(by Emily Landau, OHS Canada)
A 2002 federal report on mental illness in Canada determined that anxiety disorders — a blanket term that covers more than a dozen conditions, including generalized anxiety disorder (GAD), obsessive-compulsive disorder, post-traumatic stress disorder and panic disorder — are the most common of all mental illnesses. So why are so few people talking about them?
Mental health and wellness issues have enjoyed an enhanced profile in recent years, but anxiety disorders have not received the same levels of attention. “We talk a lot about depression, but forget about anxiety,” observes Joti Samra, Ph. D., an adjunct professor and research scientist at Simon Fraser University’s Consortium for Organizational Mental Healthcare in Vancouver.
Just why this is the case has not been pinned down, but Dr. Samra suggests it may be because anxiety does not carry some of the common tell-tale signs of depression, such as lateness or absenteeism. “For most people with mental health issues, that’s how they’re first flagged in the workplace,” she says.
Experts say anxiety disorders brought on or exacerbated by the workplace environment frequently manifest in presenteeism, a situation in which employees are present but, because of medical conditions, are not fully functioning or fully productive. Beyond presenteeism, there is the potential for conflict with colleagues, higher costs associated with prevention and accommodation, and work-related accidents.
Merv Gilbert, Ph. D., a registered psychologist and principal of the Gilbert Acton workplace health consulting firm in Vancouver, says the risk of on-the-job accidents and injuries in someone with an anxiety disorder is a “biggie.” Why? Dr. Gilbert points out that “a core feature of a lot of anxiety disorders is some degree of impairment in decision-making and concentration.”
More attention needs to be paid to the relationship between anxiety and at-work accidents, he argues. It is often the case, however, that “something has to happen [on the job] before anyone does anything.”
Dr. Gilbert cites a case in British Columbia where a worker had an accident upon returning to work — arguably too soon — following the death of a family member. “He was driving a piece of heavy equipment, and one of his coworkers looked in the cab and said, ‘He was there, but nobody was home,'” Dr. Gilbert says. “He wasn’t psychologically present,” he adds.
“I think [anxiety] is a huge buried iceberg of potential loss, not only to the individual and their families and to society, but to the employer,” comments Martin Shain, Ph. D., principal of the Neighbour@Work Centre, a workplace health consulting firm in Caledon Village, Ontario. Two questions need answers to identify the factors that contribute to an employee’s anxiety at work, Dr. Shain suggests: First, what pre-existing anxieties and concerns do people bring to their workplaces? Second, how does the workplace itself raise or lower the chances that employees will develop anxiety disorders?
Bill Wilkerson, CEO of the Global Business and Economic Roundtable on Mental Health in Port Hope, Ontario, says that anxiety disorders “are very treacherous, dynamic and disabling conditions when they’re either not treated or treated late or treated inadequately.”
Janet Haines, Ph. D., a lecturer at Australia’s University of Tasmania who has written extensively on work-related anxiety and phobia, says symptoms can be cognitive, such as feelings of impending doom, and physical, like increased heart rate, hot and cold flashes, stomach upset or tremulousness.
Most people can expect to experience these symptoms now and again. If severe anxiety becomes persistent, though, this may signal the possibility of an anxiety disorder.
The Diagnostic and Statistic Manual of Mental Disorders, Fourth Edition (DSM-IV), notes the most common anxiety disorder is GAD, characterized by “excessive anxiety and worry” for a majority of days over six months in which the anxiety causes “clinically significant distress or impairment.”
Beyond GAD, Wilkerson says, panic disorder and obsessive compulsive disorder may be the most common related conditions on the job. The former can result in a painful sensation in the chest that mimics a heart attack, while the latter causes fixations on minor details and an uncontrollable need to perform repetitive behaviours to reduce anxiety.
Wilkerson points to the case of a Toronto woman who could not leave her driveway without checking (once as many as 22 times) that she had locked the front door.
CAUSE AND EFFECT?
“The brain can heal itself, but the brain can also be bruised and damaged by social experience and bullying, chronic job stress, oppressive uncertainty [and] embedded frustration,” says Wilkerson.
“Seventy per cent of adults with anxiety and depression will have developed those symptoms in childhood.”
While there is currently no definitive knowledge of what causes anxiety disorders, experts suggest that it is a combination of biochemical traits, acquired behaviours and social experiences. “All the anxiety disorders have been found to have some kind of biological predisposition, and there have been a number of findings about brain-function abnormalities in most of the anxiety disorders,” says Dr. Michael Van Ameringen, an associate professor of psychiatry at McMaster University in Hamilton, Ontario.
“There are certain circuits in the brain that process information, respond to information, respond to things that are fear-related,” Dr. Van Ameringen explains. “These circuits can be overactive in some people, which you don’t find in people who don’t have an anxiety disorder,” he continues.
Beyond the mental turmoil experienced by those with anxiety disorders, the conditions have been linked to physical health risks, from immediate effects like fatigue and changes in appetite to some more serious long-term conditions.
“We know the division between mind and body isn’t as clear as medicine had made it out to be in the past,” notes Dr. Samra. “If you look at a range of chronic health conditions — cardiac disease, hypertension, diabetes — about half of individuals who have one of those conditions will also have co-morbid depression or anxiety.”
There is a “strong physiological component to anxiety, where people may be experiencing, most commonly, things like chronic pain, headaches and fatigue,” Dr. Samra says. “We know that depression, anxiety, stress — all of these things exist on a continuum. So all of us, at some point, fall somewhere along that scale,” she says.
For someone with an anxiety disorder, or at risk of developing one, the workplace can be a volatile environment. While most employees may characterize their workplaces as stressful, the effect is likely to be more pronounced, perhaps even debilitating, for those with anxiety disorders.
“Anxiety is really what we mean by stress, isn’t it?” asks Dr. Shain. “We’re not worried about stress unless it results in anxiety,” he observes.
With BlackBerry, e-mail and cellphones raising expectations of immediate response, today’s workplaces promise to ratchet up employee stress. “I think the workplace has been an intensified, unpleasant, technology-driven, isolating experience for lots of people,” asserts Wilkerson.
“It comes down to mental and emotional space — micromanaging, excessive e-mails, false deadlines, management practices which are driven by a world in which people are really not paying attention to each other’s own sensibilities. I think we’re treating each other more remotely.”
And it may be that loss of traditional one-to-one interaction that is worrisome. Wilkerson says harassment — which he defines as any behaviour that either “intentionally or negligently” produces injury to mental health — is responsible for a great deal of anxiety in the workplace.
Harassment may include everything from bullying and mobbing to “a situation where a supervisor is really expecting too much from a person over too long a period,” he says. The supervisor may be unaware of the negative impact, or may simply regard the demands as part of the worker’s job.
Kate, a Montreal mental health professional who suffers from GAD and social phobia, felt the full force of anxiety attacks when she was employed as an administrative staffer at a small, family-owned business. Kate was experiencing what she calls “anxious meltdowns” between 3 and 5 pm every day.
Worried about her employer’s reaction, she did not disclose her condition, but instead requested reduced hours. The employer refused, causing Kate’s anxiety to balloon.
The situation was only made worse by what she saw as harassment by one of her co-workers. “I felt trapped,” Kate recalls. “Work felt like a prison, in a way.”
The feelings worsened until it was not solely mid-afternoon episodes, but feelings of dread in the mornings, before even arriving at work. Once there, she found the workplace demands left her feeling burned out.
“When I came home, I was spending all my time at home licking my wounds, but then I wasn’t recuperated the next morning when I had to go back in.” She stayed for two more years, but acknowledges “the work I was doing wasn’t good.”
It is important for people to get some downtime, says Kathy Jurgens, national program manager of Mental Health Works in Toronto, a corporate training program offered by the Canadian Mental Health Association. “As far as someone who has anxiety in the workplace, if you’re fearing for your job, you may know you should unplug, but it might be difficult for you to actually force yourself to do so,” Jurgens says.
“We are least productive when we are the most stressed,” argues Dr. Haines. In extreme situations of untreated anxiety, she says that workers might develop a workplace phobia, or “the experience of intense anxiety triggered by the workplace and a strong avoidance response,” which can lead to absenteeism and either short-or long-term disability leave.
UNDER THE RADAR
If untreated, anxiety disorders can harm more than individuals; they can have a negative impact on the workplace as a whole. “A combination of depression, anxiety disorder and substance abuse — most often alcohol — is causing quite a cataract of lost days in the workplace,” says Wilkerson. Indeed, the Centre for Addiction and Mental Health in Toronto cites a review from the Public Health Agency of Canada that found productivity losses from mental illness amount to approximately $17.7 billion a year in Canada.
Depression may be the most public face of mental health, but there are other conditions lurking below the surface. As well, there may be considerable interplay between different conditions that fall under the mental health umbrella. “Depression usually doesn’t start as depression,” notes Simon Fraser’s Dr. Samra. “It will commonly start as chronic anxiety and turn into depression.”
But if anxiety disorders are so common on the job, why are they not more fully recognized and addressed?
Mary Ann Baynton, president of Mary Ann Baynton & Associates, a Waterdown, Ontario-based management consulting firm, suggests that while a worker with depression might be viewed as a “slacker,” that is unlikely to be the case for an anxiety sufferer. His actions are likely interpreted as ambition, attention to detail and eagerness to please, Baynton says.
Those outward behaviours are unlikely to elicit a call for change. “Some people with anxiety may just be ignored as someone who’s struggling and just given space because the thought is that they’ll deal with it and still produce,” she says.
Anxiety sufferers who opt to disclose their conditions will likely be met with some common misperceptions. “If they complain about conditions of work that are making them anxious, they can sometimes be characterized by their fellow workers as not carrying their load,” says Dr. Shain.
However, being forthcoming about conditions can be tough in light of the stigma associated with mental health conditions in general. “We’ll often feel safe quicker with a friend at Tim Hortons talking about our personal issues,” says Jurgens.
To counter misconceptions, Dr. Richard Swinson, medical director of the Anxiety Treatment and Research Centre in Hamilton, Ontario, recommends viewing an anxiety disorder the same way as a physical condition. “If we substituted the experience of a migraine, would you expect that telling people to get over that migraine headache would help?” Dr. Swinson asks.
“Everybody gets anxious and most people, fortunately, can handle that,” he says. “The people with anxiety disorders don’t have the luxury of being able to handle it.”
RAISING THE PROFILE
Like all mental illnesses, a problem in identifying an anxiety disorder is its invisibility. Unlike a broken arm, says Dr. Gilbert, “mental health disorders, in most cases, are insidious.”
Without already having the condition disclosed, a supervisor’s most important tool will be monitoring changes in usual behaviour. Dr. Gilbert points to an employee committing more errors on the job, being withdrawn, experiencing mood fluctuations, and being agitated or distracted as potential signs that the person may be suffering from some sort of anxiety disorder.
Baynton says excessive attention to detail may be another clue that an anxiety-sufferer is struggling. “Sometimes it’s the intensity of an individual that is out of proportion with the importance of the detail,” she observes. “Some of my colleagues, when they’re dealing with anxiety, will write these enormous e-mails that go on for pages.”
Fortunately, anxiety disorders are very treatable if identified and diagnosed properly. The most common methods of treatment are medications and cognitive behaviour therapy, which helps anxiety-sufferers achieve more realistic thoughts about their situations, and also uses breathing, relaxation and problem-solving skills to help them cope.
While seeking treatment is up to individual workers, experts agree they should talk to their employers. Baynton suggests that if a worker discloses his condition, or if an employer senses that the employee is struggling, there are two questions that should be asked:
• What do you need to be successful in your job?– the answer helps identify supports the worker may require; and,
• What will you do to ensure your own success?– since an anxiety-sufferer often feels out of control, says Baynton, the process helps the person to “regain a sense of control and responsibility for their own well-being at work.”
Dr. Van Ameringen further suggests that role clarity and expectations should be addressed. For example, someone with GAD probably needs “more clear direction about tasks that need to be completed,” while a person with social anxiety might benefit from reduced group work.
Employee Assistance Programs (EAPs), which fulfill both the desire for privacy and the need to explore solutions, may also prove crucial for a worker struggling with a mental health condition. “Traditionally, an employee assistance program is meant to do an assessment, support and refe to the appropriate community resource,” says Francois Legault, national director for the Employee Assistance Services Bureau at Health Canada in Ottawa.
PHYSICAL TO MENTAL
The potential link between physical and mental should not be ignored. Wilkerson says that if a worker is off the job on short-or long-term disability for an illness or injury, “in 75 per cent of those cases, if they’re off six months or more, they ll develop depression and anxiety as a secondary diagnosis.” Once the original injury heals, however, “they still can’t get back to work, and the secondary diagnosis has been missed,” he adds.
Jamey had been a manager at a Halifax youth shelter for more than two years when he experienced a depressive breakdown that forced him onto extended disability leave. Beyond managing the shelter’s day-to-day affairs, his work often involved crisis management.
“Years of front-line work among threats of suicide and violence finally took their toll,” says Jamey. On his way to work one day, he reports feeling “like a veil of tears were just on top of me like a heavy blanket.”
Jamey was diagnosed with depression and began a year-long mental health leave to recuperate.
But as his leave continued, he says his anxiety magnified. One day, while driving past his workplace to test his reaction, he experienced a panic attack in the parking lot. “You really get tight, you get the butterflies in the stomach, and my heart started to race a bit.”
The panic attacks persisted, and although he underwent visualization exercises — acting out the scenarios that caused anxiety — with his therapist, the anxiety did not subside. While listening to the radio, he heard about a difficult incident related to the work he had only recently been doing, and, again, suffered an attack. It was at that point that Jamey realized he would be unable to return to his previous job.
Returning to work following an injury or illness is challenging for anyone, but for those suffering from anxiety disorders the hurdles may be higher still. Dr. Gilbert insists that a return-to-work plan, one that incorporates relapse prevention and relapse management, can help orchestrate a return with minimal anxiety.
Measures such as allowing for a graduated return, job shadowing and time away from work for appointments with EAP counsellors or psychologists are among the tools that might smooth the worker’s transition, he suggests.
Neither Kate nor Jamey were confident that accommodation was possible in their previous jobs, and opted to secure new positions where this would be more likely. Jamey reports his manager was very supportive, but he felt the nature of the work was never going to be compatible with his anxiety.
Jamey says he is functioning well in his new position as a manager at a community mental health centre. Despite it being a high-pressure job, he says the bulk of work is managing people, and this has not caused him anxiety to date.
ARMED WITH INFORMATION
Dr. Samra remarks that mental illness is “seen as a private problem,” but perhaps that view should change. Jurgens insists that companies must develop a comprehensive education plan to hike mental health awareness. “I think it comes down to increasing mental health literacy, that they start talking about it, first and foremost,” she says.
One effort devoted to doing just that is Guarding Minds@ Work, an evidence-based process that instructs employers on how to assess and address “risks to mental health that are embedded in the way work [is] organized and managed and designed,” says Dr. Shain, who developed the resource along with Dr. Gilbert, Dr. Samra and Dr. Dan Bilsker.
The tool represents “an attempt to explain to employers why you should do something, why you should pay attention to this stuff and here’s how,” says Dr. Shain. “It’s all very well to say to employers, ‘You’ve got all these responsibilities and we’ve got this sort of perfect legal storm of pressures building on you to provide and maintain a psychologically safe workplace, but we don’t tell you how to do it,'” he says. Ultimately, the goal is that with the proper education and organizational initiatives, workplaces will move toward eliminating psychological hazards.
Providing managers with appropriate training may help in this regard. Wilkerson says there is a need for several things: a clear quantification and understanding of the new work hazards relating to cognitive, behavioural and sensory impairment; a new model of occupational health where occupational physicians play an important case-management function in companies; and that oh&s responses are as available to a worker with a mental condition or disorder as if he had suffered a burn injury or fall from a ladder.
The role of an employer “is not to treat psychological health conditions,” says Dr. Samra. “It’s to be supportive around those.”
Adds Dr. Shain: “I think anxiety disorders are one of the foreseeable harms that we are seeing more and more of in the workplace,” brought on by having to do more with less.
What he sees evolving in related law “is an increased pressure on employers to provide a psychologically safe workplace, which basically means that you have to do the same thing for mental health as for physical health. It’s a due diligence thing.”
Dr. Gilbert reports that he is optimistic about the future of mental health treatment and anxiety awareness on the job. With the emerging work force consisting of younger people now entering employment, “there’s a higher level of psychological literacy,” he suggests. “People are a lot more comfortable talking about these things, using words like depression, anxiety, panic disorder, stress and so on. So a lot of the stigma is dying off.”
And that may be good not only for the individual, but for the whole of the workplace.