By Joseph H. Friedman, M.D.
Anxiety is a normal part of life for all of us. We all have something to worry about — whether it is related to work, life or family. Often anxiety presents no major problem. But it can become a problem when it interferes with our daily activities and our quality of life. In recent years, we have come to understand that problematic anxiety — that is, excessive nervousness and constant worry — is common among people who live with Parkinson’s disease (PD), affecting perhaps 20 to 40 percent of those with the disease. For many, its effects can be more debilitating than the better-known movement symptoms of Parkinson’s. The good news: it can be treated.
Anxiety in PD: What It Is
There is a misconception that anxiety in Parkinson’s is a matter of nervousness or worry about the diagnosis itself. This is not true. In fact, scientists are coming to understand that anxiety in Parkinson’s is actually part of the disease itself. It often begins within a few years of diagnosis, or sometimes even precedes the diagnosis or the presence of movement symptoms by a few years.
What does anxiety look like in Parkinson’s? There are three types that are especially common in PD.
Generalized Anxiety. This describes the person who is nervous and worries much of the time — for example, whether the mail has arrived, whether a check has been cashed, or whether he or she will get stuck in traffic.
Panic Attacks. A person who is experiencing a panic attack suddenly feels as if he or she is doomed, or even about to die. The person may feel short of breath, and experience chest tightness, tightness in the throat or tingling in the lips and fingers. These episodes can come out of the blue, last for 10 to 20 minutes and then go away by themselves. The symptoms feel similar to those of a heart attack. Panic attacks are very disturbing even when a person knows what is happening.
Social Phobia. A fear of interacting with people in groups is common in PD. People with Parkinson’s may be self-conscious about symptoms — for example, having trouble with speech, or being embarrassed by drooling or tremor. Concern about one’s appearance can make it unpleasant for a person with Parkinson’s to be around friends and relatives. Over time, he or she can become fearful. In such circumstances, it is important for the person to get out to socialize; the longer he or she avoids social situations, the harder it will be to overcome this fear.
Anxiety in PD: What It Isn't
People with Parkinson’s disease often experience other symptoms that may be confused with anxiety. We call these symptoms “partners,” and “imitators.” It is helpful for us to learn to identify such symptoms, so that they too can be treated. Here are four of these:
Akathisia. This is a feeling of physical restlessness. In PD, this symptom can overlap with anxiety, although often, a person can’t distinguish one from the other. People who are anxious say they feel restless and vice versa.
Depression. Many people are diagnosed with depression, along with anxiety.
Cognitive issues. Anxiety and cognitive or memory problems also can develop together — particularly in the early stages of cognitive difficulties.
Sleep disturbances. Many PD symptoms interfere with sleep. Worrying makes it hard to relax and go to sleep in the first place, and it complicates getting back to sleep after waking in the middle of the night.
Effects of Anxiety in PD
In Parkinson’s, anxiety can exacerbate other problems. Many people find that their movement symptoms worsen when they are anxious. I see people with Parkinson’s disease whose tremors increase when they visit my office because they are anxious about seeing a doctor. Many people have difficulty walking when they are anxious, and are more likely to experience “freezing” — that is, the feeling that their feet are stuck to the ground.
It’s common for people with Parkinson’s to report that their symptoms worsen during stressful times — for example, when a loved one becomes injured or ill. All of this can lead to a vicious circle, with anxiety making movement more difficult, and, in turn, difficulty with movement generating anxiety. For people who experience fluctuations in the effectiveness of their medications, this can present a serious problem. Anxiety often surfaces during the “off” phase, when medications are less effective. During this phase, as movement symptoms return, anxiety surfaces and this in turn worsens those symptoms. In addition, sometimes people become anxious about medication side effects, which can cause them to be less careful about taking their prescriptions properly.
Anxiety can also exacerbate Parkinson’s disease symptoms like hallucinations, delusions and dementia. On the flip side, when people are anxious, they have difficulty concentrating and this can lead to memory problems — problems that are sometimes mistaken for dementia or Alzheimer’s disease.
Lastly, anxiety generally makes life difficult. When anxious, people may perceive that their PD symptoms have worsened although tests show otherwise. Then of course, constant worry can affect relationships and social interactions. Anxiety can annoy other people, and it’s irritating for the person with PD to be told by someone, “don’t worry so much!” People with PD are often well aware that they worry too much — but they can’t help it.
Treating Anxiety
Anxiety is as much a part of Parkinson’s as are tremor, stiffness and slowness — yet many people are not aware of this. If you or a loved one should experience new and excessive worrying, remember that it may, in fact, be part of Parkinson’s disease, and should be discussed with your doctor. It is very helpful for loved ones to remain calm and reassuring when a person with PD experiences anxiety. But this alone will not solve anxiety in PD.
Fortunately, there are many options for treating it. Even better, resolving anxiety can actually ease PD movement symptoms, which in turn will improve quality of life.
Medications prescribed for anxiety in the general population appear to work equally well for people with PD (listed below). Keep in mind, however, that people with PD who are already taking several medications may not be able, or want, to add another one.
In these cases, there are many non-drug therapies available. For example, cognitive behavioral therapy, mindfulness and other talk therapies — as well as meditation and breathing exercises — may be recommended.
Treatments for Anxiety
Antidepressants known as SSRI's
- Includes: sertraline HCI (Zoloft®), citalopram (CelexaTM) and others
- Benefits: treats both anxiety and depression; doesn’t make people sleepy; doesn’t affect balance
- Considerations: it takes a few weeks for these medications to have an effect and they must be taken continuously
Other antidepressants that are not SSRI’s
- Includes: mirtazapine (Remeron®) and venlafaxine (Effexor®)
- Benefits: treats both anxiety and depression
- Considerations: cannot be taken with MAO-B inhibitors (rasagiline, selegiline and others)
Antipsychotics
- Includes: quetiapine (Seroquel®) and clozapine (Clozaril®)
- Benefits: treats symptoms of psychosis
- Considerations: only for people with psychosis; may increase risk of falls, death
Anti-anxiety medications that are not antidepressants
- Includes: diazepam (Valium®) lorazepam (Ativan®) and alprazolam (XanaxTM)
- Benefits: these medications are effective within an hour or two, so they may be a good choice for someone who only needs them once in a while
- Considerations: may increase the risk of falling; may interfere with memory and concentration; tend to make people sleepy
Talk therapies
- Benefits: no side effects or drug interactions
- Considerations: it takes time to travel to the therapist
Conclusions
Treating anxiety is an important part of living well with Parkinson’s, and is just as important as taking care of movement symptoms. When anxiety is treated effectively, people with PD feel better, move better and live better.
Dr. Friedman is Director, Movement Disorders, Butler Hospital and Professor and Chief, Movement Disorders, Warren Alpert Medical School, Brown University.
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