Generalised Anxiety Disorder
Chronic, free-floating worry that is out of proportion to circumstance and is driven by a threat-detection system stuck in the 'on' position, producing both psychological and autonomic symptoms.
In a nutshell
A threat-detection circuit stuck in the on position: a hyper-responsive amygdala with too little top-down prefrontal inhibition. The worry is chronic and free-floating, and the physical symptoms are autonomic rather than organic. CBT retrains the circuit; SSRIs support it.
Classic presentation
Six months or more of excessive, uncontrollable worry across several domains, with restlessness, muscle tension, fatigue, poor concentration and difficulty getting off to sleep.
Key points
- The worry must be free-floating and span multiple domains. Discrete attacks with anticipatory fear point to panic disorder instead.
- The somatic symptoms (palpitations, tremor, sweating, dry mouth, gastrointestinal upset) are sustained sympathetic activation, not separate pathology to investigate.
- Worry is negatively reinforced: it feels like productive problem-solving and briefly lowers the sense of threat, so it repeats, while avoidance prevents the person from ever learning the feared outcome does not occur. That loop is what CBT targets.
- Exclude thyrotoxicosis, which reproduces palpitations, tremor and restlessness almost exactly.
- CBT is first-line for anything beyond mild disease. An SSRI is the usual first-line drug class, with an SNRI as an alternative.
- Benzodiazepines are avoided beyond a short crisis period: rapid GABA-mediated relief drives tolerance and dependence, worsening the long-term course.
First-line investigation
GAD-7 to quantify severity and track response, with thyroid function tests to exclude thyrotoxicosis, and an ECG when cardiac symptoms are prominent.
First-line management
Explain the disorder as a miscalibrated but treatable threat system, then stepped care: a low-intensity psychological intervention for mild disease, CBT beyond that.
Exam traps
- Sleep difficulty in GAD is typically getting off to sleep. Early-morning waking points to depression.
- A benzodiazepine is almost never the right long-term answer. It is the trap option.
- Symptoms confined to discrete attacks with anticipatory fear are panic disorder, not GAD.
- SSRIs can transiently increase anxiety on starting. Counsel for it rather than stopping the drug.
Educational content pending clinical review. Not medical advice.