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Cognitive Therapy For Parkinson’s Disease

A Cognitive Behavioral Model

Cognitive & Psychiatric Disorders in Parkinson’s Disease – Andrew Ridder, MD

A case example is outlined to demonstrate the benefits of developing a case conceptualization based on a guiding model of CBT for anxiety and depression in PD as shown in Fig. 1.

The CBT model outlined in Fig. 1 is a new model that has not been outlined before, and is based on standard cognitive-behavioral models where core beliefs are defined as rigid and inflexible beliefs which are developed due to early life experiences and then activated later in life due to stressors such as the diagnosis of PD. In the case of Bill his core belief I am incompetent lead him to value being able to try and prove his competence through being highly independent and solving problems and he thus had associated beliefs that A man stands on his two feet and If I cannot do things by myself, then I am incompetent.

There are also illness beliefs which arise from core beliefs that make someone more likely to react with negative emotions to PD, for Bill this was watching his best friend die of PD, and was linked with his fear I may die at any stage due to my PD. Cohort beliefs refer to values and beliefs shared amongst a generational group of individuals born at a similar time period . For a man of Bills generation, he possessed a common cohort belief that people who are disabled are weak, needy and dependent.

Data Extraction And Quality Assessment

Two investigators independently extracted the relevant data and information from the eligible studies. Basic information about the study characteristics , population, interventions and comparisons , and measurement outcomes was extracted. Another two reviewers evaluated the quality of the included studies based on the standard criteria of the Cochrane Risk of Bias Tool . Any disagreements that existed were resolved through discussion. If necessary, a senior investigator was consulted to achieve a consensus.

When Therapy Is Most Effective

can be challenging. For one, there are large groups of diverse symptoms, which can change over time, says Tsao-Wei Liang, M.D., neurologist and division director of The Jefferson Comprehensive Parkinson’s Disease & Movement Disorders Center in Philadelphia.

One moment you may be dealing with a delusional disorder, another moment you’ll be dealing with a separate delusional disorder, another time it will be hallucination, he explains. Luckily, there are patterns in PDP in its early and even middle stages, when therapy is most effective, says Dr. Liang.

There is one caveat: Therapy helps best when you still possess insight into your thoughts and feelings, so you can deal with them. Thats easiest when the hallucinations or delusions are fleetingyou feel someone sitting beside you when theres nobody there, say, or youre certain that someone stole your purse, only to find it a moment later.

Mild hallucinations can go on for years, says Dr. Liang, or they can be random and occasional. And they may not bother you enough to mention them to anyone. However, as time passes visions often become more specificyou believe you actually see cats with specific markings lounging on the sofa, say. Or you come upon a bunch of school children doing their homework at your kitchen table when you come down to breakfastor at least honestly believe that you do. The kids may disappear, but youd swear they were there. Sometimes they even talk to you, and often theyre friendly.

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How Are Cognitive Issues Diagnosed

Common ways to assess and diagnose cognitive disorders:

  • Interview the person with PD.
  • Ask family members or care partners about their observations.
  • Administer cognitive screening tests such as the Mini-Mental State Examination or Montreal Cognitive Assessment . The neurologist will ask questions that evaluate the persons understanding of where and who they are, the date and year, attention, memory, language and problem-solving skills.
  • A neurologist may suggest seeing a clinical neuropsychologist for a more detailed assessment.
  • Neuropsychological assessment can be an important diagnostic tool for differentiating PD from other illnesses such as Alzheimer’s disease, stroke or dementia.

Pharmacological Treatment Of Parkinsons Disease

Speech Therapy for Parkinsons Disease

Pharmacological treatment of PD is based on the replacement of dopamine levels in the brain, which generally promotes the temporary improvement of physical disability and control of some of the symptoms. The medication considered gold standard in the treatment of PD motor symptoms is Levodopa , a metabolic precursor of dopamine that crosses the blood-brain barrier easily. Once in the Central Nervous System, L-Dopa is metabolized basally by DOPA decarboxylase, leading to dopamine. L-Dopa is marketed in association with a decarboxylase inhibitor drug , preventing the peripheral synthesis of dopamine and ensuring the drugs arrival in the brain . Other drugs are available, in most cases in association with L-dopa, and are divided according to the mechanism of action in order to increase the concentration of dopamine levels such as Monoamine Oxidase-B , Catechol-O-Methyl Transferase inhibitors, or dopaminergic agonists such as Pramipexole . However, pharmacological treatment for PD has limitations ranging from possible drug interactions and side effects , to decrease in its efficacy with years of use and the appearance of secondary symptoms such as dyskinesias and fluctuations , due to the lack of effectiveness of the treatment of non-motor symptoms of the disease . The choice of drug or association that will be administered to the patient depends on factors such as age, stage of the disease, type of activity performed by the patient, and their mental state.

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Study Screening And Data Extraction

Two authors performed the search independently and excluded irrelevant articles according to the criteria above, and then accessed full-text articles where available. Both the authors evaluated the eligible articles, respectively, and gathered relevant information into a pre-designed data form. The form included author, year published, country of origin, study design, comorbidities, non-motor symptoms, mean age of patients, sample size and intervention for the two groups, measurement scales used, study duration and time to follow-up. Another data form was used for the outcome data gleaned from all of the scales used in the selected studies. We inverted the scales of the Parkinsons Disease Questionnaire , which measures QOL, to achieve consistency in the analysis so that high scores designated an improvement. Discrepancies were resolved by consensus discussion. When study details were incongruously documented between the two evaluating authors, a third author re-evaluated the study in question.

Language Dysfunction In Parkinsons

There are several functions within language, including naming objects, generating words, comprehension, and verbal concepts. PD most often affects a persons ability to find a word, although as PD progresses, additional language difficulties may develop, including difficulty naming, difficulty comprehending information, and the use of more simplified and less spontaneous speech.3,4

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Exercise Is Both Treatment And Prevention

There is growing evidence that exercise, particularly vigorous exercise, may provide neuroprotective effects that can improve motor function, cognition, and quality of life in patients with PD. Exercise is now considered a treatment of PD with multiple benefits and few adverse effects.3,4

Animal and prospective cohort studies provide evidence that vigorous exercise may exert neuroprotective effects and decrease the risk of developing PD. There have been several cohort studies suggesting that regular exercise during the midlife period reduces the risk for PD years later. Meta-analysis of prospective studies affirms the diminished risk of developing PD following moderate to vigorous physical activities in preceding years.5-7 An analysis of 2 prospective cohort studies that included 48,574 men and 77,254 women showed a 60% reduced risk of PD in men who performed at least 10 months of strenuous exercise per year compared to those who regularly exercised less than 2 months per year.5 Similarly, the results of the prospective Cancer Prevention Study II Nutrition Cohort, which followed over 140,000 participants from 1992 and 2001, showed that those who underwent moderate to vigorous activity had 40% lower risk of PD than those who did not.6

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Move Well With These Exercises For Early

Parkinson’s Disease Thinking Changes: Engaging Occupational Therapy

Parkinsons disease can lead to a wide range of symptoms, but some people with the condition are so early in the PD journey that they dont have strong symptoms in any one specific area. Understanding and developing strong habits early can help a person move well with Parkinsons.

MyParkinsonsTeam has partnered with PD Warrior an organization that specializes in providing rehabilitative exercise programs to people with Parkinsons disease to help spark your exercise journey.

During previous weeks in this six-part series, you learned how to warm up, tackle tremor, overcome bradykinesia , and boost agility. This weeks videos cover the steps required to perform low-impact, neuroprotective exercises that are helpful for anyone with PD, particularly those early on in the diagnosis journey. Theyll also boost your heart rate.

Consider the following guidance before you work through the video:

  • If you arent accustomed to exercising, check with your physician first.
  • If your doctor gives you clearance, it is suggested that you warm up prior to exercising and stretch after you complete your session.
  • Try to engage in exercise three times per week.
  • Feeling some muscle soreness following exercise is normal.
  • Warming up, stretching, and staying hydrated can help combat muscle soreness.

Below are the written steps of the video exercises. You can write them down or print them for reference:

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Assessment Of Quality Of Literature

Two independent authors used the Cochrane Collaboration risk-of-bias assessment tool to detect the bias in the included papers, including random sequence generation, allocation concealment, blinding of participants and personal, blinding of outcome assessment, incomplete outcome data, selective reporting and other bias falling under the seven domains .

Q: What Is Cognitive Rehabilitation What Problems Does It Address

A: Cognitive rehabilitation refers to interventions that aim to improve or maintain a persons participation in daily life activities and roles by improving cognitive function. There are different approaches to cognitive rehab:

  • Restorativetraining : aims to improve or strengthen specific cognitive skills like attention or memory through repetitive practice of tasks that challenge those skills. An example of this approach is computerized brain training games.
  • Strategy-basedapproaches : address everyday function more directly by training the use of strategies to work through or around cognitive challenges and accomplish daily activities. Such strategies can range from external devices like memory notebooks and medication alarms, to internal strategies like self-cueing and pacing, to more general planning, time management or organizational strategies for navigating daily activities and routines.

In addition to my clinical interests, my research focuses on these types of strategies and their efficacy in PD. There is variation within and overlap among different approaches to cognitive rehab, and clinicians may employ multiple approaches depending on the persons cognitive and functional strengths, limitations, and goals.

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Cognitive Behavioral Therapy For Anxiety Disorders In Parkinson’s Disease

Study Rationale:Anxiety disorders occur in up to 35 percent of people with Parkinson’s disease and can have a negative impact on gait, involuntary movements, motor fluctuations and quality of life. With this study we intend to develop a treatment module for anxiety in patients with Parkinson’s disease based on cognitive behavioral therapy methods and assess its efficacy in reducing anxiety symptoms. We also want to study what biological changes occur in the brain during this treatment.

Hypothesis:We hypothesize that after therapy, patients will be better able to manage their anxiety symptoms, and as a result will experience less anxiety symptoms. We also expect that treatment will restore the reduced connections between frontal brain areas and the deeper brain structures involved in the regulation of anxiety.

Study Design:This study is a clinical trial in which 60 patients will be randomized to cognitive behavioral therapy or usual care. Treatment will consist of eight to 10 weekly sessions and will involve the partner or caregiver. Those patients randomized to usual care will be offered the module at the end of the study follow-up period . At the beginning and end of the study, we will conduct MRI scans to assess the connections between frontal brain areas and certain deeper brain structures.

Cognitive Behavioral Group Therapy Reduces Stress And Improves The Quality Of Life In Patients With Parkinsons Disease

Parkinsonâs
  • 1Department of Neurology, University Hospital of Basel, Basel, Switzerland
  • 2Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
  • 3Department of Psychiatry, University Hospital of Basel, Basel, Switzerland
  • 4Department of Psychology, University of Basel, Basel, Switzerland

Objective: The aim of this study is to compare a cognitive behavioral group therapy with a health enhancement program for stress reduction and the impact on quality of life in patients with Parkinsons disease .

Method: Thirty patients with PD participated in the study: 16 received CBT including stress-reducing elements and 14 took part in a HEP. The two groups did not differ significantly in their baseline demographic characteristics. The patients in both groups underwent weekly sessions of 2 h duration for 9 weeks. The Parkinsons Disease Questionnaire with 39 items , the Burden Questionnaire for Parkinsons Disease and the Disease-Related Questionnaire were used for assessment. Ratings were completed at baseline and after 9 weeks .

Results: The patients in the CBT group achieved significantly better BELA, FKK and PDQ-39 scores . Subscale analysis revealed that the scores on the BELA subscales emotional well-being and somatic motor function contributed significantly to stress reduction . The FKK revealed significant improvement in social skills in the CBT group .

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Table : Behavioral Activation Example

Howard was a volunteer firefighter for more than 40 years. He stopped responding to calls when he felt he was no longer physically able to do so due to the worsening of his Parkinsons symptoms. At this point, he became quite depressed and no longer went down to the firehouse to spend time with friends. He also stopped participating in all firehouse- related activities, including those that required no physical exertion, like the monthly chili dinner.

Part of Howards treatment included reconnecting with the local fire department. He began to bring coffee down to the station and visit his friends one evening per week. He slowly began to explore ways he could remain connected to this organization that was near and dear to his heart. Four months later, he reported that he was spearheading all fundraising efforts for the fire department and his mood greatly improved. Even though Howard was no longer in the physical condition needed to fight fires, he found an alternative way to make a meaningful contribution to the cause.

Table : Behavioral Experiment

This technique involves engaging in a specific behavior designed to test out a negative prediction and evaluate the outcome.

  • Negative Thought or Prediction: It will be impossible to have dinner in a restaurant because of my tremor
  • Experiment: I will go out to dinner with my partner on Saturday
  • Outcome: I was able to eat dinner at our favorite restaurant. I ordered food that did not need to be cut and requested a straw and lid for my drink. I enjoyed getting out of the house and had a fun evening

Experiment results suggest that the negative prediction was not accurate.

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How Does Exercise Change The Brain

Exercise affects how efficiently dopamine is used in the brain it does not produce more of the hormone dopamine. According to the Parkinsons Foundation, exercise improves this efficiency by modifying the areas of the brain where dopamine signals are received.

When dopamine travels through the brain, it connects to two brain cells through a space called the synapse. For one cell to close off the signal of dopamine to send it to the next cell, a protein complex known as the dopamine transporter has to pick it up. Studies have shown that people who exercise more have less of the dopamine transporter, allowing the dopamine to stay in the synapse longer and send a longer signal.

Dr. Joseph Jankovic, neurologist at Baylor St. Lukes Medical Center, has been a principal investigator in over 100 clinical trials for treatments of Parkinsons disease. He is also the founder and director of the Parkinsons Disease Center and Movement Disorders Clinic, which has been recognized as a Center of Excellence by the National Parkinsons Foundation.

People who exercise also have increased connectivity within the brain, and they have less age-related degeneration of the brain. All of these factors support a notion that the brain benefits from long-term exercise, and this has been specifically shown in patients with Parkinsons disease.

Pilot Studies And Case Series

Parkinsons Disease Thinking Changes: Engaging Physical Therapy

Dreisig et al. reported a pilot study to explore the effects of CBT in 9 patients with PD compared to 70 matched control subjects who received treatment as usual. The 3-month CBT program included self-help and individual sessions. After this period, based on the Psychological Profile Questionnaire , the group receiving CBT showed significantly more improvement compared to the control group. However, this study was not aimed specifically at depression in PD. Overall, the percentage of moderate or major depression amongst PD patients was low , and no PD patients in the CBT group had major depression. Methodological problems also include lack of randomisation, small sample size, and choice of instrument . The study was also limited to young PD patients, which were self-referred, which could have led to selection bias. It is also important to note that the content of CBT was not described in detail making evaluation difficult. Nevertheless, the study by Dreisig et al. provided data in a small series of patients in a naturalistic setting with some control data and suggests that CBT might be effective for patients with PD.

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1Institute of Psichiatry, Federal University of Rio de Janeiro , Rio de Janeiro, Brazil

2Castelo Branco University, Rio de Janeiro, Brazil

1Institute of Psichiatry, Federal University of Rio de Janeiro , Rio de Janeiro, Brazil

3Physical Activity Neuroscience, Physical Activity Sciences Postgraduate Program Salgado de Oliveira University, Niterói, Brazil

4Physical Education Department, Faculty of Unidas de Campinas , Goiânia, GO, Brazil

5Politechnique Institute of Porto, Healthy School, Porto, Portugal

8Intercontinental Neuroscience Research Group, Yucatán, Mexico

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