Defining Atypical Anxiety in Parkinson's Disease

Basal ganglia theta power indexes trait anxiety in people with Parkinson's disease

Background

Neuropsychiatric symptoms are common and disabling in Parkinson's disease (PD), with troublesome anxiety occurring in one-third of patients. Management of anxiety in PD is challenging, hampered by insufficient insight into underlying mechanisms, lack of objective anxiety measurements, and largely ineffective treatments.In this study, we assessed the intracranial neurophysiological correlates of anxiety in PD patients treated with deep brain stimulation (DBS) in the laboratory and at home. We hypothesized that low-frequency (theta-alpha) activity would be associated with anxiety.

Methods

We recorded local field potentials (LFP) from the subthalamic nucleus (STN) or the globus pallidus pars interna (GPi) DBS implants in three PD cohorts: 1) patients with recordings (STN) performed in hospital at rest via perioperatively externalized leads, without active stimulation, both ON or OFF dopaminergic medication; 2) patients with recordings (STN or GPi) performed at home while resting, via a chronically implanted commercially available sensing-enabled neurostimulator (Medtronic Percept™ device), ON dopaminergic medication, with stimulation both ON or OFF; 3) patients with recordings performed at home while engaging in a behavioral task via STN and GPi leads and electrocorticography paddles (ECoG) over premotor cortex connected to an investigational sensing-enabled neurostimulator, ON dopaminergic medication, with stimulation both ON or OFF.Trait anxiety was measured with validated clinical scales in all participants, and state anxiety was measured with momentary assessment scales at multiple time points in the two at-home cohorts. Power in theta (4-8 Hz) and alpha (8-12 Hz) ranges were extracted from the LFP recordings, and their relation with anxiety ratings was assessed using linear mixed-effects models.

Results

In total, 33 PD patients (59 hemispheres) were included. Across three independent cohorts, with stimulation OFF, basal ganglia theta power was positively related to trait anxiety (all p<0.05). Also in a naturalistic setting, with individuals at home at rest with stimulation and medication ON, basal ganglia theta power was positively related to trait anxiety (p<0.05). This relationship held regardless of the hemisphere and DBS target. There was no correlation between trait anxiety and premotor cortical theta-alpha power. There was no within-patient association between basal ganglia theta-alpha power and state anxiety.

Conclusion

We showed that basal ganglia theta activity indexes trait anxiety in PD. Our data suggest that theta could be a possible physiomarker of neuropsychiatric symptoms and specifically of anxiety in PD, potentially suitable for guiding advanced DBS treatment tailored to the individual patient's needs, including non-motor symptoms.

A Systematic Review of Psychotherapy Approaches for Anxiety in Parkinson's Disease

OBJECTIVES

Anxiety is common in Parkinson's disease (PD), negatively impacting daily functioning and quality of life in PD patients and their families. This systematic review evaluates the effectiveness of different psychotherapeutic approaches for reducing anxiety in PD and provides recommendations for clinical practise.

METHODS

Following PRISMA guidelines, 36 studies were included and risk of bias was evaluated.

RESULTS

We identified cognitive behavioral therapy (CBT), mindfulness-based therapies, acceptance and commitment therapy, and psychodrama psychotherapies. There is good evidence-base for anxiety reduction using CBT approaches, but with mixed results for mindfulness-based therapies. Other therapeutic approaches were under researched. Most randomized control trials examined anxiety as a secondary measure. There was a paucity of interventions for anxiety subtypes. Secondarily, studies revealed the consistent exclusion of PD patients with cognitive concerns, an importance of care partner involvement, and a growing interest in remote delivery of psychotherapy interventions.

CONCLUSIONS

Person-centered anxiety interventions tailored for PD patients, including those with cognitive concerns, and trials exploring modalities other than CBT, warrant future investigations.

CLINICAL IMPLICATIONS

Practitioners should consider PD-specific anxiety symptoms and cognitive concerns when treating anxiety. Key distinctions between therapeutic modalities, therapy settings and delivery methods should guide treatment planning.

Serotonin and dopamine depletion in distinct brain regions may cause anxiety in 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine-treated mice as a model of early Parkinson's disease

In this study, we aimed to evaluate the association of early anxious behavior with serotonin, dopamine, and their metabolites in a 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) murine model of Parkinson's disease. Forty C57BL/6 male mice were randomly divided into the control group (n = 20) and the model group (n = 20). Mice in the model group were injected intraperitoneally with MPTP. The light-dark box (LDB) and elevated plus-maze were used to monitor anxious behavior. The association of early anxious behavior with neurotransmitters in the prefrontal cortex, hippocampus, and striatum was evaluated. In our murine model, MPTP induced a decreased level of 5-hydroxytryptamine and its metabolite 5-hydroxyindoleacetic acid (5-HIAA) in the prefrontal cortex, hippocampus, and striatum (all P < 0.05); however, it only induced a decreased level of dopamine and its metabolite homovanillic acid (HVA) in the striatum (both P < 0.001), with a negative correlation in the hippocampus and a positive correlation in the cortex and striatum. In the LDB, 5-hydroxytryptamine levels in the cortex and dopamine and HVA levels in the striatum were negatively correlated with anxious behavior. Moreover, in the elevate plus-maze, 5-hydroxytryptamine and 5-HIAA in the cortex and dopamine and HVA in the striatum were positively correlated with the ratio of the time spent in open arms. In the murine model of early Parkinson's disease, the balance between dopamine and 5-hydroxytryptamine systems varied among brain regions. The depletion of 5-hydroxytryptamine in the cortex and dopamine in the striatum may be associated with anxiety behaviors in MPTP-treated mice.

The interplay of personality traits, anxiety, and depression in Chinese college students: a network analysis

Background

Anxiety and depression are among the greatest contributors to the global burden of diseases. The close associations of personality traits with anxiety and depression have been widely described. However, the common practice of sum scores in previous studies limits the understanding of the fine-grained connections between different personality traits and anxiety and depression symptoms and cannot explore and compare the risk or protective effects of personality traits on anxiety and depression symptoms.

Objective

We aimed to determine the fine-grained connections between different personality traits and anxiety and depression symptoms and identify the detrimental or protective effects of different personality traits on anxiety and depression symptoms.

Methods

A total of 536 college students from China were recruited online, and the average age was 19.98 ± 1.11. The Chinese version of the Ten-Item Personality Inventory, Generalized Anxiety Disorder-7, and Patient Health Questionnaire-9 was used to investigate the personality traits and symptoms of anxiety and depression of participants after they understood the purpose and filling method of the survey and signed the informed consent. The demographic characteristics were summarized, and the scale scores were calculated. The network model of personality traits and symptoms of anxiety and depression was constructed, and bridge expected influence (BEI) was measured to evaluate the effect of personality traits on anxiety and depression. The edge accuracy and BEI stability were estimated, and the BEI difference and the edge weight difference were tested.

Results

In the network, 29 edges (indicating partial correlations between variables) bridged the personality community and the anxiety and depression community, among which the strongest correlations were extraversion-fatigue, agreeableness-suicidal ideation, conscientiousness-uncontrollable worry, neuroticism-excessive worry, neuroticism-irritability, and openness-feelings of worthlessness. Neuroticism had the highest positive BEI value (0.32), agreeableness had the highest negative BEI value (-0.27), and the BEI values of neuroticism and agreeableness were significantly different from those of most other nodes (p < 0.05).

Conclusion

There are intricate correlations between personality traits and the symptoms of anxiety and depression in college students. Neuroticism was identified as the most crucial risk trait for depression and anxiety symptoms, while agreeableness was the most central protective trait.

Anxiety in synucleinopathies: neuronal circuitry, underlying pathomechanisms and current therapeutic strategies

Synucleinopathies are neurodegenerative disorders characterized by alpha-synuclein (αSyn) accumulation in neurons or glial cells, including Parkinson's disease (PD), dementia with Lewy bodies (DLB), and multiple system atrophy (MSA). αSyn-related pathology plays a critical role in the pathogenesis of synucleinopathies leading to the progressive loss of neuronal populations in specific brain regions and the development of motor and non-motor symptoms. Anxiety is among the most frequent non-motor symptoms in patients with PD, but it remains underrecognized and undertreated, which significantly reduces the quality of life for patients. Anxiety is defined as a neuropsychiatric complication with characteristics such as nervousness, loss of concentration, and sweating due to the anticipation of impending danger. In patients with PD, neuropathology in the amygdala, a central region in the anxiety and fear circuitry, may contribute to the high prevalence of anxiety. Studies in animal models reported αSyn pathology in the amygdala together with alteration of anxiety or fear learning response. Therefore, understanding the progression, extent, and specifics of pathology in the anxiety and fear circuitry in synucleinopathies will suggest novel approaches to the diagnosis and treatment of neuropsychiatric symptoms. Here, we provide an overview of studies that address neuropsychiatric symptoms in synucleinopathies. We offer insights into anxiety and fear circuitry in animal models and the current implications for therapeutic intervention. In summary, it is apparent that anxiety is not a bystander symptom in these disorders but reflects early pathogenic mechanisms in the cortico-limbic system which may even contribute as a driver to disease progression.

Altered Fractional Amplitude of Low-Frequency Fluctuation in Anxious Parkinson's Disease

OBJECTIVE

Anxiety symptoms are persistent in Parkinson's disease (PD), but the underlying neural substrates are still unclear. In the current study, we aimed to explore the underlying neural mechanisms in PD patients with anxiety symptoms.

METHODS

42 PD-A patients, 41 PD patients without anxiety symptoms (PD-NA), and 40 healthy controls (HCs) were recruited in the present study. All the subjects performed 3.0T fMRI scans. The fractional amplitude of low-frequency fluctuation (fALFF) analysis was used to investigate the alterations in neural activity among the three groups. A Pearson correlation analysis was performed between the altered fALFF value of the PD-A group and anxiety scores.

RESULTS

Compared with HCs, PD-A patients had higher fALFF values in the left cerebellum, cerebellum posterior lobe, bilateral temporal cortex, and brainstem and lower fALFF values in the bilateral inferior gyrus, bilateral basal ganglia areas, and left inferior parietal lobule. Moreover, between the two PD groups, PD-A patients showed higher fALFF values in the right precuneus and lower fALFF values in the bilateral inferior gyrus, bilateral basal ganglia areas, left inferior parietal lobule, and left occipital lobe. Furthermore, Pearson's correlation analysis demonstrated that the right precuneus and left caudate were correlated with the Hamilton Anxiety Rating Scale scores.

CONCLUSION

Our study found that anxiety symptoms in PD patients may be related to alterations of neurological activities in multiple brain regions. Furthermore, these may be critical radiological biomarkers for PD-A patients. Therefore, these findings can improve our understanding of the pathophysiological mechanisms underlying PD-A.

Network analysis of the relationships between problematic smartphone use and anxiety, and depression in a sample of Chinese college students

Background

Problematic smartphone use (PSU) is associated with both anxiety and depression. However, the relationships between components of PSU and symptoms of anxiety or depression have not been investigated. Hence, the aim of this study was to closely examine the relationships between PSU and anxiety and depression to identify the pathological mechanisms underpinning those relationships. A second aim was to identify important bridge nodes to identify potential targets for intervention.

Methods

Symptom-level network structures of PSU and anxiety, and PSU and depression were constructed to investigate the connections between the variables and evaluate the bridge expected influence (BEI) of each node. Network analysis using data from 325 Chinese healthy college students was performed.

Results

Five strongest edges appeared within the communities in both the PSU-anxiety and PSU-depression networks. The "Withdrawal" component had more connections with symptoms of anxiety or depression than any other PSU node. In particular, the edges between "Withdrawal" and "Restlessness" and between "Withdrawal" and "Concentration difficulties" were the strongest cross-community edges in the PSU-anxiety network and PSU-depression network, respectively. Furthermore, "Withdrawal" had the highest BEI in the PSU community in both networks.

Conclusions

These findings provide preliminary evidence of the pathological pathways linking PSU with anxiety and depression, with "Withdrawal" linking PSU with both anxiety and depression. Hence, "Withdrawal" may be a potential target for preventing and intervening in cases of anxiety or depression.

Regional activity alterations in Parkinson's disease patients with anxiety disorders: A resting-state functional magnetic resonance imaging study

Background

Previous studies have revealed alteration of functional connectivity (FC) in Parkinson's disease patients with anxiety (PD-A), but local brain activities associated with anxiety in Parkinson's disease (PD) patients remain to be elucidated. Regional homogeneity (ReHo) analysis was employed to investigate alterations of regional brain activities in PD-A patients.

Methods

Resting-state functional magnetic resonance imaging (rs-fMRI) data were acquired from 42 PD-A patients, 41 PD patients without anxiety (PD-NA), and 40 age-and gender-matched healthy control (HC) subjects. ReHo analysis was used to investigate the synchronization of neuronal activities in brain regions in the three groups. The relationship between ReHo value and anxiety score in the PD-A group was also investigated.

Results

Parkinson's disease patients with anxiety showed increased ReHo values in the bilateral frontal lobes, caudate nucleus, and anterior cingulate gyrus [Gaussian random field (GRF) correction, voxel size p < 0.01, cluster size p < 0.05], compared with PD-NA patients and HC subjects, but the ReHo values of the right cerebellar hemisphere and posterior cerebellar lobe decreased (GRF correction, voxel size p < 0.01, cluster size p < 0.05). The increased ReHo values of the right superior frontal gyrus (r = 0.633, p = 0.001) and anterior cingulate gyrus (r = 0.45, p = 0.01) were positively correlated with anxiety scores in PD-A patients.

Conclusion

The development of PD-A may be associated with dysfunctional local activities in multiple brain regions, including the frontal cortex, cerebella, basal ganglia, and limbic system. Abnormal ReHo values in these brain regions may serve as neuroimaging markers for the early diagnosis of PD-A. The results suggest that using ReHo analysis to identify functional changes in core regions may advance our understanding of the pathophysiological mechanisms underlying PD-A.

Network analysis of anxiety and depression in the functionally impaired elderly

Background

Evidence from previous studies has confirmed that functionally impaired elderly individuals are susceptible to comorbid anxiety and depression. Network theory holds that the comorbidity emerges from interactions between anxiety and depression symptoms. This study aimed to investigate the fine-grained relationships among anxiety and depression symptoms in the functionally impaired elderly and identify central and bridge symptoms to provide potential targets for intervention of these two comorbid disorders.

Methods

A total of 325 functionally impaired elderly individuals from five communities in Xi'an, China, were recruited for our investigation. The GAD-7 and PHQ-9 were used to measure anxiety and depression, respectively. SPSS 22.0 software was used for descriptive statistics, and R 4.1.1 software was used for network model construction, expected influence (EI) evaluation and bridge expected influence (BEI) evaluation.

Results

In the network, there were 35 edges (indicating partial correlations between symptoms) across the communities of anxiety and depression, among which the strongest edge was A1 "Nervousness or anxiety"-D2 "Depressed or sad mood." A2 "Uncontrollable worry" and D2 "Depressed or sad mood" had the highest EI values in the network, while A6 "Irritable" and D7 "Concentration difficulties" had the highest BEI values of their respective community. In the flow network, the strongest direct edge of D9 "Thoughts of death" was with D6 "Feeling of worthlessness."

Conclusion

Complex fine-grained relationships exist between anxiety and depression in functionally impaired elderly individuals. "Uncontrollable worry," "depressed or sad mood," "irritable" and "concentration difficulties" are identified as the potential targets for intervention of anxiety and depression. Our study emphasizes the necessity of suicide prevention for functionally impaired elderly individuals, and the symptom "feeling of worthlessness" can be used as an effective target.

Phenomenology of Atypical Anxiety Disorders in Parkinson's Disease: A Systematic Review

OBJECTIVE

Anxiety is a prominent concern in Parkinson's disease (PD) that negatively impacts quality of life, increases functional disability, and complicates clinical management. Atypical presentations of anxiety are under-recognized and inadequately treated in patients with PD, compromising global PD care.

METHODS

This systematic review focuses on the prevalence, symptomology and clinical correlates of atypical presentations of PD-related anxiety following PRISMA guidelines.

RESULTS

Of the 60 studies meeting inclusion criteria, 14 focused on 'Anxiety Not Otherwise Specified (NOS)' or equivalent, 31 reported on fluctuating anxiety symptoms, and 22 reported on 'Fear of Falling (FOF)'. Anxiety NOS accounted for a weighted mean prevalence of 14.9%, fluctuating anxiety for 34.19%, and FOF for 51.5%. These latter two exceeded the average reported overall prevalence rate of 31% for anxiety disorders in PD. We identified a diverse array of anxiety symptoms related to motor and non-motor symptoms of PD, to complications of PD medication (such as "on" and "off" fluctuations, or both), and, to a lesser extent, to cognitive symptoms.

CONCLUSION

Atypical anxiety is common, clinically relevant, and heterogeneous in nature. A better understanding of the phenomenology, clinical course, and pathophysiology of varied forms of atypical anxiety in PD is needed to improve recognition, advance therapeutic development and ultimately optimize quality of life in PD.

Anxiety and Sleep Quality Amelioration in College Students: A Comparative Study between Team Sports and Individual Sports

Background: Anxiety is one of the most common mental disorders and is often accompanied by sleep disturbances. Studies have focused on the ameliorative effect of sports games on anxiety and its subsidiary issues. However, the effect on the improvement of such mental and physical disorders between individual sports and team group sports is not yet clear, especially regarding their effects on anxiety and sleep quality improvement. Therefore, this paper explores the improvement effects of individual sports and team sports participation on anxiety symptoms and sleep quality amelioration. Objective: To explore the effects of individual and team group sports participation on ameliorating college students’ anxiety symptoms and sleep quality. Methods: A total of 197 college students were sampled in the study. The self-rating anxiety scale (SAS) and Pittsburgh sleep quality index (PSQI) were used to assess the severity of anxiety symptoms and level of sleep quality. Participants were randomly divided into three groups: team sports, individual sports, and control groups. The distribution ratio of these groups was 1:1:1. Results: Generally, compared with the control group, the subjects in the team sports group and individual sports group had greater improvements in anxiety amelioration and sleep quality improvements. Specifically, the improvement effect between individual and team sports groups was different. To assess the resulting differences, improvements in anxiety symptoms and sleep quality were compared between the team sports group and the individual sports group with reference to the mean change in the control group. In the corrected model, the odds advantage ratio (OR) of anxiety symptom improvement after individual sports was 3.18 (CI 2.87–11.21), and the advantage OR of anxiety symptom improvement after team sports was 4.99 (CI 4.06–14.87). The advantage OR of sleep quality improvement after individual sports was 7.32 (CI 5.53–18.22), and the advantage OR of anxiety symptom improvement after team sports was 7.98 (CI 6.69–19.98). Conclusion: After 6 weeks of intervention, it was found that both team sports and individual sports improved anxiety symptoms and sleep quality with different effects. Team sports were better at improving anxiety, while individual sports and team sports shared the same improvement effect with no significant difference in sleep quality improvement.

Perspective: cell death mechanisms and early diagnosis as precondition for disease modification in Parkinson's disease: are we on the right track?

INTRODUCTION

Current research paradigms on biomarkers for chronic neurodegenerative diseases, such as Parkinson's disease, focus on identification of reliable, easy-to-apply tools for diagnostic screening and progression assessment.

AREAS COVERED

This perspective discusses possible misconceptions of biomarker research in chronic neurodegeneration from a clinician's view based on a not systematic literature search. Multifactorial disease triggers, heterogeneity of symptom and their progression are main reasons for the still missing availability of biomarkers.

EXPERT OPINION

Onset of chronic neurodegenerative disease entities may probably result from a decompensated endogenous repair machinery in the central nervous system, for example the neogenin receptor associated repulsive guidance molecule pathway. Future clinical research is warranted on these repair structures and aim to identify markers for the imbalance between damage and repair, which hypothetically contributes to generation of disease. An assignment to a specific chronic neurodegenerative disease entity probably appears to be secondary. Decryption of probable molecular signals of an impaired repair potential will enable an earlier diagnosis, better monitoring of disease progress and of treatment response. This concept will hopefully provide better preconditions for prevention, cure or therapeutic beneficial disease modification. These unmet therapeutic needs may be achieved for example via antagonism of repulsive guidance molecule A.

Anxiety, Depression, and Apathy as Predictors of Cognitive Decline in Patients With Parkinson's Disease-A Three-Year Follow-Up Study

Objective

Anxiety, depression, and apathy are the most common neuropsychiatric symptoms in Parkinson's disease (PD) patients. They impair cognitive functioning and have a profound impact on quality of life. This follow-up study aims to investigate the predictive value of anxiety, depression, and apathy on the development of Mild Cognitive Impairment (MCI) in PD patients.

Methods

Twenty-nine cognitively unimpaired PD patients (mean age 68.2 SD ± 7.12 years; 13 women) participated in this study. At Baseline (BL) levels of apathy (Apathy Evaluation Scale, AES), depression (Beck Depression Inventory, BDI-II), and anxiety (Beck Anxiety Inventory, BAI), were assessed. Cognitive status was reassessed three years later according to MCI/non-MCI status. For statistics, we used binary logistic regression and receiver operating characteristic curve (ROC) analysis to examine anxiety, apathy, and depression at BL as a predictor of MCI status three years later.

Results

Eight of the 29 patients developed MCI. Anxiety level at BL was found to predict MCI status at three-year follow-up (OR = 1.20, CI = 1.02–1.41, p = 0.02), while depression (OR = 1.16, CI = 0.93–1.47, p = 0.20) and apathy (OR = 1.06, CI = 0.92–1.23, p = 0.40) did not predict MCI status. The area under the ROC curve (AUC) of BAI for discriminating PD-non-MCI from PD-MCI was 0.79 (CI = 0.61–0.98). The optimal classification threshold yielded a sensitivity of 75.0 % and a specificity of 76.2 %. Neither apathy nor depression at BL discriminated between PD-non-MCI patients from PD-MCI three years later.

Conclusions

This study shows an association between anxiety and the development of MCI in PD patients, although the association between apathy, depression, and MCI did not reach a significant level.

Neuropsychiatric Treatments for Parkinson's Disease: Nonpharmacological Approaches

Although diagnosed by characteristic motor features, Parkinson's disease and other movement disorders are frequently accompanied by a wide range of neuropsychiatric symptoms that require a multidisciplinary approach for treatment. Neuropsychiatric symptoms such as depression, anxiety and cognitive symptoms strongly influence quality of life, motor symptoms, and non-motor bodily symptoms. This review summarizes our current understanding of the neuropsychiatric symptoms in movement disorders and discusses the evidence base for treatments focusing on rehabilitation and nonpharmacological approaches. A practical approach is then proposed for patient selection for specific treatments based on disease stage. The article focuses mostly on Parkinson's disease as a prototypical movement disorder with the largest evidence base but the principles discussed herein are applicable to a range of other movement disorders.

Anxiety disorders are associated with verbal memory impairment in patients with Parkinson's disease without dementia

INTRODUCTION

Preliminary evidence has demonstrated a link between anxiety and memory impairment in Parkinson's disease (PD). This study further investigated this association using the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for anxiety disorders and a standardized cognitive test battery.

METHODS

A convenience sample of 89 PD patients without dementia was recruited from neurology outpatient clinics. A cross-sectional design was applied. Participants completed two semi-structured interviews. The first interview diagnosed DSM-5 anxiety disorders, unspecified anxiety disorder, and no anxiety. The second interview applied a neurocognitive test battery comprising two tests for each domain. Logistic regression models compared cognitive characteristics associated with anxiety disorders to no anxiety.

RESULTS

Clinically significant anxiety was associated with immediate verbal memory impairment compared to the no anxiety group (OR, 95% CI 0.52, 0.30-0.89; p = 0.018), controlling for sex and age. The anxiety disorders group demonstrated immediate (OR, 95% CI 0.46, 0.26-0.83; p = 0.010) and delayed (OR, 95% CI 0.63, 0.40-0.99; p = 0.047) verbal memory impairments compared to those without anxiety, controlling for sex and age. This association remained for immediate (OR, 95% CI 0.43, 0.22-0.84; p = 0.013), but not delayed verbal memory impairment (OR, 95% CI 0.65, 0.39-1.06; p = 0.081) when additionally controlling for disease severity, education and levodopa dose.

CONCLUSION

These findings present first evidence that anxiety disorders are associated with verbal memory impairment in PD and have implications for the management and treatment of anxiety in PD.