Randal D. Beaton
Anxiety disorders as well as subclinical fear, worry and apprehension, and associated stress-related disorders such as insomnia, appear to be pervasive and increasingly prevalent in workplaces in the 1990s-so much so, in fact, that the Wall Street Journal has referred to the 1990s as the work-related “Age of Angst” (Zachary and Ortega 1993). Corporate downsizing, threats to existing benefits, lay-offs, rumours of impending lay-offs, global competition, skill obsolescence and “de-skilling”, re-structuring, re-engineering, acquisitions, mergers and similar sources of organizational turmoil have all been recent trends that have eroded workers’ sense of job security and have contributed to palpable, but difficult to precisely measure, “work-related anxiety” (Buono and Bowditch 1989). Although there appear to be some individual differences and situational moderator variables, Kuhnert and Vance (1992) reported that both blue-collar and white-collar manufacturing employees who reported more “job insecurity” indicated significantly more anxiety and obsessive-compulsive symptoms on a psychiatric checklist. For much of the 1980s and accelerating into the 1990s, the transitional organizational landscape of the US marketplace (or “permanent whitewater”, as it has been described) has undoubtedly contributed to this epidemic of work-related stress disorders, including, for example, anxiety disorders (Jeffreys 1995; Northwestern National Life 1991).
The problems of occupational stress and work-related psychological disorders appear to be global in nature, but there is a dearth of statistics outside of the United States documenting their nature and extent (Cooper and Payne 1992). The international data that are available, mostly from European countries, seem to confirm similar adverse mental health effects of job insecurity and high-strain employment on workers as those seen in US workers (Karasek and Theorell 1990). However, because of the very real stigma associated with mental disorders in most other countries and cultures, many, if not most, psychological symptoms, such as anxiety, related to work (outside of the United States) go unreported, undetected and untreated (Cooper and Payne 1992). In some cultures, these psychological disorders are somatized and manifested as “more acceptable” physical symptoms (Katon, Kleinman and Rosen 1982). A study of Japanese government workers has identified occupational stressors such as workload and role conflict as significant correlates of mental health in these Japanese workers (Mishima et al. 1995). Further studies of this kind are needed to document the impact of psychosocial job stressors on workers’ mental health in Asia, as well as in the developing and post-Communist countries.
Definition and Diagnosis of Anxiety Disorders
Anxiety disorders are evidently among the most prevalent of mental health problems afflicting, at any one time, perhaps 7 to 15% of the US adult population (Robins et al. 1981). Anxiety disorders are a family of mental health conditions which include agoraphobia (or, loosely, “houseboundness”), phobias (irrational fears), obsessive-compulsive disorder, panic attacks and generalized anxiety. According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM IV), symptoms of a generalized anxiety disorder include feelings of “restlessness or feeling keyed up or on edge”, fatigue, difficulties with concentration, excess muscle tension and disturbed sleep (American Psychiatric Association 1994). An obsessive-compulsive disorder is defined as either persistent thoughts or repetitive behaviours that are excessive/unreasonable, cause marked distress, are time consuming and can interfere with a person’s functioning. Also, according to DSM IV, panic attacks, defined as brief periods of intense fear or discomfort, are not actually disorders per se but may occur in conjunction with other anxiety disorders. Technically, the diagnosis of an anxiety disorder can be made only by a trained mental health professional using accepted diagnostic criteria.
Occupational Risk Factors for Anxiety Disorders
There is a paucity of data pertaining to the incidence and prevalence of anxiety disorders in the workplace. Furthermore, since the aetiology of most anxiety disorders is multifactorial, we cannot rule out the contribution of individual genetic, developmental and non-work factors in the genesis of anxiety conditions. It seems likely that both work-related organizational and such individual risk factors interact, and that this interaction determines the onset, progression and course of anxiety disorders.
The term job-related anxiety implies that there are work conditions, tasks and demands, and/or related occupational stressors that are associated with the onset of acute and/or chronic states of anxiety or manifestations of anxiety. These factors may include an overwhelming workload, the pace of work, deadlines and a perceived lack of personal control. The demand-control model predicts that workers in occupations which offer little personal control and expose employees to high levels of psychological demand would be at risk of adverse health outcomes, including anxiety disorders (Karasek and Theorell 1990). A study of pill consumption (mostly tranquilizers) reported for Swedish male employees in high-strain occupations supported this prediction (Karasek 1979). Certainly, the evidence for an increased prevalence of depression in certain high-strain occupations in the United States is now compelling (Eaton et al. 1990). More recent epidemiological studies, in addition to theoretical and biochemical models of anxiety and depression, have linked these disorders not only by identifying their co-morbidity (40 to 60%), but also in terms of more fundamental commonalities (Ballenger 1993). Hence, the Encyclopaedia chapter on job factors associated with depression may provide pertinent clues to occupational and individual risk factors also associated with anxiety disorders. In addition to risk factors associated with high-strain work, a number of other workplace variables contributing to employee psychological distress, including an increased prevalence of anxiety disorders, have been identified and are briefly summarized below.
Individuals employed in dangerous lines of work, such as law enforcement and firefighting, characterized by the probability that a worker will be exposed to a hazardous agent or injurious activity, would also seem to be at risk of heightened and more prevalent states of psychological distress, including anxiety. However, there is some evidence that individual workers in such dangerous occupations who view their work as “exhilarating” (as opposed to dangerous) may cope better in terms of their emotional responses to work (McIntosh 1995). Nevertheless, an analysis of stress symptomatology in a large group of professional firefighters and paramedics identified a central feature of perceived apprehension or dread. This “anxiety stress pathway” included subjective reports of “being keyed up and jittery” and “being uneasy and apprehensive.” These and similar anxiety-related complaints were significantly more prevalent and frequent in the firefighter/paramedic group relative to a male community comparison sample (Beaton et al. 1995).
Another worker population evidently at risk of experiencing high, and at times debilitating, levels of anxiety are professional musicians. Professional musicians and their work are exposed to intense scrutiny by their supervisors; they must perform before the public and must cope with performance and pre-performance anxiety or “stage fright”; and they are expected (by others as well as by themselves) to produce “note-perfect performances” (Sternbach 1995). Other occupational groups, such as theatrical performers and even teachers who give public performances, may have acute and chronic anxiety symptoms related to their work, but very little data on the actual prevalence or significance of such occupational anxiety disorders have been collected.
Another class of work-related anxiety for which we have little data is “computer phobics”, people who have responded anxiously to the advent of computing technology (Stiles 1994). Even though each generation of computer software is arguably more “user-friendly”, many workers are uneasy, while other workers are literally panicked by challenges of “techno-stress”. Some fear personal and professional failure associated with their inability to acquire the necessary skills to cope with each successive generation of technology. Finally, there is evidence that employees subjected to electronic performance monitoring perceive their jobs as more stressing and report more psychological symptoms, including anxiety, than workers not so monitored (Smith et al. 1992).
Interaction of Individual and Occupational Risk Factors for Anxiety
It is likely that individual risk factors interact with and may potentiate the above-cited organizational risk factors at the onset, progression and course of anxiety disorders. For example, an individual employee with a “Type A personality” may be more prone to anxiety and other mental health problems in high-strain occupational settings (Shima et al. 1995). To offer a more specific example, an overly responsible paramedic with a “rescue personality” may be more on edge and hypervigilant while on duty then another paramedic with a more philosophical work attitude: “You can’t save them all” (Mitchell and Bray 1990). Individual worker personality variables may also serve to potentially buffer attendant occupational risk factors. For instance, Kobasa, Maddi and Kahn (1982) reported that corporate managers with “hardy personalities” seem better able to cope with work-related stressors in terms of health outcomes. Thus, individual worker variables need to be considered and evaluated within the context of the particular occupational demands to predict their likely interactive impact on a given employee’s mental health.
Prevention and Remediation of Work-related Anxiety
Many of the US and global workplace trends cited at the beginning of this article seem likely to persist into the foreseeable future. These workplace trends will adversely impact workers’ psychological and physical health. Psychological job enhancement, in terms of interventions and workplace redesign, may deter and prevent some of these adverse effects. Consistent with the demand-control model, workers’ well-being can be improved by increasing their decision latitude by, for example, designing and implementing a more horizontal organizational structure (Karasek and Theorell 1990). Many of the recommendations made by NIOSH researchers, such as improving workers’ sense of job security and decreasing work role ambiguity, if implemented, would also likely reduce job strain and work-related psychological disorders considerably, including anxiety disorders (Sauter, Murphy and Hurrell 1992).
In addition to organizational policy changes, the individual employee in the modern workplace also has a personal responsibility to manage his or her own stress and anxiety. Some common and effective coping strategies employed by US workers include separating work and non-work activities, getting sufficient rest and exercise, and pacing oneself at work (unless, of course, the job is machine paced). Other helpful cognitive-behavioural alternatives in self-managing and preventing anxiety disorders include deep-breathing techniques, biofeedback-aided relaxation training, and meditation (Rosch and Pelletier 1987). In certain cases medications may be necessary to treat a severe anxiety disorder. These medications, including antidepressants and other anxiolytic agents, are generally available only by prescription.