Summary

Generalised Anxiety Disorder (GAD) is characterised by excessive, persistent worry about multiple life domains (work, health, finances, family) occurring on most days for at least 6 months. The anxiety is difficult to control and is associated with physical symptoms such as muscle tension, restlessness, fatigue, and sleep disturbance. GAD is common (lifetime prevalence 5-6%) and often comorbid with depression and other anxiety disorders. Treatment includes psychological therapies (CBT, applied relaxation) and pharmacotherapy (SSRIs as first-line), with a stepped care approach based on severity.

Key Facts

• Definition: Excessive worry about multiple domains, most days, for ≥6 months
• Prevalence: Lifetime 5-6%; 12-month prevalence 2-3%
• Sex Ratio: Female:Male 2:1
• Peak Age: 30-45 years; can occur at any age
• First-Line Treatment: CBT or SSRI (sertraline)
• Assessment Tool: GAD-7 scale (screening and monitoring)

Clinical Pearls

"Free-Floating Anxiety": Unlike specific phobias or panic disorder, GAD involves worry about "everything" — patients often describe feeling constantly "on edge" without a specific trigger.

GAD-7 for Screening and Monitoring: The GAD-7 is a validated 7-item questionnaire. Score ≥10 suggests moderate-severe anxiety warranting treatment. It's also excellent for monitoring response to therapy.

Comorbidity is the Rule, Not Exception: 60-90% have comorbid psychiatric conditions (depression, other anxiety disorders, substance use). Always screen for depression (PHQ-9) in patients with GAD.

Why This Matters Clinically

GAD is common in primary care and significantly impacts quality of life, work productivity, and physical health (e.g., increased cardiovascular risk). Early recognition and appropriate stepped care can lead to significant improvement in most patients.

Structured Approach

Mental State Examination:

• Appearance: May appear tense, restless
• Behaviour: Fidgeting, reassurance-seeking
• Speech: May be pressured or hesitant
• Mood: Anxious (self-reported)
• Affect: Anxious, may be tearful
• Thought: Preoccupation with worries; no psychotic content
• Cognition: May have difficulty concentrating
• Insight: Usually preserved

Physical Examination:

• Vital signs (tachycardia, elevated BP when anxious)
• Thyroid examination (exclude hyperthyroidism)
• Neurological (exclude tremor causes)
• General examination (exclude medical causes)

Assessment Tools

Natural History

GAD tends to be a chronic, fluctuating condition. Without treatment, symptoms often persist for years, with waxing and waning course related to life stressors. With appropriate treatment, most patients improve significantly.

Outcomes with Treatment

Prognostic Factors

Good Prognosis:

• Shorter duration before treatment
• No comorbid depression or substance use
• Good response to initial treatment
• Good social support
• Engagement with psychological therapy

Poorer Prognosis:

• Comorbid depression or substance misuse
• Personality disorder
• Childhood adversity
• Chronic course before treatment
• Poor treatment adherence

Key Guidelines

1. NICE CG113: Generalised Anxiety Disorder (2011, updated 2019) — Stepped care model; CBT and SSRIs as first-line; pregabalin for resistant cases.

2. BAP Guidelines (2014) — British Association for Psychopharmacology; detailed pharmacotherapy guidance.

Landmark Trials

NICE Guideline Systematic Reviews — Foundation for stepped care

• Meta-analyses of CBT, SSRIs, SNRIs, pregabalin
• Key finding: CBT and SSRIs equally effective; pregabalin effective second-line
• Clinical Impact: Established stepped care model

Baldwin et al. (2014) — World Federation guidelines

• International consensus on GAD pharmacotherapy
• Key finding: SSRIs first-line, SNRIs and pregabalin second-line
• Clinical Impact: Global standardization of approach

Evidence Strength

What is Generalised Anxiety Disorder?

Generalised Anxiety Disorder (GAD) is a condition where you feel anxious and worried most of the time, about many different things — work, health, family, money, even small everyday matters. This worry is hard to control and goes on for months or longer. It's not the same as normal stress that comes and goes; GAD is persistent and can significantly affect your daily life.

Why does it matter?

Constant anxiety is exhausting and can affect your sleep, concentration, relationships, and work. It often comes with physical symptoms like muscle tension, headaches, and tiredness. The good news is that GAD is very treatable, and most people improve significantly with the right help.

How is it treated?

There are two main approaches, often used together:

1. Talking therapy (CBT): Cognitive Behavioural Therapy helps you understand and change the thinking patterns that keep anxiety going. It's highly effective and the benefits last long after treatment ends.

2. Medication: SSRI antidepressants (like sertraline) are commonly used and effective. They take 4-6 weeks to work fully. You may need to take them for 12 months or more.

3. Self-help: Guided self-help programs, apps (like NHS-approved anxiety apps), and books can be helpful, especially for milder symptoms.

4. Lifestyle changes: Regular exercise, good sleep habits, reducing caffeine, and relaxation techniques all help.

What to expect

• Improvement usually takes several weeks, whether using therapy or medication
• You may need to try different approaches before finding what works best for you
• Many people recover fully, though some have periods of anxiety that return during stressful times
• Learning coping skills helps prevent future episodes

When to seek help

See a doctor if:

• Anxiety is affecting your daily life, work, or relationships
• You're using alcohol or drugs to cope with anxiety
• You're feeling hopeless or having thoughts of harming yourself
• You have panic attacks or physical symptoms that concern you