What causes workplace anxiety?
American psychologist, Dr Melanie Katzman writes that the pandemic has forced us into a highly alert emotional state where unpredictability has become the norm. Unpredictability can lead to uncertainty and stress, which in turn fuel fear. Some fear that they might contract the virus if they return to work, infecting their loved ones, while those who have been infected, fear re-infection or stigmatisation.
When stress (eg typically lasting six months or more) becomes persistent, irrational, overwhelming and impairs daily functioning, it may result in the development of an anxiety disorder (AD). Anxiety and depressive disorders are common internalising psychiatric disorders and often coexist.
According to the Diagnostic and Statistical Manual for Mental Health Disorders, Fifth Edition (DSM-5), AD presents as excessive and persistent fear and worry that lead to behavioural disturbances. Fear is the emotional response to a real or perceived imminent threat, whereas worry in anticipation of a future threat.
A 2017 workplace survey conducted by the Anxiety and Depression Association of America, found that 33% of respondents reported having an anxiety or panic attack at least once, in their lifetime, 56% indicated that anxiety affects their job performance, and 50% report a negative impact on relationships with colleagues and peers. Nepon et al found that 70% of individuals with AD, try to commit suicide regularly throughout their lifetime.
How can anxiety be addressed?
Helping patients overcome fear
Guidelines recommend cognitive therapy (CT) (see NICE guideline below) as the first step in helping patients overcome fear, one of the main criteria of AD as stated above. La Freniere and Newman recently published the findings of their study in which they asked participants to record their fears in a ‘worry outcome journal’. Participants were then asked to indicate how many of their fears actually came true.
They found that on average, 91.4% of worries did not come true, that participants with higher percentages of untrue worries experienced fewer symptoms, and that 30% of those whose worries did come true, reported that the outcomes turned out better than expected.
Confirmation that almost all worries do not come true, can therefore lead to symptom improvement, write La Freniere and Newman. They recommend that therapists use this technique to draw patients’ attention to the evidence that their worries are in fact unrealistic, unlikely, and unhelpful. As they realise that their long-held beliefs may be flawed, it may increase their faith in the CT model proposed by the therapist, which in turn will improve treatment outcome.
La Freniere and Newman recommend that CT should continue to aim for correcting maladaptive cognitions with renewed confidence. In cases where a patient’s worries are often shown to be (or perceived to be) true, alternatives to CT may be chosen (eg relaxation training, cognitive diffusion, or mindfulness).
In the rare instances that worry did come true, therapists should engage in reframing or identification of errors in outcome interpretations. When worries are supposedly confirmed, therapists may discuss with the patient whether their interpretations of outcome were accurate and whether the consequences were truly so dire.
The 2019 National Institute of Health and Care Excellence (NICE) guideline recommends a stepped care treatment model for patients with generalised AD (GAD):
Table 1: NICE stepped care model
Before prescribing any medication, discuss the treatment options and any concerns the person with GAD has about taking medication. NICE recommends the following in terms of pharmacotherapy for patients who do not show any improvement following step 1 and 2 approaches:
- Offer pharmacotherapy as an option
- Start with treatment with a selective serotonin reuptake inhibitor (SSRI)
- If a SSRI is ineffective, offer a serotonin–noradrenaline reuptake inhibitor (SNRI), taking side effect profile into account
- If the patient cannot tolerate SSRIs or SNRIs, consider offering pregabalin. Evaluate patients carefully for a history of drug abuse before prescribing and observe patients for development of signs of abuse and dependence
- Do not offer a benzodiazepine for treatment in primary or secondary care except as a short-term measure during crises
- Do not offer an antipsychotic in primary care
- Review the effectiveness and side effects of the agent/s every two to four weeks during the first three months of treatment and every three months thereafter
- If the drug is effective, advise the patient to continue taking it for at least a year as the likelihood of relapse is high
If the patient exhibits an inadequate response to step 3 interventions:
- If the patient does not respond to a full course of a high-intensity psychological intervention, start pharmacotherapy
- Consider referral to step 4 if the patient experience severe anxiety with marked functional impairment
- Inform the patient who has not been offered or have refused interventions in steps 1–3 about the potential benefits of these interventions, and offer them any they have not tried
- Consider offering combination pharmacotherapy treatments eg antidepressants or augmentation of antidepressants with other drugs, but exercise caution
- Combination treatments should be undertaken only by practitioners with expertise in the psychological and drug treatment of complex, treatment-refractory anxiety disorders and after full discussion with the patient about the likely advantages and disadvantages of the treatments suggested.
Tips to overcome workplace anxiety
Patients should be encouraged to:
1. Return to work: In addition to financial reasons, working can be important for self-esteem and it adds to our social identity.
2. Confide in a trusted colleague: Encourage your patient to confide in Knowing that someone accepts is aware of your condition can be comforting and it may reduce any anticipatory anxiety about having a panic attack at work.
3. Educate themselves: Symptom recognition and how to handle them can help them manage their condition better.
4. Practice time management: This includes to-do lists to help them prioritise their work. It is important that they schedule enough time to complete each task or project.
5. Plan and prepare: Getting started on major projects as early as possible reduce anxiety. Setting mini-deadlines and anticipating problems and working to prevent them are helpful in this regard.
6. Do it right the first time: Spend extra time at the outset to prevent having to redo work.
7. Be realistic: Do not over-commit or offer to take on projects if there is realistically not enough time.
8. Ask for help: Feeling overwhelmed can lead to anxiety. Ask a colleague for help.
9. Communicate effectively: Speak up calmly and diplomatically if things start unravelling.
10. Stay organised: Filing, clearing a desk or computer desktop may rank low on priority lists, but they can save time in the long run and may prevent a crisis later.
11. Avoid toxic colleagues: Try to ignore negativity and gossip in the workplace.
12. Take breaks: A walk around the block or a few minutes of deep breathing can help alleviate symptoms.
13. Set boundaries: Try not to bring work home. Do not check work emails or voice mails after hours.
14. Savour success: Take a moment to celebrate good work before moving on to the next project. Thank everyone who helped.
15. Plan a vacation: To rejuvenate and return to work refreshed to work.
16. Take advantage of employer resources and benefits. Many workplaces offer employee assistance programmes, discounts to gyms, or skill-building courses.
17. Be healthy. Eat healthfully, get enough sleep, exercise regularly, and limit caffeine and alcohol.