Generalised Anxiety Disorder (GAD)
Summary
Generalised Anxiety Disorder (GAD) is characterised by excessive, uncontrollable worry about multiple aspects of everyday life (health, work, finances, family) for at least 6 months. It is often accompanied by physical symptoms: muscle tension, restlessness, fatigue, poor concentration, irritability, and sleep disturbance. GAD has high comorbidity with depression (60% overlap). The GAD-7 is a validated screening tool. Management is stepped: psychoeducation and lifestyle changes → guided self-help / low-intensity CBT → high-intensity CBT or SSRIs → specialist referral with pregabalin or SNRIs for treatment-resistant cases.
Key Facts
- Prevalence: ~5% lifetime; Female > Male (2:1)
- Criteria: Excessive worry, most days, >6 months, difficult to control
- Physical symptoms: Muscle tension, Restlessness, Fatigue, Poor concentration, Irritability, Sleep disturbance
- Screening tool: GAD-7
- Comorbidity: 60% with depression
- Treatment: CBT (first-line); SSRIs (Sertraline); SNRIs or Pregabalin (second-line)
Clinical Pearls
"GAD = Worry About Everything, All the Time": GAD is generalised — patients worry excessively about multiple areas of life, not just one thing.
"CBT Is First-Line Before Medication": NICE guidelines recommend psychological therapy (CBT) before or alongside medication.
"Sertraline Is First-Line SSRI": Sertraline is the first-choice medication. Alternative: Escitalopram.
"Avoid Benzodiazepines Long-Term": Benzodiazepines work but cause dependence. Use only short-term (≤2-4 weeks) for crisis.
"Always Screen for Depression": 60% of GAD patients have comorbid depression. Use PHQ-9 alongside GAD-7.
Why This Matters Clinically
GAD is common and often under-recognised. It significantly impacts quality of life and work function. Evidence-based treatment (CBT, SSRIs) is highly effective.[1,2]
Incidence & Prevalence
| Parameter | Data |
|---|---|
| Lifetime prevalence | 5-6% |
| Point prevalence | 1.5-3% |
| Sex | Female:Male = 2:1 |
| Age of onset | Often childhood/adolescence; Peak 30s-40s |
Risk Factors
| Factor | Notes |
|---|---|
| Female sex | Higher prevalence |
| Family history | Genetic component |
| Childhood adversity | Trauma, abuse |
| Chronic health conditions | Associated anxiety |
| Stressful life events | Trigger or worsen |
Biological Factors
| Factor | Details |
|---|---|
| Genetic | 30% heritability |
| GABA dysfunction | Reduced GABAergic inhibition |
| Serotonin dysregulation | Basis for SSRI efficacy |
| Noradrenaline | Overactive; Basis for SNRI efficacy |
| HPA axis | Elevated cortisol |
Psychological Factors
| Factor | Details |
|---|---|
| Cognitive biases | Overestimation of threat; Intolerance of uncertainty |
| Worry as coping | Perceived "protective" function of worry |
| Avoidance | Maintains anxiety cycle |
Core Features (ICD-11 / DSM-5)
| Feature | Notes |
|---|---|
| Excessive worry | About multiple areas (health, work, family) |
| Duration | >6 months |
| Difficult to control | Cannot stop worrying |
| Functional impairment | Affects work, social life |
Physical Symptoms
| Symptom | Notes |
|---|---|
| Muscle tension | Common; Aching; Tension headaches |
| Restlessness | Feeling "on edge" |
| Fatigue | Easily tired |
| Concentration problems | Mind goes blank |
| Irritability | |
| Sleep disturbance | Difficulty falling asleep; Unrefreshing sleep |
Red Flags
[!CAUTION]
- Suicidal ideation (always assess)
- Severe functional impairment (unable to work)
- Comorbid substance use disorder
- Psychotic symptoms (reconsider diagnosis)
Mental State Examination
| Domain | Findings |
|---|---|
| Appearance | May appear anxious, tense |
| Behaviour | Restless; Fidgeting |
| Speech | May be rapid; Talkative about worries |
| Mood | Anxious; Low (if comorbid depression) |
| Thoughts | Excessive worry; Rumination; Often no suicidal ideation |
| Perception | No hallucinations |
| Cognition | Intact (but may report poor concentration) |
| Insight | Usually good |
Screening Tools
| Tool | Purpose |
|---|---|
| GAD-7 | 7-item screening; Score ≥10 = moderate anxiety |
| PHQ-9 | Screen for comorbid depression |
Exclude Organic Causes
| Investigation | Purpose |
|---|---|
| TFTs | Hyperthyroidism |
| FBC | Anaemia |
| Glucose | Hypoglycaemia |
| Caffeine/Substance use | History |
GAD-7 Scoring
| Score | Severity |
|---|---|
| 0-4 | Minimal anxiety |
| 5-9 | Mild anxiety |
| 10-14 | Moderate anxiety |
| 15-21 | Severe anxiety |
Management Algorithm (NICE Stepped Care)
GENERALISED ANXIETY DISORDER MANAGEMENT
↓
┌────────────────────────────────────────────────────────────┐
│ STEP 1: RECOGNITION & PSYCHOEDUCATION │
├────────────────────────────────────────────────────────────┤
│ ➤ Validate symptoms │
│ ➤ Explain GAD (excess worry, physical symptoms) │
│ ➤ Lifestyle advice: │
│ • Regular exercise │
│ • Sleep hygiene │
│ • Reduce caffeine and alcohol │
│ • Relaxation techniques │
└────────────────────────────────────────────────────────────┘
↓
┌────────────────────────────────────────────────────────────┐
│ STEP 2: LOW-INTENSITY PSYCHOLOGICAL INTERVENTIONS │
├────────────────────────────────────────────────────────────┤
│ ➤ Guided self-help (workbooks, online CBT) │
│ ➤ Psychoeducational groups │
│ ➤ IAPT referral (Improving Access to Psychological │
│ Therapies) │
└────────────────────────────────────────────────────────────┘
↓
┌────────────────────────────────────────────────────────────┐
│ STEP 3: HIGH-INTENSITY INTERVENTIONS │
├────────────────────────────────────────────────────────────┤
│ PSYCHOLOGICAL: │
│ ➤ Individual CBT (12-15 sessions) │
│ ➤ Applied relaxation │
│ │
│ PHARMACOLOGICAL: │
│ ➤ SSRI: Sertraline (first-line); Escitalopram │
│ • Start low (Sertraline 25 mg) — may transiently │
│ worsen anxiety │
│ • Titrate to therapeutic dose (50-200 mg) │
│ • Continue for ≥12 months if effective │
│ │
│ ⚠️ SHORT-TERM BENZODIAZEPINES (≤2-4 weeks) only if │
│ crisis — risk of dependence │
└────────────────────────────────────────────────────────────┘
↓
┌────────────────────────────────────────────────────────────┐
│ STEP 4: TREATMENT-RESISTANT / SPECIALIST │
├────────────────────────────────────────────────────────────┤
│ ➤ Trial alternative SSRI or SNRI (Duloxetine, Venlafaxine)│
│ ➤ Pregabalin (licensed for GAD) │
│ ➤ Combine CBT + Medication │
│ ➤ Secondary care referral │
│ ➤ Consider comorbidities (depression, personality) │
└────────────────────────────────────────────────────────────┘
| Complication | Notes |
|---|---|
| Depression | 60% comorbidity |
| Substance use | Self-medication with alcohol |
| Functional impairment | Work, relationships |
| Physical health | Chronic tension → Headaches, IBS |
| Suicide risk | If comorbid depression |
| Factor | Outcome |
|---|---|
| Response to treatment | Good with CBT and/or SSRIs |
| Chronic course | Often waxing and waning; Lifelong vulnerability |
| Better prognosis | Early treatment; Good social support |
Key Guidelines
| Guideline | Organisation | Year | Key Points |
|---|---|---|---|
| Generalised Anxiety Disorder and Panic Disorder (CG113 / NG116) | NICE | 2019 | Stepped care; CBT first-line |
What is generalised anxiety disorder?
GAD is a condition where you feel worried most of the time about many things (health, work, family), and find it hard to stop worrying. It often causes physical symptoms like muscle tension, tiredness, and poor sleep.
Is it common?
Yes, around 1 in 20 people have GAD at some point in their lives.
How is it treated?
- Talking therapies: Cognitive behavioural therapy (CBT) helps you manage your thoughts and worries
- Medication: Antidepressants like sertraline can reduce anxiety
- Lifestyle: Exercise, reducing caffeine, and good sleep help
Will I get better?
Yes, most people improve significantly with treatment. It may take time, but therapy and medication are very effective.
- NICE. Generalised anxiety disorder and panic disorder in adults (NG116). 2019. nice.org.uk/guidance/ng116
High-Yield Exam Topics
| Topic | Key Points |
|---|---|
| Criteria | Excessive worry, >6 months, hard to control |
| Screening | GAD-7 (≥10 = moderate) |
| Physical symptoms | Muscle tension, fatigue, poor sleep |
| First-line treatment | CBT; SSRI (Sertraline) |
| Avoid long-term | Benzodiazepines (dependence risk) |
| Comorbidity | 60% with depression |
Sample Viva Question
Q: How would you manage a patient with GAD who is not responding to sertraline?
Model Answer: I would first reassess: confirm diagnosis, screen for comorbid depression (PHQ-9), check adherence, and ensure adequate dose and duration (at least 6-8 weeks at therapeutic dose).
If truly not responding:
- Optimise: Increase sertraline dose (up to 200 mg if tolerated)
- Switch: Try another SSRI (escitalopram) or SNRI (duloxetine, venlafaxine)
- Add: Augment with pregabalin (licensed for GAD)
- CBT: Ensure psychological therapy is offered alongside
- Refer: To secondary care for treatment-resistant GAD
Short-term benzodiazepines may be considered for crisis but not for long-term management due to dependence risk.
Last Reviewed: 2025-12-24 | MedVellum Editorial Team