Anxiety (in Parkinson’s) – Webinar notes

Anxiety (in Parkinson’s) – Webinar notes

On April 22, the Oregon Health & Science University (OHSU) Parkinson’s Center hosted a webinar on anxiety’s contribution and impact in Parkinson’s Disease (PD) and ways to manage it. 

This webinar featured psychiatrist Dr. Joel Mack, and clinical psychologist Dr. Kristine Hanna.  It is part of OHSU’s series on “Essential Tools for Managing PD.”

Dr. Mack said that anxiety is a non-motor symptom of PD and can manifest in three different forms: generalized anxiety (persistent), episodic anxiety (panic attacks), and social anxiety (avoidance behavior).  It can appear at any time throughout the illness, but can be a first symptom of PD which can be seen up to five years before diagnosis and generally increases during advanced or late stage PD. Anxiety can occur during “off periods” of dopamine agonist medications such as levodopa. Additionally, having a chronic illness can cause chronic stress, which can affect hormones and brain cortisones which can also cause anxiety and depressive disorders. 

Dr. Mack noted that there are many ways to manage PD anxiety such as exercise, drug therapy such as serotonin inhibitors and antidepressants, mindfulness based therapies, tai chi, dance, and cognitive behavioral therapy (CBT).  

Dr. Hanna focused a great deal on CBT. CBT walks a person through a situation and assesses their body’s response to it (including physical sensations, mood, emotions and behaviors).  It is based on the idea that feelings and behaviors are largely influenced by the way a situation is interpreted or perceived, and attempts to condition the body’s response to respond differently to a situation and reframe thinking errors.  CBT is considered the gold standard in terms of psychological treatment for anxiety in the general population, and has promising results in treatment of anxiety and depression in PD.  Other CBT tools include behavioral activation, which is purposefully planning meaningful activities that have the potential to positively influence mood, and emotional management, which is noticing, labeling and understanding your emotional response and identifying triggers. 

For more information on anxiety in PD, please see this Stanford Parkinson’s Community Outreach webpage: 

Anxiety in PD

The session recording can be found on the YouTube link here.

See below for notes on the April 22nd webinar.

Regards, 

– Joëlle Kuehn


“Anxiety (in Parkinson’s)” – Webinar notes

Speakers: Joel Mack, MD, geriatric psychiatrist, OHSU; Kristine Hanna, PhD, clinical psychologist, Integrative Health Northwest

Webinar Host: Oregon Health & Science University (OHSU) Parkinson’s Center

Webinar Date:  April 22, 2021 

Summary by Joëlle Kuehn, Stanford Parkinson’s Community Outreach

Anxiety and the Mind-Body Connection in PD (presented by Joel Mack, MD)

Anxiety is a non-motor symptom of PD and falls under the neuropsychiatric problems, along with depression, apathy, psychosis, hallucinations/delusions, and impulse control disorder. 

Anxiety types:

  • We all experience it, it is useful evolutionarily
  • PD anxiety prevalence: 30-40%
  • May present as:
    • Generalized anxiety: persistent anxiety.  Thoughts of worry during the day, muscle tension, sleep disturbances, lack of concentration
    • Panic attacks: episodic anxiety.  Intense sudden feelings of terror and fear, shortness of breath, sweating, increased tremor
    • Social anxiety: avoidance behavior
    • A combination of the 3

When does it happen during the illness?

  • Can be anytime throughout the illness
  • Can start 5 years before motor symptoms or diagnosis occurs
  • Increases during advanced or late stage PD

Manifestations of PD anxiety:

  • Combines mind and body
  • physical/motor: pounding heart, sweating, muscle tension, nausea, fatigue, short/rapid breath, tremor/freezing
  • Behaviors: avoidance, not leaving home, escape, ritualistic behaviors, sleep disturbance, agitation
  • Cognitive: negative ruminations, worries about the future, obsessive thoughts, phobias, worse concentration, fear of falling
  • Emotions: nervous/on edge/restless, fear, panic, terror, impending doom, irritable, embarrassment
  • Environmental factors: social interactions, spouse/caregiver, medical appointments, finances, pandemic, etc.

Anxiety can occur during “off periods” where medications try to fix altered or decreased dopamine function fluctuate and hit a low. Having a chronic illness can cause chronic stress, which can affect hormones and brain cortisones which can also cause anxiety and depressive disorders. 

Managing PD anxiety:

  • Exercise and other treatments
  • Other treatments:
    • Monotherapy: SSRI, SNRI – serotonin inhibitors, antidepressants (can also help with anxiety)
    • CBT, mindfulness based therapy, relaxation therapy 
  • If these don’t work, try:
    • SSRI/SNRI + buspirone
    • SSRI/SNRI + CBT or mindfulness based therapy
    • SSRI/SNRI + clonazepam/lorazepam 
  • If those don’t work, certain symptoms of anxiety can be treated with additional medications

Mind-body interventions:

  • Mindfulness: improves anxiety, depression, quality of life
  • Tai Chi: sleep, quality of life
  • Dance: cognition, apathy, quality of life
  • Yoga: quality of life, anxiety
  • Acupuncture: depression, quality of life, sleep
  • Exercise/PT/OT: quality of life, sleep, fatigue, depression, subsets of cognition, apathy, anxiety 


Who should you talk to if you feel like you are experiencing anxiety:

  • Spouses, family, caregivers
  • Doctors
  • Mental health professionals
  • Physical and occupational therapists
  • Other members of your team

Psychological Approach for managing Anxiety in PD (presented by Kristine Hanna, PhD)

Cognitive behavioral therapy (CBT):

  • Walks patient through a situation and how to condition the body to respond differently
  • Example:
    • A situation arises that causes anxiety
    • Automatic thoughts and images occur through this situation
    • This triggers body and physical sensations as well as mood and emotions
    • It triggers a behavior of “what did I do or not do”
  • All of the thoughts, images, body/physical sensations, mood/emotions, and behaviors are impacted by our core beliefs (scripts we have about how we view our life, how did we learn them?)
  • We are a product of our experiences, and they form the automatic thoughts.  Examining thoughts and asking “what could be a more accurate way to look at the situation”
  • How you perceive a situation impacts how experience it
  • CBT explores link between emotions, thoughts, and behaviors
  • It is based on the idea that feelings and behaviors are largely influenced by the way a situation is interpreted or perceived
  • CBT is considered the gold standard psychological treatment for anxiety in the general populations, and promising results in treatment of anxiety and depression in PD

Challenge thinking errors: reframe to break unhelpful cycle

  • All-or-nothing.  Ex: “no one ever cares if I show up”
  • Catastrophizing.  Ex: “if someone is running late, thinking they’re dead somewhere”
  • Overgeneralizing
  • Mental filter
  • Hypervigilance

Emotions:

  • Looking at emotions
  • Emotions are neither good nor bad and are all important
  • Grief / loss
  • CBT Goal:
    • Learn to manage emotions
    • Understand how thoughts and behaviors influence them
  • Emotion management tools:
    • Notice, label, & understand your emotional response
    • Identify triggers
  • Use of relaxation strategies are important in the treatment of anxiety:
    • Diaphragmatic breathing: breath from diaphragm not chest
    • Progressive muscle relaxation: try to relax muscles from head to toe
    • Meditation / mindfulness: daily exercises: Try app “Headspace”

Behavioral activation:

  • A CBT tool
  • Purposefully plan activities that are meaningful to us
  •  Get clients more active and involved in life by scheduling activities that have potential to influence mood
  • Activity schedule:
    • Purposely schedule value directed activities
    • Make it a habit
  • Problem solve potential barriers:
    • Examine thoughts/beliefs
    • Plan during “on” period
    • Pace yourself
    • Plan small meaningful activities
    • Pivot and flexibility

Other important elements of CBT are exercise, sleep and stress management. 

Social connection:

  • Important aspect of anxiety treatment
  • Impacted by pandemic
  • What does your support network look like?
  • Carepartners role in CBT.  Teach effective ways to support and reinforce coping and helping identify maladaptive thoughts

Other essential ingredients:

  • Acceptance and commitment therapy (ACT)
    • Tailored treatment
    • Compassion (antidote to self-criticism)
    • Acceptance of self diagnosis
    • Value work
    • Perceived control and empower resilience

Ways to change:

  • Learn to accept the things we cannot change
  • Have the tools and courage to consciously change the thoughts and situations that can
  • Have the support and wisdom to know the difference

Question & Answer:

Question: How do you make sure all doctors in the care team are adequately communicating?

Answer (answered by moderator Lisa Mann): You can sign a release form so that they can communicate with one another. Every time you meet with a provider you can ask them copy other people on your team

Question: Could you address which came first: does anxiety impact PD, or is PD disease usually the thing that causes anxiety?

Answer (Dr. Mack): It’s a chicken and egg question. In PD we often see anxiety as an early symptom before the motor symptoms. As the disease progresses we can see it get worse as PD motor symptoms and medication treatments change. Sometimes we see the freezing of gait leading to a fear of falling which leads to anxiety over time. We try to treat the whole package. Anxiety is a symptom of PD, and even if someone experienced it previously in life we do see it as part of the illness.

Questions: Does anxiety happen just because someone got a diagnosis of a progressive chronic illness? What do you see?

Answer (Dr. Hanna): It’s understandable that when someone has to deal with a situation they didn’t intend like PD, that they experience anxiety. Situational anxiety could be reacting to the diagnosis, and working with your care team to clarify and get more information. More often than not however we work with them for anxiety over a longer period of time rather than just initially. 

Question: How does Sinemet/carbidopa levodopa impact anxiety? Can it increase or decrease it?

Answer (Dr. Mack): In general, what we see is that anxiety is associated with the low dopamine state (when levo. It’s the fluctuation of levodopa that leads to anxiety. Occasionally we see forms of anxiety with levodopa such as when they are experiencing dyskinesias. 

Question: What do you do if the caregiver is experiencing anxiety but still wants to support the family?

Answer (Dr. Hanna): As a caregiver it’s important to address your own anxiety and understand and validate that this is happening. If you feel that the anxiety’s uptick is impacting your ability to do daily activities, try to see a therapist or reach out to doctors for psychological interventions. Pay attention to it and don’t minimize it. 

Question: How do I deal with panic attacks?

Answer (Dr. Mack): A first step is to bring it up and talk about it. They can get extremely frightening. The “good” thing about them is that they will pass. You should have a clear plan on what to do when they happen. Antidepressants can be very effective in treating panic attacks over time.  

Question: How do you recommend both caregivers and PD patients handle panic attacks?

Answer (Dr. Hanna): Have a plan that both of you are on the same page. Take care of your own wellness leading up to panic attacks. Have a calm safe place, and try meditating. Try to relax, or distract yourself. Ask yourself in that moment “what’s the worst that’s going to happen and can I handle it?

Question: How do you adapt treatment if the person has mild cognitive impairment or dementia?

Answer (Dr. Mack): Medication-wise there won’t be a ton of changes, but anxiety can make cognitive impairment more pronounced and may make them feel more overwhelmed. There are adjustments that can be made in therapy to meet the person where they are at.

Answer (Dr. Hanna): It has to be tailored to each individual because they exhibit different symptoms. We try to take tasks and make it really simple for that person. We try to supplement the work with things that make tasks easier and less cognitive heavy. 

Question: What have you seen in PD anxiety regarding sleep disturbances?

Answer (Dr. Mack): There are many kinds of sleep disturbances and troubles, and sometimes they can overlap with anxiety or can play off of each other. Anxiety can make it more difficult to fall asleep, or can make people wake up in a panic, and sleep troubles can also cause anxiety. In PD, people have more vivid dreams which can cause anxiety. There are a number of sleep issues that may contribute to anxiety so it is important to figure out which one it is. 

Answer (Dr. Hanna): The first thing is doing the medical work up to determine which sleep disturbance it is. If it’s anxiety-related, there are specific ways to approach that. Whenever anxiety is present at night, an important thing is sleep hygiene, not staying in bed when you’re not sleeping, have a routine of mindfully noticing when you are feeling a panic attack coming on. If you aren’t getting sleep it doesn’t help your anxiety the next day.