Introduction

Brief Overview of Generalised Anxiety Disorder

Anxiety is a feeling we all experience – it can occur when we are worried about something, stressing about the future or experiencing fear. While most symptoms appear mentally, it can also manifest physically. It is a common feeling, but is considered a mental health problem referred to as generalised anxiety disorder (GAD) when it begins to impact daily life. In GAD, the level of worry is typically out of proportion to the actual situation, and the persistent anxiety becomes difficult to control. It can interfere with work, relationships, and routine activities, making everyday tasks feel daunting.

Medical Cannabis as an Alternative Treatment

Current treatments used to treat GAD include various different types of pharmacological therapies, such as selective serotonin reuptake inhibitors (SSRIs) and therapy. The standard treatment is effective however, approximately 50% of individuals do not respond to the first line of treatment and up to 30% of people will not respond to more than one medication.¹ Furthermore, it may take up to 12 weeks before any sense of relief is felt and whilst initially starting on medication, people often feel worse. Due to these inconveniences, alternative treatment options such as medical cannabis have been explored. Studies have shown that 50% of individuals taking medical cannabis had reported lower levels of anxiety, better quality of sleep and life in general. This has shown promising benefits which will be further explored throughout this article. 

Understanding Generalised Anxiety Disorder

Clinical Definition, Diagnosis and Symptoms

The International Classification of Diseases, 10th revision (ICD-10), is used by physicians to diagnose and classify different medical conditions. GAD has been defined as feelings of worry, apprehension about day to day life events and problems that last a minimum of 6 months. Symptoms have been organised into four categories, where one symptom from each class has to be met:²

Autonomic Arousal Symptoms:

• Palpitations and elevated heart rate
• Sweating
• Shaking
• Dry mouth

Chest and Abdomen Related Symptoms

• Chest pain
• Nausea
• Breathing difficulties
• Sensations of choking

Brain and Mind Symptoms

• The fear of death
• Feeling detached from reality or as though you're not fully present
• Feeling dizzy or light headed
• Scared of losing control

Other Symptoms

• Hot flashes/cold chills
• Difficulty relaxing and feeling restless
• Trouble concentrating
• Increased irritability
• Insomnia 

Typical Treatments for GAD

Selective Serotonin Reuptake Inhibitors

SSRIs are the first line of treatment used to treat depression and anxiety.³ A hypothesis behind the pathophysiology of GAD is low serotonin levels, hence serotonin makes a suitable therapeutic target. SSRIs work by inhibiting serotonin uptake transporters, increasing the concentration of serotonin in the brain, which aims to alleviate symptoms of GAD. They are usually taken in tablet form but can also be taken as a capsule or in liquid form.  SSRIs have little impact on different neurotransmitters such as dopamine which are crucial in various functions including motor control, making them an advantageous pharmacological therapy. Additionally, there are less side effects compared to other drug types, highlighting it’s significance in GAD treatment. 

Talking Therapy

Another form of treatment for GAD is therapy. There are different types of talking therapies available such as cognitive behavioural therapy (CBT), counselling and guided self help. It may be one to one sessions or in a group. The aim of therapy is to create a safe place to allow individuals to feel comfortable to explore their thoughts and feelings without judgment. 

CBT, in particular, focuses on identifying and challenging negative thought patterns and behaviours. Its goal is to break the cycle of unhelpful thinking that fuels anxiety. This form of therapy is practical and often includes tasks or “homework” between sessions, such as journaling or practising coping strategies.CBT sessions range from 6 to 15 weeks or even longer depending on each individual. Over the course of therapy, individuals are introduced to a variety of techniques and tools that they can begin to integrate into their daily routines to better manage and reduce anxiety symptoms.

Limitations of Current Treatment Options

Current medications and therapy have shown to be of great help for those with GAD but there are several issues that need to be addressed. 

Pharmacological Interventions (Drugs/Medication)

SSRIs are effective but according to clinical trial data, 30-40% of people fail to experience long lasting benefits and relief.⁴ The medication just does not seem to work for them. For some, the first antidepressant prescribed simply does not work, and it becomes necessary to try different types before finding one that helps. In addition, it can take between two to six weeks before evident effects on anxiety appears. This waiting period can feel particularly long and frustrating when anxiety is already having a significant impact on daily life and well-being. 

Furthermore, there is a very strong understanding on how these medications work but the long term effects of taking them are less understood. Many clinical trials are quite short, lasting around 8-12 weeks. There are very few trials lasting longer than 6 months and even fewer that run for a year. As a result, questions remain about how long someone should remain on the medication, how often adjustments should be made, and what the long-term consequences of sustained SSRI use might be.

Another problem with taking medication to help manage GAD, is the possible side effects. Around 30 to 50% of people experience common side effects such as headaches, nausea, insomnia and restlessness. One third of people on medication also experience sexual dysfunction and reduced interest. Some long term side effects include emotional blunting, weight gain and discontinuation symptoms. 

Therapy

Therapy and talking about your anxiety is important to address the underlying issues that may be causing and triggering the observed symptoms. As effective as it can be, there are also some problems associated with it. One of the main problems are the long waiting times before you can start therapy. It can take anywhere between 3 to 6 months after being referred within the National Health Service (NHS).⁵ The NHS is underfunded and many clinics have long waiting lists with limited resources. While seeking private therapy can provide faster access, it is often costly, making it inaccessible for many. Therapy also demands active participation, which can be challenging to manage alongside general life responsibilities. The time commitment for regular sessions are high, leading to a greater dropout rate for therapy than for medication, highlighting the need for more accessible and flexible treatment options. 

The Endocannabinoid System

The endocannabinoid system (ECS) plays an important role in the nervous system by regulating neuronal activity and function. Endocannabinoids are neurotransmitters (chemical messengers) that are produced when needed. They work by binding to specific receptors which then trigger a cellular change. It controls and maintains many bodily functions such as:

• Sleep
• Memory
• Immune responses
• How we deal with pain
• Inflammation
• Temperature
• Appetite 

What Makes Up the ECS

The main components of the ECS are tetrahydrocannabinol (THC) and cannabidiol (CBD). There are two main receptors – CB1 and CB2 through which the system works. CB1 receptors are found within the nervous system and the brain, and interacts with many neurotransmitters such as serotonin and dopamine (important for mood regulation) in neurones. CB2 receptors can be found in cells that are involved in the immune response.⁶

THC is the active component which interacts with the CB1 receptors, producing psychoactive effects that are also observed when taking recreational cannabis. THC interacts with CB2 receptors to regulate immune functions. Some effects of THC include:

• Euphoria
• Less pain
• Altering levels of anxiety
• Increased appetite
• Changes to memory

On the other hand, CBD is the non-active component. It does not cause intoxication and effects related to it include cognitive impairments. It works indirectly by increasing levels of natural endocannabinoids. It interacts with other receptor systems such as serotonin, producing effects such as:

• Reduced anxiety
• Feelings of tiredness
• Anti-inflammatory effects
• Modulates pain 

How Does Cannabis Help With GAD

Recently, there has been growing interest in the use of medical cannabis as a potential treatment for GAD. It has potential benefits of reducing feelings of constant worry, improve sleep, lower fastened heart rate and produce overall calming effects.⁷ 

CBD indirectly activates the ECS. Rather than binding to CB1/CB2 receptors, it blocks an enzyme instead, resulting in higher levels of anandamide (a fatty acid that promotes well-being). By increasing anandamide levels in the brain, it helps to reduce anxiety and prolongs the calming sensation for a longer period of time. Additionally, it also makes the amygdala less active (the part of the brain that regulates fear) and increases serotonin levels, reducing stress levels overall. 

In contrast, THC directly activates the cannabinoid receptors, specifically the CB1 receptors in the brain and nervous system. This enhances the endocannabinoids already present in the body. Lower doses work best to reduce anxiety by lowering the body’s response to stress and enhancing relaxation. However, higher doses may cause more anxiety, thus a balance in dosage is crucial in GAD treatment. It is important to start with lower doses and for it to be strictly monitored.

Summary

Medical cannabis is emerging as a potential treatment for GAD, specifically targeting people who haven’t had success with conventional treatments. The standard treatments, while beneficial, also have limitations whereby a large proportion of individuals with GAD need to try many different medications or wait a long time to receive therapy before any relief is felt. Hence, research into the therapeutic effects of medical cannabis could act as a solution. 

Medical cannabis works through two ways: CBD helps to increase the body’s natural calming mechanisms whilst THC has a stronger effect that requires low doses to begin with. Both these pathways can help reduce anxiety and increase the quality of life. This has promising results but further research is essential to determine optimal dosing and how it needs to be altered for each person. For those that have little to no relief in their anxiety, medical cannabis provides hope to reduce that struggle.