Generalized Anxiety Disorder (GAD)
Last updated: October 2019
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Understanding Generalized Anxiety Disorder
Feeling anxious every now and then is a normal part of life; it’s your body’s way of responding to stressful situations or threats and protecting itself, which is known as the fight-or-flight response. Anxiety can be helpful when you’re preparing for a big presentation, or it may kick in as an instinctual protective mechanism in times of need, like after a car accident: Your sympathetic nervous system turns on, which increases your heart rate and alertness, preparing you for action. But if your body is constantly in this mode, geared up for action, anxious and worried over everyday events, this amount of anxiety can become incapacitating and may be indicative of an anxiety disorder. Anxiety disorders are the most common type of mental health disorder in the United States. They are so ubiquitous that almost one third of US adults will experience an anxiety disorder sometime in their lives (NIH, 2017).
For some people, specific situations can create anxiety, fear, avoidance behaviors, or panic attacks. Some people suffer from a fear of public spaces (agoraphobia) or have social phobias, separation anxiety, panic disorders, or other specific phobias. Others cope with generalized anxiety disorder (GAD), an uncontrollable anxiety about a whole range of activities (such as work, school, or interpersonal relationships) that affects their everyday well-being. This may look like persistent worrying, overthinking situations, perceiving normal things as threatening, difficulty concentrating, or an inability to relax.
Some common physical symptoms of GAD include fatigue, sweating, irritability, restlessness, emotional distress, neck or back pain, difficulty falling asleep, nausea, headaches, and trembling (Mayo Clinic, 2017).
How Many People Have Generalized Anxiety Disorder?
Globally, almost 4 percent of people have an anxiety disorder. The United States, New Zealand, and Australia have the highest rates of anxiety of any country (Ruscio et al., 2017). Almost 6 percent of US adults will be diagnosed with GAD sometime during their lives, with diagnosis most common around middle age (NIH, 2017b). Women are twice as likely as men to experience GAD. It is commonly diagnosed alongside depression in women; men are more commonly diagnosed with co-occurring substance abuse disorders (American Psychiatric Association, 2013).
Potential Causes and Related Health Concerns
GAD is likely caused by the interplay of genetics, biology, and environmental factors, such as trauma or stressors. GAD tends to run in families. Personality and brain chemistry may also make someone more prone to GAD. Several studies have tried to explain what is happening at a biological level among people with GAD. Brain connectivity and attentional bias may be two pieces of the puzzle.
The more we do certain tasks and activities, we are essentially creating and reinforcing complex neural networks between distinct brain regions. Jack Nitschke, PhD, an associate professor of psychology and psychiatry at the University of Wisconsin’s School of Medicine and Public Health, explains that you build these circuits like you would a muscle: with exercise. He and his team used functional magnetic resonance and diffusion tensor imaging to analyze the brains of GAD patients and healthy volunteers. They found that people with GAD had reduced connections between their prefrontal and anterior cingulate cortex, which is the center of emotional regulation, and their amygdala, which initiates the fight-or-flight response to stressful situations (Tromp et al., 2012). They believe that this broken communication between areas of the brain may explain why the panic button stays on among individuals with anxiety disorders like GAD.
We don’t have nearly as many threats to our survival nowadays as we did back in the Stone Age, but our hardwiring is still essentially the same. Why can’t we turn off our anxiety when there is no survival threat? Interesting new research has begun investigating the cognitive mechanisms behind how anxiety disorders persist. It seems that there may be several cognitive “errors” in people with anxiety. A meta-analysis of 172 studies found that individuals with anxiety perceived significantly more threats when there were none compared to those without anxiety (Bar-Haim, Lamy, Pergamin, Bakermans-Kranenburg, & van IJzendoorn, 2007). One study found that frequent worriers process threatening and neutral images differently than nonworriers, suggesting they bring fear onto situations that may be safe (Grant, Judah, White, & Mills, 2015).
How Generalized Anxiety Disorder Is Diagnosed
If someone’s anxiety is interfering with their daily life, they may see a doctor or psychologist for help. Practitioners ask detailed questions about a patient’s symptoms and medical history to determine whether they meet the clinical definition of GAD. If you don’t meet the diagnostic criteria, you may be diagnosed as having a short-term bout of anxiety.
DSM Definition of Generalized Anxiety Disorder
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines generalized anxiety disorder by several key diagnostic criteria. Individuals must have difficulty controlling excessive anxiety and worry about a range of activities for most days over a period of six months or longer. They must also have three (or more) of the following symptoms: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and difficulty sleeping. The anxiety or physical symptoms must cause clinically significant distress or impairment in social, occupational, or other areas of functioning (American Psychiatric Association, 2013).
Discuss your symptoms with your health care provider. Sometimes, anxiety symptoms can be caused by other conditions that are not purely psychiatric. For example, you may have hyperthyroidism, which can make you feel flighty and anxious and cause a rapid heartbeat. Low blood sugar and heart problems may also cause anxiety. By managing these other health issues, your anxiety may clear up on its own.
What you eat can—no surprise—impact the way you feel, physically and even mentally. Research has shown that good nutrition and a healthy diet are associated with better well-being and mental health outcomes (Owen & Corfe, 2017). In the ATTICA study of Greek adults, higher intakes of sweets, meat, and meat products were associated with a higher anxiety score among women. Among men, legume and cereal intake were associated with reduced anxiety (Yannakoulia et al., 2008). In another study, risk of anxiety was associated with a greater risk of low nutrient quality (Hall, Tejada-Tayabas, & Monárrez-Espino, 2017). Note that these are associations; it’s not necessarily clear whether anxiety causes a poor diet due to stress eating or a poor diet causes anxiety. Either way, we think maintaining optimal nutrition is important and there’s still so much we don’t know yet about how our diet affects our mood. This is called nutritional psychiatry, which researchers such as The Food and Mood Centre at Deakin University are starting to explore in order to identify how we can prevent and treat mental health disorders with proper nutrition.
Nutrients and Supplements for Anxiety
While specific nutrients haven’t been shown to help with anxiety, probiotics, specifically Lactobacillus rhamnosus, may help, thanks to the gut-brain connection.
A healthy gut microbiome may mean a healthy mind. New research has shown that our gut and brain are intimately connected through what’s called the gut-brain axis. And since a lot of serotonin (the feel-good neurotransmitter) is made in the gut, a healthy gut is important. Several researchers have tried to use this gut-brain axis by giving probiotics to patients with mood disorders. And according to a meta-analysis that was published in 2019, the evidence has shown that probiotics lead to small but significant improvements in anxiety (as well as depression). The strain L. rhamnosus has been studied the most and has shown the most support for reducing anxiety of any type (Reis, Ilardi, & Punt, 2018). However, when the authors of the 2019 meta-analysis looked at all studies on Lactobacillus for anxiety, they found that it did not significantly reduce anxiety (Liu, Walsh, & Sheehan, 2019). So more research on which strains are best is needed.
What Probiotic Sources Are Worth Trying?
Whether it’s for your gut or your mind, you may want to find a good probiotic supplement containing at least 1 billion active cultures. Alternatively, fermented foods like yogurt, kefir, kombucha, sauerkraut, and kimchi are also great sources of probiotics, but they haven’t been studied for their effects on anxiety yet.
Lifestyle Changes for Anxiety
There are few things more frustrating than being told: “Just relax.” In reality, managing anxiety can be difficult and multifaceted. It may take time and lots of practice. On the upside, there are evidence-based ways to create changes in your life that can help you gain control over your anxiety and better understand your emotions.
Getting to Know Your Triggers
Certain situations may be totally fine for you, whereas others may trigger intense fear and worry. Or something seemingly random could cause anxiety to come on. Research has shown that when your body is initially presented with a physically painful situation (like a spider biting you) or a psychologically harmful one (like being laughed at in public), your brain becomes trained to fear and avoid that situation in the future to prevent further harm. So now you’re afraid of spiders or have trouble with public speaking. Whatever your triggers are, it’s important to understand them so that you can develop techniques, ideally with a trained therapist, to prepare yourself to face them when they occur. For example, you might learn to take deep breaths when you see a spider or enter social situations as a way to help calm yourself down. Or you may try exposure therapy, gradually exposing yourself to spiders or public speaking while actively managing your alarm response. (See the relaxation strategies section and conventional treatments section for more.)
We have what’s called a U-shaped response to stress: Too little and we aren’t motivated to work very hard. But too much and we’re overwhelmed. When you hit the sweet spot, stress can be motivating, improving your performance. Knowing how to distinguish between good stress and bad stress can be important in allowing yourself to avoid situations that are not healthy (a toxic relationship) while recognizing situations that may be healthier forms of stress (pushing your physical and mental limits to train for a marathon). Managing stress and learning to say no to situations, people, and things that don’t serve us is a lifelong pursuit for all of us. A few of the people who have helped guide us include psychiatrist Ellen Vora, clinical psychologist Ellen Hendriksen, and physician Martin Rossman.
Managing Panic Attacks
During a panic attack, your chest may be pounding, you may sweat or find it hard to breathe, and you may feel like you’re losing control. It can be a scary experience, and it’s more common than we previously thought: In the United States, 11.2 percent of adults experience a panic attack in a given year. According to the DSM-5, panic disorder is technically its own diagnosis, but people may also experience sporadic panic attacks with anxiety disorder (American Psychiatric Association, 2013). During a panic attack, it’s important to relocate to a safe place (stop driving if you’re in a car) and try to focus on taking deeper breaths. Remind yourself that you are going to be okay. As scary as it can feel, it’s temporary. Playing soft ambient music or counting your breaths may help—figure out what works best for you and keep practicing. Panic attack support groups, like No Panic, can provide resources, such as a recording to listen to during a panic attack, breathing exercises, and other coping strategies. And a wealth of mental health apps have been designed especially for this purpose.
Being in Nature
Being in nature can be instantly healing. Losing yourself among the trees on a hike or looking out into the ocean can give perspective to your everyday worries. Numerous studies have shown that nature-relatedness—feeling connected to the outdoors—has psychological benefits, such as improved well-being and reduced anxiety (Lawton, Brymer, Clough, & Denovan, 2017; Martyn & Brymer, 2016). Combining exercise with nature may have added benefits, with one study showing that outdoor physical activity lowered somatic anxiety (Lawton et al., 2017).
Constant access to world news—natural disasters, wars, crimes, politics—can be exhausting. Keeping up with social media can be equally tiresome if you’re constantly being notified on your phone and regularly scrolling through a highlight reel of other people’s lives. Studies have shown that high phone use, especially near bedtime, can reduce sleep quality and is associated with depression and anxiety (Adams & Kisler, 2013; Tamura, Nishida, Tsuji, & Sakakibara, 2017; Thomée, Härenstam, & Hagberg, 2011). Move your phone across the room before bed to reduce the urge to pick it up (Tosini, Ferguson, & Tsubota, 2016; Višnjić et al., 2018). While it’s not yet clear whether frequent phone use creates anxiety or if anxious people are drawn to using their phones more, it’s a good idea to give yourself a break and unplug every now and then (Vahedi & Saiphoo, 2018).
Regular exercise can improve your energy level, reduce stress and tension, and help boost your mood—it’s all those endorphins. Several meta-analyses have consistently concluded that exercise has a moderate anxiety-reducing effect (Gordon, McDowell, Lyons, & Herring, 2017; Stubbs et al., 2017). High-intensity workouts like running may be more effective at treating anxiety than low-intensity workouts like walking (Aylett, Small, & Bower, 2018). Exercising for at least 21 minutes seems to be the minimum amount of time necessary to reap the stress-relieving benefits (Petruzzello, Landers, Hatfield, Kubitz, & Salazar, 1991). Find a workout that you enjoy and can stick to, or join group workouts for added accountability.
Incorporating Mindfulness into Your Daily Routine
Trying to push uncomfortable feelings away tends to result in the opposite of the intended effect—you feel worse down the road if you bottle it all up until it explodes. Mindfulness practices can help you embrace the ebbs and flows without reactivity, so eventually, you are less reactive to your anxiety symptoms and don’t have to give in to their pull. Mindfulness doesn’t have to be any sort of formal meditation, but meditation of some sort is how mindfulness is typically taught (and various techniques are described below). You can simply observe your breath and notice your reactions to situations at any moment. With continued practice, even simple activities like washing the dishes can become a meditation. Studies have shown that mindfulness meditation impacts how the brain responds to stressful stimuli (see the new research section for more on that). If you’re new to it, we recommend the book Mindfulness for Beginners by Jon Kabat-Zinn, one of the prominent mindfulness teachers who wrote the gold standard book on mindfulness-based stress reduction (see the alternative therapies section for more on that practice). There’s also Search Inside Yourself, which is a mindfulness program developed at Google—it’s described in an easily accessible format in a book of the same name.
It may be useful to begin incorporating various relaxation techniques into your daily routine. While several of these are evidence-based, some are just tips and tricks that counselors or therapists recommend when working with their patients. Focus will be placed on three dimensions of relaxation: mind, body, and the senses.
• Try a simple breathing meditation. Set a timer for ten minutes to start and focus on each inhale and exhale. If your focus drifts away from your breath, just notice that and come back to your breath once again without judgment. (You can learn more about breathwork in our Q&A with practitioner Ashley Neese, which includes a short guided audio clip.)
• You can also try a body scan by letting your mind trace its way down from your head to your toes, noticing the sensations in each part of your body.
• If you are religious or spiritual, try praying. A loving-kindness meditation can also be used. First, think about people you love. Say a simple mantra to yourself, such as “May they be safe, may they be happy, may they be healthy.” Continue this mantra for each family member, friend, coworker, or other loved one whom you wish to send love to.
• During moments of extreme anxiety, you may feel like you’re not inside your own body. Various exercises can help you reconnect to your physical body and feel grounded. Shallow breathing is a sign of stress and anxiety. Think about how a baby breathes while asleep in their crib, their stomach rising and falling. Accessing this deeper belly breathing (called diaphragmatic breathing) can be very calming and may activate your parasympathetic nervous system, which helps your body relax (Lehrer & Gevirtz, 2014). Try it by lying on the ground. Place one hand on your stomach, and as you inhale, fill up your belly, feeling your hand rise. As you exhale, empty out your belly completely.
• There are many types of breathing exercises. Try the 4-7-8 breathing technique. You breath in to the count of 4, hold your breath to the count of 7, and then breathe out for a count of 8. Repeat. Try this anytime you need to reconnect with your breath and relax.
• Progressive relaxation techniques can also be helpful. Start by tensing and releasing different muscle groups, moving sequentially from around your head, then working your way down to your toes. Once you’re finished, relax your entire body at once. Researchers have hypothesized that continued practice of this relaxation technique can help turn on the parasympathetic nervous system in times of anxiety to aid in relaxation (Hayes-Skelton & Roemer, 2013).
• Other body relaxation strategies include massage or gentle yoga.
• Activities that play to your senses can be important forms of self-care. For one person, this might mean aromatherapy—a lavender essential oil in a diffuser, with calming instrumental music in the background. Whatever brings you joy, try creating a ritual of it before bedtime or during parts of your day when you feel especially anxious.
• You can also try visualization techniques. Close your eyes and imagine yourself in a serene environment, perhaps the beach. Imagine the feeling of the sun hitting your skin. (Or better yet, go outdoors and get the real thing.)
Can a Float Tank Reduce Stress?
In a world that can be hyperstimulating at times, float tanks and other environmental deprivation experiences have started popping up at wellness centers and spas as a way to help us unwind and slip into a meditative state. The tanks are filled with a solution of water and Epsom salt so that users float when they lie down. You float in either a darkened room or a large pod with a closed lid to eliminate any visual stimulation. One study of individuals with various anxiety and stress-related disorders showed that a one-hour float session significantly reduced stress, muscle tension, pain, and depression while improving serenity, relaxation, happiness, and overall well-being (Feinstein et al., 2018). But these effects were probably sustained only for the short-term period immediately following the float session. Currently, a clinical trial by the Laureate Institute for Brain Research in Oklahoma is recruiting subjects to determine the effects of float sessions on anxiety.
Conventional Treatment Options for Generalized Anxiety Disorder
Therapy and medication are the two most common treatment options for GAD. You may choose to do just one or both. Treatment is entirely individual and depends on your symptoms, priorities, and needs, which may change with time.
Applied Relaxation Therapy
The gold standard for GAD psychotherapy is applied relaxation. This is all about learning how to recognize early signs of anxiety and cope with the situation by relaxing instead of falling into the anxiety cycle (Chambless & Ollendick, 2001). Patients are asked to pay attention to their cognitive, emotional, physiological, and behavioral cues during situations that give them anxiety. And then you learn progressive relaxation techniques (see the relaxation strategies section). A 2014 meta-analysis of psychotherapy for GAD showed that while applied relaxation is an effective short-term treatment, cognitive behavioral therapy may be more effective in the long term (Cuijpers, Sijbrandij, Koole, Huibers, et al., 2014).
What Is a Psychiatrist Versus a Psychologist?
A psychiatrist has a medical degree and can prescribe medications, while a psychologist, sometimes referred to as a therapist, has a doctorate in psychology and cannot prescribe medications. Some individuals may see one or both, depending on whether they are interested in taking medications for their treatment or not. You can also see a licensed therapist who has a master’s degree; qualifications vary from state to state. It’s important to find someone you feel you can talk to. It may take some time to find someone who feels like the right fit, but it can be well worth it in the long run.
Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) is one of the most popular evidence-based treatments for anxiety. It’s usually delivered in hour-long, one-on-one sessions with a therapist. The theory behind CBT is that psychological problems are based on unhelpful ways of thinking and behaving. CBT emphasizes the need for individuals to learn new coping mechanisms and work on changing their own negative beliefs and reactions going forward (Kaczkurkin & Foa, 2015).
One type of CBT is called exposure therapy: Therapists gradually expose patients to objects or situations that cause them fear or anxiety. The goal of exposure therapy is for the extreme reaction to the trigger to lessen so that you can reduce your anxiety. Exposure therapy is not as common for treating GAD as it is for other anxiety disorders, such as PTSD.
In imaginal exposure, patients imagine the worst-case scenario associated with their worries and then are coached through the scenario by their therapist. Imaginal exposure is used more often for GAD. And CBT combined with imaginal exposure has been shown to be effective (Kaczkurkin & Foa, 2015).
For individuals who experience panic attacks or suffer from panic disorder, interoceptive exposure may be used. This is when the physical sensations of a panic attack are deliberately induced by spinning the patient in a chair, having them run up and down stairs, causing them to hyperventilate, or a similar means of creating a feared sensation (Kaczkurkin & Foa, 2015).
The most common pharmacotherapy treatments for anxiety are SSRIs (selective serotonin reuptake inhibitors)—such as escitalopram (Lexapro), citalopram (Celexa), and fluoxetine (Prozac)—and SNRIs (serotonin and norepinephrine reuptake inhibitors), such as venlafaxine and duloxetine (Cymbalta). Other options are tricyclic antidepressants, antiepileptics, monoamine oxidase inhibitors, and azapirones, such as buspirone (Buspar).
These are not miracle drugs. These medications each have their own potential risks and side effects to consider, including weight gain, insomnia, nausea, and reduced sexual desire. A 2015 meta-analysis found that medications (including SSRIs, benzodiazepines, and tricyclic antidepressants) are more effective than psychotherapy for anxiety disorders (Bandelow et al., 2015). Another meta-analysis showed that combining psychotherapy with antidepressant medications is more effective than antidepressants alone, preventing relapse for up to two years (Cuijpers, Sijbrandij, Koole, Andersson, et al., 2014). So if you choose to use medications to manage your anxiety, you may want to seek out regular psychotherapy as well to ensure the best possible long-term outcome.
Short-Term Anxiety Medications
For management of acute episodes of anxiety, your doctor or psychiatrist may prescribe benzodiazepines, such as alprazolam (Xanax), clonazepam (Klonopin), diazepam (Valium), or lorazepam (Ativan). These drugs provide short-term relief of anxiety, promoting muscle relaxation. They are not usually prescribed for long-term use as they may cause dependence issues and have several side effects, including drowsiness, irritability, dizziness, and memory problems. Withdrawal from benzodiazepines can cause “rebound anxiety,” which can actually make anxiety worse, so it’s important to work with your doctor to safely decrease your intake over time if you’re getting off your medication.
Alternate Treatment Options for Anxiety
There are numerous alternative treatment options for GAD, including cannabis, cannabidiol (CBD), mind-body techniques (such as yoga and meditation), and herbal supplements. A holistic approach to treatment may help improve multiple aspects of a person’s life and help them develop useful techniques to manage ongoing stress and anxiety.
Some people love the calming effects of marijuana, and they will tell you that it helps them relax or fall asleep, while others feel that it makes them super anxious. It may be personal preference, tolerance, the strain of marijuana, or other unknown factors that cause these differences. It could also be the dose: THC (tetrahydrocannabinol, the chief intoxicant in marijuana) at low doses may decrease anxiety whereas higher doses may increase anxiety (Stoner, 2017). Mental health conditions are a top reason for medical marijuana use, and many people with anxiety feel that they benefit from it (Walsh et al., 2017). Before hopping on the cannabis train, one key thing to consider is that the use of cannabis may increase the risk of developing temporary psychosis and persisting mental health disorders, such as schizophrenia or anxiety (CDC, 2018; Twomey, 2017). Consider other evidence-based options first and discuss potential risks and benefits with your doctor or psychiatrist before using.
It’s everywhere. People suggest it helps with a variety of issues, such as pain, trouble sleeping, and anxiety. Are these claims well-founded? A wealth of preclinical evidence has demonstrated that cannabidiol, a chemical from the cannabis plant that does not get you high like THC does, could be a potentially effective treatment for anxiety disorders as it has been shown to reduce the autonomic arousal and fear response in animals (Blessing, Steenkamp, Manzanares, & Marmar, 2015). However, evidence is much more limited in humans. A few studies have suggested that CBD can reduce cannabis-induced anxiety (Blessing et al., 2015; Boggs, Nguyen, Morgenson, Taffe, & Ranganathan, 2018; Niesink & van Laar, 2013), and a few small clinical studies have shown that high doses of CBD (300 milligrams or more) can reduce short-term anxiety in patients with anxiety disorders. More studies are needed to determine the safety and effectiveness of CBD as a treatment for anxiety (Bergamaschi et al., 2011; Crippa et al., 2011; Zuardi, Cosme, Graeff, & Guimarães, 1993). There is a phase 3 clinical trial studying CBD as a treatment for anxiety.
You’ve probably already heard many of the benefits of yoga. A regular yoga practice can be deeply grounding, helping you connect with your breath and body in a novel way. There are so many different kinds of yoga to try. To name a few: Hatha yoga is a general category referring to the practice of yoga postures (asanas) and breathing exercises (pranayama). There is also vinyasa, which synchronizes movement with breath. Ashtanga yoga is a set sequence of physically challenging asanas. Kundalini incorporates dynamic breathing exercises. Iyengar focuses on alignment. And Bikram yoga is a set sequence of the same twenty-six postures in a heated room.
A meta-analysis of seventeen studies found that hatha yoga reduces anxiety; however, the magnitude of this benefit was rather small, so yoga may not be an effective stand-alone treatment, especially for people with more severe anxiety (Hofmann, Andreoli, Carpenter, & Curtiss, 2016). If you’re game, try incorporating yoga into your wellness routine to see how it might benefit you physically and mentally.
Mindfulness-Based Stress Reduction
Developed by Jon Kabat-Zinn, mindfulness-based stress reduction (MBSR) is a group therapy program in which participants are taught to practice mindfulness through yoga, meditation, and body scans. The theory is that MBSR changes the way people relate to their thoughts, allowing them to realize that thoughts are only temporary, an understanding that may allow them to reduce rumination (circling on the same topic over and over) and increase emotional regulation. Although the research is nascent, studies have shown that MBSR and other meditative therapies reduce anxiety and can help individuals with an array of other mental and physical disorders (Chen et al., 2012; Eberth & Sedlmeier, 2012; Grossman, Niemann, Schmidt, & Walach, 2010; Hofmann, Sawyer, Witt, & Oh, 2010). There are several MBSR communities, including Insight LA, as well as therapists and doctors who are trained in this style of therapy. Most notably, Kabat-Zinn is the founding executive director of the University of Massachusetts Medical School’s Center for Mindfulness, which offers MBSR courses, both online and in person. He has also written several books on the topic, such as Full Catastrophe Living. The first clinical trial comparing MBSR to an antianxiety medication is currently recruiting subjects (see the clinical trials section for more).
Holistic approaches often require dedication, guidance, and working closely with an experienced practitioner. There are several certifications that designate an herbalist. The American Herbalists Guild provides a listing of registered herbalists, whose certification is designated RH(AHG). Traditional Chinese medicine degrees may include LAc (licensed acupuncturist), OMD (doctor of Oriental medicine), or DipCH (NCCA) (diplomate of Chinese herbology from the National Commission for the Certification of Acupuncturists). Traditional Ayurvedic medicine from India is accredited in the US by the American Association of Ayurvedic Professionals of North America (AAPNA) and the National Ayurvedic Medical Association (NAMA). There are also functional, holistic-minded practitioners (MDs, DOs, NDs, and DCs) who may use herbal protocols.
Used in Indian Ayurvedic medicine, ashwagandha is a nightshade plant that is considered an adaptogen, meaning it regulates your body’s ability to respond to stress (Singh, Bhalla, de Jager, & Gilca, 2011). A 2014 review found that ashwagandha improved anxiety and stress at a wide range of doses (Pratte, Nanavati, Young, & Morley, 2014). Ashwagandha may be a good supplement for you to add your daily arsenal to help manage stress; however, these studies have not focused on individuals with diagnosed anxiety disorders, so results should be interpreted modestly.
Used for restlessness and nervousness, passionflower has long been thought to help with anxiety symptoms. A couple studies have provided evidence that passionflower may help reduce anxiety among those undergoing surgery (Dantas, de Oliveira-Ribeiro, de Almeida-Souza, & Groppo, 2017; Kaviani, Tavakoli, Tabanmehr, & Havaei, 2013). In one study of individuals with GAD, passionflower was shown to be as effective as a benzodiazepine (an antianxiety medication) in reducing anxiety symptoms, with less impairment (Akhondzadeh et al., 2001). Further well-controlled clinical trials are needed. In the meantime, there is no shortage of supplements for anxiety or calming containing passionflower.
Drinking tea may be more than a relaxing ritual. Chamomile, made from the dried flowers of the Asteraceae plant, has been shown to be effective at treating anxiety symptoms, and GAD specifically. Several studies in recent years have found that chamomile significantly reduces GAD, with some studies suggesting it can even help with severe GAD (Amsterdam et al., 2009; Keefe, Guo, Li, Amsterdam, & Mao, 2018; Keefe, Mao, Soeller, Li, & Amsterdam, 2016; Mao et al., 2016). Subjects in these studies were given around 1,500 milligrams of chamomile per day. The amount of chamomile in a typical cup of tea can vary greatly between brands and you may not be getting the full dose by taking it via tea. Instead, you may opt to take a chamomile supplement for more dose accuracy.
L-theanine, found in green tea leaves, is an amino acid that is hypothesized to be neuroprotective. A few small studies have shown that L-theanine may reduce anxiety among healthy subjects and perhaps may have a more pronounced anxiolytic effect among people with schizophrenia (Ritsner et al., 2011; Yoto, Motoki, Murao, & Yokogoshi, 2012). But a recent study from Australia found that large doses of L-theanine as an add-on to antidepressant medication among individuals with GAD was not effective (Sarris et al., 2019). Just because the research hasn’t supported green tea for anxiety yet doesn’t mean you should quit your daily cup if it helps you unwind—rituals like this can be super grounding. But you might switch to chamomile for added benefits.
Prepared from the plant Piper methysticum, kava (or kava kava) is a drink that has long been consumed in the Pacific Ocean cultures of Polynesia, including Hawaii and Fiji, to relieve anxiety and insomnia. Several preclinical studies have shown that kava extracts bind to various neurotransmitters. A number of clinical trials, but not all, have reported kava’s therapeutic potential for individuals with GAD (Lakhan & Vieira, 2010). A recent meta-analysis found that kava is a good short-term treatment for anxiety, but it is not recommended for long-term use since there have been several case reports of liver toxicity in recent years (Smith & Leiras, 2018). This led the FDA to release a consumer advisory warning about kava-containing supplements in 2002. Although these side effects are rare, be careful about using kava.
New and Promising Research on Anxiety
There’s some really interesting research being done for anxiety treatment that would have seemed pretty far-out only a few years ago, like altering your brain through meditation, taking MDMA, and immersing yourself in virtual reality.
The Science of Meditation
The amygdala is a key node in our brain’s stress circuitry. Studies have shown that meditators have sustained reductions in amygdala activity, reducing anxiety-provoking reactions. One of the most robust studies on meditation, called the Shamatha Project, studied meditators before, during, and five months after a curated three-month retreat program involving six hours of daily meditation. Compared to the control subjects on the wait list, the retreat participants showed marked improvements in self-regulation, attentional control, and functioning (Sahdra et al., 2011; Zanesco et al., 2016). In another study, a group of highly experienced vipassana meditators (averaging over 9,000 hours of lifetime practice) were shown to have reduced amygdala reactivity and stronger connectivity between their prefrontal cortex and amygdala, which enabled them to be less prone to emotional ups and downs, compared to nonmeditators. They also found a strong correlation between the number of lifetime hours of meditation practice and the speed of amygdala recovery from stress, demonstrating the benefits of a sustained lifetime practice (Kral et al., 2018).
While the street drug “ecstasy” or “molly” has gained a reputation for its use in rave culture, the pure drug MDMA has been used to aid in psychotherapy since the 1960s. Unlike other medications, it’s administered in small doses during a few therapy sessions to help patients open up so that they can discuss difficult topics that may ordinarily be hard to dive into. A small study of autistic adults showed that two eight-hour sessions of MDMA-assisted psychotherapy along with three nondrug psychotherapy sessions reduced subsequent social anxiety, as measured one month after treatment ended (Danforth et al., 2018). The Multidisciplinary Association for Psychedelic Studies is conducting the first phase 3 study of MDMA-assisted psychotherapy for the treatment of PTSD. Their mission is to make MDMA an FDA-approved prescription medicine by 2021. While more research is needed on MDMA for GAD in particular as well as use in general, psychedelics is an exciting field that has reemerged in recent years.
Virtual reality (VR) is here. People are starting to own their own headsets, and companies with innovative software are multiplying. VR has also found new applications for treating a variety of conditions, such as autism, anxiety, and specific phobias. Therapists can work with patients in a virtual environment that is safe and controlled, exposing them to situations or environments and working with them on managing their reactions. Used most often for soldiers with PTSD and people with social anxiety disorder, a clinical study in France is expanding VR’s use to patients with GAD. They hope to determine if six relaxation-optimized VR experiences can improve anxiety (one is being on a serene beach with mountains in the distance). This type of technology could dictate the future of mental health treatment.
Clinical Trials for Generalized Anxiety Disorder
Clinical trials are research studies intended to evaluate a medical, surgical, or behavioral intervention. They are done so that researchers can study a particular treatment that may not have a lot of data on its safety or effectiveness yet. If you’re considering signing up for a clinical trial, it’s important to note that if you’re placed in the placebo group, you won’t have access to the treatment being studied. It’s also good to understand the phase of the clinical trial: Phase 1 is the first time most drugs will be used in humans, so it’s about finding a safe dose. If the drug makes it through the initial trial, it can be used in a larger phase 2 trial to see whether it works well. Then it may be compared to a known effective treatment in a phase 3 trial. If the drug is approved by the FDA, it will go on to a phase 4 trial. Phase 3 and phase 4 trials are the most likely to involve the most effective and safest up-and-coming treatments.
In general, clinical trials may yield valuable information; they may provide benefits for some subjects but have undesirable outcomes for others. Speak with your doctor about any clinical trial you are considering. To find studies that are currently recruiting for GAD, go to clinicaltrials.gov. We’ve also outlined some below.
Switching between different medications to find which works best for you can be a long and arduous process, especially in the case of antidepressants and antianxiety medications, when many people understandably want a solution now and don’t want a whole range of possible side effects, such nausea or weight changes. John Papastergiou, assistant professor of pharmacy at the University of Toronto, is working to minimize the confusion—and unwanted side effects—with something called pharmacogenomic testing. Using the Pillcheck drug response test, the researchers are hoping to gain insight into a patient’s predicted response to various antidepressants based on their genetics. This would enable patients and practitioners to make more informed decisions on the best medications for GAD, depression, and other mood disorders.
Mindfulness-Based Stress Reduction
Georgetown University is conducting the first clinical trial to compare the effectiveness of MBSR versus an anxiety medication. Subjects will receive either escitalopram, the gold standard SSRI treatment for anxiety, or eight weeks of MBSR training for two and a half hours per week as well as a one-day weekend retreat. The MBSR group will also be asked to practice at home daily for forty-five minutes. The researchers hope to provide further clinical evidence for the effectiveness of MBSR, which would give many people another viable treatment option besides anxiety medication.
There’s been an influx of meditation and mindfulness phone apps in recent years. Many of them are not evidence-based. Can these apps reduce clinical anxiety or help with other mental health issues? Judson Brewer, MD, PhD, the director of research and innovation at the Mindfulness Center at Brown University, is investigating whether the Unwinding Anxiety app can be adapted for individuals with GAD. The app focuses on teaching people how to understand the perpetuating cycles of anxiety, recognize these mental loops, and bring mindful awareness to themselves to unlearn this anxiety. (To learn more about Brewer, listen to him on this episode of The goop Podcast: Why We Crave.)
A team of researchers and physicians at Massachusetts General Hospital are studying Kundalini yoga—which focuses on breathing techniques, meditation, postures, and deep relaxation—to see if it can reduce anxiety among GAD patients. The study will last twelve weeks, with one weekly session of either Kundalini yoga or CBT, and stress education for comparison.
Acceptance and Commitment Therapy
Acceptance and commitment therapy (ACT) is a form of psychotherapy that stems from CBT. People are taught to stop avoiding and denying their inner emotions through mindfulness and acceptance. Michael Twohig, PhD, a professor in the department of psychology at Utah State University, is investigating whether six weeks of two-hour group ACT sessions, combined with the use of the ACT Daily mobile app, can lessen the daily worries consistent with GAD.
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