Generalised anxiety disorder (GAD) is a mental health condition that causes excessive and disproportional anxiety and worry that negatively impacts the person’s everyday activity. Symptoms should be persistent, occurring most days for at least six months, and not caused by substance use or another condition.
Panic disorder involves recurrent panic attacks. The panic attacks are unexpected (they appear randomly, often without a trigger) and result in worry about further attacks and maladaptive behaviour changes relating to the attacks (e.g., avoiding activities).
Secondary causes of anxiety include:
- Substance use (e.g., caffeine, stimulants, bronchodilators and cocaine)
- Substance withdrawal (e.g., alcohol or benzodiazepine withdrawal)
- Hyperthyroidism
- Phaeochromocytoma
- Cushing’s disease
Presentation
Emotional and cognitive symptoms of GAD include:
- Excessive worrying
- Unable to control the worrying
- Restlessness
- Difficulty relaxing
- Easily tired
- Difficulty concentrating
Physical symptoms (caused by overactivity of the sympathetic nervous system) include:
- Muscle tension
- Palpitations (e.g., a feeling of their heart racing)
- Sweating
- Tremor
- Gastrointestinal symptoms (e.g., abdominal pain and diarrhoea)
- Headaches
- Sleep disturbance
Panic Attacks
Panic attacks involve a sudden onset of intense physical and emotional symptoms of anxiety. They come on quickly (within minutes) and last a short time (e.g., 10 minutes) before the symptoms gradually fade. The duration and frequency vary between individuals. Panic attacks are relatively common and do not always indicate a panic disorder.
Physical symptoms include tension, palpitations, tremors, sweating, dry mouth, chest pain, shortness of breath, dizziness and nausea.
Emotional symptoms include feelings of panic, fear, danger, depersonalisation (feeling separated or detached) and loss of control.
Phobia
Phobia involves an extreme fear of certain situations or things, causing symptoms of anxiety and panic. There are many types, including fear of animals, heights, pathogens, flying, injections or environments.
Examples of common specific phobias include:
- Claustrophobia (fear of closed spaces)
- Acrophobia (fear of heights)
- Arachnophobia (fear of spiders)
- Glossophobia (fear of public speaking)
- Trypanophobia (fear of needles)
Agoraphobia is a fear of situations in which they may be unable to escape if something goes wrong. For example, this could be a fear of busy places, public transport, or anywhere outside their home.
Social phobia involves a fear of social situations (also called social anxiety disorder).
GAD-7
The Generalised Anxiety Disorder Questionnaire (GAD-7) can help assess the severity. It involves seven questions, each scored depending on how often the symptoms are experienced. The total score indicates the severity:
- 5-9 indicates mild anxiety
- 10-14 indicates moderate anxiety
- 15-21 indicates severe anxiety
Management
Mild anxiety may be managed with active monitoring and advice about self-help strategies (e.g., meditation), sleep, diet, exercise and avoiding alcohol, caffeine and drugs.
Moderate to severe anxiety may require more intervention. Options include:
- Cognitive behavioural therapy
- Medication
SSRIs (particularly sertraline) are the first-line medication for generalised anxiety disorder and panic disorder.
Other options for generalised anxiety disorder mentioned in the NICE guidelines (2020) are:
- SNRIs (e.g., venlafaxine)
- Pregabalin
Propranolol is a non-selective beta-blocker often used to treat physical symptoms of anxiety. It helps reduce sympathetic nervous system overactivity, improving symptoms such as palpitations, tremors, and sweating. However, it does not treat the underlying anxiety and only has a short-term effect. The main contraindication is asthma (it can cause bronchoconstriction in asthmatic patients).
Benzodiazepines (e.g., diazepam) work by stimulating GABA receptors (similar to the effects of alcohol). GABA receptors have a relaxing effect on the rest of the brain, giving relief from anxiety. However, prolonged use quickly results in down-regulate GABA receptors, leading to tolerance (reduced effects at the same dose) and dependence (significant withdrawal symptoms on stopping). The NICE guidelines (2020) recommend not offering benzodiazepines for GAD. The exception is using them for a short duration during a crisis, stopping them as soon as possible.
Last updated June 2024
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