Anxiety disorder: generalised (GAD)

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💭 Generalised Anxiety Disorder (GAD) is characterised by chronic, excessive worry that is hard to control and impairs day-to-day functioning. It often coexists with depression or other anxiety disorders and frequently presents in primary care.

📊 Epidemiology

• Lifetime prevalence ~6%; more common in women.
• Onset typically in early adulthood but can occur at any age.
• High comorbidity with depressive disorders and other anxiety spectra.

🧬 Aetiology & Risk Factors

• Genetic: Family history of anxiety ↑ risk.
• Biological: Dysregulation of serotonin, noradrenaline, GABA; HPA-axis sensitisation.
• Environmental: Chronic stress, trauma, adverse life events, ACEs.
• Psychological traits: Intolerance of uncertainty, perfectionism, threat-biased attentional style.

📐 Diagnostic Criteria (DSM-5)

• Excessive anxiety/worry on most days for ≥6 months about multiple activities/events.
• Difficulty controlling the worry.
• ≥3 associated symptoms (≥1 in children):
  • Restlessness/“keyed up”
  • Easy fatigability
  • Poor concentration/“mind blank”
  • Irritability
  • Muscle tension
  • Sleep disturbance
• Clinically significant distress/impairment; not better explained by substances/medical illness.

🧰 Practical UK tip: Use the GAD-7 to screen and monitor severity (mild 5–9, moderate 10–14, severe ≥15). Offer information about NHS Talking Therapies (self-referral available in many areas).

🧑‍⚕️ Clinical Features

• Persistent, generalised worry (health, finances, family, work/school).
• Somatic symptoms: headaches, GI upset, muscle tension, tremor, palpitations.
• Hypervigilance, startle, avoidance, reassurance seeking, safety behaviours.
• Common comorbidities: depression, other anxiety disorders, substance misuse, insomnia.

🔍 Differential Diagnosis

• Panic disorder, social anxiety disorder, OCD, PTSD, illness anxiety, adjustment disorder.
• Depressive disorder with anxious distress.
• Medical: hyperthyroidism, arrhythmia, asthma exacerbation, anaemia, chronic pain.
• Substance/medication-induced: caffeine, stimulants, steroids, salbutamol, withdrawal states.

🧪 Investigations (targeted)

• Clinical diagnosis; tests rule out mimics/complicators.
• Typical baseline: TSH/T4, FBC, U&E, glucose/HbA1c; ECG if cardiopulmonary symptoms or drug initiation that warrants it.
• Consider drug screen if indicated; review caffeine/OTC supplements.

🧭 Management

• Psychological therapies (first-line):
  • 🧠 High-intensity CBT (worry exposure, cognitive restructuring, behavioural experiments).
  • 🧘 Applied relaxation/mindfulness-based approaches as adjuncts.
• Pharmacotherapy:
  • 💊 SSRIs first-line in UK primary care: e.g., sertraline (start low, go slow; review at 2–4 weeks; continue ≥12 months after response).
  • 🔁 If not tolerated/ineffective: alternative SSRI/SNRI (e.g., escitalopram/ venlafaxine per local formulary). Monitor BP with venlafaxine.
  • 🧩 Pregabalin can be considered when SSRIs/SNRIs are unsuitable or not tolerated (note misuse potential; follow MHRA advice).
  • ⏱️ Benzodiazepines are not routine; consider only very short-term crisis management with a clear stop plan.
  • 💬 Buspirone may help in some cases but is not a first-line UK choice; check local guidance.
• Lifestyle & Self-management:
  • Regular aerobic exercise, sleep hygiene, structured routine.
  • Reduce caffeine, alcohol, and recreational drugs; smoking cessation.
  • Psychoeducation about anxiety cycles, reassurance-reduction strategies.
• Special situations: Perinatal period (prefer psychological therapies first; sertraline often preferred if medication needed), older adults (start lower doses), comorbid depression (treat both).

🛡️ Risk & Safety

• Assess for self-harm/suicidal ideation, substance misuse, and functional impairment at each review.
• Provide a written safety-net: crisis numbers, how to access urgent care, when to seek help.

📈 Prognosis

• Course is often chronic-relapsing; many improve substantially with CBT and/or medication.
• Early intervention and maintenance treatment reduce relapse; plan gradual taper after sustained remission.

🧑‍🏫 Teaching tip (for juniors): Start with GAD-7 + brief psychoeducation; discuss Talking Therapies referral. If moderate–severe or marked functional impairment, add sertraline, review in 2–4 weeks, and actively manage side-effects (nausea, activation, sleep). Document risk and comorbidities, and always rule out medical mimics.