This Essay will discuss Anxiety disorders and its prevalent diagnosis within society with a focus on patients who choose to self-medicate, exploring the reasons behind why they choose to do so and the inherent social and health dangers associated with this behaviour. I will discuss why anxiety disorders are almost at epidemic proportions in all sections of society today with a majority still undiagnosed. The possible failure in diagnosis and treatment of this condition and discuss reasons as to the growing prevalence in self-medicating and the resultant effects it may have on the condition, society and pre hospital care.
As a student Paramedic and also having family members serving in the emergency services, I have always been mindful of the impact that certain work related experiences and/or exposures may have on an individual’s mental health. I have had close contact with a person who could not accept that they were suffering from a diagnosed form of anxiety (GAD) and then try and “tuff it out” e. g. Denial then self-medicating with alcohol (depressant) creating a self-destructive behavioural pattern prior to finally agreeing to receive professional treatment.
Paramedics are at the frontline when it comes to mental health issues (MHI) and when patients suffering from MHI present at calls, they more times than not present with serious medical conditions ranging from panic attacks, respiratory distress, overdose, self-harm to physical injuries from violence be it perpetrator and/or victim. At this stage patients require immediate medical attention. Posing the question, if the correct and proper diagnosis, intervention and treatments were accessed, administered or offered to these patients then would they have progressed to the stage where emergency pre hospital care was required ?
When we begin to look into what may be causing increased anxiety disorders in society we could easily assume that it is due to an under diagnosis of the condition or could we argue that the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) with its greater listings of mental health conditions may have made it easier to be diagnosed with an anxiety disorder? Other considerations may be that Psychiatrists are over analysing and misinterpreting normal behaviours which would have been dismissed as eccentric or odd behaviours in the past.
Within certain professional mental health circles there is a growing concern that the adverse effects of psychiatric medications may be causing chronic ill effects and possibly compounding some patient’s disorders. “Psychiatry’s drug-based paradigm of care is the primary cause of the epidemic” (Whitaker, 2010). With Australians’ anxiety and depression symptoms having increased in the last 5 years (Australian Psychological Society, 2015) it may still be under diagnosed with average diagnosis times between the onset of symptoms and actual diagnosis averaging between 9 to 12 years.
More distressing is that only a very small percentage of those that are diagnosed receive adequate help/treatment. A 2011 random study has shown that 46% of participants have met criteria for having had at least 1 mental illness at some time in their lives (Angell, 2011). If we extrapolate this result across Australia, one can assume that there is an almost epidemic amount of mental health conditions still undiagnosed within Australia.
To adequately look at this mental health issue we must first understand what constitutes an anxiety disorder. Anxiety is a term that encompasses a number of related disorders: Generalized anxiety disorder (GAD) suffers are constantly feeling anxious and worried which is out of proportion to what their life is really reflecting. Social phobia is where a person has an intense fear of being embarrassed, humiliated or criticised. Specific phobias are when a person has an intense fear of a particular item or situation.
Obsessive-compulsive disorder (OCD) is an ongoing and reoccurring obsession/compulsion which causes impairment in normal daily activities. Post-traumatic stress disorder (PTSD) suffers experience reoccurring recollections of the traumatic event as nightmares, flashbacks or hallucinations, they may show a loss of interest, estrangement from others and experience sleep disturbances (Bandelow et al. , 2012). Panic disorders aka panic attacks can occur in conjunction with other kinds of anxiety disorders.
The patient experiences periodic episodes of intense, overwhelming and often uncontrollable feelings of anxiety or terror, this combined with a range of physical symptoms such as shortness of breath, increased heart rate, dizziness and excessive perspiration can lead people to believe they are having a heart attack or are about to die. From a Paramedics perspective, it is vital that thorough assessments are carried out whilst attending patients suffering from anxiety disorders as there is the real possibility of the manifestation of physical symptoms and conditions.
Anxiety can be described as a blurring in the way a person thinks, acts and feels and a condition that cannot be totally eradicated. Treatments can dramatically reduce its effects, but it never totally goes away (Smith, 2013). The variety of symptoms can be explained by alterations occurring in relevant brain regions which are specific to a particular anxiety disorder (Smith, 2013) and thus require many varied medical treatment regimes. Cognitive behaviour therapy (CBT) or anxiety management therapy is usually the first treatment option, then in conjunction with drug therapy if required.
CBT focuses on identifying, understanding and changing behaviour and thinking patterns. This involves education, relaxation and controlled exposure to anxiety provoking stimuli. It is used for GAD, social anxiety disorders with OCD requiring more focused CBT techniques that focus on exposure and response prevention (ERP). PTSD requires Trauma focused psychological treatments including CBT, ERP and eye movement desensitization and reprocessing (EMDR) (Sharpiro & Maxfield, 2002).
When looking at drug therapies for the treatment of anxiety in Australia we are confronted with an overwhelming number of drug treatments ranging from benzodiazepines e. g. midazelam, temazepam and diazepam for short term management of anxiety disorders, ? – adrenoceptor antagonists (beta blockers), anti convulsants (Lyrica: pregabalin), azapirones (5-HT1A receptor agonists: buspirone) and long term drug treatment regimes with antidepressants – Selective Serotonin Reuptake Inhibitors (SSRI’s) which act by blocking the reabsorption/reuptake of serotonin by nerve cells in the brain and leaving more serotonin improving mood.
Serotonin & norepinephrine reuptake inhibitors (SNRI’s) increase the levels of both neurotransmitters (serotonin & norepinephrine) by inhibiting their reabsorption back into to the brains cells e. g. venlafaxine, aropax (paroxetine), duloxetine and the off-label use of both atypical and typical antipsychotic drugs. The prescription and application of the above drugs can be as wide and varied as the signs and symptoms of the patients themselves presenting with anxiety disorders. The pharmacological treatment for GAD is short term anxiolytics: benzodiazepines, ? adrenoceptor antagonists, pregabalin and buspirone which is a partial serotonin agonist that presents no sedative effects, no cognitive or psychomotor impairment properties and has minimal withdrawal symptoms (Cadieux, 1996).
Panic attacks are commonly treated with SSRI’s or SNRI’s and short term treatment with benzodiazepines or tricyclic antidepressants (TCAs). Social Anxiety Disorder is treated with SSRIs or short term benzodiazepines. OCD is treated with SSRIs with TCA (clomipramine) as an alternative.
PTSD is treated with antidepressants (venlafaxine, paroxetine, sertraline) and atypical antipsychotic drugs (AAP). Benzodiazepines have shown to give rapid relief to those suffering from anxiety, although with a wide range of possible side effects e. g. sedation, Impaired motor co-ordination, loss of coordination, impaired memory, poor concentration, slurring of speech and paradoxical agitation. A mechanism of tolerance can develop from this medication with long term/high dose patients as there is a decrease in the efficacy of GABA-A receptors (Arana & Hyman, 1991).
If the patient develops a dependence (can develop in a short period of time “days”) this is a major concern due to the fact that the patient may experience accelerated side effects and/or withdrawal symptoms that almost sync the symptoms of GAD, which can compound and/or worsen the patient’s condition/disorder and expose the patient to possibly seek out alternative self-therapy’s/medications both legal (prescription, alcohol) or illicit drugs to self medicate.
As a Paramedic when confronted by a patient who may be experiencing an episode, one has to be concerned that the patient may be suffering from some of the above mentioned side effects and also from any number of other prescribed or non-prescribed drugs that they may have taken. This is problematic as the patient may have overdosed on an unknown mixture, quantity of substances/drugs and as such any drug contradictions or possible adverse drug reactions cannot be anticipated by the Paramedic.
The patient may be incoherent/not rational and non-cooperative which can put the patient and the pre hospital health worker in a potentially time critical, medically acute and dangerous situation. Those suffering from anxiety disorders have a higher instance of self-harm and suicide with many choosing to self-medicate and not seek professional help. Some who suffer from anxiety may not seek help as they think that their thoughts and/or feeling are normal and this is how you are supposed to feel as they have felt this way for a long time and believe that everyone else must feel this way too.
To them this is normal and do not require any professional help. They may have been the victim of abuse, physical/mental or sexual and have tried to deal with the effects themselves, have tried to seek help but to have only been let down by the system or may not understand the condition and the resulting mental and physical consequences of not getting the correct diagnosis and treatment “denial”.
Have a high dependence on prescription medication and/or other substances which may have led them to a belief that self-medicating is working for them even though this pharmacological abuse may have initiated or even further advance their condition into depression or a type of emotional blunting as they try to chase a state of emotional anaesthesia as they are unable to tolerate their current life stressors/emotions without the need of self medication.
Many develop secondary medical conditions from the disorders themselves if not adequately managed: migraines, chronic fatigue syndrome, sleep apnoea, premenstrual syndrome and irritable bowel syndrome these are all compounding considerations when attending as a Paramedic in the pre hospital healthcare situation.
Further “gateway” mental health conditions can also develop from the initial anxiety disorder with the drug treatment regimens, drug/alcohol abuse, secondary physical medical conditions and further anti-social behaviours all being possible catalysts which may perpetuate the initial disorder or develop more serve mental health conditions. The individual and social thoughts vary as much as the disorders and treatments do themselves, when asked what impact anxiety has on a person’s life almost 74% of people stated strong to almost overwhelming with 14% saying slight and only 4% saying little to no effect. 4% of all persons asked, believe that others would think less of them if they were suffering from an anxiety disorder. 82% of all persons asked, believe that anxiety has a strong impact on a person’s relationships with family, friends and work colleagues and 78% of all age groups believe that it has a strong impact on a person’s job performance. (Canadian Mental Health Association, 2002).
In 2010 anxiety disorders cost Australia approximately 12. billion dollars in medical & pharmaceutical treatments, workplace costs, lost productivity and job turnover (LaMontagne & Sanderson & Cocker, 2010). In writing this essay, l believe l have challenged my implicit bias, although I believe the most socially effective mental health treatment plan en mass for those suffering a medical diagnosed anxiety disorder is to have adequate and appropriate pharmacological treatment as soon as possible then to be followed up with CBT.
My mental Illness implicit association tests suggested that I slightly associate effective more with medication than with therapy and slightly associate dangerous more with mentally ill people than physically ill people. This second view is supported by an Australian Bureau of Statistics (ABS) survey that shows direct links with those who have been incarcerated and have also had an incidence of a mental health disorder.
The study states that of the 385,100 individuals who have been incarcerated 41% have suffered from a mental-health issue. These individuals also have 5 times the incidence of substance use/abuse disorders when compared to the general public and are twice as likely to suffer from an anxiety disorder (Australian Bureau of Statistics, 2008). But further studies have shown that the risk of a serious crime being committed by someone suffering from a serious mental health disorder is small (Wallace et al. , 2012).
