Pollock – a review for healthcare staff

(See also what the International Movie Database says about Pollock)

Please note: This article may spoil your spontaneous enjoyment of the film. A number of significant events are revealed, so if you want to watch the film without preconceptions, we advise you to read the article after watching the film.

THEME: Anxiety
– a millstone around your neck or an air balloon?

Jackson Pollock – a psychopathological mixed bag

In November 2006 a large painting by Jackson Pollock called "No. 5, 1948" was sold at the fancy price of USD 140 million and became the world's most expensive painting to date.

The artist Jackson Pollock, a hardened alcoholic, died prematurely at the age of 44 when he drove his car off the road in a state of intoxication. "Is he the greatest living painter in the United States?" asked an extensive feature published in Life magazine in 1948. Of course, you can't help but be drawn to him – a guy who drips and pours paint on large rough cotton canvases laid out on his studio floor. Is he a genius? Or a madman?

By Herman Holm, Head of Department, Psychiatry UMAS, Malmö

The film

Ed Harris spent around 10 years researching and filed countless applications before the film about Pollock became a reality. After being given a book on Pollock by his father in 1986, he hit on the idea of making a film that would showcase Pollock's life and work in as much detail as possible. Pollock's art may appear accidental and unplanned, but according to Harris, if you take that view, you are completely on the wrong track.

"Jackson fully believed and lived by his statement "Don't use the accident, because I deny the accident." One cannot even approximate Pollock's work unless every stroke, every pour, every slap, every fling, every shake, every splash, every splatter and every flick has a specific intention."

Recently, many researchers have demonstrated that you can distinguish an authentic Pollock from an imitation by fractal analysis. This means that a small fragment of the painting is a reduced-size copy of the painting as a whole. Trees and plants are usually taken as examples of natural fractals where each small leaflet of a fern frond is a model of the fern as a whole.

Ed Harris directed the film himself. He also plays the lead role of artist Jackson Pollock, to whom he, uncannily enough, bears a striking resemblance. The film boasts an impressive amount of detail. All the paintings shown, the interiors, the arguments etc. form a richly authentic portrayal of Jackson Pollock.

In a poignant scene, he paints a 6x2 m painting commissioned by Peggy Guggenheim. The painting, as it emerges, looks identical to Pollock's original which is now on display at the Museum of Art in Iowa, having hung for many years in Peggy Guggenheim's private residence in New York. The film was nominated for two Oscars (in the best actor and the best supporting actress categories) and bagged one for Marcia Gay Harden, who plays Jackson Pollock's wife Lee Krasner.

A psychiatrist's dream

A psychiatrist's dream or, perhaps, nightmare, he heavily abused alcohol throughout most of his life and, on top of that, showed a wide variety of symptoms. He was diagnosed as a schizophrenic, manic depressive, pathological introvert, a "social outcast", a "psychic regenerator." What would have happened if Jackson Pollock, instead of living during the first half of the 20th century, had lived during its second half, or if he had lived today?

The treatments he received included a number of hospitalisations, often following heavy drinking, and repeated psychoanalytic sessions with a Jungian analyst. In one stable period in his life, he also apparently maintained contact with an elderly GP, who, besides providing a stable point of medical contact, gave him some kind of psychopharmacological drug.

Portrait of the artist as a young man

Pollock grew up the youngest of five brothers. His father is described as quiet, reserved, shy, and clearly had difficulty holding down a job, which is why his family often had to move. By the age of 10, Pollock had lived in six different places in three different states. At school he was quiet, reserved and had many problems speaking and making himself understood. He also had a short temper, easily became aggressive and often got involved in fights.

He was never really any good at school and had difficulty following the curriculum. He took to drawing at a very early age and even then decided to follow the path of an artist. Those around him would say that drawing had a calming effect on him and helped him express things which he could not verbalise. One obvious key to much of his art is the use of deep symbolic figures. His early work teems with animals, naked women, coffins, trees and other objects.

I can't say with any certainty if they were partly the result of his many years spent in Jungian psychoanalysis or whether they were there from the beginning (if Jungians are to be believed, such symbols existed, of course, before Jackson was even born).

If he had been taken to a modern-day psychiatric practice for children and adolescents, he would have been put on an ADHD programme relatively quickly, and who knows what Jackson would have become on a small dose of CNS stimulants? This is an important question from many points of view. Would it have affected his creative work and, if so, in what way? Would it have affected his social skills and his sense of well-being? There is an idea that the worse an artist feels the better his/her art – but the question is whether or not this is true.

Jackson Pollock, the Alcoholic

On the whole, Jackson Pollock fulfils all the criteria for alcohol addiction. This is well depicted in the film, where we see various shots of him drinking impulsively, abstaining from alcohol and, eventually, his final decline and the tragic fatal accident in which he drove his car off the road while in a state of heavy intoxication.

Many people have interpreted Jackson's drinking as a form of self-medication for his underlying depression and anxiety. At the age of 20, Jackson moved in with his elder brother and his wife in New York. The film conveys a clear picture of the overcrowding and the tense relationship between Jackson and his sister-in-law.

In her letters, she described how, before going on one of his drinking binges, Jackson would spend days in silence and depression, often retreating completely from the outside world. Another image that keeps recurring time and again is Jackson's inability to handle separations. Quite often, an intense period of drinking would ensue, for example, whenever his brother and his wife left New York.

Or when the particularly thorough district medical officer, upon whom he relied when living with his wife in the countryside north of New York, died. Or when his good friend, the artist and teacher Thomas Benton broke contact with him when Pollock was sacked, on account of his alcohol addition, from the Works Progress Administration, who gave him work and for whom he painted large murals on official buildings. On all these occasions, it was violent drinking, of the kind we can observe both in his real life and in the film, that literally landed him in the gutter.

But, Jackson Pollock also had periods of continuous abstinence, not least as a result of his marriage to Lee Krasner who managed to impose a few limits. For two years after they had moved to the countryside, carried on the crest of the green wave, Pollock, in fact, remained fully abstinent.

During this time he could rely on an elderly and considerate district medical officer who maintained regular contact with him. It was during this period that Pollock came up with his drip and pour technique. Jack Pollock thus became "Jack the Dripper" and earned himself a good name in the artistic hall of fame. It is hard not to be fascinated by both his art and the methods he used to produce it. To catch a glimpse of his art, please visit http://www.jacksonpollock.org.

Jackson Pollock created most of his art and his best art at the end of the 1940s, when he was better able to keep his drinking under control and enjoyed lengthy periods of abstinence. Was his anxiety channelled into art then, or was he simply going through a period when he was less anxious?

Bipolar?

It is clear that Jackson Pollock went through periods of depression during which he would retreat from the outside world and, more or less, spend all his time in bed. There are paintings depicting him as crying and helpless during these periods.

At other times he kept furiously busy and active 24 hours a day. It is highly likely that his conditions had their roots in a bipolar disorder.

At your practice

What would a treatment contract with Jackson Pollock be like? Which objectives would you set for his treatment and which modern medical treatment would you prescribe? What would your position be on the issue of possibly limiting an effective therapy in order to ensure there is some anxiety left to fuel artistic creation?

By Herman Holm, Head of Department, Psychiatry UMAS, Malmö

From fear to anxiety

Fear

We recognise fear both in ourselves and in others. Most of us sometimes carry memories from our early years, of situations that struck terror into our hearts.

I remember an episode when I was 4 years old. On the odd summer evening, my younger sister and I would be left on our own in a forest summer house out in the country for a couple of hours, while our parents popped over to visit some neighbours a few kilometres away. Suddenly, the sky went dark and it began to thunder. Both my sister and I felt terror starting to creep up inside us. It all ended by me deciding to run out barefoot into the rain towards the safety of my parents, with lightning flashing around me. That's how I remember it, at least.

I can still feel the way the different bodily signals, such as palpitations and alarm, built inside me. How my whole awareness of what was happening narrowed down to my terror of being struck by lightning and the promise of rescue that could be found in the immediate distance. This event is easy to describe, both from a physiological and a psychological perspective.

Although I was only a four-year-old, the fear pumped out adrenalin, cortisol and much else which prepared my escape towards the safety which would be the denouement of the drama. I ran fast, without feeling the stones underneath my feet, the whole of my small body was physiologically and cognitively set on reaching one goal, which I did, indeed, reach in what was presumably quite a decent time, considering that I was only four.

Fear as a model

The feelings triggered by danger are the same as the symptoms which usually present under various anxiety conditions. The difference between fear and anxiety conditions is not so much one of intensity as one of duration and consequences. Suffering from an anxiety syndrome means that you carry fear and discomfort without finding any ways of easing this condition, which leads to considerable disturbances in terms of leading a normal functioning everyday life.

This criterion is present in the great majority of anxiety syndromes described in DSM-IV. For many of the anxiety syndromes, for example generalised anxiety disorder (GAD), a duration is also specified and the diagnosis indicates that one must have experienced symptoms "most days over a period of at least six months."

A series of experimental animal models to trigger anxiety is used in research for various purposes, including measuring the ataractic effects of different types of substances. Subjecting animals to direct discomfort is, of course, a simple, but not always particularly good model, because it doesn't distinguish between a simple fearful reaction and more deeply-rooted anxiety.

As we know, fear is more often than not fully comprehensible and has a clear purpose. On the other hand, what makes anxiety so painful is that, in most cases, we can't comprehend it and it doesn't have a purpose, for example to achieve a behaviour that will quickly relieve the symptoms. To induce such a state, we can design models that include conflicts, a major element of unpredictability, throw in uncontrollability and unknown alternatives which, applied with some unpredictability, may be rewarding as well as punishing.

Naturally, the same thing applies if one wanted to trigger anxiety in people, which is something that has been done to people illegally kept in detention and torture centres.

Anxiety, anxiety is my birthright
my throat's wound,
my heart's cry in the world.
Pär Lagerkvist 1916

Why am I affected by anxiety?

This question recurs in most patients who turn to us for help with their condition. The answers provided by those treating them have varied. For many years, there has been a prevailing psychoanalytical Freudian theory that there are non-resolved conflicts lying in the unconscious, often with roots in childhood.

The idea here is to become conscious of them through psychotherapeutic interviews and be given a chance to work through them. There are many people who can attest that they have found this type of treatment helpful, but the 2005 report by the Swedish Council on Technology Assessment in Health Care (SBU) entitled "Treating Anxiety Syndromes" puts it in brief: "Therapies drawing on psychodynamic theories have been studied to a very limited extent in the case of anxiety syndromes" and it states that effects "have not been demonstrated in scientific studies."

A view which is currently becoming increasingly prevalent is that it can be put down to genetic vulnerability and genetic changes in serotonin and the GABA system. There is credible evidence in the form of studies on twins etc. to substantiate this view and Pär Lagerkvist's poem "Anxiety, anxiety is my birthright," now almost 100 years old, seems to be proving true.

At the same time, we must bear in mind that the increase in the risk for children of people suffering from various anxiety syndromes is still relatively low and that even where one identical twin, for example, develops anxiety hysteria, it need not necessarily mean that the genetically identical twin will do so as well. But, there is a genetic component, nonetheless.

Another, presumably more fruitful and exciting, way of looking at this is to view the connection between genetic vulnerability and environmental factors. In this field there are many studies emerging that show that the presence of certain environmental factors, coupled with a genetic predisposition, can indeed play a large role.

What should we treat and whom should we treat?

Different people have different thresholds of what is bearable anxiety. There is a difference in this respect between us, doctors, too. Some of us are more inclined to prescribe treatment, some more restrained. Regardless of this, now that we have decided to provide treatment, we must ask ourselves what medication to prescribe. Some of the available anxiolytics? Perhaps an SSRI preparation for many people diagnosed with several anxiety syndromes?

One type of psychotherapeutic treatment, cognitive behavioural therapy (CBT) has been praised, not least in the SBU report, as being superior by far to any other treatment in some cases, excluding specific phobias (here with an accent on behavioural therapy). It has a similar effect on many other anxiety syndromes.

The guidelines that I, myself, follow when contemplating these difficult considerations can be summarised as follows:

• How much pain and functional impairment does the condition cause the patient?
• To what extent do I consider anxiety symptoms as relevant reactions to a difficult life situation?
• As we know, typical examples are very strong anxiety reactions to acute trauma which one often encounters. As far as I am concerned, much of the treatment here consists of normalising the condition in order to make it understandable and manageable for the patient.
• How does the patient himself/herself assess his/her conditions and his/her willingness to receive treatment?
• What are the possibilities of a uniform treatment plan and follow-up of the action taken?

Jackson Pollock creates a painting with his 'drip and pour' technique on a cloth placed on the floor

By Hannes Holm, Film director, Stockholm

Anxiety and creativity – the best of friends/foes

I remember one night, around 20 years ago. I was heading back home after a night's shooting with my sound supervisor, who was many years older than me and very experienced. Filming at night is often quite tiresome. Not just because nights are when you normally sleep, but also because the food that nourishes film is light, and it's dark at night. This is why we have to arrange a lot of lighting in dense darkness.

In the car, the sound supervisor, my fellow passenger, came over a bit philosophical and went into great detail. He said that there is one thing by which you can always tell a film director. A special hallmark that they all have. As at that time I already considered myself a film director, I asked him with interest what those hallmarks were.

"They can't drive," he said, and went on: "I think I've been in a car with all of Sweden's major film directors, Bergman, Troell, Widerberg, and none of them, not one, could drive a car. They can't drive for shit." I then retorted: "Yes, and I can't drive either," because I really wanted to belong to that crowd of film directors. "I didn't mean it like that, Hannes. You can drive. You drive really well," he answered momentarily not realising that at the same time he had relegated me to the category of any old film worker.

For a second I thought I ought to drive off into a ditch to prove that I, too, was a film director. But I changed my mind. These days I actually think I am a film director. I haven't won a Guldbagge yet, but I guess that's only because my driving is still pretty much OK.

Creative anxiety

This is only one example of a slightly foregone conclusion about an artist. Over time I would come across many more. Artists are messy, wilful, hard of hearing, asocial, childish, often suffer from many phobias and constantly have to grapple with anxiety. I would agree with much of what's been said and the rest is simply cliché. But show me one artist who hasn't been affected by anxiety at least at some point during their lives, if not constantly. Having been a film director for some time, I am quite aware that anxiety and being an artist are the best enemies there can be.

There is a scene in the film about Pollock which I love. It's when Jackson Pollock receives a commission for a painting from his patron, Peggy Guggenheim. She wants to adorn her private residence with a gigantic mural. You can see the immense joy he feels when he gets the commission.

But, in the following scene it is time to rise to the challenge. He now has to create the painting. Pollock sits alone in his studio staring at a 6x2 meter large white canvas that he has to fill with his genius. There's no mistaking the feeling that the room is infused with anxiety. Time goes by without him doing anything. Days turn into weeks, weeks turn into months. All he does is sit huddled up in a corner in a state of absolute listlessness. But, eventually something happens. He gets up and resolutely walks over to the white canvas. He grabs a tin of paint and starts painting. It all ends with his wife finding him on the toilet the next morning. It is only by his spattered clothes and his tired expression that she understands that something is finally happening. The painting is finished and it's brilliant.

I am convinced that most artists can relate to this scene. You have to create something new out of nothing, give expression to something inside you, preferably something of your own and interesting. And in Pollock's case, his work must also be both brilliant and pioneering. Most people only have to be asked to give a short speech at their best friend's wedding for anxiety to creep in, like an ill-disposed partner.

You can't find your way into the speech and your brain feels empty. The only creative thing you can come up with is a bunch of different excuses for not giving the speech, and then, precisely at that moment, at the eleventh hour, the twelfth minute, the thirteenth second! If you can only clutch at a tiny straw, suddenly the whole speech falls into place. Well, in most cases, it does … Once you've had an experience like that, it's easier to understand why those working professionally in the creative arts sometimes feel a bit shitty. It's the reason why Ingmar Bergman constantly had trouble with his stomach, why van Gogh cut off his ear and why, ultimately, Stig Dagerman took his own life.

 "Creative anxiety is strong and the key is to overcome it."

Ed Harris as Jackson Pollock in the film

Anxiety as a driving force

Naturally, anxiety is to a large degree the driving force behind creativity. Sometimes, anxiety is there from the beginning, as in Pollock's case, and creativity becomes an instrument of survival in order to keep anxiety at bay. In other cases, creating art is based on the initial desire to create and your anxiety increases the more courageous you become in your creating. I was, in fact, not so surprised one day a few years ago when I heard Thore Skogman talk about the intense anxiety he feels during his work. Why him? He is the one who wrote that funny song about electricity, a let's-take-the-piss kind of bloke.

In my own experience, anxiety engendered creativity in earnest at the beginning of the 1980s. My good colleague and friend, Måns Herngren, and I were, by a sheer stroke of good (?) luck, asked to do a TV series with some money that they suddenly realised had been left over. We were about 20. We had both dropped out of secondary school after a period of on-and-off attendance and neither of us had any training whatsoever in film.

I remember particularly well one night in a corridor of our broadcasting house. Our own film team was due at 8 the next morning and we didn't have a clue what we were going to film. Our project manager had a family and had already gone home at 5 that afternoon, so we were left on our own. What could we do? There was only one solution. We started laughing, and we laughed continuously for an hour.

We were supposed to put life into the TV licence money. Us, who couldn't even write? If only our Swedish teachers had seen us! Us, whose essays never got read aloud. That night we sat down after all that side-splitting. We talked for two, three hours and then wrote for another two hours and then the team came and we did the filming and then the whole thing was broadcast to every TV in Sweden.

Only in retrospect did I understand that it was anxiety that forced us to laugh and stay up all night. Because, although we weren't highly educated, we were well brought-up, and having to suffer the shame of not coming up with anything would have been worse than what we actually created. But, it turned out alright, I thought, of its own accord.

Taming anxiety

It wasn't until a few years later that I understood the lesson I learned then. I learned how to handle my anxiety. Much of creativity and art is about being able to handle your constant enemy. Who wouldn't have gone mad just staring at a white canvas for months? When asked where an author's authorship resides, many authors, like Ulf Lundell, answer "in your arse." That means learning to sit on your arse in front of your word processor until something happens.

The greater part of Måns' and my film "Adam & Eva" came to life on a gigantic yellow sofa. We sat, lounged and lay on it for months. Often we would fall asleep. Days would go by without us getting anywhere. But neither of us at any time said, "Oh, what the hell, let's just chuck it in and come up with something new." We stayed calm, in fact, our anxiety remained quite calm until it eventually resolved itself.

Creative anxiety is strong and the key is to overcome it. What would have happened to Pollock if he had never been able to finish his commission for Peggy Guggenheim? If he hadn't been able to deal with it, his art would have ended there. "No, it's not working. No, I'm not an artist." etc. For three years, my colleague Måns and I worked, more or less full-time, on a manuscript that never saw the light of day.

I'm not sure what would have happened if we had experienced such a failure at a tender age. But, the experience we had acquired taught us to simply move on. Creative anxiety doesn't have to mean failure. Another important thing is being able to handle the anxiety triggered by a creative fiasco.

I always maintain respect for creative anxiety through the things I experience during filming. Often, policeman behave in front of the camera as if they were anything but policemen, and on many occasions, when I've had to ask big sturdy policemen to say a line, what came out was a pitiful little "peep" hardly worth filming.

I've worked with pilots who have carried out strictly prohibited "Figure 8" manoeuvres on the director's instructions and, after the camera was switched off, they've gone through post-traumatic stress because they did things contrary to everything they had learned before. Among most ordinary film crews, you will rarely find anyone willing to stand in front of the camera. They've hardened too much, become too experienced, to willingly subject themselves to the forces of anxiety that dwell there.

Again, you have to handle and overcome your anxiety and not assume, for that matter, that you have beaten it when you see that your film has become a box-office and a critical success. Creative anxiety can be your downfall at any time. So, you need patience and courage. Artists, like lion tamers, achieve their successes through painstaking long-term work. But, suddenly, it may happen that the lion tamer loses control of the situation and gets eaten up by his adepts. Similarly, anxiety can deal a final blow to the artist, although they may have coexisted peacefully for years. This happened in Pollock's case.

The art of suffering

So when do you reach the limit? When does creative anxiety reach a state of pure disease, a condition that should, in fact, be treated? It's beyond doubt that people within the creative professions "have a higher ceiling" than ordinary mortals. But, how, then, do you know when you've hit the ceiling, particularly considering that anxiety is part and parcel of your professional identity?

Many creative workplaces today, such as film studios and theatres, are prepared for this. An actor told me once: "If you're going to have a breakdown, have it at Dramaten in Stockholm." But, in other areas, things don't look so good at all. Just consider the mass media today – their ruthlessness and intense scrutiny make things even more complicated.

Ordinary people are thrown into reality shows without any protection from the exposure they'll be subjected to. Obviously ill artists, who have lost control of their own anxiety, are celebrated when they stage scandalous antics. They're not celebrated for their art, though, but for generating attention and boosting sales. It was like that previously as well. But, today, it happens much faster. Andy Warhol's prophecy that in the future we'll have a lot more celebrities has come true. But, only for 10 minutes no longer applies.

Suffering itself doesn't make great art. My understanding is that creativity and art are born of suffering, but that the actual product is not connected with the suffering involved in its creation. People working in the creative professions are not a different kind of people. They are the same as everybody else. I do admit, though, that most artists can't drive for shit.

By Herman Holm, Head of Department, Psychiatry UMAS, Malmö

The different anxiety conditions
– a primary healthcare perspective

Anxiety syndromes – an entire family

DSM-IV and ICD-10 recognise around ten different anxiety syndromes, with many of them divided into different subdiagnoses. Remarkably, most of these are not accounted for in the Nordic Family Book, a 50-year-old reference book, or in psychological literature, for that matter. Panic disorder, post-traumatic stress syndrome and generalised anxiety disorder are relatively recent newcomers from a diagnostic point of view, although these conditions have existed for as long as humanity itself. Previously, they were grouped under the common name anxiety neurosis.

There is a major argument for differentiating anxiety syndromes, not least from a treatment perspective.

The ones I will mention are as follows:

• Panic disorder
• Specific phobia
• Social phobia
• Obsessive-compulsive disorder
• Post-traumatic stress syndrome (PTSD)
• Generalised anxiety disorder (GAD)

Panic disorder

I remember when the concept of panic disorder was introduced in Sweden in the 1980s in connection with DSM-III and DSM-III-R. One of the head doctors at the clinic shook his head and said that panic disorder was nothing other than the humble anxiety attack. This was before SSRI, when the treatments available for these conditions in most places were limited to dynamic psychotherapy or, alternatively, benzodiazepines.

After meeting a great many people with panic disorder, I became convinced that it was, in fact, a specific condition which was also amenable to treatment. The typical form of this illness is a preacute condition characterised by strong somatic symptoms, usually palpitations, trembling and difficulty breathing, in conjunction with psychological symptoms where the sufferer is dominated by a conviction/fear that s/he is going to die or go insane.

It frequently affects people with no previous history of psychological illness or instability. It is often misconstrued as a somatic condition and on rare occasions the person ends up on an emergency ward.

Anxiety neurosis, a form
of neurosis (see also) where
anxiety and a state of uneasiness
are dominant.
Nordic Family Book 1955

It has been shown that treatment with several different SSRI preparations in most cases eliminates the signs of panic. Frequently, an SSRI preparation has to be administered at the full dose, i.e. at the same dose used in treating depression, which produces the same spectrum of side effects, not least those related to sexual function. When the pharmacological treatment is discontinued, most patients experience a relapse.

In a number of controlled studies, CBT has demonstrated the same positive results, but in addition to that it carries a lower risk of relapse.

A treatment which is evidence-based is clomipramine (Anafranil®).Many of my patients' panic symptoms have disappeared after they have spent 4-5 weeks on this drug at doses of 20-30 mg. I tend to let the patient slowly and gradually increase the dose himself/herself from 10 to a maximum of 150 mg/day. In the absence of panic symptoms, the patient reduces the dose by 10 mg at a time down to the lowest effective dose, which in many cases is astoundingly low (10-40 mg/day). Unfortunately, most of them experienced a relapse of variable lengths once the treatment was discontinued.

Benzodiazepines in the form of alprazolam or clonazepam are effective, but they cause significant discontinuation problems in most patients after only a short period of administration. It is not uncommon for people who have received no help for their panic syndrome to start to abuse alcohol or benzodiazepines.

"It is not uncommon for people who have received no help for their panic syndrome to start to abuse alcohol..."

Specific phobia

This is the most prevalent anxiety syndrome, accounting for around 10% of all sufferers. In this condition, it is not uncommon for patients to have phobias of spiders, altitudes, snakes and lifts. In a majority of cases, these people are only moderately affected, because they know what they need to do to avoid anxiety. No snake – no anxiety.

Medication is ineffective in treating this type of anxiety. The classical behavioural therapy involving exposure and deconditioning has proved to be extremely successful. Most patients can be cured, sometimes in a single session, and follow-ups carried out after 12 months show sustainable results.

Social phobia

Many people wonder where to draw the line between shyness and social phobia. The deciding factor is often the degree of disability and functional impairment. Not daring to eat or have coffee with one's work colleagues or use public transport for fear of being stared at or noticed may easily be diagnosed as a social phobia. But what do you do with a patient who is affected by strong anxiety only in certain situations, such as when giving oral presentations, but feels fine otherwise?

In 1997 Peter Kramer wrote the book "Listening to Prozac," which deals with the effects of the first SSRI preparation released on the U.S. market. He was confused by the results when he prescribed Prozac for people with social phobia. There were many examples of patients who managed to break the pattern of their social isolation, start meeting other people, get married, manage to compete successfully at work etc.

This psychiatrist, or rather psychotherapist, felt an uneasy fascination when confronted with such successes, and he introduced the term cosmetic psychopharmacology. At the same time, he respects the fact that this pharmacological treatment has reduced the level of suffering of the individuals receiving it. This was before SSRI was indicated for social phobia in studies. In Sweden today, five different SSRI preparations have been approved for the treatment of social phobia, but, funnily enough, not Fluoxetin which is, in fact, the generic name for Prozac®.

Cognitive behavioural therapy has proved successful in this area as well and there are many studies where the effects of CBT and pharmacological treatment have been shown to be equally strong.

The Flower of Pain, 1898, Edward Munch

Obsessive Compulsive Disorder (OCD)

I am somewhat doubtful as to whether OCD should be included in this group, i.e. anxiety syndrome. Certainly, these patients suffer severe anxiety but this group is different in many ways. They often become ill at quite an early age (50% develop symptoms by the age of 15) and 25% of them have motor or vocal tics. It differs from other anxiety disorders in terms of gender distribution, because it affects men and women equally.

Men develop this condition earlier and, viewed as a group, suffer from more severe symptoms. OCD also differs from other anxiety syndromes, in that it does not occur in a large proportion of placebo responders. OCD was previously one of the few available indications for psychosurgery (capsulotomy), a form of treatment which has since been abandoned.

The compulsiveness may express itself in a range of different forms, from the mild and manageable to the entirely disabling. The prevalence of OCD has been estimated in several stages and the current proportions usually stand at 1.5-2% for point prevalence and at around 2.5 for lifetime prevalence (both these figures say something about the chronicity of the illness). Most patients describe their troubles concerning obsessive thoughts and/or actions as alien, as something that comes entirely from outside them.

Clomipramine and SSRI have a symptom-alleviating effect and over one half of patients often need higher doses than those receiving treatment for depression with the same preparation. There is some evidence to suggest that clomipramine is slightly more effective, but it also produces more severe side effects.

Many patients have made a lot of progress and been greatly helped by cognitive behavioural therapy. Regardless of the therapy, or of whether you combine medication and CBT, the pattern that most commonly emerges is that you can observe a scaling down of symptoms, particularly those originating from anxiety. However, obsessive thoughts/actions usually persist, albeit in a somewhat limited form.

More often than not, the effects of treating obsessive-compulsive disorders are incomplete and the symptoms persist, as outlined in the SBU report "Treating Anxiety Syndromes 2005."

Post-traumatic stress syndrome (PTSD)

This syndrome emerged in the wake of the Vietnam war. The first scientific article using this new term was published in 1980. However, a condition with similar symptomatology did exist previously. The term "shell shock" was coined in the wake of World War I (after the English word for shell) in response to consideration of the effects of shock waves on the nervous system. The condition was characterised by fatigue, lack of initiative, autonomous arousal with tremor, sweating, hyperventilation etc.

PTSD is characterised by a triad consisting of:

• Reliving of the trauma in both waking and sleeping conditions (nightmares occur almost as a rule). Small irrelevant signals which remind one of the trauma may function as triggers and cause intense psychological discomfort.
• Constant avoidance of anything that is connected with the previous trauma.
• Persistent symptoms of excessive psychological strain, which often express themselves as sleeping disorders and irritability.

I usually think of a person running between two poles in a tense condition, with one of the poles representing involuntary reliving and the other avoidance.

This is, in all truth, a painful and debilitating condition, frequently connected with abuse and high suicide rates. The lifetime prevalence in Vietnam veterans with PTSD is estimated to be around 15%.

Anxiety and apprehension

Both pharmacological and psychotherapeutic treatment in the form of CBT has proven to be effective. What happens most commonly is that these patients are treated with SSRI, with or without benzodiazepines. There have been few studies of treatment with mirtazepin (Remeron®), an antidepressive which stimulates both serotoninergic and adrenergic systems through presynaptic alfa2 blocking, but some of the experiences in this field have been published.

Mirtazepin also has a relatively strong sedative effect. There have been exciting studies on healthy subjects which have shown an improved quality of sleep (more deep sleep, less REM sleep). Many patients with PTSD have responded relatively well to this treatment. I think it is wise to combine it with psychotherapeutic support or CBT, if available.

Generalised Anxiety Disorder (GAD)

What I envisage when I think of this diagnosis is a middle-aged single woman, if this chronic, often life-long, condition has started in early adulthood. It is roughly twice as common in women than in men and in older age. The prevalence in people over 55 is estimated at 7%. In contrast to other anxiety syndromes, I think that the diagnosis criteria according to DSM-IV for this condition are somewhat looser.

• Excessive fear or worry most days over a minimum period of six months
• Difficulty controlling worry
• Related to three or four of the following six relatively unspecific symptoms: restlessness, exhaustion, concentration difficulties, muscular tension, irritability, sleep disorders.
• In addition, there are three criteria which are often mentioned in the context of DSM IV: namely, that GAD cannot be better explained as a result of another psychological disorder, that there is clinically significant suffering and that it is not a consequence of direct physiological effects or some substance.

In the past, before 1980, the term "anxiety neurosis" was used and covered both what we today call panic disorder and general anxiety disorder, two syndromes that differ vastly in terms of their treatability. Panic disorder is often amenable to effective treatment, which cannot be said for GAD.

Most people with this condition who have received medical help usually take benzodiazepines. In a majority of cases, their symptoms do not alleviate, not even those related to discontinuation, which are difficult to distinguish from the underlying anxiety symptoms. Frequently, they spiral into chronically using benzodiazepines and, in some cases, develop tolerance and dependence.

There are many placebo-controlled studies involving an SSRI therapy and, in contrast to diseases such as OCD, they produce a relatively large proportion of placebo responders. In some cases where the response rate is 60%, the effect, as a rule, is four to eight weeks overdue.

Studies involving cognitive therapy show that GAD, in contrast to many other anxiety syndromes, receives only moderate support according to the SBU report "Treating Anxiety Syndromes 2005."

When to refer the patient

As in other psychological conditions, the incidence of an imminent suicide, difficult forms of disability or refractoriness to therapy may be reasons for referring the patient to a psychiatrist. Likewise, therapies such as CBT are often not provided in primary healthcare, and in many places it is rarely available within the public psychiatric establishment. I would like to promote the practice of offering patients the opportunity to receive consultation by phone or have access to a second opinion. If the communication between the two doctors works, then that is in many ways rewarding for both of them and a benefit to the patient.