Generalised Anxiety Disorder Symptoms and Treatment

Authored by , Reviewed by Dr Laurence Knott | Last edited | Meets Patient’s editorial guidelines

This article is for Medical Professionals

Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Generalised Anxiety Disorder article more useful, or one of our other health articles.


Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.

Synonym: anxiety neurosis

This article refers to the International Classification of Diseases 11th edition (ICD-11) which is the official classification system for mental health professionals working in NHS clinical practice. The literature occasionally refers to the Diagnostic and Statistical Manual of Mental Disorders (DSM) classification system which - whilst used in clinical practice in the USA - is primarily used for research purposes elsewhere.

See also the Generalised Anxiety Disorder Assessment (GAD-7) calculator.

The International Statistical Classification of Disease and Related Health Problems (ICD-11) defines generalised anxiety disorder (GAD) as follows:[1]

Generalised anxiety disorder is characterised by marked symptoms of anxiety that persist for at least several months, for more days than not, manifested by either general apprehension (ie ‘free-floating anxiety') or excessive worry focused on multiple everyday events, most often concerning family, health, finances, and school or work, together with additional symptoms such as muscular tension or motor restlessness, sympathetic autonomic over-activity, subjective experience of nervousness, difficulty maintaining concentration, irritability, or sleep disturbance. The symptoms result in significant distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. The symptoms are not a manifestation of another health condition and are not due to the effects of a substance or medication on the central nervous system.

Generalised anxiety disorder (GAD) in a child or adolescent is excessive worry and tension about everyday events that the child or adolescent cannot control and that is expressed on most days for at least six months, to the extent that there is distress or difficulty in performing day-to-day tasks.[2]

Prevalence of generalised anxiety disorder is difficult to ascertain without precise diagnostic criteria. Anxiety disorders are often under-recognised and undertreated in primary care.[4]

  • Anxiety disorders are the most common psychiatric disorders. A survey in 2007 estimated the prevalence of generalized anxiety disorder (GAD) among adults in England to be 4.4%. In primary care settings, GAD has been estimated to occur in 7 to 8% of patients.
  • GAD is most common in people aged between 35 and 55 years of age, and is more common in women than in men.
  • Differences in rates across cultural groups are evident. This may be due to variation in symptom presentation and the interpretation of symptoms as much as true differences in prevalence.[5]
  • Generalised anxiety disorder is more prevalent in elderly populations than was once thought.[6]

Risk factors

  • Some factors associated with GAD include female sex, lower education level, poor health, and presence of life stressors.
  • Other factors include being divorced or separated, and living alone or as a lone parent.

Patients with GAD typically present with excessive anxiety about ordinary, day-to-day situations. The anxiety is intrusive, causes distress or functional impairment, and often encompasses multiple domains (eg, finances, work, health). The anxiety is often associated with physical symptoms, such as sleep disturbance, restlessness, muscle tension, gastrointestinal symptoms, and chronic headaches.

Diagnosing GAD requires caution to identify confounding variables and comorbid conditions. Screening and monitoring tools, such as GAD-7, can be used to help make the diagnosis and monitor response to therapy.

There are a number of related conditions to GAD that need to be differentiated at an early stage. There may be confusion and overlap:

Anxiety is commonly a feature of other disorders.

Other conditions to consider include:

  • Schizophrenia. This can present with anxiety. Ask what the patient thinks caused the symptoms. An irrational answer may show unexpressed delusional ideas.
  • Dementia. This is often associated with anxiety and often with depression. Check the memory of any middle-aged or older patient presenting for the first time with anxiety. Screening for dementia gives some quick but validated tests.
  • Anxiety and depression. These frequently co-exist.[8] Ask about depressive symptoms. Those symptoms that appear first or are most severe determine the diagnosis.
  • Alcohol dependency. Can cause anxiety as a symptom of withdrawal and may be worse in the morning. Abuse of many other drugs can also produce anxiety.
  • Physical illness. This is much less likely to present as simply GAD:
    • Thyrotoxicosis. May produce irritability, restlessness, tremor and tachycardia.
    • Phaeochromocytoma. Normally is part of multiple endocrine neoplasia - usually MEN2.
    • Hypoglycaemia. This is usually part of failure of control of diabetes but insulinoma can be part of MEN.

There are a number of validated screening tests that can be used, including the Beck's Anxiety Inventory, General Health Questionnaire, Hamilton Anxiety Scale (HAS) and the Hospital Anxiety and Depression Scale (HADS). There are limitations in the use of routine questionnaires but providing these limitations are recognised, the general consensus is that they are worth employing in evaluation and treatment.[9, 10]

Evidence-based guidelines are laid down by the National Institute for Health and Care Excellence (NICE).[11] Relevant issues are as follows:

  • Identify the diagnosis and inform the patient as soon as possible so treatment can be commenced.
  • The patient's preference for method of GAD treatment.
  • Make independent interpreters available if necessary.
  • Emphasise to the patient that the disease can be managed and give as much information as possible, including written information and access to self-help and psycho-educational groups.
  • Make an assessment of the patient's functional disability and distress.
  • Assess past experience and response to previous treatment.
  • In terms of long-term effectiveness, the best results are from psychotherapy, followed by medication, followed by self-help.
  • Patients with mild learning disability or mild acquired cognitive impairment should be offered the same services as other people with GAD, making appropriate adjustment for the disability.
  • People with GAD and a moderate-to-severe learning disability or moderate-to-severe acquired cognitive impairment should be offered specialist referral.
  • Placebo response can vary from 20% to over 50%.
  • Treatment should be available in primary care with only the most difficult cases requiring referral.
  • Make the patient aware of the hazards of over-the-counter medications.
  • Provide contact details in the event of a crisis.

The stepped-care model

NICE recommends the following approach:[11]


Step 1:
all known and suspected presentations of GAD
Identification, assessment, education, monitoring.

Step 2: diagnosed GAD that has not improved after education and active monitoring in primary care
Low-intensity psychological support, non-facilitated or guided self-help, psycho-educational groups.

Step 3: GAD with an inadequate response to step 2 interventions or marked functional impairment
Cognitive behavioural therapy (CBT)/applied relaxation or drug treatment.

Step 4: complex treatment-refractory GAD and very marked functional impairment, such as self-neglect or a high risk of self-harm
Specialist drug and/or psychological treatment, multi-agency teams, crisis intervention, outpatient or inpatient care.

There are frequently comorbid conditions - eg, depression, substance abuse - which may need treating too. NICE recommends that the most severe condition be treated first.[11] If treating a child or adolescent, be much more reluctant and cautious about prescribing.[12]

Psychological therapy

CBT is the technique of choice for an effective and lasting response:

  • It must be delivered by appropriately trained professionals.
  • The optimum duration of therapy would seem to be about 16-20 hours, delivered in a weekly session of one or two hours and completed within four months.
  • If offering briefer CBT, it should be about 8-10 hours and should be designed to integrate with structured self-help materials.

Anxiety management treatment is also better than no treatment and its efficacy may equal that of CBT. It is a structured therapy involving education, relaxation training, and exposure. Relaxation involves practising techniques that lead to muscular or bodily relaxation. Exposure entails (over a period of time) graded, repeated confrontation (through visualisation, image, or the stimulus) with a stimulus that causes anxiety.

Recently a simplified protocol for the treatment of a wide range of psychological conditions - transdiagnostic CBT - has been used to good effect in the management of GAD.[13]

Pharmacological treatment

Before prescribing, consider:

  • Age of patient.
  • Previous treatment response.
  • Risks of deliberate self-harm or accidental overdose.
  • Tolerability.
  • Possible interactions with existing medications.
  • The patient's preference.
  • Cost, where equal effectiveness.

Where a rapid response is required:

  • The sedative antihistamines may be effective or the benzodiazepines. The latter should not be used beyond four weeks. Apparent dependence may be because the disease has returned as the drug is withdrawn or there may be a physical dependence.
  • It has been suggested that buspirone is less sedative and less addictive than benzodiazepines but it should be used with similar caution.

Antidepressants are often good at alleviating anxiety, even if there is no true depression.[14] They take longer to work than benzodiazepines but they can be continued for longer.

  • NICE recommends a selective serotonin reuptake inhibitor (SSRI) or venlafaxine as the first choice. If one SSRI is not suitable or there is no improvement after a 12-week course and if a further medication is appropriate, another SSRI should be offered. Long-term treatment and doses at the upper end of the indicated dose range may be necessary. NICE recommends sertraline first-line but acknowledges that this is an unlicensed use. SSRIs licensed for the treatment of GAD in the UK are escitalopram and paroxetine.
  • At the start of GAD treatment, patients should be informed about:
    • Potential side-effects (including transient increase in anxiety at the start of treatment).
    • Possible discontinuation/withdrawal symptoms.
    • Delay in onset of effect.
    • Time course of treatment.
    • Need to take medication as prescribed.
  • If there is no benefit in 12 weeks an antidepressant from a different class may be tried.
  • SSRIs and venlafaxine should be tailed off, as sudden discontinuation can produce withdrawal.
  • If sertraline is ineffective, offer an alternative SSRI or a serotonin-noradrenaline reuptake inhibitor (SNRI), such as duloxetine or venlafaxine.
  • Pregabalin may be considered in patients who cannot tolerate SSRIs or SNRIs.
  • Duloxetine, although not mentioned by NICE, is licensed for the treatment of GAD and has been found effective.

NB: beta-blockers and monoamine-oxidase inhibitors are not usually considered appropriate options for GAD.[15]

Editor's note

Dr Krishna Vakharia, 11th May 2022

NICE guidance: Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults

NICE has published guidance on safe prescribing and withdrawal of medicines associated with dependence or withdrawal symptoms in adults. It has concentrated on benzodiazepines and Z drugs, opioids, gabapentin and pregabalin, and antidepressants. Whilst antidepressants are not associated with dependence, they are associated with withdrawal symptoms.

The guidance discusses the factors to be considered prior to prescribing and the information required for the patient during initiation and withdrawal of these types of medications.

Recommendations for initiation. Advise the patient about and document:

  • The type of medication and why it has been prescribed.
  • How the medication works and its common side-effects.
  • The starting dose and when doses will be adjusted.
  • Who to contact if any queries or concerns.
  • How long the medication will take to work and how long the treatment is for.
  • How long the prescription given is for - eg, one week, three weeks etc.
  • The risks of dependence and overdose.
  • Review date.

Recommendations for withdrawal:

  • If there is no benefit or it is no longer benefitting the patient.
  • There are symptoms and signs of dependence.
  • The condition is resolved.
  • There are more harms than benefits to taking the medication.
  • The patient wishes to stop treatment.

Withdrawal should be done slowly (unless an emergency) taking in factors such as length of time on the medication, how high the dose is (may need to reduce dose first) or any social factors that will affect stopping the medication.[16]

Self-help

  • Self-help interventions are effective but are best used as part of a stepped-care approach.[17]
  • NICE advocates instructing the person to work through the materials systematically over a period of six weeks. Occasional contact with a therapist is advocated (eg, a five-minute telephone call).[11]
  • Internet-based self-help CBT has proved effective but the evidence base is currently small.[18]
  • Interventions such as exercise, yoga, mindfulness-based meditation, t'ai chi, or qi gong may have benefits as adjunctive therapy for patients with depression, anxiety disorders, or both.[19]
  • If one form of GAD therapy does not work, another may be tried. More than one style may be used simultaneously.
  • If two interventions have been tried without success then referral to mental health services is required.

Monitoring

  • Primary healthcare professionals should monitor progress. Review interval should be determined on a case-by-case basis but is likely to be every 4-8 weeks.
  • For patients on medication, NICE recommends a review every 2-4 weeks for the first three months and three-monthly thereafter.
  • Medication should be continued for a minimum of one year.
  • A short, self-complete questionnaire should be used to monitor outcomes wherever possible.

Generalised anxiety disorder is usually a chronic disease that is controlled rather than cured but the ambience of the doctor should be positive towards a favourable result.[20]

Generalised anxiety disorder often pursues a waxing and waning course and long-term support and education are required.[12]

Studies of older individuals with GAD report a duration of 20 years or more. Significant quality of life impairment and increased burden of healthcare cost have been noted in older adults. Chronic anxiety conditions are associated with increased morbidity, possibly due to cardiovascular complications and insulin resistance linked to an acceleration of the ageing process.[6]

Further reading and references

  • Anxiety disorders; NICE Quality Standards, Feb 2014

  • Garakani A, Murrough JW, Freire RC, et al; Pharmacotherapy of Anxiety Disorders: Current and Emerging Treatment Options. Front Psychiatry. 2020 Dec 2311:595584. doi: 10.3389/fpsyt.2020.595584. eCollection 2020.

  • Strawn JR, Geracioti L, Rajdev N, et al; Pharmacotherapy for generalized anxiety disorder in adult and pediatric patients: an evidence-based treatment review. Expert Opin Pharmacother. 2018 Jul19(10):1057-1070. doi: 10.1080/14656566.2018.1491966.

  1. International Classification of Diseases 11th Revision; World Health Organization

  2. Gale CK, Millichamp J; Generalised anxiety disorder in children and adolescents. BMJ Clin Evid. 2016 Jan 132016. pii: 1002.

  3. Generalised anxiety disorder; NICE CKS (October 2017)

  4. Bandelow B, Michaelis S, Wedekind D; Treatment of anxiety disorders. Dialogues Clin Neurosci. 2017 Jun19(2):93-107.

  5. Marques L, Robinaugh DJ, LeBlanc NJ, et al; Cross-cultural variations in the prevalence and presentation of anxiety disorders. Expert Rev Neurother. 2011 Feb11(2):313-22. doi: 10.1586/ern.10.122.

  6. Lenze EJ, Wetherell JL; A lifespan view of anxiety disorders. Dialogues Clin Neurosci. 201113(4):381-99.

  7. Locke AB, Kirst N, Shultz CG; Diagnosis and management of generalized anxiety disorder and panic disorder in adults. Am Fam Physician. 2015 May 191(9):617-24.

  8. Alonso J, Angermeyer MC, Bernert S, et al; 12-Month comorbidity patterns and associated factors in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatr Scand Suppl. 2004(420):28-37.

  9. Weeks JW, Heimberg RG; Evaluation of the psychometric properties of the Beck Depression Inventory in a non-elderly adult sample of patients with generalized anxiety disorder. Depress Anxiety. 200522(1):41-4.

  10. Bunevicius A, Staniute M, Brozaitiene J, et al; Screening for anxiety disorders in patients with coronary artery disease. Health Qual Life Outcomes. 2013 Mar 1111:37. doi: 10.1186/1477-7525-11-37.

  11. Generalised anxiety disorder and panic disorder in adults: management; NICE Clinical Guideline (January 2011 - updated July 2019)

  12. Davidson JR, Feltner DE, Dugar A; Management of generalized anxiety disorder in primary care: identifying the challenges and unmet needs. Prim Care Companion J Clin Psychiatry. 201012(2). pii: PCC.09r00772. doi: 10.4088/PCC.09r00772blu.

  13. Norton PJ, Barrera TL; Transdiagnostic versus diagnosis-specific cbt for anxiety disorders: a preliminary randomized controlled noninferiority trial. Depress Anxiety. 2012 Oct29(10):874-82. doi: 10.1002/da.21974. Epub 2012 Jul 5.

  14. Schmitt R, Gazalle FK, Lima MS, et al; The efficacy of antidepressants for generalized anxiety disorder: a systematic review and meta-analysis. Rev Bras Psiquiatr. 2005 Mar27(1):18-24. Epub 2005 Apr 18.

  15. Farach FJ, Pruitt LD, Jun JJ, et al; Pharmacological treatment of anxiety disorders: current treatments and future directions. J Anxiety Disord. 2012 Dec26(8):833-43. doi: 10.1016/j.janxdis.2012.07.009. Epub 2012 Aug 15.

  16. Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults; NICE guidance (April 2022)

  17. Lewis C, Pearce J, Bisson JI; Efficacy, cost-effectiveness and acceptability of self-help interventions for anxiety disorders: systematic review. Br J Psychiatry. 2012 Jan200(1):15-21. doi: 10.1192/bjp.bp.110.084756.

  18. Andersson G, Paxling B, Roch-Norlund P, et al; Internet-based psychodynamic versus cognitive behavioral guided self-help for generalized anxiety disorder: a randomized controlled trial. Psychother Psychosom. 201281(6):344-55. doi: 10.1159/000339371. Epub 2012 Sep 6.

  19. Saeed SA, Cunningham K, Bloch RM; Depression and Anxiety Disorders: Benefits of Exercise, Yoga, and Meditation. Am Fam Physician. 2019 May 1599(10):620-627.

  20. Gale C, Davidson O; Generalised anxiety disorder. BMJ. 2007 Mar 17334(7593):579-81.

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