Self-report measures have the advantages of brevity, ease of administration and scoring, and a decreased demand on human resources, which are often limited in high-volume outpatient clinics and private practice settings. The Beck Anxiety Inventory (BAI) and the Trait Anxiety subscale of the State-Trait Anxiety Inventory (STAI-T) are among the most widely used self-report measures of anxiety, although each has limitations. The BAI is biased toward somatic and panic-like symptoms of anxiety, which have been shown to be less characteristic of GAD, whereas the STAI-T appears to confound anxiety and depression and may be more a measure of general negative affectivity than anxiety. Despite this limitation, the STAI-T has demonstrated sensitivity to treatment change in studies of cognitive-behavioral therapy for GAD.
The Penn State Worry Questionnaire (PSWQ) measures a general trait-like tendency to worry excessively. As such, it is an especially useful instrument to assess the severity of pathological worry characteristic of GAD. It has been shown to discriminate among the anxiety disorders, as individuals with GAD score significantly higher on the PSWQ than any other anxiety disorder group, and it is also sensitive to change in studies of cognitive-behavioral therapy for GAD (Molina and Borkovec, 1994). The Generalized Anxiety Disorder Questionnaire-IV (GADQ-IV) is a brief measure designed to screen for the presence of GAD, based on DSM-IV diagnostic criteria.
Several other dimensions of individual functioning also warrant attention during assessment, as these may significantly impact and/or contribute to overall severity of GAD (Table 2). Among these, people with GAD often have maladaptive beliefs about worry, including the assumption that worry serves a protective function or that worry will prevent negative and feared outcomes from occurring. Asking a patient to describe their beliefs about the effects of worry may identify targets to address in treatment.
Emotional functioning is another important area to examine, as it has been shown that people with GAD have difficulty identifying their emotions or may consciously attempt to avoid experiencing emotions by using worry as a cognitive avoidance strategy. In such cases, interventions aimed at improving emotion regulation may be of benefit. While overt avoidance may not be as common in GAD as in phobic disorders, subtle behavioral avoidance is often present and may serve as a maintaining factor.
Careful probing during the clinical evaluation and between-session patient self-monitoring can help to identify areas of avoidance to target in treatment. Interpersonal functioning may also be impaired, and social or intimate relationships are often a major focus of patient's excessive worrying. Fears of disapproval, negative evaluation and appearing incompetent are common in patient's clinical presentation and need to be addressed.
Finally, careful assessment of comorbid Axis I and Axis II psychopathology is crucial, as GAD has been found to be a highly comorbid disorder with 30-day and lifetime comorbidity rates estimated at 66.3% and 90.4%, respectively (Wittchen et al., 1994). Comorbid psychopathology has been shown to be associated with increased severity of GAD. Among the most common co-occurring conditions are other anxiety disorders, depressive disorders and substance use disorders.
As public awareness and recognition of GAD continues to grow, clinicians will likely evaluate and treat these patients with increasing frequency. Accurate detection, diagnosis and assessment of disorder severity can inform the clinician's interventions and improve treatment effectiveness. A small but sufficient group of empirically supported instruments to assess the severity of GAD are now available and should be judiciously combined with one's clinical acumen.
Dr. Belzer is a research fellow in affective, anxiety and related disorders, Department of Psychiatry, Columbia University College of Physicians and Surgeons and the Anxiety Disorders Clinic of New York State Psychiatric Institute. He has indicated he has nothing to declare.