Diagnostic framework #
A DSM-oriented adult assessment requires excessive, hard-to-control worry on most days for at least 6 months, associated symptoms and impairment. Establish whether worry is generalized across topics rather than confined to one feared situation. ICD wording and thresholds should be documented separately when that system is used.
Targeted clinical assessment #
Ask about reassurance seeking, overpreparation, procrastination, muscle tension, fatigue and sleep. Assess the feared outcome and what the person does to prevent it. Establish depression, suicidality, alcohol or sedative use and prior treatment response; document concrete goals such as completing work without repeated checking.
Differential diagnosis #
| Alternative | Discriminator |
|---|---|
| OCD | Intrusive unwanted content with rituals or mental neutralization. |
| Panic disorder | Unexpected attacks with anticipatory fear and avoidance. |
| Depression / bipolar illness | Anxiety may occur within a mood episode; establish lifetime elevation. |
| Medical or substance contribution | Thyroid symptoms, stimulants, caffeine and sedative withdrawal change the work-up. |
Indicated investigations #
| Clinical question | Investigation |
|---|---|
| Autonomic or systemic symptoms | Physical examination and targeted thyroid or other medical tests when indicated. |
| Cardiac/QT vulnerability | Review ECG, electrolytes and interacting medicines for the selected treatment. |
| Possible hyponatraemia | Check sodium when symptoms or susceptibility make it relevant. |
Treatment sequence #
View treatment map
- Education and lower-intensity care
Explain the worry/avoidance cycle; use structured self-help and monitor function.
- Marked impairment or insufficient improvement
Offer high-intensity CBT/applied relaxation or medicine according to preference.
- Partial medication response
Consider adding high-intensity psychological treatment.
- Complex/refractory illness
Reassess comorbidity and seek specialist review before combinations.
| Step | Approach |
|---|---|
| Education and lower-intensity care | Explain the worry/avoidance cycle; use structured self-help and monitor function. |
| Marked impairment or insufficient improvement | Offer high-intensity CBT/applied relaxation or medicine according to preference. |
| Partial medication response | Consider adding high-intensity psychological treatment. |
| Complex/refractory illness | Reassess comorbidity and seek specialist review before combinations. |
Doses & prescribing #
Each prescribing record identifies its population and source jurisdiction; international labeling does not establish Indian approval. The clinician selects treatment after assessment.
Escitalopram
Generalised anxiety disorder
Adults · Immediate-release tablets · Oral · United Kingdom product information
- Starting dose
- 10 mg once daily.
- Titration
- Increase according to response and tolerability within the label range; a fixed increment is not specified in this UK SmPC.
- Treatment range / target
- 10–20 mg/day.
- Maximum / limits
- 20 mg/day for ordinary adults; lower limits apply below.
- Trial & duration
- Reevaluate benefit and dose regularly; continuation guidance below.
- Monitoring
- Activation, suicidality, sodium when indicated, bleeding and QT-related vulnerability.
- Population & organ-function adjustments
- Age >65: start 5 mg/day, maximum 10 mg/day. Mild/moderate hepatic impairment: 5 mg/day for 2 weeks, then up to 10 mg/day. Severe renal/hepatic impairment needs caution.
- Important cautions
- Avoid MAOIs and known QT prolongation or contraindicated QT-prolonging combinations.
Nonresponse & escalation #
Check adherence, tolerability, diagnostic fit and whether psychotherapy actually targeted worry and avoidance. NICE supports an alternative medicine or high-intensity psychological treatment after a full unsuccessful drug course. A GAD-7 change alone does not establish restored function.
Maintenance & discontinuation #
NICE advises continuing an effective medicine for at least a year because recurrence is common. Discuss a staged reduction when appropriate, with review for withdrawal and return of persistent worry. Tapering speed depends on exposure, prior withdrawal and the medicine.
Special populations & comorbidity #
Depression, chronic pain and substance use commonly coexist and can alter priorities. Pregnancy/lactation requires a drug-specific discussion. In older adults, account for falls, sodium, polypharmacy and lower escitalopram dose limits; prescribing choices must match organ function.
Follow-up #
NICE recommends reviewing effectiveness and adverse effects every 2–4 weeks during the first 3 months, then every 3 months. Review earlier where activation, suicidality or clinical deterioration warrants it. Track worry, avoided tasks, sleep and function.
Clinical pitfalls #
Repeated reassurance may become part of the maintaining cycle. Do not substitute sedation for treatment of persistent worry or overlook a coexisting mood episode when anxiety intensifies. Document benzodiazepine exposure and dependence rather than interpreting withdrawal as refractory GAD.
Assessment tools #
Choose the instrument for its intended purpose; interpretation accompanies the linked tool.
Patient discussion #
Open a plain-language explanation
Anxiety can become a cycle of worry, body tension and avoidance. Treatment helps change that cycle and restore everyday activity.
References · 3
- NICE CG113: GAD and panic treatment · United Kingdom · Checked 2026-10-26 · Supports: Treatment sequence; Nonresponse & escalation; Maintenance & discontinuation; Follow-up
- NIMH: Generalized anxiety disorder · United States · Checked 2026-10-26 · Supports: Diagnostic framework; Targeted clinical assessment; Differential diagnosis; Special populations & comorbidity; Clinical pitfalls
- Escitalopram tablets: SmPC sections 4.2–4.5 · United Kingdom product information · Checked 2026-10-26 · Supports: Indicated investigations; Special populations & comorbidity; Escitalopram — Generalised anxiety disorder (Immediate-release tablets)