Parkinson’s Disease And Panic Attacks

Anxiety As An Early Warning Sign

It may be that anxiety disorders that are diagnosed as much as two decades before Parkinsons disease may be a harbinger of the disease, says Gregory Pontone, M.D., director of the Johns Hopkins Movement Disorders Psychiatry Clinic. Parkinsons disease, like Alzheimers disease, has what experts call a long approach, he says, and anxiety may be part of that long approach.

One theory is that the anxiety that comes before Parkinsons results from the same underlying changes in brain chemistry and circuitry. Others believe that Parkinsons disease and anxiety share a common genetic risk factor. Either way, taking a closer look at the link can help doctors understand the causes of Parkinsons and treat patients with the disease.

Dealing With Panic Attacks While Dealing With Parkinsons Disease

Twice in the last month I have experienced what I am calling a panic attack. Ive never experienced something such as I did when it happened. I had shortness of breath, my heart was beating much faster than normal. I figured since the only activity I was involved in at the time was trying to go to sleep and not being able to, it concerned me. It scared me enough that I told my husband about it the following day.

I consulted Dr. Google and heres what I found:

A study showed that panic attacks in Parkinsons disease could possibly be a long-term complication of levodopa therapy. Key word here is possibly. I skipped that one and continued my search. Possibly isnt definitive enough for me.

So, Dr. Google led me to the Parkinsons Foundation, which stated, Anxiety is a common non-motor symptom of PD. It is important to note that anxiety is not simply a reaction to the diagnosis of Parkinsons, but is instead a part of the disease itself, caused by changes in the brain chemistry of the brain.

They went on to say that, Anxiety attacks usually start suddenly with a sense of severe physical and emotional distress. Individuals may feel as if they cannot breathe or are having a heart attack. They may feel they are experiencing a medical emergency. These episodes usually last a few minutes to an hour, particularly when associated with off periods, though they can last for longer periods of time.

What The New Research Suggests

Spanish researchers looked at a small group of Parkinsons patients who werent on medications for the disease and found that 42% had experienced mild hallucinations. They either saw a person or animal out of the corner of their eye, or someone near or next to them. About a third of participants reported that these hallucinations had occurred months, or even years, before they were diagnosed. Another study from Finland found that people with Parkinsons were given antipsychotics at a higher rate than those without PDand some had started antipsychotics up to four years before their diagnosis.

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Moving With Mood Changes In Aging And Parkinsons: A Look At Depression And Anxiety

In this one-hour webinar a panel of physicians and people with PD that include a psychiatrist, neurologist, and a music producer discuss how and why mood changes, such as depression and anxiety, happen in Parkinsons, how you and your loved ones can talk about these symptoms with each other and with your providers, and what treatment options are available.

Webinar Notes on the Stanford PD Community Blog

Parkinsons Disease And Anxiety: Why Does Anxiety Happen

People with Parkinson’s disease experience a number of different symptoms. As well as tremor, rigidity and slow movement, many PD patients feel depressed or anxious and struggle with the emotional impact of their illness.

Around 31% of people with Parkinsons disease will experience significant symptoms of anxiety. Those with early-onset Parkinsons are thought to have a higher risk of developing anxiety than older patients. Its unclear whether this occurs due to chemical changes in the brain, Parkinson’s medication side-effects or a combination of social, environmental and genetic factors, though scientists are devoting more research to this area.

According to Richard Brown, Professor of Neuropsychology and Clinical Neuroscience at Kings College London:

Anxiety, like all behavior and emotion, is ultimately controlled by our brain. Anxiety is related to a complex set of brain areas and chemicals, many of which are affected in Parkinsons.

There is no cure-all treatment for anxiety stemming from Parkinson’s disease because the cause of anxiety in PD is difficult to determine. If you experience anxiety with Parkinson’s disease, your doctor will suggest appropriate treatment that takes all of your PD symptoms into account.

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Anxiety And Laterality Of Parkinson’s Disease

A number of studies have examined the relationship between anxiety and laterality of parkinsonian symptoms. These studies have shown that anxiety in patients with Parkinson’s disease was associated with mainly left sided symptoms. If anxiety in patients with Parkinson’s disease was a psychological response to disability, then patients with right sided parkinsonism would be expected to be more anxious: in fact the opposite is the case.

Anxiety And Parkinsons Research

What does this finding mean for the future of diagnosis or treatment of Parkinsons? Ongoing research is compelling, says Pontone. Part of what we are doing is looking at anxiety disorders that occur long before the onset of Parkinsons to see if there are characteristics that may differentiate that anxiety or predict an increased risk of Parkinsons disease.

Meanwhile, because theres an established link between anxiety and Parkinsons disease, patients and their families should be upfront with their doctors about anxiety symptoms. Behavioral therapy and medications for example, anti-anxiety meds or antidepressants can effectively treat anxiety disorders. Theres no need for anyone to suffer in silence.

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Parkinsons Isnt The Only Disease With Psychosis

While it may be true that some people with psychosis go on to develop Parkinsons, its important to note how they are equally likely to develop other neurological disorders. Lewy body dementia has similar motor symptoms to PD with one key difference, says Elana Clar, M.D., a movement disorders neurologist at New Jersey Brain and Spine in Oradell, NJ. With typical Parkinsons, we don’t expect cognitive issues to become profound until a decade-plus later. In Lewy body dementia, cognitive symptoms are there from the outset and can include hallucinations, delusions, depression, and apathy. So, psychosis may foreshadow many conditions, not only PD.

How Stress And Anxiety Are Related To Parkinsons And What You Can Do About It

People with Parkinsons disease often notice that their symptoms are worse when they are under stress. Stress, or emotional strain due to difficult circumstances, is an inevitable part of life for everyone, and can be caused for example, by tension with family or employers. Stress is therefore a response to an external situation.

In addition to life stress, people with PD may experience anxiety as part and parcel of their PD itself, caused by chemical imbalances in the brain. Anxiety is a very common non-motor feature of PD and is often accompanied by depression. Anxiety can also fluctuate throughout the day along with dopamine levels, with anxiety experienced most acutely during OFF periods.

Anxiety is fueled by internal forces and can persist when all external causes of stress have been resolved. It is often difficult for a person with PD to separate out stress and anxiety because practically, they may manifest in indistinguishable ways. Both can cause excessive worry, poor sleep, and inattention, as well as physical symptoms such as rapid heart rate, trouble breathing, sweating and headaches. In a past blog, I explored the perspectives of people with PD as it relates to their mental health.

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Anxiety And Depression In Parkinsons And How To Manage Them

Approximately 50-60% of people living with Parkinsons experience varying levels of depression and anxiety. Learn about the differences between depression and anxiety and how they are related different types of depression and anxiety causes of depression and anxiety in people living with PD when and how to treat depression and/or anxiety the latest in treatments, including non-pharmacological interventions. The speaker is Gregory Pontone, MD, director, Johns Hopkins Parkinson’s Disease Neuropsychiatry Clinic.

Managing Anxiety And Depression In Parkinsons Disease

A combination of medication and other therapies can help ease non-motor symptoms affecting those with Parkinsons disease.

Most people think of Parkinsons disease as marked only by tremors, muscular rigidity and slow, imprecise movements, but Parkinsons is more than a movement disorder.

Most people with Parkinsons also have quite a few non-motor symptoms, such as anxiety, depression and psychosis. Many of these symptoms may have started before the Parkinsons disease became obvious.

The effects are widespread. Several years ago, a large clinical study of more than 1,000 people with Parkinsons disease of various durations demonstrated that only 1.4 percent of the participants did not report any non-motor symptoms.In other words, 98.6 percent of the study participants had some form of NMS. Psychiatric symptoms accounted for 60 percent, while visual hallucinations that could have signified psychosis were present in about 35 percent of patients.

Thats why taking action is important. If you or a loved one has had a new diagnosis of Parkinsons disease, we recommend an immediate evaluation for depression, mood and cognitive problems. Frequent monitoring should also be done throughout the course of the disease.

Here are some of the common symptoms and treatment methods for Parkinsons patients with depression and dementia:

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The Relationship Between Stress Anxiety And Parkinsons Disease

This blog post explains that stress and anxiety can be difficult to discern from one another because they manifest in indistinguishable ways. PD symptoms worsen and can become less responsive to medication during periods of stress. Adding medications to control anxiety can be helpful, but lifestyle modifications including exercise, meditation, psychotherapy and other complementary therapies should be considered.

Sleep Disorders Are Another Possible Pd Clue

One is called REM sleep behavior disorder . In normal REM sleep, your body is relaxed and your muscles dont move. With this disorder, a switch gets turned off, and people move in relation to their dream content. We call it dream enactment, explains Mya Schiess, M.D., a professor of neurology at McGovern Medical School at the University of Texas Health Science Center in Houston. You might kick your partner, or thrash around so much you fall out of bed, she says. RBD probably has the highest risk factor for the development of Parkinsons, Dr. Schiess adds, as well as Lewy Body dementia.

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Help For Depression And Anxiety

Depression is a serious matter for anyone. For people with Parkinson’s, it can affect critical elements of disease management such as staying socially connected, exercising and proactively seeking needed care.

It is not always easy to recognize depression in oneself. Be on the lookout for a lack of interest in activities and situations that once brought you joy. Pay attention to observations made by family and friends, and talk to your doctor if you’re not feeling like yourself. Sometimes, your physicians may not even ask you about these conditions if you don’t mention changes in mood or outlook.

Depression and anxiety can be treated with medications, lifestyle changes , and therapy or counseling with a qualified practitioner. Support groups also may be a source of help.

NOTE: If you are in crisis, call the National Suicide Prevention Lifeline at or visit www.suicidepreventionlifeline.org.

What The Research Says

Researchers believe that depression and anxiety in Parkinson’s are due to changes in brain chemistry that are caused by the disease itself. The same pathways that create dopamine in the brain which are impacted in PD also create the brain chemical serotonin, which regulates mood, appetite and sleep. Scientists think that the effect of Parkinson’s on serotonin, as well as other brain chemicals that support mood, is responsible for symptoms of depression and anxiety.

The Michael J. Fox Foundation actively pursues research that can shed light on the connection between mood changes and Parkinson’s and lead to treatment breakthroughs for people living with the disease. The MJFF-funded Study of Antidepressants in Parkinson’s Disease found that certain antidepressants eased depression in people with Parkinson’s without worsening movement symptoms. Still, more work remains to find more and better treatments for depression and anxiety. Researchers are looking at several different therapies: medications such as buspirone for anxiety, as well as cognitive behavioral therapy and non-invasive brain stimulation for both depression and anxiety. Join recruiting studies in your area through MJFF’s online tool Fox Trial Finder.

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What Treatment Is Available

There are many things you can do that may help to reduce feelings of anxiety. Learning how to relax, recognising triggers that make you anxious and regular exercise can all help to control anxiety. Reducing your intake of alcohol and caffeine , particularly late in the evening, may also help, as these can intensify anxiety symptoms.

Antipsychotics Can Trigger Pd

When you have Parkinsons, your brain doesnt make enough dopamine, says Dr. Clar. Thats the feel-good chemical that’s also responsible for sending signals from your brain to the muscles in your body that control movement. Antipsychotic meds block dopamine receptors in the brain. So, even though your brain might still be producing dopamine, it cant send signals the right way, thanks to those drugs. The result is that a person can have the physical symptoms of Parkinsons but not actually have Parkinson’s, says Dr. Clar. Some of that confusion could have muddied the results of the study, too.

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Other Conditions Can Mimic Parkinsons

There are many types of Parkinsonian disorders, says Elana Clar, M.D., a movement disorders neurologist at New Jersey Brain and Spine in Oradell, NJ. Experts refer to Parkinsons disease as a brain disorder that progresses slowly with symptoms that include stiffness and tremors and, later, non-motor issues like depression and yes, hallucinations. Parkinsonism includes a range of conditions that look like Parkinsons but arent treatable with standard PD meds. They have additional symptoms, including falls and dementia. The problem? Those conditions sometimes mimic PD, with no single test to make a foolproof diagnosis.

Anxiety And Antiparkinsonian Medications

There is no consensus on whether antiparkinsonian medications are responsible for symptoms of anxiety in Parkinson’s disease.

Stein et al found that the levodopa dose was similar in anxious and non-anxious patients. Hendersonet al noted that 44% of patients with Parkinson’s disease noticed anxiety symptoms before starting levodopa. Menza et al found that the levodopa dose did not significantly correlate with anxiety levels: they suggested that anxiety in patients with Parkinson’s disease is unlikely to be a side effect of levodopa treatment. In contrast, Vasquez et al found that panic attacks were related to levodopa therapy but not to other agonist drugs.

Lang reported anxiety in five of 26 patients when pergolide was added to their treatment regimen. Menza et al found no differences in measures of anxiety in patients receiving or not receiving pergolide. Menzaet al found no differences in measures of anxiety in patients receiving or not receiving selegeline.

The temporal relationship between panic attacks and off periods have led some authors to suggest that panic attacks may be related to falling brain levodopa levels. Anxiety fluctuations may be an important component of levodopa induced fluctuations. In a double blind placebo controlled trial, Maricle et al found that anxiety levels fell and motor performance improved during a levodopa infusion.

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Other Complementary Therapies For Anxiety In Pd

Complementary therapies are a growing group of treatments which may improve the symptoms of PD without medication. I have written past blogs on two complementary therapy approaches for several symptoms of PD art therapy and music therapy.

Various complementary therapy modalities have been developed that may lower stress and anxiety in PD. These include yoga, massage, the Alexander technique, neurofeedback and others. Some of these therapies have been studied in small trials with data suggesting that they may be helpful for the anxiety of PD. Others have not yet been studied, although anecdotally, people with PD may feel that they are very useful in combatting anxiety. In general, this group of therapies may be effective for the anxiety of PD but needs to be studied more rigorously.

Types Of Anxiety Disorders Found In Parkinson’s Disease

Generalised anxiety disorder, panic disorder, social phobia, phobic disorder, agoraphobia, obsessive-compulsive disorder, and anxiety disorder not otherwise specified have all been identified in patients with Parkinson’s disease . The diagnoses in the patients with Parkinson’s disease appear to be clustered in the panic disorder, phobic disorder, and generalised anxiety disorder areas.

Box 1: Anxiety disorders found in Parkinson’s disease

• Generalised anxiety disorder

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The Finnish Study Raises More Questions

The Finnish study reviewed the number of new prescriptions for antipsychotics for people with PD over two decades10 years before their official Parkinsons diagnosis. Still, antipsychotics taken before PD diagnosis dont necessarily mean these folks were hallucinating or having paranoid thoughts before PDs physical symptoms appeared, says Daniel Weintraub, M.D., professor of psychiatry at the University of Pennsylvanias Perelman School of Medicine in Philadelphia. People can end up on antipsychotics for other reasonsthey can them because they’re depressed or because of trouble sleeping, he explains.

Anxiety In Parkinsons 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 childrens 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.

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

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