20th November 2023

Generalised Anxiety Disorder

Generalised anxiety disorder (GAD, ICD10 F41.1)) is characterised by symptoms of anxiety that are present (unsurprisingly) in general day-to-day life rather than being related to particular circumstances. It is natural to have worries and anxieties, but in GAD, they are hard to control and disproportionate to the context.

Predisposition, onset and maintenance

In the UK, 1 in 25 people will be affected by GAD, and it is more common in females than males. The lowest incidence is in 18-29 years and 60+ years (4.1% and 3.7% respectively), and the highest is in 45-59 years (7.7%). Let’s talk about the triple vulnerability model for developing GAD:

Generally poor prognosis with a chronic course of illness. After 3 years, around 30% of treated patients will be in remission; after 6 years, 68% will continue to have mild symptoms, and in 9% the symptoms will still be severe.

Focused history

Make sure to elicit any underlying comorbidities and identify any medications that could be inducing symptoms. When asking about the symptoms, make sure to inquire about how much this affects their functioning socially, in daily activities and at work or school. Address possible causes as they may help to guide future treatments.

Assessment of physical factors and investigations

Similarly to panic disorder, there are no specific tests for GAD, and investigations should be undertaken to rule out other physical causes.

Diagnosis

A diagnosis can be made when patients describe a 6-month history of anxiety that is present on most days and not related to a specific situation. ICD-10 suggests that at least 4 of the following should be present: autonomic stimulation, impairments in concentration, muscular tension or aches, physical symptoms such as chest, GI and breathing difficulties, mental symptoms such as dizziness, light-headedness, derealisation, nervousness and fears someone close to them may come to harm and finally overreaction to mild stimulus. DSM-5 takes into consideration irritability, restlessness, feelings of fatigue and sleep problems.

Treatment

Biological treatments – SSRIs are first-line according to NICE; if ineffective, then a second SSRI can be tried before moving on to SNRIs or pregabalin if antidepressants are contraindicated or as an adjuvant. Like panic disorder, benzodiazepines should only be offered in crises.

Psychological treatments – In mild-moderate cases, 5-14 week independent self-help courses can be offered, or courses with others would last 6 weeks. Applied relaxation or CBT focused on behavioural and cognitive methods may be useful for moderate-severe cases; these are offered as weekly sessions for 3-4 months.

Social – Advice on alcohol cessation and identifying social support networks.

References

• Smyth R. (2019). Oxford Handbook of Psychiatry, fourth edition.
• National Institute for Health and Care Excellence. (2020). Generalised anxiety disorder and panic disorder in adults: management [Clinical guideline CG113]. https://www.nice.org.uk/guidance/cg113/ifp/chapter/Generalised-anxiety-disorder-GAD
• International Statistical Classification of Diseases, tenth revision (ICD-10), Version:2016, https://icd.who.int/browse10/2016/en#/F40-F48
• International Statistical Classification of Diseases, eleventh revision (ICD-11), Version 01/2023, https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f1712535455
• Taylor DM; Barnes TRE; Young AH. (2021). The Maudsley Prescribing Guidelines in Psychiatry, fourteenth edition.