Anxiety

Parkinson’s disease (PD) can impact you emotionally. While PD is known to influence many aspects of movement, Parkinson's Outcomes Project research shows that two non-motor symptoms — anxiety and depression — play a key role in the disease and have the greatest impact on overall health. Fortunately there are proven strategies, including mindfulness meditation and exercise, that can help manage anxiety.

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.

Types of Anxiety

Anxiety is not simply a reaction to a Parkinson’s diagnosis, 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 of anxiety:

Characterized by feelings of nervousness and recurring thoughts of worry and fear. This worrying is more than 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 or nausea, trouble breathing or swallowing, racing heart, sweating and increased tremors.
Also called social anxiety disorder, social avoidance involves avoiding everyday social situations because of a fear of embarrassment at having Parkinson's symptoms — such as tremor, dyskinesia or trouble walking — noticed in public. Exposure to social situations can lead to severe anxiety in these individuals. This goes away when the person is removed from or avoids the situation.
OCD can cause persistent, unwelcome thoughts or images (obsessions). These are accompanied by an urgent need to engage in certain rituals (compulsions) to try to control or eliminate these thoughts. For example, a person with OCD may be obsessed with germs or dirt and wash their hands over and over. Performing these so-called rituals only provides temporary relief, while not performing them markedly increases anxiety.

Anxiety is not tied to disease progression — it can begin before a PD diagnosis or develop much later. Additionally, while some people with Parkinson's experience anxiety on its own, many are diagnosed with anxiety along with depression. If left unchecked, anxiety can worsen a person’s overall health condition.

Causes of Anxiety

Living with Parkinson's and brain changes related to the disease can influence anxiety. Here's how:

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. Anxiety and depression are also linked to low GABA and can be treated with a class of anti-anxiety medications designed to boost levels. In some cases, anxiety is directly related to motor symptom fluctuations. People can experience severe anxiety during “off” periods, sometimes even full-blown anxiety attacks.

50%

of people with PD will experience some form of depression.

40%

of people with Parkinson’s will experience an anxiety disorder.

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, mood changes and behaviors. A person living with anxiety can experience symptoms so intense that it makes daily living difficult.

Symptoms of anxiety can 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

An anxiety disorder diagnosis is made in Parkinson's only if signs are not easily confused with movement symptoms and there is clear change from a person's previous behavior. For example, even though someone may have a legitimate concern that a tremor or change in walking ability may be noticed in public, a social avoidance diagnosis is only made if the concern is excessive, social situations are avoided and the anxiety interferes with social or work life.

Anxiety Treatment Options

The good news is that there are effective anxiety treatments. These include medications and psychological counseling, specifically cognitive behavioral therapy — an evidence-based psychotherapy shown to be effective in the general population that preliminary research shows may also be helpful for people with Parkinson's.

Care should be tailored to each person’s individual needs. Depending on the severity of symptoms, psychotherapy can be used alone or combination with medication.

SSRIs (antidepressants)

A newer class of antidepressant drugs called selective serotonin reuptake inhibitors (SSRIs) are typically the first-line treatment for anxiety disorders and depression, which often occurs simultaneously. They include:
- fluoxetine (Prozac®)
- sertraline (Zoloft®)
- paroxetine (Paxil®)
- citalopram (Celexa®)
- escitalopram (Lexapro®)
For people who experience anxiety attacks, very low dosages should be used at first. Evidence shows these medications can increase attacks when first started at higher dosages.

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 PD symptoms, 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 people can experience serious withdrawal symptoms such as seizures and severe stiffness, called spasticity.

NOTE: Benzodiazepines should be used with caution in older people with Parkinson’s or in those with dementia. If used regularly, they should never be stopped suddenly to avoid serious withdrawal symptoms.
Also called talk therapy, psychotherapy includes many varieties of counseling. It can help people diagnosed with an anxiety disorder better manage their symptoms.

Mental health professionals who provide therapy include psychologists, social workers, psychiatrists, licensed professional counselors and specially trained nurses. You might choose to do therapy one-on-one, with a loved one or family, or in a group.

Finding a compatible therapist is key to quality therapy. Benefits can include:
- changing negative thinking patterns and behaviors.
- developing positive thoughts about yourself or your journey with Parkinson's.
- discovering vital support, understanding and education.
- building coping skills that will last a lifetime.
People with PD sometimes look to complementary therapies to support traditional anxiety treatments. Some of these include:
- Relaxation techniques
- Massage therapy
- Acupuncture
- Aromatherapy
- Various forms of meditation
- Music therapy
For information on complementary, or supplemental, wellness strategies, licensing and certification, visit the National Center for Complementary and Integrative Health at the National Institutes of Health website.

Tips for Living with Anxiety

Addressing anxiety can help you live better with Parkinson's. Like other PD symptoms, each person experiences anxiety and responds to treatments differently. These strategies can help:

Empower yourself by discovering how PD symptoms, including anxiety, can impact you.
Keep a diary of your moods, your medications and your PD symptoms.
Notice what triggers your anxiety symptoms.
Talk with your doctor about anxiety.
Share how you are feeling with loved ones and family, who can help you explore ways to cope.
Find a support group for people with PD.
Be flexible — try different approaches to coping with anxiety.
Understand that symptoms change; if a coping strategy stops working, try a new approach.

MY PD STORY: Todd Vogt

"One of the first things I thought was that my days as a competitive rower were over. After several months of dwelling on things, I returned to rowing."

READ Todd's STORY

Page reviewed by Dr. Kathryn P Moore, Movement Disorders neurologist at Duke Health, a Parkinson's Foundation Center of Excellence.