generalised anxiety disorder

Last reviewed 01/2018

Generalised anxiety disorder (GAD) is one of a range of anxiety disorders that includes panic disorder (with and without agoraphobia), post-traumatic stress disorder, obsessive-compulsive disorder, social phobia, specific phobias (for example, of spiders) and acute stress disorder. Anxiety disorders can exist in isolation but more commonly occur with other anxiety and depressive disorders.

GAD is a common disorder, of which the central feature is excessive worry about a number of different events associated with heightened tension

• a formal diagnosis using the DSM-IV classification system requires two major symptoms occurring more days than not, for at least 6 months (excessive anxiety and worry about a number of events and activities, and difficulty controlling the worry) and three or more additional symptoms from a list below:

The anxiety and worry are associated with at least three of the following six symptoms (with at least some symptoms present for more days than not, for the past 6 months):

• restlessness or feeling keyed up or on edge
• being easily fatigued
• difficulty concentrating or mind going blank
• irritability
• muscle tension
• sleep disturbance

Symptoms should be present for at least 6 months and should cause clinically significant distress or impairment in social, occupational or other important areas of functioning

NICE suggest a stepped care model for GAD (2):

• Stepped Care Model for Intervention in GAD

  • Focus of the Intervention	Nature of the Intervention
    STEP 4: Complex treatment-refractory GAD and very marked functional impairment, such as self-neglect or a high risk of self-harm	Highly specialist treatment, such as complex drug and/or psychological treatment regimens; input from multi-agency teams, crisis services, day hospitals or inpatient care
    STEP 3: GAD with an inadequate response to step 2 interventions or marked functional impairment	Choice of a high-intensity psychological intervention (CBT/applied relaxation) or a drug treatment
    STEP 2: Diagnosed GAD that has not improved after education and active monitoring in primary care	Low-intensity psychological interventions: individual non-facilitated self-help*, individual guided self-help and psychoeducational groups
    STEP 1: All known and suspected presentations of GAD	Identification and assessment; education about GAD and treatment options; active monitoring

  * A self-administered intervention intended to treat GAD involving written or electronic self-help materials (usually a book or workbook). It is similar to individual guided self-help but usually with minimal therapist contact, for example an occasional short telephone call of no more than 5 minutes.

Notes:

• choice of this diagnostic category is problematic since there is much overlap with conditions such as agoraphobia. Problems also arise with the confusion of "anxiety neurosis" with "anxiousness", the latter being a symptom rather than a syndrome. Anxiousness may occur with any psychiatric disorder, but anxiety neurosis only occurs in the absence of other psychiatric symptoms. Lastly, it may also be difficult to separate anxiety from mild depressive states.

Reference:

• 1) American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders (fourth edition). Washington DC: American Psychiatric Association. This guideline uses DSM-IV criteria because the evidence for treatments is largely based on this system
• 2) NICE (January 2011). Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults