Generalised Anxiety Disorder (GAD)

Definition | Aetiology | Pathophysiology | Risk factors | Signs and symptoms | Investigations | Management

Definition

Generalised Anxiety Disorder (GAD) is a chronic mental health condition characterised by excessive, uncontrollable worry about various aspects of life, lasting for six months or more, and associated with physical and psychological symptoms.

Aetiology

  • Genetic factors: family history of anxiety disorders.
  • Neurobiological factors: dysfunction in the amygdala and prefrontal cortex.
  • Neurotransmitter imbalances: reduced serotonin and gamma-aminobutyric acid (GABA) activity.
  • Psychosocial factors: adverse childhood experiences, chronic stress, perfectionism.

Pathophysiology

  • Overactivity of the amygdala leading to excessive fear and worry.
  • Impaired regulation of the hypothalamic-pituitary-adrenal (HPA) axis, increasing cortisol levels.
  • Reduced GABAergic inhibition, leading to heightened neuronal excitability.

Risk factors

  • Family history of anxiety or mood disorders.
  • Chronic stress or exposure to prolonged uncertainty.
  • Personality traits such as neuroticism or perfectionism.
  • Female sex (higher prevalence in women).
  • History of childhood adversity or trauma.
  • Comorbid conditions (e.g., depression, irritable bowel syndrome).

Signs and symptoms

  • Psychological symptoms:
    • Excessive, persistent worry about everyday situations.
    • Restlessness or feeling on edge.
    • Difficulty concentrating or mind going blank.
  • Physical symptoms:
    • Muscle tension and headaches.
    • Fatigue and sleep disturbances.
    • Gastrointestinal discomfort (e.g., nausea, diarrhoea).
    • Palpitations, dizziness, or sweating.
  • Significant impairment in daily functioning.

Investigations

  • Clinical assessment: detailed psychiatric history and mental state examination.
  • Structured screening tools: Generalised Anxiety Disorder-7 (GAD-7) scale.
  • Collateral history: from family members or caregivers.
  • Blood tests: FBC, U&Es, LFTs, TFTs, vitamin B12, folate to rule out medical causes.
  • ECG: if palpitations or autonomic symptoms present.

Management

1. Psychological therapies:

  • Cognitive Behavioural Therapy (CBT) as first-line treatment.
  • Relaxation techniques and mindfulness-based cognitive therapy (MBCT).
  • Applied relaxation therapy for managing physical symptoms.

2. Pharmacological management:

  • First-line: Selective serotonin reuptake inhibitors (SSRIs) (e.g., sertraline, escitalopram).
  • Second-line: Serotonin-noradrenaline reuptake inhibitors (SNRIs) (e.g., venlafaxine, duloxetine).
  • Pregabalin as an alternative if SSRIs/SNRIs are not tolerated.
  • Benzodiazepines (e.g., diazepam) for short-term crisis management only.

3. Lifestyle modifications:

  • Regular physical exercise to reduce stress.
  • Sleep hygiene education to improve sleep quality.
  • Dietary changes (reducing caffeine, alcohol, and stimulants).

4. Referral:

  • Improving Access to Psychological Therapies (IAPT): for CBT and counselling.
  • Psychiatrist referral: for severe or treatment-resistant cases.
  • Community mental health team (CMHT): if anxiety significantly impairs functioning.
PsychiatrymypanotesGeneralised Anxiety Disorder (GAD)