Anxiety and Parkinson’s

What is anxiety?

Anxiety can be an entirely normal feeling and is often an appropriate response to a dangerous or threatening situation. What is often understood as ‘anxiety’ can range from worry and stress to the bodily symptoms associated with fear and panic (the ‘fight or flight’ response). The bodily symptoms of such anxiety may include sweating, pounding of the heart, shortness of breath, tightness in the chest and unpleasant feelings in the stomach. Psychological symptoms of anxiety include excessive worries, ruminating thoughts and a sense of tension.

If anxiety goes on for a long time, it can also cause symptoms such as feeling worried all the time, feeling tired, over-reacting to a situation, lacking insight into the reality of a situation, poor concentration, irritability, poor sleep, muscle pain and tension. It may even lead to depression.

At times, anxiety can be so severe that it interferes with day-to-day functioning. At this point, anxiety is no longer a ‘normal’ reaction and may be considered as a psychiatric condition.

Very often, severe and unrelenting symptoms of anxiety can co-exist with the symptoms of depression. Treating the depression can sometimes clear up the anxiety symptoms and vice versa.

Anxiety and Parkinson’s

In Parkinson’s, anxiety may be based on the very real fear of functioning with a disability. However, at times, it can take on a life of its own and be unrelated to the physical state of the person with Parkinson’s. Just like depression in Parkinson’s, anxiety in Parkinson’s may also be related to changes in brain chemicals, particularly in noradrenaline and serotonin.

Some people with Parkinson’s have anxiety related to the ‘on/off’ state of their motor symptoms. When ‘off’ and less able to move well, they may develop significant anxiety symptoms and, at times, may even have panic attacks.

A panic attack is an overwhelming feeling of fear or terror that comes out of the blue and is accompanied by physical symptoms of sweating, a racing heart and shortness of breath. The person often feels as if they are going to die and if they do not recognise what is happening to them, they may end up in A&E believing that they are suffering from a heart attack.

A typical panic attack may last up to

15 or 20 minutes, or in some cases, even longer.

What can be done about anxiety?

For those who experience mild and intermittent anxiety, conservative measures such as avoiding stimulants, including caffeinated drinks, tea/ coffee, alcohol and cigarettes, may be helpful. Identifying and avoiding triggers of anxious episodes may also be helpful. Some people find other methods, such as relaxation tapes, yoga, massage, acupuncture, mindfulness and complimentary therapies beneficial.

If anxiety is specifically related to motor function, then improving the management of motor symptoms may improve anxiety symptoms. For example, an ‘off’ episode anxiety may improve by altering anti-Parkinson’s medication regimens to lengthen the duration of ‘on’ episodes and reducing fluctuations in motor symptoms.

Likewise, those with no clear ‘on/off’ phenomena may experience generalised anxiety if their motor symptoms are under-treated.

In such cases, increasing the anti-Parkinson’s medication may be beneficial. This should be discussed with their Parkinson’s specialist before any changes are made.

For anxiety symptoms that do not respond to changes in anti-Parkinson’s medication regimens, trying either talk therapy, such as cognitive behaviour therapy (CBT), or medications may be helpful. CBT and other forms of psychotherapy, such as relaxation therapy, have been shown to be very helpful for people without Parkinson’s.

However, clinical experience has shown that these methods may only work for some people with Parkinson’s. Nonetheless, they have proved to be helpful in practice and most Parkinson’s specialists would support their use in Parkinson’s.

Psychiatric medication may have a role to play in treating those with severe anxiety that is interfering with daily functioning and impacting on quality of life. Again, as with psychotherapy and psychological treatments there is very little direct evidence that such interventions work specifically in Parkinson’s, and recommendations for their use are taken from their efficacy in treating anxiety in people who do not have Parkinson’s.

The most common medications used to treat anxiety in these circumstances are anti-depressants such as serotonin reuptake inhibitors (SSRIs). These medications may improve both anxiety and depressive symptoms, particularly because the conditions often co-exist and overlap. Another medication that sometimes can be used to control anxiety symptoms jn Parkinson’s disease is pregabalin. Once again, the research evidence for the benefit of this medication for anxiety comes from studies in people without Parkinson’s disease. Sometimes, benzodiazepines may be used for a short time in times of high stress/ anxiety. However, these medications should be used with caution as they may cause excess sedation and drowsiness, unsteadiness of gait, slurring of speech and even confusion. Whereas most psychiatric medications are not addictive, the benzodiazepines can be highly addictive and after about six weeks of use, may be difficult to taper off without withdrawal symptoms.

Benzodiazepines are also used as muscle relaxants so may be helpful if muscle tension and pain is also experienced. This group of medication works very rapidly to alleviate symptoms of anxiety but does not treat the underlying abnormality in brain chemistry that is causing the anxiety in the first place. In contrast, using anti-depressants to treat anxiety takes longer (about two weeks before symptoms start improving), but will ultimately be more effective as the underlying brain changes will be improved.

Advice to family, friends and carers

Anxiety can be a very difficult problem to live with and it may restrict normal day-to-day activities, such as going out and socialising. If anxiety symptoms start to significantly affect quality of life, then a family member, friend or carer should try to encourage a discussion about this with their doctor. This may result in a referral to a mental health specialist who may recommend treatment. Helping and reminding a person with Parkinson’s to undertake relaxation exercises can also be of benefit.

Acknowledgements

The PAI would like to thank Parkinson’s UK for permission to use PDS Leaflet FS96 as the basis for this Information Sheet.

Our thanks to Professor Brian Lawlor, Consultant Psychiatrist in St. James’s Hospital, Dublin for endorsing this leaflet.

DISCLAIMER – The information on these pages is not intended to be taken as advice. No changes to your treatment should be made without prior consultation with your doctor or allied health professional.