Generalised anxiety disorder: symptoms, causes and treatment

Key points

• Generalised anxiety disorder (GAD) is diagnosed when worry occurs on most days for at least 6 months, is hard to control, and moves between topics rather than fixing on one thing [1][9].
• Muscle tension, tiredness, poor sleep and stomach problems often reach a GP before the worry is named [2].
• The GAD-7 questionnaire scores anxiety from 0 to 21, with 5, 10 and 15 the cut-points for mild, moderate and severe [4].
• NICE sets out four steps of care, and at step 3 offers a choice between a high-intensity psychological intervention and drug treatment, by the person’s preference [1].
• If drug treatment is chosen, NICE suggests sertraline first, and advises against benzodiazepines except short-term during a crisis [1].

What generalised anxiety disorder is

Generalised anxiety disorder, usually shortened to GAD, is an anxiety condition in which worry is present on most days, is difficult to control and is not attached to one particular thing. NICE states the worry should occur on a majority of days for at least 6 months [1]. That six-month rule separates GAD from a stressful few weeks.

If you need help now. Samaritans: call 116 123, free, 24/7. Shout: text SHOUT to 85258. NHS 111, then choose the mental health option. Call 999 if anyone is in immediate danger.

The Adult Psychiatric Morbidity Survey 2023/4 found that 7.5% of adults in England met the criteria for GAD, 8.9% of women and 5.7% of men [3].

What marks GAD out is movement. Worry settles on one topic, then moves to the next, so people often cannot say what is making them anxious [9].

Symptoms

Mental and physical symptoms occur together, and the physical ones usually prompt the first GP appointment [1][2].

Worry and thinking:

• worry on most days that is hard to switch off, moving between family, health, money and work [1][9]
• trouble concentrating, irritability, low mood, feeling on edge [2]

Physical symptoms:

• muscle tension and aches [2]
• tiredness that rest does not fix, and trouble sleeping [2]
• stomach problems, including nausea and changes in bowel habit [2]
• a more noticeable or unusual heartbeat, lightheadedness or dizziness [2]

Behaviour:

• putting off decisions, checking, seeking reassurance, or avoiding what sets the worry off [1][2]

GAD is often mistaken for ordinary worrying, or for physical illness, because tension, fatigue and gut symptoms get investigated first [2]. NICE advises considering GAD in people who attend primary care often, or who repeatedly seek reassurance about bodily symptoms [1].

Types

GAD has no recognised subtypes, so severity bands are used instead. Severity is judged by GAD-7 score, where 5, 10 and 15 are the cut-points for mild, moderate and severe anxiety [4], and by NICE’s four steps of care, with step 4 reserved for severe anxiety and marked functional impairment [1].

Two presentations are common. Some arrive with physical complaints and the worry is identified later [1]. Others have GAD alongside depression or another anxiety disorder. NICE says to treat the primary disorder first, meaning the one that is more severe and where treatment is more likely to improve overall functioning [1].

Causes and risk factors

There is no single cause. The NHS states that GAD does not usually have an obvious cause [2].

Higher risk is linked to:

• another anxiety disorder, or depression [2]
• a family history of mental health conditions [2]
• stressful or traumatic experiences, including domestic violence, child abuse or bullying [2]
• a painful long-term physical health condition [2]
• a history of drug or alcohol misuse [2]

Two popular explanations go beyond the evidence. Family history raises risk but does not decide the outcome, and no single gene has been identified [2]. Calling GAD a chemical imbalance overstates what is known [2][8].

How it is diagnosed

In England a GP usually makes the diagnosis and starts treatment. Psychiatrists, registered with the GMC, and practitioner psychologists, registered with the HCPC, diagnose in specialist services [1].

Assessment is a conversation. NICE states it should weigh distress and lost functioning, not just the number, severity and duration of symptoms [1].

The GAD-7, published by Spitzer and colleagues in 2006, is the questionnaire used most [5]. Its seven items each ask how often a symptom has been present over the past two weeks, scored 0 to 3, giving a total of 0 to 21 [4]. The bands are [4]:

• 0 to 4: minimal anxiety
• 5 to 9: mild anxiety
• 10 to 14: moderate anxiety
• 15 to 21: severe anxiety

Used as a screen, 10 or above prompts further assessment [4]. NHS Talking Therapies use a clinical cut-off of 8 or above, the point at which a score counts as a probable case, and count a change of 4 points or more as reliable change [7]. It is repeated each session to track progress [6].

A score is not a diagnosis: the GAD-7 covers two weeks, so it cannot show the six-month pattern or tell GAD apart from another anxiety disorder [1][4].

Adults aged 18 and over in England can refer themselves to NHS Talking Therapies, and nine out of ten were seen within 6 weeks [6].

Treatment

NICE sets out stepped care for GAD, offering the least intrusive effective treatment first [1].

• Step 1. Assessment, education about GAD and treatment options, and active monitoring [1].
• Step 2. Low-intensity psychological help if step 1 has not helped: self-help alone, guided self-help with practitioner support, or a psychoeducational group [1].
• Step 3. A choice between a high-intensity psychological intervention and drug treatment [1].
• Step 4. Specialist treatment, including complex drug or psychological regimens, crisis services or inpatient care [1].

Step 3 is a choice, not a sequence. NICE states the person should be given verbal and written information on the benefits and disadvantages of each, and that the choice should follow their preference, because there is no evidence either works better [1]. Therapy is not offered first by default.

The psychological option is CBT or applied relaxation, usually 12 to 15 weekly sessions of 1 hour, fewer if the person recovers sooner and more if clinically required [1].

Decisions about medicines belong to a prescriber. NICE recommends an SSRI and suggests sertraline first because it is the most cost-effective, noting that in January 2011 sertraline did not hold a UK marketing authorisation for this use [1]. If sertraline is ineffective, NICE recommends an alternative SSRI or an SNRI, and suggests pregabalin where those cannot be tolerated [1]. It advises against a benzodiazepine for GAD except as a short-term measure during a crisis, and against an antipsychotic in primary care [1].

A 2025 Cochrane review of 37 trials and 12,226 adults found antidepressants more effective than placebo for treatment response, with high certainty, though more stopped because of unwanted effects [8].

Living with generalised anxiety disorder

Avoidance is the habit that keeps GAD going. The NHS advises against avoiding situations that make you anxious, and suggests slowly building up time in them [2].

Practical steps the NHS suggests [2]:

• talk to someone you trust about how you are feeling
• cut down on caffeine, alcohol, cigarettes and gambling
• keep a regular sleep pattern, eat regularly, and exercise to reduce tension
• use a breathing exercise when tension rises

If worry affects your work or study, you do not have to give a diagnosis to ask for changes. Describe what you find difficult and what would help.

Peer support is available through Mind’s online community, Side by Side [9].

When to speak to a professional

Speak to a GP if:

• worry has been present most days for months and is hard to control [1][2]
• muscle tension, poor sleep or stomach problems are not settling [2]
• you think you may have GAD, or treatment already tried is not helping [2]
• you are using alcohol or drugs to take the edge off the worry [1][2]

If you are 18 or over in England, you can refer yourself to NHS Talking Therapies without a GP [2][6]. A GP appointment still helps if physical symptoms need checking or you want to discuss medication.

Get help straight away if you are struggling to keep yourself safe. Samaritans: call 116 123, free, 24/7. Shout: text SHOUT to 85258. NHS 111, then the mental health option. Call 999 if anyone is in immediate danger.

Common questions

How is GAD different from other anxiety disorders?

The worry has no fixed target. It moves between family, health, money and work, so people often cannot say what is making them anxious [9]. In phobias and panic disorder the fear is specific [2].

What does my GAD-7 score mean?

Scores of 5, 10 and 15 are the cut-points for mild, moderate and severe anxiety, and 10 or above prompts further assessment when it is used as a screen [4]. NHS Talking Therapies count 8 or above as a case [7].

Do I have to take medication for GAD?

No. At step 3 NICE offers a choice between a high-intensity psychological intervention and drug treatment, and states the choice should follow the person’s preference [1].

How long does treatment take?

CBT or applied relaxation is usually 12 to 15 weekly sessions of 1 hour, fewer if someone recovers sooner [1].

Clinical review pending

References

1. National Institute for Health and Care Excellence. Generalised anxiety disorder and panic disorder in adults: management. NICE clinical guideline CG113, published 26 January 2011, last updated 15 June 2020. Guideline text accessed via NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK552847/
2. NHS. Generalised anxiety disorder (GAD). nhs.uk. https://www.nhs.uk/mental-health/conditions/generalised-anxiety-disorder-gad/
3. NHS England Digital. Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England, 2023/4. Chapter: Common mental health conditions. https://digital.nhs.uk/data-and-information/publications/statistical/adult-psychiatric-morbidity-survey/survey-of-mental-health-and-wellbeing-england-2023-24/common-mental-health-conditions
4. Child Outcomes Research Consortium. Generalised Anxiety Disorder Assessment (GAD-7). corc.uk.net. https://www.corc.uk.net/outcome-measures-guidance/directory-of-outcome-measures/generalised-anxiety-disorder-assessment-gad-7/
5. Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Archives of Internal Medicine, 2006. https://pubmed.ncbi.nlm.nih.gov/16717171/
6. NHS England. NHS Talking Therapies for anxiety and depression Manual, version 7.1. https://www.england.nhs.uk/wp-content/uploads/2018/06/nhs-talking-therapies-manual-v7.1-updated.pdf
7. National Collaborating Centre for Mental Health. The Improving Access to Psychological Therapies Manual: Appendices and helpful resources, version 2. Royal College of Psychiatrists. https://www.rcpsych.ac.uk/docs/default-source/improving-care/nccmh/nccmh-iapt-manual-appendices-helpful-resources-v2.pdf
8. Kopcalic K, Arcaro J, Pinto A, Ali S, Barbui C, Curatoli C, Martin J, Guaiana G. Antidepressants versus placebo for generalised anxiety disorder (GAD). Cochrane Database of Systematic Reviews, 2025, Issue 1. https://www.cochrane.org/evidence/CD012942_antidepressants-generalised-anxiety-disorder
9. Mind. Anxiety disorders. mind.org.uk. https://www.mind.org.uk/information-support/types-of-mental-health-problems/anxiety-and-panic-attacks/anxiety-disorders/