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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Excessive, uncontrollable worry about multiple topics for ≥6 months with functional impairment
- GAD-7 for severity screening: 5–9 mild, 10–14 moderate, ≥15 severe
- NICE CG113 stepped care: Step 2 → guided self-help/psychoeducation; Step 3 → CBT or SSRI; Step 4 → specialist/combined
- First-line drug: sertraline (off-label but most cost-effective per NICE). Licensed alternatives: escitalopram, duloxetine, pregabalin, venlafaxine
- CBT is the psychological treatment of choice — 12–15 sessions of individual high-intensity CBT
- Very commonly comorbid with depression (~50%) — treat the primary/more severe disorder first
Overview
Generalised anxiety disorder (GAD) is characterised by excessive, pervasive and difficult-to-control worry about a range of everyday events and activities, accompanied by physical symptoms of autonomic arousal and muscle tension. Unlike normal worry, GAD is persistent (≥6 months), disproportionate to circumstances, and causes significant functional impairment. It frequently coexists with depression and other anxiety disorders. The pathophysiology involves dysregulation of the serotonergic and noradrenergic systems, amygdala hyperactivity, and altered prefrontal cortical function.
Epidemiology
GAD is one of the most common anxiety disorders in primary care, with a UK prevalence of approximately 4–5% of adults. It is more common in women (2:1 ratio) and peaks between ages 35–55. Risk factors include female sex, family history, adverse childhood experiences, chronic physical illness, unemployment, and social deprivation. GAD is frequently under-recognised because patients often present with somatic symptoms (palpitations, GI upset, tension headaches) rather than reporting worry directly.
Clinical Features
Symptoms
Excessive worry about multiple everyday events — finances, health, family, work — shifting focus
Difficulty controlling the worry — the worry feels uncontrollable and intrusive
Restlessness, feeling keyed up or on edge
Fatigue and poor concentration
Muscle tension — particularly neck, shoulders, jaw
Sleep disturbance — difficulty falling asleep due to racing thoughts (initial insomnia)
Irritability
Somatic symptoms: palpitations, dry mouth, sweating, GI upset, dizziness, frequent urination
Signs
Visible restlessness, fidgeting, inability to sit still
Tremor, tachycardia
Muscle tension (palpable on examination)
Hypervigilance, exaggerated startle response
Investigations
First-line
GAD-7 questionnaireValidated severity measure: 5–9 mild, 10–14 moderate, ≥15 severe. Also useful for monitoring treatment response
Clinical assessmentStructured history: nature/duration/triggers of worry, functional impact, comorbidity screen (depression, substance misuse), risk assessment
Second-line
Bloods to exclude organic causesTFTs (hyperthyroidism), FBC, glucose, calcium, ECG (if palpitations). Phaeochromocytoma screen if episodic hypertension
PHQ-9Screen for comorbid depression — present in ~50% of GAD patients
Specialist
Specialist psychiatric assessmentIf complex, treatment-refractory, or significant comorbidity (personality disorder, substance misuse)
1
Step 1 — Identification and education
- Psychoeducation about GAD — normalise, explain the condition, provide written information
- Active monitoring if mild symptoms
2
Step 2 — Low-intensity interventions
- Guided self-help based on CBT principles (workbooks or online)
- Psychoeducational groups
- Consider exercise as adjunct
3
Step 3 — High-intensity interventions
- Individual CBT: 12–15 sessions (first-line psychological therapy)
- SSRI: sertraline (off-label but most cost-effective per NICE). Start 50 mg, titrate to max 200 mg
- If SSRI not tolerated: SNRI (duloxetine 60–120 mg or venlafaxine 75–225 mg) or pregabalin 150–600 mg/day
- Review at 4–6 weeks — if partial response, optimise dose; if no response, switch class
- Continue medication for ≥12 months after remission before considering gradual taper
4
Step 4 — Complex/treatment-refractory GAD
- Specialist mental health team assessment
- Combined CBT + drug treatment
- Consider augmentation strategies under specialist supervision
- Do NOT offer antipsychotics for GAD in primary care (NICE)
Complications
- Depression: ~50% comorbidity — assess for depression at every review
- Substance misuse: Self-medication with alcohol or benzodiazepines worsens long-term outcomes
- Functional impairment: Significant impact on work, relationships, and quality of life comparable to chronic physical illness
- Chronic course: Without treatment, GAD tends to be chronic and relapsing — early treatment improves prognosis
- Physical health: Chronic anxiety associated with cardiovascular disease, IBS, and chronic pain syndromes
UKMLA Exam Tips
- 1GAD = excessive worry about MULTIPLE topics for ≥6 months. Distinguish from: panic (episodic), phobia (specific trigger), OCD (obsessions + compulsions)
- 2GAD-7 ≥10 = moderate — threshold for active treatment (SSRI or CBT)
- 3Sertraline is most cost-effective first-line drug per NICE, although off-label for GAD. Licensed options: escitalopram, duloxetine, venlafaxine, pregabalin
- 4Do NOT prescribe benzodiazepines for GAD beyond 2–4 weeks — tolerance, dependence, and withdrawal risk
- 5Do NOT offer antipsychotics for GAD in primary care (NICE CG113)
- 6Initial insomnia (difficulty falling asleep) is typical of anxiety; early morning waking is typical of depression
- 7If GAD + depression coexist, treat the more severe/functionally impairing condition first (NICE)
practicetest your knowledge on generalised anxiety disorderApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — psychiatry and beyond.
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