Panic

Panic is not a disorder unto itself, and neither is a panic attack.  The modern conceptualization is that panic is a form of anxiety that may or may not include agoraphobia.  This last term is taken from the Greek, and literary means “fear of the marketplace”.  It is a fear of being unable to escape in a crowded situation, fear of bridges, and fear of travel in any kind of conveyance.   Much of the fear is anticipation of having a panic attack in these sort of situations.  The fear is heightened if the person believes the situation is such that no one will come to their assistance.  The agoraphobia is rarely initiated by a specific trauma, as is a post-traumatic stress disorder.  It is also not secondary to a fear of being socially embarrassed, as is a social phobia.  All these anxiety disorders impel one to flee the situation, but for different reasons.  Situations that involve travel or crowds  are feared and consequently avoided.  Many agoraphobics do not experience panic, but most suffer with the disorder.

Many agoraphobics develop anticipatory anxiety of being in public places, then avoid these situations for fear of having an attack.  Phobic avoidance develops over time, which reinforces the avoidant behavior.  The combined disorder of agoraphobia with panic tends to be more functionally debilitating than either disorder in isolation.  Anticipation of a fearful situation reaches the point of panic, and the panic is so startling that a person would do anything to avoid another panic attack.

Many patients complain of panic, but rarely do they meet the criteria.  Most people experience acute unpleasant anxiety and label that as panic.  Several symptoms overlap with generalized anxiety, but a few are better indicators of true panic than the rest.  The onset of panic and anxiety may be sudden, but panic tends to peak within ten minutes and then subside.  Generalized anxiety has less intensity at the onset, and tends to take a long time to resolve-if ever.  There are intense fears of dying or going insane while enduring a panic attack.  It almost seems like a medical problem when the heart beats so strongly.  A miasma of nausea, dizziness, palpitations, chest pains and shortness of breath overwhelm one to the point they fear dying.  Sweat pours forth in buckets.  Generalized anxiety often is accompanied by sweat, but typically not as intense or circumscribed.
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The good news is that most people who believe they are experiencing panic are actually experiencing acute anxiety.  The onset of panic is so strong and unforgettable, that it creates a cycle of fear and avoidance.  Generalized anxiety does not have specific fears that could be avoided.  Many people have agoraphobic symptoms, but fortunately, few will fall prey to the disorder.  It is commonplace for people to fear bridges, especially if they can see through a metal roadbed.  It is also normal to have fear of being trapped while waiting in line, or have a fear of being immobilized in a crowded elevator.  It is rare these mild anxieties develop into a Panic Disorder with Agoraphobia.

Treatment of all phobias is cognitive-behavioral in nature.  The main thrust of the therapy is to gradually expose the patient to the feared object.  The hope is to decouple the feared situation from the biological and psychological reaction. A psychologist will have the person imagine driving over a bridge, and discuss their emotional and cognitive apprehensions.  As the therapy progresses, the psychologist will attempt increased contact with the feared situation until the person masters their reaction.  Another method is to directly expose the patient to the feared situation in an aggressive fashion, which often alleviates the anticipatory anxiety of the next exposure.  There is a greater risk of being overwhelmed or even traumatized by this second sort of treatment, such that it should only be attempted with professional assistance.  Medication is not advised for long-term control of panic, but temporary usage can assist the therapy by lowering the overall level of anticipatory anxiety.  Please leave your comments regarding this article in the space provided below.

Vascular Dementia

Vascular dementia is a progressive loss of cognitive skills over time, secondary to a blockage or rupture of a blood vessel in the brain.  This term used to be called “multi-infarct dementia”, and other classification systems refer to it as an “arteriosclerotic dementia.”  The primary form is atherosclerosis, in which the plaques of fatty deposits form in the innermost layer of the cerebral artery.  It is almost exclusively a problem of the older adult.  Very young children are prone to arteriovenous malformations, which are congenital defects of the cerebral vascular system.  Most of these AVM’s are located in the brain stem, and do not result in the sort of symptoms observed in the older adult.

The primary deficit of multiple strokes is an impairment of memory.  The impairment may be the ability to recall old information or learn new information.  It is rare that someone forgets old information, yet learns new information at an average level.  The most common scenario is a decreased ability to retain new information, with increasing impairment of long-term personal information that declines with every subsequent stroke.  The specific deficit regarding loss of old personal information is called “episodic memory”, and it may be affected in isolation of other memory impairments.  A specific deficit of this type of memory is exceedingly rare, such that an impairment of new learning is much more common.

Vascular dementia is not limited to memory impairment alone.  The diagnostic criteria stipulates that a patient must have a memory impairment, as well as one other cognitive deficit, in order to be appropriately diagnosed with “Vascular Dementia”.  The most common cognitive impairment from stroke is difficulty with motor control; not just unilateral paralysis, but an impaired ability to carry out motor routines, despite a functional motor system.  Many stroke victims have difficultly recognizing and utilizing objects, despite having an intact sensory system.  Lastly, many stroke suffers have difficulty switching between mental tasks, making plans, and organizing the steps necessary to accomplish a plan.

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Psychological problems are common after suffering one or more strokes.  It is not common to have delusions of persecution or grandiosity after a stroke.  Some forms of progressive dementia affecting the right prefrontal-temporal area exhibit delusions as an early symptom of the disease.  Neglect of the right or left visual space should not be mistaken for a delusion.  It is frequently the case that the patient suffered with a Delusional Disorder prior to the onset of the stroke.  The most common psychological symptom of “Vascular Dementia” is depression.  The depression may arise from difficulty with psychological adjustment to their declined condition, or a general psychomotor retardation without any awareness as to their own psychological condition.  This takes the form of a significantly reduced reaction time, both simple and complex.  The person appears chronically fatigued, laconic, and wanting to be left alone.  This type of depression is often deemed to be “organic” in nature.

The neuropsychological treatment of “Vascular Dementia” is to first determine the exact nature of the deficits through testing.  If the patient is experiencing psychological symptoms of depression or delusions, the clinician must determine if the patient is aware of their abnormal state.  For example, psychotherapy is appropriate for an adjustment problem in a self-aware person, but inappropriate for a severely depressed person with no awareness of their symptoms.  Neuropsychologists use the patient’s remaining cognitive strengths to compensate for their deficits.  Please leave comments regarding this article in the space provided below.