Introduction
The patient, a 30 years old African American woman, was diagnosed with a generalized anxiety disorder (GAD). GAD is a relatively common disorder, and its rate is approximately 5.7% (Majid, Seghatoleslam, Homan, Akhvast, & Habil, 2012). It is often accompanied by different comorbidities that can include depressive disorders, addictions, and other illnesses related to behavioral changes. For several decades, the first-line intervention for GAD was pharmacotherapy. However, today researchers and medical professionals focus on psychological interventions as well in order to address the residual GAD symptoms that frequently remain in patients who undergo different therapies.
Review of Literature: Theory
One of the suggested interventions for addressing persistent symptoms of GAD in patients is mindfulness-based stress reduction (MBSR). Patients with GAD demonstrate persistent worry, anxiety, and other symptoms such as poor sleep, irritability, and muscle tension. According to MBSR, these issues may arise due to a patient’s inability to develop an accepting and gentle attitude toward oneself (Hoge et al., 2013). Using MBSR, patients take part in intensive training in mindfulness meditation, which can reduce anxiety symptoms and improve their quality of life (Majid et al., 2012). MBSR is an “intensive, structured, client-centered approach” that has been effectively tested in different settings, including schools, hospitals, and clinics (Majid et al., 2012, p. 2). MBSR applies to GAD because the nature of worry is future-directed; patients who participate in MBSR are trained to develop present-moment mindful awareness by using acceptance techniques. The underlying core of MBSR is the focus on the present moment, emotions, and bodily sensations; the focus should not be based on negative assumptions or approaches. Instead, MBSR is used to teach patients to approach their feelings and symptoms of anxiety and depression in a nonjudgmental way to reduce irritation and stress levels, thus helping them to accept emerging feelings and themselves.
MBSR is used in this case to address the patient’s worries and anxieties related to her employees and family. High job pressure, high expectations of her family, and the status of a golden child all contribute to Jasmine’s emerging worries and stress. MBSR practices that will be used are daily practices in a group session and home practices supported by audio recordings. Group sessions include “breath-awareness, a body-scan, and gentle Hatha yoga” that will help Jasmine focus on internal present-moment experiences and cultivate an accepting approach to herself (Hoge et al., 2013). At-home activities include different present-focused activities (e.g., the development of awareness during eating, cleaning, etc.).
With the help of MBSR, Jasmine will be able to better focus on her sensations and needs, therefore becoming aware of how job pressure and family increase stress levels and affect her well-being. Practices focused on moment-present awareness are needed to support Jasmine in building and engaging an accepting approach toward herself and her family, thus reducing the level of stress that she is currently experiencing due to her fear that she will not be accepted by her family if her status changes. MBSR effectively addresses not only the symptoms of GAD but also processes that lead to the development of this disorder.
Review of Literature: Evaluation
The researcher aims to use the tools suggested by Majid et al. (2012) and Hoge et al. (2013) to evaluate the levels of anxiety in the patient at the beginning of the intervention, during, and after it. Penn State Worry Questionnaire (PSWQ) is used by Majid et al. (2012) to measure the levels of anxiety in participants. Hoge et al. (2013) suggest using the Beck Anxiety Inventory (BAI) to evaluate participants’ anxiety symptoms. In Jasmine’s case, both of these tools will be used prior, during, and after the intervention to examine the anticipated progress in the reduction of Jasmine’s anxiety symptoms. The use of two tools is necessary to ensure the similarity in results. To address the lack of progress, cognitive-behavioral therapy (CBT) is suggested as a tool for intervention. If MBSR is ineffective, Majid et al. (2012) suggest supporting it with CBT that helps the client change their cognitive processes; in Jasmine’s case, it will help her develop personal coping strategies that will address the issues she has with her family and employee. CBT will be integrated into treatment as there is evidence that the combination of MBSR and CBT is highly effective among patients with GAD (Majid et al., 2012). Thus, MBSR will directly address Jasmine’s stressors, teaching her how to develop an accepting approach to herself and others, while CBT will change her cognitive processes related to these stressors (e.g., the view of herself as a golden child, inability to negotiate with her employer about high work pressure, etc.).
Journal Article Critique & Intervention Justification
As the effect of MBSR was addressed in other studies, the aim of the study conducted by Majid et al. (2012) was to examine whether an eight-week group MBSR program would be effective in treating patients with GAD. Pointing out that patients who underwent the MBSR program showed a more significant reduction in depression and anxiety symptoms, Majid et al. (2012) conducted a study that included thirty-three patients from different age groups (25 to 39 years old) who participated in an 8-week MBSR program. A quantitative method was chosen for this study, and its design was exploratory. The sample consisted only of male participants. In this study, MBSR was delivered by an experienced MBSR instructor. Patients attended a one-to-one orientation interview with the instructor, where they learned different meditation techniques such as body scan, mindful yoga, and sitting meditation.
For eight consecutive weeks, patients met for two hours in a group format; both teacher-led exercises and discussions of the mindfulness-based techniques were included. Each session was focused on a specific stress-reduction technique (Majid et al., 2012). Cognitive exercises (observing the association between worried thoughts, mood, and behavior) were introduced by the instructor to participants; they used it as homework (Majid et al., 2012). Participants were asked to practice meditation each week for at least 30 minutes. At the end of the intervention, participants completed self-reports. Using pre- and post-intervention scores on patient’s depression, anxiety, and worry symptoms, Majid et al. (2012) found that participants showed a reduction in depressive and anxiety symptoms. According to them, “MBSR produced clinically meaningful changes on measures of anxiety, mood, and worry” (Majid et al., 2012, p. 27). The authors conclude that mindfulness can ensure higher levels of psychological experience in patients with GAD and reduce their levels of anxiety (Majid et al., 2012).
The study conducted by Hoge et al. (2013) examined the influence of MBSR sessions on stress reactivity in participants diagnosed with GAD. Ninety-three individuals with diagnosed GAD participated in the study. Trier Social Stress Test was completed before the treatment. All participants were randomized into two groups: MBSR or Stress Management Education. MBSR program consisted of 8-week sessions that included breath-awareness, a body-scan, and gentle Hatha yoga (Hoge et al., 2013). Breath-awareness taught the participants to develop an awareness of body sensations. The body-scan technique included sequences of focusing on body sensations in its different parts, and Hatha yoga consisted of gentle stretching and focus on present experiences (Hoge et al., 2013). Participants were also instructed on how to engage in mindfulness practice at home (e.g., use present-focused awareness during different activities such as cleaning or eating).
Stress Management Education did not contain any mindfulness components and consisted of lessons that covered sleep physiology, insomnia, optimal nutrition, and factors that could buffer the impact of stress (Hoge et al., 2013). Stress Management Education was used separately from the MBSR program and took eight weeks to complete. Out of 89 subjects who were included in the modified ITT analysis, three of them discontinued before receiving any treatment, and one was later removed due to the lack of eligibility. Hoge et al. (2013) notice that quality of sleep improved in both groups, although the MBSR group showed somewhat greater results. Scores in stress reactivity tests were slightly different in MBSR and SME groups (SUDS scores 28.7 in the MBSR group and 39.4 in SME group). As to self-evaluation tests, a greater agreement with positive statements was observed in the group that completed the MBSR program (from 15.9 pre-intervention to 18.6 post-intervention) compared to the SME group (16.9 to 16.5). As to negative statements, the mean score decreased in both groups but did not differ between them. According to Hoge et al. (2013), significant reductions were found in almost all clinical outcome measures (CGI-S, CGI-I, BAI, PSQI) expect for HAM-A. It is suggested that no effect was observed on HAM-A due to its weigh on somatic rather than psychological symptoms (Hoge et al., 2013).
The intervention chosen for the client is the MBSR program. It is suggested that Jasmine will use the techniques common for MBSR such as breathing awareness, body scan, and yoga to develop a nonjudgmental approach toward events in her life and symptoms of GAD. A focus on one’s body can help overcome worrying (Ruiz, 2014). MBSR can also help her cope with the fear of being rejected by her family. Mindful eating and walking are interventions that can shift the focus from anxiety to awareness of one’s sensations.
Diversity Issues
According to Asnaani, Richey, Dimaite, Hinton, and Hofmann (2010), White Americans are more likely to be diagnosed with GAD compared to Hispanic and African Americans. However, Asnaani et al. (2010) assume that such results can be due to differing cultural perceptions of anxiety symptoms. The study conducted by Majid et al. (2012) included only male participants, which indicates that MBSR is useful for them. At the same time, as the educational level of these participants differed significantly ( the study included individuals with high school diplomas, college graduates, and individuals who did not complete high school), it is evident that MBSR is suitable for citizens with various educational levels. Therefore, MBSR’s outcomes should not be affected by Jasmine’s educational level.
The study conducted by Hoge et al. (2013) included male and female participants of different age (mean age of participants is 41 y.o.) and race (White, Black, Asian, and Other). No differences between races or sexes were observed in the study (Hoge et al., 2013). Jasmine is a 30-year-old African American woman; it is assumed that the results of both studies will benefit her treatment.
Generalized anxiety disorder is more common among women than men (ADAA, 2017). Asnaani et al. (2010) point out that difficulties in diagnosis might emerge exactly due to the specific wording of DSM-5, which might not reflect culturally specific experiences. Thus, the prevalence of GAD in the White population can be due to differently understood worded prompts in the diagnostic criteria. Individualistic vs. collectivistic values might also influence the rates of diagnosed GAD among different ethnic groups.
References
ADAA. (2017). Facts & statistics. Web.
Asnaani, A., Richey, J. A., Dimaite, R., Hinton, D. E., & Hofmann, S. G. (2010). A cross-ethnic comparison of lifetime prevalence rates of anxiety disorders. The Journal of Nervous and Mental Disease, 198(8), 551-555.
Hoge, E. A., Bui, E., Marques, L., Metcalf, C. A., Morris, L. K., Robinaugh, D. J., & Simon, N. M. (2013). Randomized controlled trial of mindfulness meditation for generalized anxiety disorder: effects on anxiety and stress reactivity. The Journal of Clinical Psychiatry, 74(8), 786-803.
Majid, S. A., Seghatoleslam, T., Homan, H. A., Akhvast, A., & Habil, H. (2012). Effect of mindfulness based stress management on reduction of generalized anxiety disorder. Iranian Journal of Public Health, 41(10), 24-28.
Ruiz, F. J. (2014). The relationship between mindfulness skills and pathological worry: The mediating role of psychological inflexibility. Anales de Psicología/Annals of Psychology, 30(3), 887-897.