14th February 2025

Generalised anxiety disorder (GAD)

Generalised anxiety disorder is characterised by a global sense of worry and fear regarding everyday events, disproportionate to any inherent risk. It presents with both cognitive and somatic symptoms and causes significant distress and functional impairment.

Epidemiology and aetiology of GAD

GAD is also common, with a lifetime prevalence of roughly 5%. Incidence peaks in middle age.

Risk factors include female gender (especially for early onset), stressful events, being single, dysfunctional relationships and unemployment. It has a genetic component, sharing heritability with depression. Patients may have psychological vulnerabilities such as insecure attachment to primary caregivers, intolerance of uncertainty, or have received parenting which is overprotective or lacking warmth.

Presentation and diagnosis of GAD

In GAD, significant anxiety symptoms are present most days for at least 6 months. There may be either generalised apprehension (“free-floating” anxiety) or excessive worry related to daily events. This is accompanied by somatic symptoms such as muscle tension, restlessness, sympathetic overdrive (e.g. dry mouth, palpitations, sweating), or gastrointestinal upset. Sleep and concentration are often impaired.

Commonly used screening tools include the Hamilton Anxiety Rating Scale (HAM-A) and the Generalised Anxiety Disorder 7 (GAD-7) self-scoring tool.

Symptoms must not be caused by another condition, such as hyperthyroidism, phaeochromocytoma, lung disease, caffeine or cocaine use, or alcohol or benzodiazepine withdrawal. As such, thyroid function tests, urine drug screen, 24-hour urine metanephrines, pulmonary function tests and ECG may be needed. Medications can also cause anxiety symptoms such as commonly used salbutamol and thyroxine.

Management of GAD

NICE recommends patient education and low-intensity psychological interventions such as guided self help as first-line treatment. If response is inadequate or there is marked functional impairment, high-intensity psychological intervention such as CBT or drug treatment is indicated.

An SSRI would be the first-line medication, followed by an SNRI if ineffective, or pregabalin as a third-line option. Benzodiazepines are only to be used as a short-term measure in a crisis.

Beta blockers such as propranolol are commonly used for somatic symptoms.