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.

Definition

Generalised anxiety disorder is excessive, persistent and difficult-to-control worry about multiple everyday events, present on most days for at least 6 months, with associated anxiety symptoms causing distress or functional impairment.

Epidemiology

GAD is common and frequently coexists with depression, other anxiety disorders, substance misuse and physical illness. Course and severity vary, with chronic or relapsing symptoms more likely when impairment, comorbidity or ongoing stress is substantial.

Pathophysiology

GAD reflects interacting biological, psychological and social factors affecting threat appraisal, attention, uncertainty tolerance and learned coping behaviours. Autonomic arousal produces real physical symptoms, while worry, checking, reassurance seeking and avoidance can maintain the cycle; the exact biological mechanism is not a single brain-circuit lesion.

First principles

GAD is persistent worry, not any episode of anxiety

The worry is excessive, difficult to control and spread across several everyday domains, with associated symptoms such as restlessness, fatigue, poor concentration, irritability, muscle tension or sleep disturbance. Confirm duration, distress and impairment before applying the diagnosis.^1,2

Anxiety symptoms can still be physical illness

Palpitations, tremor, breathlessness, chest discomfort, gastrointestinal symptoms, weight change, sleep disruption and agitation may occur in anxiety but can also signal cardiac, respiratory, endocrine, neurological, medication, stimulant or withdrawal illness. Use history, examination and targeted testing to avoid both over-investigation and premature closure.^1,2

Worry and avoidance maintain the problem

Worry, reassurance seeking, checking and avoidance can briefly reduce distress while preventing learning that feared outcomes may not occur. CBT and applied relaxation target these maintaining processes; treatment should therefore build skills and functioning rather than only suppress symptoms.¹

Treatment is stepped and preference-led

NICE recommends the least intrusive effective intervention first: identification and education, then low-intensity psychological treatment, then a choice of high-intensity psychological treatment or medication when impairment or inadequate response warrants it. More complex or risky illness needs specialist care.^1,2

Medication benefit and medication harm both need a plan

SSRIs and SNRIs may initially increase anxiety, agitation or sleep problems before benefit develops. Pregabalin and benzodiazepines carry dependence and withdrawal risks; prescribing requires discussion of interactions, misuse, respiratory risk, pregnancy and a gradual stopping plan.^1,3,4

Presentation

Excessive, difficult-to-control worry about multiple domains on most days for at least 6 months, accompanied by anxiety symptoms and clinically significant distress or functional impairment.^1,2,5

Cardinal features

Excessive worry across several areas rather than one specific trigger
Difficulty controlling the worry
Restlessness or feeling on edge
Fatigue, poor concentration or irritability
Muscle tension
Sleep disturbance
Functional impairment, avoidance or repeated reassurance seeking

Red flags

Suicidal thoughts, self-harm, severe depression or inability to care for basic needs
Chest pain, syncope, sustained arrhythmia, severe breathlessness or neurological deficit
Weight loss, heat intolerance, marked tremor or other features of thyrotoxicosis
Discrete unexpected panic attacks with fear of recurrence or avoidance of places
Alcohol, benzodiazepine, stimulant or other substance intoxication or withdrawal
Psychosis, mania, delirium or rapidly changing mental state

Investigations

Clinical diagnostic and functional assessment

Establish the duration, breadth and controllability of worry, associated symptoms, impairment, avoidance, reassurance seeking, sleep, substance use, comorbid depression or other anxiety disorders, previous treatment and the person's goals. GAD-7 or another validated measure can support baseline severity and outcome monitoring but does not make the diagnosis alone.

Expected finding: A formulation supporting GAD, another anxiety disorder, comorbidity, a substance-related problem or a non-psychiatric cause, with function and risk documented.

^1,2

Suicide, self-harm and safeguarding assessment

Ask about suicidal thoughts, self-harm, severe depression, substance misuse, abuse, neglect, risk to others, protective factors and support. Severe anxiety with self-neglect or suicide risk belongs in the specialist step-4 pathway rather than routine reassurance.

Expected finding: An individualised safety and follow-up plan with escalation when the person cannot remain safe or engage with treatment.

^1,5

Medication, stimulant and withdrawal review

Review prescribed and over-the-counter medicines, caffeine, nicotine, recreational drugs, alcohol, benzodiazepines and recent dose changes. Consider medication-induced anxiety, intoxication and withdrawal before starting a long-term anxiety medicine.

Expected finding: A modifiable stimulant, interaction, adverse effect, intoxication or withdrawal syndrome, or no contributory substance exposure.

^1,3

Targeted physical examination and tests

Examine and investigate when symptoms or risk factors suggest a physical cause. Depending on the presentation, this may include thyroid function, FBC, glucose, electrolytes, renal function, ECG, pregnancy testing or other targeted assessment; do not use a routine normal test to overrule a concerning history or examination.

Expected finding: A relevant medical cause such as arrhythmia, thyrotoxicosis, anaemia, hypoglycaemia, medication toxicity or withdrawal, or a reassuring targeted assessment that supports but does not prove GAD.

^1,2

Treatment-response and adverse-effect monitoring

If drug treatment is used, review effectiveness and side effects every 2 to 4 weeks during the first 3 months and every 3 months thereafter. Monitor activation, suicidality, adherence, interactions, misuse, withdrawal and emerging physical-health problems.

Expected finding: Improvement, incomplete response, intolerance, activation, withdrawal, dependence or a need to change the treatment step.

^1,3,4

Management

Step	Detail	Source
Recognise, formulate and assess safety	Confirm excessive, difficult-to-control worry across multiple domains, duration, distress and functional impact. Screen for depression, panic, OCD, PTSD, social anxiety, bipolar disorder, psychosis, substance use, medication effects, physical illness, self-neglect and suicide or self-harm risk. Escalate urgently if the person cannot remain safe or has a dangerous medical presentation.^1,2,5	NICE CG113 recommendations and assessment appendix
Step 1: explain the diagnosis and actively monitor	Explain GAD, expected symptoms, treatment options, the role of worry and avoidance, and how to seek help. For mild or subclinical symptoms with limited impairment, no significant comorbidity and no immediate safety concern, agree active monitoring and a defined review rather than indefinite reassurance.^1,2	NICE CG113 stepped care
Step 2: offer low-intensity psychological treatment	For diagnosed GAD that has not improved with education and active monitoring, offer individual non-facilitated self-help, individual guided self-help or a psychoeducational group. Use routine outcome measures and agree how progress, engagement and risk will be reviewed.¹	NICE CG113 recommendation 1.2.1
Step 3: offer high-intensity therapy or medication	For marked impairment or inadequate response to step 2, offer a choice of high-intensity CBT or applied relaxation, or drug treatment, guided by preference, prior response, comorbidity, access and risk. If one modality only partially helps, consider adding the other rather than repeatedly cycling through low-intensity advice.^1,2	NICE CG113 stepped care
Choose an SSRI and counsel before starting	If drug treatment is chosen, offer an SSRI and consider sertraline first. Use current BNF and local formulary guidance for the individual drug, dose, interactions and patient-specific precautions. Explain that activation may cause increased anxiety, agitation or sleep problems initially, that full anxiolytic benefit develops over at least a week, that adherence matters and that treatment should continue after remission to reduce relapse.^1,6	NICE CG113 drug-treatment recommendations and BNF sertraline
Switch or step up after inadequate response or intolerance	If sertraline is ineffective, offer an alternative SSRI or SNRI while considering withdrawal propensity, interactions, overdose toxicity, prior response and preference. If an SSRI or SNRI is not tolerated, consider pregabalin only after reviewing misuse risk, controlled-drug requirements, respiratory risk, renal function, pregnancy or reproductive factors and the current BNF.^1,6,7,4,8	NICE CG113 and current MHRA safety guidance
Avoid routine benzodiazepines and antipsychotics	Do not offer a benzodiazepine for GAD in primary or secondary care except as a short-term measure during a crisis, and do not use an antipsychotic for GAD in primary care. If a benzodiazepine is used in crisis, use a clear short duration, review and stopping plan, taking dependence, withdrawal, sedation, falls and respiratory-depression risks seriously.^1,3,4	NICE CG113 and NICE NG215
Review drug treatment and continue effective treatment	Review effectiveness and side effects every 2 to 4 weeks during the first 3 months and every 3 months thereafter. If effective, advise continuing treatment for at least 1 year because relapse is common, then review the balance of benefit, relapse risk, side effects, withdrawal and preference rather than stopping automatically.^1,3	NICE CG113 recommendations 1.2.32 to 1.2.33
Refer complex, risky or treatment-refractory GAD	Refer for specialist assessment when anxiety remains refractory to CBT and drug treatment, functional impairment is very severe, there is self-neglect, persistent suicidal thinking, significant substance or personality comorbidity, complex physical illness or failure of step 3. Specialist care should review previous treatment fidelity, adherence, home environment, support and family or carer impact and develop a collaborative care plan.^1,2	NICE CG113 step-4 recommendations
Taper medicines and safety-net relapse or withdrawal	Do not stop antidepressants, pregabalin or benzodiazepines abruptly. Agree a gradual, person-led reduction with smaller decrements as the dose becomes lower, distinguishing withdrawal from returning anxiety. Give clear crisis contacts and return advice for suicidal thoughts, self-neglect, severe agitation, breathing difficulty, intoxication or rapidly changing symptoms.^1,3,4	NICE CG113, NICE NG215 and MHRA dependence guidance

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

Differentials

Depression

Pervasive low mood, anhedonia, hopelessness and biological change dominate; anxiety and depression commonly coexist.

Panic disorder

Recurrent discrete panic attacks with fear of further attacks or avoidance rather than continuous broad worry.

Social anxiety, phobia or OCD

Fear is focused on social scrutiny, a specific object or situation, or intrusive thoughts and compulsions.

PTSD

Trauma-linked re-experiencing, avoidance and hyperarousal.

Hyperthyroidism or other physical illness

Weight loss, heat intolerance, tremor, syncope, arrhythmia, neurological signs or other examination and test abnormalities.

Substance, medication or withdrawal anxiety

Temporal relation to caffeine, stimulants, alcohol, benzodiazepines, recreational drugs or prescribed medicines.

Complications

Comorbid depression, self-harm or suicide risk
Alcohol, benzodiazepine or other substance misuse
Functional, occupational and relationship impairment
Dependence, withdrawal, sedation or respiratory harm from medicines
Repeated healthcare use and delayed diagnosis of physical illness
Chronic or relapsing anxiety

Prognosis

GAD often fluctuates and can be chronic, but many people improve with psychological treatment, medication or both. Relapse prevention, sustained treatment when effective, functional goals and a gradual withdrawal plan are important because symptoms and treatment discontinuation effects can recur.

Guidelines

Generalised anxiety disorder and panic disorder in adults: management (CG113) (NICE, 2026)
Medicines associated with dependence or withdrawal symptoms (NG215) (NICE, 2022)

References

Evidence checked: 2026-08-03

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.