bullying and occupational health interventions
Maurice Lipsedge and Anne Margaret Samuel
CHAPTER 11
Introduction
In the occupational health setting, just as in primary care, many people will seek medical help on the basis of physical symptoms when in reality there is an underlying psychiatric disorder. Somatisation is a useful concept. It covers situations where people seek help for somatic symptoms which they themselves erroneously attribute to an underlying physical disorder, when in fact a specific psychiatric illness, generally anxiety or depression (or both) is responsible. Employees may present to an occupational health department with a physical symptom rather than an emotional problem because of the widespread belief that physical symptoms are more acceptable to health care staff.
Anxiety
Anxiety is an experience familiar to everybody. People feel anxious before examinations and interviews, when their children return home late or when they have a near miss when driving. Anxiety is a normal short-term reaction to threat or danger and it prepares the individual for a physical response, namely fight or flight from the perceived threat.
The three questions to ask about a patient who may be suffering from an anxiety state are:
(1) Is the anxiety continuous or intermittent?
(2) Does the anxiety occur only in certain situations?
(3) Is the patient depressed as well as anxious?
Persistent anxiety
When the anxiety is more or less continuous, the diagnostic term
‘generalised anxiety disorder’ is used. This condition occurs in about 6%
of the general population, and women are affected twice as often as men.
Patients will generally present with physical symptoms which indicate overactivity of the autonomic nervous system: palpitations, rapid heart beat, increased muscle tension (which can often cause headaches – ‘a tight band around the head’), excessive sweating, pins and needles, faintness, dizziness, shakiness, epigastric discomfort and sometimes nausea or diarrhoea. They may also present with dysphagia, insomnia, fatigue or poor concentration. They will worry that one or more of their physical symptoms may have a sinister implication, and there may be fear of heart disease, cancer, AIDS and so on.
An employee may seek help for a single somatic symptom, such as difficulty in swallowing. Other somatic symptoms of anxiety, together with apprehensiveness and excessive worry, will confirm a diagnosis of anxiety. In addition to undue worry about health, a prominent psychological feature is endless concern about both major and trivial problems and excessive anxiety about coping with everyday situations and interactions with people, including colleagues, subordinates and supervisors, as well as with clients and other members of the public.
Patients may also feel unreal or complain that their surroundings appear to be unfamiliar (termed ‘depersonalisation’ and ‘derealisation’, respectively).
Causative factors
When assessing a patient with anxiety (and/or depression) it is useful to classify causative factors into those that are:
(1) predisposing (2) precipitating (3) maintaining.
Predisposing factors include a vulnerable personality characterised by obsessionality or fear of rejection and of negative evaluation. There may be a genetic predisposition or childhood experience of rejection, separation or abuse. Another childhood influence may be the modelling effect of overanxious parents. It is useful to distinguish between trait anxiety, which is a lifelong anxious disposition, and state anxiety, which is a discrete episode.
Precipitating factors include major adverse life events. Anxiety is often triggered by threatened loss of status, job or security. (Depression tends to be a reaction to an established loss.) A potent cause of anxiety is severe short-term stress, especially when this involves a conflict of loyalties such as commitment to the employer versus responsibility for children, spouse or other relatives.
Maintaining (or perpetuating) factors include an intolerable situation at work, such as a combination of bullying and the imposition of unrealistic targets coupled with inadequate resources.
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Panic disorder
This consists of discrete episodes of intense anxiety with an abrupt onset occurring several times a month. Each paroxysmal attack lasts for at least several minutes and, as with generalised anxiety disorder, there are both psychological and somatic symptoms. The physical symptoms are virtually the same as in generalised anxiety disorder but they occur in an intense and concentrated form. Patients interpret these physical symptoms in a catastrophic manner, believing that they are about to have a fatal heart attack, an epileptic fit, a faint or become acutely psychotic. A vicious spiral rapidly develops in which the more frightened the patient becomes, the more pronounced are the physical symptoms (see Figure 11.1). Thus, in panic disorder, physical symptoms lead to catastrophic thoughts of serious illness or social embarrassment which in turn exacerbate the physical symptoms.
Panic disorder occurs in up to 3.5% of the population. Panic attacks can supervene on a pre-existing generalised anxiety state or depressive disorder and can coexist with agoraphobia. In the early stages of panic disorder, the attacks are not necessarily associated with a specific situation. The differential diagnosis is outlined in Box 11.1.
Case 11.1 Panic disorder
A 40-year-old labourer, employed by his firm for 20 years, presented to the occupational health department with a 10-year history of panic attacks, which had begun when he was committed to doing a great deal of overtime. He had become very upset that he rarely saw his wife and children. During the attacks he would feel very anxious and experience a choking sensation in his throat, and would hyperventilate and sweat profusely. His symptoms persisted, even after he sensibly reduced his hours of work and had some debt counselling.
He had been treated with lorazepam, to which he became addicted. From time to time he had tried coming off the drug but experienced such devastating choking sensations that he resumed it. Eventually he became so anxious about having cancer or suffering a heart attack that he started drinking heavily as a form of self-medication.
Figure 11.1 The cognitive model of acute anxiety (based on Salkovskis, 1992).
By the time he was seen he had a very high level of free-floating anxiety and a constant sense of apprehension, difficulty in relaxing and epigastric dis-comfort. He had had to give up his hobby of fishing due to intrusive ruminations about death while waiting for the fish to bite.
He was switched from lorazepam to diazepam (which has a longer half-life and makes eventual withdrawal easier) and was encouraged gradually to increase his physical exercise. He also had sessions of anxiety management with a clinical psychologist, and he learned to recognise the link between some of his worrying thoughts and his physical symptoms.
He responded well to this regime and was able to continue working.
Phobic anxiety disorders
Unlike other anxiety disorders, phobic anxiety occurs in specific situations (Table 11.1). There is an irrational fear and avoidance of specific objects or situations. Although sufferers recognise that their fear is excessive and inappropriate, they cannot be argued out of it.
While specific phobias, such as a fear of certain small animals, are very common and rarely cause occupational disability, agoraphobia, which can merge with travel phobia, can cause significant occupational impair-ment. In agoraphobia the patient feels anxious in crowded places or open spaces, or places or situations from which escape would be difficult or Box 11.1 Differential diagnosis of generalised anxiety and panic disorder (1) Depression
Anxiety may frequently accompany depressive illness. The two conditions share many symptoms (see Box 11.2) and where anxiety and depression coexist, patients may need a combination of treatments (e.g. antidepressants and cognitive–behavioural therapy).
(2) Alcohol abuse (3) Drugs
• Excessive caffeine consumption.
• Illicit drugs, especially amphetamine.
• Withdrawal from a benzodiazepine (typically taken as a hypnotic or tranquilliser).
(4) Physical conditions
• Thyrotoxicosis.
• Paroxysmal tachycardia.
• Hypoglycaemia.
• Temporal lobe epilepsy (ask about déjà vu and olfactory and gustatory hallucinations as well as marked depersonalisation and derealisation, and remember that epileptic phenomena are short-lived and intermittent rather than continuous).
• Phaeochromocytoma is an extremely rare cause of symptoms that resemble panic attacks.
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embarrassing, for example supermarket queues, traffic jams and public transport. Patients tend to feel safer in their own homes but in the most severe cases they insist that somebody is with them at all times.
Whereas agoraphobia tends to occur in young women, social phobias occur equally commonly in men and women. They include an intense fear of being scrutinised or evaluated by others. This may lead to avoidance of speaking or eating in public, conversing with strangers or of writing in the presence of others. Note that social phobia as well as generalised anxiety disorder, panic disorder and agoraphobia can all be associated with alcohol misuse.
Treatment of anxiety disorders
Physical examination
Physical examination may reveal an underlying physical cause, especially thyrotoxicosis, and also serves to reassure the patient.
Psychological treatment
• Explain the fight–flight mechanism – autonomic activity once had survival value but is counterproductive in contemporary life.
• Describe the inverted U-shape relationship between anxiety and performance.
• Explain the self-perpetuating vicious circle which links excessive worry to increased activity of the sympathetic nervous system.
• Help patients to devise a problem-solving approach to their difficulties.
• Provide tape-recorded instructions on relaxation techniques and arrange for anxiety management training.
The more intractable cases benefit from cognitive–behavioural therapy.
The cognitive–behavioural therapy of agoraphobia includes graded exposure to the feared situation (see case 11.2), while training in social skills and assertiveness as well as cognitive–behavioural therapy are effective in the treatment of social phobias.
Case 11.2 Phobic anxiety
A 40-year-old delivery man presented to the occupational health department with symptoms of anxiety and frequency of micturition over the previous few Table 11.1 Comparison of anxiety disorders in terms of duration and specificity to certain situations
Duration Situation specific?
Generalised anxiety disorder Long No
Panic attacks Brief No
Phobic anxiety Brief Yes
months. He attributed the anxiety to the recent introduction of a new monitoring device which he found difficult to cope with because he thought his manager would be checking up on him. This made his bladder problem worse and he resorted to carrying a bottle with him during the day to save time finding a lavatory.
This man was suffering from ‘sphincter phobia’ – a fear of needing to go to the lavatory at inconvenient or embarrassing times. He responded well to behavioural psychotherapy. This involved being given two cups of tea at the start of each session and then being sent out to walk increasing distances, with a full bladder and without his bottle. He made good progress and was able to carry out his job without stopping to micturate more than once a morning, although he continued to carry his bottle with him for reassurance.