C conditions is not all inclusive. Conditions, other than those Listed in Section C, may be claimed to have a consequential relationship toGeneralized Anxiety Disorder and/or its treatment. Other conditions may be considered for entitlement based on the individual merits and medical evidence provided for each case. Consultation with Medical Advisory is strongly recommended.

• Sexual Dysfunction (e.g., Erectile Dysfunction)
• Irritable Bowel Syndrome
• Bruxism
• Xerostomia
• Periodic Limb Movement Disorder
• Restless Leg Syndrome
• Obstructive Sleep Apnea

References For Generalized Anxiety Disorder

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Revision (DSM-IV-TR) Washington: American Psychiatric Association, 2000.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Revision ( DSM-IV-TR ) Washington: American Psychiatric Association, 2000.
3. Australia. (2010). Amendment statement of principles concerning anxiety disorder. No. 42 of 2010.
4. Australia. (2011). Amendment statement of principles concerning anxiety disorder. No. 15 of 2011.
5. Australia. (2007). Statement of principles concerning anxiety disorder. No. 102 of 2007.
6. Australia. (2010). Amendment statement of principles concerning anxiety disorder. No. 43 of 2010.
7. Australia. (2011). Amendment statement of principles concerning anxiety disorder. No. 16 of 2011.
8. Sadock B.J., Sadock V.A. Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 8th ed. Philadelphia: Lippincott Williams & Wilkins, 2005.