CHAPTER 11 - IMAGES OF ANXIETY
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Increased basal ganglia activity is often a finding we have seen with anxiety
disorders. When there is increased activity on the left side it is often associated
with anxiety and irritability (expressed anxiety) and when there is increased
activity on the right side there is often anxiety, social withdrawal and conflict
avoidance. Increased activity in the temporal lobes has also been associated with
anxiety. When there is also increased cingulate activity a person may have trouble
with repetitive thoughts about his or her anxiety. Here are several examples.
Marsha, a critical care nurse, was forced into treatment by her husband. She was
36-years-old when she first began experiencing panic attacks. She was in a grocery
store when all of a sudden she felt dizzy, short of breath, with a racing heart and
a terrible sense of impending doom. She left her cart in the store and ran to her
car where she cried for over an hour. After her first episode, the panic attacks
increased in frequency to the point where she stopped going out of her house,
fearing that she'd have an attack and be unable to get help. She stopped working
and made her husband take the children to and from school. Her subsequent symptoms
typically included shortness of breath, heart palpitations, cold hands, a terrifying
sense of impending doom, sweating and negative thinking. She was opposed to any
medication, because in the past her mother, in attempting to treat her own panic
attacks, became addicted to Valium and was often quite mean to my patient Marsha.
She did not want to see herself as being in any way like her mother. She believed
that she "should" be able to control these attacks. Her husband, seeing
her dysfunction only worsen, made the appointment and physically brought her to see
a family counselor. The counselor taught her relaxation and how to talk back to
negative thoughts, but it didn't help her. Her condition worsened and her
husband brought her to see me.
underside active view
note increased right basal ganglia activity (arrow)
Given her resistance to medication I decided to order a SPECT study to evaluate and
then also be able to show her her own brain function. Her SPECT study was abnormal.
It revealed marked increased focal activity in the right side of her basal ganglia.
This is a very common finding in patients who have a panic disorder. Interestingly,
patients who have active seizure activity also have focal areas of increased
activity in their brains. My colleagues and I wonder if the basal ganglia findings
are the behavioral equivalent to seizures with the intense level of emotions
associated with panic attacks.
The findings on her scan convinced Marsha to try medication. I put her on Klonopin,
an anti-anxiety medication that is also used for seizure control. In a short period
of time she became able to go out of her house, back to work and resume her life. In
addition to the medication, I taught her the group of "Basal Ganglia
Prescriptions" (given later) including sophisticated biofeedback and relaxation
techniques and worked with her on correcting the negative "fortune-telling
thoughts. Several years later she was able to completely stop her medication and has
remained "panic free."
A Case Of Post Traumatic Stress Disorder
Mark, a 50-year-old business executive, was admitted to the hospital shortly after
he tried to kill himself. His wife had just started divorce proceedings against him,
and he felt as though his life was falling apart. He was angry, hostile, frustrated,
distrusting and chronically anxious. His co-workers felt that he was "mad all
the time." He also complained of a constant headache. Mark was also a decorated
Vietnam Veteran, an infantry soldier with over 100 kills. He told me that he lost
his humanity in Vietnam and that the experience made him "numb."
underside active view
note increased left basal ganglia activity (arrow)
In the hospital, he said that he was tormented by the memories of the past. Mark had
post traumatic stress disorder (PTSD). He felt that with his wife leaving him, he
had no reason to live. Due to the severity of his symptoms, along with a history of
a head injury in Vietnam, I ordered a brain SPECT study. It was abnormal, showing
marked increased activity in the left basal ganglion. It was the most intense
activity in that part of the brain I had ever seen.
Left-sided basal ganglion findings are often seen in people who are chronically
irritable or angry. Mood stabilizers, such as Lithium, Tegretol, or Depakote, are
often helpful in decreasing the irritability and calming down focal "hot"
areas in the brain. I placed Mark on Depakote. Almost immediately, his headaches
went away and he began to feel calmer. The hospital staff noted how much calmer he
was. He stopped snapping at everyone and he became more able to do the psychological
work of healing from his divorce and the wounds from Vietnam.
In working with Mark, I often felt that his experiences in Vietnam had reset his
basal ganglia to be constantly on the alert. Nearly everyday for 13 months of the
war, he had to be "on alert" in order to avoid being shot. Through the
years, he never had the chance to learn how to reset his brain back down to normal.
The medication and therapy allowed him to relax, and feel, for the first time in 25
years, that he had truly left the war zone.
Here are several other examples.
underside active view
note increased right basal ganglia
28 year old woman with chronic anxiety, conflict avoidance
underside active view
note increased right basal ganglia
44 year old man with chronic mild anxiety, conflict avoidance
underside active view
note increased right and left basal ganglia
48 year old man with panic disorder
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