Good afternoon, and welcome to today's webinar, Applying ACOM's Clinical Guidelines for Anxiety Disorders. My name is Heather Hodge, and I'm with the American College of Occupational and Environmental Medicine. Before we get started, just a few housekeeping items. All participants are muted during the entirety of the webinar. We are recording today's session, and we'll email the link of the recording to all registrants. There are two features available to communicate with the panelists and other attendees. You may post general messages in the chat box. Messages can be shared with either the panelists or all participants. Use the drop-down box to select who you want to share your message with. Go ahead and give it a try by introducing yourselves to all panelists and attendees. Let us know your role and where you are from. Questions on the other hand should be submitted in the Q&A box. Panelists are monitoring this box for questions, so please be sure to post all questions here and not in the chat box. We are delighted to have Dr. Pamela Warren and Dr. Daniel Bruns with us as faculty today. Dr. Bruns is President and Clinical Health Psychologist of Health Psychology Associates PC in Greeley, Colorado. He has been a practicing health psychologist for over 30 years and specializes in the psychological assessment and treatment of injured workers suffering from chronic pain. In addition to practicing in his clinic, he is a Senior Clinical Instructor for the University of Colorado Occupational Medicine Program and has served as a physician educator for the State of Colorado's Workers' Compensation System. Dr. Bruns has been involved in development of over 20 medical guidelines, is currently co-chair of the ACOM Evidence-Based Practice Workplace Mental Health Panel, and is a past co-chair of the Colorado Medical Treatment Guidelines for Chronic Pain and CRPS. Dr. Bruns is also the author or co-author of numerous research articles and book chapters about the assessment and treatment of patients with injuries or chronic pain, was the principal investigator, along with Dr. Warren, in a 15-year longitudinal study of 29 million patients, which tested the economic effects of the biopsychosocial model and co-authored two standardized psychological tests designed to assess injured patients. Dr. Bruns has also served as a technical expert for the Center for Medicare and Medicaid Services regarding Medicare and Medicaid policy, regarding integrated care, substance abuse, and patients with complex needs, and is on the Executive Board of the Society for Health Psychology. Dr. Warren is a licensed clinical psychologist specializing in occupational health psychology. She maintains a clinical practice and provides professional consultation to employers, insurers, case managers, federal agencies, as well as medical and mental health professionals on the management and prevention of behavioral health issues, including disability concerns. Dr. Warren currently practices at Carl Physician Group in Urbana, Illinois, and serves on the faculty at the University of Illinois in the School of Medicine, Department of Psychiatry, as well as the Psychology Department. In addition, Dr. Warren serves on the Reed Group Medical Disability Advisory Board and is co-chair for the ACOM Evidence-Based Practice Workplace Mental Health Panel. She also serves as panel member for ACOM's Evidence-Based Practice Chronic Pain and Disability Prevention and Management Panels and has worked on another 20 different national guidelines. Dr. Warren has served on the International Association of Rehabilitation Professionals Case Management Board of Directors and on a panel of experts on the Disability Research Institute Advisory Board regarding mental and cognitive functioning and demands related to work for the Social Security Administration. In addition to having many publications in peer-reviewed journals, Dr. Warren has written three books and also serves on the editorial board of the Psychological Injury and Law Journal and is the co-head of the Disability and Return to Work sections of the journal. We are so glad that you're both able to join us today and we're looking forward to another fantastic webinar. I'll turn it over to you now, Dr. Bruns. Good morning, or good afternoon, depending on where you are. It's a pleasure to be here today. Before we begin, I'd like to express my thanks and Dr. Warren's as well to all the people who helped make this guideline possible. First of all, the editor-in-chief, Kurt Hegman, who's a brilliant scientist, and the entire guideline teams at ACOM and Regroup. So, thank you. So, what's the importance of these mental health guidelines? According to the World Health Organization, mental health disorders are the most disabling category of all, accounting for 31% of the world's disability. So, why is that? If you think about other conditions like, say, heart disease, that's a very disabling condition, but it's associated with a shortened lifespan. In contrast, mental health disorders may not shorten the lifespan. And so, you may have a person who is disabled by that for a lifetime, decades on end. And that increases their contribution to disability. Among mental health disorders, the most common are anxiety disorders, affecting 40 million adults every year in the United States. So, that is a lot. About one in six U.S. adults experience symptoms of a generalized anxiety disorder. But the stats can be confusing at times, because this is not generalized anxiety, but symptoms of that. And so, the statistics are compiled different ways, like mild, moderate, or severe. And so, sometimes they seem contradictory. They're just defining the problem in slightly different ways. Societal events can affect the prevalence of mental health disorders. Do you remember about 18 months ago, with the lockdown, and there was like a wave of anxiety that spread across the United States. I remember going to a grocery store, and the place was cleaned out. It was just remarkable. I remember one person was walking out with like a box of Tabasco. It was like, I don't know, it was like at least a dozen bottles of Tabasco, because it was the last thing left on the shelf to buy. So, people were panicked. It was like a national anxiety attack. And sometime later, in the six months that followed August 2020, this study tracked what happened. And there is an increase in the prevalence of anxiety and depressive disorders. An additional 17 million people began experiencing symptoms of depression or anxiety during that time. And so, societal events can affect the prevalence of anxiety broadly for the nation. And events in a person's life, an individual's life, can affect their anxiety level too. Now, mental health disorders are associated with social stigmas. People with mental health disorders are thought of as being, you know, weak or strange or disturbed. And it's really not fair. It's just another type of condition some people suffer from. And to mischaracterize them as weak is not fair, any more than it would be to say that a person with diabetes is weak or disturbed because of having that condition. And so, while it's just another condition that people sometimes suffer from, they can often be highly functional in the workplace but may require accommodation to be successful. So, I want to talk generally about anxiety. And, you know, sometimes the hardest questions are the simple ones. So, like, what is anxiety? That's a pretty simple question. And at first, it seems easy enough to answer. But then on closer inspection, it seems more difficult because there are very different ways of trying to explain what anxiety is. There are biological ways of describing anxiety. You've all probably heard the term the fight or flight response. That's a survival instinct present in most animals. If you kick an ant hill, all the ants speed up. And so, the fight or flight response is a way of adjusting to threat in our environment. I remember some years ago, I was at a picnic up in the mountains. And we were all just having a relaxed time. It was a number of families together there. And then, kind of out of the blue, a bear showed up and decided it wanted the food. This was a big bear. I don't know. I'm guessing it may have been, you know, 500 pounds or something. But it was saying, this food is mine. And it was aggressive. And everybody went from relaxed to suddenly going 100 miles an hour trying to get out of the way. And there were a bunch of kids around. And everybody was, you know, screaming for their kids. And people were trying to get away, except for this one boy. And this one boy got out his iPhone and wanted to get a selfie with the bear. And I have to admit, I yelled at him. Because sometimes it takes anger to impress upon others the seriousness of a situation. And so the fight or flight response unites two emotions. Flight is anxiety. But fight is anger. And they can be closely associated. Anxiety is a valuable emotion. It's not always maladaptive. It prepares us to respond to threat, to respond to danger. Like in the situation with the bear, it's like suddenly we had to do something. And anxiety motivates us. It empowers us with adrenaline in our bloodstream to do something. I remember a worker who got injured when he was working on a metal tower in a thunderstorm and got electrocuted. And I asked him why he was doing that. And he said, no, I don't worry about stuff like that. Well, you know, you should. There are things in life that are dangerous. And you should feel anxiety doing that because you could get hurt or killed. And anxiety is this instinct that tells us, you know, don't do that. Get away. This is dangerous. And that can be adaptive and helpful. But anxiety disorders occur when this adaptive instinct becomes dysregulated somehow. One theory of anxiety is called monoamine theory. Sometimes called chemical imbalance theory. And that's a belief that anxiety disorders result from chemical dysregulation in the body. Anxiety may be the product of aberrant levels of what are called HPA axis hormones. Most important of which is adrenaline, which accelerates the person. Or maybe the product of aberrant levels of what are called monoamine neurotransmitters. These are things like serotonin, dopamine, norepinephrine that act upon the brain. And aberrant levels of those chemicals can predispose a person towards having anxiety. So you would think that if it's a chemical imbalance, there would be a test for it. But turns out we don't have one yet. Turns out that the level of adrenaline we might see in anxiety is difficult to distinguish from the level of adrenaline you might see if a person is excited. Or if they're exercising. So it's unfortunate this time we don't have a biological test for anxiety. But the belief is that the treatment for this anxiety as a disease state is a medication with the hope that the medication can normalize the level of chemicals and restore the imbalance. There's also cognitive theory, which is based on the belief that emotions originate in our thoughts. And so anxiety can result in excessive self-criticism, if you believe I have to be perfect, and if I'm not, it's terrible. Or unrealistic appraisals of life dangers. Let me give you a couple of examples. I remember a patient with a needle phobia. And I said, so why do you get so scared? And we had to sort through her thoughts. And a lot of times anxiety originates in thoughts that maybe originated in childhood. Maybe we've never spoken out loud. Maybe aren't clear in our mind. And so in cognitive therapy, you're trying to explore what is the belief that triggered this. In this case, the person said, well, I just thought, well, if I got a needle stick, what if I start bleeding and it never stops and I bleed to death? It's like, well, okay. But she said that, you know, now that I say it out loud, that's kind of silly. Another patient of mine was a nice man from Guatemala. He'd never been to school. He had never seen a doctor before. He had was very medically uninformed. And, but he introduced back and was being administered an MRI and they rolled him in. And he didn't have any way of understanding what was happening. He thought he was being rolled into a coffin. And after that, he came out, he was terrified and combative. He wasn't ready to go into a coffin. And, but it was based on his belief about what was happening, which wasn't correct, but you can see why he was terrified and combative. So the role of cognitive therapy is to understand. So what's the thought process going on? That's triggering these feelings. And then how do we address it? So according to cognitive theory, there are tests for anxiety, which are psychometric questionnaires. You can assess for anxious patterns using questionnaires and the treatment for anxiety or cognitive therapies. So there are diagnostic criteria for anxiety disorders. And again, note that not all anxiety is a disorder. Some is adaptive. So there are many forms of anxiety discussed in the literature. And one of the things we did starting out, was Dr. Warren and I tried to identify, what are all the types of anxiety this guideline should cover? It then went to the research team that did an incredible job summarizing almost 1400 studies about anxiety in an almost thousand page long summary. And then it comes back to Dr. Warren, Dr. Hageman and myself to try to make sense of all this. And along with the clinical panel to interpret all the information. But each of these conditions has a separate set of diagnostic criteria. So here's the criteria for generalized anxiety. This is generalized worrying. So a person may have excessive worrying, feel tense, have distorted ideas about problems, be irritable, restless, difficultly concentrating, be jumpy or easily startled. All of these symptoms suggest the presence of what's called generalized anxiety, which again is one pattern of anxiety. So the guidelines looked at all these studies and came to some conclusions about what to recommend. And so first of all, we look at methods of assessment. And as we said before, unfortunately there are no biological methods of assessing anxiety. There's something in the works called pharmacogenomic testing, which looks at your genome and tries to predict what medication might work for you. It's promising, but still not quite there yet. And so there's no recommendation for this. Or other biological tests. There are recommendations for mental health type tests, questionnaires, both screen tools, which are very brief and can be administered by staff in the clinic, or more complex, longer psychometric tests of anxiety that often include validity tests to see if a person is magnifying or minimizing. Now, let me also explain levels of evidence. The evidence in the guidelines is rated A, B, and C, with C being solid scientific evidence. B, there's evidence, moderate evidence, and strong evidence. So moderate evidence is actually a B level, which is pretty difficult to obtain. And A level evidence is rare. It's hard to achieve that level. And note also, the evidence can be for a treatment that is helpful, or against a treatment that is harmful. So it can be helpful or harmful evidence. With regard to psychological treatments, the gold standard is probably cognitive behavioral therapy with moderate evidence for that. Remember that if you believe that anxiety is a product of cognitions, then the role of cognitive behavioral therapy is to explore the belief system that generates the feeling, and basically apply two tests. One, is that belief true? And two, is it helpful? And if a belief doesn't pass both those tests, if it's not true or not helpful, then you need to replace that belief. And that's what CBT does. There's also something called acceptance and commitment therapy. It teaches people that there's some things in life that are difficult, but have to be accepted. And when that happens, you have to commit yourself to applying your values to working through a difficult situation. Bibliotherapy is a very simple way Bibliotherapy is kind of a self-taught home CBT program. There are destructive methods that try to not obsess about things, but think about something else. And there's other treatments too. But the ones on top are the ones with the most support by the evidence. There's also pharmaceutical treatments. We think of anxiety as a disease. The gold standard here are antidepressant medications. Most of which also have anti-anxiety effects. There's also antipsychotic medications. They're stronger and also have stronger side effects. In many cases, the side effects are so strong as to make them not usable for a person. Beta blockers can also be helpful. They're in bed mostly for blood pressure or hypertension, but by blocking adrenaline, they can prevent the racing heart seen in panic attacks. And then also pregabalin has moderate evidence as well. Now, what's not in the list here are tranquilizers, benzodiazepines. Now there's C-level evidence for certain times when they're helpful. Short-term for focus problems, benzodiazepines can be helpful, but there's also evidence longer-term that they're harmful, that they become habit-forming. A person can become dependent or even addicted to them. And so there's also evidence of harm. So the guidelines summarize just what we know about the nature of anxiety, the prevalence, the causes, the tests, the treatments. but then what do you do with that? And for the next part, I'm going to turn it over to my colleague and co-presenter, Dr. Warren, who will talk about the clinical application of these guidelines. Dr. Warren. Thank you, Dr. Bruns. Give me two shakes. Well, good afternoon, everybody. It is wonderful to be with you here today, and we are going to look at the application and how to use the guideline in clinical care. Please keep in mind, as I believe that Dr. Bruns pointed out earlier, that this is a culmination of almost 1,000 pages of information. So really all that is possible to do is to provide a broad overview today. We also need to make sure that as we're looking at this, that there is more in-depth information. And if you're going to use this guideline, although we'll be looking at the treatment algorithms, and those provide an overview, please take a look at the written information so that you can find more of the ins and outs on how to apply some of these things, because it can give the impression that it's one and done. You just do these simple, easy steps, yes, no, and then that's it. And there's really more of a science to it than that. So with that, let's get started. What we're going to be looking at today are the major anxiety disorders that impact on the workplace. And the primary one, anxiety disorders that impact on the workplace are anxiety disorder with anxious mood, panic disorder with or without agoraphobia, and generalized anxiety disorder. We'll also look at social anxiety disorder phobias as well. But when we're looking and talking about what's going on with is there an actual anxiety disorder that's occurring, what to do? We want to evaluate for sure. We want to go ahead and screen those results with screening tools, but then what? Let's say it's positive, and you're getting ready to go ahead and refer this person on to mental health. But in the meantime, you have to sort out are there other potential co-diagnoses, comorbid conditions going on? Frequently, when we do file or peer reviews, what is seen is that both lay people, but also professionals are wondering, can this person with an anxiety disorder, can they actually work? We also find that many times just the psychological diagnosis, in this case, an anxiety disorder is the primary reason that's given why a person can't work without any regards to, is there any type of impairment in functioning? When we look to both clinical practice, but also empirical research, it is clear that there's an overestimation frequently that there is a lot of impairment. And that's not to say that there's no impairment, but is it sustained? And does it go on forever and indefinitely? No, and that's good news. And that's part of the treatment process in educating both professionals, but also people who are getting treatment for anxiety disorders, so that they can begin to understand and become part of their own treatment team as well. So the bottom line to be aware of is that the majority of people with anxiety disorders do continue to work. When we're talking about anxiety disorders with anxious mood, usually there's a specific stressor that's occurred and a person begins to experience a significant level of anxiety, symptoms of anxiety, within three months of the stressor occurring. Typically, it doesn't go on longer than six months. However, there are instances where it can, and that's where more intensive treatment needs to occur. The key thing to be aware of is that a person experiences significant anxiety after the stressor occurs. And although they may be at a risk for suicidal attempts, clinically, that needs to be evaluated and addressed. And if that is a factor, needs to be addressed not only in treatment, but also in terms of is hospitalization needed as well to stabilize that individual. Then typically what's seen is that the anxiety decreases once the stressor is terminated. And this gives an overly simplistic look at what's going on. But the thing to realize is that this is a low level diagnosis as opposed to going up on a continuum in which a person might be experiencing increased stress. That's not to say in the moment that a person can't have significant distress. They can, but we'll begin to look at what to do. So when we're trying to think about how do we manage this, phobic disorders, social anxiety, generalized anxiety, what do we do? What are the treatments? And what you're gonna see is that there's a lot of, there are a lot of similar treatments that are done for specific types of anxiety disorders, but there are also some tweaks, some differences. For example, exposure disorder is something that goes on with phobic disorders. It's to try to help the person gain exposure and to prevent them from trying to eliminate, get away from being in the anxious situation so that they can learn to manage their anxiety and overcome it. So simply put, what we're looking at is the commonalities are almost always across the board that sometime event or situation has occurred in which the person has had a negative reaction. It's an emotional reaction. It's usually some type of anxiety response. Typically what happens too is that there's internalized self-talk. The person's talking about how awful the situation was in regards to what occurred and boy, they sure don't wanna go through it again. And that's understandable, but what occurs the longer that this type of internalized self-focus goes on in self-talk, a person begins to develop what's called anticipatory anxiety. And that is they think about, I don't wanna be in that situation again and try to avoid situations or similar situations in which they might potentially be anxious. So then the person begins to avoid any type of exposure and that plays a role that's maintained by this internalized self-talk. And the problem with it is there's nothing to really break up that self-talk as Dr. Brunson talked about with some people that he's worked with. Instead, it's more like a sock in the dryer and it goes around and around and that's where treatment can help break that up and help people learn different ways of managing it. The person also learns to fear to experience any sense of anxiety at all. And they overestimate that harm will happen to them. And we'll talk about that later as we go on. So again, they try to avoid situations that cause anxiety. With social anxiety, it's pretty clear when you see someone, certainly anyone could be in a situation socially and be uncomfortable, but reliably, a person with social anxiety is usually visibly uncomfortable around others. They are maybe sitting away from them or try to make themselves as invisible as possible. What they also notice is that there is going into the social situation, they start to anticipate that others may not like them or reject them, even though that may not happen. They're looking at a person's facial expressions. Did they talk to them? Did they not talk to them? The tone of voice. And they begin to assign negative meaning to how people interact with them. There's often a sense of uncertainty. What do I do? What do I say? Feels like the whole world's looking at me. Kind of like when you were a teenager and you felt like, oh, I better not do anything. I'll never forget. We were just walking in the store one time when my daughter was a teenager and I was doing something. My daughter put her arm down and said, mom, stop that. And as though everybody was watching us when it was something really mild and there was nothing really going on. But instead in a social situation, a person just doesn't know what to say. They feel tongue tied. Many times they try to find reasons to not go to social situations and may leave much earlier than others. And there's this rumination, replaying almost like a Monday morning quarterback. How did it go? What did people say? And again, thinking about, did it go well? And almost always the person assigns a negative type of overview about what happened in that situation. So let's look now in terms of generalized anxiety disorder. Dr. Brents has touched on this earlier. And again, you're seeing treatments that are pulling up along the side on the treatment guideline. But it's characterized by this excessive worry and anxiety about multiple events and situations. In many instances, you can't point to a specific trigger and say, aha, that's it. It's life in general. The worry is usually out of proportion to what's going on in the situation. What also happens is that the person is overestimating. Their heart might be beating wildly and they're convinced that there's some type of cardiac event that's about to happen. And they may end up in an emergency department or may not, but they may have more frequent appointments to their primary care physician to try to get a sense of what's going on. Typically too, individuals with generalized anxiety disorder report it's hard to control their anxiety, both physically and their anxious thoughts. They can't push them away. It's almost as though it takes up room in their head and they don't have room for anything else. This feeling of, I've had patients tell me, I feel this feeling just come over me. My hands sweat, my heart's speeding up. I feel like I'm gonna come out of my skin. I just feel wired. And there's a constant worry about they're realizing the quality of their interactions with others is being impacted because they are becoming anxious. With panic disorder, we have, again, the treatment guidelines, and it's not possible in the very short time that we have today to go into every single aspect. And that's why I'm trying to get you to look at, here are the characteristics, and we'll give some vignettes in just a few moments. And here's an overview of some of the treatments. But typically a person has intense fear or physical discomfort. It is uncomfortable. The important thing is that it's short-lived in nature. Typically it lasts 15 to 20 minutes so that if somebody says they're having a panic attack all day long and constantly, that's a good sign, a red flag or yellow flag, that some additional investigation, evaluation needs to take place because that's not really what happens with panic attacks. The frequency and severity of panic attacks vary from person to person. It makes one person anxious, may not affect another person with panic disorder. And they do develop, as with other anxiety disorders, this anticipatory anxiety. Let's avoid anything that would make me anxious at all costs. And so the world that they live in gets smaller and smaller and they begin to restrict what they do. There's worry again, much like with generalized anxiety disorder, about cardiac concerns and neurological concerns. I'm not sleeping. I've had one patient say, I got five hours of sleep, but am I going to have a heart attack? Am I going to have a stroke? And so there's this over-projection on potential harm. Typically people who have a panic attack are worried about losing control in social situations, being in a movie theater, or being trapped at church and can't get out. They frequently want to sit at the end of the row. They fear going crazy or looking like they're crazy, even though all it looks like to the average person is that they're tremendously uncomfortable and anxious. As Dr. Bruns touched on with benzodiazepines, we do want to be very cautious with them and try to use them only very short-term. They are effective and that's why they're used, but they should not be used long-term because of the high potential for addiction. And in safety-sensitive jobs, of course we find that it can impact on memory, recall of things that need to be done, the speed that a person can process. And then if verbal instructions are given, the person may have problems with recall as well. Other risks are the person can be overly sedated. There's an increased risk potentially of motor vehicle accidents, potential for falls, but even more importantly, with long-term usage, empirical research is now showing that with long-term usage on a daily basis, not short-term, not just a few days, that there is an increased potential to develop dementia. And so we need to restrict benzodiazepines in the workplace related to anxiety for these reasons. So what do we do? When we're talking about the stay-at-work plan, what we want to look at is this, is that you can see across the top are adjustment disorder with anxious mood, panic disorder, generalized anxiety disorder, and phobic disorder. So typically what we're looking at is the level of impairment, and it's broken down so that you can see at a glance, and this is within the guideline as well. Typically with adjustment disorder, a person can be very uncomfortable to be sure, but they had experienced a milder level of anxiety. And so because of that, we still want to look if they're asking to be off of work, we want to look to see are there some psychosocial issues, either at home or within the workplace, we want to identify those. But typically people who have an adjustment disorder with anxious mood really only maybe need a temporary leave as their starting treatment, but they do not need to have a long-term, permanent work restrictions or accommodations made for them. As we look at panic disorder, remember a person does not experience a panic disorder 24 hours a day. That's the problem with anxiety. It gives the impression that it's going on constantly, and that's what begins to drive people into treatment as well. Typically panic attacks last for 15 to 20 minutes, and there's a high degree of physical arousal, increased heart rate, hands may be sweaty, muscular tension, there could be muscle, there could be eye tics, muscle spasms. But what we need to do with people to keep them at work, especially with employers, is to begin to have people who are having a panic attack and are in treatment, allow them short breaks so that they can utilize those techniques to manage the anxiety, manage the panic attack and bring it under control. And there are people who come into my office who are in full-blown panic attack, and we work on teaching very specific tools to help them control that. And that's a tremendous relief because then they know that they have a tool that they can shut this down reliably. With generalized anxiety disorder, although it's listed mild to severe, it's important to realize in the diagnostic and statistic manual five, so DSM-5, it's not really broken down mild to severe. Severe relates to when a person is not having treatment. So it may be impacting across several aspects in their life. They may be having problems sleeping, they're having trouble focusing at work, and that is more severe. Once a person is in treatment and once the treatment has gotten started, it tends to decrease down to a moderate to mild range. And that's the goal, to help people address what's going on, what do they need to do to address these concerns. But in nearly all cases, there's no need for permanent work restrictions or accommodations aside from, again, giving people periodic breaks, allowing them to come to their treatment appointments so that they can stay in the workplace. And of course, the need to look at, are there any type of job sensitivity issues, safety issues? With a phobic response, it's important to remember that usually a person with phobia is not anxious unless they're in the situation that's making them anxious. So things like fear of flying, fear of snakes. I've had patients who've been afraid to ride up in elevators or drive on the interstate or drive across bridges or just some I can think of. They're not anxious in everyday life, for the most part. It's the anticipation of when they have to do that that increases their anxiety, to full blown being very anxious wanting to avoid that situation at all costs. But typically a person with a phobic response doesn't need to avoid the thing that makes them anxious or that is causing the phobic response. Instead, we need to work in treatment on what's called exposure and response reduction. So it's called ERP. We wanna prevent them leaving the situation. With staying at work, it's much the same. You can see that, again, we're assessing for psychosocial issues across the board. We wanna make sure people that are getting regular breaks and that they do have with panic disorder and generalized anxiety disorder, they have a chance to take those breaks within the workplace so they can utilize the tools that they need. As we're looking at interesting findings, when we're looking at most people who come in and are talking about perceived cognitive impairment, really what we're finding when you do the actual standardized testing is that there's not necessarily cognitive impairment that's occurring regularly on a sustained basis with anxiety disorders. Instead, it's that negative thinking that the person is having trouble stopping that keeps the anxiety going. There have been a series of studies, in fact, looking primarily at generalized anxiety disorder. And what was found was this, is that a meta-analysis of 40 studies found that people who with generalized anxiety disorder may have some problems with recall, may have some problems with speed of processing, but only in those situations, not in life in general, but only in those situations in which they're anxious. So that's an important thing to know. We do want to always look at safety considerations, keeping people safe within the workplace, as well as how do we help them if they're taking medications. Sometimes people are taken off of work because they're starting some psychotropic medications and there may be side effects. But if those side effects are started at a very low levels, those side effects can be minimized to increase the safety to the person, compliance with taking the medicine. And that's the goal. Always with stay at work plans, we want to stay at work and return to work plans, can work with the person either who's off of work, but then returning to work or helping them stay at work to develop a different set of tools to manage the workplace stressors, how their anxiety impacts on them staying at work, et cetera. And so what we'll do now is switch over to some vignettes. And these are not actual patients, but instead just a compilation of several patients. So in this case, a man has come in recently for anxiety. He's reporting various problems. He does feel this wired. He's worried, very worried about his physical health. He keeps checking to see if he's anxious. If he gets distracted, he'll immediately then look, am I experiencing anxiety? Do I have that feeling of being wired? It's affecting his appetite. He's finding, even though he's self-employed and has a highly successful business, that he's having some concentration issues at work, but still able to get his job done. His wife has noticed that he seems to be more anxious and more quiet and withdrawn. He, on the positive side, exercises daily and always has for years, but that doesn't really seem to help him manage his anxiety. He also reports that in the evening, he has started drinking alcohol as a means to help him to relax. And it works, but the problem is now he's having sleep problems. He sums it up as his life is great, except this anxiety is taking over my life. With the physical exam, everything seems to be within normal limits and putting his routine blood work, except his blood pressure is elevated. What we also have recognized is that he is having a sleep disturbance, but importantly, he's been sleeping between five and six hours of sleep. Then he wakes up and he just worries about not sleeping. He reports this decreased inability to relax. If he's just sitting there, he feels so anxious. He just can't get his muscles to relax. And he is having increased muscle pain because of this physical tension. When we complete the psychological evaluation, initially life is good. Everything on the psychological evaluation seems to be within normal limits, except he notes almost as an aside that he was golfing with friends recently and they were reporting different physical problems that they were having, including one man who was having severe sexual dysfunction. This man began spending a lot of time thinking about all of those problems and how awful it would be if he experienced them. In fact, it really began to worry him. The remaining psychological evaluation and mental status evaluation were normal. There was no type of suicidal ideation. But he does report that he's having these anxious thoughts, not about things that are actually happening, interestingly enough, including sexual dysfunction, but instead that they could happen, and that's what's worrying him so much, and it's decreasing the quality of his life. For his high blood pressure, he was prescribed distolic, which was helpful. A side effect, a very helpful one, is that as his blood pressure decreased in his heart rate, so did his anxiety. He could feel that. Although he was tried on some other psychotropic medications, such as Celexa and Paxil, there are too many side effects for him, and what ended up working better was a mood stabilizer, Lamotrigine, and it was built up gradually so that at first he was saying nothing was working, but then he realized it is working for him and that he's feeling more like himself. The hydroxine that he was taking two and three times a day has been stopped, and so he's feeling better on those fronts, and what he's received ongoing is cognitive behavioral therapy to help him address those cognitive distortions, reframe them in a more realistic way, stopping the worrying, and what's been most helpful for him is a journal to track not what he fears will happen, but what's actually happening, and gives him a real sense in real time about what's occurring. Relaxation training was taught to him in a variety of different ways so that he could reduce the physical tension, and as a result, right now, this man is feeling much, much better. At this point, I'm going to turn this over to Dr. Bruins. I should have advanced my slides here. Hold on a second. Forgot to do that. Dr. Bruins, we're seeing your calendar instead of the slides. Oops, sorry about that. How's that? There we go. Okay. Click the wrong button. Okay. Sorry about that. I failed to advance these. Okay. Here's an anatomy of an accident. Okay. Here's an anatomy of an accident. This occurred on a highway, and there was my patient who was driving a semi, and he was passing an exit ramp when a car that was somewhere behind him tried to exit in front of him and took this path. It actually cut so close, he actually bumped into the back of the car as he was jamming on the brakes. Now, the driver took evasive actions and first swerved left, then back right, and then first right, then left, then back to the right, going off of the road. He ended up rolling his vehicle while the driver just continues on and doesn't stop, leaves the scene of the accident. The semi goes off the road, witnesses see the driver of their car leaving the scene. The driver is not ticketed. He is initially briefly knocked out, has a period of loss of consciousness. When he comes to, he realizes that his fuel tanks have been punctured. He may have lost 300 gallons of diesel fuel, and he recognizes the risk of fire, and he can't get out of the truck because he's pretty badly injured and worries that the truck is going to burst into flame and he'll die in the fire. Eventually, his first responders come. He's taken out of the vehicle. Later on, he is surprised that his diesel fuel leaked into a local stream, and so he was fined $8,000 for polluting the stream, which just infuriated him. So even though he was not faulted in the accident, he was faulted for breaking a local environmental law. He was diagnosed with a mild traumatic brain injury, multiple physical injuries, and later on went on to develop chronic pain. He didn't have PTSD. PTSD is often prevented by a brain injury because you have amnesia. You don't recall the frightening things to have flashbacks about. So TBI can be like a prophylactic for PTSD sometimes. Long term, the driver was exhibiting signs of chronic fight or flight response, chronic anxiety, and he developed driving phobia, which is the flight response, and also became intensely angry at reckless drivers. He said in therapy that the next time somebody cuts me off, I'm not going to risk my life. I'll just ram them. Let them pay the consequence. And so there was a risk of him not being a safe driver anymore, both because he was terrified, and he could become paralyzed while driving his truck, or ultimately that he could just explode and not drive safely by ramming somebody. So he was a liability risk. Treatments involved medications for helping to tone down the anxiety, both beta blockers and SSRIs, and also psychological treatments. We use CBT to address his dysfunctional thinking about phobic thoughts that he had gone 25 years without an accident. He was really a safe driver, and he was believing that if I go out again, I'm going to have another accident. I'm going to roll my truck again. And he said, well, no, that's not true. It took 25 years for this unusual thing to happen. You're blowing up the risk. It's not as dangerous as you fear. We used exposure therapy. We're going to have you just start driving around your own vehicle to get comfortable driving again. Start driving your truck locally, just to get used to driving your truck in less difficult situations. We also used relaxation training and anger management. So all of these things helped him to eventually get back to work. And so even though situations like this can understandably give rise to an anxious response, these are treatable conditions, and these people often return to work successfully once they've had adequate treatment. So in the remaining time, we'd like to address questions. So how should we do this? I actually will go ahead and read the questions, Dr. Brines. Just a reminder to our attendees, if you do have questions, please post them in the Q&A box. Our first question is, for the purposes of educating a patient at the first level, for which the term anxiety is not clear or doesn't mean anything specific, could it be useful to use the word fear to name the feeling that anxiety produces? Yeah, I might start with the word stress. That, geez, this is really a stressful situation. It really stressed you out. I understand how you'd be stressed out going back to work or be afraid of what other people might do. So, yeah, so I would try to find a word, world that's comfortable to the patient and see if there's terminology that they use, that they feel comfortable with to begin there, before I start using diagnostic labels that often can put a person off. What would you say, Dr. Warren? I would agree with you, Dr. Brines. We don't want to medicalize things ahead of time. A person may or may not have an anxiety disorder. Fear is fine. I like fear is fine. I like stress. I think it's about asking the person, like you would if you met them someplace, what happened? Describe to me what happened and try to rephrase it in their own terminology. Because the worst thing we could do is just right out of the bat say, well, you've got an anxiety disorder and you're here for treatment. I don't normally do that. I normally sit down and I ask the person about why they think that they're here, what's their impression of why they were referred, and then in terms of getting more information and talking in their own terminology. Very good. Okay. Any thoughts about anxiety of workforce people while unemployed, in an unemployed status? It could be considered as not a disorder. It can. It can. I mean, that's a really broad question. We do know that people who are out of the workforce longer develop certain types of, I guess it's frame of mind is the way to put it, so that they become adapted, if you will, to not working. So when you're working with somebody who's been off of work for a long time and are anxious about working, it's much like working with anybody who's trying a new skill or if they're rusty on it, how to warm it up and how to break this task down into smaller, discreet, obtainable steps so that you're working with them. A lot of times, people who've been out of the workplace also have job coaches or they are working, they have other people who've been, who are working and they may turn to them and lean on them for questions that they may have, but people can have anxiety not working, but it's also equally true that the longer that a person's been out of work, so once we pass like a two-year mark, the whole mindset of a person has changed as well. Dr. Burns, what would you say? Let's say, I agree with that. One of the ways I look at it is just trying to distinguish that a person may have anxiety that might be realistic and or an anxiety disorder, which is not, and so a person might say, I'm out of the workforce, I'm three months behind in my rent, I worry about being evicted. Well, that could happen and so there you try to do problem solving about what can we do about this. In other cases, a person may worry about something that is implausible. You know, I have panic attacks, I've been told, you know, I've gone to the ER 10 times, they say it's not a heart attack, but I believe it's a heart attack. It's like, well, that's an incorrect belief and so distinguishing realistic threats, realistic challenges in the environment and problem solve around that from ones that aren't realistic that a person is worrying about unnecessarily. So, one involves problem solving, the other involves trying to address distorted thoughts and so kind of depending on which it would be, I would take one approach or the other. Good, thank you. So, for COVID long haulers, when should CBT be initiated in the acute or chronic conditions? What is the evidence for each? Okay, so I want to step in to say that that's not, I'm glad to give some answer, but COVID itself is not an anxiety disorder and it's still unfolding and I believe that ACOM has a specific guideline related to COVID. If we're talking about COVID early on, it also depends, has the person been, where are they? Do they have a mild case of COVID versus more severe? The more severe, the person may not even be able to function, follow along, they may be in the ICU, they may be intubated, they may be on a ventilator, so we can't do anything at that point. I think it's, that's a very broad question. Typically, what, when we're dealing with the long haul haulers, those people have been dealing with the symptoms long term and then you have to sort out a whole other category of situations, not just is there a mental health condition, but are there valid cognitive impairments as well? And in some instances there may be, depending on the physical damage that's been done. Are there, is there cardiac damage? Has there been significant lung damage? Is the person still on oxygen? So related to CBT and lung COVID, that CBT would not be my first step. It would be doing some of those earlier evaluation steps first. And Dr. Bruns, I'm interested in what your take on this would be. Yeah, I agree. I think it depends on the phase and we're still understanding this new disease. I can think of patients I've had who have been seriously cognitively compromised, having hallucinations and delusions and when they're very, very ill with COVID and then trying to, it's like a brief psychosis when COVID was apparently attacking the person's brain. And so with those people, you know, some people are just too sick to be doing cognitive strategies, which takes some mental wherewithal to do. I think early on, it may be beginning with medications to try to stabilize people. I think the CBT requires a person to be in a little better shape in order to have the mental energy and clarity to do that. CBT is thinking about how you think. And so it's a little bit more complicated. And CBT also doesn't work well for people who are illiterate or very low levels of education or people who are cognitively compromised. So it's too complex for that. So it might first begin with medications because it may well be related to their disease state. And then later on when the person is in better shape, it might try CBT. Very good. Okay. Dr. Bruns and Dr. Warren have graciously agreed to stay on a couple extra minutes. So we'll get to a couple more questions here. I have a 32 year old intelligent, educated male with Asperger's and some social general anxiety who has been helped by taking SSRIs for years. How long does he stay on them for life? Has he been evaluated? I mean, I guess my question would be who prescribed the medication? Is he being followed up on the medication regularly? Have attempts been made to try to decrease the medication to see what happens? Is he also receiving ongoing psychological care? Just because a person has Asperger's, it depends. And if he's a very high functioning individual, CBT can work, but there's a way that a person thinks very literally with Asperger's that you sometimes have to break things down in a few more steps than you might normally. So the question I would have is some people do stay on medication for the rest of their life. This individual, I don't have enough information to say how long he's been on it. He's stabilized. That's great. Is he seeing a psychiatrist? Have there been attempts to reduce his medicine? If so, how has he done? Have they tried to decrease him off of the medications altogether? So I think there's a lot to that question. But again, some people are on medications, psychotropic medications long-term. Dr. Bruns? I would agree. I had nothing to add to that. I think that's a good answer. Okay. Very good. Okay. So let's see. Could you please elaborate on what journaling and relaxation therapy entail? I've been leaping at first. How about you, Dr. Bruns? Go ahead if you want. No, it's okay. Okay. Well, journaling can be used in a variety of therapies, but often with CBT as you're trying to understand what gives rise to your symptoms, the thoughts, the feelings, and so on. And so I think that journaling can be a valuable tool, although it's a structured journaling. Some people just write randomly, and I don't know if that is much value. But I think journaling to try to understand the relationships between your thoughts, your emotions, and symptoms is a value. And what was the other half of the question? I think relaxation training. Relaxation training. What does that entail? Yes. Well, there can be breathing techniques that can slow your heart down. There can be progressive relaxation to reduce muscle tension. So different relaxation techniques can be used for different symptoms. So that can be valuable as well for anxiety. Very good. Okay. Last question, and we will try to get answers to the other questions that were submitted. How do you recommend addressing an employee whose anxiety is provoked by interactions with managers and or co-workers? Well, I mean, it depends on what is the anxiety itself. It sounds to be potentially, are there some workplace issues that need to be parsed out? It also begs the question, are there some psychosocial issues that are going on? Sometimes there are things going on behind the scenes that have to do with maybe there are just some poor relations with interactions with other co-workers. So we don't really know. I would also wonder, does this person just have problems expressing him or herself? And it comes out in the workplace. And so it's a form of social anxiety. I think that what would have to be done is to ask this person either to perhaps talk to somebody in the employee assistance program, so EAP, to begin to parse some of that out, or would this person be willing to work with a mental health professional to sort some of this out? We don't want to pathologize it. We want to make it, we don't want to say you have an anxiety disorder right out of the back, out of the chute. We want to try to frame it as, hey, let's make things run easier at work. You seem to have some bumps along the way. Let's see if we can get some tools to make this easier. What are your thoughts, Dr. Bruns? Yeah, I agree. I would look at what you're saying to see what is it within the individual that, are they prone to anxiety? I also wonder about what's happening in the workplace. And sometimes people are harassed by another employee or there's something else happening in the workplace that's a problem somehow. And so it may be something happening within the individual or maybe a broader workplace problem that needs to be looked into as well. So I would just explore both of those to try to understand why is this happening now? Right. Thank you, Dr. Bruns and Dr. Warren. On behalf of the ACOM leadership, thank you for presenting today. And to our attendees, thank you for joining us today. As a reminder, today's webinar was recorded. A link will be emailed to all registrants later today or tomorrow. Please check the ACOM website often for new webinars and have a great day. And everyone, please stay safe. Thank you so much. Thank you, everybody. Bye.

anxiety disorders

clinical applications

types

cognitive behavioral therapy

medications

case studies

workplace strategies

individualized treatment

ongoing evaluation

collaboration with mental health professionals