Mental Health

Generalised Anxiety Disorder

Persistent, difficult-to-control worry across multiple areas of life, with physical and cognitive symptoms causing distress or impairment, managed using a NICE stepped-care pathway.

In a nutshell

GAD is excessive, difficult-to-control worry across multiple domains for at least 6 months with distress or impairment. Exclude dangerous physical, substance, bipolar, psychotic and depressive explanations, then follow NICE stepped care: education/monitoring, low-intensity treatment, high-intensity CBT or medication, and specialist referral for complex or risky disease.

Classic presentation

Persistent worry about several areas of life with restlessness, fatigue, poor concentration, irritability, muscle tension and sleep disturbance, causing functional impairment and not better explained by panic, depression, substance use or physical illness.

Key points

GAD is chronic, broad and difficult-to-control worry; discrete attacks with fear of recurrence suggest panic disorder instead.
GAD-7 supports severity and follow-up but does not replace clinical diagnosis, physical assessment or suicide-risk formulation.
Step 1 is identification, education and active monitoring for mild or subclinical presentations; step 2 is low-intensity psychological treatment.
Step 3 is a choice of high-intensity CBT/applied relaxation or drug treatment when impairment is marked or step 2 has not helped.
If medication is chosen, NICE suggests an SSRI and considers sertraline first; if ineffective, consider another SSRI or SNRI, with pregabalin only when SSRI/SNRI intolerance warrants it.
SSRIs/SNRIs can initially activate anxiety; pregabalin, benzodiazepines and antidepressants all require an explicit withdrawal plan, while pregabalin also needs misuse, respiratory and pregnancy precautions.
Effective drug treatment should usually continue for at least 1 year in GAD, with review; complex, treatment-refractory, self-neglecting or suicidal presentations need specialist care.

First-line investigation

Clinical assessment of worry, duration, impairment, comorbidity, substances and safety, with GAD-7 as an adjunct and targeted physical tests or ECG only when indicated.

Management

Establish the formulation and safety

Confirm broad, persistent, difficult-to-control worry and impairment while screening for depression, panic, bipolarity, psychosis, substance use, withdrawal, self-neglect and suicide risk.^1,2,5
Assess chest pain, syncope, severe breathlessness, neurological change, thyrotoxicosis features and other medical red flags before attributing symptoms to GAD.^1,2

Start at the right step

For mild or subclinical symptoms with limited impairment, provide education and active monitoring with a defined review; for diagnosed GAD not improving, offer low-intensity self-help or psychoeducation.^1,2
For marked impairment or inadequate response to step 2, offer high-intensity CBT/applied relaxation or medication using shared decision-making.¹

Use psychological therapy or medication safely

If medication is chosen, offer an SSRI and consider sertraline first; explain activation, delayed benefit, interactions, overdose risk, adherence and withdrawal, and check current BNF/local formulary details.^1,6
If sertraline is ineffective, consider an alternative SSRI or SNRI; consider pregabalin only for SSRI/SNRI intolerance after checking dependence, respiratory, renal, interaction and pregnancy risks.^1,7,4,8

Avoid harmful shortcuts and refer complex disease

Do not use benzodiazepines routinely or antipsychotics in primary care; crisis benzodiazepine use needs a short, explicit review and stopping plan.^1,3
Refer step 4 presentations with refractory illness, severe functional impairment, self-neglect, persistent suicidal thoughts or significant comorbidity for specialist assessment and collaborative care planning.^1,2

Review, prevent relapse and taper

Review drug effectiveness and side effects every 2 to 4 weeks during the first 3 months and every 3 months thereafter; continue effective treatment for at least 1 year before a planned review of stopping.^1,3
Taper antidepressants, pregabalin or benzodiazepines gradually, with smaller reductions as the dose falls, and safety-net suicidal thoughts, self-neglect, breathing difficulty, misuse, withdrawal or rapidly changing symptoms.^1,3,4

Exam traps

Panic attacks are discrete episodes; continuous worry across multiple domains is the GAD pattern.
Do not explain all palpitations, syncope, weight loss or tremor as anxiety without a targeted physical assessment.
Do not use benzodiazepines as routine GAD treatment; NICE permits only short-term crisis use.
Do not offer an antipsychotic for GAD in primary care.
Pregabalin is not a harmless routine alternative: check misuse/dependence, respiratory, renal, interaction and pregnancy risks.
Review drug treatment every 2 to 4 weeks for the first 3 months, then every 3 months; effective treatment is generally continued for at least 1 year.
Severe anxiety with self-neglect, persistent suicidal thoughts, major comorbidity or failure of CBT and drug treatment is a step-4 specialist presentation.

Illustrations

Threat, worry and avoidance loopSchematic showing threat appraisal leading to worry, reassurance seeking and avoidance, with short-term relief maintaining long-term anxiety; CBT targets the loop through graded behavioural and cognitive work.PassFinals · original

GAD-7 and clinical formulationA structured assessment panel showing GAD-7 as an adjunct alongside duration, breadth of worry, impairment, comorbidity, physical mimics, substance use and safety assessment.PassFinals · original

NICE stepped-care pathwayFour-step pathway from identification, education and active monitoring through low-intensity treatment, high-intensity CBT/applied relaxation or medication, to specialist treatment-refractory care.PassFinals · original

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.