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Generalised anxiety disorder
Short Text
Introduction
This pathway covers the management of GAD in adults in primary, secondary and community care.
GAD is a common disorder of which the central feature is excessive worry about a number of different events associated with heightened tension. It can exist in isolation but more commonly occurs with other anxiety and depressive disorders. The guideline covers both 'pure' GAD, in which no comorbidities are present, and GAD comorbid with other anxiety and depressive disorders in which GAD is the primary diagnosis.
GAD varies in severity and complexity, and can follow chronic or remitting courses. Where possible, the goal of an intervention should be complete relief of symptoms (remission), which is associated with better functioning and a lower likelihood of relapse.
Source guidance
The NICE guidance that was used to create the pathway.
Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults: management in primary, secondary and community care. NICE clinical guideline 113 (2011)
Quality standards
Quality statements
Effective interventions library
Successful effective interventions library details
Implementation
Assessment tools
The baseline and self-assessment tools are Excel spreadsheets that can be used by organisations to identify if they are in line with practice recommended in NICE guidance and to help them plan activity that will help them meet the recommendations.
Audit support
Audit support provides ready-to-use criteria, including exceptions, definitions, suggested data sources and a data collection tool.
Commissioning guides
Commissioning guides provide information on key clinical and service-related issues to consider during the commissioning process. Each guide contains a commissioning and benchmarking tool, which is a resource that can be used to estimate and inform the level of service needed locally as well as the cost of local commissioning decisions.
Costing support
Costing support includes national cost impact reports that summarise the national costs and savings and discuss the assumptions used; costing templates to assess the impact on local budgets; and costing statements when the impact is not significant or impossible to quantify at a national level.
Learning resources
Learning resources are designed to support people to run workshops and for individual learning. They include clinical case scenarios, presentations for trainers and tests for participants.
Slide sets
Slide sets provide a framework for discussion and assist in local dissemination of the guidance. The slides contain the key messages from NICE guidance and can be tailored for local presentations.
Pathway information
Information for patients and the public
NICE produces booklets for patients and the public, called 'Understanding NICE guidance'. They summarise, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written a booklet for patients and the public explaining its guidance on generalised anxiety disorder and panic disorder in adults.
NICE has also produced a Guide to self-help resources for generalised anxiety disorder for people with generalised anxiety disorder, their families and carers.
Patient-centred care
Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent and the code of practice that accompanies the Mental Capacity Act. In Wales, healthcare professionals should follow advice on consent from the Welsh Government. If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children.
Supporting information
Glossary
Cognitive behavioural therapy
Generalised anxiety disorder
A self-administered intervention intended to treat GAD involving written or electronic self-help materials (usually a book or workbook). It is similar to individual guided self-help but usually with minimal therapist contact, for example an occasional short telephone call of no more than 5 minutes.
Non-steroidal anti-inflammatory drugs
Serotonin–noradrenaline reuptake inhibitor
Selective serotonin reuptake inhibitor
Person with suspected generalised anxiety disorder (GAD)
Person with suspected generalised anxiety disorder (GAD)
Principles of care
Principles of care
Principles of care
Information and support
Build a relationship and work in an open, engaging and non-judgemental manner.
Explore with the person:
- their worries, in order to jointly understand the impact of GAD
- treatment options, indicating that decision making is a shared process.
Ensure that discussion takes place in settings in which confidentiality, privacy and dignity are respected.
Provide information appropriate to the person's level of understanding about the nature of GAD and the range of treatments available.
If possible, ensure that comprehensive written information is available in the person's preferred language and in audio format.
Offer independent interpreters if needed.
Inform the person about local and national self-help organisations and support groups.
Supporting families and carers
When families and carers are involved in supporting a person with GAD, consider:
- offering a carer's assessment of their caring, physical and mental health needs
- providing information, including contact details, about family and carer support groups and voluntary organisations, and helping families or carers to access these
- negotiating between the person with GAD and their family or carers about confidentiality and the sharing of information
- providing written and verbal information on GAD and its management, including how families and carers can support the person
- providing contact number and information about what to do and who to contact in a crisis.
The following may be helpful:
- the 'Understanding NICE guidance' booklet on Treating generalised anxiety disorder and panic disorder in adults
- the Guide to self-help resources for generalised anxiety disorder for people with GAD, their families and carers.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeAdditional considerations for people with a learning disability or acquired cognitive impairment
Additional considerations for people with a learning disability or acquired cognitive impairment
Additional considerations for people with a learning disability or acquired cognitive impairment
For people with a mild learning disability or mild acquired cognitive impairment, offer the same interventions as for other people with GAD, adjusting the method of delivery or duration of the intervention if necessary to take account of the disability or impairment.
When assessing or offering an intervention to people with a moderate to severe learning disability or moderate to severe acquired cognitive impairment, consider consulting with a relevant specialist.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodeStepped-care model for GAD
Stepped-care model for GAD
Step 1: All known and suspected presentations of GAD
View the 'Step 1: All known and suspected presentations of GAD' pathStep 2: Diagnosed GAD that has not improved after step 1 interventions
View the 'Step 2: Diagnosed GAD that has not improved after step 1 interventions' pathStep 3: GAD with marked functional impairment or that has not improved after step 2 interventions
View the 'Step 3: GAD with marked functional impairment or that has not improved after step 2 interventions' pathStep 4: Complex, treatment-refractory GAD and very marked functional impairment or high risk of self-harm
Step 4: Complex, treatment-refractory GAD and very marked functional impairment or high risk of self-harm
Step 4: Complex, treatment-refractory GAD and very marked functional impairment or high risk of self-harm
Assessment and treatment
This step normally refers to community mental health teams but may include specialist services and specialist practitioners in primary care.
Assessment
Offer the person a specialist assessment of needs and risks, including:
- duration and severity of symptoms, functional impairment, comorbidities, risk to self and self-neglect
- a formal review of current and past treatments, including adherence to previously prescribed drug treatments and the fidelity of prior psychological interventions, and their impact on symptoms and functional impairment
- home environment
- support in the community
- relationships with and impact on families and carers.
Review the needs of families and carers and offer an assessment of their caring, physical and mental health needs if one has not been offered previously.
Develop a comprehensive care plan in collaboration with the person with GAD that addresses needs, risks and functional impairment and has a clear treatment plan.
Treatment
Inform people with GAD who have not been offered or have refused the interventions in steps 1–3 about the potential benefits of these interventions, and offer them any they have not tried.
Consider offering combinations of psychological and drug treatments, combinations of antidepressants or augmentation of antidepressants with other drugs, but exercise caution and be aware that:
- evidence for the effectiveness of combination treatments is lacking and
- side effects and interactions are more likely when combining and augmenting antidepressants.
Combination treatments should be undertaken only by practitioners with expertise in the psychological and drug treatment of complex, treatment-refractory anxiety disorders and after full discussion with the person about the likely advantages and disadvantages of the treatments suggested.
When treating people with complex and treatment-refractory GAD, inform them of relevant clinical research in which they may wish to participate, working within local and national ethical guidelines at all times.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePanic disorder pathway
View the 'panic disorder overview' pathPaths in this pathway
- Step 1: All known and suspected presentations of GAD
- Step 2: Diagnosed GAD that has not improved after step 1 interventions
- Step 3: GAD with marked functional impairment or that has not improved after step 2 interventions
Pathway created: March 2012 Last updated: March 2012
Copyright © 2013 National Institute for Health and Clinical Excellence. All Rights Reserved.