Wednesday, August 23, 2017

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What fear looks like part 3


Another in a series of posts featuring images that somehow depict panic and anxiety. These are photos that can set my heart to racing before I've consciously realized what I'm looking at. Seriously.*








See any common themes?

* From an an article about neuroscientist Joseph LeDoux:
"Over the last decade or so, LeDoux and others have worked out this circuitry in lab rats step by step, each accreted detail sending a small ripple through the world of human psychology. His laboratory has been able to show that as soon as conditioned animals hear the tone that precedes a shock, the auditory information travels to a way station in the brain known as the sensory thalmus, an essential stop for any incoming information about the world, and then immediately continues on to the amygdala. In rats, a fear-inducing sound goes from the ear to the amygdala in 12 milliseconds - that is, 12 one-thousands of a second. Moreover, LeDoux says, cells in this corner of the amygdala, known as the lateral nucleus,"learn" and memorize the fearful stimulus with incredible rapidity and tenacity. The research suggests that all it takes is one terrifying experience to form a lifelong emotional memory, one that is extremely difficult to erase.

"While LeDoux's lab has concentrated on this downstairs circuit, the laboratory of Michael Davis, now at Emory University in Atlanta after 29 years at Yale, has sketched out what might be considered the high road in the processing of fear, one that may more closely mirror the routine processing of fearful information in humans. It passes from the sensory organs, like eyes and ears, and lingers in the cortex, where conscious memories are formed, before threading down to the amygdala. Davis has also tentatively identified a separate destination, called the bed nucleus of the stria terminalis, which is heavily connected to the amygdala and seems to control chronic states of fear like anxiety and worry.

"This may sound like a lot of dense neural cartography, but the significance for psychiatry, if the same dual circuitry pertains to humans, would be profound. It suggests that because there are two different neural routes to the amygdala, two different kinds of fear-related memory can form. Indeed, one of the provocative things about LeDoux's circuit is where it doesn't go. It doesn't go to the thinking part of the brain first. And what that implies - certainly in rats, and almost certainly in humans ... is that we experience, learn and unconsciously commit to emotional memory many fearful situations, without ever being aware of what has triggered the racing heart and quick pulse.

"One hallmark of a panic attack, for example, is that its victim cannot understand what has triggered such a powerful reaction. The implication of fear-conditioning experiments in animals is that we have a separate memory of a fearful stimulus, be it a bear or a dinner party, lodged in the amygdala, probably informed by things we have heard or seen but do not consciously remember. So it's as if we walk through the world half-blind, bumping into archival stimuli, things we never knew scared us, things that we can't consciously remember but that nevertheless set in motion inexplicable and disturbing sensations of dread. Freudian analysts who have followed the work of LeDoux and others have been quick to point out that neuroscience's version of unconscious fear, in the words of Dr. Jean Roiphe, a Manhattan analyst, "strongly corresponds with the Freudian notion that it's indelible and never goes away."

(Italics are mine.)

WHAT FEAR LOOKS LIKE, PART 1

WHAT FEAR LOOKS LIKE, PART 2

Anxiety Attacks Symptoms


Anxiety attacks symptoms can vary from person to person but I have listed the most common ones below:


  • speeding heartbeat

  • breathing too fast

  • feeling sick to your stomach

  • shaking or trembling

  • pale face OR blushing

  • racing thoughts



Many people also report having thoughts of catastrophe or even a suddenly blank mind.

Having an anxiety attack is something that can come on when you are in a situation where you feel unsure about what to do , or in a situation where you have previously had a traumatic experience.

My own anxiety attacks symptoms most noticeably involve my chest and abdominal region. I can feel my chest tighten and sometimes even experience mild chest pain.

The most pervasive sign of an anxiety attack for me is this feeling of cold dread deep in my stomach. And then my legs and arms start to shake. My legs will feel rubbery and cold and although they are perfectly functional they feel like I can't move them correctly.

Noticing anxiety attacks symptoms seems to make them worse, it is as though I am worried about something, then I start to feel worried about how anxious I am getting!

Actually even writing about it isn't so great!

Got to go -- talk to you later!


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Panic on the subway



This bit starts with the ER visit that came at the tail end of my first-ever panic attack, and ends with my second-ever panic attack:

-------------------

The ambulance deposited me in the emergency room at Stamford Hospital, where a nurse put me in a robe and ushered me behind a curtain. A doctor put a stethoscope to my chest, an EKG tech wired me up and recorded my heart’s electrical rhythms, and I was discharged with a clean bill of health. “There’s nothing wrong with your heart,” the doctor said.

Nothing wrong?

My parents had made the 90-minute drive to the hospital from their home on Long Island, and now they drove me back out onto the Connecticut Turnpike and to the McDonald’s parking lot where I’d left my car. There, my mother joined me in my Ford and my father continued on alone in his Cadillac. During the next 90 minutes, down through Westchester and the Bronx, over the Throgs Neck Bridge, and east to my parents’ home, I must have apologized 25 times for ruining our plans for their 25th anniversary celebration. We’d had a plan, and I’d fucked it up. That was the way I saw it. My mother, God bless her, assured and reassured me. “That you’re okay, that’s what’s really important.”

But I wasn’t okay. I didn’t realize it then, but today I can see, clearly, that I was in a state of shock, that I’d been through a trauma that, strange as it might seem, had had the same effect on me as if I’d been in a car wreck.

Back at home in the city, though, I carried on as though all was normal. 7:15 alarm. Shower, shave, choose a tie from the tie rack. “Good morning” to the doorman on the way outside. Join the herd streaming downstairs to the southbound 96th Street IRT platform. Exit at 59th Street, head west to Madison. Enter the GM Building, push onto the elevator to the 50th floor. Take off suit jacket, start the computer, scan the Wall Street Journal. “Hey, Mike, hey, Jane, good weekend?”

Monday at work began uneventfully. To a degree I was just going through the motions, but it wasn’t like I hadn’t done that before at work.

Things were still okay at the end of the workday. Downstairs I made my way east on 59th Street, remembering that just a few months back it would’ve been dark and cold at 5:30, glad for the lengthening days. As I joined the stream of commuters descending from street level to the subway platform, though, my mood shifted. There were too many people, too close to me. This was odd; I’d never found crowds particularly upsetting. In fact, some of my fondest memories involved times I’d been part of the power of crowds, one tiny drop in a tidal pull of energy: in the press of concertgoers immediately in front of the stage, for instance, or with my voice joined with those of tens of thousands of others at hockey and basketball games. I looked to the exit, considering just walking home, the thought defeated by the prospect of navigating the crowd to make my escape. At that moment a push of stale, warm air pushed over the platform from the tunnel to the south, and the train barreled into the station and screeched to a halt.

“Step lively! Watch the closing doors!”

I squeezed my way to the middle of the car, and as the train pulled out of the station, I felt a tiny flutter in my chest, and was immediately swept up in a flood of disturbing thoughts. What if it happens again? What if they were wrong, and there is something wrong with my heart?

The train jostled in the darkness of the tunnel, and I reached for the strap to steady myself. I told myself it wasn’t going to happen again, that I was fine, that I was just still shaken up from my experience the day before on the Connecticut Turnpike. But then I felt a sharp pain in my chest, and no amount of logic could’ve helped me avoid the wave of fear engulfing me suddenly. My heart jackhammered. My breath heaved. My legs felt weak, like they were about to give out. I stared at the advertisement above me for what must have been 10 seconds before realizing that it was one I’d laughed at a hundred times before (“Anal warts? Try LASERS!”), but if I’d opened my mouth in that moment it would have been not to laugh but to scream. This time, I knew, it was for real; I was having a heart attack. I was about to die.

Hardly realizing what I was doing, I made my way through the crowd toward the nearest doors, ignoring the annoyed expressions on the faces of those I was pushing past. Escape: that was my imperative, the thing I wanted with an urgency I’d never felt before. There was no question of taking this subway all the way to 96th Street, my stop. We pulled into 72nd Street, and I was off that train and up on the street in a matter of seconds.

The sidewalks were crowded, but nothing like the train had been, and I felt a great sense of relief, like I’d avoided a cataclysm. Like I’d escaped death. I caught my breath, then began walking uptown. I saw my reflection in the floor-to-ceiling windows of a bank branch. I looked completely normal. It seemed strange, to look normal after what I’d just been through.

Is Your Psychiatrist Paying Attention




In my post of 2/24/2010, Counting Symptoms that Don't Count, I discussed how many psychiatrists these days are taking huge shortcuts in order to squeeze as many patients into an hour as they possibly can. I described how they are focusing just on symptom counts without trying making the slightest effort to ascertain whether or not the symptoms in question are clinically significant for a particular diagnosis, or whether they might require psychotherapy rather than drug treatment.

As I have pointed out many times in this blog, in order to make such a determination, the doctor has to take into account the timing, pervasiveness, persistance, and subjective quality of a symptom. The psychiatrist has to know what other symptoms are present at the same time and at different times. Most importantly, the doctor has to know something about the psychosocial context of a symptom.

One of my partners reported a particular glaring example of what can happen when this is not done: A patient with no previous psychiatric history became depressed right after finding her husband in bed with another woman.  Her "depression" was characterized, not surprisingly, mostly by anger and preoccupation with the discovered affair.  Nevertheless, when she came to the attention of a psychiatrist, he diagnosed her with "major depressive disorder."  Really?  I mean, really???

Another time saving "convenience" is for the doctor to write down the information that the patient is relaying during an interview on the patient's chart, using either pen and paper or a computer, as the patients speaks. This not only saves time, but solves a second problem: Some insurance companies do not want to pay for a doctor's time unless it is spent face to face with the patient. Even time spend reviewing the patient's record and writing down all the information that insurance companies demand in order to pay the doctor is supposed to be donated, I guess. So instead of writing a progress note after the patient leaves, it is written with the patient still in the room!

So, aside from wasting the patient's time while the doctor does that, what's wrong with that?

Well, I'll tell you.  When a doctor is writing or typing away on a computer, his or her attention is split between doing that and observing the patient. Often a patient's body language or facial expression can give a doctor a clue that what the patient is saying may not be completely accurate or may not be the whole story, so that the doctor then needs to ask for clarification with follow-up questions. When the doctor is staring at a chart instead of the patient, that is probably just not going to happen.

Even more important, patients will often mutter vitally important information quickly and in passing, or even under their breath. This is particularly likely to happen if the information patients are relaying is troublesome to them in one way or another, such as reporting things they are ashamed of. If the doctor is not paying close attention, he or she will literally not hear it!

In my book, How Dysfunctional Families Spur Mental Disorders, I describe in detail a videotape of a psychiatry trainee doing a diagnostic interview in front of two senior faculty members in order to practice for her upcoming oral boards. In the videotape, a real patient was used. During the interview, the patient stated in passing that she had been repeatedly molested by a close relative. In fact, the matter even ended up in court. After the interview, the examiners both said that they "suspected" that a trauma history was "likely" in the patient.

There were three doctors in the room, all of them preoccupied with the trainee's performance.  All three of them either missed or forgot that abuse was not only likely, but had actually been mentioned!