Recognise persistent, difficult-to-control worry across several domains, distinguish generalised anxiety disorder from focused anxiety and physical illness, and sequence education, psychological treatment, medication and specialist review safely.
The core presentation is worry that spreads across ordinary domains such as health, family, work, money or minor decisions and feels difficult to control. NICE's diagnostic appendix describes worry on most days for at least six months, with associated restlessness, fatigue, poor concentration, irritability, muscle tension or disturbed sleep. Duration helps distinguish a sustained disorder from a brief stress response, but diagnosis also requires distress or functional impairment. Ask what the person predicts, how much time worry occupies, what they do for reassurance, and how it affects sleep, attention, relationships and work.
Assessment should establish whether another problem better explains the anxiety. Panic disorder centres on recurrent unexpected attacks and concern or behavioural change after them; social anxiety centres on scrutiny and negative evaluation; OCD involves obsessions and compulsions; PTSD follows trauma with re-experiencing and avoidance. Depression, mania, harmful substance use and medicine effects can coexist or dominate. Consider thyroid disease, arrhythmia, respiratory disease, anaemia and other physical causes from the history and examination rather than ordering an indiscriminate panel.
Heritable emotional sensitivity, early adversity, modelling of worry and learned avoidance can combine without defining one necessary cause.
Illness, caring, work, financial insecurity and discrimination may trigger or maintain worry, particularly where outcomes remain hard to control.
Stimulants, sedative withdrawal, sleep loss and physical illness can generate arousal that becomes incorporated into persistent threat prediction.
Ambiguous events are interpreted as more dangerous and less manageable, repeatedly recruiting attention toward possible future harm.
Checking, reassurance and avoidance briefly lower distress, which reinforces the behaviour while preventing corrective learning about uncertainty.
Sleep disruption and autonomic and muscular tension feed fatigue, irritability and concentration problems that are then interpreted as further evidence of threat.
Concern moves across several life areas, occurs repeatedly and remains difficult to postpone or settle despite reassurance or problem solving.
Restlessness, muscle tension, irritability, fatigue, poor concentration and disturbed sleep accompany the cognitive worry pattern.
Repeated checking, reassurance, indecision, procrastination and poor sleep interfere with work, relationships, self-care or ordinary responsibilities.
New agitation, marked restlessness, insomnia or intensified anxiety soon after an antidepressant starts or increases requires prompt review.
Panic, social scrutiny, obsessions or trauma reminders dominate rather than worry moving across multiple everyday domains.
Depressive rumination centres on loss and hopelessness, while reduced sleep with increased energy and disinhibition suggests mania or hypomania.
Thyroid disease, arrhythmia, respiratory illness, stimulants and alcohol or sedative withdrawal may reproduce cognitive and autonomic anxiety.
Fear restricted to panic attacks, social scrutiny, contamination, trauma reminders or a single object points toward a more specific disorder.
Persistent impairment, insomnia and hopelessness can evolve into major depression and increase self-harm risk requiring repeated direct assessment.
Alcohol, sedatives or stimulants may be used to control distress or fatigue and subsequently worsen anxiety through intoxication or withdrawal.
Avoidance, repeated healthcare use, work loss, strained relationships and chronic sleep disruption can become more disabling than individual worry episodes.
The frequency and emotional force of a thought do not make the feared outcome more likely, a distinction CBT can test behaviourally.
Repeated short-lived relief prevents learning that uncertainty can be tolerated and often expands the range of future checking.
NICE does not rank high-intensity psychological intervention above medication for GAD overall, so an informed individual choice is central.
Activation, akathisia, emerging mania and ordinary symptom fluctuation require different actions and should not be collapsed into one label.
Diagnosing GAD from somatic anxiety or a screening score without establishing diffuse persistent worry and impairment.
Ordering broad tests without a clinical hypothesis while missing caffeine, stimulant or sedative withdrawal exposure.
Offering long-term benzodiazepines instead of the stepped psychological and antidepressant pathway.
Starting an SSRI without explaining activation, withdrawal and the age-appropriate suicide monitoring schedule.
Calling treatment refractory before checking whether therapy was completed faithfully or medication exposure was adequate.
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An adult with GAD remains markedly impaired after completing guided CBT-based self-help and has no immediate safety concern. Which next offer best follows NICE stepped care?
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes
Use the least intrusive effective step. After explanation and active monitoring, offer CBT-based non-facilitated self-help, guided self-help or psychoeducational groups when symptoms persist. Marked functional impairment or inadequate response leads to an informed choice between individual high-intensity CBT or applied relaxation and drug treatment; NICE finds no evidence that one mode is superior overall. CBT is normally twelve to fifteen weekly one-hour sessions. The choice should reflect previous response, access, adverse effects, withdrawal concerns and the person's values.
When an SSRI is chosen, NICE says to consider sertraline first for cost effectiveness while recognising that its use for GAD is off-label; document informed agreement. If it is ineffective, consider another SSRI or an SNRI, weighing withdrawal burden, overdose toxicity and interactions. Pregabalin is an alternative when SSRIs and SNRIs cannot be tolerated, but it is a controlled drug with abuse, dependence, withdrawal and pregnancy concerns. Review early activation and suicide risk actively. Effective medication is generally continued for at least a year because relapse is common, then reduced gradually rather than stopped abruptly.
Assess suicide risk and early activation, bipolar history, QT risk, hyponatraemia, bleeding, sexual effects and serotonergic interactions; use lower limits in older adults or hepatic impairment and taper gradually when stopping.