Generalised Anxiety Disorder (GAD)
Definition
- Generalised Anxiety Disorder (GAD) is a chronic and excessive worry about multiple aspects of daily life that is difficult to control, occurring on most days for at least 6 months.
Associated with physical, emotional, and cognitive symptoms, leading to functional impairment.
Causes & Risk Factors
Pathophysiology
- Dysregulation of the Amygdala & Prefrontal Cortex → Increased Fear Response & Impaired Regulation of Worry.
- Neurotransmitter Imbalance (↓ GABA, ↓ Serotonin, ↑ Norepinephrine).
Risk Factors for GAD
|
Risk Factor |
Description |
|
Family History |
Genetic Predisposition (Higher in First-Degree Relatives). |
|
Personality Traits |
High Neuroticism, Perfectionism. |
|
Chronic Stress |
Work, Finances, Relationships. |
|
History of Trauma |
Childhood Neglect, Abuse, Parental Overprotection. |
|
Comorbid Mental Health Disorders |
Depression, Panic Disorder, PTSD. |
|
Chronic Medical Conditions |
Chronic Pain, IBS, Thyroid Dysfunction. |
|
Substance Abuse |
Caffeine, Alcohol, Drug Dependence. |
🔹 GAD has a strong genetic and environmental component.
Clinical Features
♠ Symptoms of GAD
|
Category |
Common Symptoms |
|
Excessive Worry (Core Symptom) |
Difficult to Control, Persistent for ≥6 Months. |
|
Cognitive Symptoms |
Difficulty Concentrating, Mind Goes Blank. |
|
Autonomic Symptoms |
Palpitations, Sweating, Trembling. |
|
Muscle Tension |
Restlessness, Jaw Clenching, Headaches. |
|
Sleep Disturbance |
Difficulty Falling Asleep Due to Worry. |
|
Irritability |
Easily Frustrated, Low Patience. |
Signs on Examination
|
Feature |
Description |
|
Agitation & Restlessness |
Fidgeting, Nail Biting. |
|
Muscle Tension |
Tense Neck, Jaw Clenching. |
|
Autonomic Overactivity |
Sweating, Tachycardia. |
🔹 Excessive, persistent worry and autonomic hyperactivity are key features of GAD.
Referral Criteria (NICE Guidelines)
Urgent Referral (If Severe Symptoms or Risk to Self/Others)
- Active Suicidal Ideation or Self-Harm.
- Severe Functional Impairment (Unable to Work, Socially Isolated).
- Acute Anxiety Crisis (Severe Panic, Agitation).
Routine Referral (If First-Line Treatments Fail)
- No Improvement with Initial Psychological or Pharmacological Therapy.
- Comorbid Severe Depression or PTSD.
- Patient Preference for Specialist Input.
🔹 Severe cases require psychiatric referral, while mild-moderate cases are managed in primary care.
Diagnosis
Clinical Diagnosis (Based on ICD-10/DSM-5 Criteria)
|
Criterion |
Description |
|
Excessive Anxiety & Worry |
Present Most Days for ≥6 Months. |
|
Difficult to Control Worry |
Patient Cannot ‘Switch Off’ Their Worries. |
|
At Least 3 Physical or Psychological Symptoms |
Restlessness, Fatigue, Poor Concentration, Irritability, Muscle Tension, Sleep Disturbance. |
|
Significant Distress or Functional Impairment |
Affects Work, Relationships, Daily Life. |
|
Not Due to Another Medical or Psychiatric Condition |
Exclude Hyperthyroidism, Depression, Substance Use. |
Differential Diagnosis
|
Condition |
Key Differences |
|
Panic Disorder |
Episodic Attacks, No Chronic Worry. |
|
Depression |
Persistent Low Mood, Loss of Interest. |
|
Social Anxiety Disorder |
Anxiety Specific to Social Situations. |
|
Obsessive-Compulsive Disorder (OCD) |
Compulsions & Intrusive Thoughts. |
|
Hyperthyroidism |
Tremor, Weight Loss, Heat Intolerance. |
🔹 Diagnosis is clinical; blood tests may be done to exclude medical causes (e.g., thyroid dysfunction).
Management (NICE Guidelines)
Stepwise Approach to GAD Management
|
Step |
Intervention |
|
Step 1 (Low-Intensity Psychological Therapy – First-Line) |
Self-Help, Psychoeducation, Online CBT. |
|
Step 2 (High-Intensity Psychological Therapy) |
Cognitive Behavioural Therapy (CBT) or Applied Relaxation Therapy. |
|
Step 3 (Pharmacological Therapy – If Psychological Therapy Insufficient) |
SSRI (Sertraline First-Line). |
|
Step 4 (Specialist Referral – If Severe or Treatment-Resistant) |
Psychiatry, Complex Case Management. |
First-Line Pharmacological Treatment (If Needed)
|
Drug |
Mechanism |
Considerations |
|
Sertraline (SSRI, First-Line) |
Increases Serotonin Levels. |
Start Low, Increase Gradually, Takes 4-6 Weeks to Work. |
|
Alternative SSRIs (Escitalopram, Paroxetine) |
Same as Sertraline. |
Consider If Sertraline Not Tolerated. |
|
SNRI (Venlafaxine, Duloxetine) |
Serotonin & Noradrenaline Reuptake Inhibition. |
More Effective but Higher Side Effect Profile. |
|
Pregabalin (Second-Line, Off-Label for Anxiety) |
Modulates GABA Activity. |
Used If SSRIs Are Contraindicated. |
|
Beta-Blockers (Propranolol – Symptom Relief) |
Reduces Autonomic Symptoms (Palpitations, Tremors). |
Does Not Treat Psychological Symptoms. |
|
Benzodiazepines (Short-Term Only) |
Enhances GABA (Rapid Anxiolytic). |
Avoid Long-Term Use Due to Dependence Risk. |
🔹 CBT is the first-line treatment, with SSRIs if pharmacological intervention is needed.
Prognosis & Complications
Prognosis
|
Condition |
Outcome |
|
Mild GAD (With Therapy) |
Good Prognosis. |
|
Chronic GAD (Severe Anxiety) |
Higher Risk of Relapse. |
Complications of Untreated GAD
|
Complication |
Features |
|
Depression |
Common Comorbidity. |
|
Substance Abuse |
Alcohol, Drugs as Self-Medication. |
|
Social Isolation |
Avoidance Behaviour. |
|
Suicidal Thoughts |
Higher Risk in Severe GAD. |
🔹 Early treatment improves outcomes and prevents complications.
UKMLA Key Points
- Best first-line treatment for mild-moderate GAD: CBT.
- Best first-line pharmacological treatment: Sertraline (SSRI).
- When to refer urgently: Suicidal ideation, severe functional impairment.
- Best medication for autonomic symptoms: Propranolol (Beta-Blocker).
- Avoid long-term use of: Benzodiazepines (Addiction Risk).
- Duration of SSRI treatment: At least 6 months, then gradual tapering.