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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Generalised anxiety disorder

Psychiatry · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Anxiety with immediate danger or medical instability

Suicidal intent, inability to maintain food or fluids, severe self-neglect, dangerous substance withdrawal, delirium, chest pain, syncope or an abrupt neurological change must not be attributed to generalised anxiety without urgent assessment.

Action: Assess ABCDE and bedside glucose when physically unwell, define the suicide scenario and access to means, and arrange same-day medical or mental-health care. Maintain observation and safeguarding proportionate to the identified risk and document a named handover.

Synopsis

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.

  • GAD involves excessive anxiety and worry about several events or activities on most days, difficulty controlling the worry, associated tension symptoms and clinically important distress or impairment.
  • NICE uses a stepped pathway: identification, education and active monitoring; then low-intensity CBT-based help; then a choice of high-intensity CBT or applied relaxation versus medication when impairment is marked or earlier care has not worked.
  • Assess function, depression, other anxiety disorders, substances, medicines and physical illness instead of diagnosing from a GAD-2 or symptom count alone.
  • If medication is chosen, discuss early SSRI or SNRI activation, delayed benefit, interactions, withdrawal and the need to continue effective treatment after remission.
  • For people under 30 starting an SSRI or SNRI, explain the minority risk of suicidal thinking or self-harm, review within one week and monitor weekly during the first month.
  • Benzodiazepines are not routine GAD treatment; NICE limits them to a short-term measure during crises, with an agreed stop plan.
  • Escalate treatment-refractory GAD, very marked impairment, self-neglect, persistent suicidality or complex comorbidity for specialist assessment rather than accumulating unreviewed medicines.

Key red flags

A current suicide plan, recent attempt, escalating self-harm or belief that others would be better off without the person requires urgent safety planning and crisis assessment.

Sudden severe anxiety with chest pain, syncope, focal neurology, hypoxia, fever, confusion or marked autonomic disturbance requires a physical emergency pathway.

Rapid reduction in alcohol, benzodiazepines or other sedatives can cause dangerous withdrawal and should not be managed as uncomplicated worsening anxiety.

Several nights without sleep with increased energy, pressured speech, grandiosity or disinhibition suggests mania or antidepressant activation rather than ordinary GAD fluctuation.

Investigation priorities

01
Comprehensive anxiety assessmentFirst step

Define worry themes, controllability, duration, associated symptoms, distress and functional impairment.

Management branches

Steps one and twoExplain, monitor and offer low-intensity care

GAD is diagnosed without marked impairment, immediate danger or a need for specialist care.

  1. Explain the worry-arousal-avoidance cycle, agree functional outcomes and actively monitor symptoms, sleep, mood, substances and safety.
  2. If difficulty persists, offer preferred CBT-based non-facilitated self-help, guided self-help or a psychoeducational group delivered to the NICE format.
  3. Review completion and outcome rather than counting referral alone, and move to step three when impairment remains clinically important.

Key medicines

Escitalopram oralFor licensed adult GAD treatment, give 10 mg by mouth once daily; according to response this may be increased to a maximum of 20 mg once daily.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.
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Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

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.

  • NICE CG113 GAD and panic disorder recommendationsStepped GAD assessment, psychological treatment, prescribing, activation and follow-up.
  • NICE CG113 GAD diagnostic assessment appendixWorry pattern, duration, associated symptoms, impairment and treatment-step indicators.
  • Escitalopram tablets summary of product characteristicsLicensed GAD dosing, contraindications, interactions and safety modifiers.
  • NICE NG215 dependence and withdrawal recommendationsShared decisions and gradual withdrawal from dependence-forming medicines and antidepressants.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom