Anxiety in Parkinson’s Disease

It is normal to feel anxious at times. We worry about our children, our spouses, our friend, our finances, arriving on time for an appointment. There is always something to worry about. But some people worry too much. They worry to the point that it interferes with their lives. An appropriate amount of anxiety is a necessity for a normal life. But where “appropriate” crosses the line to “inappropriate” is not always clear.

We consider a person to suffer from an anxiety disorder if they have excessive fears or concerns that are beyond what is considered reasonable. It is normal to worry about your adult children’s health but so much that you call them every hour. The psychiatrists divide anxiety into a number of different forms, but for our purposes, we can consider anxiety a disorder in which someone worries too much about a problem, whether a possible problem, like what will I do if my roof caves in, or an actual problem, like how will I pay the mortgage this month.

It is my belief that anxiety is one of the most important and underappreciated behavioral problems in people living with PD. I write this because anxiety is common, affecting about 20-40% of people with Parkinson’s Disease (PWP) and because it causes a great deal of distress both to the patient and to those who interact with the patient. It impairs memory, by distracting the patient’s ability to concentrate and is occasionally misidentified as dementia. It may interfere with sleep. We all have experienced difficulty falling or staying asleep when we are worried, whether the worry is justified or not. Then the problem with sleep itself causes more anxiety, a worry about being able to sleep! It causes patients to amplify the problems caused by their Parkinson’s Disease symptoms. Each “off” period or problem getting out of a chair may seem like the end of the world even thought the patient has lived through thousands of these spells. It precipitates calls to the doctor and trips to the emergency departments. It causes irritability in those around the patient and a great sense of frustration. I believe that it may also cause a sense of restlessness.

Anxiety is relatively common in the general population but generally affects women more than men and it usually begins in young adults. In PWP anxiety affects men and women about equally, and starts soon before or with the onset of the motor features of PD. The anxiety in PWP usually falls into one or more of the following three general categories: generalized anxiety, panic attacks or social phobia. People with generalized anxiety are the ones we think of as “nervous.” They are always worried about something, and generally to a level of severity that is unwarranted. Panic attacks are episodes in which the patient suddenly goes into a panicked state, sometimes feeling short of breath, with chest pain and a strong sense of impending doom. Although it is common to think of panic attacks as being exaggerated responses to stressful situations, this is usually not the case. Most panic attacks have no identifiable precipitant. For no apparent reason the patient suddenly has an attack. These usually last about 20 minutes then pass. They cause innumerable trips to the emergency room. The third common anxiety state in PWP is social phobia. This is a fear of being around other people and having to interact. Much of this is understandable as the PWP may have speech problems or difficulty following the train of thought, being unable to always finish sentences, drooling, or having some problem that makes them embarrassed to interact in public. After a time, having to be in the public eye produces a feeling of dread.

Anxiety occasionally appears as an isolated problem, but a large percentage of PWP who suffer anxiety often suffer from depression as well. And both anxiety and depression, like all behavioral problems, is increased in people who have memory and cognitive problems.

Anxiety has been poorly studied in PD. We believe that it can be treated either with medications or with talk therapy. There are data that certain psychological approaches, particularly cognitive behavioral therapy, may be successful in treating anxiety, without the use of any medications. We think that the usual drugs given for anxiety in the general population will also work in PWP, but there are few data to support this. Furthermore, some of the most commonly used drugs for anxiety, drugs like diazepam (Valium), lorazepam (Ativan), alprazolam (Xanax) are considered “relatively contraindicated” in older people because they contribute to reduced balance and an increased risk of falls.

In general most Parkinson’s Disease specialists use the same drugs used to treat depression, as most of these also treat anxiety. So, drugs like sertraline (Zoloft), fluoxetine (Prozac), citalopram (Celexa), escitalopram (Lexapro), mirtazapine (Remeron), are frequently used. This list is not complete, and many other drugs probably work equally well. Sometimes the side effect profile of a medicine helps make the choice easier. Mirtazepine, for example, is sedating and often increases appetite, so it’s a good choice for someone who is anxious, losing weight and has insomnia, but not a good choice for an overweight person who sleeps too much. It is important to understand that the antidepressants take a few weeks to treat the anxiety, just as they take several weeks to treat depression. These drugs cannot be used on “as needed” basis. The drugs work to reduce anxiety in general and should not be taken only when feeling anxious. They need to be taken every day, as prescribed. This is different than the valium-like anti-anxiety medications, which can be taken daily, or only taken when needed as each pill is effective, whereas the antidepressants take weeks to begin to be effective. Anxiety can be severe enough to require psychiatric hospitalization.

Anxiety is yet another problem that is part of the Parkinson’s Disease spectrum. It has a strong influence on quality of life, and, we believe, is treatable, using the same medications as used in the general population. The medications that help PWP move better are not helpful for anxiety.

Anxiety is a common and underappreciated mental health issue, which should be brought to the attention of the doctors.