ABSTRACT: Undetected or hidden strokes and other undiagnosed circulatory and circulatory-related disorders can cause moodiness, insomnia, irritability, chronic fatigue, anguish, eating and metabolic disorders, biological instability, panic, withdrawal, abnormal behavior, unusual or bizarre somatic complaints and other characteristic signs and symptoms of depression. A generalized cerebrovascular insufficiency or deficit of any kind may have symptoms of hypoglycemic and hypoxic depression. Because of the similarities which these disorders have with conventional depression medical and mental health professionals are often predisposed to overlook or neglect potentially serious underlying cardiovascular causes of depression symptoms. This tendency can result in unnecessary hardship, suffering, neglect, misdiagnosis, complication, stereotyping, litigation and inappropriate or counterproductive treatment and expense. Unfortunately for the patient a psychiatric diagnosis is often conveniently, hastily, and permanently invoked in such instances without properly ruling out such disorders. Such a predisposition stems from a poor understanding of these disorders and a multitude of counterproductive expediencies, incentives and traditions in the medical and mental health professions. Compounding the problem is the fact that the adaptive and dynamic nature of the circulatory and neurovascular systems often creates deceptiveness, compensation, complexity and obscurity which tend to mask the real circulatory nature of the disorder. The true extent of such misdiagnosis may never be known but the significance of the problem is becoming more and more apparent as improved vascular research and neuroimaging evolve. Barring proper diagnosis and treatment the best course of action for such victims may be personal fitness, lifestyle modification and continued efforts to seek appropriate help and investigate the problem.

INTRODUCTION

Any disorder or condition which causes a significant reduction in the quantity or the quality of blood, oxygen, or glucose reaching the major arteries of the brain-- especially at the base of the brain-- can cause a serious and oftentimes confusing array of symptoms which may closely parallel psychiatric disorders-- especially depression. The fact that such disorders are often obscure and will not manifest themselves on standard neurological tests and neuroimaging studies frequently leads to misdiagnosis, inappropriate (and oftentimes counterproductive) treatment and/or treatment of the superficial clinical manifestations only-- to the exclusion and neglect of the true underlying disorder itself.

In any profile resembling depression or in any other bizarre or poorly explained neurological or psychological syndrome the possibility that a difficult to diagnose circulatory problem exists should be strongly considered.

PROFESSIONAL FALLACIES

The financial and logistical incentives, counterincentives, and expediencies of the medical, counseling, psychiatric, and mental health professions-- combined with a generalized poor understanding of the true nature of such disorders-- results in systematic stereotyping and poor clinical treatment of such individuals and denial of the serious flaws in the professional methodology utilized to arrive at such erroneous assessment and treatment.

ROUTINELY UNDIAGNOSED AND MISDIAGNOSED CIRCULATORY DISORDERS

Some of the various and obscure-- yet very serious-- underlying circulatory-related physiological disorders which may be brushed off as "depression" or some other type of psychological or psychiatric disorder include: cardiac and cerebrovascular insufficiency, vertebrobasilar artery insufficiency, arteriosclerosis, fibromyalgia, angiogram-negative subarachnoid hemorrhages and their sequelae, whiplash, strained or injured neck (muscles, disks, or vertebrae which impinge on arteries), nuchal rigidity (rigid or stiff neck), other neck complaints and trauma, heart disease, arterial stenosis, steal syndrome (short-circuited or reverse blood flow in an arterial system), undetected aneurysm, hypothyroidism, vascular disorders of metabolic and/or hormonal origin (including diabetes), vascular disorders stemming from obesity and vascular inefficiency or exhaustion, anemia, apnea, hypoglycemia, blood and blood cell anomaly, pulmonary disorders, pituitary disorders, adrenal insufficiency, adrenal fatigue, certain malignancies, infections, collagen vascular disease, vitamin/mineral deficiencies and toxicity, etc.


PHYSIOLOGICAL FACTORS

Poor conditioning, rapid growth, sexual and hormonal changes, aging, genetic defects, hypertension (high blood pressure), PMS, illness, disease, substance abuse and poor nutrition-- as well as physical, psychosocial, emotional and environmental stressors-- predisposes one to cardiovascular and cerebrovascular stress and exhaustion. As vascular systems are placed under extra stress from these and other factors adverse physiological changes may occur in the related circulatory organs and systems. If vasodilatory reserves become depleted severe exhaustion or stress may lead to obscure hypotensive or hypertensive stroke and circulatory impairment of the arteries which supply the areas of the brain responsible for mood, sleep, stress management and bodily regulation. Such circulatory stress and breakdown may cause a continual disruption of the delicate balance of cerebrovascular systems and may lead to a state of perpetual circulatory exhaustion or imbalance-- from which the effected systems may have a difficult time recovering. This is especially true if the individual's sleep pattern has become severely disrupted or if prolonged or severe insomnia occurs.

PARALLEL SYMPTOMATOLOGY

A. SLEEP DISORDERS, EATING DISORDERS, MOOD DISORDERS. Many cerebrovascular disorders of this nature have symptoms which parallel psychiatric and psychological disorders. Individuals suffering from such disorders may exhibit emotional instability due to the disruption and exhaustion of neurovascular resources-- especially in the area of the hypothalamus (the brain structure which is responsible for the regulation of mood, appetite, sleep, etc.). Anemia or anemic blood flow and hypoglycemia (whether of systemic or obstructive origin) are well-known causes of insomnia, eating anomaly, moodiness, irritability and depression-like symptoms. This may further lead clinicians to presume that the problem is psychogenic in nature.

Individuals afflicted with cerebrovascular or cardiovascular disorders may adopt abnormal sleep or napping patterns in an attempt to cope with symptoms of exhaustion or insomnia of cardiovascular origin. Such adaptation may be beneficial as long as the sleep pattern which they adopt provides adequate (but not excessive) amounts of sleep and takes into account other important aspects of sleep hygiene. It is this author's opinion that a regular short nap might be greatly beneficial to such people by helping them to avoid circulatory exhaustion and allowing them to replenish their vasodilatory reserves. However, a regular nap which becomes too consistently deep or lengthy may result in a bimodal or multimodal sleep pattern (a double sleep cycle or a multiple sleep cycle) which might result in severe insomnia problems if the napping cycle gets out of phase or otherwise confuses or disrupts nightly sleep.

One's nightly sleep (for those who are not shift workers) should be the overwhelmingly predominant period of sleep for most people. Much like a large ship needs to have most of the weight at the bottom of the ship in order to keep the ship from tipping over or becoming "inverted". It is important that one does not significantly reduce (or lighten) nightly sleep by compensating with naps which are too deep, too lengthy, or too heavy during the day or early evening. Such compensation may eventually result in insomnia due to the sleep pattern flip-flopping and becoming inverted or out of phase.

The ability to sleep is greatly influenced by a powerful daily metabolic clock which acts as sort of a built-in sleep interval timer by greatly increasing and decreasing a person's energy level at regular times of the day. This built-in sleep interval timer is usually able to coordinate itself with one's daily routine and schedule and will usually evolve or adapt itself as needed to compensate for seasonal changes and changes in schedule, etc. The daily metabolic clock increases the person's metabolism during the day to provide energy for daily activity and then slows down person's metabolism in the late evening to prepare for sleep. Normally a person's metabolic daily energy clock is primarily synchronized by the nightly sleep and not by a nap. However, if an individual has a sleep pattern-- such as a double sleep cycle-- in which the main base of sleep was consistently shortened and compensated for by regular deep and lengthy naps then (just like a top heavy ship) some event may come along which might cause the bimodal or multimodal sleep pattern to invert and become out of phase with one's daily schedule by basing its primary synchronization on the nap rather than the nightly sleep.

For individuals who have too lengthy or too deep of naps regularly the metabolic (energy) decrease during their nap may begin to equal the metabolic decrease of their main nightly sleep period. Since a regular napper will usually have a consistently shorter or longer period of activity and energy following the nap than preceding the nap the normal length of time the metabolism increases following their daily nap may result in the body's metabolic clock staying too high for too long to allow the induction of sleep if the sleep pattern has become inverted due to missing a nap or missing a period of nightly sleep. Conversely, a regular napper whose sleep pattern has become inverted may begin to feel sleepy or groggy at an unexpected time during the day-- right at the time one's deeply embedded metabolic sleep clock has calculated that it is time to slow down to prepare for sleep. A person with a sleeping pattern which has more than one predominant deep sleep period per day is most likely to have their sleep pattern become out of phase during periods of extreme stress or significant schedule disruption. Eliminating the excessive stress and returning to one's normal schedule will often help the person get back to their original sleep pattern.

If a person is unable to regain their normal sleep pattern by reducing stress or returning to a more normal schedule it may be that the metabolic daily energy clock is in the wrong phase or inverted. In other words the person's energy level has become synchronized to the nap instead of to the main nightly sleep. Just as a top-heavy ship may be difficult to restore to an upright position once it has become inverted it may be equally difficult to get one's metabolic sleep clock back in phase with one's daily schedule once it is inverted.

It is important for most people who start to experience insomnia to try to maintain as much normalcy in their daily activity pattern as possible-- even if they are exhausted. The tendency to want to try to sleep during the day because one did not sleep well the previous night usually just results in more anxiety and confusion to the body's metabolic clock. The ability to sleep is greatly improved if one has performed some activities to increase the metabolism during the day because it is the drop-off of the metabolism at the end of the day which signals and helps trigger the body to sleep that night. If a person's sleep pattern gets disrupted for a lengthy period of time and the person resorts to resting or attempting to sleep during the day (due to feelings of sleep deprivation or exhaustion-- resembling jet-lag) the person's normal cyclical daily metabolic increase may be defeated. Once this daily metabolic energy increase/decrease cycle is disrupted it becomes very difficult for the person to regain a regular sleep pattern because the decline following the daily metabolic energy increase is no longer there to help trigger nightly sleep.

It is important for those whose daily metabolic energy clock has become a plateau rather than a sleep-promoting cycle to do as much as possible to try to get it back into a day (increase) & night (decrease) cycle again. A good strategy is to try to do vigorous distance walking during the middle of the day-- even if feeling too sleep deprived and exhausted to do so. The activity of walking briskly during the middle of the day will help the body's metabolism to increase during the day which will increase the probability that sleep will result later that evening. The circulatory, fitness and weight-reduction benefits of distance walking will also help to remedy other possible medical causes of the insomnia.

If the person with out-of-phase sleeping is sleeping at the wrong time or if the person's metabolic energy clock has become strongly synchronized to the nap instead of to the nightly sleep the person may (as a possible last resort) need to force himself to actually try to miss a sleep cycle intentionally to force the pattern to revert back to being synchronized with the nightly sleep. This can be very challenging especially if the person is already in a sleep-deficit situation. A person intentionally trying to stay awake when already exhausted and sleep deprived runs the risk of making things worse. Care needs to be taken that a person trying such an experiment will not need to be participating in any activity which may become dangerous due to the person being impaired by sleep deprivation. Obviously, consultation with a physician or other specialist who truly understands sleep disorders is encouraged.

Clinically the result of sleep frustration and exhaustion due to insomnia may be diagnosed as "psychological" by those not totally understanding the physiological factors involved. Those experiencing severe insomnia should determine if their sleep, lifestyle, and nutritional habits are healthy and try to stay in good physical condition and avoid harmful substances. The possibility that an underlying circulatory problem is related to such disorders may be critical to proper diagnosis and treatment.

Many insomnia articles have conflicting information regarding whether sleep-related problems are caused by trying to go to sleep too early or too late. Some researchers and authors seem convinced that individuals with persistent insomnia problems are going to bed too early whereas other researchers and authors believe that such individuals are trying to go to bed too late. Consistency is probably the most important factor. Irregular sleep schedules whether accompanied by underlying circulatory problems or not can cause sleep-related disorders. Where "early-to-bed" or "late-to-bed" timing is probably most important is likely more related to the daily work or activity schedule of the person. A crucial factor may be the time of day when the individual is under the most stress. If the individual normally encounters the most stress early in the morning then the individual should probably be on an earlier sleep schedule. Those who encounter the highest degree of stress in the afternoon or evenings should consider going to bed later and waking up later so that they will have the greatest amount of energy and be most refreshed at the time of day when they need it the most. Being on too early of a sleep schedule may cause those who typically encounter the greatest degree of stress late in their daily schedule to become fatigued or exhausted right at the time when they need the most energy. Such stress can lead to burnout which may manifest itself in depression-type symptoms. Such problems may be magnified, intensified or unnecessarily perpetuated if the individual has an undiagnosed or misdiagnosed underlying medical problem of some kind.

B. PANIC ATTACK SYMPTOMS. Cerebral vasospasms, shock, and transient ischemic attacks (TIA) --all of which are corollaries to poor cerebral blood flow-- may create severe cerebrovascular distress resulting in an array of neurological and endocrinological responses and side effects. Such symptoms may be confusing to both the victim and the observer and may easily be misdiagnosed as "panic attacks". Such symptoms are likely to be precipitated by stressful and exhausting events and lifestyles.

C. BIPOLAR SYMPTOMS. Individuals with circulatory disorders affecting the brain are likely to be very sensitive and susceptible (both in a negative and a positive way) to anything which may increase or decrease stress or affect their emotions. This instability and sensitivity leaves them prone to experience mood swings which may cause periods of tremendous discouragement, frustration and exhaustion eventually followed by a dramatic "rebounding" effect as the biological components of the circulatory system overreact in an effort to regain homeostasis. This biological rebounding effect (following on the heels of such severe discouragement or fatigue) may create a temporary false feeling of euphoria, optimism, and elation in the individual-- which may be viewed as reflective of a psychiatric "bipolar disorder"-- even though the problem is primarily a circulatory phenomenon.

The fact that the cardiovascular system is so closely intertwined with the autonomic nervous system which has two dramatically different modes (the sympathetic and the parasympathetic) of operation (one which activates the body and raises blood pressure and the other which relaxes and reduces blood pressure) may be a paramount factor in the bimodal appearance of such individuals with underlying circulatory disorders who are likely to be most dramatically affected by autonomic changes and thus misdiagnosed as being bipolar.

D. SUICIDAL SYMPTOMS. Cerebrovascular instability-- not unlike a heart attack-- will often be accompanied by severe mood expressions and a possible "cry-for-help" from the victim. Individuals experiencing such awful problems may view that life is not worth living anymore and may even consider and/or attempt suicide. Such distress and despair is a natural consequence of oxygen and glucose deprivation to the brain. The person's brain may actually feel somewhat like it is temporarily or chronically suffocating due to internal blood flow-related problems. To brush such a distress signal off as a mere mood disorder is the same as offering psychoanalysis to a person who is drowning who needs physical assistance much more than counseling. Misdiagnosing such a problem may actually increase the possibility of the individual attempting suicide as the person senses lack of professional insight and begins to lose hope for ever having the problem resolved.

E. ABNORMAL BEHAVIOR. Other behaviors deemed by many professionals to be "abnormal" such as withdrawal, avoidance of normal activities, crying, sexual disinterest or maladaptation, pacing, etc., may be related to undiagnosed circulatory disorders and may actually be coping mechanisms for such disorders-- since there is evidence that many of these and other apparently "abnormal" behaviors may actually help reduce cerebrovascular stress and tension and result in vasodilation and improved cerebral blood flow.

Certain phobias may also be related to an individual's attempt to cope with such disorders. Any type of situation, activity, or event which creates uncertainty, uneasiness, reduced circulation, exhaustion or fatigue that could result in tension or stress which may adversely impact the cardiovascular or cerebrovascular system may be greatly feared by those experiencing such disorders. These phobias may include fear of crowds, fear of traveling, fear of heights or motion (due to dizziness or lightheadedness), fear of isolation (if the person is experiencing cardiovascular distress which may require assistance or support), fear of immobility or confinement (when movement may be required to increase circulation), fear of certain medications or medical treatments (which may have had adverse reactions in the past), fears concerning eating and metabolism (and subsequent adverse reactions), etc.

Personality fluctuations and/or changes may also be evident. The person may appear to act inconsistently with their past history. The individual may become bitter, irritable, hostile, resentful, or frustrated due to disorders of this type. The person may exhibit incoherence, forgetfulness, apathy, disorientation, stupor, etc., directly resulting from poor cerebral circulation. Conversely, at other times, the person may seem to be quite normal if the circulatory system has been able to temporarily regain a measure of neurovascular homeostasis.

Such individuals may constantly describe bizarre or unsubstantiated physical complaints and may wrongfully be diagnosed as psychotic, delusional or as being a hypochondriac. They may even strongly feel or insist that they have a circulatory or heart disorder. Attempts to discredit such symptoms or to view them as psychosomatic may further impair their ability to obtain a proper diagnosis and proper treatment. It is especially disturbing when individuals are stereotyped as delusional or psychotic when they are otherwise responsible and rational in all other areas of their life. Unfortunately the fact that such individuals may have medical records filled with a history of professional speculation that the person's "real problem" is psychological can cause perpetual neglect and bias against trying to confirm whether the problems are real or not. There is tremendous reluctance in the medical profession for one professional to dispute longstanding viewpoints of other professionals-- even when new discoveries cast doubt on old methodology. Hasty and inaccurate categorizing and labeling of people may serve the expediencies and self-interests of the professionals, but it can be a tremendous disservice, injustice and expense to the victim-- and to honest science.

EPIDEMIOLOGICAL FACTORS

Certain key factors should be looked at before ruling out a possible subclinical (yet serious) underlying cerebrovascular disorder as an explanation to bizarre and poorly explained neurological and affective symptoms:

A. AGE OF ONSET. When depression or other affective disorders are seen for the first time after the developmental years, or when an unusual increase or change of symptoms occurs as the person ages, the odds greatly increase that the origin may be circulatory in nature. This is due to the fact that the human circulatory system and related systems begin to experience reduced capacity, function, and resilience as the person ages.

Despite this, it is also possible for younger individuals to have problems of this nature. Younger people are more likely to be involved in high risk activities which could result in obscure trauma to the head and neck and thus result in hidden cerebrovascular disorders. Although it is less common for younger individuals to experience cerebrovascular disease and cerebrovascular accidents a much higher percentage of those who do have such will have extracerebral circulatory disorders and subarachnoid hemorrhages which will be more difficult to properly diagnose due to lack of actual brain damage. These are also the precise types of strokes which can lead to generalized cerebrovascular insufficiencies and depression-like symptoms. Also, the vascular resiliency of younger individuals may allow for a certain degree of compensation, collateral circulation, revascularization, and adaptation to occur which may mask the real disorder.

Less morbid cerebrovascular disorders and conditions (stemming from genetic flaws, developmental anomalies, or undiagnosed juvenile-onset cerebrovascular injury) which may have resulted in minor depression-like symptoms at an early age may worsen later in life due to further complication from the effects of aging, stress, exhaustion, and trauma. Thus, a prior history of depression-like symptoms which suddenly or gradually become more severe may be a clue of an underlying cerebrovascular disorder.

B. ARRAY OF SYMPTOMS. If lightheadedness, visual disturbances, vascular-type headaches, dizziness, vertigo, restlessness, abnormal drowsiness or ischemic instability (especially after meals), tinnitus, flushing, psychological disorganization or incoherence, syncope, insomnia, anxiety, neck pain or stiffness, abnormal blood pressure, intolerance to stress, irritability, violence, mood swings, heart palpitations, tremors, or vasospasm are present the problem is probably of circulatory genesis-- especially if several of these symptoms are present in the same individual.

Absence of typical stroke-related neurological and cognitive symptoms does not rule out many types of vascular disorders-- especially extracerebral or subarachnoid vascular disorders-- since brain cells may be able to survive (but not thrive) with a generalized reduction in the quality of blood or blood flow.

C. EVENTS WHICH MAY HAVE TRIGGERED THE DISORDER. If an individual describes a specific event or combination of events which could have led to a cerebrovascular accident such should be given serious consideration as a possible explanation to depressive or affective symptomatology. Such events include (but are not limited to): sudden severe headache (especially following straining or lifting); head, neck, lung or heart trauma; history of high blood pressure; and events which may have resulted in hypotensive stroke such as serious blood loss, severe exhaustion, emotional stress, medications which radically lower blood or raise blood pressure, general anesthesia and/or prolonged surgery.

Unfortunately, even angiography-- which may be used to try to pinpoint such disorders-- may actually trigger vasospasm and hypotensive stroke due to the sensitivity which sufferers of such disorders may have to the contrast material used for the test.

D. NEWER DIAGNOSTIC TESTS AND ANALYSIS. Newer testing methods (such as Transcranial Doppler Ultrasound) which are able to safely measure the dynamic flow of blood in the basal arteries and the circle of Willis will eventually lead to a reduction of diagnostic errors of this type. Further, better understanding and improved computerized analysis of presently available tests such as PET, SPECT, and MRI scans will help provide evidence of underlying cerebrovascular disorders by showing metabolic evidence, high signal intensity white matter lesion evidence, and other evidences which are associated with such disorders. Finally, more thorough computerized assessment of diagnostic symptoms will eventually help to screen out such individuals from improper diagnosis and treatment.

E. PUBLIC AWARENESS. Greater public access to medical information and instantaneous worldwide communication resulting from advances in computers and electronics will also help to dispel many of the myths and poor methodologies of these professions.

PROPER TREATMENT

For those exhibiting apparent or obvious evidences of an underlying circulatory disorder which may resemble or be diagnosed as depression the treatments utilized should steer away from potentially counterproductive, expensive, ineffective and dangerous treatments-- especially such treatments as electroconvulsive shock treatment which could create further cardiovascular trauma from electric shock and general anesthesia. If general anesthesia is ever needed for any procedure it is critical that the proper agents are utilized since some of the major anesthetic agents greatly reduce cerebrovascular perfusion pressure.

Proper treatment for such individuals may involve sophisticated cerebrovascular diagnostic tests, appropriate medication, relaxation and mental imagery, sense of hope and purpose, adequate social and emotional support, and psychological coping skills needed to deal with the severe nature of this type of health disorder. However, more benefit is likely to result from lifestyle modification including stress reduction, proper cardiovascular forms of exercise, proper nutrition, weight control, sleep management, avoidance of harmful substances (drugs, tobacco, alcohol), and proper education about the nature of such disorders. Strengthening the cardiovascular system and increasing blood volume and quality through proper fitness and nutrition are of prime importance. A low glycemic diet (similar to the diet which a diabetic or hypoglycemic individual would follow) may help provide sustained and well regulated energy to the brain (and the body as a whole) and help maintain a healthy weight. Such a diet centers around having smaller more frequent meals with low glycemic foods, complex carbohydrates and dairy and vegetable protein. Rarely do you see someone with depression who is in excellent physical condition and who eats properly and avoids harmful substances and rests properly. Other simple strategies such as power napping (to the extent that such naps do not become detrimental by confusing one's sleep pattern as mentioned previously) may greatly benefit those who are susceptible to depression symptoms caused by circulatory exhaustion since such a strategy may allow replenishment of vasodilatory reserves, hormones, and neurotransmitters and thus be a form of preventive mitigation of symptoms. Faith, meditation and other spiritually oriented approaches may be very beneficial. Social support and love is also paramount. Obviously, if there is a medical treatment for the real underlying disorder this should be considered also.

CONCLUSION

Responsible diagnosis and management of patients presumes the ability and desire on the part of the professional to be able to distinguish, discern, and treat the underlying cause of a disorder whenever possible. Failure to do so can lead to further complication and hardship incurred by the patient-- and eventual embarrassment, contempt, and possible malpractice fears faced by the professional. It is in the best long-term interest of both the client and the professional to try to distinguish and treat the underlying cause of obscure cerebrovascular disorders-- not just to treat superficial and deceptive symptoms. This must be done despite professional incentives, training, indoctrination, and expediency oftentimes to the contrary.

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