Mental Health

Anxiety Disorders

Overview

Anxiety disorders are the most common mental health disorder, exceeding mood disorders and substance abuse in the general population. One-year prevalence for criterion-based anxiety disorders is 16% (ranging from 14-30% in primary care settings) and lifetime prevalence is 28.8%; lifetime prevalence is 22.7% for isolated panic attacks.18 For most of these diagnoses there is a female predominance of 2:1.3 Often acquired in childhood, these disorders tend to persist throughout life.

This spectrum of disorders is characterized by excessive fear and anxiety, which are disproportionate to any perceived threat. The disorders differ in regard to the objects or situations, which precipitate symptoms, and the cognitive and behavioral responses of the patient. Specific anxiety disorders tend to be highly co-morbid with other disorders in this class, as well as major depressive disorder and substance abuse disorders. In large surveys, anxiety and related disorders were independently associated with a significant 1.7-2.5 times increased risk of suicide attempts.19

Anxiety can be nearly constant, as in generalized anxiety disorder, or episodic. Episodes of anxiety can come on without warning or provocation, as in panic disorder, or may occur predictably in certain situations, as in simple or social phobia. The patient’s lifestyle is impacted by efforts to avoid precipitating situations or objects, as well as the symptoms of anxiety themselves.

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is the most common anxiety disorder encountered in primary care. It presents as excessive anxiety and worry over several situations or activities which occurs more often than not for at least 6 months. The anxiety and worry must be accompanied by 3 (or more) of the following 6 symptoms:

1. restlessness, feeling keyed up or on edge
2. being easily fatigued
3. difficulty concentrating or “mind going blank”
4. irritability
5. muscle tension
6. sleep disturbance (typically difficulty falling asleep, staying asleep, or restless unsatisfying sleep

Adults with GAD often worry about routine concerns which are shared by persons without this disorder: job responsibilities, health, finances, family matters. In GAD, however, anxieties are excessive and interfere with psycho-social functioning – concerns are disproportionate and pre-occupying. By comparison with non-pathological anxieties, worries in GAD are more intense, last longer, and create higher subjective levels of distress. They are also less likely to have clear precipitants. Non-pathological anxiety is also much less likely to be accompanied by physical symptoms.

A 12-month prevalence of GAD is approximately 3% with a 2:1 female pre-dominance. Median age of onset is approximately age 30. The course is typically chronic, with symptoms waxing and waning over time and in response to situational stressors. GAD is more common in those with chronic medical conditions.

Comorbidities include somatic symptoms (e.g., fatigue, muscle tension memory loss, insomnia, indigestion, cramping). Major depressive disorder is the most common co-existing psychiatric illness, occurring in almost two-thirds of individuals with this disorder. Alcohol abuse occurs in more than one third, and more than one quarter have panic disorder.20 Other conditions that may be associated with stress (e.g., irritable bowel syndrome, head-aches) may accompany generalized anxiety disorder.

Treatment may include psychotherapy, such as cognitive behavioral therapy or behavioral therapy. SSRI are usually the first line agents in terms of psychopharmacology, but SNRI antidepressant medications are also utilized. Benzodiazepines are commonly prescribed, but are associated with significant adverse effects of sedation, memory impairment, and risk of psychological and/or physical dependence. Clinicians should look at other strategies if long-term treatment is indicated. Buspirone, a non-benzodiazepine anxiolytic, has also been shown to have some benefit in GAD. It causes less sedation, and does not cause physical dependence. However, it lacks the efficacy of other agents and is more commonly added to antidepressants as an augmenting agent.

Specific Phobia

In this disorder, the patient experiences marked fear, anxiety, or avoidant behavior in response to a specific object or situation, e.g., flying, animals, heights, or seeing blood. The patient’s experience causes clinically significant distress or impairment in the social, occupational or other important areas of function. The 12-month community prevalence in the U.S. is 7-9%.3

The principal concern for the police physician in evaluating LEOs with a specific phobia is whether the precipitating object or situation is neutral or interferes with the performance of the essential functions of the job. For example, a well-circumscribed fear of flying may have little impact on the day-to-day performance of a police officer who has no required flight responsibilities. It would be incompatible with the duties of an air marshal.

Treatment is typically with psychotherapy, either exposure therapy or cognitive behavioral therapy. Systematic desensitization is a very helpful behavioral strategy. In a recent meta-analysis, Hofmann and Smits showed efficacy of psychotherapy to be moderate at approximately 25% with an attrition rate of 14%. In cases where exposures can be predicted, prior use of benzodiazepines, beta blockers or SSRIs may be helpful in controlling symptoms.21

Agoraphobia

Marked fear or anxiety about two of the following five situations:

1. using public transportation
2. being in open spaces
3. being in enclosed spaces
4. standing in line or being in a crowd
5. being outside of the home alone

When experiencing symptoms, individuals typically believe escape from the precipitant is difficult or impossible, or that assistance is unavailable. Panic-like symptoms are experienced (see Panic Disorder below). Agoraphobic situations are avoided or endured with intense fear or anxiety. In extreme cases, people become housebound. In two-thirds of cases, onset occurs before the age of 35; the mean age of onset is 17; 30-50% of cases experience a preceding panic attack. The condition is usually persistent with only 10% remission rate. This diagnosis is associated with significant occupational impairment and 30% are completely home bound and unable to work.3

There is little research in the treatment of agoraphobia in the absence of panic disorder. Treatment can include CBT, systematic desensitization, and expo-sure therapy. Those with panic disorder and agoraphobia should be pharmacologically treated as panic disorder below. Agoraphobic persons who are not well controlled are unlikely to seek work as a police officer. The police physician is more likely to encounter agoraphobia as an acquired condition in incumbent LEOs.

Social Anxiety Disorder (SAD)

Persons with SAD, also known as social phobia, experience intense fear or anxiety in one or more social situations in which they are potentially scrutinized by others. Social interactions such as meeting an unfamiliar person, being observed eating or drinking, performing in front of others are common contexts for this disorder.

With exposure to the precipitant, the individual reliably fears acting in a manner, or showing anxiety symptoms which will result in humiliation or a negative evaluation from others. Exposure to the feared social situation may bring on intense anxiety feelings with rapid heartbeat and breathing, sweating, and feelings of impending doom. Such situations are avoided or endured with intense fear and anxiety.3

For some individuals, the condition is very circumscribed – with a specific fear of speaking in public only, or a fear of asking someone on a date. As with other anxiety disorders, understanding how and when, if at all the precipitant condition will arise while on-duty is critical to assessing the impact of this diagnosis on the ability to work as a police officer. Persons with generalized SAD in poor control may be unlikely to seek work as a police officer.

The 12-month prevalence of SAD in the U.S. is approximately 7%. For diagnosis, the condition must last at least 6 months. In 30% of cases, remission of symptoms will occur within 1 year. In 60% of cases without specific treatment, the condition lasts for several years or longer.3

Treatment may include CBT as well as pharmacotherapy SSRI or SNRI anti-depressants. Benzodiazepines should be avoided if possible. In management of circumscribed disease where exposures are predictable – such as public speaking – anti-adrenergics and beta-blockers may be used to control symptoms.

This condition is often comorbid with other anxiety conditions (which it normally precedes) and with depressive disorder, bipolar disorders, and substance use disorders. Self-medication with legal and illegal substances is common.

Panic Disorder

Panic disorder is characterized by recurrent episodes of intense fear and somatic symptoms called panic attacks. These events are incapacitating and occur with no clear precipitant. DSM-5 lists the following criteria for a panic attack: 3

An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and includes ≥4 of the following symptoms:

• palpitations, pounding heart, or accelerated heart rate
• sweating
• trembling or shaking
• sensations of shortness of breath or smothering
• feelings of choking
• chest pain or discomfort
• nausea or abdominal distress
• feeling dizzy, unsteady, light-headed, or faint
• chills or heat sensations
• paresthesias (numbness or tingling sensations)
• derealization (feelings of unreality) or depersonalization (being detached from oneself)
• fear of losing control or going crazy
• fear of dying

For the diagnosis of panic disorder, recurrent panic attacks must occur. At least 1 attack must be followed by at least one of the following:

1. persistent concern or worry about additional panic attacks or their consequences
2. significant maladaptive change in behavior related to the attacks.

Maladaptive changes may include reluctance to leave the home, or reorganizing daily life to insure help is available in the event of an attack. Activities of daily living such as shopping and use of public transportation may be curtailed. The behavior resembles that of agoraphobics, but the motivation in this case is preventing and/or minimizing the impact of panic attacks.

When panic attacks occur in the setting of another mental health disorder, but criteria for panic disorder is not met, the specifier “with panic disorder” is appended to the diagnostic label. In this case, the police physician should consider guidance applicable to panic disorder as well as that pertaining to the primary diagnosis.

The 12-month prevalence of panic disorder is 2-3%, with a mean age of onset between 20-24. As with other anxiety disorders, there is a 2:1 female predominance. The typical course of panic disorder is chronic, but with waxing and waning frequency of attacks. Some individuals can experience years of remission between periods of active disease; 50% of those with panic disorder have both expected and unexpected panic attacks.

In most cases panic disorder occurs with other psychopathology. Other anxiety disorders, bipolar disorder, major depressive disorder, and alcohol use disorder are all associated with higher prevalence of panic disorder. Panic disorder is also significantly comorbid with several general medical conditions: asthma, COPD, hyperthyroidism, irritable bowel syndrome, cardiac arrhythmia and dizziness.

First-line agents for pharmacologic treatment of panic disorder are SSRIs, with venlafaxine, a SNRI antidepressant, as a second-tier alternative. Other treatments for those who do not respond to multiple SSRIs or venlafaxine could include tricyclic antidepressants and benzodiazepines. Short-term benzodiazepine use may also have an adjunct role in accelerating the course of treatment. CBT is recommended in conjunction with pharmacotherapy. For patients experiencing agoraphobic symptoms, CBT and behavioral forms of psychotherapy may be useful adjuncts in treatment.21

Substance/Medication-Induced Anxiety Disorder

LEOs in this diagnostic category experience panic attacks or anxiety, but the symptoms can be shown to develop during or soon after substance intoxication or withdrawal, or after exposure to a medication. Additionally, the implicated substance or medication is known to be capable of inducing these symptoms. Causal agents include amphetamines, cocaine, steroids, sedatives, hypnotics, anxiolytics, and others. This diagnosis must be carefully distinguished from substance use disorder; it is used when the panic or anxiety symptoms predominate.

Anxiety Disorder Due to Another Medical Condition

LEOs in this diagnostic category experience mood changes similar to those with other anxiety disorders, but there is evidence from history, physical examination, or laboratory testing that the disturbance is the direct patho-physiological consequence from another medical condition. The diagnosis is not meant to include anxiety disorders which arise in the setting of chronic illness. This diagnosis should only be made when:

• A clear temporal association is present between the anxiety symptoms and onset, exacerbation, or remission of the medical condition and anxiety symptoms.
• Features atypical of a primary anxiety disorder are present, e.g., unusual age of onset or course.
• Evidence in the literature exists to support that a known physiologic mechanism causes anxiety.
• The condition is not better explained by a primary anxiety disorder, or another mental health disorder such as adjustment disorder.

Diagnostic clarity is essential for the police physician in considering workability of the officer or candidate.