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Anxiety

Like people with other chronic diseases, people with Parkinson’s disease (PD) often struggle with mental health difficulties. While the illness is known to impair many aspects of movement, research from the Parkinson's Outcomes Project has found that two non- motor symptoms — depression and anxiety — play a key role in the disease as well and its effect on people’s quality of life.

Feeling worried is an understandable reaction to a Parkinson’s diagnosis. But when feelings of constant worry or nervousness go beyond what is understandable, a person may be experiencing anxiety, which is more serious.

Anxiety is a common non-motor symptom of PD. It is important to note that anxiety is not simply a reaction to the diagnosis of Parkinson’s, but is instead a part of the disease itself, caused by changes in the brain chemistry of the brain. As many as two out of five people with PD will experience one of these forms:

  • Generalized Anxiety Disorder: Generalized anxiety disorder (GAD) is characterized by feelings of nervousness and recurring thoughts of worry and fear. This worrying is in excess of what would normally be expected given the situation and often leaves the person feeling out of control. Physical symptoms that may accompany these feelings include butterflies in the stomach and nausea, trouble breathing or swallowing, racing of the heart, sweating and increased tremors. 
  • Anxiety Attacks: Anxiety, or panic, attacks usually start suddenly with a sense of severe physical and emotional distress. Individuals may feel as if they cannot breathe or are having a heart attack. They may feel they are experiencing a medical emergency. These episodes usually last a few minutes to an hour, particularly when associated with “off” periods, though they can last for longer periods of time. 
  • Social Avoidance: Social avoidance, or social anxiety disorder, involves avoiding everyday social situations because of a fear of embarrassment at having Parkinson's symptoms, such as tremor, dyskinesias, or trouble walking noticed in public. Exposure to social situations can lead to severe anxiety in these individuals, which goes away when the person is removed from or completely avoids the situation.
  • Obsessive-Compulsive Disorder: People with obsessive-compulsive disorder (OCD) may be plagued by persistent, unwelcome thoughts or images (obsessions), and by the urgent need to engage in certain rituals (compulsions) to try to control or rid themselves of these thoughts. As an example, they may be obsessed with germs or dirt, and wash their hands over and over. Performing these so-called rituals, however, only provides temporary relief, and not performing them markedly increases anxiety.

Anxiety is not tied to disease progression — it can begin before a PD diagnosis or develop much later on. Additionally, while some people with PD experience anxiety on its own, many are diagnosed with anxiety along with depression. While anxiety is less well-studied than depression, it may be just as common. If left unchecked, anxiety can worsen a person’s overall health condition.

Causes of Anxiety

Psychological Factors

Common fears and worries that go along with PD may trigger anxiety. One is a fear of being unable to function independently, particularly during a sudden “off” period (the time of day when medication is not working). This can lead to a fear of being left alone. Another is a concern about being embarrassed—often related to interacting with others in public.

Biological Factors

Many of the brain pathways and chemicals affected by Parkinson’s are the same as those affected by anxiety and depression. People with Parkinson’s have abnormal levels of the brain chemical GABA. Similarly, anxiety and depression are linked to low levels of this neurotransmitter as well, and can be treated with one class of anti-anxiety medications designed to increase these levels. In some cases, anxiety is directly related to changes in motor symptoms. Specifically, patients who experience “off” periods can develop severe anxiety during these states sometimes to the point of full-blown anxiety attacks.

How Is Anxiety Diagnosed?

Anxiety is usually diagnosed by a primary care physician, or a mental health professional, who will ask questions about certain symptoms. The doctor will talk with the patient about mood changes and behaviors. For people with an anxiety disorder, their symptoms become so intense that they are unable to function normally in life. Overall, it is easier to diagnose anxiety than depression in PD, because symptoms of anxiety and PD do not overlap as much. 

In general, symptoms of anxiety may include:

  • Excessive fear and worry
  • Uncontrollable or unwanted thoughts
  • Sudden waves of terror
  • Nightmares
  • Ritualistic behaviors
  • Problems sleeping
  • Pounding heart
  • Cold and sweaty hands
  • Dizziness
  • Nausea

In people with Parkinson’s, a diagnosis of an anxiety disorder is made only if the symptoms involve a clear change in a patient’s previous behavior and are not easily confused with motor symptoms. For example, even though a patient may have a legitimate concern that a tremor or change in walking ability may be noticed in public, a diagnosis of social avoidance is only made if the patient realizes that the concern is excessive, the social situation is avoided, and it causes interference in the person’s social or work life.

What Are Treatment Options for Anxiety?

There are two main types of treatment options for anxiety:  medications and psychological counseling (psychotherapy).  Depending on the severity of symptoms, psychotherapy can be used alone or combination with medication. Care should be tailored to each person’s individual needs.

Medication Therapy

SSRIs (antidepressants)

A newer class of antidepressant drugs called selective serotonin reuptake inhibitors (SSRIs) are typically the first-line treatment for depression and anxiety disorders. They include:

  • fluoxetine (Prozac®)
  • sertraline (Zoloft®)
  • paroxetine (Paxil®)
  • citalopram (Celexa®)
  • escitalopram (Lexapro®)

For patients with anxiety attacks, very low dosages should be used at first. Evidence shows these medications can increase attacks when first started at higher dosages. An added benefit of using SSRIs is that they also work for depression, which often occurs simultaneously. 

Benzodiazepines (anti-anxiety medications)

An older class of medications called benzodiazepines is used to treat anxiety disorders and target the brain chemical GABA. They include:

  • diazepam (Valium®)
  • lorazepam (Ativan®)
  • clonazepam (Klonopin®)
  • alprazolam (Xanax®)

These medications can be very effective for anxiety, sometimes working better than antidepressants. They take effect very quickly, often providing some relief after a single dose. Also, they can help with other symptoms of PD, including certain types of tremor, muscle cramping and sleep changes. Major drawbacks include memory difficulties, confusion, increase in balance problems and tiredness. These medications should not be stopped suddenly, as patients can have serious withdrawal symptoms such as seizures and severe stiffness called spasticity.

NOTE: Benzodiazepines should be used with caution in older patients with Parkinson’s or in those with dementia. If used regularly, they should never be stopped suddenly to avoid serious withdrawal symptoms.

Psychotherapy

Psychotherapy or “talk therapy” refers to many varieties of counseling. This type of treatment can help people diagnosed with an anxiety disorder understand their illness and better manage their symptoms. Mental health professionals who provide therapy include psychologists, social workers, psychiatrists, licensed professional counselors, and specially-trained nurses. The first step is to find a compatible therapist. Quality therapy can be beneficial because:

  • Cognitive behavioral therapy (CBT) is very effective at helping people change negative thinking patterns and behaviors to solve their problems and engage in life.
  • CBT encourages patients to develop more positive thoughts about themselves, the environment around them and their future: in this case the outcome related to their illness.
  • Counseling sessions can provide vital support, understanding and education. Patients may be seen alone, as a couple or family, or in a group.
  • Psychotherapy offers two advantages: no drug side effects and coping skills that can be used over the long term.

Non-Conventional Therapies for Anxiety

  • Relaxation techniques
  • Massage therapy
  • Acupuncture
  • Aromatherapy
  • Various forms of meditation
  • Music therapy

For information on therapies, licensing and certification, visit the website of the National Center for Complementary and Alternative Medicine at the National Institutes of Health. Anyone considering non-conventional treatment for an anxiety disorder should be sure to discuss the following options with their doctor. 

Tips for Living with Anxiety

  • Educate yourself about PD and its symptoms, including anxiety.
  • Keep a diary of your moods, your medications and your PD symptoms.
  • Figure out what sets off anxiety for you.
  • Talk with your doctor about anxiety, so you can get medical help.
  • Tell your care partner and family members how you are feeling, so they can understand your emotions better and help you find ways to cope.
  • Find a support group for people with PD.
  • Be flexible in your approaches to coping with anxiety; try different approaches.
  • Understand that symptoms change; if a coping strategy stops working, try a new approach.
  • Like other PD symptoms, each individual experience anxiety differently.
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