It gets closer and my hands begin to tremble violently, sweat starts to form on my brow. I breathe in and out deeply but quietly, with the hopes of calming myself without showing how terrified I am. My hope is quickly snuffed out as my chest tightens and my breath gets trapped in my throat. It’s as if there’s some monstrous hands gripping my heart in an unwavering iron grip and like those same hands are wrapped around my throat strangling the life from me. I try desperately to fight against the feeling as it gets closer to me but my struggling only tightens their grip. It’s finally upon me now, and my whole-body tenses as I brace for the worst. “Here’s your coffee sir” the 5’1” Starbucks employee sweetly chirps to me as they gently place a hot cup of black coffee into my clammy, shaking hands. Most people would only experience the feelings in my Starbucks story under horrific and extremely stressful times in their lives. For those with generalized anxiety disorder, like myself, this could be part of your average day.
wHAT is Generalized Anxiety Disorder?
The Diagnostic and Statistical Manual of Mental Health (DSM-5) which is used by psychiatrists to diagnose mental health conditions defines Generalized Anxiety Disorder (GAD) as a chronic state of excessive worrying or tension that is oftentimes unprovoked and not within voluntary control. People who are affected by GAD may often experience: Inability to control excessive worrying, Difficulty concentrating, mind going blank, fatigue, excessive sweating, feeling out of breath, and a variety of other symptoms. According to the Anxiety and Depression Association of America 6.8 million adults are affected by GAD in the United States alone, with women being twice as likely to be affected compared to men (ADAA., 2022). Research shows an increase in prevalence of anxiety disorders in youth between the ages 5 and 17 in the United states (ADAA., 2022). To make matters worse, GAD, amongst other anxiety disorders have been positively associated with development of depressive disorders, coronary heart disease, and other serious diseases.
How is Generalized Anxiety Disorder treated
Despite how many people are affected by such a gruesome condition the Anxiety and Depression Association of America reports that only around 43.2% of the affected population receives treatment (ADAA., 2022). The current first line of treatment are drug therapy and cognitive behavioral therapy (CBT). For drug therapy those affected by GAD are prescribed anti-anxiety and antidepressant medications like: benzodiazepines, selective serotonin reuptake inhibitors, and serotonin-norepinephrine reuptake inhibitors (ADAA., 2023). CBT is a non-chemical treatment that focuses on identifying, understanding, and changing thinking and behavior patterns through many sessions guided by a trained therapist. While these treatment choices enjoy popularity, they fall short in addressing the needs and desires of individuals living with GAD. Mindfulness practices may serve as a fulfilling alternative.
What is mindfulness and what different types are there?
According to the Greater Good Magazine published by the University of California Berkeley mindfulness practices involve maintaining a moment-by-moment awareness of our thoughts, feelings, bodily sensations, and environment, while holding a perspective of nonjudgmental acceptance (UC Berkeley., 2021). That is, we maintain awareness of our thoughts and feelings without being critical of them. How a patient goes about accomplishing this depends on what specific mindfulness practice they choose. Mindfulness is a very ancient practice that has stood the test of time, so naturally many different styles of mindfulness practice have arisen throughout the centuries. For the sake of brevity, we will only focus on mindfulness-based stress reduction (MBSR) and Mindfulness-based cognitive therapy (MBCT) in this blog. MBSR is a group program consisting of one 2.5 hour session each week for a total of 8 weeks, often combined with one additional silent retreat day (Haller et al., 2021). The essential elements of the MBSR practice are sitting/walking meditation, relaxation techniques, and yoga (Haller et al., 2021). An example of a mindfulness meditation/relaxation technique is mindfulness breathing. In this technique you focus on your breathing while sitting in a quiet and comfortable space with your eyes closed. When focusing on your breath the key is to simply maintain attention on the breath without judgement and control. Simply be a spectator and breathe. MBCT is a form of MBSR that combines core concepts from CBT that are already widely used in clinical/therapy settings.
Mindfulness vs drug therapy
When a patient finds a medication that proves effective for them, drug therapy presents a relatively low-effort approach to managing GAD, in comparison to mindfulness. However, for the majority, this treatment avenue brings about numerous complexities when contrasted with the practice of mindfulness. With the exception of benzodiazepines, which take effect within a few days, the other medications commonly used usually take between 4 and 6 weeks to begin to take effect compared to MBSR and MBCT which take 8 weeks to yield results giving drug therapy an advantage (Brogaard et al., 2017). This slight advantage could be overshadowed by the fact that all of the commonly used medications are usually accompanied by a variety of negative side effects and withdrawal symptoms. According to the Anxiety and Depression Association of America, such effects could include: headaches, dry-mouth, dizziness, insomnia, weight gain, nausea, brain fog, increased anxiety, mental numbness, sexual dysfunction, and in the case of benzodiazepines: addiction. In contrast, studies have shown that no adverse side effects manifest in a GAD affected person who participated in MSBR or MBCT treatments (Ninomiya, A. et al., 2020).
It is important to note that around 67% of GAD affected people are resistant to typical drug therapy (Majid et al., 2012), meaning most GAD affected people on medication will have endured the harsh side effects previously mentioned while having gained no benefit from the treatment. In the case of MBCT studies, it was found to be effective in reducing general anxiety and feelings of worry for patients in secondary care who are often resistant to drug therapy (Ninomiya, A. et al., 2020).
Mindfulness vs CBT
CBT treatment has been reported to be the most effective and is the current gold standard of typical treatments for GAD (Piet et al., 2010). Benefits are usually seen in 12 to 16 weeks depending on the individual (Haller et al., 2021), compared to MBSR and MBCT where benefits are seen in a shorter period of 8 weeks. Recent research done with 182 individuals has shown that the positive effects on GAD as a result of CBT treatment remain with an individual long after treatment stops, and that CBT results in equivalent or greater reduction of anxiety and worry compared to MBSR and MBCT (Wong, S. Y. et al., 2016). Though in the same study the difference in reduction was not significant after a period of 5 months. Despite CBT being deemed so effective in the world of psychiatry, CBT still comes with its own drawbacks. CBT usually requires one-on-one sessions with a trained therapist the biggest obstacle that most GAD affected people face with CBT is a lack of therapist’s availability and affordability. In fact, the primary reason that many GAD affected people are first offered drug therapy is because worldwide there are not enough qualified therapists trained in CBT available to meet one-on-one demands (Ninomiya, A. et al., 2020). MBCT and MBSR treatments on the other hand can and usually are group sessions making them generally less expensive and more available (Ninomiya, A. et al., 2020). According to psychology today, CBT can be done in groups to minimize cost (Psychology Today., 2021).
Conclusions and further considerations
In the case of MBSR and MBCT none of the negative side effects or lack of availability involved in drug therapy and CBT are observed making these mindfulness practices a reasonable alternative for treating GAD. While mindfulness practices show distinct advantages over drug therapy and CBT, we must acknowledge some discrepancies within mindfulness treatment. Firstly, and most importantly, there is limited reliable research done on the effectiveness of mindfulness practices. For example, the meta-analysis by Haller et al., 2021 from which a great deal of the studies used in this blog were utilized, noted that after reviewing 8,013 different articles on mindfulness only 23 of those articles met standards for being considered reliable studies. In the same meta-analysis it was reported that some of these studies may have not properly reported on elements such as risk of bias, and adverse effects. It is also not clear if these studies were designed to really optimize the effects of mindfulness treatment. The “dosage” for mindfulness is also debated, as GAD affected patients report the amount of time daily they dedicate to certain practices like meditation to receive results is varied (Jaizerai et al., 2017). Finally, it should also be noted that this blog is by no means declaring mindfulness practices to be superior to typical practices. It should be understood that mindfulness can yield positive results equal to typical treatments if guided by a reliable therapist or simply be used you give your mind a restful break. If you are interested in exploring mindfulness as an alternative you should speak with a medical professional specializing in treating psychiatric conditions.
Currently, the experimental data suggests that mindfulness may be beneficial for GAD sufferers. Ultimately mindfulness still needs to be further explored before it can be widely adopted by the therapist as a practical and effective treatment for GAD. Hopefully after we fully understand mindfulness, my trips to Starbucks can be less horror flick and more harmonious.
Written by Daisaku Y. Edwards, BS and edited by Aldrin V. Gomes, PhD
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