Depression and Anxiety in Parkinson s Disease. Bill Collins Symposium for Parkinson s Disease 2018 Robert Underwood, Ph.D. Licensed Psychologist

Transcription

1 Depression and Anxiety in Parkinson s Disease Bill Collins Symposium for Parkinson s Disease 2018 Robert Underwood, Ph.D. Licensed Psychologist

2 Today s Discussion Review of Parkinson s Disease and Nonmotor Symptoms Why are Anxiety and Depression Important in PD? Symptoms of Depression and Anxiety Causes of Depression and Anxiety in PD Treatment for Depression and Anxiety

3 Parkinson s Disease 1 ½ million individuals with PD in U.S. Second most common NGD behind AD Average age of onset 60 Men to women ratio 2:1 Age is biggest risk factor 1% over age 60 and 4% over age 80 with PD Genetic form only 5-10% of cases

4 Traditionally, we think about PD as a movement or motor disorder.

5 Wait!!! That is not the whole picture. Parkinson s disease is more than just a motor disorder.

6 PD Non-Motor Symptoms Sleep Disturbance Autonomic Dysfunction Bladder Dysfunction (i.e., incontinence, urgency, nocturia) Sexual Dysfunction Orthostatic Hypotension Fatigue Gastro-Intestinal Dysfunction Constipation Sensory Dysfunction Pain Anosmia Cognitive Dysfunction Psychological Symptoms

7 PD is a Neuropsychiatric Disorder Combination of motor and non-motor symptoms Dopamine system impacts: Motor functions Emotions Motivation and Impulse regulation Serotonin and NE affected

8 Psychological Conditions Associated Depression with Parkinson s Disease Anxiety Psychosis Apathy Impulse Control Disorders/Disinhibition

9 Why are Depression and Anxiety Important in PD? NPF Parkinson s Outcomes Project: Depression and anxiety are the number one factors impacting the overall health of people with Parkinson s. Depression is a main predictor of increased disability and poor quality of life in PD, even more than physical symptoms! (Martinez et al 2011; NPF Parkinson s Outcome Project; Global Parkinson's Disease Survey Steering Committee, Mov. Dis. 2002)

10 Why are Depression and Anxiety Important in PD? Depression and anxiety may be associated with a more rapid decline in cognitive and motor symptoms. (Uekermann, 2003; Starkstein,1992) Untreated depression makes PD motor symptoms worse. Effects on caregiver stress can be significant and lead to diminished life satisfaction, increased caregiver depression, and earlier nursing home placement.

11 Why are Depression and Anxiety Important in PD? Symptoms are easily overlooked or misdiagnosed since many symptoms are overlapping people are more concerned with motor symptoms. Only 20% of depressed PD patients received treatment for depression! (Mayeux, 1986; Huber, 1988, Starkstein, 1990) They Are Very Common!! Occur in up to 50% or more of individuals with PD

12 Clinical Depression About 40% - 50% occurrence of depression in PD 5-20% Major Depression 10-30% milder depression General population: 6% Clinical depression vs. normal sadness Diagnostic continuum Early, pre-motor sign of PD? Many symptoms of clinical depression are also symptoms of PD itself!!!

13 Depression Symptoms Affective Symptoms Depressed mood most of the day or Anhedonia (not enjoying life/activities) Hopelessness Helplessness Worthlessness Loneliness/Emptiness Apathy/Motivation Isolation/Withdrawal* Cognitive Symptoms Decreased concentration* Slowed thinking (bradyphrenia)* Suicidality Indecision Forgetfulness* Pessimistic thinking *Overlapping symptom with PD itself

14 Depression (cont.) Physical Symptoms Fatigue (mental and physical)* Loss of Energy* Sleep Disturbance* Appetite changes Restlessness Sexual Dysfunction*

15 PD with Depression: Does it look Different? More: chronic Less: guilt brooding less self-blame pessimism and negativity suicide co-existing anxiety (Bonnett, et al. 2012; Cummings, 1992)

16 Anxiety in PD Can exist separately or co-occur with Dep. Wide range of prevalence rates in literature for anxiety in PD: 13-65% Probably around 30-40% General population (of any AD) = 8.3% Recent study 31% prevalence in PD (Broen, 2016) Generalized Anxiety 14% Social Phobia 13.8% Specific Phobia 13% Panic Disorder 6.8% Comorbid anxieties 31%

17 Generalized Anxiety Disorder Excessive anxiety, worry and tension Worry is difficult to control Symptoms must be present for six months Anxiety is associated with three (or more) of the following six symptoms: Restlessness* Feeling on edge/uneasiness Being easily fatigued* Difficulty concentrating Irritability Muscle tension* Sleep disturbance* Can t relax Overlapping symptoms with PD itself*

18 Social Anxiety Disorder Anxious/Self-conscious in everyday social situations Intense fear of being watched, judged, criticized or doing something embarrassing Physical symptoms of profuse sweating, blushing, trembling, nausea may accompany to the point of panic attack Social situations are avoided or else endured with an extreme amount of anxiety Ruminate for hours or days about how they were perceived or judged Six months of symptoms necessary

19 Panic Attacks Begin suddenly, often out of blue Usually peak in a few minutes Can occur in context of different mental conditions Rapid heart rate Sweating Flushed face/hot flashes Shaking* Nausea/abdominal cramping Dizziness/lightheadedness Chest pain Headache Fear of losing control Fear of dying/doom Fear of heart attack Shortness of breath Choking Numbness/tingling Panic Disorder: recurrent, unexpected panic attacks spend long periods in constant fear of another attack

20 Anxiety Disorder, NOS Motor Fluctuation-Associated Anxiety Up to 30% prevalence (Pontone, 2009) Episodic anxiety related to motor fluctuations in the form of wearing-off panic attack or situational anxiety with phobic avoidance related to a fear of experiencing off" periods or freezing. Fear of falling Anticipatory anxiety Or does excessive anxiety cause more motor fluctuations? Not a DSM-IV diagnosis. Not Otherwise Specified - full criteria for one of the other anxiety disorders is not met.

21 Causes of Depression and Anxiety in PD Complex interaction of neurobiological and psychological factors remember Neuropsychiatric Disorder 1. BIOLOGICAL Degeneration of NT: Dopamine, Serotonin, NE, GABA Raphe nuclei and Locus coeruleus (serotonergic and noradrenergic) Degeneration of meso-cortico-limbic dopamine projections, especially meso-limbic pathway, to ventral striatum, anterior cingulate cortex (motivation), orbitofrontal cortex, and thalamus Striatal-thalamic-prefrontal and limbic circuits Caudate and inferior frontal and pre-frontal lobe have metabolic abnormalities in depression Depression and Anxiety are part of Parkinson s disease itself

22 Causes of Depression and Anxiety in PD Complex interaction of neurobiological and psychological factors remember Neuropsychiatric Disorder 2. PSYCHOLOGICAL Reactive stress of coping with a chronic, progressive disease Implications of diagnosis/chronic symptoms on job, Q of L, family, perceived or actual loss Embarrassment/fear of judgement = isolation/withdrawal Worries about future Genetically Predisposed? = Perfect Storm 3. PSYCHOSOCIAL VARIABLES

23 Treatment of Depression and Anxiety SSRI studies show usually first choice of meds for depression in PD SNRI (Effexor, Wellbutrin) Tricyclic antidepressants (amitriptyline) Impact all three NT (ST, NE, DA) Close collaboration with psychiatry Psychotherapy CBT Exercise mood effect, favorably impacts the PD disease process Support Groups / Support System Remain socially engaged Education and Coping Style

24 Closing Thoughts! Psychological symptoms in PD are VERY common! Psychological symptoms are part of the disease itself. If left untreated, they can make motor symptoms and quality of life worse. Psychological symptoms can result in significant caregiver burden. Don t hesitate to discuss with your movement disorder neurologist. Consider support groups or psychotherapy. Exercise!!!!!

25 Don t Forget the Caregiver!

26 Support Resources Bill Collins Parkinson s Support Center University of Louisville Physicians Movement Disorder Clinic American Psychological Association National Parkinson Foundation Parkinson s Disease Foundation Michael J Fox Foundation Kentucky Psychological Association