22nd February 2024

Generalised Anxiety Disorder

Background

Generalised anxiety disorder (GAD) is the most common anxiety disorder worldwide. It affects 4.5% of the adult population in England and is twice as common in females. 

GAD is defined as persistent worry and anxiety about more than one different thing. The worry can be related to anything from the outcomes of day-to-day activities to concerns about the individual’s own health or the health of a loved one. If left untreated it can take a chronic course, which can be as debilitating to the individual as a chronic physical health condition. GAD can have a significant impact on occupational and social functioning, As a result, patients are reported to have a poor quality of life and are at an increased risk of suicide. 

Presentation 

GAD presents with excessive anxiety, worry, and somatic symptoms. These symptoms can include shaking, dizzy spells, palpitations, and sweating. These symptoms must occur on more days than not, for at least a 6-month period, for a diagnosis of GAD. The worry can be about anything and everything. It is not fixated on a particular thing, as is the case in other anxiety disorders such as anxiety induced by a phobia (phobia disorder), by embarrassing social situations (social anxiety disorders), fear of having a serious illness (illness anxiety disorder), or excessive worry due to the presence of one or more physical symptoms (somatic symptoms disorder). 

Patients with GAD are known to frequent healthcare settings, more so than the rest of the population. Their somatic symptoms often distract the patient and clinicians from the underlying psychological cause. Depression is often co-morbid in patients with GAD. However, GAD can also occur without any other comorbid mood disorders. If GAD occurs in isolation, it is referred to as “pure” GAD. 

Investigation

For young patients with physical symptoms such as tachycardia, shortness of breath, weight change or cognitive impairment in addition to psychological symptoms, an organic cause should be ruled out first, e.g., hyperthyroidism. This can include routine blood tests, thyroid function tests, urinalysis, and an ECG. Other mood or anxiety disorders should also be ruled out. 

Patients over the age of 35 years presenting with somatic symptoms and who have had no previous history of GAD should be investigated for a physical cause first. GAD should be considered if they have key symptoms of GAD and there is no physical cause for the somatic symptoms. 

The GAD-7  is a 7-item questionnaire; each question is rated out of 3, with scores ranging from 0-21. This scale is used to measure the severity of anxiety and to monitor response to treatment and is not used as a diagnostic tool. Scores range from 0-4 is minimal, 5-9 is mild, 10-15 is moderate and >15 indicates severe anxiety.  

Diagnosis

According to the DSM 5, for a diagnosis of GAD, patients should present with the following:

 2 key symptoms:

• Disproportionate worry and anxiety about many different activities or events
• Inability to control the worry.

At least 3 of these additional symptoms:

• Difficulty concentrating
• Sleep disturbance
• Restlessness
• Fatigue
• Irritability
• Muscle tension

Management

If untreated, GAD can follow a chronic or relapsing pattern; therefore, treatment should aim to put symptoms into remission in the first instance. The more successful the treatment is at the beginning, the lower the likelihood of relapse. In patients with harmful substance misuse, treating their dependency on illicit substances can help treat their GAD symptoms. In patients who have comorbid anxiety or mood disorder, managing their primary disorder can help improve their GAD symptoms. 

The latest NICE guidelines recommend a “stepped care” approach, where the aim is to provide the least intrusive approach first. Which step of the treatment model is chosen depends on the patient’s symptoms and duration, severity, previous history, comorbidities, and current functionality. The next step is chosen if the patient’s symptoms do not improve with the current intensity of intervention. 

Image Source: Wikimedia Commons (2011). CG123, Licensed under a creative commons licence. Available for free at: https://www.nice.org.uk/guidance/cg123/chapter/1-guidance (Accessed: 6 October 2023).

Step 1

Education and active monitoring if:

• Symptoms are few, intermittent or present for <6 months (diagnostic criteria for GAD not fully met)
• Symptoms only cause mild distress and either no or only some impairment to everyday function.
• No other mood or anxiety disorder
• No history of mood or anxiety disorders

Step 1 treatment strategies

At this stage, providing reassurance, educational material and active monitoring of symptoms can help treat mild presentations and prevent the need for more intensive treatment. Education can involve written or verbal information about GAD and how it can be managed. It can also include material on national organisations and self-help groups where patients can discuss their experiences. Information on what to do in a crisis and who to contact should also be provided to the patient.  

Step 2

Active treatment with low intensity psychological intervention if:

• Symptoms meet the diagnostic criteria for GAD.
• Symptoms cause clinically significant distress and /or cause impairment in the patient’s day to day life and activities. 
• Current diagnosis of another mood or anxiety disorder
• History of a mood or anxiety disorder

Step 2 treatment strategies

CBT themed self-help which involves little input from a healthcare professional, or guided self-help where a healthcare practitioner facilitates the therapy and monitors progress. It can also involve group CBT therapy.

Step 3

High intensity psychological or pharmacological intervention if:

• There is significant functional impairment.
• Some functional impairment or poor response to the interventions in step 2
• History of a mood or anxiety disorder

Step 3 treatment strategies

• Individual high intensity therapies
  • CBT
  • Applied relaxation (patients are taught how to apply relaxation techniques  when they encounter anxiety inducing situations)
• Drug treatment can be based on patient factors such as their comorbidities and medications, as well as the patient’s preferences. There is no evidence at present to suggest that one drug class is superior to another.
  • SSRI (Sertraline – recommended by NICE)
  • SNRI
  • Pregabalin if SSRI / SNRIs are not tolerated. 
  • Benzodiazepines are not recommended as a treatment for GAD in primary or secondary care, except in a crisis as an acute therapy. 
  • Antipsychotics are not recommended as an initial treatment option as clinical efficacy is believed to be poor.

The effectiveness and side effects of medications should be reviewed within two weeks and, if effective, should be continued for at least a year to avoid the likelihood of relapse. 

At this step, if symptoms have not improved after the completion of a high-intensity psychological regimen, treatment with medication should be offered (and vice versa). If the drug treatment has not helped, an alternative drug should be considered. If symptoms have only partially responded to a drug therapy, an alternative drug treatment should be considered or if high-intensity psychological treatments haven’t been tried, these should be offered. 

Step 4

Referral for psychiatric management if:

• GAD is not improving with CBT and pharmacological treatment. 
• Severe functional impairment
• Suicidal ideation or high risk of self-harm
• Significant psychiatric comorbidities. 

Step 4 treatment strategies

At this stage, a combination of high-intensity psychological and drug therapy is recommended, however, this should only be commenced by specialists. Input from multidisciplinary teams, e.g., the crisis team, community psychiatry etc may also be required. 

References

• Kendall T, Cape J, Chan M, Taylor C. Management of generalised anxiety disorder in adults: Summary of nice guidance. BMJ. 2011;342(jan26 1):c7460–c7460. 
• Hoge EA, Ivkovic A, Fricchione GL. Generalised anxiety disorder: Diagnosis and treatment. BMJ. 2012;345(nov27 2). 
• Bittner A, Goodwin RD, Wittchen H-U, Beesdo K, Höfler M, Lieb R. What characteristics of primary anxiety disorders predict subsequent major depressive disorder? The Journal of Clinical Psychiatry. 2004;65(5):618–26. 
• Introduction: Common mental health problems: Identification and pathways to care: Guidance [Internet]. NICE. NICE; 2011 [cited 2023May1]. Available from: https://www.nice.org.uk/guidance/cg123/chapter/1-guidance