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How to avoid the Swedish disease of ‘hitting the wall’

David Crouch, who “hit the wall” himself, looks at what you can do to avoid this uniquely Swedish condition, which causes thousands to take long-term sick leave. 

How to avoid the Swedish disease of ‘hitting the wall’
This is one of the pictures used to illustrate an article in Svenska Dagbladet on utmattningssyndrom or ED. Photo: Staffan Löwstedt/SvD/TT

At first I bought one of those super-bright therapy lamps. Perhaps it was the winter darkness that was making me feel this way. In my head, it felt like trying to wade through thick, sticky mud. Like permanently cycling uphill. 

There were times when I just had to stay in bed, especially at the weekends, or take a long nap in the afternoons. Perhaps I was just getting old? I lost my lust for reading, my alcohol intake went up. I developed a short fuse and would lose my temper over nothing.

Maybe I was depressed? I went to vårdcentralen, the local healthcare centre. They tried various drugs on me, to little effect. Eventually they sent me to a psychologist. “You’re not depressed, you’re clinically exhausted,” she said. “You should do less.” 

It was a good diagnosis, but telling me to do less was like asking a fly to crawl out of a spider’s web. I needed help. My life required major surgery. 

As I neared my actual burnout, I tried plunging into very cold water. I was like Rutger Hauer’s character in Blade Runner, who senses that he is dying and drives a nail through his hand to keep himself alive

Last week, we looked at Sweden’s epidemic – in which I am a statistic – of what they call “hitting the wall”, known among doctors as exhaustion syndrome (utmattningssyndrom). The medical term in English is “exhaustion disorder” (ED). 

My experience with the condition shows how hard it can be to identify, even for health professionals. 

This is one of the pictures used to illustrate an article in Svenska Dagbladet on utmattningssyndrom or ED. Photo: Staffan Löwstedt/SvD/TT

It all started in the mid-1990s, when doctors in Sweden realised they were seeing people with a common set of symptoms.

Patients were very tired, their heads were in a mess, they found it hard to read or absorb information, and they felt generally crappy. Sweden had been through a deep economic crisis and many people had lost their jobs. For many, this was a period of major upheaval. 

From this, a new diagnosis emerged for exhaustion caused by chronic stress; it was officially recognised by Sweden’s medical establishment in 2005. Since then it has been gradually – and unevenly – implemented in clinical practice. There is a considerable overlap between ED and clinical burnout, which is recognised abroad. However, ED is unique to Sweden in that it includes not only work-related stressors but also those that occur in private life.

According to Sweden’s National Board of Health and Welfare, someone may have ED if they experience all three of A, B and C below:

A. Physical and mental symptoms of fatigue for at least two weeks, with symptoms having developed as a result of one or more identifiable stressors that have been present for at least six months

B. A clear picture of impaired mental energy, reflected in reduced initiative and endurance, or extended time necessary to recover from mental strain

C. At least four of the following symptoms should have been present daily during the same two-week period. These should cause clear suffering or impaired function at work or in other social contexts, and should not be caused by drugs, medicines or disease:

  1. Difficulties with concentration or memory
  2. Significantly reduced ability to handle tasks or to do things under time pressure
  3. Mood swings or irritability
  4. Significant physical weakness or fatigue
  5. Physical symptoms such as chest pain, palpitations, stomach upset, dizziness or sound sensitivity
  6. Sleep disturbance.

“Dizziness and sound sensitivity”? Yep. “Significant physical weakness”? From cycling 50km for fun, I went to finding it exhausting to take a gentle stroll. 

This is one of the pictures used to illustrate an article in Svenska Dagbladet on utmattningssyndrom or ED. Photo: Staffan Löwstedt/SvD/TT

Some clinicians find the ED diagnosis problematic. There are no studies to show how ED is distinct from depression or even how it differs from normal tiredness among healthy people, as Christian Rück, professor of psychiatry at Stockholm’s Karolinska Institute, points out.

The danger is that we medicalise symptoms that are just part of normal life, he says, defining people as sick when actually they are not, and subjecting them to ineffective or unnecessary treatments. 

The uncertainties around ED mean that Sweden doesn’t even know for sure how many cases there are, or whether the number is rising or falling. “Many doctors do not accept the diagnosis, and not all vårdcentralen use it,” says Kristina Glise at Gothenburg’s Institute for Stress Medicine, who was one of the group of researchers who originally developed the ED diagnosis.

It is also unclear what treatments work for which symptoms, other than changing how people work. “We have not found measures that can shorten the illness other than at the workplace,” Glise says. Since 2018, employers have been legally responsible for taking an active part in the rehabilitation of employees diagnosed with ED.

Swedish trade union Unionen offers the following tips for spotting someone who is heading “into the wall”. The victims themselves are usually not so good at recognising the signs:

  • Fatigue and sleep disorders: they commonly to go to bed late and get up early to catch up on work. The result is that they constantly feel tired
  • Careless with diet: “I don’t have time to eat properly” is the common refrain 
  • Regular exercise and social events are not prioritised
  • Headaches and pain in the body, especially tension in the neck and shoulders
  • Sensitivity to sound
  • Slightly irritated, anxious or depressed, with a shorter fuse than usual
  • Poor memory and difficulty concentrating.
This is one of the pictures used to illustrate an article in Svenska Dagbladet on utmattningssyndrom or ED. Photo: Staffan Löwstedt/SvD/TT

During the two years of my battle with ED, I had superb care from a local occupational therapist. She taught me to recognise my symptoms and to re-organise my life so that I learned to work regular hours, take frequent breaks and exercise, and find effective methods to de-stress and relax.

But could I have avoided hitting the wall in the first place?

I regret that nobody was able to warn me of what was coming if I didn’t take the necessary steps. Hopefully, this and my previous article might encourage you to do so. 

David Crouch is the author of Almost Perfekt: How Sweden Works and What Can We Learn From It. He is a freelance journalist and a lecturer in journalism at Gothenburg University.

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WHO says European festivals should go ahead despite monkeypox risk

Most new cases of monkeypox are currently detected in Western Europe. The World Health Organisation says this is no reason to cancel more than 800 festivals scheduled to take place on the continent this summer.

WHO says European festivals should go ahead despite monkeypox risk

The World Health Organization said Friday that European summer festivals should not be cancelled due to the monkeypox outbreak but should instead manage the risk of amplifying the virus.

A surge of monkeypox cases has been detected since May outside of the West and Central African countries where the disease has long been endemic.

Most of the new cases have been in Western Europe.

More than 3,200 confirmed cases and one death have now been reported to the WHO from 48 countries in total this year.

“We have all the summer festivals, concerts and many other events just starting in the northern hemisphere,” Amaia Artazcoz, the WHO’s mass gatherings technical officer, told a webinar entitled “Monkeypox outbreak and mass gatherings: Protecting yourself at festivals and parties”.

The events “may represent a conducive environment for transmission”, she said.

“These gatherings have really close proximity and usually for a prolonged period of time, and also a lot of frequent interactions among people,” Artazcoz explained.

“Nevertheless… we are not recommending postponing or cancelling any of the events in the areas where monkeypox cases have been identified.”

Sarah Tyler, the senior communications consultant on health emergencies at WHO Europe, said there were going to be more than 800 festivals in the region, bringing together hundreds of thousands of people from different countries.

“Most attendees are highly mobile and sexually active and a number of them will have intimate skin-to-skin contact at or around these events,” she said.

“Some may also have multiple sexual contacts, including new or anonymous partners. Without action, we risk seeing a surge in monkeypox cases in Europe this summer.”

Risk awareness

The UN health agency recommends that countries identify events most likely to be associated with the risk of monkeypox transmission.

The WHO urged festival organisers to raise awareness through effective communication, detect cases early, stop transmission and protect people at risk.

The outbreak in newly-affected countries is primarily among men who have sex with men, and who have reported recent sex with new or multiple partners, according to the WHO.

People with symptoms are advised to avoid attending gatherings, while people in communities among whom monkeypox has been found to occur more frequently than in the general population should exercise particular caution, it says.

The normal initial symptoms of monkeypox include a high fever, swollen lymph nodes and a blistery chickenpox-like rash.

Meg Doherty, from the global HIV, hepatitis and sexually-transmitted infection programmes at WHO, said: “We are not calling this a sexually-transmitted infection.

“Stigmatising never helps in a disease outbreak,” she added.

“This is not a gay disease. However, we want people to be aware of what the risks are.”