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Aging Gracefully

Mental Health - Coping with Anxiety and Neurodegenerative Diseases in the Age of Neuroplasticity


Photography by oko.gallery, 2018.

As we get older we feel that our capacity to control the events in our life is diminishing, together with our physical capabilities. Most of us worry for a time but then we set the problem aside and do something else. Individuals with anxiety disorder cannot do that. They feel that that they cannot cope well with the stressful events in life.

They also often feel fatigued, tense, have difficulty breathing, stomach problems, migraines and often suffer from insomnia. Every little event that is outside their routine worries them and too many times they do not see the situation ever getting better, so, they slide into depression. Those are the symptoms of personality disorders, such as anxiety disorder, which seems nowadays to be common in elderly. Somehow we have convinced ourselves that that is the normal path of getting old; although, it does not have to be that way.

The most prescribed medications today in Australia are minor tranquillisers (benzodiazepine - temazepam, nitrazepam, diazepam, oxazepam and alprazolam) with almost 15% of elderly population being on a regular prescription. Minor tranqualisers help with insomnia and anxiety but are also used for treatment of seizures, muscle spasms, and alcohol withdrawal. However, benzodiazepine has serious side-effects. Its long-term regular use has been found to be strongly associated with cognitive decline and reduction in motor functioning. Barlow (2002) investigated the influence of benzodiazepine on elderly and found it increases risk of falls, which often results in braking bones and hip fractures (Footnote: Barlow, D. H. (2002) Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd edition,). New York: Guilford ). Some research even indicate its association with dementia (Footnote: Zhong, G., Wang, Y.;Zhan,Y.,& Zhao, Y., (2015) Association between Benzodiazepine Use and Dementia: A Meta-Analysis, PloS One, Billioti de Gage, S., Begaud, B., Bazin, F., Verdoux, H., Dartigues, J-.F., Peres, K., Kurth, T., & Pariente, A. (2012). Benzodiazepine use and risk of dementia: prospective population based study, BMJ). Furthermore, they produce both physiological and psychological dependence, which makes it hard for people to stop using them. (Footnote: Methew, S.J. & Hoffman, E.J. (2009). Pharmacotherapy for generalised anxiety disorder. New York: Oxford University Press.)

Mounting research is now guiding most physicians to prescribe benzodiazepine for no more than a week or two, as it's benefits are useful in case of extreme and stressful events. However, psychological treatments, such as Cognitive Behavioural Therapy (CBT) have been proven to be more beneficial in the long term (Footnote: Barlow, D. H., Allen, L. B. & Barsden, S. (2007). Psychological treatments for panic disorders, phobias, and generalised anxiety disorder. In P. E. Nathan & J. M. Gorman (Eds.), A guide to treatments that work (3rd ed.). New York: Oxford University Press). These treatments teach individuals how to relax but also coping techniques to counteract and control the worrying process (Footnote: Craske, M. G. & & Barlow, D. H. (2006). Mastery of your anxiety and worry. New York: Oxford University Press). Awareness and mindfulness based therapies showed significant improvements in treatments of elderly. Awareness therapy also improves concentration and trains patients to increase their tolerance to uncertainty about future (Footnote: Dugas, M. J., Schwarts, A., & Francis, K. (2012) Intolerance of uncertainty, fear of anxiety, and adolescent worry. Journal of Abnormal child Psychology, 40, 863-870) and change their cognition in regard to worrying. In many cases those therapies are incorporated with medication to decrease the impact of neurocognitive diseases (Alzheimer’s disease, Parkinson disease).

Gene-inherited tendencies may reveal our vulnerability towards certain diseases, however, it is the gene-environment interactions that influence our future health pathways. Furthermore, some reports suggest that genetic influence on our overall health is overemphasised (Footnote: Mill, J. (2011). Epigenetic essects on gene function and their role in mediating gene-environment interaction. In K. S. Kendler, S. Jaffee, & D. Romer (Eds) The dynamic genome and mental health. The role of genes end environments in youth development. (pp.145-171), New York: Oxford University Press).). Prominent neuroscientist, Robert Spalosky concluded that, "genetic influences are often less powerful than is commonly believed. The environment, even working subtly, can still mold and hold its own in the biological interactions that shape who we are.” (Footnote: Sapolsky, R. M., Romero, L. M., Munck, A. U. (2000). How do glucocorticosteroids influence stress responses? Integrating permissive, suppressive, stimulatory and preparative actions. Endocr. Rev.21:55–89, p.15). Although the environment cannot change our genes, it can change the gene expression. Genes can be turned “on” or “of” by cellular material that is located outside of the genome, with stress, nutrition and healthy lifestyle.

Our environment and the choices we make, when young or old, have great influence on our health and longevity. With that knowledge in mind, most people want to know how they can keep their brain sharp and their motivation high as they get older. We refer to neuroplasticity as the brain’s capacity to regenerate and change throughout life span. Human brain demonstrates unique ability to form new brain cells and new neuronal pathways. Flexibility is easier to us than we think and with special treatment we can avoid cognitive rigidity and bad habits. It is never too late to develop good brain health habits and flourish mentally. Extensive research has demonstrated that Cognitive Behavioural Therapy (CBT), such as Awareness Drawing Therapy, can significantly improve individual’s quality of life. Beneficial factors, such as mental and social involvement when integrated with physical activity can decrease the rate of cognitive decline in someone already diagnosed with dementia and improve their quality of life dramatically. Individuals with personality disorders, such as anxiety disorder, can reduce the symptoms substantially.

Lewis R. Bexter and his colleagues conducted a well-known study (1992.) with Obsessive Compulsive Disorder (OCD) patients who had never been treated and used their brain imaging scans for comparison. (Footnote: Baxter, L. R. (1992). Neuroimaging studies of obsessive compulsive disorder. Psychiatric Clinics of North America, 15(4) :871-884.). They treated patients with exposure and response prevention, cognitive-behavioural therapy (CBT) known to be successful in OCD, and then repeated the brain scans. Then they conducted another study with the different group of patients and found the same changes in brain function. Their prominent study demonstrated that brain circuits can normalise by the psychological treatment alone. Afterwards, the similar effect has been shown regarding depression, anxiety, PTSD, panic disorder, specific phobias and schizophrenia (Footnote: Barsaglini, A., Sartori, G., Benetti, S., Petersson-Yeo, W. & Mechelli, A. (2014). The effects of psychotherapy on brain function: a systematic and critical review, PubMed, 114:1-14 ).

Psychological factors, just as medication, are crucial in treatment of many diseases and it seems that often regions they effect overlap (although not perfectly). However, the way those regions are affected (even in same disease) differ greatly. It seems that cognitive-behavioural therapy facilitates what is called top=down changes – the changes in thinking patterns which further affect emotional regions, while the opposite happens with the treatment involving medication (Footnote: Kennedy, S.H., Konarski, J. Z., Segal, Z. V., Lau, M. A., Bieling, P. J., McIntyre, R. S., & Mayberg, H. S. (2007). Differences in brain glucose metabolism between responders to CBT and venlafaxine in a 16-week randomised controlled trial. The American Journal of Psychiatry, 164(5), 778 – 788.)

Therefore, some people may respond better to medications and others to psychological treatments, so it is important to select the best treatment for the particular individual. Brain imaging (MRI, FMRI PAT scans) can be used as a tool to distinguish which regions are activated and which connections are more prevalent.

Precision medicine (personalised medicine) is an approach to patient care that permits doctors to customise treatments that are likely to most benefit the patient. The next frontier in precision medicine would be to predict which region activation is crucial and to determine whether, for example, CBT would be more beneficial than drugs treatment, or which combination of therapy and medication is best suited. This can be useful even if the main purpose is in prevention or delay, because in many cases, such as activation of neurodegenerative diseases, the process begins many years before any symptoms become apparent. Disease gradually damages the brain, affecting certain regions more than others, thus, early intervention to strengthen neurological pathways or establish new ones, could be our only hope in slowing its progression.

Our time widely known experiment done on mice discovered that the nervous system of rodents who were raised in enriched environment had more connections between nerve cells in the cerebellum, the part of brain which controls motor activity, and grew more dendrites than the brain of ordinary mice (Footnote: Greenough, W. T., Withers, G. S. & Wallace, C. S. (1990). Morphological changes in the nervous system arising from behavioral experience: What is the evidence that they are involved in learning and memory? In L. R. Squire & E. Lindenlaub (Eds.), The biology of memory , Symposia Medica Hoescht 23 ( 159-183). Stuttgart/New York: Schattauer Verlag. ). Similarly, recent studies with monkeys confirm those findings and indicate growth of grey matter in regions of brain responsible for social cognition. Certainly, human beings are different to other animals; however, this plasticity is present in humans (Footnote: Barlow, D. H. Ellard, K. K., Sauer-Zavala, S. Bullis, J. R. & Carl, J. R. (2014). The origins of neroticism. Perspectives on Psychological science, 9, 481-496.) and it seems that even structure of our nervous system adapts readily to our environment, regardless of age.

We wish to finish this article with the optimistic note regarding neurodegenerative diseases, stroke survivors, those with brain injuries but also for those who suffer from many personality disorders. For example, in previous years prognosis for people affected by neurodegenerative diseases were poor and professionals in the field of neurological sciences would never dare to offer any glimpse of false hope. However, new research is presenting new horizons and a much brighter future for those patients; at least when it comes to dealing with the symptoms.

We used to think that once our brain is developed - it cannot change, and once our neurons die they can never be replaced, yet now we know that brain cells can regenerate, same as new synapses to form, throughout our lives and even in the aging brain. There is a range of preventative strategies that we should implement to reduce the risk of cognitive decline but also improve our prognosis if we are facing the positive diagnosis: enjoy physical activity, healthy diet, regularly check blood pressure and blood glucose, engage in social activities, follow your therapy regularly and be creative, join the clubs and learn new skills to keep your mind active and stimulated.

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  1. Sab CasaleJune 24, 2019

    My brother is recently diagnosed with OCD and he is on medication but now I am thinking maybe he could try this new CBT. I am not sure what he can expect but he has been down lately. Can you help and tell me more about it?

    • Hello Sab,
      OCD or Obsessive Compulsive Disorder is often considered to be the culmination of the anxiety disorders. As you well know, your brother probably shows some of the symptoms, OCD is characterised by driven repetitive behaviour, due to persistent, uncontrollable thoughts, images, or impulses. It is often accompanied with severe generalised anxiety, avoidance, panic attacks and depression. It can also be accompanied with a tick, also referred to as PANS. I cannot tell when your brother developed the disease (his history) or if he has any of the other disorders, hence, I will speak in general terms.

      One hypothesis suggests that individuals with OCD at some point in their early life considered some thoughts to be dangerous and unacceptable. They believe that those thoughts or impulses may cause terrible things to happen. These early experiences may have resulted in equating thoughts with specific actions (named thought - action fusion) and, thus, thoughts are suppressed.

      When it comes to medication, the most effective seem to be those that inhibit the reuptake of serotonin, such as SSRIs , but relapse can occur. That is why psychological treatment (e.g. exposure and ritual prevention - ERP) can be beneficial. Other Cognitive Behaviour Therapies (CBT) may also show good results. The main focus is on overestimation of threat and the control of intrusive thoughts. Creative but intensive activities (e.g. Awareness Drawing Therapy) combined with occasional exposure to intrusive thoughts may also be beneficial. Emphasis is on individual’s own cognitive capabilities.

      In many cases medication and the psychological treatments are combined but research has shown that even ERP alone produces superior results to medication alone. However, I cannot give you a more specific advice, as I am not familiar with the severity of your brother’s illness. I do not know where your brother lives, but I would suggest you to do a research and find the closest clinic which specialises in ERP treatments or similar CBT.

      If you are contemplating Psychosurgery I would advise you to reconsider and try ERP or other forms of CBT. or perhaps opt for the deep brain stimulation.
      I hope this helps.

  2. Hellen A.June 28, 2019

    I find this article to be really informative and I am all for the precision medicine. I would not consider myself old but would definitively need to do something about my lifestyle to prevent or delay any of this diseases, if I can. You gave advices, which would be great to follow, but we can hardly find the time! I was thinking (when I find the time) to enrol to mindfulness classes or pilates. What are your opinions? Can you suggest any other forms of boosting the brain?

    • Good Morning Hellen,
      Thank you for asking those questions. Many of us are so busy with our everyday activities that we forget to plan for the future. Mindfulness, pilate and going to the gym are all effective activities and they may help with the relaxation, improving mood, or deeply connecting us to ourselfs. That is all great in itself compared to not doing anything. Neurogenesis, or the growth of new brain cells, is mostly restricted to the hippocampus and subventricular zone. These are involved in learning and memory, spatial navigation, and mood regulation.

      Therefore, I would advise activity, such as, as I have mentioned previously, a traditional training in drawing, not just any unstructured art therapy. It is beneficial both for those who want to prevent the onset of a progressive neurodegenerative disease and for those who already have it. It works on a range of motion, strength, memory enhancement, coordination, or sensation and involves multiple brain regions. Other activities to consider would be dancing, pottery or acting on stage and similar. It has to be something you want to do. Something that is meaningful to you. And not only that. You should do whatever you love doing and do it a lot! Repetition is important.

      It is best to choose an activity that combines physical activity with intense concentration. It forces your brain to learn new skills daily and you would be able to see improvements. Seeing improvements gives you the motivation to continue. The process creates new synapses or strengthens the existing by being challenging and stimulating in all aspects. Social engagement is also crucial. Neuroplasticity has to be specific, so you have to train what you want to get better. Crosswords and similar games might improve your recall of words but it will not do much for your ability to concentrate, improve memoryor make new synaptic connections.
      I hope you find an activity that suits you best.

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