Generalized Anxiety Disorder

Generalized Anxiety Disorder (GAD) is the medical name for anxiety. Everyone worries about important things in life, such as family, work, and health. People who have GAD are extremely worried about these and other smaller things, even when there is little reason to worry about them ^[1]. There are multiple ways in which the worrying of GAD is worse. The first is the intensity of the worry. Usually, people with GAD tend to worry to a greater extent than others, to the point where it causes them symptoms or impacts their lives in a meaningful way. The second is the diversity of worry. In GAD, the sufferer may be concerned about all sorts of little things, or worry about all facets of larger life items. Importantly, people with GAD are unable to relax or get rid of their concerns, even though they often realize that the anxiety is more intense than it needs to be. From an evolutionary perspective, anxiety is healthy and normal. It allows us to plan for the future (for example, if our ancestors were going to experience extended periods of time with little amounts of food). However, our stressors are much different than those of our ancestors.

Regardless, our bodies react in almost the same way as they did if the threats we faced were severe. People with GAD can experience trouble concentrating, fatigue, irritability, breathing problems, and hot flashes ^[1]. GAD is considered multifactorial. In other words, part of it may be caused by genetics and family history, while the rest may be environmental or due to exposure to specific situations. In the latest edition of the DSM (the DSM-5, the manual used to categorize mental illness), it is accepted that mental illness generally occurs on a continuum. In other words, we all experience various thoughts and behaviours, but those of us who are on the extreme end of things will be categorized as having a disorder. With a condition like GAD, individuals must have 3 or more anxiety symptoms for a period of 6 months on an almost daily basis to be considered diagnosed with GAD ^[2]. The symptoms must cause clinically significant distress or impairment in social, occupational, or other areas of functioning. In this article, we will discuss some of the naturopathic supplemental approaches that have been shown to help with GAD. Many of them can also be used at a lower dose or lower frequency for periods of excessive stress.

First-Line Treatments

GAD is typically treated with a combination of therapy and medications. Therapy can take the form of counseling, psychotherapy, cognitive behaviour therapy, or other forms of talk therapy. The evidence shows that cognitive behavioural therapy (CBT) is particularly useful for people with GAD ^[3]. CBT involves helping patients understand their thoughts, behaviour, and feelings all interact with each other. The goal is to eventually morph negative thoughts into positive thoughts, with an eye towards changing how someone thinks about the situations they encounter. In particular, the therapy significantly decreases the cardinal symptom of pathological worrying. The treatments seem to be most effective for younger adults and those who seek individual treatment. CBT also has a good rate of maintenance, showing overall that patients are still feeling better 6 and 12 months after treatment.

Medications that are prescribed for GAD are usually anti-anxiety or antidepressants. Antidepressants are obviously used to treat depression primarily, but they can also be quite helpful with anxiety. Oftentimes, people who have anxiety have depression as well. The most common type of medication prescribed is a benzodiazepine. These drugs bind to GABA receptors, helping to create a relaxing effect ^[4]. GABA is an inhibitory neurotransmitter and it is also activated when drinking alcohol. Another class of medications that is used is called selective serotonin reuptake inhibitors (SSRIs). They reduce amygdala hyper-reactivity to fear-eliciting stimuli, which means that the medications reduce how intensely the brain reacts to stressful situations. The unfortunate part of using medication is that they often have side-effects. The benzodiazepines for example have been shown to be effective in the short-term, but less so in the long-term. The side effects can include things like fatigue, mental issues, and blurry vision. Withdrawal can also be an issue, so it’s important to wean off these medications slowly if that is the approach that is decided.

Selected Supplement Options

Omega-3 Fatty Acids

Omega-3 polyunsaturated fatty acids (PUFAs) are major components of brain cell membranes. There is limited evidence available on the exact effect of PUFAs in humans. One study showed that supplementation could help students who suffered from anxiety due to exams. They had improved appetite and mood, better concentration, and less fatigue ^[5]. In other studies, students that received 2.5g per day of PUFAs had a decrease in anxiety symptoms. The purported mechanism of action of omega-3 fatty acids is that they decrease inflammation. In particular, they decrease inflammatory pathways that occur in the brain and that promote anxiety.

Inositol

Inositol has been investigated for treatment of anxiety. One well-controlled trial tested inositol as compared to medication. Twenty subjects of both sexes aged 18-65 years were treated with 18g of inositol daily for one month. The results showed that inositol successfully decreased anxiety symptoms. These results were in-line with results of an earlier study that showed that 12g of daily inositol was helpful in reducing panic symptoms ^[6]. In a smaller study that was conducted, inositol was used at 18g per day for six weeks in those who suffered from obsessive compulsive disorder and was shown to be helpful. Even in people with eating disorders like bulimia and binge eating disorder, inositol can be used and can have positive effects. Inositol is best used at higher doses (12 to 18g). It seems to have a better therapeutic effect at these doses, but also may cause more side effects. The most common side effect is mild gastrointestinal distress.

L-theanine

L-theanine, an amino acid contained in green tea leaves, has been thought to cause anti-stress effects by inhibiting cortical neuron excitation and it can be quite helpful for anxiety ^[7]. In one study, 200mg of L-theanine or caffeine plus placebo were administered to 14 participants. The participants then performed mental and physiological tasks under conditions of physical or psychological stress and completed a mood-related questionnaire. The results showed that L-theanine reduced the Tension-Anxiety scores as compared with placebo. In another study, L-theanine was compared with a standard benzodiazepine (alprazolam) and placebo on behavioural measures of anxiety in healthy human subjects using the model of anticipatory anxiety. Sixteen healthy volunteers received 1mg of alprazolam, 200mg of L-theanine, or placebo. The acute effects of alprazolam and L-theanine were assessed under a relaxed and experimentally induced anxiety condition. Subjective reports of anxiety were completed, including multiple validated questionnaires. These were completed before, during, and after task administration. The results showed that L-theanine caused relaxing effects during baseline testing.

 Final Thoughts

In this article, we discussed how serious anxiety can cause a number of uncomfortable physical symptoms; chiefly worrying thoughts. The severity of anxiety also varies depending on coping skills that have been learned through experiences in life. Long-term stress can be devastating physiologically to a number of organ systems. From a diagnostic perspective, GAD is diagnosed using the DSM-5 criteria, which include the need for symptoms to be present for at least 6 months. Symptoms must also have a significant impact on the activities of daily life for GAD to be considered as a diagnosis. However, for many people the stressors that they are regularly exposed to can cause quite a bit of distress, even if it does not perfectly fit the diagnosis of GAD. Conventional treatments can be very helpful. In particular, therapy through the use of CBT has shown long-lasting positive effects. Medications are also helpful, but are often accompanied by unpleasant side effects.

Naturopathic medicine offers a number of supplement options. We discussed omega-3 fatty acids (or PUFAs), inositol, and L-theanine. These therapies can be tried alone or in conjunction with one another. Remember that inositol is most helpful at higher doses (up to 18g) and may be accompanied by mild gastrointestinal side effects. In addition to these therapies, there are a number of other options available. B vitamins can address underlying biochemical imbalances or nutrient depletions. There are also a large number of herbal options that can help decrease anxiety, including items like rhodiola, ginseng, withania, and kava. Herbs can be consumed as teas, tinctures, tablets, or capsules. With all the options available, it is always our recommendation that you seek advice from your naturopathic doctor, who will be able to tailor treatments to your individual presentation.