🔑 Key Learning

  • Generalised anxiety disorder is diagnosed after 6 months of excessive, disproportionate worry with ≥3 core physical/cognitive symptoms
    • GAD-2 or GAD-7 can aid assessment 
  • Management follows a stepped approach beginning with education and self-help, progressing to CBT and pharmacological treatments (SSRIs - sertraline)
  • Panic disorder involves spontaneous panic attacks with autonomic symptoms and is also managed using CBT or SSRIs (sertraline).
    • Beta-blockers (propranolol) can be used for physical symptoms.
  • Agoraphobia involves fear of public spaces due to difficulty escaping perceived unsafe environments

😟 Generalised Anxiety Disorder (GAD)

 

📋 Diagnosis (DSM-5 Criteria)

Symptoms present for at least 6 months:

  • Persistent and excessive worry about everyday issues
  • Anxiety is disproportionate to actual risk

Plus ≥3 of the following:

  • Restlessness or feeling on edge
  • Fatigue
  • Poor concentration
  • Irritability
  • Muscle tension (e.g. neck/shoulders)
  • Sleep disturbance or insomnia

🧪 Screening Tools

  • GAD-2 and GAD-7 questionnaires
    • Score 0–3 per item
    • GAD-7 thresholds:
      • 5 = mild
      • 10 = moderate
      • 15 = severe

  

💊 Management of GAD (NICE CG113)

NICE recommend the following stepwise process in the management of GAD

Step 1: Education and active monitoring

  • Psychoeducation
  • Lifestyle advice and follow-up

Step 2: Low-intensity psychological interventions

  • Non-facilitated individual self-help
  • Guided individual self-help
  • Psychoeducational group therapy (CBT-based)

Step 3: High-intensity intervention or pharmacological therapy

Offer to those with:

  • Significant functional impairment
  • Inadequate response to Step 2

Psychological options:

  • Individual high-intensity CBT
  • Applied relaxation therapy

Pharmacological options:

  • 1st line: Sertraline (SSRI)
  • 2nd line: alternative SSRI (e.g. escitalopram, paroxetine) or SNRI (e.g. duloxetine, venlafaxine)
  • If contraindicated or not tolerated → consider pregabalin

Note: Continue antidepressants for at least 12 months after improvement to reduce relapse risk

Step 4: Specialist referral

  • Refer for psychiatric assessment if above steps fail

😱 Panic Disorder

👀 Clinical Features

Sudden and recurrent panic attacks involving:

  • Palpitations, tachycardia
  • Nausea, chest pain
  • Hyperventilation or breathlessness
  • Paraesthesia or dizziness
  • Sense of doom or fear of dying

💊 Management (NICE CG113)

Follows a stepped care approach:

Step 1: Recognition and diagnosis

Step 2: Primary care management

  • Mild to moderate:
    • Low-intensity interventions (facilitated or self-help CBT-based resources)
  • Moderate to severe:
    • CBT or
    • SSRI (e.g. sertraline)

Duration:

  • Continue antidepressant for at least 6 months after improvement before tapering

🏘️ Agoraphobia

Description

  • An anxiety disorder which is characterised by an irrational fear of open spaces and crowds. 
  • Intense anxiety in places where escape might be difficult or help unavailable
  • Commonly triggered in crowds, public transport, shopping centres
  • May lead to avoidance of leaving home altogether

📝 Exam Clues & Clinchers

  • 1st line pharmacological management for severe GAD or panic disorder? → Sertraline
  • Palpitations + hyperventilation + paraesthesia → panic disorder
  • GAD-7 score of 10 → indicates moderate anxiety
  • Avoidance of public places due to fear of entrapment → agoraphobia
  • GAD improved on SSRI → continue for 12 months
  • Panic disorder improved on SSRI → continue for 6 months

🔗 Useful Links and References

NICE CKS: Generalised Anxiety Disorder [2023]. Available at URL: https://cks.nice.org.uk/topics/generalized-anxiety-disorder/ 

NICE: Generalised Anxiety Disorder and Panic Disorder in Adults [CG113] 2020. Available at URL: https://www.nice.org.uk/guidance/cg113/chapter/Recommendations#principles-of-care-for-people-with-panic-disorder