Psych · General adult psychiatry — anxiety disorders
Generalised anxiety disorder
Also known as GAD · Generalized anxiety disorder · Free-floating anxiety · Chronic worry disorder · Anxiety neurosis (historical)
Exam-exhaustive fellowship reference on generalised anxiety disorder — DSM-5-TR and ICD-11 criteria; epidemiology and burden; neurobiology and worry models; differentials; GAD-7 and HAM-A; CBT; SSRI/SNRI dosing; pregabalin and buspirone; benzodiazepine cautions; depression comorbidity; NICE/Canadian/WFSBP/ANZ stepped care. FRANZCP-primary, globally tagged.
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FRANZCPMRCPsychABPNMD-DNBNEET-SS
Red flags
- New or worsening suicidal ideation — especially with comorbid depression or early after starting an SSRI/SNRI — same-day risk review, means restriction, documented safety plan
- First late-life or abrupt 'anxiety' with weight loss, focal neurology, arrhythmia, fever or substance clues — exclude organic and substance-induced causes before a pure GAD label
- Chronic high-dose benzodiazepines as sole 'treatment' — dependence, falls, cognitive harm, and blocked psychological work; plan exit strategy
- Severe agitation with medical instability (thyrotoxicosis, withdrawal, hypoxia) — medical resuscitation first, not outpatient CBT booking alone
- Akathisia or marked activation after antidepressant start/titration — reassess risk and regimen immediately
- Pregabalin or benzodiazepine misuse, diversion, or combining with alcohol/opioids — harm-reduction and specialist review
Meet the patient
A 34-year-old teacher is in your clinic — referred after her ninth GP visit this year. Headaches. "IBS." Insomnia. Three normal sets of bloods and a normal abdominal ultrasound. She apologises for wasting your time, then says: "I worry about the kids, the mortgage, my mother's health, whether I locked the door. If I stop worrying, something terrible will happen." Her PHQ-9 is creeping up too.[3][18]
Every registrar's first instinct: reassure and discharge as "the worried well." Every examiner's first question: "Which criteria make this GAD, and name a drug with a dose." Both instincts are wrong without both answers.[3][5]
References20ShowHide
- [1]Spitzer RL, Kroenke K, Williams JB, Löwe B A brief measure for assessing generalized anxiety disorder: the GAD-7 Arch Intern Med, 2006.PMID 16717171
- [2]Hamilton M The assessment of anxiety states by rating Br J Med Psychol, 1959.PMID 13638508
- [3]Tyrer P, Baldwin D Generalised anxiety disorder Lancet, 2006.PMID 17174708
- [4]Slee A, Nazareth I, Bondaronek P, Liu Y, Cheng Z, Freemantle N Pharmacological treatments for generalised anxiety disorder: a systematic review and network meta-analysis Lancet, 2019.PMID 30712879
- [5]Katzman MA, Bleau P, Blier P, Chokka P, Kjernisted K, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders BMC Psychiatry, 2014.PMID 25081580
- [6]Bandelow B, Allgulander C, Baldwin DS, Costa DLDC, Denys D, et al. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for treatment of anxiety, obsessive-compulsive and posttraumatic stress disorders - Version 3. Part I: Anxiety disorders World J Biol Psychiatry, 2023.PMID 35900161
- [7]Gelenberg AJ, Lydiard RB, Rudolph RL, Aguiar L, Haskins JT, Salinas E Efficacy of venlafaxine extended-release capsules in nondepressed outpatients with generalized anxiety disorder: A 6-month randomized controlled trial JAMA, 2000.PMID 10865302
- [8]Allgulander C, Dahl AA, Austin C, Morris PL, Sogaard JA, Fayyad R, et al. Efficacy of sertraline in a 12-week trial for generalized anxiety disorder Am J Psychiatry, 2004.PMID 15337655
- [9]Davidson JR, Bose A, Korotzer A, Zheng H Escitalopram in the treatment of generalized anxiety disorder: double-blind, placebo controlled, flexible-dose study Depress Anxiety, 2004.PMID 15274172
- [10]Rickels K, Pollack MH, Feltner DE, Lydiard RB, Zimbroff DL, Bielski RJ, et al. Pregabalin for treatment of generalized anxiety disorder: a 4-week, multicenter, double-blind, placebo-controlled trial of pregabalin and alprazolam Arch Gen Psychiatry, 2005.PMID 16143734
- [11]Allgulander C, Hartford J, Russell J, Ball S, Erickson J, Raskin J, et al. Pharmacotherapy of generalized anxiety disorder: results of duloxetine treatment from a pooled analysis of three clinical trials Curr Med Res Opin, 2007.PMID 17559726
- [12]Pollack MH, Zaninelli R, Goddard A, McCafferty JP, Bellew KM, Burnham DB, et al. Paroxetine in the treatment of generalized anxiety disorder: results of a placebo-controlled, flexible-dosage trial J Clin Psychiatry, 2001.PMID 11411817
- [13]Mitte K Meta-analysis of cognitive-behavioral treatments for generalized anxiety disorder: a comparison with pharmacotherapy Psychol Bull, 2005.PMID 16187860
- [14]Hunot V, Churchill R, Silva de Lima M, Teixeira V Psychological therapies for generalised anxiety disorder Cochrane Database Syst Rev, 2007.PMID 17253466
- [15]Chessick CA, Allen MH, Thase M, Batista Miralha da Cunha AB, Kapczinski FF, de Lima MS, et al. Azapirones for generalized anxiety disorder Cochrane Database Syst Rev, 2006.PMID 16856115
- [16]Hidalgo RB, Tupler LA, Davidson JR An effect-size analysis of pharmacologic treatments for generalized anxiety disorder J Psychopharmacol, 2007.PMID 17984162
- [17]Kessler RC, Brandenburg N, Lane M, Roy-Byrne P, Stang PD, Stein DJ, et al. Rethinking the duration requirement for generalized anxiety disorder: evidence from the National Comorbidity Survey Replication Psychol Med, 2005.PMID 16045073
- [18]Wittchen HU Generalized anxiety disorder: prevalence, burden, and cost to society Depress Anxiety, 2002.PMID 12497648
- [19]Rickels K, Shiovitz TM, Ramey TS, Weaver JJ, Knapp LE, Miceli JJ Adjunctive therapy with pregabalin in generalized anxiety disorder patients with partial response to SSRI or SNRI treatment Int Clin Psychopharmacol, 2012.PMID 22302014
- [20]Rickels K, DeMartinis N, García-España F, Greenblatt DJ, Mandos LA, Rynn M Imipramine and buspirone in treatment of patients with generalized anxiety disorder who are discontinuing long-term benzodiazepine therapy Am J Psychiatry, 2000.PMID 11097963