What is anxiety?

Anxiety disorders are among the most prevalent mental health conditions in the world. They encompass a family of related but distinct presentations: generalised anxiety disorder (GAD), panic disorder, social anxiety disorder, specific phobias, and agoraphobia. What unites them is excessive and persistent fear or worry that is disproportionate to actual threat, causes significant distress, and substantially impairs daily functioning. In the UK, GAD affects around 5% of the general population and is among the most common reasons for presentation in primary care.

Anxiety disorders are highly treatable. NICE recommends a stepped-care model: starting with lower-intensity self-help and psychoeducation, progressing to high-intensity cognitive behavioural therapy (CBT) or pharmacotherapy, and reserving specialist care for those who do not respond. Despite this, a significant proportion of people with anxiety disorders receive no effective treatment at all, with serious consequences for long-term mental and physical health.

What the research tells us

Our research summaries are written by clinicians and researchers who have read and critically appraised the original studies. The sections below reflect the main areas covered by NICE guidance on anxiety disorders (CG113, CG159), applied to the NES evidence base.

Prevalence, the treatment gap, and the cost of waiting

Anxiety disorders have been rising in prevalence in the UK. A 2021 cohort study tracking anxiety disorder rates in the UK found significant increases in recorded diagnoses over the preceding decade, with the rise concentrated in working-age adults and disproportionate in women and people in lower socioeconomic groups. The study highlights that much of this increase reflects better recognition rather than a simple increase in underlying rates, but that the treatment infrastructure has not kept pace.

The consequences of leaving anxiety untreated are clinically significant. A 2023 systematic review of what happens when anxiety disorders are left untreated found that untreated anxiety tends to follow a chronic and worsening course. Spontaneous recovery is uncommon without intervention. Comorbid depression develops in a substantial proportion of untreated cases, functional impairment accumulates, and by the time people eventually access services their conditions are often considerably more complex and costly to treat. The review makes a strong case for timely intervention rather than watchful waiting.

GAD: worry, intolerance of uncertainty, and treatment

Generalised anxiety disorder is characterised not by specific fears but by pervasive, uncontrollable worry across multiple domains of daily life. Intolerance of uncertainty is now recognised as one of the core cognitive mechanisms driving GAD: people with GAD tend to experience uncertainty as inherently threatening and respond by worrying as a form of mental control. NICE-recommended CBT for GAD specifically targets this process, alongside avoidance, reassurance-seeking, and overestimation of threat.

A 2025 network analysis of anxiety symptoms in young people found that worry and rumination function as central nodes in the anxiety symptom network, with strong connections to sleep problems and low mood. Targeting worry directly, rather than individual symptoms, may therefore have outsized downstream effects. This is consistent with the NICE recommendation that CBT for GAD focus explicitly on worry as a problem behaviour, not just as a symptom to be reduced.

NICE recommends panic disorder be treated with either CBT or an SSRI. The two approaches have comparable efficacy in trials, and the choice should be led by patient preference and clinical context.

Social anxiety disorder: underdiagnosed and undertreated

Social anxiety disorder is one of the most prevalent anxiety conditions globally, yet it remains frequently misidentified as shyness or introversion and is substantially underdiagnosed in primary care. NICE CG159 recommends individual CBT using Clark and Wells’s cognitive model as the first-line treatment, ahead of pharmacotherapy. The core mechanisms involve biased attentional processing, unhelpful self-focused attention, and safety behaviours that maintain anxiety by preventing disconfirmation of feared beliefs.

A 2024 study on how exposure therapy works in social anxiety found that expectancy change, specifically the extent to which feared outcomes are disconfirmed during exposure, is a crucial mechanism driving treatment gains. This has direct clinical implications: exposure exercises that are poorly designed, cut short, or accompanied by safety behaviours do not produce the expectancy change needed to sustain recovery. A 2024 trial of remotely delivered video feedback as part of cognitive therapy for social anxiety disorder found that internet-based delivery of this technique, normally conducted face-to-face, produced significant reductions in social anxiety and self-focused attention, supporting the feasibility of adapting evidence-based CBT components to remote delivery.

CBT: gold standard, access, and closing the gap

CBT is the best-evidenced psychological treatment across most anxiety disorders, recommended by NICE as first-line for GAD, panic disorder, and social anxiety. The key challenge in UK services is not the quality of CBT where it is delivered, but the consistent gap between those who need it and those who receive it in a timely way.

A 2023 systematic review of solutions to improving CBT access for anxiety found that stepped-care models, group formats, guided self-help, and digital delivery can each improve throughput, but only when combined with active monitoring and clear pathways for stepping up or down. Passive waiting-list management without active clinical review is associated with deterioration during the wait. The review found that guided self-help, where a practitioner provides limited but structured support for a self-directed CBT programme, is an effective Step 2 intervention for many people with anxiety and has a substantially larger evidence base than is often recognised in service design.

Neuroimaging research is beginning to shed light on why CBT works differently for different people. A 2023 meta-analysis of task-based fMRI studies found that pre-treatment patterns of amygdala reactivity and prefrontal regulation activity showed promise as predictors of CBT response in anxiety disorders. While still at an early stage, this line of research raises the prospect of matching patients to treatments more precisely rather than relying solely on clinical presentation and preference.

Pharmacological treatment: what NICE recommends and what GPs actually prescribe

For GAD, NICE recommends SSRIs as the pharmacological first-line, with sertraline specifically recommended as the first choice. SNRIs (venlafaxine, duloxetine) are alternatives, and pregabalin is recommended for patients for whom SSRIs or SNRIs are not appropriate. Benzodiazepines should not be used beyond short-term management of acute symptoms because of dependence risk.

A striking 2025 qualitative study of GP prescribing for anxiety found that beta-blockers are frequently used in primary care for anxiety despite having no recommendation in NICE guidance and a limited evidence base. GPs described prescribing them pragmatically for situational anxiety (such as performance anxiety or anticipatory social anxiety) when patients declined SSRIs, wanted to avoid long-term medication, or needed rapid symptom management before an event. The study raises important questions about the gap between guideline recommendations and real-world clinical practice, and about whether some patients’ needs are not well served by the current NICE framework for anxiety pharmacotherapy.

A 2025 systematic review ranking antidepressants by their physical health side effect profiles provides useful comparative data for informed prescribing decisions when SSRIs and SNRIs are being considered for anxiety.

Anxiety in children and young people

Anxiety disorders are among the most common mental health conditions in childhood and adolescence, and there is strong evidence that early intervention can prevent chronic illness and reduce burden across the lifespan. NICE guidance (NG47) recommends parent-guided or individual CBT as first-line treatment for most anxiety presentations in children.

Family transmission is a well-established risk pathway. A 2024 study of anxiety risk in families affected by parental mood disorders found elevated rates of anxiety in children of parents with anxiety and depression, and a 2025 RCT of an online intervention to prevent intergenerational transmission of anxiety found that brief, scalable parenting programmes can meaningfully reduce anxiety in children of anxious parents. Intervening at the parental level may be one of the most efficient points in the system for reducing childhood anxiety at population scale.

On the treatment side, a 2024 trial found that digitally augmented CBT for child anxiety was more efficient and no less effective than standard parent-led CBT, supporting the use of technology to extend the reach of evidence-based interventions without sacrificing quality. A 2023 review of physical activity for youth anxiety found moderate support for exercise as an adjunct to treatment, with consistent evidence of benefit on anxiety symptoms in young people, though effect sizes were smaller than for structured psychological therapy.

Comorbidity, transdiagnostic approaches, and anxiety in context

Anxiety rarely presents alone. Comorbid depression, PTSD, and substance use are common, and the boundaries between anxiety disorders themselves are often blurred in clinical practice. Transdiagnostic group therapy for mixed anxiety and depression is as effective as single-diagnosis group approaches and substantially more practical for services with limited capacity. NICE guidance increasingly acknowledges this reality, and the field is moving towards treatments that target common underlying processes, particularly worry, avoidance, and intolerance of uncertainty, rather than discrete diagnostic categories.

Climate-related anxiety is an emerging presentation that clinicians are beginning to encounter more regularly. It is important not to pathologise what may be a rational response to genuine risk, while also recognising that some people develop disproportionate distress that impairs functioning. Research on solastalgia and climate anxiety projections suggest that this is a growing clinical consideration that existing frameworks address poorly.

Key practice points

• Treat early. Watchful waiting has a cost. Untreated anxiety tends to become chronic, with comorbid depression developing over time. The evidence does not support a “wait and see” approach.
• Use the stepped-care model actively, not as a queue. Guided self-help and low-intensity CBT are effective for many people. Active monitoring with clear step-up criteria prevents deterioration during waits.
• Design exposure therapy carefully. Expectancy change is the active mechanism in exposure. Poorly designed exposures with safety behaviours or premature termination will not produce durable improvement.
• Ask about social anxiety specifically. It is frequently misidentified as personality or shyness. NICE recommends individual CBT using the Clark and Wells cognitive model as first-line, ahead of pharmacotherapy.
• Use NICE-recommended pharmacotherapy, but understand what GPs actually prescribe. SSRIs are first-line; beta-blockers are widely used in primary care for situational anxiety despite no guideline support. Be aware of this gap when working across primary and secondary care.
• Intervene in the family system for childhood anxiety. Parent-focused programmes can reduce intergenerational transmission and may be more scalable than individual child treatment for high-risk families.
• Don’t pathologise climate concern, but take eco-anxiety seriously as a clinical presentation when it causes functional impairment.

Featured blogs

• Sitting in the waiting room: what happens when anxiety disorders are left untreated? 2023. Systematic review finding that untreated anxiety follows a chronic course, with spontaneous recovery uncommon and comorbid depression developing over time.
• Pragmatic prescribing: why GPs offer beta-blockers for anxiety, despite guideline gaps 2025. Qualitative study revealing the real-world gap between NICE pharmacotherapy recommendations and GP prescribing practice for anxiety in primary care.
• Exposing how exposure works: expectancy change is crucial for successful exposure treatment 2024. Examines the core mechanism of exposure therapy, with implications for how clinicians should design and deliver exposure exercises for anxiety disorders.
• Improving access to CBT for people with anxiety: a review of solutions? 2023. Systematic review of strategies for expanding CBT access, including stepped care, group formats, guided self-help, and digital delivery.
• Preventing the intergenerational transmission of anxiety: encouraging insights from new online RCT 2025. RCT finding that brief online parenting programmes can reduce anxiety in children of anxious parents.
• Guided self-help for anxiety: the importance of choice 2023. Examines the evidence for guided self-help as a Step 2 intervention, and why patient choice in the format and pace of self-help programmes matters for outcomes.

Listen: podcast episodes

• Cathy Creswell and Rachel: Child anxiety and what parents can do (2022, 26 min). Professor Cathy Creswell from the University of Oxford and Rachel, a parent of a child with anxiety, on what we know about how childhood anxiety develops and what actually helps.
• Michel Dugas: Behavioural experiments for intolerance of uncertainty (2022, 18 min). Professor Michel Dugas on intolerance of uncertainty as the core driver of GAD, and how behavioural experiments can directly target it within a CBT framework.

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