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This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
The Bottom Line
- GAD = excessive worry about multiple topics more days than not for >=6 months
- Symptoms include restlessness, fatigue, poor concentration, irritability, muscle tension, and sleep disturbance
- Rule out hyperthyroidism, arrhythmia, asthma/COPD, caffeine/stimulants, withdrawal, and medication effects
- First-line: CBT and SSRI/SNRI; buspirone is scheduled and takes weeks
- Benzodiazepines are short-term bridges only in selected patients
Overview
Generalized anxiety disorder is persistent excessive anxiety and worry that is difficult to control, occurs about multiple activities, and causes distress or impairment. DSM-5-TR requires symptoms for at least 6 months and at least 3 associated symptoms in adults. The anxiety is not confined to panic attacks, social scrutiny, obsessions, trauma reminders, or somatic concerns.
Epidemiology
GAD often begins in adolescence or early adulthood and commonly coexists with MDD, panic disorder, social anxiety disorder, insomnia, chronic pain, irritable bowel syndrome, and substance use. Patients frequently present with somatic symptoms rather than naming worry.
Clinical Features
Symptoms
Excessive worry about work, school, health, finances, or family
Restlessness or feeling keyed up/on edge
Muscle tension, headaches, GI discomfort, fatigue
Poor concentration, irritability, or sleep disturbance
Suicidal ideation, severe depression, psychosis, or inability to function
Signs
Anxious affect, reassurance-seeking, fidgeting, muscle tension
Normal physical examination is common
Tachycardia, tremor, diaphoresis, or weight loss suggests medical/substance mimic
Signs of intoxication or withdrawal
Investigations
First-line
DSM-5-TR assessmentDocument duration >=6 months, worry domains, impaired control, associated symptoms, and impairment
Depression/suicide screenGAD commonly coexists with MDD and substance use
Focused medical screenTSH, CBC, CMP, pregnancy test, ECG, toxicology when indicated by atypical or new symptoms
Second-line
GAD-7Severity and monitoring tool
Medication/substance reviewCaffeine, stimulants, decongestants, albuterol, steroids, thyroid hormone, alcohol/benzodiazepine withdrawal
Differentiate anxiety disordersPanic attacks, social scrutiny, obsessions, and trauma point to other diagnoses
Specialist
Psychotherapy/psychiatry referralSevere impairment, suicidality, SUD, treatment resistance, or structured CBT preference
1
First-line treatment
- CBT targeting worry exposure, cognitive restructuring, relaxation, and intolerance of uncertainty
- SSRI/SNRI such as escitalopram, sertraline, paroxetine, venlafaxine, or duloxetine; start low and titrate slowly
- Education and scheduled follow-up to avoid reassurance loops
2
Medication alternatives
- Buspirone is non-sedating, nonaddictive, scheduled, and delayed onset
- Hydroxyzine can be used short-term but is sedating and anticholinergic
- Avoid chronic benzodiazepines due to dependence, falls, cognitive effects, and overdose risk
3
Long-term care
- Continue medication 6-12 months after response before gradual taper if stable
- Treat insomnia, caffeine excess, comorbid depression, pain, and substance use
- Use functional recovery as a key outcome
Complications
- Major depression:
- Alcohol or sedative self-medication:
- Functional impairment and avoidance:
- Chronic insomnia:
- Benzodiazepine tolerance/dependence:
USMLE Step 2 CK Exam Tips
- 1GAD duration is >=6 months; panic disorder is discrete unexpected attacks
- 2Buspirone is scheduled, not PRN
- 3First-line long-term pharmacology is SSRI/SNRI, not alprazolam
- 4New anxiety with weight loss/tremor/tachycardia: check hyperthyroidism or stimulants
- 5CBT is a correct first-line answer
- 6Avoid benzodiazepines in older adults with falls/cognitive impairment
practicetest your knowledge on generalized anxiety disorderApply what you've learnt with USMLE Step 2 CK-style questions from the iatroX Q-Bank — psychiatry and beyond.
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