Hector Warnes’s Comment

Barry Blackwell: The anxiety enigma

            My comment on this essay, which conveys the life work of a great psychiatrist, is a request  for clarity on some concepts Barry presented.

            Hopefully Barry would subscribe to the "dimensional" rather than the "categorical" classification of mental illnesses.  If this is the case, there are degrees of amplitude or intensity that help us  formulate a more precise diagnosis. Often we end up grouping those different dimensions as spectrum disorders. In my clinical experience, Obsessive Compulsive Disorder may belong to the cluster of Anxiety Disorders or to the cluster of Bipolar Disorders (when cyclical). Unfortunately for us, the degree of interrater reliability in descriptive or phenomenological psychopathology is not too accurate, nor is  the finding of a clear-cut etiology. We do not have reliable biological markers for each disorder.  I am jealous of Barry’s vast experiences and, in particular, I agree with his admiration for George Engel’s biopsychosocial model.            

            What escapes my grasping is the fact that the anxiolytics can control a panic attack (fear of going insane, of losing control, of having a heart attack, impending doom, of fainting in the street, etc.), while so can THE ANTDEPRESSANTS eScitalopram, citalopram or mirtazapine, in due time -- not immediately, but after a couple of weeks, at least. Once the effect of eScitalopram or citalopram  is successful, the anxiolytic can be suspended gradually.  Most of these cases before being referred to a psychiatrist are examined at  emergency departments, private physicians or cardiologists because of cardiac arrhythmias, palpitation, racing heart, dyspnea, gastritis, vertigo, fainting,  muscle spasm and so on. In the past, this anxiety crisis with neurovegetative overexcitement used to be called the "Hyperventilation syndrome" because of respiratory alkalosis and other metabolic changes caused by fight-flight reactions usually of an subconscious nature. The patients could not pinpoint the cause of this alarming symptoms at the time they were experiencing it. They only thought that they were on the brink of a medical collapse.

            I understand that  Stress disorders (The Tier Social Stress Test) are to be distinguished from Anxiety Disorders (there are too many scales on Anxiety and/or depression  to mention). I like Barry’s concepts of the "stress biopsia" and of the placebo effect which exist beyond doubt. I wish I had more patients in my clinical practice with positive placebo genesis.  I came across a adenosine thallium stress test (adenosine increases the strain or acts as stressor). Further, there are countless studies that have shown that at least 50 percent of Anxiety disorders have depressive features that, as Barry put it, would indicate the presence of an Anxious depressive disorder. Even in the usual scales with which we are familiar that there is often a great deal of overlapping.  I am also aware that the follow up of Anxiety Disorders sooner or later may show depressive psychopathology and/or cardiovascular or other somatic or neurological  pathologies (eg- stroke). I am not aware of  the systematic follow up of cases of spontaneous recovery and the context and life situations which would facilitate this outcome.   Of course, it would depend  on   early childhood experiences and the "wear and tear" of life events. Aaron Beck, a former psychoanalyst influenced by the Stoic Greek and Roman philosophers, was the founder of the cognitive therapy which has gained wide acceptance although systematic  long term follow up studies of its  effectiveness are contradictory.

            The AMYGDALA is the key center that shows hyperresponsiveness to perceived internal or external threats as shown by  functional neuroimaging.

            The father of psychosomatic medicine was actually considered to be the Hungarian Franz Gabriel Alexander (1891-1964), who moved to Chicago in 1930 after a distinguished career as a psychoanalyst in Berlin. He graduated in medicine in Budapest and also studied at the Physiological Institute in Cambridge. He introduced briefer psychoanalytic therapies in Chicago which he called: "The corrective emotional experience.”  In his writings, he  introduced physiological  principles of malfunctioning of the autonomic nervous system (organ neurosis).

            The term "psychosomatic" was first introduced by Heinroth in 1818

            Since the 18^th century there have been many reports on the connection between the emotions of terror, fear, anger and sadness and cardiac events. John Hunter, a prominent Surgeon who suffered from angina pectoris, died suddenly after an outburst of anger. There are disparities regarding who was the real "father" of psychosomatic medicine.  Some would raise the name of Georg Groddeck (1866-1934), who introduced psychoanalytic psychosomatics translated into English in two books one named  the Meaning of Illness in 1977. Groddek had a psychosomatic sanatorium where he treated prominent Europeans and was a personal friend of Freud and Ferenczi. In this psychoanalytic line, Helen Flanders Dunbar, Edward Weiss, Felix Deutsch, Eric Wittkower  and, of course, George Engels figure prominently in the USA.

            Another Hungarian, Hans Selye (or János Hugo Bruno Selye) (1907-1982) ,after  having spent a year (1931) at John Hopkings University on a Rockefeller Foundation Scholarship, went to the department of Biochemistry at McGill University (Montreal) where he started studying stress and first published his findings in the British Journal Nature in 1936. Instead of studying the autonomic nervous system response, Selye studied rat Hipothalamic-Pituitary-Adrenal responses and found three stages in response to stressful stimuli: alarm, resistance and exhaustion. In 1945,  he moved to the University of Montreal where he led 40 research assistants and had 15 laboratories.  He always recognized his debt to Walter Cannon and Claude Bernard.  Let  us not forget that besides "the Wisdom of the Body" (1932) (regarding the principle of homeostasis and the fight-flight response to danger), in 1942 Cannon wrote an article, "Voodoo Death,"  which occurs following a curse or a fright. Cannon attributed it to overstimulation of the sympathetic nervous system which would bring about a cardiotoxic release of adrenaline (not unlike the cardiotoxic overdose of cocaine). Curt Richter (1894–1988) in his experiments came to his own conclusion that it was the vagotonic excess which would be pathogenic (eg cardiac arrest). What ever the cause of the sympathicotonic or parasympathicotonic overstimulation the patient’s entraptment was originally caused by a curse and a  sense of helplessness from some ‘evil’ wishes from another person conveyed by a  Witch doctor or other sources.

            I would say that Psychoneuroimmunoendocrinology is the continuation of Selye’s countless animal research on the issue, while Psychosomatic Medicine has expanded along  psychophysiology, early childhood  and later  life events, including the cognitive and emotional conflicts often of an unconscious nature. Lately, depression is considered a risk factor, along with the well-known other risk factors in cardiovascular illnesses (obesity, the metabolic syndrome, arterial hypertension, hyperlipidemia, sedentary life style, smoking, alcoholism and so on).  A few decades ago the emphasis was placed on a type of behavioral style called personality type A (time-urgency and work-addiction were significant traits) and, more recently, the emphasis was placed on  greater pent-up hostility, loss and a no-exit situation.

            In my opinion,  Eric R. Kandel (2005) and Bruce S. McEwen (2015) have been best able to integrate all aspects of the psychobiosocial approach to illness.

References:

Alexander F. Psychosomatic Medicine: its Principles and Applications. 2nd ed. New York/  London: Norton; 1987.

Beck AT. The evolution of the cognitive model of depression and its neurobiological correlates. Am J Psychiatry 2008; 165: 969-77.

Cannon WB. The Wisdom of the Body. New York: W.W. Norton; 1932.

Cannon WB. Voodoo Death. American Anthropologist. 1952; 44: 169-81.

Groddeck  G. The Meaning of Illness: Selected Psychoanalytic Writings. NewYork:  International Universities Press; 1977.

Kandel ER. Psychiatry, Psychoanalysis and the New Biology of the Mind. Washington: American Psychiatric Publishing; 2005.

Kirschbaum C. Pirke KM, Hellhammer DH. The Tier Social Stress Test, a test for investigating psychobiological stress responses in a laboratory setting- Neuropsychhobiology 1993; 28: 76-81.

McEwen BS. In search of resilience: stress, epigenetic and brain plasticity, Ann NY Acad. Sci.2016; 1373: 56-64.

McEwen, BS, Karatsoreos IN. Sleep deprivation and circadian disruption: stress, allostasis and allostatic load. Sleep Med. Clin. 2015; 10: 1-10.

Pettigrew TJ, Hunter J. The Medical Portrait Gallery. Lancet 1838-39; ii: 119-20.

Selye, H. A syndrome produced by diverse nocuous agents. Nature 1936; 138; 32.

October 5, 2017