Psychiatry
AKT · Psychiatry/Anxiety & stress
Generalised anxiety disorder
Overview
Excessive, hard-to-control worry about multiple domains on most days for ≥6 months, with somatic arousal (restlessness, fatigue, poor concentration, irritability, muscle tension, sleep disturbance).
Recognise
- Free-floating, persistent worry across many areas
- Autonomic/somatic: palpitations, tension, GI upset
- Restlessness, fatigue, poor concentration, sleep disturbance
Red flags
- Suicidal ideation; severe functional impairment → step up care
Differentials & how to tell them apart
Panic disorderdiscrete recurrent attacks vs continuous worry
Hyperthyroidismweight loss, tremor, tachycardia — check TFTs
Depressionpervasive low mood/anhedonia primary
Investigations
Clinical; GAD-7 to grade and monitor. Exclude hyperthyroidism (TFTs), substance/caffeine, phaeochromocytoma if paroxysmal.
Management
- 1Step 1 education + active monitoring. Step 2 (no improvement): low-intensity — guided self-help / psychoeducational groups (CBT-based).
- 2Step 3 (marked impairment): high-intensity CBT or applied relaxation, OR drug treatment — SSRI (sertraline) first-line.Gate: If sertraline ineffective → another SSRI or an SNRI; only if neither tolerated → pregabalin
- 3Do NOT offer a benzodiazepine (except short-term in crisis) or an antipsychotic in primary care.
Sertraline (SSRI) — first-line drug; if ineffective → alternative SSRI or SNRI
Duloxetine / venlafaxine (SNRI) — second-line
Pregabalin — if SSRI/SNRI not tolerated
Key points
<30 yrs: review within 1 week (suicidality signal). Pregnancy: lowest effective dose; SSRI/SNRI after ~20 weeks → small PPHN risk; specialist perinatal advice.
Monitor & prognosis
GAD-7; early SSRI/SNRI activation (transient ↑anxiety/agitation); under-30 weekly suicide-risk for first month.
Chronic and fluctuating; responds to CBT + SSRI.
Source: NICE CKS GAD (2025) / CG113