Anxiety

Key Facts

  • Most common presentation of anxiety in PD includes general anxiety, anxiety attacks, obsessive-compulsive disorder, and social avoidance.
  • Anxiety can be related to non-motor fluctuations.
  • Management of anxiety may include the use of selective serotonin reuptake inhibitors (SSRIs) or benzodiazepines.

 Clinical Best Practices

  • Determine prior to treatment whether the anxiety is related to non-motor fluctuations.
  • If using SSRI, start with a low dose.

Anxiety is less well studied, yet may be as common as depression in PD. About 40% of PD patients experience anxiety including panic attacks particularly in the "off" state.

Common Causes

  • Fear of being unable to function
  • Embarrassment, often related to having people notice symptoms
  • “Off” state anxiety possibly associated with undermedication
  • Norepinephrine, GABA, serotonin, and glutamate dysfunction
  • May also present itself as social phobia, although this should be distinguished from embarrassment regarding public display of symptoms

Barriers to Diagnosis

  • It can be difficult to determine whether long-term anxiety is related to non-motor fluctuations (ie, “off” state). If not related, assess severity and treat accordingly.
  • Many PD patients experience levels of anxiety that require a psychiatrist, and referral is recommended.

Treatment Options

  • Adjust Parkinson’s medications to reduce “off” times in patients
  • Improve sleep quality
  • Increase physical activity
  • Prescribe SSRIs or benzodiazepines
  • Refer to a psychiatrist or neuropsychiatrist

Important Caveats to Therapy

  • Use benzodiazepines carefully in patients with co-morbid dementia, or in older PD patients
  • Benzodiazepines should be tapered when stopped
  • Anti-anxiety effects are not sudden with antidepressants, sometimes taking weeks for full effect
  • If you are going to use a SSRI start with a dose lower than the normal starting dose to avoid worsening of anxiety
References: 

Aarsland D, Marsh L, Schrag A. Neuropsychiatric symptoms in Parkinson’s disease. Mov Disord. 2009;24(15):2175-2186.