The earlier in life individuals have symptoms that meet criteria for generalized anxiety disorder, the more comorbidity they tend to have and the more impaired they are likely to be. The advent of chronic physical disease can be a potent issue for excessive worry in the elderly. In the frail elderly, worries about safety—and especially about falling—may limit activities. In those with early cognitive impairment, what appears to be excessive worry about, for example, the whereabouts of things is probably better regarded as realistic given the cognitive impairment.
In children and adolescents with generalized anxiety disorder) the anxieties and wor- ries often concern the quality of their performance or competence at school or in sporting events, even when their performance is not being evaluated by others. There may be ex- cessive concerns about punctuality. They may also worry about catastrophic events, such as earthquakes or nuclear war. Children with the disorder may be overly conforming, per- fectionist, and unsure of themselves and tend to redo tasks because of excessive dissatis- faction with less-than-perfect performance. They are typically overzealous in seeking other things they are worried about.
Generalized anxiety disorder may be overdiagnosed in children. When this diagnosis is being considered in children, a thorough evaluation for the presence of other childhood anxiety disorders and other mental disorders should be done to determine whether the worries may be better explained by one of these disorders. Separation anxiety disorder, so- cial anxiety disorder (social phobia), and obsessive-compulsive disorder are often accom- panied by worries that may mimic those described in generalized anxiety disorder. For example, a child with social anxiety disorder may be concerned about school performance because of fear of humiliation. Worries about illness may also be better explained by sep- aration anxiety disorder or obsessive-compulsive disorder.
Temperamental. Behavioral inhibition, negative affectivity (neuroticism), and harm avoidance have been associated with generalized anxiety disorder.
Environmental. Although childhood adversities and parental overprotection have been associated with generalized anxiety disorder, no environmental factors have been identi- fied as specific to generalized anxiety disorder or necessary or sufficient for making the di- agnosis.
Genetic and physiological. One-third of the risk of experiencing generalized anxiety disorder is genetic, and these genetic factors overlap with the risk of neuroticism and are shared with other anxiety and mood disorders, particularly major depressive disorder.
There is considerable cultural variation in the expression of generalized anxiety disorder.
For example, in some cultures, somatic symptoms predominate in the expression of the disorder, Whereas in other cultures cognitive symptoms tend to predominate. This differ- ence may be more evident on initial presentation than subsequently, as more symptoms are reported over time. There is no information as to whether the propensity for excessive worrying is related to culture, although the topic being worried about can be culture spe- cific. It is important to consider the social and cultural context when evaluating whether worries about certain situations are excessive.
In clinical settings, generalized anxiety disorder is diagnosed somewhat more frequently in females than in males (about 55%—60% of those presenting with the disorder are female). In epidemiological studies, approximately two-thirds are female. Females and males who experience generalized anxiety disorder appear to have similar symptoms but demonstrate different patterns of comorbidity consistent with gender differences in the prevalence of disorders. In females, comorbidity is largely confined to the anxiety disor- ders and unipolar depression, whereas in males, comorbidity is more likely to extend to the substance use disorders as well.
Excessive worrying impairs the individual’s capacity to do things quickly and efficiently, whether at home or at work. The worrying takes time and energy; the associated symp- toms of muscle tension and feeling keyed up or on edge, tiredness, difficulty concentrat- ing, and disturbed sleep contribute to the impairment. Importantly the excessive worrying may impair the ability of individuals with generalized anxiety disorder to encourage con- fidence in their children.