📚 Module OverviewNICE CG113
GAD is a common anxiety disorder characterised by excessive, uncontrollable worry about multiple everyday events. This 'free-floating anxiety' persists for at least several months and is often accompanied by physical symptoms like restlessness, fatigue, muscle tension, and poor concentration. It is a chronic, fluctuating condition that often begins in adolescence and can significantly impair daily functioning.
Screening can be done using the GAD-2 tool, with the GAD-7 questionnaire being useful for diagnosis and monitoring symptom severity.
Understanding the cognitive-behavioural model helps explain GAD to patients. It involves a self-perpetuating cycle:
- Thoughts: Intrusive, negative "what if...?" thoughts about the future. The person may develop 'Type 2 worry' – worrying about the act of worrying itself.
- Physical Symptoms: The body's 'fight or flight' response is activated, releasing adrenaline and causing palpitations, muscle aches, sweating, and dizziness.
- Feelings: A constant state of being 'on edge', anxious, demoralised, and fatigued.
- Behaviours: Attempts to control worry by seeking reassurance, avoiding triggers, or using substances like alcohol. These behaviours provide short-term relief but reinforce the anxiety long-term.
CBT Stepped-Care Model
NICE recommends a stepped-care approach for managing GAD, starting with the least intrusive interventions. Pharmacological therapy is not first-line unless it's a patient preference or psychological therapies are unsuitable or have failed.
| Step | Description | Recommended Interventions |
|---|---|---|
| Step 1 | Recognition & Diagnosis All suspected cases. |
- Identification and assessment. - Education about GAD and treatment options. - Active monitoring. |
| Step 2 | Diagnosed GAD Mild functional impairment. |
Low-intensity psychological interventions: - Individual non-facilitated self-help (e.g., CBT workbooks). - Individual guided self-help (therapist-supported). - Psychoeducational groups. |
| Step 3 | GAD with Marked Functional Impairment or no response to Step 2. | Choice of: - High-intensity psychological intervention (e.g., individual CBT, applied relaxation). OR - Pharmacological treatment (see table below). |
| Step 4 | Complex, Treatment-Refractory GAD With very marked functional impairment or high risk of self-harm. |
Referral to specialist mental health services for highly specialised treatment and management. |
💊 Pharmacological ManagementBNF
If drug treatment is chosen, an SSRI is first-line. Treatment should be reviewed every 2-4 weeks initially and continued for at least 12 months after remission to reduce the high risk of relapse.
| Treatment Line | Medication & Dosage | Monitoring & Alerts | Duration |
|---|---|---|---|
| First-Line | An SSRI. NICE suggests Sertraline as the most cost-effective option, but it's unlicensed for GAD.
Starting Dose: Start low and go slow, e.g., Sertraline 25mg daily, titrating up after the first week. |
Review: 2 weeks after starting, then every 2-4 weeks for the first 3 months. Alerts: Increased anxiety and agitation in early stages. Risk of suicidal thoughts, especially in young adults. Risk of hyponatraemia, particularly in the elderly. Serotonin syndrome. |
At least 12 months post-remission. |
| Second-Line | If first SSRI is ineffective or not tolerated, offer an alternative SSRI or an SNRI (e.g., Venlafaxine MR, Duloxetine). | Venlafaxine: Monitor blood pressure. Requires high doses (e.g., 150mg) for noradrenergic effect. High risk of discontinuation symptoms. | At least 12 months post-remission. |
| Third-Line | Consider Pregabalin if SSRIs/SNRIs are not tolerated. | Alerts: Risk of misuse and dependence. Common side effects include dizziness and drowsiness. Many potential drug interactions. | As per specialist advice. |
| Caution! | Benzodiazepines (e.g., Diazepam) | Do NOT use for long-term treatment. Should only be considered for short-term use (2-4 weeks) during a crisis. | Max 2-4 weeks. |
Bonus: Clinical Case Study
Patient: Sarah, a 34-year-old primary school teacher.
PMH: None. Presents frequently with non-specific symptoms (headaches, stomach upset).
Presenting Complaint: Reports feeling "constantly worried" for the last 8 months about her job, her parents' health, and finances. She feels restless, tired all the time, and is finding it hard to sleep. Her GAD-7 score is 16.
Consultation Plan (SOAP Format)
S (Subjective): Sarah describes excessive and uncontrollable worry affecting multiple areas of her life. She recognises the worry is disproportionate. She reports associated physical symptoms (fatigue, poor sleep, restlessness) and significant functional impairment ("I can't switch off, it's affecting my teaching"). She expresses interest in trying medication as she feels she "needs something to help her get on top of things" before engaging with therapy.
O (Objective): GAD-7 score = 16 ('Severe anxiety'). No physical health concerns identified from history. No signs of depression or self-harm risk at this stage.
A (Assessment):
- Diagnosis of GAD with marked functional impairment, based on symptoms, duration, and GAD-7 score.
- Patient has expressed a preference for pharmacological treatment initially. According to NICE Step 3, this is an appropriate option.
- Sertraline is the recommended first-line, cost-effective choice.
P (Plan):
- Medication: Recommend trial of Sertraline. Start at 25mg once daily for one week, then increase to 50mg once daily.
- Counselling: Explain the rationale for a 'start low, go slow' approach to minimise initial side effects like increased anxiety. Advise that it may take 4-6 weeks to feel the full benefit. Counsel on common side effects (e.g., nausea, dizziness) and the low risk of dependency. Reassure her that her worries are a symptom of a recognised condition.
- Psychological Therapy: Explain that medication works best alongside psychological therapy. Provide details on how to self-refer to the local NHS Talking Therapies service.
- Monitoring: Schedule a telephone review in 2 weeks to assess side effects and provide support. Follow up again at 4 weeks.
- Safety Netting: Advise her to contact her GP immediately if she feels her mood worsens or if she has any thoughts of self-harm.
Example Dialogue
Pharmacist: "Thanks for sharing that, Sarah. It sounds incredibly tough. What you're describing fits very well with a condition called Generalised Anxiety Disorder, or GAD. It's very common, and the constant worrying and physical symptoms you feel are key features."
Sarah: "So it's not just me? I feel like I'm losing control."
Pharmacist: "Not at all. It's a recognised medical condition. Based on what you've said, and your preference, we could start a medication called Sertraline. It's an antidepressant, but it's also very effective for anxiety. The key thing to know is that it takes time to work, often a few weeks, and you might even feel a bit more jittery at first. That's why we start with a really low dose. How does that sound as a starting point?"
❤️ Lifestyle & Self-Help Resources
Alongside formal treatment, signposting to reliable resources for self-management is a key part of holistic patient care.
- Guided Self-Help: Northumberland Self-Help Leaflets - A range of excellent CBT-based workbooks.
- Mental Wellbeing & CBT Techniques: NHS Every Mind Matters - Provides tools and advice for managing anxiety and boosting mental wellbeing.
- Peer Support: Mind - A leading mental health charity providing advice, support, and local groups.
- Mindfulness: Recommend apps like Headspace or Calm, which teach mindfulness techniques to help patients observe thoughts without engaging with them.
- Alcohol Reduction: Drinkaware - Provides tools to help people cut down on alcohol, which can exacerbate anxiety.
🎯 OSCE Preparation
Patient Requesting Diazepam
Scenario: Mr. Jones, 45, was started on Sertraline 50mg for GAD two weeks ago. He's come to the pharmacy saying, "This new tablet isn't working, I still feel wound up. My friend gets diazepam from his doctor, and it works straight away. Can you ask my GP to give me that instead?"
Key Communication & Counselling Steps:- Acknowledge & Validate: "Thanks for telling me, Mr. Jones. It's completely understandable to feel frustrated when you're not feeling better yet. It takes a lot of courage to start these treatments, and it's disappointing when they don't seem to work straight away."
- Explore & Gather Information: "Can you tell me a bit more about how you've been feeling since you started the sertraline? Have you noticed any side effects at all?"
- Explain the Mechanism (Sertraline): "I can understand why you'd ask about diazepam, as it does work very quickly to calm things down. However, the reason we don't use it long-term is because the body gets used to it very quickly, and it can become addictive. The sertraline works in a completely different, more long-term way. It gradually rebalances the chemicals in the brain, but it's a slow process and can take at least 4 to 6 weeks to really start making a difference. It's very normal not to feel much benefit after only two weeks."
- Address the Side Effects / Initial Worsening: "In fact, it's quite common to feel a bit more on edge or anxious when you first start taking sertraline. Did your GP mention this might happen? It's a sign the medicine is starting to work, and it usually settles down after the first couple of weeks."
- Formulate and Agree on a Plan: "The best advice is to persevere with the sertraline for at least another 2-4 weeks to give it a proper chance to work. Diazepam isn't the right long-term solution for GAD. However, I can certainly let your GP know how you're feeling. We also need to make sure you have your next review booked in. In the meantime, some people find simple breathing exercises helpful when they feel particularly wound up."
- Safety Netting & Close: "The most important thing is, if you start to feel much worse or have any thoughts of harming yourself, you must contact your GP straight away or call 111. How do you feel about continuing with the sertraline for now, knowing that it needs a bit more time?"