Abstract

Stress and Anxiety levels are on the increase in todays busy society which is so focused on work
ethic. Today, people tend to neglect time to relax and wind-down, and this can be the cause of
many cases of anxiety and depression. This is the case for Isabella, a 29 year old who has
suffered anxiety attacks since she was 16. In the present day, Isabella is highly aversive of social
situations in which she has to communicate with others, due to fear of blanking out. In
accordance to the DSM-5, her symptoms have been diagnosed as Generalised Anxiety Disorder,
and the decision to implement Mindfulness-Based Stress Reduction (MBSR) has been made after
the careful reviewing of previous Minfulness-Based Therapy trials. MBSR should be used as a
first-hand approach as it firstly improves sleep, reducing mental and therefore physical stress.
The reduction of this stress can pave the way for improvement, and subsequently further
alternative methods of treatment including Avoidance Therapy.

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The people of todays world are finding it more and more difficult to find time to themselves.
With an increase in praise for a strict work ethic, the importance of social activities and both
mental and physical wellbeing are overshadowed. To combat stress, various methods including
meditation, and physical and mental exercises have been employed. For more serious cases
where stress may lead to self-harm, the patient must be introduced to specific psychiatry.
However, the clinical methods of stress reduction, known as Mindfulness Based Stress
Reduction (MBSR) and Mindfulness Based Cognitive Treatment (MBCT) have been proven by
multiple studies to be effective in treating severe stress, anxiety and depression, without the use
of medication. The aim of this essay is to focus on the report of anxiety by 29 year old Isabella,
and to provide an accurate diagnosis, and an effective treatment plan which centres on
mindfulness-based stress reduction techniques.

Upon initial assessment, Isabella was diagnosed with Adjustment Disorder with
Anxiety. This diagnosis can be explained by her verbal account of anxiety attacks and constant
worry of negative outcomes. It is reasonable to diagnose her with an adjustment disorder
considering that she initially turned down her promotion at work, and also the fact that she
avoids having conversations with colleagues or affiliates due to a fear of stumbling on words.
However, Isabella further explains that she had her first anxiety attack at the age of 16, and
claims she was always a worrier but cannot remember when this began. This information
indicates that whatever the stressor was which stimulated her condition occurred at least 10 years
ago. This description does not thus fit with the diagnosis of an adjustment order. According to
The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American
Psychiatric Association, 2013, herein referred to as DSM-5), in order to be properly diagnosed
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with an adjustment order, ones symptoms must have occurred as a response to a stressor within
3 months of it happening, and symptoms should not persist more than 6 months

Although Isabella may not have an adjustment disorder, it is quite clear that she may
be suffering from a Generalised Anxiety Disorder (GAD). Her reported symptoms are analogous
to those outlined in the DSM-5. These include her difficulty sleeping, her mind going blank
during conversations, and a general feeling of being on edge due to her worrying. These
symptoms fulfill three out of six symptoms outlined byt eh DSM-5, which is sufficient to assume
a generalised anxiety disorder. In addition to this, Isabella meets the criteria for GAD which
states that the individual has difficulty controlling the worry, and that the duration of these
symptoms has persisted for the past 6 months. Point (D) of the diagnostic criteria states that the
anxiety or stress should lead to social and occupational areas of functioning (5th ed.; DSM-5;
American Psychiatric Association, 2013), which is what can be seen in Isabella. It is also
important to note that these symptoms are not a result of drug use.

Isabellas scores on the Depression Anxiety and Stress Scale (DASS) further highlight
her stress levels. According to the DASS by Lovibond & Lovibond (1995), a depression score of
10 is interpreted as Mild, 19 for anxiety is interpreted as Severe, and a stress score of 40 is
seen as Extremely Severe. From this we can see that Isabellas condition appears to skew
towards anxiety and stress, rather than depression. This further supports the symptoms of GAD.
While there is much here to suggest that Isabella is suffering specifically from anxiety, there are
also several possible comorbidities that can be assumed from her report. These include Panic
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Disorder, differentiated from isolated panic attacks as she reports she had been having these
anxiety attacks since the age of 16. Alongside GAD, she may also be experiencing Social
Anxiety, or even Agoraphobia. Social Anxiety is implied by her avoidance of social situations,
such as having conversations with colleagues, and fear of giving presentations, while symptoms
for Agoraphobia include a fear of negative outcomes from being seen in public (5th ed.; DSM-5;
American Psychiatric Association, 2013). For this, Isabella states that she avoids public
transport, or eating at restaurants, and she mentions she rarely visits cinemas in fear of being
stared at. Although Isabellas symptoms do in fact show comorbidity with other disorders, they
cannot be better defined by the criteria of any other disorder, which means the best assumption is
that she is suffering from GAD. However, it is still necessary to determine whether her
symptoms occur more days than not throughout the week in order to provide a holistic diagnosis.

With the assumption that Isabella is indeed suffering from a generalized anxiety disorder,
the next step would be to determine the most effective treatment. There are many treatments
available for anxiety, both on a psychological and psychiatric level. Due to the fact that Isabella
presents no harm to herself, or society, it is unnecessary to address the situation by
administration of psychiatric medication. A pschological method of reducing anxiety and stress
which is widely clinically implemented is mindfulness-based stress reduction (MBSR). As
described by Winbush, Gross & Kreitzer (2007), MBSR is a clinically standardized
psychoeducational intervention which aims to aid individuals in self-management, and to change
individuals perspective on worrisome and intrusive thoughts. However, before determining
whether this is an effective first-line treatment for Isabella, the methods of MBSR and MBCT
must be scrutinized.
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Division 12 Task Force criteria of the Workgroup criteria for identification of

empirically supported therapies (Chambless & Ollendick, 2001. P. 689) outlines a list of criteria
under which treatment is considered effective. Through analysis of various case-studies, it is
shown that mindfulness-based therapy can be considered effective in treating anxiety. Chambless
& Ollendick (2001) state that in order for treatment to be effective, experiments must be
conducted with treatment manuals or equivalent clear description of treatment (Chambless &
Ollendick, 2001. P. 689, table 1, III), and also that the characteristics of the patient must be
specified. Both the initial diagnosis of Isabella, and subsequent further in-depth diagnosis were
made following the guidelines of the DSM-5, according to self-reported symptoms of the patient.
This satisfies the first half of criteria for and effective treatment plan.

The second half of the criteria includes the analysis of different studies involving the
treatment, and in particular, if those studies provide a critical comparison between MBSR and
other forms of treatment. The various studies conducted on this matter have emerged with both
the advantages and disadvantages of mindfulness-based therapy. A study conducted by Warchand
(2012) concluded that both MBSR and MBCT should be used on conjunction for the best results,
and should be used for both anxiety patients and healthy individuals. His study involves
clinically based methods that employ manuals and standardized techniques. This satisfies the
criteria of effective methods of treatment, set by Chambless & Ollendick (2001). Mindfulnessbased therapy is also seen as an effective method of stress reduction, as well as anxiety and
depression reduction by Khoury et al. (2013). Fjorback, Arendt, Ornbol, Fink & Walach (2011)

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made a comparison between patients and a wait list control and found that MBSR significantly
improved mental health in 11 studies, compared to the efficacious wait list or treatment as usual
control groups. The results of these studies clarify that MBSR is an empirically validated method
of managing stress, however there is still the question of whether this method can be conducted
in a home-setting, in order for patients to have greater access to its effects. Another limitation of
this specific study includes the lack of follow-up studies.

A study conducted by Galante in 2012 however, does involve follow-up studies. In this
experiment, Galante initially compared MBCT to usual treatment. A one year follow-up MBCT
trial showed a reduction of the rate of relapse in patients with three or more episodes of
depression by 40%. Although this study involved depression patients, it is still necessary to
review to determine the effectiveness of MBCT. MBCT, as researched by other psychologists
including Warchung (2012), and Fjorback,et al (2011), has been shown to be more effective in
patients with depression, and preventing relapse in depression. As Isabellas score 10 for
depression in the DASS is seen as mild, it is evident that she needs to focus more on addressing
her symptoms of stress and anxiety, for which she scored either sever or extremely sever in the
DASS.

At this point, it appears that MBSR is the most effective first-line treatment for
Isabellas case. However, it would be negligent not to consider other treatment alternatives such
as Avoidance therapy. Due to the fact that she is avoiding social situations such as conversations
and public speaking, it may therefore be beneficial to expose her to the distress and uncertainty
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of those specific situations. However, considering the trauma she already endures at the thought
of these experiences, avoidance therapy may in fact intensify her anxiety, and create a new
traumatic experience for her. Although avoidance therapy may be difficult, and not
recommended as a first-line treatment, it should not be neglected. MBSR should be implemented
first, altering Isabellas outlook on negative outcomes, and once improvements are shown, she
should be introduced to Avoidance therapy. Further support includes the fact that MBSR has
been evidenced to improve sleep by decreasing sleep-interfering cognitive processes including
worry (Winbush, Gross & Kreitzer, 2001). This strongly supports MBSR being a first-line
approach as it works quickly to improve sleep, therefore allowing her body to physically reduce
stress. With this initial reduction of stress, the improvement of Isabellas mental well-being can
be made easier through MBSR.

In accordance to the DSM-5, it can be safely assumed that Isabella is suffering from a
generalized anxiety disorder. This is determined in the fact that she has high social aversion, and
uncontrollable worry. Her symptoms have persisted in the last 6 months; however it is unclear
whether she experiences these symptoms more days than not throughout the week. However,
with that minor detail aside, it is clear that her other symptoms are alluding to GAD. Her
symptoms indicate comorbidity with disorders including Panic Disorder, Social Anxiety, and
Agoraphobia; however, the majority of the symptoms are most efficiently characterized by GAD.
With many recent studies legitimizing the practice, and effects of mindfulness-based therapy, it is
appropriate to first carry out this method of treatment for Isabella. MBSR treatment should come
before any other treatment as it works with Isabella and her own cognition; changing her
perspective on negative outcomes, fear, worry, and anxiety. Alternative methods of treatment
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should only be implemented once the patient shows significant signs of improvement from
MBSR. These alternative methods may include avoidance therapy.

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American Psychiatric Association. (2013). Cautionary statement for forensic use of DSM-5. In
Diagnostic and statistical manual of mental disorders (5th ed.). doi:10.1176/appi.books .
9780890425596.744053
Chambless, D.L., Ollendick, T.H (2001) Empirically Supported Psychological Interventions:
Controversies and Evidence. Annual Review, Vol 52. 685 - 716

Fjorback, L. O., Arendt, M., Ornbl, E.,... Walach, H. (2011). Mindfulness-based stress reduction and
mindfulness-based cognitive therapy - a systematic review of randomized controlled trials. Acta
Psychiatrica Scandinavica, 124(2):102.
Galante, J. (2012) Effects of mindfulness-based cognitive therapy on mental disorders: a systematic
review and meta-analysis of randomised controlled trials. Journal of Research in Nursing. Vol 18, no. 2
133 155

Khoury, B., Lecomte, T.,... Hofmann, S. G. (2013). Mindfulness-Based therapy: A comprehensive metaanalysis. Clinical Psychology Review, 33(6), 763-771.
Marchand, W. R. (2012). Mindfulness-based stress reduction, mindfulness-based cognitive therapy, and
zen meditation for depression, anxiety, pain, and psychological distress. Journal of Psychiatric Practice,
18(4), 233.

S.H. Lovibond, P.F. Lovibond (1995). Manual for the depression anxiety stress scales. Sydney, N.S.W. :
Psychology Foundation of Australia, c1995. Section 4, pp. 23-30.

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Winbush, N. Y., Gross, C. R., & Kreitzer, M. J. (2007). The effects of mindfulness-based stress reduction
on sleep disturbance: A systematic review. Explore, 3(6), 585

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