Generalised anxiety disorder — assessment and stepped management (MEQ)

(i) Assessment priorities. Structure as risk, substances, medical exclusion, differential anxiety formulation, MSE, collateral and function. Risk: expand passive burden thoughts into full assessment — ideation frequency, intent, plan, means, prior attempts, hopelessness, protective factors, alcohol-related impulsivity. Substances: quantify caffeine and alcohol; ask stimulants, cannabis, sedatives. Medical: review for thyrotoxic features, arrhythmia symptoms, medications; baseline labs as indicated (repeat TSH if clinically indicated, U&E/LFT before pharmacotherapy, pregnancy test if relevant). Scales: GAD-7 of 15 is in the commonly used severe band and tracks severity but does not replace diagnosis; PHQ-9 12 indicates concurrent depressive symptoms needing full MDD criteria review. Bipolar screen before antidepressant. Prior treatment adequacy. Collateral if available. Capacity for outpatient plan.[1][4][6]

(ii) Working diagnosis and differentials. Working diagnosis: generalised anxiety disorder (excessive multi-domain worry more days than not for more than 6 months, difficulty controlling worry, at least three associated symptoms, impairment) with concurrent depressive symptoms and hazardous caffeine/alcohol use. Differentials with discriminators: panic disorder (no unexpected discrete attacks described); social anxiety (not scrutiny-bound only); OCD (no ego-dystonic obsessions/compulsions); illness anxiety (not solely health preoccupation); MDD primary (possible comorbidity — check anhedonia, pervasive low mood); substance-induced anxiety (caffeine/alcohol contribution); medical (thyroid etc.).[6]

(iii) Stepped management. Psychoeducation; reduce caffeine; address alcohol with motivational approach; sleep hygiene. Offer high-intensity CBT for GAD: worry monitoring, cognitive restructuring, worry postponement, imaginal exposure, intolerance-of-uncertainty experiments, applied relaxation, drop reassurance safety behaviours, homework, ~12–20 sessions depending on protocol.[5] Named first-line drug example: sertraline 25–50 mg orally each morning, early review in 1–2 weeks for activation/suicidality and side-effects, titrate toward 100 mg if tolerated and incomplete response, plan 4–6 weeks at therapeutic dose with serial GAD-7/PHQ-9. Shared decision-making; crisis contacts; GP liaison. Continue effective treatment after response rather than stopping at first improvement.[2][4]

(iv) Benzodiazepines, pregabalin, buspirone. Benzodiazepines: short-term bridge only if severe distress, with stop date — not indefinite monotherapy (dependence, falls, cognitive harm, rebound).[4] Pregabalin: evidence-based alternative or adjunct (RCT including alprazolam comparator arm); start low (e.g. 75 mg twice daily concept in normal renal function), titrate per label, counsel sedation/dizziness/misuse risk.[3] Buspirone: 5-HT1A partial agonist, delayed onset, divided dosing; less useful after chronic benzo use; not a stat rescue.[4]

(v) Depression comorbidity. Concurrent depression elevates suicide risk and disability; treat both; SSRI strategy addresses both domains; more frequent early review after antidepressant initiation; safety plan; do not discharge to empty follow-up; escalate setting if risk rises.[4][6]