Journal List > J Korean Neuropsychiatr Assoc > v.51(1) > 1017575

Kim: Diagnosis and Psychological Assessment of Generalized Anxiety Disorder


Of the anxiety disorders which may be identified in a clinical setting, generalized anxiety disorder (GAD) has often been overlooked for several reasons : 1) its unremarkable place in the diagnostic hierarchy, 2) relationship to excessive anxiety and worry, and 3) comorbidity with other mental disorders which may take clinical precedence. However, clinicians should be attentive to the clinical signs leading to a diagnosis of GAD. This paper reviewed the availability of reliable assessment tools to help clinicians diagnose and assess GAD. First, diagnostic interview tools targeting GAD were introduced. Then, the tools for assessing worry (intensity/frequency/topic), factors associated with its maintenance (cognitive avoidance, intolerance of uncertainty), and tools for assessing generalized anxiety (severity/aspects), comorbid condition and differential diagnosis were reviewed. Lastly, cultural and developmental aspects related to GAD were addressed. The considerations included in this report were summarized in a flow chart and table that are practically useful in the diagnoses and assessment of GAD. Thus, this review provided guidelines for clinicians in the Korean psychiatric setting to enable appropriate diagnosis, assessment, and treatment of GAD.


1. American Psychiatric Association. Diagnostic and Statistical Manual of mental disorders. 2000. 4th ed. Washington DC: American Psychiatric Association.
2. Sadock BJ, Kaplan HI, Sadock VA. Synopsis of psychiatry. 2007. 10th ed. Philadelphia: Lippincott Williams & Wilkins: A Wolters Kluwer Business;622–627.
3. Oh KS. Diagnosis and differential diagnosis of generalized anxiety disorder. Korean J Psychopharmacol. 2004. 15:3–8.
4. Lee SH, Yang JC, Suh HS, Lee JY, Kim MS, Kim CH, et al. Korean medication algorithm project for generalized anxiety disorder 2009 (III): treatment strategy for comorbid conditions. J Korean Neuropsychiatr Assoc. 2010. 49:564–569.
5. Maier W, Gänsicke M, Freyberger HJ, Linz M, Heun R, Lecrubier Y, et al. Generalized anxiety disorder (ICD-10) in primary care from a cross-cultural perspective: a valid diagnostic entity? Acta Psychiatr Scand. 2000. 101:29–36.
6. Zimmerman M, Chelminski I. Generalized anxiety disorder in patients with major depression: is DSM-IV's hierarchy correct? Am J Psychiatry. 2003. 160:504–512.
7. Borkovec TD, Costello E. Efficacy of applied relaxation and cognitive-behavioral therapy in the treatment of generalized anxiety disorder. J Consult Clin Psychol. 1993. 61:611–619.
8. Tallis F, Davey GC, Capuzzo N. Davey GCL, Tallis F, editors. The phenomenology of nonpathological worry: a preliminary investigation. Worrying perspectives on theory, assessment and treatment. 1994. Chichester: Wiely;61–89.
9. Yoo SJ, Kwon SM. Personality trait of worries. Psychol Sci. 2000. 9:15–37.
10. Blalock JA, Joiner TE. Interaction of cognitive avoidance coping and stress in predicting depression/anxiety. Cogn Ther Res. 2000. 24:47–65.
11. Brawman-Mintzer O, Lydiard RB, Emmanuel N, Payeur R, Johnson M, Roberts J, et al. Psychiatric comorbidity in patients with generalized anxiety disorder. Am J Psychiatry. 1993. 150:1216–1218.
12. Kessler RC, Keller MB, Wittchen HU. The epidemiology of generalized anxiety disorder. Psychiatr Clin North Am. 2001. 24:19–39.
13. Gasperini M, Battaglia M, Diaferia G, Bellodi L. Personality features related to generalized anxiety disorder. Compr Psychiatry. 1990. 31:363–368.
14. Noyes R Jr. Comorbidity in generalized anxiety disorder. Psychiatr Clin North Am. 2001. 24:41–55.
15. Watson D. Rethinking the mood and anxiety disorders: a quantitative hierarchical model for DSM-V. J Abnorm Psychol. 2005. 114:522–536.
16. Leahy R, Holland S. Treatment plans and interventions for depression and anxiety disorders. 2000. New York: Guilford Press.
17. Gordon D, Heimberg RG. Reliability and validity of DSM-IV generalized anxiety disorder features. J Anxiety Disord. 2011. 25:813–821.
18. Nut DJ. Generalized anxiety disorder: a comorbid disease. Eur Neuropsychopharmacol. 2004. 16:S109–S118.
19. Allgulander C. Generalized anxiety disorder: between now and DSM-V. Psychiatr Clin North Am. 2009. 32:611–628.
20. Goodman WK. Selecting pharmacotherapy for generalized anxiety disorder. J Clin Psychiatry. 2004. 65:Suppl 13. 8–13.
21. Kim MS, Yu BH, Kim CH, Yang JC, Lee SH, Lee JY, et al. Korean medication algorithm project for generalized anxiety disorder 2009 (1): initial treatment strategy. J Korean Neuropsychiatr Assoc. 2010. 49:546–552.
22. Lee JY, Kim MS, Lee SH, Yang JC, Kim CH, Yu BH, et al. Korean medication algorithm project of generalized anxiety disorder 2009 (II): medication algorithm & long-term medication treatment strategy. J Korean Neuropsychiatr Assoc. 2010. 49:553–563.
23. Brown TA, Di Nardo PA, Barlow DH. Anxiety Disorders Interview Schedule for DSM-IV. 1994. San Antonio, TX: The Psychological Corporation.
24. Brown TA, Di Nardo PA, Lehman CL, Campbell LA. Reliability of DSM-IV anxiety and mood disorders: implications for the classification of emotional disorders. J Abnorm Psychol. 2001. 110:49–58.
25. Di Nardo P, Moras K, Barlow DH, Rapee RM, Brown TA. Reliability of DSM-III-R anxiety disorder categories. Using the Anxiety Disorders Interview Schedule-Revised (ADIS-R). Arch Gen Psychiatry. 1993. 50:251–256.
26. Newman MG, Zuellig AR, Kachin KE, Constantino MJ, Przeworski A, Erickson T, et al. Preliminary reliability and validity of the generalized anxiety disorder questionnaire-IV: a revised self-report diagnostic measure of generalized anxiety disorder. Behavior Therapy. 2002. 33:215–233.
27. Kim KH. Diagnosis and evaluation of Generalized anxiety disorder. The 2ed Simposium of Psychopathology Research Society. 2007. 11. 26. Seoul: Psychopathology Research Society under Korean Clinical Psychological Association.
28. Meyer TJ, Miller ML, Metzger RL, Borkovec TD. Development and validation of the Penn State Worry Questionnaire. Behav Res Ther. 1990. 28:487–495.
29. Molina S, Borkovec TD. Davey GCL, Tallis F, editors. The Penn State Worry Questionnaire: psychometric properties and associated characteristics. Worrying: Perspectives on theory, assessment, and treatment. 1994. New York: Wiley;265–283.
30. Kim JW, Min BB. Intolerance of uncertainty and problem orientation in worry. A annual convention of the Korean Psychological Association. 1998. Seoul: The Korean Psychological Association;83–92.
31. Lim YJ, Kim YH, Lee EH, Kwon SM. The Penn State Worry Questionnaire: psychometric properties of the Korean version. Depression and Anxiety. 2008. 25:E97–E103.
32. Rygh JL, Sanderson WC. Treating generalized anxiety disorder: evidence-based strategies, tools, and techniques. 2004. New York: Guilford.
33. Borkovec TD, Hazlett-Stevens H, Diaz ML. The role of positive beliefs about worry in generalized anxiety disorder and its treatment. Clin Psychol Psychother. 1999. 6:126–138.
34. Tallis F, Eysenck M, Mathews A. Elevated evidence requirements and worry. Per Individ Differ. 1991. 12:21–27.
35. Stöber J. Worry, problem elaboration and suppression of imagery: the role of concreteness. Behav Res Ther. 1998. 36:751–756.
36. Cho SH. Effects of positive and negative beliefs about worry on two types of worry [dissertation]. 2002. Seoul: Seoul University.
37. Roemer L, Medaglia E. Antorny MM, Orsillo SM, Roemer L, editors. Generalized anxiety disorder: a brief overview and guide to assessment. Practitioner's guide to empirically based measures of anxiety. 2001. New York: Kluwer Academic Publisher;189–195.
38. Davey GC, Tallis F, Capuzzo N. Beliefs about the consequences of worrying. Cognit Ther Res. 1996. 20:499–520.
39. Borkovec TD, Inz J. The nature of worry in generalized anxiety disorder: a predominance of thought activity. Behav Res Ther. 1990. 28:153–158.
40. Roemer L, Salters K, Raffa SD, Orsillo SM. Fear and avoidance of internal experiences in GAD: preliminary tests of a conceptual model. Cognit Ther Res. 2005. 29:71–88.
41. Gosselin P, Langlois F, Freeston MH, Ladouceur R, Laberge M, Lemay D. Cognitive variables related to worry among adolescents: avoidance strategies and faulty beliefs about worry. Behav Res Ther. 2007. 45:225–233.
42. Sexton KA, Dugas MJ. The Cognitive Avoidance Questionnaire: validation of the English translation. J Anxiety Disord. 2008. 22:355–370.
43. Song SJ, Kim EJ. A validation study of the Korean version of the Cognitive Avoidance Questionnaire. Korean J Clin Psychol. 2009. 28:515–531.
44. Dugas MJ, Schwartz A, Francis K. Intolerance of uncertainty, worry, and depression. Cognit Ther Res. 2004. 28:835–842.
45. Yook K, Kim KH, Suh SY, Lee KS. Intolerance of uncertainty, worry, and rumination in major depressive disorder and generalized anxiety disorder. J Anxiety Disord. 2010. 24:623–628.
46. Dugas MJ, Marchand A, Ladouceur R. Further validation of a cognitive-behavioral model of generalized anxiety disorder: diagnostic and symptom specificity. J Anxiety Disord. 2005. 19:329–343.
47. Freeston M, Rhéaume J, Letarte H, Dugas K, Ladouceur R. Why do people worry? Pers Individ Differ. 1994. 17:791–802.
48. Dugas MJ, Gagnon F, Ladouceur R, Freeston MH. Generalized anxiety disorder: a preliminary test of a conceptual model. Behav Res Ther. 1998. 36:215–226.
49. Choi HK. Dysfunctional effects of chronic worry on problem-solving [dissertation]. 1997. Seoul: Joong-Ang University.
50. Oh YA. The relationship between intolerance of uncertainty and worry: The mediation effects of experiential avoidance [Thesis]. 2009. Seoul: Catholic University.
51. Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol. 1988. 56:893–897.
52. Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA. Manual for the State-Trait Anxiety Inventory (Form Y). 1983. Palo Alto, CA: Mind Garden.
53. Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol. 1959. 32:50–55.
54. Lovibond PF, Lovibond SH. The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav Res Ther. 1995. 33:335–343.
55. Brown TA, Chorpita BF, Korotitsch W, Barlow DH. Psychometric properties of the Depression Anxiety Stress Scales (DASS) in clinical samples. Behav Res Ther. 1997. 35:79–89.
56. Lehrer PM, Woolfolk RL. Self-report assessment of anxiety: somatic, cognitive, and behavioral modalities. Behav Assess. 1982. 4:167–177.
57. Scholing A, Emmelkamp PM. Self report assessment of anxiety: a cross validation of the Lehrer Woolfolk Anxiety Symptom Questionnaire in three populations. Behav Res Ther. 1992. 30:521–531.
58. First MB, Gibbon M, Spitzer RL, Williams JBW. Structured Clinical Interview for DSM-IV Axis I Disorders, Research Version (SCID-I). 1996. New York: Biometrics Research, New York State Psychiatric Institute.
59. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998. 59:Suppl 20. 22–33. quiz 34–quiz 57.
60. First MB, Gibbon M, Spitzer RL, Williams JBW, Bengamin LS. Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). 1997. Washington DC: American Psychiatric Association.
61. Williams KE, Chambless DL, Ahrens A. Are emotions frightening? An extension of the fear of fear construct. Behav Res Ther. 1997. 35:239–248.
62. Berg CZ, Shapiro N, Chambless DL, Ahrens AH. Are emotions frightening? II: an analogue study of fear of emotion, interpersonal conflict, and panic onset. Behav Res Ther. 1998. 36:3–15.
63. Cho MJ, Chang SM, Hahm BJ, Chung IW, Bae A, Lee YM, et al. Prevalence and correlates of major mental disorders among Korean adults: a 2006 national epidemiologic survey. J Korean Neuropsychiatr Assoc. 2009. 48:143–152.
64. Hofstede G. Cultures and organizations: software of the mind. 1991. London: McGraw-Hills;.
65. Stanley MA, Averill PM. Muffy M, editor. Strategies for treating generalized anxiety in the elderly. Handbook of counseling and psychotherapy with older adults. 1999. New York: Wiley;511–525.
66. Wisocki PA. Worry as a phenomenon relevant to the elderly. Behav Ther. 1988. 19:369–379.
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