Generalised Anxiety Disorder (GAD)

GAD prevalence rates in adults have been reported to be 5.9% across UK ⁽⁷⁾. Rates of people reporting symptoms of GAD (scores indicating moderate to severe symptoms on the GAD-7 scale) in Scotland were 16% in 2021 ⁽⁸⁾. Higher prevalence rates are reported in women than men, with a disproportionate impact highlighted for young women aged 18-24 years ⁽⁹⁾. Higher prevalence rates have been reported in older adults, where it is the most common anxiety disorder (ranging from 1.2% to 15% in community populations and up to 28% in clinical settings) ⁽¹⁰⁾. The high comorbidity rates of anxiety disorders in children and young people (CYP) ⁽²⁾, and difficulty in establishing differential diagnosis for GAD and other anxiety disorders in very young patients means that GAD is not often identified as a specific diagnosis in children and adolescents. The prevalence rates for anxiety problems in CYP in the UK is estimated to be between 5-19%, and between 2-5% in children younger than 12 years ⁽¹¹⁾. Prevalence rates for GAD have been estimated to be 0.7%, with slight differences in reporting rates between girls (0.8%) and boys (0.6%) ⁽¹²⁾. For children with learning disabilities a point prevalence for mental health problems of 36% has been suggested ⁽¹³⁾. 

For adults with learning disabilities, obtaining prevalence rates is more challenging due to methodological challenges. NICE (2016) report that for mental health problems in general rates may be as high as 40% ⁽⁴⁾. Hatton et al (2017) ⁽¹⁴⁾ estimate between 31 and 43% of adults with learning disabilities are at risk of experiencing mental health problems in general.  A prevalence study in a Scottish sample indicated 4% of adults with learning disability met diagnostic criteria for an anxiety disorder ⁽¹⁵⁾. A recent large scale whole country study of people with intellectual disabilities in Scotland ⁽¹⁶⁾ reported co-morbidity rates of 21.7% and significantly higher rates of risk for mental health problems in those with a dual diagnosis of intellectual disability and autism ⁽¹⁷⁾.  Anxiety prevalence is increased for those with specific syndromes such as Rett and Fragile X syndrome compared to people with learning disabilities not attributed to a genetic syndrome ⁽¹⁸⁾.  For GAD, a point prevalence rate of 1.7% for people with learning disabilities has been suggested ⁽¹⁹⁾.

This information is for commissioners, managers, trainers, and practitioners to consider the evidence base for the delivery of psychological interventions for people with GAD. This information is also for people diagnosed with GAD, their families, and carers.

This topic page covers evidence-based psychological interventions for the treatment of anxiety presentations in children and young people and GAD specifically in adults, including those who may present in specialist settings. Full guidance on identifying, assessing, and managing GAD can be found in the NICE guidance ⁽⁵⁾. This topic does not cover the management of panic disorder with/out agoraphobia. This topic does not cover pharmacological interventions or interventions which are not informed by psychological theory. There are a wider range of non-psychological interventions and supports that are beyond the scope of this topic and full guidance on best practice can be found ⁽⁵⁾. Further guidance on delivering psychological services and care for people presenting with anxiety in other settings will be available on this site e.g., CAMHS settings and Intellectual disability services (content under development).

There are a range of psychological interventions that could be included in the treatment tables for GAD. However, in order to be consistent with a focus on interventions with the highest levels of efficacy and the strongest levels of evidence where these exist, psychological interventions for the treatment of GAD with low strength evidence and low levels of efficacy have not been included.

Overview of Evidence for Children and Young People

Psychological therapies have been evaluated in relation to mixed anxiety disorders (e.g., any combination of GAD, Social Anxiety Disorder, and phobias) in CYP ^(12,20). The most substantial evidence for psychological therapies for anxiety disorders/GAD in Children and Young People (CYP) is in relation to CBT. There is also some high-level evidence for Attention Bias Modification (ABM) for anxiety disorders (including Specific Phobias, Social Anxiety Disorder, and Generalized Anxiety Disorder), with small levels of efficacy reported.  

The summary in the evidence table demonstrates that, across ‘anxiety disorders’ for CYP, CBT has moderate to large effects on symptom reduction ^(21-25) including in children aged 8 and under ⁽²⁴⁾, and remission ^{(21-23,26,27)} with effects that may be durable at 2 + years post-treatment ⁽²⁸⁾. The papers listed here focus on interventions for children and young people that have the highest quality research and outcomes. Further details on the range of psychological interventions that are appropriate for children with anxiety can be found in the Early Intervention framework.

CBT for anxiety in CYP can include a range of components, and treatment outcome has been found to differ according to the component delivered, i.e., exposure is associated with more positive outcomes than anxiety management/relaxation strategies ⁽²⁹⁾. Outcomes of CBT have been shown to be poorer for higher pre-treatment symptom severity and parent psychopathology ⁽³⁰⁾. Evidence suggests that positive CBT outcomes are maintained irrespective of the type of anxiety disorder ⁽²²⁾ although one meta-analysis found that those with primary social anxiety were less likely to recover using a generic CBT model than those with other primary anxiety disorders ⁽³¹⁾.

CBT may be delivered with the child only, child and parent, parent only, or in groups, and can be delivered in clinics, in school or online. Meta-analyses indicate little difference in the effects of CBT in relation to mode of delivery ⁽²²⁾, although child reported outcomes indicate greater efficacy for group than individual CBT, and amongst older young people ⁽²⁶⁾. Brief, intensive, and concentrated CBT resulted in lower attrition than standard CBT and showed comparable efficacy ⁽³²⁾, and meta-analyses indicate little difference in effects of CBT on the basis of mode of delivery (i.e. group, individual, or digital) ^(22,23,33), age of young person ⁽²⁶⁾ and delivery in clinic versus community ⁽²²⁾.  There is also little evidence for an effect of parental involvement on differences in outcomes ^{(22,23,26,32,34,35)} although confounding variables such as age, developmental stage and treatment setting are acknowledged ^{(22,25,26,33)}. For example, parents are more likely to be involved in treatment with young children and less likely to be involved in treatment within school settings ⁽²⁶⁾. Group CBT with parent/family involvement has been reviewed but the evidence is out of date and lower quality and therefore there is not enough information to make a specific recommendation in the table (36,37). Similarly, while there is some evidence to suggest reduction in anxiety symptoms as a result of one parent-led CBT programme (Timid to Tiger) (38), a recent meta-analysis did not find support for this across trials of parent-led programmes more (39) and therefore there is not yet enough information to include these in the evidence table.

Some studies report that CBT has delivered symptom reduction in anxiety in young people with Autistic Spectrum Conditions, showing a range of effect sizes from small to large ^(26,27,40). Some care should be taken in interpreting these findings, as some autistic people and advocates view the targeted ‘symptoms’ as being inherent to being autistic, with the resulting inference being that CBT aims to treat autism itself; a view which does not fit with a neurodiversity affirming approach.  More information about good practice in adapting and evaluating evidence-based psychotherapies for autistic and otherwise neurodivergent people is available here (content under development).  Less literature is available on the outcomes of CBT with other neurodivergent children and young people. There is a lack of evaluation of CBT for anxiety disorders amongst children with intellectual disabilities ⁽²⁶⁾ – see ‘Overview of Evidence for People with Learning Disabilities’ for further information.

Overview of Evidence for Adults

Treatment is typically offered in primary care, with referral to specialist services as necessary. Treatment follows a stepped model of care, starting from low intensity interventions (often delivered as part of enhanced psychological practice) to specialist interventions depending on response to treatment and level of functional impairment (NICE). NICE recommends provision of individual non-facilitated self help (provision of materials, often computerised packages, with instructions for systematic use over 5-7 weeks), facilitated self-help interventions based on CBT principles (support provided by a trained practitioner), or psychoeducational groups based on CBT principles for people diagnosed with GAD with no response to education on managing anxiety and active monitoring. Services should support patients to make an informed choice between the options available. NICE has evaluated evidence for some specific computerised packages ⁽⁴¹⁾ and services are encouraged to review the evidence as this develops. The evidence table below also includes mindfulness-based group interventions which have similar outcomes on anxiety outcomes at end of treatment, although the literature on outcomes at longer term follow up is less established.

Guided self-help interventions (based on CBT principles) can be provided primarily in primary care and is supported by strong evidence of large efficacy evidenced by meta-analytic studies. However, barriers and limitations to delivery of self-help interventions should be considered (e.g., computer literacy, internet access and high attrition rates). A review of the evidence for the use of technology-enabled psychological therapies and interventions (NES, 2020) provides further guidance.

Cognitive Behaviour Therapy or Applied Relaxation with a trained practitioner should be offered following insufficient response to initial interventions. NICE recommends that these interventions should be delivered by trained practitioners, using a GAD specific treatment protocol (see UCL Competence Framework for the delivery of effective psychological interventions https://www.ucl.ac.uk/pals/research/clinical-educational-and-health-psychology/research-groups/competence-frameworks), over the specified time period (i.e. over 12-15 weekly sessions). This recommendation is reflected in the strong evidence of medium to large efficacy identified for these interventions. CBT can also be delivered remotely with similar outcomes ⁽⁴²⁾. Whilst not mentioned in the NICE recommendations, evidence of medium to large efficacy also provides support for the recommendation of mindfulness-based therapies (Mindfulness-based Cognitive Therapy (MBCT)/ Mindfulness-Based Stress Reduction (MBSR), Acceptance and Commitment Therapy and metacognitive therapy, presenting alternative options for use in primary / secondary care settings based on informed choice or as a further intervention if symptoms persist after completing CBT or Applied Relaxation.

Combined treatment regimens may be required for complex or severe presentations. This may include one of the psychological therapies outlined in the evidence table (e.g. individual CBT) with pharmacological interventions and adjunctive care coordinated by multidisciplinary teams e.g. crisis services, outpatient settings or inpatient care.

Overview of Evidence for Older People 

Available evidence for CBT for generalized anxiety with older people indicates that CBT is effective ​(43)​. When compared with treatment for younger adults CBT has similar outcomes but with smaller effect sizes ​(44)​. However, studies used standard CBT protocols with no age-appropriate adaptations. Clinicians are advised that there are differences in presentation of psychological problems in later life and to consult Delivering Effective Psychological Therapies and Interventions to Older People for further information on factors relevant to practice. 

A systematic review and meta-analysis suggests that remotely delivered CBT is more effective in reducing self-reported anxiety and depressive symptoms than non-CBT control in older people ​(45)​. 

Overview of Evidence for People with Learning Disabilities

Large scale trials of psychological interventions in general populations tend to exclude people with learning disabilities.  Current available evidence within CYP and adult populations is mainly gained from small studies, or from single case studies.  Research specifically relating to CBT for anxiety disorders has focused on people who have mild learning disabilities (43), and available evidence is mainly limited to single case studies of both individual and group interventions. Despite the lack of research relating specifically to people with learning disabilities, CBT and other psychological therapies are used frequently in clinical services, adapted to make them acceptable and effective for people with LD.  More information relating to this can be found in here (content under development).

A systematic review of CBT for anxiety in adults with learning disabilities ⁽⁴⁴⁾ identified limited evidence consisting of case reports and case series.  Studies mostly targeted non-specific anxiety or PTSD, with some studies including mixed presentations in a transdiagnostic group, rather than GAD as a specific presentation.  The review concluded the available evidence is broadly supportive of the use of CBT for anxiety for adults with learning disabilities whilst highlighting the need for further research.   A recent systematic review of CBT for anxiety in people with learning disabilities ⁽⁴⁵⁾ sought to include children and young people as well as focus on treatment of anxiety (not restricted to GAD).  Evidence was limited to uncontrolled studies and case series.  The review concluded there is encouraging evidence of the benefit and feasibility of CBT for anxiety for people with learning disabilities with appropriate adaptations. The evidence in people with moderate to severe and profound learning disabilities related to anxiety is too underdeveloped to result in recommendations for stand alone psychological interventions. One randomised controlled trial of an adapted computerised CBT intervention for people with mild to moderate learning disabilities demonstrated positive outcomes on anxiety symptoms at post treatment and follow up ​(46)​.

Overview of Evidence for Harms and Adverse Effects

Psychological therapies have the potential to have adverse effects. Until recently, information on potential harms and rates of adverse effects have not been gathered systematically. Reports of adverse effects are increasingly included in research trials and gathered as part of service provision and are emerging in this area.  A Cochrane review investigating CBT for anxiety disorders in children and adolescents ⁽²⁶⁾ reported that no adverse effects were reported across included studies; however, note that it is not clear how many studies monitored adverse effects systematically.  In adults the reporting of adverse effects is very inconsistent with a review of internet delivered intervention ⁽⁴⁶⁾ noting adverse events were rarely reported. As a result, we do not know if psychological interventions cause more, fewer or similar numbers of adverse effects than no treatment or another treatment, because the evidence in this area is insubstantial at present.

Recommendation	Who for?	List of Interventions	Type of Psychological Practice	Evidence	Efficacy
First line recommendation	Mild/Moderate anxiety in school age CYP (evidence includes studies of broad anxiety symptoms as well as GAD diagnoses)	CBT-based intervention packages delivered through various formats: -Group psychoeducation (47) -School-based prevention and intervention programmes based on CBT principles (48-54) - Bibliotherapy based on CBT principles (55) - Computerised or digitally enabled CBT (56-58)	Skilled/Enhanced	A    A     A   A	Medium   Low     Low   Low-medium
First line recommendation	Moderate/Severe anxiety in school age CYP (evidence for individual CBT includes studies of broad anxiety symptoms and diagnoses, rather for GAD specifically)	CBT delivered in the following ways: -Individual CBT (26,59) -CBT with parental/family involvement (20,26,33,59,60) -Group CBT (25,26,33,61) -Technology delivered CBT (56-58) -Parent only CBT (26,35)   Treatment efficacy can be enhanced by booster sessions (62)	Specialist	A                A	Medium Medium     Medium Low-Medium Low   High
First line intervention	CYP with mild to moderate learning disabilities and anxiety (evidence for individual CBT includes studies of broad anxiety symptoms and diagnoses, rather for GAD specifically)	CBT (or specific components including relaxation and exposure) with appropriate adaptations to needs based on formulation (4,45) Parent training programmes specifically designed for parents or carers of children with learning disabilities to help prevent or treat mental health problems in the child, and to support carer wellbeing (4)	Specialist     Enhanced/specialist	C     B	N/A     N/A
Alternative (lower efficacy and evidence less well established)	Moderate/Severe anxiety in school age CYP (trials included CYP with GAD and other anxiety disorders)	Attention/Cognitive Bias Modification (63-65)	Specialist	A	Low
Alternative (lower efficacy and evidence less well established)	Moderate/Severe anxiety in adolescents and young adults (trials included CYP with GAD and other anxiety disorders)	Mindfulness Based Stress reduction (66)	Enhanced/  specialist	A	Low

Recommendation	Who for?	List of Interventions	Type of psychological practice	Evidence	Efficacy
First line recommendation	Adults presenting in primary care meeting diagnostic criteria for GAD (mild/moderate)	Individual digitally enabled guided self-help based on CBT principles (5,41,67-70)	Skilled/Enhanced	A	Medium – high
		Psychoeducational groups based on CBT principles (5,71,72)	Skilled/Enhanced	A	Medium - high
Alternative if preferred (lower efficacy)		Individual non-facilitated self-help based on CBT principles (5,73,74)	Informed	A	Low-high
Alternative if preferred (longer term efficacy less established)		Mindfulness-based (MB) Therapy (i.e. MB Cognitive Therapy/ MB stress reduction) (72,75-78)	Enhanced	A	Medium-high
First line recommendation	GAD with insufficient response to guided self-help or psychoeducation interventions or GAD with marked functional impairment	Disorder specific CBT (12,42,69,78-90)	Specialist	A	Medium-high
		Applied relaxation (84,91,92)	Enhanced	A	High
Alternative recommendation		Mindfulness-based (MB) Therapy (i.e. MB Cognitive Therapy/ MB stress reduction) (72,75-78,93)	Enhanced	A	Medium- high
		Metacognitive Therapy (94,95)	Specialist	A	Medium-high
Alternative recommendation		Acceptance and commitment therapy (92,93)	Specialist	A	N/A
First line recommendation	Complex presentations, refractory GAD and very marked functional impairment	Combined treatment regimens including psychological therapy, medication, and adjunctive care from MDTs (5)   This includes one of the psychological therapies outlined above e.g., CBT with adjunctive care coordinated by multidisciplinary teams (including pharmacological interventions) e.g., crisis services, outpatient settings or inpatient care.	Specialist	A	N/A
First line recommendation	Adults with mild to moderate learning disabilities and anxiety symptoms	CBT (or specific components including relaxation and exposure) with appropriate adaptations to needs based on formulation (4,44,45)	Specialist	B	N/A

With thanks to Alice Loyal and Louise Waddington from NHS Wales who participated in the advisory and technical groups.

Advisory group: Gemma Brown, Alex Doherty, Audrey Espie, David Gillanders, Andrew Jahoda, Anne Joice, Sean Harper, Wendy McAuslan, Fhionna Moore, Suzy O’Connor, Suzanne Roos, Alia Ul-hassan, Naomi Whyte.

Technical group: Gemma Brown, Naomi Harding, Anne Joice, Jill Jones, Leeanne Nicklas, Allyson McDougall, Fiona Moore, Suzy O’Connor, Marie Claire Shankland.

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