In July 2024, Parkinson Canada hosted a webinar on stress and Parkinson’s disease. The webinar featured guest speakers Kim Mortson and Dr. Rick Helmich. Kim was diagnosed with Parkinson’s in 2018 and spoke about her experience managing stress and practicing gratitude. Dr. Helmich, a movement disorder specialist in the Netherlands, focused on the effects of stress on Parkinson’s. The speakers offered practical advice for managing stress.
Kim Mortson is a certified personal trainer, nutrition, and wellness specialist. She shared her Parkinson’s story. Kim was diagnosed in January 2018, but started experiencing symptoms three years before her diagnosis. Her Parkinson’s progressed slowly until the spring of 2023, when her symptoms began to accelerate rapidly. By December 2023, Kim was relying on a walker or wheelchair for mobility. In January 2024, Kim had DBS surgery. When preparing for DBS surgery, she hired someone to teach her stress management techniques so she could be mentally prepared for DBS.
Kim described some things she does to cope with stress, such as spending time in nature, exercising, doing puzzles, avoiding alcohol, connecting with family and friends, and focusing on the present moment. Since learning to manage stress more effectively, Kim reports that the PD symptoms improved, particularly the non-motor symptoms. She is calmer and is less critical of herself and her situation. She has set stricter boundaries in their work and feels that life is more manageable and positive now that she practices stress management on a daily basis.
Here are some key points from Dr. Helmich’s presentation:
Effects of Stress on Parkinson’s Symptoms: Stress can worsen Parkinson’s symptoms like tremors, freezing of gait, and dyskinesia. A questionnaire study involving 5,000 people with PD in the US showed that almost all participants reported worsened symptoms during stress. Another study showed that dopaminergic medication is less effective in reducing tremors when people are stressed. Study results also showed that many people reported that their PD symptoms improved when they did something they enjoyed, like exercise.
What is Stress? Stress activates large parts of the brain and affects the dopamine system. Stress leads to a release of dopamine from the basal ganglia. For people with Parkinson’s who have very little dopamine, stress can squeeze out the very last drops of dopamine that are available, which can then cause them to have a deficit of dopamine that makes symptoms worse. In normal circumstances, stress comes and goes and is part of daily life. The more dangerous form of stress is chronic stress. Under chronic stress, the area of the brain around the amygdala (which is associated with anxiety and fear) is activated and grows. Alternately, there are areas of the brain such as the hippocampus (which is important for memory) and frontal cortex (which is associated with thinking and reasoning) that are deactivated and shrink under chronic stress. Chronic stress can lead to symptoms of anxiety and depression. Thirty to forty percent of individuals with PD have symptoms of anxiety and depression.
Does Stress Affect the Onset of Parkinson’s Disease? Stress does not cause Parkinson’s, but it can unmask it. Dr. Helmich shared a clinical case of a patient with video who developed Parkinson’s symptoms following a traumatic event.
Does Stress Affect the Course of Parkinson’s Disease? While evidence from human studies is limited, animal models suggest that stress combined with Parkinson’s can negatively impact the dopamine system.
Can We Reduce Stress in Parkinson’s Disease? Stress-reducing interventions like propranolol (a beta blocker) and non-pharmacological methods like mindfulness and exercise can improve both motor and non-motor symptoms in PD. A study showed that mindfulness intervention (mindfulness and yoga) led to reduced anxiety, depression, and motor symptoms. The MIND-PD study in the Netherlands is currently investigating the effects of mindfulness on brain MRI imaging and clinical symptoms in people with PD.
A recording of the webinar is available on the Parkinson Canada YouTube Channel
You can find relevant resources about stress on the Stanford Parkinson’s website: Complementary Therapies in PD
Below are my notes on the webinar,
Elizabeth
“Under Pressure: Stress and Parkinson’s”
Speakers: Kim Mortson and Rick Helmich, MD
Webinar Host: Parkinson Canada
Webinar Date: July 10, 2024
Summary by: Elizabeth Wong, Stanford Parkinson’s Community Outreach
Kim Mortson’s Story
Kim was diagnosed with Parkinson’s disease in 2018, after experiencing symptoms for three years. Initially, the symptoms progressed slowly, but last spring they accelerated rapidly and she needed a walker and wheelchair to get around. This had a major impact on her personal and professional life, as she is a business owner in the fitness industry.
Kim described several stressful events that occurred around the time her Parkinson’s symptoms worsened, including the COVID-19 pandemic, moving multiple times, her husband’s cancer diagnosis, her mother’s death, and construction issues with their new home. The stress exacerbated their symptoms, leading to insomnia, isolation, and a loss of identity.
In December 2023, she got scheduled for deep brain stimulation (DBS) surgery. This prompted her to focus on preparing for the surgery by improving her physical and mental health. She hired someone to teach her stress management techniques and she reconnected with their faith.
Kim described some things she does to cope with stress, such as spending time in nature, exercising, doing puzzles, spending time with her pets, eating healthy meals, avoiding alcohol, connecting with family and friends, and focusing on the present moment. She emphasized the importance of practicing gratitude, which has helped her focus on the positive aspects of their life.
Since learning to manage stress more effectively, Kim reports that the Parkinson’s symptoms improved, particularly the non-motor symptoms. She is calmer, lives in the moment, takes her daily life slower, talks to her god, and is less critical of herself and her situation. She has set stricter boundaries in their work and feels that life is more manageable and positive now that she practices stress management on a daily basis.
Rick Helmich, MD presentation titled: “Under Pressure: the effect of stress on Parkinson’s disease”
The work presented largely comes from research work of his team in the Netherlands.
Effects of stress on Parkinson’s symptoms
Under stress, many people with Parkinson’s experience worsening symptoms such as tremors, gait freezing and dyskinesia. They also find that dopaminergic medication is less effective during stress.
A study looked at the severity of tremor during rest and under stress when people were taking dopaminergic medication. The study results showed that dopaminergic medication is less effective in reducing tremor when people are under stress. From clinical observations, people can reduce some of their symptoms by using meditation techniques .
To learn more about how stress affects PD, a large questionnaire study of about 5,000 people with PD in the U.S. was conducted asking them about their experiences with stress and with ways to reduce stress. The questionnaire results showed almost all patients indicated that their PD symptoms worsen during stress. People noted similar effects on their symptoms under the different types of stress (such as stress caused by conflict, time pressure, social stress, worrying). Many people also responded that when they did something they enjoyed, like exercise, their symptoms actually got better.
What is stress?
When under stress, large parts of the brain are activated and that has an effect on the dopamine system. Stress leads to a release of dopamine from the basal ganglia. But in people with Parkinson’s who have very little dopamine, stress can squeeze out the very last drops of dopamine that are available, which then causes people to have a deficit of dopamine that makes symptoms worse. Additionally, stress activates the noradrenaline system [also known as the norepinephrine system] that affects several different brain regions and increases the excitability of those brain regions.
Stress in normal circumstances is good. Acute stress is stress that comes and goes and is part of daily life. The more dangerous type of stress that many people with PD live with is chronic stress. Chronic stress can lead to symptoms of anxiety and depression. Thirty to forty percent of individuals with PD have symptoms of anxiety and depression.
Chronic stress has a negative effect on the brain. Under chronic stress, the area of the brain around the amygdala (which is associated with anxiety and fear) is activated and grows, and there are areas of the brain such as the hippocampus (which is important for memory) and frontal cortex (which is associated with thinking and reasoning) that are deactivated and shrink.
Does stress affect the onset of Parkinson’s disease?
Story of a patient who developed tremors the day following a very traumatic experience when her husband had a heart attack while abroad was presented. [Video excerpt of conversation with the patient was shown]. This story was published earlier this year in the Journal of Parkinson’s disease called “The Last Straw: How Stress Can Unmask Parkinson’s Disease.”
There were also patients who developed Parkinson’s after COVID wondering if COVID could have caused their Parkison’s disease. In all the cases, the Parkinson’s disease was not caused by the stress but unmasked by the stress.
Generally, Parkinson’s symptoms can be present long before someone is actually diagnosed with Parkinson’s disease. This means the disease has already been going on in the brain for a long time before diagnosis. Research suggests a stressful event can affect the brain to unmask the disease.
Does stress affect the course of Parkinson’s disease?
There is not a lot of evidence when examining if stress is bad for the brain of someone with Parkinson’s. In animal models, the injection of neurotoxin leads to Parkinson’s disease in mice, if an injection of toxin is combined with prolonged periods of stress, fewer dopamine cells survive, suggesting that Parkinson’s disease combined with stress might be bad for the dopamine system. There is currently no such evidence in humans with Parkinson’s disease but there are studies in progress looking at this.
Can we reduce stress in Parkinson’s disease?
When someone is under stress, the noradrenaline is activated in Parkinson’s disease. A study was conducted to look at if the noradrenaline system could be inhibited in people with Parkinson’s by giving propranolol, which is a beta blocker that inhibits the noradrenaline system. The study examined propranolol or placebo’s effects on Parkinson’s tremor at rest and under stress. Results found that propranolol reduced the different types of PD tremor (such as resting tremor, postural tremor, and kinetic tremor) compared to placebo. For patients who suffer from a lot of tremor and who are under stress, propranolol might help to reduce the impact of stress on their tremor.
Non-pharmacological interventions like mindfulness or meditation can help reduce stress. As part of the questionnaire study, participants were asked about their experience with mindfulness. Forty percent of the whole group had some experience with mindfulness; and out of those participants who had experience with mindfulness, 93% would recommend the practice to other people.
When looking at the difference between people who practiced mindfulness a lot (several times a day) compared to mindfulness a little (once a month or less), the results of the questionnaire study showed that people who practiced mindfulness a lot had more advantages on their Parkinson’s symptoms.
Results of a randomized controlled trial showed that mindfulness intervention such as mindfulness yoga resulted in a lower level of anxiety and depression and less severe motor symptoms compared to those in the control group where they did stretching and resistance training.
There are a lot of stress-reducing strategies. It does not have to be mindfulness. Parkinson’s patients also mention physical exercise as an activity that reduces stress. Stress reducing interventions may improve motor and non-motor symptoms in Parkinson’s disease.
He recommends watching the YouTube video by Dutch jazz musician Rene van Helsdingen who has Parkinson’s tell the story of how he copes with stress and uses the tremor to help him with improvisation.
The MIND-PD study in the Netherlands is a randomized controlled study that is currently in progress looking at the effects of mindfulness intervention on brain MRI imaging and clinical symptoms for people with Parkinson’s disease.
Question-and-Answer
Q: [For Dr Helmich] Is stress from Parkinson’s disease different from normal stress?
A: No, the stress is the same, but I do think that people with Parkinson’s have more risk of becoming stressed because they can have more challenges and Parkinson’s disease could also affect the coping strategies that people have to deal with the stress. For example, it might be less easy for someone with Parkinson’s to go for a run or swim to cope with the stress because of the motor symptoms they have.
Q: [For Kim] Have you noticed any difference in how you experience stress now that you have Parkinson’s compared to when you were younger?
A: I knew it was a double edged sword. I knew I had to do exercise to slow down Parkinson’s and make my life more manageable but at the same time the Parkinson’s was making exercise more challenging.
Q: [For Dr Helmich] Is the stress from drugs or other factors?
A: I think the stress in Parkinson’s disease is really caused by the disease itself and not by the drugs, so it is the loss of dopamine. There is one exception, some people with severe ON-OFF fluctuations can experience a lot of stress during these OFF periods. In those cases, you could say the stress is caused by the combination of Parkinson’s disease and the wearing off of that drug.
Q: [For Dr. Helmich] Can stress or depression start a year or two ahead of any clinical signs of Parkinson’s?
A: Yes, many people that I see who I ultimately diagnosed with Parkinson’s disease tell me they suffered from burnout or depression a few years earlier. I think that is because even though there might not be overt symptoms of tremor or slowness in those years before the diagnosis, people know that something is not quite right and they have to work harder to keep up and that is very stressful.
Q: [For Kim] How did you come to the decision to get DBS and was it in consultation with a neurologist?
A: Yes, last April, my neurologist had suggested that DBS surgery might be an option and I knew at that point that things had been accelerating. From there, I was referred to Toronto Western Hospital.
Q: [For Kim] You have some great strategies for managing stress throughout the day. Do you find that stress can affect your sleep at night and if so, what do you do about it?
A: Post DBS surgery, I’ve been sleeping well. However, prior to DBS surgery, my sleep was affected and I would practice gratitude and do prayers. I would recount my day and think about what I was grateful and positive about. I focused on my positives. I would leave the bedroom and go to the couch and take that quiet time to listen and look out windows and see the sky. I would try deep breathing techniques, or put on a meditation recording on my phone to bring anxiety and stress levels down.
Q: [For Dr Helmich] How effective are anti-anxiety medications for Parkinson’s disease?
A: I think anti-anxiety medications are effective in helping individuals clinically diagnosed with anxiety or depression. But the majority of Parkinson’s patients are in the in-between category where they are not clinically depressed nor clinically have an anxiety disorder, but they report worrying or rumination of stress levels. If someone is in the in-between category, then I think lifestyle changes are probably more effective, but if there are severe symptoms then please see a psychiatrist. I think medication is a good option for those people.
Q: [For Dr Helmich] What are your thoughts on using medical marijuana to alleviate stress?
A: That is a difficult question. Marijuana makes you drowsy and that can reduce symptoms like tremor or dyskinesia. I don’t prescribe marijuana to patients because I think there are other solutions that are more effective in the long-term for dealing with stress than marijuana.
Q: [For Dr Helmich] If someone is having stress, is it ok to adjust their medication based on their times of stress?
A: Yes, I think that could work. Under stress, medication is less effective. Additionally, sometimes people can enter a vicious cycle. For example, when they are at a restaurant, they have tremors, and then they begin to stress about people seeing their tremors, and they shake even more. During those times, it could help to take a little more levodopa. In thinking about the role of medication in the wearing-off period, people can experience severe anxiety when the effects of levodopa wears off. There can be other possible solutions like long acting drugs or DBS.
[Moderator comment- if you are experiencing stress and want to adjust medication, talk to your healthcare provider to make sure that it’s appropriate for you in your particular circumstance.]
Q: [For Kim] As a personal trainer, do you find that working causes you stress, or is work an outlet for your stress, or is it both?
A: It is finding that balance. I had a very active business where I was working too much and I recognize that now. I have been very conscious of my boundaries and I can sense when things are getting a bit overwhelmed for me. I am very cognizant of saying “no” to things if it’s adding too much to my workload. I’ve learned my boundaries more and I am cautious of how much I take on.
Q: [For Dr. Helmich] What can you tell us about stress levels and its effect on the care partner?
A: That is very important. I think if someone in a relationship gets Parkinson’s it can be very stressful for that relationship. It is important to keep the relationship going in the sense of continuing to speak with each other. We offer couples therapy for the patient and partner to deal with stress.
Q: How can I support someone with Parkinson’s disease related stress?
A: [Kim’s response] Listen. Often, the patient feels very isolated because nobody can truly understand. Listen and be empathetic. Let them talk to you without offering many suggestions. Sometimes, all they need is just somebody to listen to them.
Q: [For Dr Helmich] I heard that vitamin B12 deficiency may be related to cognitive changes or balance. Is there any evidence that it may also affect anxiety or mood?
A: That evidence in Parkinson’s disease to my knowledge does not exist. Vitamin B12 is important for neural function and it might be reduced by large doses of levodopa or through [levodopa infusion] pump therapy, so if someone is on pump therapy, vitamin B12 levels should be monitored. If vitamin B12 levels are too low, it’s bad for the brain as a whole, but not specifically because it causes stress or anxiety.
Q: [For Dr Helmich] Since you consume dopamine faster when you are stressed, if you increase the dose (of dopamine) before a more stressful event like a presentation, would that help?
A: Yes, that is a true observation. I think it makes sense because ultimately when our brain is more active, which is that case during stress, we need more dopamine. There could possibly be room for an increase in dose of dopamine before a stressful event. Please discuss it with your healthcare provider.