ANXIETY

BY MATT JACKSON, PHD

This article hits close to home. I have an anxiety disorder. I work hard at it, and I’ve been pretty successful coping. But there are still days when I just can’t control it. Sometimes I wake up, and without a conscious thought to it, my nervous system is on fire. My muscles feel permanently constricted. My mind races frantically from one point to the next. What I need most is to relax, but even thinking about trying to relax intensifies my anxiety. I’m not alone—40 million adults in the United States experience an anxiety disorder every year 1 —and about half of all people use medicinal cannabis to manage anxiety. 1,2 Count me in.

It’s normal to worry about things big and small: about work, a presentation, paying the bills, where the world is heading. But when worries interfere with day-to-day functions, anxiety becomes a disorder. Past trauma, specific phobias, or just daily life can trigger panic—the quintessential anxiety disorder is post-traumatic stress disorder (PTSD) 3 —and what gets triggered is a neurological response centered in fear. For example, people with PTSD have a hyperactive amygdala, an evolutionarily ancient part of our brain that stores fear-related memories and responds to threats with fear, aggression, and defensive behavior. 3 The effects aren’t just psychological, though. Anxiety can cause physical symptoms such as headaches, nausea, and gastrointestinal problems.

Treating anxiety disorders is generally at two-part process. The first part is medication, primarily with selective serotonin re-uptake inhibitors (SSRIs) for long-term anxiety management and benzodiazepines such as Valium—which can be addictive—for acute attacks. As with any medication, there can be side effects: nausea, drowsiness, headaches, and sexual problems. The second part, cognitive behavioral therapy (CBT), is just as important. CBT is a type of professional counseling that helps people recognize thought patterns and change behaviors that lead to anxiety. Both medication and CBT are equally effective, and their effects combine for the best chance at long-term anxiety management. 4

Millions of people are using cannabis as an alternative medication for anxiety disorders, and in several surveys, most people reported exceptional anxiety relief. 2,5,6 But there’s also a bit of a paradox, because 10–20% of users consistently report anxiety as a negative side effect of cannabis. 2,6

Honestly, at this point in time, we have more questions than answers. We know our ECS plays a role in anxiety. Patients with PTSD have more type I cannabinoid (CB1) receptors in their nervous systems and lower concentrations of natural endocannabinoids that activate those receptors. We also know that anxiety is a major negative side effect of pure THC, but pure CBD can reduce anxiety by decreasing neural activity in the amygdala, similar to benzodiazepines. 2 However, when we look at how people respond to the whole cannabis plant, these trends don’t really hold.

We often focus on THC and CBD as the main components of cannabis, but they alone can’t explain the differences between cannabis cultivars. A cannabis plant has over 150 different terpenes; different combinations give each cultivar its unique smell and taste. 2 It’ll take a long time before we understand how all these components work in concert—a synergistic action called the “entourage effect”—but meanwhile, scientists have asked the experts: cannabis users!

One thing is clear, not all cultivars of cannabis are equally effective for relieving anxiety. In one survey, 84% of users in Canada reported that medical cannabis helped relieve their anxiety. About 40–50% of people reported anxiety relief using C. indica and hybrid cultivars, compared to 7-10% reporting increased anxiety. The results for C. sativa cultivars were far more mixed; 30% reported increased anxiety, the same percentage of people reporting relief. 5

Another study went even deeper and examined the total cannabinoid and terpene content in cannabis cultivars that were reported as best for anxiety (Bubba Kush, Skywalker OG Kush, Kosher Kush) and least effective (Chocolope, CBD Shark, Tangerine Dream). Interestingly, one slightly C. sativa-dominant hybrid (Blueberry Lambsbread) made the list as both most effective and least effective, 1 meaning people had vastly different experiences with the same cultivar.

So, how can you find the cultivar of medical cannabis uniquely suited for your anxiety? Try focusing on cultivars that are pure C. indica or C. indica-dominant hybrids and have low CBD. Try a few cultivars at different doses and keep notes on which is most effective for you.

But what about long-term anxiety management? Well, here’s where it gets a little tricky. If you find that medical cannabis helps with sudden anxiety attacks but doesn’t reduce how often the attacks occur, then there are concerns about dependency, even if cannabis itself isn’t considered addictive. After all, long-term management is the main reason why SSRIs are prescribed first, instead of benzodiazepines. But if you want to avoid pharmaceuticals altogether, you should consider integrating medical cannabis with professional therapy—CBT counseling in particular.

Unfortunately, easy access to medical cannabis appears to be leaving therapy out of the equation for some. In one study, 80% of Californians who used medical cannabis for anxiety or depression were not prescribed cannabis for that reason, 1 so they wouldn’t have received professional recommendations for therapy. In another study, only 20% of Canadians using medical cannabis for anxiety disorders had ever received CBT counseling. Some of these people were also using considerable amounts of cannabis—23% used≥3 grams cannabis per day. 5 Another study hinted that stronger doses of cannabis may not provide better symptom relief but could cause more side effects, both positive and negative 6 —you can read more about that study in the Research Corner on page 14.

Overall, medical cannabis could prove extremely effective for relieving anxiety symptoms. Each person is unique though, so finding the cultivar and dosage that works for your anxiety will require some experimentation. But even with that, conventional medication or cannabis is only half the battle. If you face persistent anxiety attacks, talk to your doctor; professional CBT counseling may be the missing piece for long-term anxiety management.

References | 1Kosiba, J., Maisto, S., and Ditre, J. “Patient-reported use of medical cannabis for pain, anxiety, and depression symptoms: Systematic review and meta-analysis.” Social Science & Medicine 233 (2019): 181-92. https://doi.org/https://doi.org/10.1016/j.socscimed.2019.06.005. 2Kamal, B., Kamal, F., and Lantela, D. “Cannabisand theanxietyoffragmentation—asystemsapproach forfinding an anxiolyticcannabischemotype.” Frontiersin Neuroscience12 (2018): 730. https://doi.org/10.3389/fnins.2018.00730. 3Zoellner, L., Rothbaum, B., and Feeny, N. “PTSD notan anxietydisorder? DSM committeeproposal turnsbackthehandsoftime.” Depression and Anxiety28, no. 10 (2011): 853-6. https://doi. org/10.1002/da.20899. 4Cuijpers, P., Sijbrandij, M., Koole, S., Andersson, G., Beekman, A., and Reynolds, C. “Adding psychotherapy to antidepressant medication in depression and anxiety disorders: a meta-analysis.” World Psychiatry 13, no. 1 (2014): 56-67. https://doi.org/10.1002/wps.20089. 5Turna, J., Simpson, W., Patterson, B., Lucas, P., and Van Ameringen, M. “Cannabis use behaviors and prevalence of anxiety and depressive symptoms in a cohort of Canadian medicinal cannabis users.” Journal of Psychiatric Research 111 (2019): 134-39. https://doi.org/https://doi.org/10.1016/j.jpsychires.2019.01.024. 6Stith, S., Vigil, J., Brockelman, F., Keeling, K., and Hall, B. “Theassociation between cannabisproductcharacteristicsand symptom relief.” NatureScientificReports9, no. 1 (2019): 2712. https:// doi.org/10.1038/s41598-019-39462-1.