Susan, a 58-year old high school special education teacher, describes feeling overwhelmed in the last eight months. She reports that she frequently walks into a room to retrieve an item, only to forget what she is looking for. Her husband noticed that she appears more distracted than usual, frequently repeating stories or requiring clarification. She is able to carry out her duties at work; however, she occasionally has the wrong material prepared for classes. In the last several weeks she also reports experiencing headaches. Susan’s parents were hospitalized approximately one year ago for health problems; at that time her mother was diagnosed with Alzheimer’s disease. She is concerned that she is experiencing memory loss similar to her mother and exhibiting early signs of dementia. Susan decides to seek a referral from her general physician for a neuropsychological evaluation to determine if her symptoms are attributed to a neurodegenerative disease, or a disorder with complaints that mask as memory impairment.
The results of the neuropsychological assessment reveal that Susan’s immediate and delayed recall of verbal and visual information is within expected performance levels based on her age and educational attainment, which does not support early indicators of an Alzheimer’s dementia. Susan also performed within expected levels on tasks involving visuospatial abilities, processing speed, executive functioning, and language. In contrast, her attention and working memory performance is stronger on more complex attention tasks than on simple attention tasks (i.e., repeating digits backward compared to forward). This implies that Susan has some difficulty attending to information she might characterize as straightforward and therefore not rehearse the material efficiently for repetition. The same is to be said on other measures that require Susan to attend to problems that increase in difficulty; her performance strengthens as her attention improves.
Generally, poor attention in conjunction with intact memory functioning and no other major impairment or medical issues is consistent with anxiety and mild depression masking as memory deficits. Poor processing speed, also known as psychomotor slowing, is typical of an individual experiencing clinically significant depression. Susan’s performance on processing speed tasks was within expected levels, but it was noted that she made multiple errors on timed tasks. This information indicates that Susan sacrificed accuracy for speed and a general inattention to detail. On self-report measures of mood, Susan expressed feeling anxious and mildly depressed, and would likely benefit from individual psychotherapy to develop effective coping strategies and psychological flexibility.
Findings related to anxiety and cognitive deficits tend to be inconsistent, which may in part be due to limited research compared to depression and cognition (Shafto, James, & Abrams, 2019). According to available studies, levels of anxiety can either enhance or diminish performance on neuropsychological measures of attention and memory. Adults concerned that their symptoms are related to memory loss may be more inclined to notice additional cognitive complaints, as well as develop health-related anxiety (Kinzer & Suhr, 2016, p. 198). Increased anxiety related to a neuropsychological evaluation can potentially influence the individual’s effort. This can lead to poor performance on the assessment and invalid results. Research suggests that individuals with anxiety disorders tend to focus attention on information when it is immediately presented, in order to determine if the situation is threatening. In nonthreatening situations, individuals may not attend closely to details, which limits their ability to remember information at a later time (Sogutlu & Alaca, 2019).
Adults over the age of 30 generally experience word–finding difficulty, more commonly known as the tip-of-the-tongue phenomenon. The tip-of-the-tongue phenomenon occurs when a person expresses the feeling that a word is mentally just out of reach (Cleary, 2019). Word–finding difficulty is a hallmark symptom of some neurological conditions, including Alzheimer’s Disease and Mild Cognitive Impairment (MCI). Mild Cognitive Impairment is a term to describe a collection of symptoms that indicate a person is at risk of developing dementia later in life. Symptoms include cognitive decline without the associated functional component that is necessary for a dementia diagnosis. Individuals with MCI and anxiety are likely to perform more poorly on activities of daily living (e.g., hygiene, dressing, cooking) and executive functioning (e.g., organization, attention, memory, work completion) tasks (Chen, Hu, Jiang, & Zhou, 2018).
The overarching question then becomes how does an individual determine if their symptoms are related to anxiety or memory loss, and what, if any, effective treatments exist? Returning to the vignette, after a neuropsychological evaluation, Susan learned that her memory complaints were actually due to anxiety rather than memory loss. She then sought treatment from a licensed therapist to manage her symptoms and develop coping skills. In this example, Susan’s neuropsychological evaluation focused on assessments that gauge her cognitive abilities in a variety of domains.
Neuropsychological assessments are standardized tests that measure an individual’s cognitive and functional abilities compared to peers based on age, education level, and other demographic variables (e.g., gender). The cognitive domains assessed include mental status, memory, attention, executive functioning, visuospatial ability, processing speed, language, intellectual functioning, and mood. Neuropsychological evaluations can be an effective diagnostic tool when differential diagnoses are in question.
Once the assessment is completed, an individual can work with a licensed psychotherapist to develop coping skills to manage anxiety, as well as to explore effective strategies to decrease perceived executive functioning and memory deficits. Research suggests that short-term meditation treatment protocols are effective in managing anxiety and memory complaints (Moss et al., 2012). Traditional Cognitive Behavioral Therapy (CBT) trains the individual to confront maladaptive thoughts and replace them with positive or neutral self-talk. The individual can then strengthen these skills through practice and generalization to a variety of situations, thus working toward behavior change. Acceptance and Commitment Therapy (ACT), a third-wave behavioral therapy, encourages the individual to acknowledge anxious or negative thoughts from a present, non-judgmental space. ACT also incorporates experiential practices, or mindfulness, to develop a connection to the present moment. The focus of coping strategies is on identifying and engaging in committed action to live within their values.
Anxiety can often mask as cognitive complaints, such as memory or attention difficulties, due to concerns regarding factors outside their control. It is important to seek a neuropsychological evaluation to gain insight into the etiology of perceived deficits. From there, behavioral therapy can alleviate distress related to anxiety and provide effective coping strategies that strengthen the individual’s connection to the present moment.
To learn more, please contact our office at 732-873-1212, email azultanky@BehaviorTherapyAssociates.com or complete the contact form on our website https://behaviortherapyassociates.com/contact-us/
Ashley M. Zultanky, Psy.D. is a clinical psychology Post-Doctoral Fellow at Behavior Therapy Associates and is a Certified School Psychologist in New Jersey. Dr. Zultanky has experience treating children through adults individually and in groups. She has extensive training in neuropsychological, psychological, and psychoeducational assessment of a variety of populations, including learning disability, ADHD, neurodegenerative diseases, epilepsy, tumor, and traumatic brain injury. She has experience with individuals presenting with a variety of issues, including at least the following: depression, anxiety, adjustment issues, ADHD, social skills difficulties, academic and learning difficulties, developmental delays, autism spectrum disorder, anger issues, complicated bereavement, chronic illness, and history of trauma and substance abuse. She also leads social skills training groups for a variety of ages. Dr. Zultanky also has specialized experience in the areas of sport psychology, performance-related difficulties, and executive functioning.
Behavior Therapy Associates is offering teletherapy as a convenient way to maintain social distancing and allow clients to receive needed services, including psychotherapy, psychological counseling, psychological coaching (sometimes referred to as executive coaching), and psychological consulting. This can be arranged easily by contacting our office at 732-873-1212 or info@BehaviorTherapyAssociates.com
Also, please check out this link from the Centers for Disease Control and Prevention to better understand Coronavirus and for tips to manage related Anxiety and Stress.
References
Chen, C., Hu, Z., Jiang, Z., & Zhou, F. (2018). Prevalence of anxiety in patients with mild
cognitive impairment: A systematic review and meta-analysis. Journal of Affective Disorders, 236, 211-221. https://doi-org.kean.idm.oclc.org/10.1016/j.jad.2018.04.110
Cleary, A. M. (2019). The biasing nature of the tip-of-the-tongue experience: When decisions
bask in the glow of the tip-of-the-tongue state. Journal of Experimental Psychology: General, 148(7), 1178-1191. https://doi-org.kean.idm.oclc.org/10/1037/xge0000520
Kinzer, A., & Suhr, J. A. (2016). Dementia worry and its relationship to dementia exposure,
psychological factors, and subjective memory concerns. Applied Neuropsychology: Adult, 23(3), 196-204. https://doi-org.kean.idm.oclc.org/10.1080/23279095.2015.1030669
Moss, A. S., Wintering, N., Roggenkamp, H., Khalsa, D. S., Waldman, M. R., Monti, D., &
Newberg, A. B. (2012). Effects of an 8-week meditation program on mood and anxiety in patients with memory loss. The Journal of Alternative and Complementary Medicine, 18(1), 48-53. https://doi-org.kean.idm.oclc.org/10/1089/acm/2011.0051
Shafto, M. A., James, L. E., & Abrams, L. (2019). Age-related changes in word retrieval vary by
self-reported anxiety but not depression symptoms. Aging, Neuropsychology, and Cognition, 26(5), 767-780. https://doi-org.kean.idm.oclc.org/10.1080/13825585.2918.1527284
Sogutlu, L., & Alaca, N. (2019). The relationship between subjective memory complaints and objective memory performance, depression and anxiety levels in patients under 55 years of age. Turk Psikiyatri Dergisi, 30(1), 1-7.
