case study for generalized anxiety disorder

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Generalized Anxiety Disorder Case Study: James

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Generalized anxiety disorder, (GAD) is a traumatic illness, and is hard to understand unless you are experiencing it yourself. While specific anxiety disorders are complicated by panic attacks or other features of the disorder, GAD has no specific focus. (Durand, 2007 p.130). The person constantly worries about everyday life; not being able to figure out what to do with their worries. All the while making themselves and everyone around them miserable. (p.130). The worries seem to take over control of one's life, almost to the point of not being able to function at all.

It seems that GAD tends to run in families based on studies conducted, and seems to happen more to women than men. (Durand, 2007 p.132). And evidence shows that GAD may be proved to be just as heritable, the same as other anxiety disorders. (p.133). The textbook states that this disorder originated in 1980, however therapists were working with patients with anxiety way before the criteria was developed. (p.133). For many years, clinicians believed that people who were generally anxious just didn't seem to have anything specific to focus on, thus calling it the 'free floating' disorder. (p.133).

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) has specific criteria that characterized GAD. As stated in our textbook, the features are:

• Excessive anxiety and worry for 6 months or more about a number of events or activities. • Difficulty in controlling the worry. • At least three of these symptoms: (1) restlessness of feeling all keyed up; (2) becoming fatigues easily; (3) difficulty concentrating; (4) irritability; (5) muscle tension; (6) sleep disturbance. • Significant distress or impairment. • Anxiety is not limited to one specific issue. (Durand, 2007 p.131).

Generalized anxiety disorder has been studied using various criteria. The National Comorbidity Survey (NCS) focused on noninstitutionalized American civilians ages 15 to 54. The results were reported and found there was a clear predominance of women with GAD, with a 2:1 female/male ratio. It was lowest among the younger age group but increased with age. (NA, 1997). 'There was a significant regional difference in GAD as well, with a higher lifetime prevalence in the Northeast than in other parts of the country.' (1997). Studies have shown that many people could not really pinpoint a clear age of onset of GAD or an onset dating back to childhood. (Barlow, 1993 p.156). There have also been twin studies which conclude that GAD is somewhat greater for identical female twins than for non-identical twins, but only if one twin already had generalized anxiety disorder. (Durand, 2007 p.132). But later researched showed that what seemed to be inherited was the ability to become anxious rather than GAD itself. (p.132). It's amazing to know that people with GAD seem to show less responsiveness on most physiological measures, such as heart rate, blood pressure, skin conductance and respiration rate than do people with other anxiety disorders. (p.133).

Although it seems to prove that GAD is quite common, I am amazed that more people don't have this disorder. I think that many people have general anxieties on a daily basis, but most people are able to handle them successfully. I did not realize that most people with GAD have usually had symptoms of anxiety or feelings of being worried throughout life, but just didn't know when it all started. The criterion has changed over the years as well as doctors have become more knowledgeable about this disorder. I first had knowledge of this disease in 1997 when I noticed strange things happening.

He was not really watching as he stared directly at the television set. I would notice that he had no expressions at all; nothing during the humorous scenes, or the dramatic ones. He once told me that it was as if he was someone else, watching himself try to crawl out of his own skin. That was 10 years ago when I was married to this man who was suffering from generalized anxiety disorder. I didn't understand and I really didn't want to. I thought he was just being lazy and unmotivated. Although this disorder seems to be simple to others, it is quite alarming to the person who is suffering from it, and the onset is rather quick, whereas, treatments are difficult. Everyone experiences anxiety, but in most people, it does not last for months at a time.

The case study I am choosing is about James who is a doctor suffering from generalized anxiety disorder. At 31 years of age and living in New York, he is unemployed because of his constant anxiety, even at the thought of working. He now lives with his parents off a small trust fund set up for him by an uncle. Although he was an overachiever throughout his academic career, James is having a hard time keeping it together, while his parents are somewhat supportive but disappointed with his medical career. Let's see what we can learn about this horrible and crippling disorder. 'Generalized anxiety disorder is associated with irregular neurotransmitters in the brain. Neurotransmitters are chemicals that carry signals across nerve endings. Neurotransmitters that seem to involve anxiety include norepinephrine, GABA (gamma-aminobutyric acid), and serotonin.' (na, 2001). So it was thought that reduced levels of GABA initiated excessive anxiety, although neurotransmitters are much to complex to be interpreted that simply. (Durand, 2007 p.45).

The brain is a very fascinating and intricate part of who we are and if the brain is not functioning properly, then our reactions to certain situations are not in balance. This is why some people still believe that undeniable psychological disorders are said to be caused by biochemical imbalances. (Durand, 2007 p.50). So in James' case, his brain was not functioning right and he was experiencing an unnatural balance of change within his various neurotransmitters, causing him to become anxious, easily irritated, distracted and quite tense. He also complained of headaches, body aches and pains and always feeling tired.

Genetics does play a major role is determining whether a person will or will not have a psychological disorder. The textbook states that the research is beginning to acknowledge genes that relate to some psychological disorders. (Durand, 2007 p.70). I feel that genetics does contribute to some disorders, but I also think that the environment and society can cause debilitating stress to induce certain disorders, such as anxiety. If the gene linked to the disorder is dormant, a stress related incident can bring it to the surface, thus bringing on the disorder. My research has shown that there are brain abnormalities indicated with generalized anxiety disorder. A study of 30 patients displayed that compared to 20 healthy volunteers, 11 patients had significant brain abnormalities mainly in the right temporal lobe. (Nutt, 2003 p.209). The temporal lobe controls the processes of recognizing various sights and sounds and long term memory storage. (Durand, 2007 p.48). However there are two temporal lobes on each side of the brain, located at the level of the ears. The lobes help a person distinguish one sound from another as well as one smell from the other. The right lobe controls visual memory while the left lobe controls verbal memory. (Johnson, 2006) So this would explain why James kept making mistakes because he was probably having a hard time remembering simple procedures.

The first thing James would need to do would be to seek professional help and see if he has this disorder, although being a medical doctor, he may have self diagnosed himself, however he should see a psychiatrist. There are no laboratory tests that can determine if a person has anxiety or a mental illness, but a doctor will perform a battery of tests to weed out other illnesses, such as an overactive thyroid gland, which can produce anxiety and its symptoms. (NA, 2007 WebMD). James' next plan of attack would be to discuss the different types of medications that are available for providing relief from this disorder. Since James has generalized anxiety disorder, which has been called a 'free-floating' disorder because of his constant worrying and nervousness, as stated earlier, he would need a medication that treats low levels of GABA. (Roberts, ch.17 p.6). The textbook states that the drub benzodiazepine (minor tranquilizers) is the most frequently prescribed. (Durnad, 2007 p.134). The drug is used for short-term relief and can be hard to stop taking because of dependence issues. One such drug in particular is called Xanax, which is shown to enhance the function of GABA in the brain. It also slows down the central nervous system. This drug is extremely addicting; it's the drug my ex-husband did not want to give up, so we got a divorce.

There is also evidence that antidepressants can be used for GAD and may be a better choice. (p.134) The most common antidepressants are prozac and zoloft. 'These drugs are shown to affect the concentration and activity of the neurotransmitter serotonin, a chemical in the brain thought to be linked to anxiety disorders.' (na, 2004). Some of these drugs that I have researched for GAD, are also used for treating migraines, because I was prescribed some for headaches. No wonder I was always in a good mood, even though it felt like my head was about to explode.

Because the drugs prescribed for this disorder are recommended to be taken for short periods of time, therapy should be initialized as well. The side effects of these drugs are: Xanax (benzodiazepines): drowsiness, fatigue, decreased concentration, confusion, blurred vision, pounding or irregular heartbeat, impaired coordination, short term memory problems, dizziness. (Smith et al, 2006).

Prozac (Selective Serotonin reuptake inhibitors): nausea, insomnia, headaches, decreased sex drive, dizziness, weight gain or loss, nervousness, sweating, drowsiness/fatigue, dry mouth, diarrhea or constipation, skin rashes. (Smith et al, 2006) These medications offer so many side effects, it's a wonder anyone wants to take them at all. But I guess for the person who is suffering from anxiety attacks or generalized anxiety disorder, the side effects may be a welcomed relief There are also natural remedies to help with GAD such as valerian root and kava kava, which has been treating anxiety for years, but the results are not well documented. (Smith et al, 2006) Some natural remedies can actually make anxiety worse and taking supplements may interact with the prescription anxiety medications, so it's a good idea to discuss this with a doctor.

Another approach to treatment is to help James with therapy sessions to try to figure out why he is experiencing all this anxiety and worry. One session may include showing James pictures of things that may make him anxious and then teaching him how to relax deeply to fight his tension. It's called cognitive behavioral treatment, developed in the early 1990s, and is quite successful; however we need both medications and therapy to treat GAD. (Durand, 2007 p.134).

Acupuncture, which is one medical treatment that does no harm to the body, only releases energy and gets it moving in the system; (NA, 2007) biofeedback, which is the ability to allow the patient hear or see feedback of their body's physiological state while relaxing;(Grohol, 2004) and hypnotherapy shown as an appropriate treatment modality for those individuals who are highly suggestible, have also been used to treat anxiety. (Grohol, 2004).

So which treatments work the best? That is hard to say because everyone is different and will react differently to each treatment. As stated in the textbook, a combined treatment of therapy and medications suggested there were no advantages for both, and that people did better in the long run when having psychological treatments only. (Durand, 2007 p.144). So it's suggested to start with psychological treatment first and then followed by drug treatments for the patients who are not responding to therapy. (p.144).

How does environment influence our behavior? Do we imitate what we see around us? Are we simply looking for acceptance, thereby, acting or saying what we think society expects? Who decides what acceptable behavior is? Although the environment may affect a person's behavior, there are many other elements to explore that influence the way we are.

James is coping with generalized anxiety disorder, as was stated earlier. At 31, he is allowing this disorder to control his life which is leading to being emotionally and physically drained. Although he realizes that he is an intelligent and capable person, he knows to avoid any situation that may exacerbate the anxieties that he is experiencing. With minimal support from his family and friends, James feels that he is dealing with this all alone and just wants to lead a normal life. Perhaps the stress and strain of becoming a doctor led to James' anxiety disorder as it may have been dormant within his genetic makeup, and is now just surfacing.

Many people develop generalized anxiety disorder (GAD) during adolescence, but do not seek professional help until they are adults. (NA, 2001). When they do finally get help, they claim they have been anxious and nervous all their lives. (2001). These people cannot just 'get over it' but society seems to not grasp that concept. Some of the environmental influences that could lead to general anxiety are: • Work. This would affect James immensely because his whole life has been based around his becoming a doctor. Even his father wanted him to follow in his footsteps and have a prestigious career. • School. Although James did not experience anxieties until after he graduated from medical school, I'm sure he still felt anxious with tests and schoolwork. • Relationships. This would be dealing with James' parents as they are somewhat supportive but disappointed that his career has not been progressing. He also lost his relationship with his girlfriend of three years because of the stress. • Health. Because James is dealing with this disorder, his health is rapidly declining. He is having headaches, body aches and pains and is always tired. His emotional health is affected as well with feelings of laziness and worthlessness. • Financial. James is realizing that if he cannot work, he cannot earn a paycheck. He is living off a small trust fund set up for him by his great uncle, but that won't last forever. All of these things are considered threats and can cause James to worry excessively which is interfering with his life.

Is the environment to blame for James' anxiety or is it more biological? I think that genetics and the environment work together to produce this disorder. I feel that if a person is genetically prone to have anxiety and fear; if the person never leaves the house, then what does he/she have to worry about? The environment has to play a role in the mobility of this disorder. If James were to isolate himself from the world, he would still have anxiety; however he would not be able to face his fears, thus restricting his life. His thought process would be 'what if this happened, or what if that happened?' He would always be having threatening thoughts and images playing over and over in his mind. (Alloy, 2006 p.189).

Our textbook states that GAD generally runs in families, which I mentioned earlier. (Durand, 2007 p.132). With all the research and studies that are performed, it will show that generalized anxiety disorder is inherited. So genetics and biology has to be the most important because people who aren't suffering from anxiety will react more favorable to a stressful situation, than someone who is suffering from GAD. It seems that we all have to face the same environmental influences, but the threat of each situation interacts with the biological aspect of a person, thus bringing on the symptoms of the disorder. (p.133).

James needs to be treated by a psychiatrist, not a family physician. He needs to be seen by someone who deals with psychological disorders daily and is educated with the treatments available. Psychological treatments work better in the long run and work just as well as prescription medication. Our textbook states that, 'as we learn more about generalized anxiety, we may find that helping people with this disorder to focus on what is actually threatening is useful.' (Durand, 2007 p.134).

Research has indicated that psychological treatments work very well for children who suffer from GAD. (Durand, 2007 p.135). But I feel that unless a child is diagnosed early in life, the treatments won't be as effective. I'm sure that James was experiencing some form of anxiety as a child, but children are difficult to diagnose, and if the parents don't know what to look for, they won't know the child needs help. But children respond to cognitive-behavioral treatments along with family therapy. (p.135).

I feel that psychosocial treatments would be the best way to start with a patient. In James' case, I think he should start with therapy for at least three months. He needs to confront the fear, phobias and anxieties head on to figure out what's making him feel emotionally and physically drained. I would also suggest to James that he should educate and read everything he can on this disorder. Having this knowledge will benefit him so he may get the most out of his treatments. If I had a disorder, I would want to know everything about it. And I would be asking a million questions. Sometimes I feel that everyone in society could use some form of therapy to deal with the stressors of life.

Next, I would try medications in addition to therapy to help James with possible other symptoms of GAD, such as depression. (Smith et al, 2006). The medication, however, would only be used on a temporary basis, as addiction can occur. My ex-husband was on medication for his GAD, but he was not seeing anyone for therapy. I think that was the biggest problem. He was increasing his dosage without telling his doctor, thus becoming extremely dependent on the drugs. As a doctor, James should know that some of the medications used for GAD are very addictive and hopefully would only be used as directed.

There are certain beliefs about thoughts and thought processes that are included in cognitive forms. (Papageorgiou, 2004 p.228). 'There are two types of worries; Type 1 and Type 2. Type 1 worries deal with external daily events such as the welfare of a partner, and non-cognitive internal events such as concerns about bodily sensations. Type 2 worries are focused on the nature and occurrence of thoughts themselves such as worrying that worry will lead to insanity. It's basically worry about worry.' (Wells, 1997 p.202). The cognitive model claims that the varieties of worry are typically type 2 worries in which the patients negatively appraise the activity of worrying. (p 202). I feel that the cognitive psychological model best applies to understanding and treating this disorder. I believe that by using cognitive therapies and similar research studies, we can begin to know what it takes to treat the people who are suffering with better results now and in the future. There are new medications that can help people with GAD, but there are side effects that may be too harsh or severe. I believe that more psychosocial therapies may need to be developed in order to help these people, so they can live a normal life without medications, because of the problems they present to the body.

I believe that James could once again become a successful doctor if and when he gets his generalized anxiety disorder under control. The treatments are available; all he has to do is seek them out. I feel that with therapy coupled with medications would benefit James tremendously. Eventually he will be able to stop taking the medications and perhaps enjoy a fairly normal life. The good news is that only 4% of the population meets the criteria for GAD during a given one-year period. However it is still one of the most common anxiety disorders. (Durand, 2007 p.132). . My research for this paper has helped me so far in understanding what a person is going through with crippling anxiety. It's not something that a person can just 'get over' and I know I wanted to tell my ex-husband that many, many times. However, he became addicted to the prescriptions drugs, and became a drug addict in about two weeks. Because of my first hand experience with this disorder, I chose to do my projects on it.

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Cognitive-Behavioral Therapy for Generalized Anxiety Disorder: Case Formulation and Evidence-Based Treatment Strategies

• First Online: 19 July 2023

Cite this chapter

• Nicole J. LeBlanc 5 ,
• Anna Bartuska 6 ,
• Lillian Blanchard 7 &
• Luana Marques 5  

Part of the book series: Current Clinical Psychiatry ((CCPSY))

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Generalized anxiety disorder (GAD) is a prevalent chronic disorder that is associated with significant psychosocial impairment. The hallmark feature of GAD is excessive and uncontrollable worry that occurs across multiple domains of life. Cognitive-behavioral therapy (CBT) is the most widely studied psychotherapy for GAD and has received strong empirical support in randomized controlled trials. Most CBT models conceptualize worry as an ineffective emotion regulation strategy that individuals use to cope with fear and anxiety. CBT for GAD therefore involves teaching patients to notice their habitual responses to fear and anxiety and utilize more helpful emotion regulation strategies when feeling these emotions. Common treatment strategies include psychoeducation, self-monitoring of worry episodes, applied relaxation, mindfulness exercises, cognitive reappraisal, behavioral experiments, imaginal exposure, and valued actions. In this chapter, we describe the goals and evidence base for these treatment strategies and demonstrate their use with a case vignette.

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Roemer L, Orsillo SM. Expanding our conceptualization of and treatment for generalized anxiety disorder: integrating mindfulness/ acceptance-based approaches with existing cognitive-behavioral models. Clin Psychol. 2002;9:54–68. https://doi.org/10.1093/clipsy.9.1.54 .

Behar E, Dobrow DiMarco I, Hekler EB, Mohlman J, Staples AM. Current theoretical models of generalized anxiety disorder (GAD): conceptual review and treatment implications. J Anxiety Disord. 2009;23:1011–23. https://doi.org/10.1016/j.janxdis.2009.07.006 .

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Fresco DM, Mennin DS, Heimberg RG, Ritter M. Emotion regulation therapy for generalized anxiety disorder. Cogn Behav Pract. 2013;20:282–300. https://doi.org/10.1016/j.cbpra.2013.02.001 .

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LeBlanc, N.J., Bartuska, A., Blanchard, L., Marques, L. (2023). Cognitive-Behavioral Therapy for Generalized Anxiety Disorder: Case Formulation and Evidence-Based Treatment Strategies. In: Sprich, S.E., Petersen, T., Wilhelm, S. (eds) The Massachusetts General Hospital Handbook of Cognitive Behavioral Therapy. Current Clinical Psychiatry. Humana, Cham. https://doi.org/10.1007/978-3-031-29368-9_6

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AMY B. LOCKE, MD, FAAFP, NELL KIRST, MD, AND CAMERON G. SHULTZ, PhD, MSW

A more recent article on  generalized anxiety disorder and panic disorder in adults  is available.

Am Fam Physician. 2015;91(9):617-624

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Generalized anxiety disorder (GAD) and panic disorder (PD) are among the most common mental disorders in the United States, and they can negatively impact a patient's quality of life and disrupt important activities of daily living. Evidence suggests that the rates of missed diagnoses and misdiagnosis of GAD and PD are high, with symptoms often ascribed to physical causes. Diagnosing GAD and PD requires a broad differential and caution to identify confounding variables and comorbid conditions. Screening and monitoring tools can be used to help make the diagnosis and monitor response to therapy. The GAD-7 and the Severity Measure for Panic Disorder are free diagnostic tools. Successful outcomes may require a combination of treatment modalities tailored to the individual patient. Treatment often includes medications such as selective serotonin reuptake inhibitors and/or psychotherapy, both of which are highly effective. Among psychotherapeutic treatments, cognitive behavior therapy has been studied widely and has an extensive evidence base. Benzodiazepines are effective in reducing anxiety symptoms, but their use is limited by risk of abuse and adverse effect profiles. Physical activity can reduce symptoms of GAD and PD. A number of complementary and alternative treatments are often used; however, evidence is limited for most. Several common botanicals and supplements can potentiate serotonin syndrome when used in combination with antidepressants. Medication should be continued for 12 months before tapering to prevent relapse.

Generalized anxiety disorder (GAD) and panic disorder (PD) are among the most common mental disorders in the United States and are often encountered by primary care physicians. The hallmark of GAD is excessive, out-of-control worry, and PD is characterized by recurrent and unexpected panic attacks. Both conditions can negatively impact a patient's quality of life and disrupt important activities of daily living. The rates of missed diagnoses and misdiagnosis of GAD and PD are high, with symptoms often ascribed to physical causes.

This article reviews the diagnosis and management of GAD and PD in adults. Diagnosis and care of children and adolescents with these conditions require special considerations that are beyond the scope of this review.

Epidemiology, Etiology, and Pathophysiology

The 12-month prevalence for GAD and PD among U.S. adults 18 to 64 years of age is 2.9% and 3.1%, respectively. In this population, the lifetime prevalence is 7.7% in women and 4.6% in men for GAD, and is 7.0% in women and 3.3% in men for PD. 1

The etiology of GAD is not well understood. There are several theoretical models, each with varying degrees of empirical support. An underlying theme to several models is the dysregulation of worry. Emerging evidence suggests that patients with GAD may experience persistent activation of areas of the brain associated with mental activity and introspective thinking following worry-inducing stimuli. 2 Twin studies suggest that environmental and genetic factors are likely involved. 3

The etiology of PD is also not well understood. The neuroanatomical hypothesis suggests that a genetic-environment interaction is likely responsible. Patients with PD may exhibit irregularities in specific brain structures, altered neuronal processes, and dysfunctional corticolimbic interaction during emotional processing. 4

Typical Presentation and Diagnostic Criteria

Generalized anxiety disorder.

Patients with GAD typically present with excessive anxiety about ordinary, day-today situations. The anxiety is intrusive, causes distress or functional impairment, and often encompasses multiple domains (e.g., finances, work, health). The anxiety is often associated with physical symptoms, such as sleep disturbance, restlessness, muscle tension, gastrointestinal symptoms, and chronic headaches. 5 Diagnostic and Statistical Manual of Mental Disorders , 5th ed, (DSM-5) diagnostic criteria for GAD are listed in Table 1 . 5 Some factors associated with GAD include female sex, unmarried status, lower education level, poor health, and presence of life stressors. 6 The age of onset is variable, with a median age of 30 years. 1

A number of scales are available to establish diagnosis and assess severity. The GAD-7 ( Table 2 7 ) has been validated as a diagnostic tool and a severity assessment scale, with a score of 10 or more having good diagnostic sensitivity and specificity. 8 Greater GAD-7 scores correlate with more functional impairment. 8 The scale was developed and validated based on DSM-IV criteria, but it remains clinically useful after publication of the DSM-5 because the differences in GAD diagnostic criteria are minimal. The PRO-MIS Emotional Distress–Anxiety–Short Form for adults and the Severity Measure for Generalized Anxiety Disorder–Adult, available from the American Psychiatric Association at http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures , are intended to aid clinical evaluation of GAD and monitor treatment effectiveness.

PANIC DISORDER

PD is characterized by episodic, unexpected panic attacks that occur without a clear trigger. 5 Panic attacks are defined by the rapid onset of intense fear (typically peaking within about 10 minutes) with at least four of the physical and psychological symptoms in the DSM-5 diagnostic criteria ( Table 3 ) . 5 Another requirement for the diagnosis of PD is that the patient worries about further attacks or modifies his or her behavior in maladaptive ways to avoid them. The most common physical symptom accompanying panic attacks is palpitations. 9 Although unexpected panic attacks are required for the diagnosis, many patients with PD also have expected panic attacks, occurring in response to a known trigger. 9 The Severity Measure for Panic Disorder–Adult ( http://www.psychiatry.org/File%20Library/Practice/DSM/DSM-5/SeverityMeasureForPanicDisorderAdult.pdf ) is an assessment scale that can complement the clinical assessment of patients with PD.

Differential Diagnosis and Comorbidity

When evaluating a patient for a suspected anxiety disorder, it is important to exclude medical conditions with similar presentations (e.g., endocrine conditions such as hyperthyroidism, pheochromocytoma, or hyperparathyroidism; cardiopulmonary conditions such as arrhythmia or obstructive pulmonary diseases; neurologic diseases such as temporal lobe epilepsy or transient ischemic attacks). Other psychiatric disorders (e.g., other anxiety disorders, major depressive disorder, bipolar disorder); use of substances such as caffeine, albuterol, levothyroxine, or decongestants; or substance withdrawal may also present with similar symptoms and should be ruled out. 5

Complicating the diagnosis of GAD and PD is that many conditions in the differential diagnosis are also common comorbidities. Additionally, many patients with GAD or PD meet criteria for other psychiatric disorders, including major depressive disorder and social phobia. Evidence suggests that GAD and PD usually occur with at least one other psychiatric disorder, such as mood, anxiety, or substance use disorders. 10 When anxiety disorders occur with other conditions, historic, physical, and laboratory findings may be helpful in distinguishing each diagnosis and developing appropriate treatment plans.

Some studies evaluating anxiety treatments assess non-specific anxiety-related symptoms rather than the set of symptoms that characterize GAD or PD. When possible, the treatments described in this section will differentiate between GAD and PD; otherwise, treatments refer to anxiety-related symptoms in general.

Medication or psychotherapy is a reasonable initial treatment option for GAD and PD. 11 Some studies suggest that combining medication and psychotherapy may be more effective for patients with moderate to severe symptoms. 12 The National Institute for Health and Care Excellence (NICE) guidelines on GAD and PD in adults are a useful review of available evidence; however, information about self-help and group therapies may have less utility in the United States because of their relative lack of availability. 11

Compassionate listening and education are an important foundation in the treatment of anxiety disorders. 11 Patient education itself can help reduce anxiety, particularly in PD. 13 The establishment of a therapeutic alliance between the patient and physician is important to allay fears of interventions and to progress toward treatment.

Common lifestyle recommendations that may reduce anxiety-related symptoms include identifying and removing possible triggers (e.g., caffeine, stimulants, nicotine, dietary triggers, stress), and improving sleep quality/quantity and physical activity.

Caffeine can trigger PD and other types of anxiety. Those with PD may be more sensitive to caffeine than the general population because of genetic polymorphisms in adenosine receptors. 14 Smoking cessation leads to improved anxiety scores, with relapse leading to increased anxiety. Many studies show an association between disordered sleep and anxiety, but causality is unclear. 15 In addition to decreased depression and anxiety, physical activity is associated with improved physical health, life satisfaction, cognitive functioning, and psychological well-being. Physical activity is a cost-effective approach in the treatment of GAD and PD. 16 , 17 Exercising at 60% to 90% of maximal heart rate for 20 minutes three times weekly has been shown to decrease anxiety 16 ; yoga is also effective. 18

First-Line Therapies . A number of medications are available for treating anxiety ( Table 4 ) . Selective serotonin reuptake inhibitors (SSRIs) are generally considered first-line therapy for GAD and PD. 19 – 22 Tricyclic antidepressants (TCAs) are better studied for PD, but are thought to be effective for both GAD and PD. 19 , 20 In the treatment of PD, TCAs are as effective as SSRIs, but adverse effects may limit the use of TCAs in some patients. 23 Venlafaxine, extended release, is effective and well tolerated for GAD and PD, whereas duloxetine (Cymbalta) has been adequately evaluated only for GAD. 24 Azapirones, such as buspirone (Buspar), are better than placebo for GAD 25 but do not appear to be effective for PD. 26 Mixed evidence suggests bupropion (Wellbutrin) may have anxiogenic effects for some patients, thus warranting close monitoring if used for treatment of comorbid depression, seasonal affective disorder, or smoking cessation. 27 Bupropion is not approved for the treatment of GAD or PD.

Medications should be titrated slowly to decrease the initial activation. Because of the typical delay in onset of action, medications should not be considered ineffective until they are titrated to the high end of the dose range and continued for at least four weeks. Once symptoms have improved, medications should be used for 12 months before tapering to limit relapse. 11 Some patients will require longer treatment.

Benzodiazepines are effective in reducing anxiety, but there is a dose-response relationship associated with tolerance, sedation, confusion, and increased mortality. 28 When used in combination with antidepressants, benzodiazepines may speed recovery from anxiety-related symptoms but do not improve longer-term outcomes. The higher risk of dependence and adverse outcomes complicates the use of benzodiazepines. 29 NICE guidelines recommend only short-term use during crises. 11 Benzodiazepines with an intermediate to long onset of action (such as clonazepam [Klonopin]) may have less potential for abuse and less risk of rebound. 30

Second-Line Therapies . Second-line therapies for GAD include pregabalin (Lyrica) and quetiapine (Seroquel), although neither has been evaluated for PD. Pregabalin is more effective than placebo but not as effective as lorazepam (Ativan) for GAD. Weight gain is a common adverse effect of pregabalin. There is limited evidence for the use of antipsychotics to treat anxiety disorders. Although quetiapine seems to be effective for GAD, the adverse effect profile is significant, including weight gain, diabetes mellitus, and hyperlipidemia. 31 Hydroxyzine is considered a second-line treatment for GAD, 32 but there are minimal data for its use in PD. Its rapid onset can be appealing for patients needing immediate relief, and it may be a more appropriate alternative if benzodiazepines are contraindicated (e.g., in patients with a history of substance abuse). Based on clinical experience, gabapentin (Neurontin) is sometimes prescribed by psychiatrists to treat anxiety on an as-needed basis when benzodiazepines are contraindicated. Of note, the placebo response for medications used to treat GAD and PD is high. 13

PSYCHOTHERAPY AND RELAXATION THERAPIES

Psychotherapy includes many different approaches, such as cognitive behavior therapy (CBT) and applied relaxation ( Table 5 ) . 33 , 34 CBT may use applied relaxation, exposure therapy, breathing, cognitive restructuring, or education. Psychotherapy is as effective as medication for GAD and PD. 11 Although existing evidence is insufficient to draw conclusions about many psychotherapeutic interventions, structured CBT interventions have consistently proven effective for the treatment of anxiety in the primary care setting. 34 – 36 Psychotherapy may be used alone or combined with medication as first-line treatment for PD 37 and GAD, 11 based on patient preference. Psychotherapy should be performed weekly for at least eight weeks to assess its effect.

Mindfulness has similar effectiveness to traditional CBT or other behavior therapies, 38 particularly mindfulness-based stress reduction. 39 A meta-analysis of 36 randomized controlled trials on meditation showed that meditative therapies reduce anxiety symptoms, but most studies looked at anxiety symptoms rather than anxiety disorders. 40 Transcendental meditation has similar effectiveness to other relaxation therapies. 41

After a treatment course, rebound symptoms may occur less often with psychotherapy than with medications. Successful treatment requires tailoring options to individuals and may often include a combination of modalities. 11 , 37 , 42 Combined treatment with medications and psychotherapy reduces relapse even at two years. 43

COMPLEMENTARY AND ALTERNATIVE MEDICINE THERAPIES

Although a number of complementary and alternative products have evidence for treating depression, most lack sufficient evidence for the treatment of anxiety. Botanicals and supplements sometimes used to treat GAD and PD are listed in Table 6 . Kava extract is an effective treatment for anxiety 44 ; however, case reports of hepatotoxicity have decreased its use. 45 St. John's wort, tryptophan, 5-Hydroxytryptophan, and S-adenosyl-l-methionine should be used with caution in combination with SSRIs because of the increased risk of serotonin syndrome. 46

Evidence indicates that music therapy, aromatherapy, acupuncture, and massage are helpful for anxiety associated with specific disease states, but none have been evaluated specifically for GAD or PD.

Referral and Prevention

For patients with GAD or PD, psychiatric referral may be indicated if there is poor response to treatment, atypical presentation, or concern for significant comorbid psychiatric illness. There is insufficient evidence to support a concise recommendation on the prevention of PD and GAD in adults.

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Generalized Anxiety Disorder in Very Young Children: First Case Reports on Stability and Developmental Considerations

Affiliation.

• 1 Department of Psychiatry and Behavioral Sciences, Tulane University School of Medicine, 1430 Tulane Ave., #8448, New Orleans, LA 70112, USA.
• PMID: 30345136
• PMCID: PMC6174746
• DOI: 10.1155/2018/7093178

Generalized anxiety disorder (GAD) is purported to start in early childhood but concerns about attenuation of anxiety symptoms over time and the development of emerging cognitive and emotional processing capabilities pose multiple challenges for accurate detection. This paper presents the first known case reports of very young children with GAD to examine these developmental challenges at the item level. Three children, five-to-six years of age, were assessed with the Diagnostic Infant and Preschool Assessment twice in a test-retest reliability study. One case appeared to show attenuation of the worries during the test-retest period based on caregiver report but not when followed over two years. The other two cases showed stability of the full complement of diagnostic criteria. The cases were useful for demonstrating that the current diagnostic criteria appear adequate for this developmental period. The challenges of accurate assessment of young children that might cause missed diagnoses are discussed. Future research on the underlying dysregulation of negative emotionality and long-term follow-ups are needed to better understand the etiology, treatment, and course of GAD in this age group.

Publication types

• Case Reports

Effectiveness of ACT on Emotional Processing, Irrational Beliefs and Rumination In Generalized Anxiety

Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

Learn about our Editorial Process

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

Generalized Anxiety Disorder ( GAD ) is a chronic condition characterized by excessive, uncontrollable worry about various life domains, accompanied by restlessness, fatigue, irritability, muscle tension, and sleep disturbances.

Acceptance and Commitment Therapy ( ACT ) is a psychological intervention that aims to increase psychological flexibility through six core processes:

• Acceptance: embracing thoughts and feelings without trying to change them
• Cognitive defusion: observing thoughts objectively without getting caught up in them
• Present moment awareness: focusing on the here-and-now experience
• Self-as-context: recognizing the self as the observer of thoughts and feelings
• Values: clarifying what truly matters and gives life meaning
• Committed action: taking effective actions guided by one’s values

ACT may be suitable for GAD because it targets experiential avoidance, cognitive fusion, and values-inconsistent behaviors, which are common maintaining factors in GAD. By cultivating acceptance, mindfulness, and valued living, ACT can help reduce the impact of anxiety.

• This study investigated the effectiveness of Acceptance and Commitment Therapy (ACT) on emotional processing, irrational beliefs and rumination in patients with generalized anxiety disorder (GAD).
• Factors like emotional processing deficits, irrational beliefs, and rumination significantly contribute to the development and maintenance of GAD.
• The research found that ACT significantly improved emotional processing, reduced irrational beliefs, and decreased rumination in GAD patients compared to a control group.
• The study provides support for ACT as a promising treatment for addressing key cognitive and emotional factors in GAD, though it had some limitations like a small sample size.
• GAD is a prevalent and impairing disorder worldwide, so identifying effective psychological treatments is universally important.

Generalized anxiety disorder (GAD) is a common, chronic and costly emotional disorder that impairs quality of life and functioning.

Several biological, cognitive, behavioral and emotional risk factors are involved in GAD development, including deficits in emotional processing, which is considered a core mechanism (McNamara et al., 2016).

Irrational beliefs and rumination also play a key role in creating and perpetuating GAD through negative cognitive appraisals.

While pharmacotherapy alone is insufficient to address all of the complex, multidimensional issues in GAD, psychological treatments in conjunction with medication may enhance outcomes and prevent relapse. Acceptance and commitment therapy (ACT) is one treatment that has shown promise for anxiety disorders .

However, no prior studies have specifically examined ACT’s impact on emotional processing, irrational beliefs and rumination in GAD patients. This study sought to address that research gap and investigate ACT’s effectiveness in targeting those key cognitive-emotional factors to inform GAD treatment .

Patients with GAD were recruited from daily psychiatric treatment centers in Golpayegan, Iran in early 2019.

30 eligible participants were selected based on inclusion and exclusion criteria and randomly allocated to an ACT treatment group (n=15) or control group (n=15).

The ACT group attended 8 weekly ACT therapy sessions lasting 90 minutes each, focused on core ACT processes like acceptance, cognitive defusion, present-moment awareness, self-as-context, values, and committed action.

The control group did not receive the ACT intervention during the study period. All participants completed study measures before and after the intervention phase.

Participants were 30 adult outpatients (aged 18+) diagnosed with GAD by a psychiatrist. They were required to have at least a high school diploma level of education.

People were excluded if they had disease recurrence, hospitalization, or a physical illness preventing attendance, missed 3+ sessions, or experienced unforeseen accidents during the study.

• Spitzer’s Generalized Anxiety Disorder Scale (2006): This 7-item scale assesses the severity of GAD symptoms experienced over the past 2 weeks, including excessive anxiety, difficulty controlling worry, restlessness, irritability, and sleep disturbance. Higher scores indicate greater GAD symptom severity.
• Baker Emotional Processing Scale (2007): This scale measures deficits in emotional processing, which involves the ability to accurately identify, experience, regulate, and express emotions adaptively. It assesses dimensions such as emotional awareness, expression, and regulation , with higher scores reflecting greater difficulties in effectively processing emotions.
• Jones Irrational Beliefs Questionnaire (1968): This questionnaire assesses the extent to which an individual holds various irrational beliefs, which are rigid, extreme, and unrealistic cognitive appraisals that contribute to emotional distress. These beliefs often involve themes of demandingness, awfulizing, low frustration tolerance, and global self-rating. Higher scores indicate a greater endorsement of irrational beliefs.
• Nolen-Hoeksema & Morrow’s Rumination Questionnaire (1991): This measure assesses the tendency to engage in rumination, which is a maladaptive cognitive process involving repetitive and passive focus on one’s symptoms of distress and their possible causes and consequences. It captures dimensions such as brooding and reflection, with higher scores indicating a greater propensity to ruminate in response to negative mood states.

Statistical Analysis

The data were analyzed using analysis of covariance (ANCOVA) with SPSS-24 software. ANCOVA compared the post-treatment scores of the ACT and control groups on the dependent variables while controlling for pre-treatment scores.

The ANCOVA results showed that compared to the control group, the ACT group had significantly greater improvements in:

• Emotional processing (p<0.001)
• Irrational beliefs (p<0.001)
• Rumination (p<0.001)

This indicates ACT was effective at enhancing emotional processing abilities, reducing irrational thinking, and decreasing ruminative tendencies in GAD patients.

This study provides insight into how acceptance and commitment therapy can effectively target several important cognitive and emotional factors involved in generalized anxiety disorder.

By increasing acceptance, diminishing cognitive fusion with anxious thoughts, enhancing present-focused awareness, and promoting action aligned with values, ACT was able to significantly improve patients’ ability to adaptively process emotions, decrease irrational beliefs that exacerbate anxiety, and reduce maladaptive rumination.

This builds on prior research showing ACT’s benefits for anxiety while uniquely demonstrating its impact on the specific mechanisms of emotional processing, irrational beliefs, and rumination in GAD.

The findings suggest targeting those factors in an acceptance and mindfulness-based approach can lead to significant clinical gains.

Future studies should replicate this with larger samples while examining longer-term effects and mediating variables. Therapy-component research would also clarify the active ingredients.

Overall, this study points to ACT’s promise as an effective, process-based therapy for generalized anxiety disorder.

The study had several methodological strengths:

• Use of a randomized controlled design with pre-post assessment
• Manualized ACT intervention delivered by trained therapists
• Selection of GAD-diagnosed participants based on clinical assessment
• Valid, reliable outcome measures of key constructs
• Appropriate statistical analysis plan

Limitations

Some limitations should be noted:

• The sample size was relatively small, limiting generalizability. Larger replication studies are needed.
• The sample lacked ethnic diversity as participants were recruited from one region in Iran. Results may not generalize to other cultural contexts.
• The study lacked a long-term follow-up assessment. The durability of ACT’s effects is unclear.
• The control group received no intervention or placebo, so some effects could be due to nonspecific factors. An active treatment comparison group would be informative.

Implications

This study has significant clinical implications, suggesting acceptance and commitment therapy may be an effective treatment choice for generalized anxiety disorder.

By targeting emotional processing deficits, irrational beliefs, and rumination – key factors in GAD’s onset and persistence – ACT provides an avenue for meaningful symptom relief and improved functioning.

The findings support training therapists in ACT for GAD and making it more widely available, especially given the high prevalence and healthcare costs of the disorder.

Still, individual patient characteristics and preferences should guide treatment selection, and ACT should be integrated with other evidence-based approaches like pharmacotherapy.

Policymakers and mental health organizations may look to this research to inform treatment guidelines and recommendations for GAD.

Further research is still needed on ACT’s efficacy and mechanisms across diverse GAD samples to refine its clinical application.

Primary reference

Ara, B. S., Khosropour, F., & Zarandi, H. M. (2023). Effectiveness of acceptance and commitment therapy (act) on emotional processing, irrational beliefs and rumination in patients with generalized anxiety disorder.  Journal of Adolescent and Youth Psychological Studies (JAYPS) ,  4 (4), 34-44. https://doi.org/10.61838/kman.jayps.4.4.5

Other references

MacNamara, A., Kotov, R., & Hajcak, G. (2016). Diagnostic and symptom-based predictors of emotional processing in generalized anxiety disorder and major depressive disorder: An event-related potential study.  Cognitive therapy and research ,  40 , 275-289. https://doi.org/10.1007/s10608-015-9717-1

Keep Learning

Here are some questions for a college class to discuss this paper:

• What are the key cognitive and emotional factors that contribute to generalized anxiety disorder? How does ACT aim to target these factors based on its treatment model?
• Considering the study’s limitations, what further research would help clarify or strengthen the findings on ACT for GAD? How could future studies improve upon the methodology?
• How might cultural factors influence the manifestation and treatment of GAD and the appropriateness of ACT? What cultural adaptations, if any, would make ACT more relevant for diverse groups?
• The study used therapist-delivered ACT, but could self-help or digital versions be effective for GAD as well? What benefits and drawbacks might those formats have compared to in-person therapy?
• Given the multifaceted nature of GAD, what other evidence-based treatment elements could potentially combine well with ACT to optimize outcomes? How should clinicians decide on combination vs. monotherapy approaches?

Speaking to Millennial Moms’ Anxiety

Author julie chavez shares her experience of anxiety in the midst of motherhood..

Posted April 23, 2024 | Reviewed by Kaja Perina

• What Is Anxiety?
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• Millennial moms are struggling with anxiety and other mental health disorders more than previous generations.
• Parental anxiety can have negative social, emotional, and behavioral impacts on children.
• Author Julie Chavez shares her personal experience with anxiety in the midst of motherhood.

While postpartum depression and anxiety are becoming more well-known and understood, many mothers struggle with anxiety and depression later on in their parenting journey, often due to burnout from trying to do it all with so little support.

Balancing career obligations, growing children, and a wide range of emotions that often get neglected can trigger an overwhelming mental health crisis in some moms. In author Julie Chavez's case, debilitating panic attacks stopped her in her tracks, waving a red flag that her mental health was suffering in the midst of what her therapist described as a "mid-mom crisis."

Chavez is not alone. In fact, one study found an increase in generational rates of persistent generalized anxiety disorders and a range of less persistent disorders in millennial moms (Najman et al., 2021). While it is not clear whether this finding reflects actual changes in symptom levels over a generation or whether there has been a generational change in the recognition of and willingness to report symptoms of mental illness, it is notable that today's moms are struggling with their mental health.

When moms struggle, their entire family struggles too. Research has demonstrated that anxiety not only lowers the quality of life for the mom suffering from anxiety, but it also can lead to negative emotional, behavioral, and social outcomes for her children, no matter where they are in their development (Sweeney, S., & Wilson, C., 2023).

Reading can be therapeutic, and sharing our stories offers an opportunity to feel less alone in our inner struggles with mental health (Jack, S. J., & Ronan, K. R., 2008). Chavez shares her reflections on her mental health journey in her memoir, Everyone but Myself, published this year by Zibby Books.

1. The first line of your book reads, “In the moment it’s happening, a panic attack can convince you of nearly anything.” Share a bit about experiencing your first panic attack at 38—what precipitated the onset of debilitating anxiety at this time in your life?

I had just returned to work after nearly a decade as a stay-at-home mom, but I hadn't made the right adjustments. My husband was still traveling for work, and I took 30 hours and plopped it onto an already full schedule (because stay-at-home moms may not get paid, but they are definitely working). The conditions left me depleted and tired, but the more insidious effect was my disconnection from my feelings. Quite simply, I didn't make time to feel tired or communicate my loneliness or connect with my husband (travel makes this a challenge even when there's plenty of time).

When I had a scary reaction to an immunotherapy shot that left me terrified of dying, I didn't take the time to deal with the emotions and fear around that event. I simply kept moving, which left me in a precarious place. My first panic attack was related to having buried that traumatic moment, and the debilitating anxiety sprung out of Pandora's box after the first panic attack. It was incredibly destabilizing. I see, in retrospect, that my body was demanding my attention .

2. You masterfully describe the inner life of a mom trying to hold it all together for her children in the midst of a personal mental health crisis. How do you think parents can care for their mental health in such a demanding season of life?

I believe it's essential that parents have space to care for their mental health in a way that's deep and non-performative (bubble baths aren't an instant cure-all, sadly).

My major tenets are exercise, therapy , time with friends, and downtime (typically, for me, this is reading). I have to schedule these in, and it's challenging to protect your boundaries . But I believe that parents can reframe it well by considering what habits they're passing down to their children. We are showing them, in a very literal way, how to protect themselves and their own peace. Otherwise, we will forever be at the mercy of the urgent, neglecting the important.

3. In Chapter 3, you talk about batting down the anxious thoughts that popped into your head like a game of “Whac-A-Mole.” You use another metaphor about being a balloon, and anxiety is the helium that lifts you out of the present moment. How have metaphors helped you?

Metaphors are helpful to me because anxiety is slippery and often looks different for individuals. I go by what Mister Rogers told me when I was small: What's mentionable is manageable. If I can get my head around the concept of what's happening, I feel better. This is where therapy is a wonderful tool to fact-check our thoughts and smooth out our bad mental habits.

4. In your book, you talk a lot about the pressure to be the perfect mom. How do you see society’s standards for motherhood impacting our mental health?

The modern world doesn't help, but I believe that motherhood is hard because it's important. Loving my children and helping them grow is a privilege, and I want to do it justice. Keeping them safe, teaching them well, helping them understand themselves: It's a tall order.

But I think where society makes it hard is by refusing to acknowledge the mental load and by perpetuating a system that has so little support for parents. Most parents are working outside the home, but we still ask for school volunteers like it's 1980 and most moms are staying at home. The system continues to rely on the unpaid labor of parents, and it's one of the conditions leading to burnout.

5. You introduce the idea of a “mid-mom crisis.” Can you share more about this and how it impacted your mental health at the time?

The mid-mom crisis is the point at which your kids move from needing you in a small-child sort of way into greater independence. It's a moment in which you can see, over there on the horizon, that they will one day move into their own lives. This is how it should be, but you know it will be a massive change.

If you're a person who anticipates and looks ahead anxiously, this can be scary and hard. Having a name for this was very helpful for me. It honored the closeness I have with my boys but also acknowledged that there was work to do. It was time to turn back to myself and find more of who I wanted to be in the next season of life.

6. You mention several books that you read during this difficult season that played a part in your healing—how has reading helped you cope with mental health struggles? What books were most healing to you (if any), and what did you avoid?

Reading is grounding for me, especially when I take time to sit down and read (though I confess that I listen to a lot of audiobooks while shelving books at the library). Thrillers were a no-go when I was at my lowest because they introduced extra stress , especially since I'm an immersive reader. Healing books included memoirs like those from Kelly Corrigan, Gift from the Sea by Anne Morrow Lindbergh, and upbeat novels like The Rosie Project. These were books that either made me feel seen or simply made me feel happy and hopeful.

7. How can readers put their own needs at the top of their to-do list in order to protect their mental health?

Make appointments—with a therapist, with a doctor, with a friend, with yourself. Set timers when you're at home because there will always be something else to attend to (the timers force you to prioritize and ask what really needs to get done on a given day). Rest isn't something to be earned; it's a wholly necessary part of keeping ourselves healthy, both physically and mentally.

And remember to be kind to yourself. You're doing your best, both when you're crushing life and when life is crushing you. Everything changes, so sometimes all there is to do is hold on.

Learn more about Julie Chavez by visiting www.juliewriteswords.com .

Najman JM, Bor W, Williams GM, Middeldorp CM, Mamun AA, Clavarino AM, Scott JG. Does the millennial generation of women experience more mental illness than their mothers? BMC Psychiatry. 2021 Jul 17;21(1):359. doi: 10.1186/s12888-021-03361-5. PMID: 34273942; PMCID: PMC8285825.

Sweeney, S., & Wilson, C. (2023). Parental anxiety and offspring development: A systematic review. Journal of Affective Disorders , 327 , 64–78. https://doi.org/10.1016/j.jad.2023.01.128

Jack, S. J., & Ronan, K. R. (2008). Bibliotherapy. School Psychology International , 29 (2), 161–182. https://doi.org/10.1177/0143034308090058

Heather Rose Artushin, LISW-CP, is a child and family therapist passionate about the power of reading.

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The Difference Between Feeling Anxious and Having an Anxiety Disorder

Feeling anxious can be a deeply uncomfortable experience. it's also perfectly normal..

What does anxiety feel like to you? Here are a few descriptions I have heard over the years:

From the literal:

To the metaphorical:

Like a pit in my stomach

Like an internal storm

It's a sinking feeling

And my favorite: “It’s like a toddler. It never stops talking, tells you your wrong about everything, and wakes you up at 3 a.m.”

The American Psychological Association defines anxiety as “an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure.” Feeling anxious can be a deeply uncomfortable experience. It’s also perfectly normal. Just because it’s awful doesn’t make it a disease that needs to be treated.

The key difference between having an anxiety disorder and normal anxiety is the extent of dysfunction and distress it causes. Generalized Anxiety Disorder , one of the most common diagnoses, is characterized by persistent, excessive, and unrealistic worry about everyday things. This worry could be multifocal such as finance, family, health, and the future. It is excessive, difficult to control, and is often accompanied by many non-specific psychological and physical symptoms. Excessive non-stop worry is the central feature of generalized anxiety disorder.

Diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) aka the “bible” of Psychiatry, include the following:

Put simply, feeling anxious at a given point in time about something stressful going on in your life does not mean you have an anxiety disorder. High anxiety may be appropriate and even adaptive in certain contexts. For instance, going off to college, switching jobs, or dealing with a break up may fill you with dread but that doesn’t make it pathological. There is plenty of evidence showing that anxiety can be beneficial under some circumstances. It might motivate you to prepare for a test or remind you to check the battery on the fire alarm.

In some situations, such as in Ukraine, anxiety can be protective. As Dr. David Rosmarin recently wrote in The Wall Street Journal since the Russian invasion, residents who experience nervousness and worry, “are probably better off than their neighbors who are less anxious. They are more likely to survive a military attack, since a stress response yields benefits such as greater situational awareness, quicker response time, and even constriction of blood flow in the event of injury.”

Anxiety is not “all bad,” and an absence of anxiety is not “all good.” Unfortunately, the current conversation about anxiety in any form portrays it as something to be minimized, avoided, and treated. By pathologizing anxiety, we miss out on the opportunity to learn and potentially grow from it. Plus, we are making people anxious about being anxious. Because of all the negative implications swirling around anxiety, they are mistakenly led to believe that there is something wrong with them.

I have met many young people who have diagnosed themselves with anxiety because they took an online screening test that only asked two questions — one about feeling nervous and the second about being unable to control worry over the past two weeks. There is no inquiry about context. No nuance is explored. In under a minute they are diagnosed as a likely case of generalized anxiety disorder.

Here are the questions:

Answering “more than half the days,” to one question and “several days,” to the other is enough to screen in. Pretty much anyone going through a rough patch will qualify. The intention behind this simple test is to rapidly identify those in need of treatment. There may be other unintended consequences as well. Labeling oneself as having an anxiety disorder can shift a person’s self-concept. Believing you have a mental illness might impact your response to an awkward social situation or influence a decision to take on a challenge.

Of course, its entirely possible that I am overly anxious about over pathologizing anxiety. These concerns are a perfectly normal and healthy response to something that is stressing me out.

Dr. Samantha Boardman is a clinical instructor in psychiatry and assistant attending physician at Weill-Cornell Medical College in New York City. She is the author of “Everyday Vitality, Turning Stress Into Strength" and provides insight and advice on how to build vitality and boost resilience at The Dose.

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A case study for the use of medical cannabis in generalized anxiety disorder

Chad walkaden.

Counselling and Consulting Services, New South Wales, 2099, Australia

Despite the increasing prevalence and acceptance of the medical cannabis use among the general public, the evidence required by physicians to use cannabis as a treatment is generally lacking. Research on the health effects of cannabis and cannabinoids has been limited worldwide, leaving patients, health care professionals, and policymakers without the evidence they need to make sound decisions regarding the use of cannabis and cannabinoids. This case study outlines an intervention that involved a patient integrating medical cannabis into her treatment to better manage a generalized anxiety disorder and the debilitating symptoms of vertigo. This case demonstrates how the patient drastically improved her quality of life and reinforces the need for more rigorous testing on the use of medical cannabis to support patients and better manage the symptoms associated with their medical conditions.

INTRODUCTION

Despite the increasing prevalence and acceptance among the general public, the prescription of cannabis for treating a range of medical conditions continues to be viewed with caution 1 .

In the USA, there are 34 states that have legalized medical cannabis 2 . These legislative changes equate to over 59 million people that are legally using cannabis across the country 3 . While this represents roughly 18% of the population, the number could be considerably larger if the prescription of cannabis as a treatment was supported by physicians and the associations they are part of. Among other points, the claims against the prescription of medical cannabis include recommendations that approved conventional drugs are undertaken before cannabis products are used for treatment 4 and that medical cannabis undergoes the same rigorous approval process of other medications prescribed by physicians, including randomized, placebo-and active-controlled trials 5 .

Notwithstanding the requirement for evidencebased information on the health effects of cannabis and cannabinoids, a conundrum exists whereby the federal government has not legalized cannabis and continues to enforce restrictive policies and regulations 6 . As a result, research on the health effects of cannabis and cannabinoids has been limited in the United States, leaving patients, health care professionals, and policymakers without the evidence they need to make sound decisions regarding the use of cannabis and cannabinoids 6 . This lack of evidence-based information is the cause of the growing need to understand the role medical cannabis can have in improving the health outcomes for patients with complex medical conditions.

CASE HISTORY

a. The 88-year-old female presented to seek support around a decline in her quality of life and challenges with her emotional and psychological well-being.

b. Her challenges were primarily associated with managing a generalized anxiety disorder and the debilitating symptoms of vertigo. She described experiencing “wonky days” that consisted of intense dizziness, extreme nausea, imbalance, and worry about what is going to happen if her symptoms worsened. She described a consistently low mood, discomfort in her daily life and a belief that she was losing control of her life.

c. This problem commenced 24 months earlier and was compounded by an anxiety about the continual impact of these concerns if not resolved. The patient was also experiencing ongoing grief associated with losing her late husband of 68 years five years earlier.

d. The debilitating symptoms were consistent over 24 months before the intervention. In a typical week, the symptoms consisted of “wonky days” that had a frequency of three to four times per week at an intensity where her quality of life was impacted to a score of eight out of 10.

e. Initially, the benzodiazepine Kalma, was prescribed to treat her anxiety. However, the patient stopped taking this after two days due to incessant shaking. The patient was then prescribed another benzodiazepine, Xanax. She reported that she did not consume this drug due to concern that she would have a reaction similar to what she experienced with Kalma, since the active ingredient is the same, alprazolam.

f. Relevant history includes lymphatic cancer and ongoing grief from the loss of her late husband. There was no relevant family history.

g. The assessment revealed a white Australian female that was the mother of three adult daughters, several grandchildren and one great-grandson. She presented as friendly and was easy to engage and establish rapport with. She described strong family, peer and community relationships that provided practical and emotional support. Before these challenges, she provided an overview of a fulfilling, healthy, stable, and happy adult life. She was able to articulate her challenges with her independence, mobility and the uncertainty about the continual impact of debilitating symptoms for herself and her family. She expressed desperation to improve her deteriorating health that was a significant risk to her quality of life and overall survival. From the onset of these challenges, she had sought support from her medical team and this care continued throughout the intervention.

METHODS AND RESULTS

a. The patient undertook a mental health intervention in a format that consisted of weekly individual consulting sessions for the initial six weeks before it extended to individual sessions once every two weeks for a further 10 weeks.

b. The mental health intervention was based on a humanistic methodology that combines a reparative approach most commonly associated with counselling, with the addition of exercise, meditation and other lifestyle components incorporated into her treatment plan.

c. Throughout the intervention, the patient maintained a written record of her reflections and progress. In the beginning, she described her circumstances by saying “I just want the wonkiness to stop”, “I have lost my capacities” and “I have lost my independence”.

d. During the initial four weeks, the patient was supported to reframe her beliefs about her changing capacities and she was encouraged to explore the ongoing grief that was associated with the loss of her late husband.

e. By the fifth week, a protocol was designed for the patient to complete on a daily basis. This protocol involved the patient being instructed to replace known problematic times where her symptoms spiked with guided strategies that targeted the compounding impact of the beliefs associated with her debilitating symptoms. While the patient reported that the protocol resulted in reductions in the frequency of her symptoms to a maximum of one to two days per week, the intensity of her symptoms when occurring were still scored at an eight out of 10.

f. In the sixth week, the patient reported that she had sourced her own medical cannabis oil that was made from the OG Kush strain of cannabis. She reported that she maintained a daily dose of 2 ml of a medical cannabis that contained Tetrahydrocannabinol or more commonly known as THC. The patient reported that, after incorporating the cannabis oil into the protocol, the intensity of her symptoms ceased and that she could be free from any symptoms for a period of at least two weeks.

g. By the tenth week, the patient reported significant improvements to her quality of life. She reported that the “wonky days” had almost been completely eliminated and she was continuing to adhere to her protocol that involved recommencing daily physical exercises and meditation practices. At this stage of the intervention, the patient reported that “life is as good as it gets”.

h. In the fifteenth week, the patient stopped using medical cannabis due to the inability to access more. She reported that the “wonkiness” returned and that she was again suffering from daily nausea, dizziness and an imbalance to her mobility.

i. In the sixteenth and final week of the intervention, the patient had reintegrated medical cannabis into her daily protocol and she had been able to once again regain her quality of life through the cessation of her symptoms.

j. In a review three months after the intervention, the patient reported that she had now resumed the daily protocol that includes taking a dose of 2 ml of medical cannabis in the morning. The patient reported that, since finishing the intervention, she experienced a four-week period where she was unable to access a further supply of medical cannabis. She reported that, during the four weeks, her physical health, mental health and quality of life deteriorated. These deteriorations included a life alert system being installed in her home by her family due to concern about her safety. The patient also reported that she had informed her medical team about her daily consumption of a medical cannabis oil. She reported that her medical team could not prescribe her a cannabis oil but that they supported and encouraged her to continue the cannabis oil as a daily treatment. The patient did not have a scheduled annual blood test due to her fear of needles. Thus, no blood tests have been completed to identify any chemical changes that were associated with her introducing medical cannabis into her life.

While it is clear that the popularity of cannabis is increasingly for the general public, there is a clear need to gain more scientific knowledge about the associated benefits and risks of cannabis for patients with medical conditions.

Undoubtedly, there are many unsubstantiated claims about the use of cannabis for treating several medical conditions. However, there is scientific evidence that compounds naturally found in marijuana have therapeutic benefit for symptoms of diseases such as HIV/AIDS, multiple sclerosis, cancer and specific forms of epilepsy 6 . More specifically for anxiety, scientific evidence is also showing cannabis is expected to relieve tension and help young females relax 7 .

Although the future role that medical cannabis will play in healthcare is unknown, this case demonstrates how the patient was able to significantly benefit from the introduction of medical cannabis into her mental health intervention for the treatment of vertigo and a generalized anxiety disorder. In this case, the benefits for the 88-year-old patient using medical cannabis as a treatment in the both the short term and longer-term far outweighed the potential risks that may require consideration for children or adolescents 8 .

This case demonstrates how the patient was able to use medical cannabis to reduce the debilitating symptoms associated with her vertigo to drastically improve her quality of life. A pattern seems evident for the patient where her symptoms for vertigo fluctuated according to whether or not she was able to access medical cannabis. This case also highlights the legislative conundrum for patients, physicians and government 9 . Despite her medical team supporting her continual use of medical cannabis, she was not able to receive a prescription. As a result, she accessed medical cannabis from an illegal and unregulated source. While the patient reported to trust this source and only use medical cannabis according to her daily protocol, there are potential safety risks associated with her self-medicating cannabis to combat her symptoms and not having accurate information about dosing, consistency and quality of the cannabis.

This case is a preliminary finding and reinforces the need for more rigorous testing on the application of medical cannabis to be used as a treatment for different medical conditions, including generalized anxiety disorder.

◊ This case study outlines the potential benefit of medical cannabis for the management of generalized anxiety disorder and debilitating symptoms of vertigo ◊ The patient drastically improved her quality of life ◊ There is a need for more rigorous testing on the use of medical cannabis to support patients and better manage their symptoms ◊ Also, there are significant safety risks posed for the patients if they access medical cannabis from an unregulated source and use it without supervision.

Conflict of interests: Chad Walkaden is a private Mental Health Consultant, Director of Chad Walkaden Counselling and Consulting Services and the Founder of Cosecha, an application to assist patients with medical conditions use medical cannabis the right way to support them to live better longer.

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