Anxiety disorder: generalised

Overview

•Excessive, pervasive, difficult-to-control worry across multiple life domains - present more days than not for ≥6 months, causing significant functional impairment

•Affects ~2,000/100,000/year; 2:1 female:male; peak incidence 40-50 years

•Comorbid depression in up to 50% - screen at every review

Investigations

•GAD is a clinical diagnosis - investigations exclude organic causes

•GAD-7 questionnaire - baseline severity and treatment monitoring (mild 5-9, moderate 10-14, severe 15-21)

•TFTs - hyperthyroidism mimics GAD precisely; must exclude

•ECG - exclude arrhythmia (SVT, AF) causing palpitations

•FBC, U&Es, LFTs, glucose - anaemia, electrolyte disturbance, hypoglycaemia

•Medication review - salbutamol, theophylline, corticosteroids, antidepressants (early treatment), high caffeine all worsen anxiety

Differential diagnosis

Key differentials to exclude
ConditionDistinguishing feature
HyperthyroidismIdentical picture (tremor, palpitations, anxiety, weight loss, heat intolerance) - TFTs essential
Cardiac arrhythmiaPalpitations dominant; ECG discriminates
PhaeochromocytomaEpisodic hypertension, sweating, headache; rare but important
Panic disorderDiscrete, severe paroxysmal episodes - not chronic and pervasive
Social anxiety disorderWorry restricted to social situations/fear of embarrassment
PTSDLinked to identifiable trauma; re-experiencing and avoidance present
Alcohol/benzo withdrawalSevere anxiety on withdrawal; careful history essential

Condition	Distinguishing feature
Hyperthyroidism	Identical picture (tremor, palpitations, anxiety, weight loss, heat intolerance) - TFTs essential
Cardiac arrhythmia	Palpitations dominant; ECG discriminates
Phaeochromocytoma	Episodic hypertension, sweating, headache; rare but important
Panic disorder	Discrete, severe paroxysmal episodes - not chronic and pervasive
Social anxiety disorder	Worry restricted to social situations/fear of embarrassment
PTSD	Linked to identifiable trauma; re-experiencing and avoidance present
Alcohol/benzo withdrawal	Severe anxiety on withdrawal; careful history essential

Management

NICE stepped-care model - escalate based on severity and response. Psychoeducation at every step.

Step 1 · All presentations
1Psychoeducation, active monitoring, sleep hygiene, exercise, reduce caffeine/alcohol
↓
Step 2 · Mild-moderate (GAD-7 5-14)
1Low-intensity psychological intervention: individual guided self-help (CBT principles) or psychoeducational group
2Review at 6 weeks - if no improvement, escalate
↓
Step 3 · Moderate-severe or Step 2 failure
1High-intensity CBT or applied relaxation (first-line psychological)
2Pharmacotherapy: sertraline (first-line SSRI) - start low, titrate
3If SSRI not tolerated: escitalopram, paroxetine; SNRI venlafaxine as alternative
4Pregabalin - useful if cannot tolerate SSRIs/SNRIs or rapid effect needed (Schedule 3 CD in UK)
↓
Step 4 · Complex/refractory
1Specialist referral (CMHT), complex drug regimens, crisis support

🚨
When starting any SSRI in a patient under 30 years: explicitly warn of increased risk of suicidal thinking/self-harm in early weeks. Arrange weekly face-to-face or telephone review for the first 4 weeks and document the warning.

⚠️
Benzodiazepines - not recommended for long-term GAD. If used at all, limit to maximum 2-4 weeks in acute situational crises only. Never use as maintenance treatment due to tolerance, dependence, and rebound anxiety.

Follow-up

•Review at 2-4 weeks after initiating treatment (tolerability and early response)

•Under-30s on SSRIs: weekly review for first month (suicide risk)

•Reassess with GAD-7 at each review to track response objectively

•No improvement after 12 weeks of adequate pharmacotherapy - review diagnosis, step up or switch agent

•If effective, continue pharmacotherapy for at least 12 months before gradual withdrawal - relapse rates high with early cessation

Complications

Key complications
Depression - up to 50% develop depressive episode
Substance misuse - alcohol as self-medication; worsens prognosis
Suicidal ideation - especially with comorbid depression or early SSRI
Benzodiazepine dependence - iatrogenic from inappropriate prescribing
Occupational/social impairment - absenteeism, relationship difficulties
Cardiovascular disease - chronic HPA activation

Diagnostic criteria (DSM-5)

•Worry across multiple domains (not one), ≥6 months, more days than not

•≥3 of 6 associated symptoms (≥1 in children):

•Restlessness/feeling on edge

•Easy fatigue

•Difficulty concentrating/mind going blank

•Irritability

•Muscle tension

•Sleep disturbance

•Not attributable to substance, medication, or another medical condition

🎯
GAD-7 score ≥10 (moderate-severe) typically warrants active treatment beyond watchful waiting. Use GAD-2 (score ≥3) to trigger full GAD-7 in primary care screening.