Patients can experience severe levels of anxiety in many forms. The fragile patient may experience anxiety discharged into the parasympathetic branch of the autonomic nervous system (ANS) and suffer dizziness, blurred vision, ringing in the ears, and problems thinking. But some patients who hyperventilate suffer panic attacks where they get dizzy too. Are they fragile? How can we tell?
A person is fragile if her anxiety is discharged into the parasympathetic branch of the ANS (what Davanloo called cognitive/perceptual disruption), and her defenses are regressive. In her case, her dizziness is due to the drop in blood pressure and blood flow to the brain and dilation of her blood vessels. In her case, we can regulate her anxiety by drawing her attention to it. “This dizziness is a sign of anxiety. Are you aware of feeling anxious right now?” Then we cognize about her anxiety with her, helping her use the defense of intellectualization. “So we see that you were angry with your boyfriend. This triggered some anxiety. Then the anxiety made you dizzy. Do you see that sequence too?” Repeating this a few times is usually enough to bring the patient’s anxiety down and her dizziness stops.
Another patient who has a panic attack may experience her anxiety very differently. She starts to hyperventilate, gasping for air, and then becomes dizzy. Is she fragile? As you observe her, you will notice that she is tense and previously was sighing. Hence, her anxiety is in the striated muscles. However, you also notice that her pupils are dilated, she is hyperventilating, and her pulse rate seems higher. That means her sympathetic nervous system has escalated. When the patient hyperventilates, the blood becomes alkaline due to a drop in carbon dioxide levels, leading blood vessels to constrict. That causes her lightheadedness and sometimes fainting. Do not have the patient breathe into a paper bag. Instead, simply slow the patient’s breathing by having her inhale slowly for five seconds and exhale for five seconds over the course of a minute or two. Or invite her to hold her breath for fifteen seconds. The patient’s carbon dioxide levels will return to normal, vasoconstriction will end, and dizziness will disappear. Then summarize the process for the patient to show causality and regulate the anxiety. “We saw that you were angry with your boyfriend. That made you anxious. And when you became anxious you started to hyperventilate. Then the hyperventilation made you dizzy. Do you see that sequence too?” Then invite her to face the feelings that triggered her anxiety. “Would you like to take a look at this anger so we can help you feel anger instead of having symptoms?”
When assessing dizziness, notice where the patient’s anxiety is discharged in the body (parasympathetic or sympathetic branch of the autonomic nervous system). That will determine how you regulate her anxiety.